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INTERESTING IMAGE
Year : 2018  |  Volume : 33  |  Issue : 3  |  Page : 250-252  

18F-Fluorodeoxyglucose positron emission tomography-computed tomography imaging of inferior vena cava tumor thrombus extending into the right atrium in a patient with cholangiocarcinoma treated with 90Y-Microspheres


1 Nuclear Medicine Unit, “Santa Maria Goretti” Hospital, Latina, Italy
2 Division of Interventional Radiology, S. Camillo Hospital, Rome, Italy
3 Department of Biomedicine and Prevention, University Tor Vergata, Rome; IRCCS Neuromed, Pozzilli, Italy

Date of Web Publication11-Jun-2018

Correspondence Address:
Luca Filippi
Nuclear Medicine Unit, “Santa Maria Goretti” Hospital, Via Canova, Latina
Italy
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijnm.IJNM_50_18

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   Abstract 


We present a case of a 42-year-old male patient affected by unresectable, chemorefractory cholangiocarcinoma, with prior placement of biliary stent. Because of the absence of extrahepatic metastases, he was submitted to liver-direct therapy with 90Y-microspheres. 18F-fluorodeoxyglucose positron emission tomography-computed tomography (FDG PET-CT) performed before the procedure showed intense tracer uptake in the hepatic lesion and along the biliary stent. The patient underwent radioembolization with 90Y-resin spheres (1.1 GBq). 18F-FDG PET-CT, acquired 6 weeks after the procedure, showed no response of the hepatic lesion and the appearance of an area of markedly increased uptake extending through the inferior vena cava into the right atrium, confirmed as extensive tumor thrombus at the enhanced multislice CT subsequently performed. 18F-FDG PET-CT proved to be a useful imaging tool not only for the evaluation of metabolic response but also for the early detection of extrahepatic progression after 90Y-radioembolization.

Keywords: 18F-fluorodeoxyglucose, 90Y-microspheres, positron emission tomography-computed tomography, radioembolization, tumor thrombus


How to cite this article:
Filippi L, Lacanfora A, Cianni R, Schillaci O, Bagni O. 18F-Fluorodeoxyglucose positron emission tomography-computed tomography imaging of inferior vena cava tumor thrombus extending into the right atrium in a patient with cholangiocarcinoma treated with 90Y-Microspheres. Indian J Nucl Med 2018;33:250-2

How to cite this URL:
Filippi L, Lacanfora A, Cianni R, Schillaci O, Bagni O. 18F-Fluorodeoxyglucose positron emission tomography-computed tomography imaging of inferior vena cava tumor thrombus extending into the right atrium in a patient with cholangiocarcinoma treated with 90Y-Microspheres. Indian J Nucl Med [serial online] 2018 [cited 2019 Dec 6];33:250-2. Available from: http://www.ijnm.in/text.asp?2018/33/3/250/234138



A 42-year-old male patient without any significant medical past history presented with jaundice and abdominal pain on his right side in July 2017. Ultrasound and computed tomography (CT) scan demonstrated a large tumor in the central part of the liver without any abdominal lymph nodes or extrahepatic localizations. Fine-needle biopsy and histological examination diagnosed an intrahepatic cholangiocarcinoma (ICC). In order to reduce the bilirubin levels, a biliary stent was implanted. Subsequently, the patient was submitted to chemotherapy. After 1 month due the appearance of toxicity, chemotherapy was stopped.

Since tumor was exclusively localized to the liver, a locoregional therapy with 90 Y-microspheres was considered.99m Tc-macroaggregated albumin scan performed before the radioembolization procedure did not reveal any lung shunting of extrahepatic uptake.

18F-fluorodeoxyglucose positron emission tomography-computed tomography (FGD PET-CT), performed before the treatment with 90 Y-microspheres [Figure 1], showed an area of focal tracer uptake in the IV segment of the liver, with a maximum standardized uptake value (SUV max) of 12.8. Furthermore, an area of 18 F-FDG accumulation was detected along the hepatobiliary stent, most likely due to inflammation. Radioembolization was performed through the injection of 1.1 Gbq of 90 Y-resin microspheres (SIRS-Spheres®, Sirtex Medical, Lane Cove, Australia). No side effects were registered. The patient was submitted to 90 Y-PET scan to assess the microspheres' distribution pattern.[1] the images demonstrated poor tumor uptake with the majority of the dosage distributing to nontarget areas of the left lobe [Figure 2]. No significant toxicity or relevant symptomatology was registered in the weeks following the procedure.
Figure 1: 18F-fluorodeoxyglucose positron emission tomography-computed tomography performed before the treatment with 90Y-microspheres showed an area of focal tracer uptake in the IV segment of the liver, with a maximum standardized uptake value (SUV max) of 12.8, as well shown in the axial (a) and coronal (b, white arrow) slices. Furthermore, mild tracer uptake is evident along the hepatobiliary stent, most likely due to inflammatory processes

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Figure 2: 90Y-positron emission tomography-computed tomography following radioembolization procedure showed no sites of extrahepatic uptake of microspheres, as shown by the maximum intensity projection (a); axial slices (b) demonstrated poor tumor uptake with the majority of the dosage distributing to nontarget areas of the left lobe

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18F-FDG PET-CT, acquired 6 weeks after the radioembolization [Figure 3], showed no response of the hepatic lesion, also detecting an elongated area of intense 18 F-FDG uptake (SUV max 20.8) extending through the inferior vena to right atrium. The subsequently performed enhanced multislice CT axial slice showed an arterial-phase gross filling defect (dimensions 42 mm × 33 mm) in the right atrium, consistent with tumor thrombus. Death occurred 3 months after the 90 Y-radioembolization procedure.
Figure 3: Axial fused (a) and coronal fused (b, white arrow) positron emission tomography-computed tomography images, acquired 6 weeks after the radioembolization procedure, showed no response of the hepatic lesion, also detecting an elongated area of intense 18F-fluorodeoxyglucose uptake (SUV max 20.8) extending through the inferior vena cava to the right atrium, as well evident in the coronal (b, yellow arrow) and axial (c) slice. The subsequently performed enhanced multislice computed tomography axial slice (d) showed an arterial-phase gross-filling defect (dimensions 42 × 33 mm) in the right atrium, consistent with tumor thrombus

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Despite many advances in diagnosis and therapy, the management of ICC still remains a challenge for physicians. Surgery is the first choice but is often practicable due to advanced presentation.[2],[3] Patients with unresectable ICC are often submitted to chemotherapy but with limited benefits on survival.[4] In this panorama, locoregional treatments such as transarterial chemoembolization and radioembolization with 90 Y-loaded may be considered.[5] The median overall survival of ICC patients treated with 90 Y-microspheres reported in previously published papers resulted of 15.2 months from the procedure,[6] which is the optimal imaging modality and the best time point for assessing response after 90 Y RE has not been established yet. Identifying patients with poor clinical outcome is becoming of utmost importance in oncology to timely start as early as possible adjuvant or palliative treatments.[7],[8] We present a rare and fatal complication in a nonresponder ICC patient after 90 Y-radioembolization. This case points out the usefulness of metabolic imaging with 18 F-FDG not only for monitoring the response of the hepatic lesion after 90 Y-radioembolization but also for the early detection of extrahepatic progression.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Bagni O, D'Arienzo M, Chiaramida P, Chiacchiararelli L, Cannas P, D'Agostini A, et al. 90Y-PET for the assessment of microsphere biodistribution after selective internal radiotherapy. Nucl Med Commun 2012;33:198-204.  Back to cited text no. 1
    
2.
Buettner S, van Vugt JL, IJzermans JN, Groot Koerkamp B. Intrahepatic cholangiocarcinoma: Current perspectives. Onco Targets Ther 2017;10:1131-42.  Back to cited text no. 2
    
3.
Anderson CD, Pinson CW, Berlin J, Chari RS. Diagnosis and treatment of cholangiocarcinoma. Oncologist 2004;9:43-57.  Back to cited text no. 3
    
4.
Konstantinidis IT, Groot Koerkamp B, Do RK, Gönen M, Fong Y, Allen PJ, et al. Unresectable intrahepatic cholangiocarcinoma: Systemic plus hepatic arterial infusion chemotherapy is associated with longer survival in comparison with systemic chemotherapy alone. Cancer 2016;122:758-65.  Back to cited text no. 4
    
5.
Camacho JC, Kokabi N, Xing M, Prajapati HJ, El-Rayes B, Kim HS, et al. Modified response evaluation criteria in solid tumors and European association for the study of the liver criteria using delayed-phase imaging at an early time point predict survival in patients with unresectable intrahepatic cholangiocarcinoma following yttrium-90 radioembolization. J Vasc Interv Radiol 2014;25:256-65.  Back to cited text no. 5
    
6.
Filippi L, Schillaci O, Cianni R, Bagni O. Yttrium-90 resin microspheres and their use in the treatment of intrahepatic cholangiocarcinoma. Future Oncol 2018;14:809-18.  Back to cited text no. 6
    
7.
Singh P, Anil G. Yttrium-90 radioembolization of liver tumors: What do the images tell us? Cancer Imaging 2014;13:645-57.  Back to cited text no. 7
    
8.
Miller FH, Keppke AL, Reddy D, Huang J, Jin J, Mulcahy MF, et al. Response of liver metastases after treatment with yttrium-90 microspheres: Role of size, necrosis, and PET. AJR Am J Roentgenol 2007;188:776-83.  Back to cited text no. 8
    


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  [Figure 1], [Figure 2], [Figure 3]



 

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