IMAGES IN PULMONARY, CRITICAL CARE, SLEEP MEDICINE AND THE SCIENCES Massive Pulmonary Carcinoid Tumor Deemed Inoperable until 68Ga DOTATATE Positron Emission Tomography/Magnetic Resonance Imaging K. L. Ordidge1, J. M. Brown1,2, L. Succony1,2, N. Navani1,2, G. Hardavella1,2, D. R. Lawrence3, F. Fraioli4, A. Groves4, and S. M. Janes1,2 1 Lungs for Living Research Centre, UCL Respiratory, Division of Medicine, Rayne Building, University College London, London, United Kingdom; 2Department of Thoracic Medicine, University College London Hospital, London, United Kingdom; 3The Heart Hospital, London, United Kingdom; and 4Institute of Nuclear Medicine, University College Hospital, London, United Kingdom
Figure 1. (A) Computer tomography of the chest with contrast showing a large mass with apparent chest wall invasion (arrowhead). At this point, the tumor was deemed inoperable. (B) However, gallium 68 DOTA-octreotate positron emission tomography magnetic resonance imaging revealed intact fat planes (arrows) surrounding the tumor and no invasion into the chest wall.
A 59-year-old man presented with left chest and shoulder pain. He never smoked and denied cough, breathlessness, and systemic symptoms. Contrast-enhanced computed tomography (CT) revealed a 16 3 10 cm mass involving the anterior chest wall (Figure 1A, arrowhead), contiguous with the anterior mediastinal lymph nodes. A subsequent CT-guided percutaneous needle biopsy revealed an atypical carcinoid with mitotic index of 3%. Carcinoid tumors show a poor chemosensitivity, so although chest wall invasion was suggested by both CT imaging and chest wall pain, surgical options were further explored.
Author Contributions: K.L.O., J.M.B., N.N., D.R.L., A.G., and S.M.J. were involved in the conception and design of the report. K.L.O., J.M.B., L.S., and G.H. were involved in the acquisition of the data including acquisition of the scans and preparation of the histological specimens. K.L.O., N.N., L.S., F.F., and S.M.J. prepared the manuscript. All authors read and approved the final manuscript. Patient consent was obtained for publication. Am J Respir Crit Care Med Vol 190, Iss 5, pp e16–e17, Sep 1, 2014 Copyright © 2014 by the American Thoracic Society DOI: 10.1164/rccm.201309-1635IM Internet address: www.atsjournals.org
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American Journal of Respiratory and Critical Care Medicine Volume 190 Number 5 | September 1 2014
IMAGES IN PULMONARY, CRITICAL CARE, SLEEP MEDICINE AND THE SCIENCES
Figure 2. (A) Hematoxylin and eosin staining of the tumor biopsy. (B) MIB-1 (mindbomb E3 ubiquitin protein ligase 1) monoclonal antibody staining for proliferation (in brown) indicating a 3% mitotic index. (C) Photograph of the encapsulated atypical carcinoid after surgical resection.
We have recently acquired the first whole-body, fusion positron emission tomography (PET) magnetic resonance imager in the United Kingdom. PET/magnetic resonance imaging (MRI) was therefore performed using the tracer gallium 68 DOTA-octreotate (DOTATATE), which binds somatostatin receptors on carcinoid tumors. While the PET component assesses tracer binding, simultaneous 3 T MRI provides high spatial and image contrast, allowing further functional and anatomical information to be obtained (1). The PET/MRI showed intense, heterogeneous, tracer uptake within the tumor and the anterior mediastinal lymph node mass only (Figure 1B). Crucially, the PET/MRI showed preservation of the mediastinal fat planes and no chest wall invasion (Figure 1B, arrows). Distant metastatic disease was excluded. Based on these images, surgical resection was undertaken. The tumor was encapsulated and weighed 840 g. Histology confirmed previous biopsy findings (Figure 2). The postoperative period was uneventful, and repeat PET/MRI 2 months later confirmed disease clearance. No further therapy was offered despite nodal involvement. One year later, the patient remains well, disease-free, and under surveillance. This is the first report of the utility of gallium 68 DOTATATE PET/MRI in thoracic carcinoid. The case highlights how this emerging technology can be used in the anatomical staging of disease, giving simultaneous information about tumor receptor expression, anatomy, and soft tissue differentiation. PET/MRI allows exact anatomical matching, eliminating inconsistency posed by movement, and, importantly, when scanning the lungs minimizes respiration artifact (1). It further reduces radiation dosage compared with conventional PET CT and limits diagnostic delay and patient inconvenience associated with separate CT, PET, and MRI. Determining the sensitivity and specificity of PET/MRI in detecting nodal metastases will be an important next step in understanding potential clinical roles for this technique. n Author disclosures are available with the text of this article at www.atsjournals.org.
Reference 1. Pichler BJ, Kolb A, Nagele ¨ T, Schlemmer HP. PET/MRI: paving the way for the next generation of clinical multimodality imaging applications. J Nucl Med 2010;51:333–336.
Images in Pulmonary, Critical Care, Sleep Medicine and the Sciences
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Figure 1. (A) Computer tomography of the chest with contrast showing a large mass with apparent chest wall invasion (arrowhead). At this point, the tumor was deemed inoperable. (B) However, gallium 68 DOTA-octreotate positron emission tomography magnetic resonance imaging revealed intact fat planes (arrows) surrounding the tumor and no invasion into the chest wall.
A 59-year-old man presented with left chest and shoulder pain. He never smoked and denied cough, breathlessness, and systemic symptoms. Contrast-enhanced computed tomography (CT) revealed a 16 3 10 cm mass involving the anterior chest wall (Figure 1A, arrowhead), contiguous with the anterior mediastinal lymph nodes. A subsequent CT-guided percutaneous needle biopsy revealed an atypical carcinoid with mitotic index of 3%. Carcinoid tumors show a poor chemosensitivity, so although chest wall invasion was suggested by both CT imaging and chest wall pain, surgical options were further explored.
Author Contributions: K.L.O., J.M.B., N.N., D.R.L., A.G., and S.M.J. were involved in the conception and design of the report. K.L.O., J.M.B., L.S., and G.H. were involved in the acquisition of the data including acquisition of the scans and preparation of the histological specimens. K.L.O., N.N., L.S., F.F., and S.M.J. prepared the manuscript. All authors read and approved the final manuscript. Patient consent was obtained for publication. Am J Respir Crit Care Med Vol 190, Iss 5, pp e16–e17, Sep 1, 2014 Copyright © 2014 by the American Thoracic Society DOI: 10.1164/rccm.201309-1635IM Internet address: www.atsjournals.org
e16
American Journal of Respiratory and Critical Care Medicine Volume 190 Number 5 | September 1 2014
IMAGES IN PULMONARY, CRITICAL CARE, SLEEP MEDICINE AND THE SCIENCES
Figure 2. (A) Hematoxylin and eosin staining of the tumor biopsy. (B) MIB-1 (mindbomb E3 ubiquitin protein ligase 1) monoclonal antibody staining for proliferation (in brown) indicating a 3% mitotic index. (C) Photograph of the encapsulated atypical carcinoid after surgical resection.
We have recently acquired the first whole-body, fusion positron emission tomography (PET) magnetic resonance imager in the United Kingdom. PET/magnetic resonance imaging (MRI) was therefore performed using the tracer gallium 68 DOTA-octreotate (DOTATATE), which binds somatostatin receptors on carcinoid tumors. While the PET component assesses tracer binding, simultaneous 3 T MRI provides high spatial and image contrast, allowing further functional and anatomical information to be obtained (1). The PET/MRI showed intense, heterogeneous, tracer uptake within the tumor and the anterior mediastinal lymph node mass only (Figure 1B). Crucially, the PET/MRI showed preservation of the mediastinal fat planes and no chest wall invasion (Figure 1B, arrows). Distant metastatic disease was excluded. Based on these images, surgical resection was undertaken. The tumor was encapsulated and weighed 840 g. Histology confirmed previous biopsy findings (Figure 2). The postoperative period was uneventful, and repeat PET/MRI 2 months later confirmed disease clearance. No further therapy was offered despite nodal involvement. One year later, the patient remains well, disease-free, and under surveillance. This is the first report of the utility of gallium 68 DOTATATE PET/MRI in thoracic carcinoid. The case highlights how this emerging technology can be used in the anatomical staging of disease, giving simultaneous information about tumor receptor expression, anatomy, and soft tissue differentiation. PET/MRI allows exact anatomical matching, eliminating inconsistency posed by movement, and, importantly, when scanning the lungs minimizes respiration artifact (1). It further reduces radiation dosage compared with conventional PET CT and limits diagnostic delay and patient inconvenience associated with separate CT, PET, and MRI. Determining the sensitivity and specificity of PET/MRI in detecting nodal metastases will be an important next step in understanding potential clinical roles for this technique. n Author disclosures are available with the text of this article at www.atsjournals.org.
Reference 1. Pichler BJ, Kolb A, Nagele ¨ T, Schlemmer HP. PET/MRI: paving the way for the next generation of clinical multimodality imaging applications. J Nucl Med 2010;51:333–336.
Images in Pulmonary, Critical Care, Sleep Medicine and the Sciences
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