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Whole body diffusion for metastatic disease assessment in neuroendocrine carcinomas: comparison with OctreoScan® in two cases.

Cossetti RJ, Bezerra RO, Gumz B, Telles A, Costa FP - World J Surg Oncol (2012)

Bottom Line: Neuroendocrine tumor (NET) patients must be adequately staged in order to improve a multidisciplinary approach and optimal management for metastatic disease.NETs significantly reduce water diffusion as compared to normal tissue.In this article we report the use of DWI in MRI and WBD in two cases of metastatic pulmonary NET staging in comparison with OctreoScan® in order to illustrate the potential advantage of DWI and WBD in staging NETs.

View Article: PubMed Central - HTML - PubMed

Affiliation: Centro de Oncologia, Hospital Sírio Libanês, Rua Dona Adma Jafet 91, São Paulo 01308-050, Brazil.

ABSTRACT
Neuroendocrine tumor (NET) patients must be adequately staged in order to improve a multidisciplinary approach and optimal management for metastatic disease. Currently available imaging studies include somatostatin receptor scintigraphy, like OctreoScan®, computed tomography (CT), scans and magnetic resonance imaging (MRI), which analyze vascular concentration and intravenous contrast enhancement for anatomic tumor localization. However, these techniques require high degree of expertise for interpretation and are limited by their availability, cost, reproducibility, and follow-up imaging comparisons. NETs significantly reduce water diffusion as compared to normal tissue. Diffusion-weighted imaging (DWI) in MRI has an advantageous contrast difference: the tumor is represented with high signal over a black normal surrounding background. The whole-body diffusion (WBD) technique has been suggested to be a useful test for detecting metastasis from various anatomic sites. In this article we report the use of DWI in MRI and WBD in two cases of metastatic pulmonary NET staging in comparison with OctreoScan® in order to illustrate the potential advantage of DWI and WBD in staging NETs.

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Comparison of DWI (A), 111 In-pentetreotide scintigraphy images (B) and T1-weighted (C) showing bone metastasis in left sacral bone detected by diffusion-weighted imaging (blue arrow) and confirmed by T1 sequence (green arrow). The hyperintense signal in the right subcutaneous fluid (yellow arrow) is a pitfall due to T2 shine-throught effect and should not be interpreted as metastasis. OctreoScan® image (B) reveals correlation between radiotracer uptake (red arrow) and MR findings.
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Figure 1: Comparison of DWI (A), 111 In-pentetreotide scintigraphy images (B) and T1-weighted (C) showing bone metastasis in left sacral bone detected by diffusion-weighted imaging (blue arrow) and confirmed by T1 sequence (green arrow). The hyperintense signal in the right subcutaneous fluid (yellow arrow) is a pitfall due to T2 shine-throught effect and should not be interpreted as metastasis. OctreoScan® image (B) reveals correlation between radiotracer uptake (red arrow) and MR findings.

Mentions: A 31-year-old female underwent dermatological evaluation for resection of a subcutaneous nodule. Pathological analysis demonstrated an adenocarcinoma with positive margins. The patient underwent wide excision of surgical margins and pathology revealed a NET with positive staining for chromogranin A and neuron-specific enolase. A chest CT scan showed a pulmonary mass in the left lobar bronchia. The patient underwent left pneumectomy. Pathology confirmed a 4.5-cm well-differentiated neuroendocrine carcinoma, with a low mitotic count of 1 mitosis per 10 HPF (high power field). There was no vascular or pleural invasion and surgical margins were free. One lymph node was involved. A staging abdominal ultrasound revealed the presence of two hepatic nodules in segment VIII, measuring 1.8 and 1.0 cm. An abdominal MRI showed multiple hepatic nodules, with additional lesions in segments II and V. Octreoscan showed increased activity on pulmonary and hepatic tumoral lesions. Laboratory screening was unremarkable. The patient was treated with somatostatin analogs. Follow-up abdominal MRI revealed multiple new hepatic and bone lesions. In the WBD images, a new small sacral lesion was detected in correlation with a low signal nodule on the T1-weighted images and therefore raised suspicion for metastasis (Figure 1A and 1 C). The Octreoscan® performed in the same week of the WBD/MRI showed focal uptake in this area (Figure 1B) confirming that WBI added valuable information for staging. Everolimus was added to the treatment regimen. Follow-up images revealed stable disease after three months.


Whole body diffusion for metastatic disease assessment in neuroendocrine carcinomas: comparison with OctreoScan® in two cases.

Cossetti RJ, Bezerra RO, Gumz B, Telles A, Costa FP - World J Surg Oncol (2012)

Comparison of DWI (A), 111 In-pentetreotide scintigraphy images (B) and T1-weighted (C) showing bone metastasis in left sacral bone detected by diffusion-weighted imaging (blue arrow) and confirmed by T1 sequence (green arrow). The hyperintense signal in the right subcutaneous fluid (yellow arrow) is a pitfall due to T2 shine-throught effect and should not be interpreted as metastasis. OctreoScan® image (B) reveals correlation between radiotracer uptake (red arrow) and MR findings.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC3472201&req=5

Figure 1: Comparison of DWI (A), 111 In-pentetreotide scintigraphy images (B) and T1-weighted (C) showing bone metastasis in left sacral bone detected by diffusion-weighted imaging (blue arrow) and confirmed by T1 sequence (green arrow). The hyperintense signal in the right subcutaneous fluid (yellow arrow) is a pitfall due to T2 shine-throught effect and should not be interpreted as metastasis. OctreoScan® image (B) reveals correlation between radiotracer uptake (red arrow) and MR findings.
Mentions: A 31-year-old female underwent dermatological evaluation for resection of a subcutaneous nodule. Pathological analysis demonstrated an adenocarcinoma with positive margins. The patient underwent wide excision of surgical margins and pathology revealed a NET with positive staining for chromogranin A and neuron-specific enolase. A chest CT scan showed a pulmonary mass in the left lobar bronchia. The patient underwent left pneumectomy. Pathology confirmed a 4.5-cm well-differentiated neuroendocrine carcinoma, with a low mitotic count of 1 mitosis per 10 HPF (high power field). There was no vascular or pleural invasion and surgical margins were free. One lymph node was involved. A staging abdominal ultrasound revealed the presence of two hepatic nodules in segment VIII, measuring 1.8 and 1.0 cm. An abdominal MRI showed multiple hepatic nodules, with additional lesions in segments II and V. Octreoscan showed increased activity on pulmonary and hepatic tumoral lesions. Laboratory screening was unremarkable. The patient was treated with somatostatin analogs. Follow-up abdominal MRI revealed multiple new hepatic and bone lesions. In the WBD images, a new small sacral lesion was detected in correlation with a low signal nodule on the T1-weighted images and therefore raised suspicion for metastasis (Figure 1A and 1 C). The Octreoscan® performed in the same week of the WBD/MRI showed focal uptake in this area (Figure 1B) confirming that WBI added valuable information for staging. Everolimus was added to the treatment regimen. Follow-up images revealed stable disease after three months.

Bottom Line: Neuroendocrine tumor (NET) patients must be adequately staged in order to improve a multidisciplinary approach and optimal management for metastatic disease.NETs significantly reduce water diffusion as compared to normal tissue.In this article we report the use of DWI in MRI and WBD in two cases of metastatic pulmonary NET staging in comparison with OctreoScan® in order to illustrate the potential advantage of DWI and WBD in staging NETs.

View Article: PubMed Central - HTML - PubMed

Affiliation: Centro de Oncologia, Hospital Sírio Libanês, Rua Dona Adma Jafet 91, São Paulo 01308-050, Brazil.

ABSTRACT
Neuroendocrine tumor (NET) patients must be adequately staged in order to improve a multidisciplinary approach and optimal management for metastatic disease. Currently available imaging studies include somatostatin receptor scintigraphy, like OctreoScan®, computed tomography (CT), scans and magnetic resonance imaging (MRI), which analyze vascular concentration and intravenous contrast enhancement for anatomic tumor localization. However, these techniques require high degree of expertise for interpretation and are limited by their availability, cost, reproducibility, and follow-up imaging comparisons. NETs significantly reduce water diffusion as compared to normal tissue. Diffusion-weighted imaging (DWI) in MRI has an advantageous contrast difference: the tumor is represented with high signal over a black normal surrounding background. The whole-body diffusion (WBD) technique has been suggested to be a useful test for detecting metastasis from various anatomic sites. In this article we report the use of DWI in MRI and WBD in two cases of metastatic pulmonary NET staging in comparison with OctreoScan® in order to illustrate the potential advantage of DWI and WBD in staging NETs.

Show MeSH
Related in: MedlinePlus