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Herpes Zoster Mimicking Breast Cancer With Axillary Lymph Node Metastasis on PET/CT Eun Kyoung Choi, MD, Jin Kyoung Oh, MD, PhD, and Yong-An Chung, MD, PhD Abstract: Herpes zoster is a reactivated varicella-zoster virus infection and demonstrates typical dermatomal distribution. We herein describe a case of a 41-year-old woman with a history of ovarian cancer. Intense hot uptake in the left breast and enlarged ipsilateral axillary lymph nodes were noted on 18 F-FDG PET/CT for adjuvant chemotherapy response evaluation. Blinded to the patient’s clinical information, these lesions were interpreted as incidental breast cancer with axillary nodal metastasis. However, clinically she presented with vesicles along the T4 dermatome and palpable enlarged nodes in the left axilla. On 3-month follow-up PET/CT after antiviral treatment, these intense hot uptake areas were no longer visualized. Key Words: herpes zoster, PET/CT, breast cancer (Clin Nucl Med 2015;40: 572–573) Received for publication August 18, 2014; revision accepted March 11, 2015. From the Department of Radiology, Incheon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Incheon, South Korea. Conflicts of interest and sources of funding: none declared. Reprints: Jin Kyoung Oh, MD, PhD, Department of Radiology, Incheon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, 56, Dongsu-ro, Bupyeong-gu, Incheon 403-720, South Korea. E-mail: [email protected]. Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0363-9762/15/4007–0572
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REFERENCES 1. Weitzman D, Shavit O, Stein M, et al. A population based study of the epidemiology of Herpes Zoster and its complications. J Infect. 2013;67:463–469. 2. Egan C, Silverman E. Increased FDG uptake along dermatome on PET in a patient with herpes zoster. Clin Nucl Med. 2013;38:744–745. 3. Kofoed K, Rønholt F, Gerstoft J, et al. [Herpes zoster: clinical manifestation, diagnosis and treatment]. Ugeskr Laeger. 2011;173:114–119. 4. Yawn B, Saddier P, Wollan P, et al. A population-based study of the incidence and complication rates of herpes zoster before zoster vaccine introduction. Mayo Clin Proc. 2007;82:1341–1349. 5. Castellucci P, Nanni C, Farsad M, et al. Potential pitfalls of 18F-FDG PET in a large series of patients treated for malignant lymphoma: prevalence and scan interpretation. Nucl Med Commun. 2005;26:689–694. 6. Kerrou K, Montravers F, Grahek D, et al. [18F]-FDG uptake in soft tissue dermatome prior to herpes zoster eruption: an unusual pitfall. Ann Nucl Med. 2001; 15:455–458. 7. Joyce J, Carlos T. Herpes Zoster mimicking recurrence of lymphoma on PET/CT. Clin Nucl Med. 2006;31:104–105. 8. Sharma R, Jaimini A, Mondal A, et al. Pitfall of 18F-FDG-PET imaging in oncology: herpes zoster with axillary lymphadenopathy. Hell J Nucl Med. 2008; 11:51–52. 9. Kang BJ, Lee JH, Yoo Ie R, et al. Clinical significance of incidental finding of focal activity in the breast at 18F-FDG PET/CT. AJR Am J Roentgenol. 2011; 197:341–347. 10. Chae EY, Cha JH, Kim HH, et al. Analysis of incidental focal hypermetabolic uptake in the breast as detected by 18F-FDG PET/CT: clinical significance and differential diagnosis. Acta Radiol. 2012;53:530–535. 11. Korn RL, Yost AM, May CC, et al. Unexpected focal hypermetabolic activity in the breast: significance in patients undergoing 18F-FDG PET/CT. AJR Am J Roentgenol. 2006;187:81–85.
Clinical Nuclear Medicine • Volume 40, Number 7, July 2015 Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Clinical Nuclear Medicine • Volume 40, Number 7, July 2015
Herpes Zoster Mimicking Breast Cancer
FIGURE 1. A, 41-year-old patient with ovarian cancer undergoing chemotherapy showed newly developed intense focal uptake areas in left breast (arrowheads) and axilla (arrows) on MIP image of PET/CT. These lesions were not present on the previous PET/CT 4 months before. B and C, On axial fusion images, a band-like hot uptake area was noted involving lower inner quadrant of left breast (arrowheads). On unfused CT images, irregular skin thickening was seen in left breast (arrowheads). D and E, On axial fusion and unfused CT images, multiple enlarged lymph nodes were also seen in left axilla, with intense focal FDG uptake (arrows). The lesions’ appearance over a relatively short period of time without a history of breast cancer raised the possibility of benign inflammatory disease of the breast. However, only few FDG-avid inflammatory diseases involving the breast have yet been reported. Marked skin thickening of the breast was also noted, requiring exclusion of a rapidly growing breast malignancy and metastasis. Considering the location of these lesions, incidental breast cancer with ipsilateral lymph node metastases was more likely than metastases from ovarian cancer. Clinically, the patient suffered from a typical rash and vesicles with pain along the T4 dermatome, including the left breast, and was diagnosed with herpes zoster. F, After antiviral therapy, she showed complete resolution of previously noted hot uptake in breast and axilla on 4-month follow-up PET/CT examination. Herpes zoster usually affects the elderly and immunocompromised patients, such as those undergoing chemotherapy.1,2 The most common sites for herpes zoster are along the thoracic dermatome.3,4 The disease is a cause of false-positive PET/CT in cancer patients,5,6 mimicking lymphoma recurrence or, when the thoracic dermatome is involved, axillary node metastasis.5,7,8 The present case involved the breast with ipsilateral axillary lymph node enlargement, mimicking incidental breast cancer with axillary lymph node metastasis, which is a rather unusual pattern compared to previous reports of false-positive PET/CT in herpes zoster. The malignancy rate of incidental hypermetabolic breast lesions detected by PET/CT ranged from 37.5 to 83.3%.9–11 Because of this varying accuracy for prediction of malignancy of incidental breast uptake, differentiation between malignant and benign lesions warrants correlation with clinical history and physical examination.
© 2015 Wolters Kluwer Health, Inc. All rights reserved. Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
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Herpes Zoster Mimicking Breast Cancer With Axillary Lymph Node Metastasis on PET/CT Eun Kyoung Choi, MD, Jin Kyoung Oh, MD, PhD, and Yong-An Chung, MD, PhD Abstract: Herpes zoster is a reactivated varicella-zoster virus infection and demonstrates typical dermatomal distribution. We herein describe a case of a 41-year-old woman with a history of ovarian cancer. Intense hot uptake in the left breast and enlarged ipsilateral axillary lymph nodes were noted on 18 F-FDG PET/CT for adjuvant chemotherapy response evaluation. Blinded to the patient’s clinical information, these lesions were interpreted as incidental breast cancer with axillary nodal metastasis. However, clinically she presented with vesicles along the T4 dermatome and palpable enlarged nodes in the left axilla. On 3-month follow-up PET/CT after antiviral treatment, these intense hot uptake areas were no longer visualized. Key Words: herpes zoster, PET/CT, breast cancer (Clin Nucl Med 2015;40: 572–573) Received for publication August 18, 2014; revision accepted March 11, 2015. From the Department of Radiology, Incheon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Incheon, South Korea. Conflicts of interest and sources of funding: none declared. Reprints: Jin Kyoung Oh, MD, PhD, Department of Radiology, Incheon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, 56, Dongsu-ro, Bupyeong-gu, Incheon 403-720, South Korea. E-mail: [email protected]. Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0363-9762/15/4007–0572
572
www.nuclearmed.com
REFERENCES 1. Weitzman D, Shavit O, Stein M, et al. A population based study of the epidemiology of Herpes Zoster and its complications. J Infect. 2013;67:463–469. 2. Egan C, Silverman E. Increased FDG uptake along dermatome on PET in a patient with herpes zoster. Clin Nucl Med. 2013;38:744–745. 3. Kofoed K, Rønholt F, Gerstoft J, et al. [Herpes zoster: clinical manifestation, diagnosis and treatment]. Ugeskr Laeger. 2011;173:114–119. 4. Yawn B, Saddier P, Wollan P, et al. A population-based study of the incidence and complication rates of herpes zoster before zoster vaccine introduction. Mayo Clin Proc. 2007;82:1341–1349. 5. Castellucci P, Nanni C, Farsad M, et al. Potential pitfalls of 18F-FDG PET in a large series of patients treated for malignant lymphoma: prevalence and scan interpretation. Nucl Med Commun. 2005;26:689–694. 6. Kerrou K, Montravers F, Grahek D, et al. [18F]-FDG uptake in soft tissue dermatome prior to herpes zoster eruption: an unusual pitfall. Ann Nucl Med. 2001; 15:455–458. 7. Joyce J, Carlos T. Herpes Zoster mimicking recurrence of lymphoma on PET/CT. Clin Nucl Med. 2006;31:104–105. 8. Sharma R, Jaimini A, Mondal A, et al. Pitfall of 18F-FDG-PET imaging in oncology: herpes zoster with axillary lymphadenopathy. Hell J Nucl Med. 2008; 11:51–52. 9. Kang BJ, Lee JH, Yoo Ie R, et al. Clinical significance of incidental finding of focal activity in the breast at 18F-FDG PET/CT. AJR Am J Roentgenol. 2011; 197:341–347. 10. Chae EY, Cha JH, Kim HH, et al. Analysis of incidental focal hypermetabolic uptake in the breast as detected by 18F-FDG PET/CT: clinical significance and differential diagnosis. Acta Radiol. 2012;53:530–535. 11. Korn RL, Yost AM, May CC, et al. Unexpected focal hypermetabolic activity in the breast: significance in patients undergoing 18F-FDG PET/CT. AJR Am J Roentgenol. 2006;187:81–85.
Clinical Nuclear Medicine • Volume 40, Number 7, July 2015 Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Clinical Nuclear Medicine • Volume 40, Number 7, July 2015
Herpes Zoster Mimicking Breast Cancer
FIGURE 1. A, 41-year-old patient with ovarian cancer undergoing chemotherapy showed newly developed intense focal uptake areas in left breast (arrowheads) and axilla (arrows) on MIP image of PET/CT. These lesions were not present on the previous PET/CT 4 months before. B and C, On axial fusion images, a band-like hot uptake area was noted involving lower inner quadrant of left breast (arrowheads). On unfused CT images, irregular skin thickening was seen in left breast (arrowheads). D and E, On axial fusion and unfused CT images, multiple enlarged lymph nodes were also seen in left axilla, with intense focal FDG uptake (arrows). The lesions’ appearance over a relatively short period of time without a history of breast cancer raised the possibility of benign inflammatory disease of the breast. However, only few FDG-avid inflammatory diseases involving the breast have yet been reported. Marked skin thickening of the breast was also noted, requiring exclusion of a rapidly growing breast malignancy and metastasis. Considering the location of these lesions, incidental breast cancer with ipsilateral lymph node metastases was more likely than metastases from ovarian cancer. Clinically, the patient suffered from a typical rash and vesicles with pain along the T4 dermatome, including the left breast, and was diagnosed with herpes zoster. F, After antiviral therapy, she showed complete resolution of previously noted hot uptake in breast and axilla on 4-month follow-up PET/CT examination. Herpes zoster usually affects the elderly and immunocompromised patients, such as those undergoing chemotherapy.1,2 The most common sites for herpes zoster are along the thoracic dermatome.3,4 The disease is a cause of false-positive PET/CT in cancer patients,5,6 mimicking lymphoma recurrence or, when the thoracic dermatome is involved, axillary node metastasis.5,7,8 The present case involved the breast with ipsilateral axillary lymph node enlargement, mimicking incidental breast cancer with axillary lymph node metastasis, which is a rather unusual pattern compared to previous reports of false-positive PET/CT in herpes zoster. The malignancy rate of incidental hypermetabolic breast lesions detected by PET/CT ranged from 37.5 to 83.3%.9–11 Because of this varying accuracy for prediction of malignancy of incidental breast uptake, differentiation between malignant and benign lesions warrants correlation with clinical history and physical examination.
© 2015 Wolters Kluwer Health, Inc. All rights reserved. Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
www.nuclearmed.com
573
