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INTERESTING IMAGE
Year : 2018  |  Volume : 33  |  Issue : 2  |  Page : 167-168  

Unilateral Brown Fat Suppression on FDG PET/CT-detecting Sympathetic Denervation


Department of Nuclear Medicine, AIIMS, New Delhi, India

Date of Web Publication15-Mar-2018

Correspondence Address:
Dr. Nishikant Avinash Damle
Department of Nuclear Medicine, AIIMS, Ansari Nagar, New Delhi - 110 029
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijnm.IJNM_166_17

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   Abstract 


We present here a case of primitive neuroectodermal tumor (PNET) who initially presented with involvement of the right 3rd rib and underwent neoadjuvant chemotherapy, rib excision, and adjuvant chemoradiotherapy and later underwent posterolateral thoracotomy, pleural nodule excision, and the right 11th rib metastatic lesion excision. Follow-up 18F-FDG PET/CT/computed tomography revealed unilateral brown fat suppression in the form of decreased metabolic uptake in the ipsilateral cervical, axillary, and paravertebral brown fat as compared to metabolically active contralateral brown fat, likely due to paravertebral sympathetic chain damage.

Keywords: 2-deoxy-2-(fluorine-18) fluoro-D-glucose positron emission tomography/computed tomography, brown fat, sympathetic chain, unilateral


How to cite this article:
Arora S, Damle NA, Reddy K S, Parida GK, Singhal A, Arunraj ST, Bal C, Singh R, Raju S, Chakraborty D. Unilateral Brown Fat Suppression on FDG PET/CT-detecting Sympathetic Denervation. Indian J Nucl Med 2018;33:167-8

How to cite this URL:
Arora S, Damle NA, Reddy K S, Parida GK, Singhal A, Arunraj ST, Bal C, Singh R, Raju S, Chakraborty D. Unilateral Brown Fat Suppression on FDG PET/CT-detecting Sympathetic Denervation. Indian J Nucl Med [serial online] 2018 [cited 2019 Dec 12];33:167-8. Available from: http://www.ijnm.in/text.asp?2018/33/2/167/227511



Brown fat is known to be innervated by sympathetic nervous system.[1] Sympathetic fibers from the thoracolumbar region of spinal cord leave the spinal nerves and connect with paravertebral sympathetic chain which can be damaged due many conditions including trauma, malignancies, vascular injury, and iatrogenic injury.[2],[3],[4] The superior cervical ganglion that provides innervations to the head and neck region receives sympathetic fibers from upper thoracic region,[5] and damage to these fibers can result in Horner's syndrome. Few previous studies have shown uptake of FDG PET/CT in the brown fat [6],[7] and have tried to correlate disruption of sympathetic innervations of brown fat using the same. Usually, the brown fat FDG uptake, which is commonly seen in winter season, is bilaterally symmetrical in cervical, interscapular, paravertebral, and axillary region.[6]

We present here a case where 2-deoxy-2-(fluorine-18) FDG positron emission tomography/computed tomography (18-F-FDG PET/CT) showed unilateral uptake corresponding to the brown fat [Figure 1]. This 9-year-old male who initially presented with PNET of the right 3rd rib was treated with neoadjuvant chemotherapy and 3rd rib excision followed by adjuvant chemoradiation. He again presented with pleural metastases for which he underwent posterolateral thoracotomy and excision of parietal pleural nodule followed by bone marrow transplant. Two years later, he again presented with lytic expansile at the right 11th rib lesion with paravertebral soft-tissue component for which he underwent chemoradiation. Follow-up 18F-FDG PET/CT revealed paravertebral soft-tissue thickening near costovertebral junction in the region of right 10th and 11th ribs with minimal FDG uptake which show significant reduction in size and metabolic uptake as compared to previous PET/CT. Interestingly, 18F-FDG PET/CT revealed unilateral brown fat metabolic suppression in the form of decreased FDG uptake in the ipsilateral cervical, axillary, and paravertebral brown fat as compared to metabolically active contralateral brown fat which suggested paravertebral sympathetic chain damage during the posterolateral thoracotomy/rib excision surgery or due to infiltration by the paravertebral soft-tissue mass. On detailed clinical enquiry, the patient revealed a history of absent sweating on the ipsilateral side. This finding suggests that unilateral lack of brown fat uptake on 18F-FDG PET/CT can be a pointer of sympathetic denervation and must be brought to the notice of the treating clinician.
Figure 1: 18F FDG PET/CT MIP image (a), Axial CT(b and d), Fused PET/CT (c and e) and Coronal images (f-h) reveals unilateral decreased FDG uptake corresponding to right cervical, axillary and paravertebral brown fat (black arrow) and preserved FDG uptake in brown fat on left side.

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Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Bahler L, Molenaars RJ, Verberne HJ, Holleman F. Role of the autonomic nervous system in activation of human brown adipose tissue: A review of the literature. Diabetes Metab 2015;41:437-45.  Back to cited text no. 1
    
2.
Hara M, Matsuzaki Y, Shimizu T, Tomita M, Ayabe T, Enomoto Y, et al. Malignant peripheral nerve sheath tumor with Horner's syndrome: A case report. Ann Thorac Cardiovasc Surg 2008;14:246-8.  Back to cited text no. 2
    
3.
Flaherty PM, Flynn JM. Horner syndrome due to carotid dissection. J Emerg Med 2011;41:43-6.  Back to cited text no. 3
    
4.
Nasser BA, Mesned A, Moazamy YE, Kabbani MS. Horner's syndrome after paediatric cardiac surgery: Case report and review of the literature. Cardiol Young 2015;25:569-72.  Back to cited text no. 4
    
5.
Lee JH, Lee HK, Lee DH, Choi CG, Kim SJ, Suh DC, et al. Neuroimaging strategies for three types of Horner syndrome with emphasis on anatomic location. AJR Am J Roentgenol 2007;188:W74-81.  Back to cited text no. 5
    
6.
Yeung HW, Grewal RK, Gonen M, Schöder H, Larson SM. Patterns of (18)F-FDG uptake in adipose tissue and muscle: A potential source of false-positives for PET. J Nucl Med 2003;44:1789-96.  Back to cited text no. 6
    
7.
Cohade C, Mourtzikos KA, Wahl RL. “USA-fat”: Prevalence is related to ambient outdoor temperature-evaluation with 18F-FDG PET/CT. J Nucl Med 2003;44:1267-70.  Back to cited text no. 7
    


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