Delineation of Implantation Metastases Along the Abdominal Surgery Corridor

Follow-up study of NSCLC patient with secondary adrenal gland malignancy

Irene Greil, MD

Case study data provided by Klinikum Nuremberg, Nuremberg, Germany

 |  2012-12-18

History
A 57-year-old male patient was hospitalized for a severe gastroenteritis. The diagnostic workup revealed a suspicious pulmonary lesion in the right upper lobe, which on biopsy was confirmed to be a non-small cell lung carcinoma (NSCLC) in the upper lobe (May 2011). The patient was referred for a PET•CT study with fludeoxyglucose F 18* injection (18F FDG).

 

*Siemens' PETNET Solutions is a manufacturer of fludeoxyglucose F 18 injection (18F FDG). Indication and important safety information as approved by the US Food and Drug Administration can be found at the bottom of the page for 18F FDG, adult dose 5-10 mCi, administered by intravenous injection.

 

Examination Protocol
Scanner: Biograph mCT 40
Dose: 370 MBq 18F FDG
Parameters: 2 min/bed

 

Fig. 1: The initial PET•CT study showed a known SPN with a SUVmax of 18.8. In addition, a second 18F FDG avid lesion was depicted in the left adrenal gland with a SUVmax of 10.8.

 

Fig. 2: The second 18F FDG PET•CT study performed 4 months after adrenalectomy and 3 months after pulmonary resection, revealed multiple 18F FDG avid foci up to 2 cm in diameter in the region of the left adrenal gland adjacent to the diaphragm with subcutaneous spread in the
dorsal and dorso-caudal direction.

 

Fig. 3: A follow-up PET•CT scan 6 weeks after termination of the chemotherapy showed only minimal treatment response in a few of the metastatic foci, especially in the subcutaneous nodules. Lesions in the adrenal bed showed progression, along with new lesions in the perirenal space and in the caudal pole of the left kidney, which together suggest therapy failure.

 

Diagnosis
The initial PET•CT study (Figure 1) showed a known singular pulmonary nodule (SPN) with a SUVmax of 18.8. In addition, a second 18F FDG avid lesion was depicted in the left adrenal gland with a SUVmax of 10.8. To exclude an additional secondary malignancy, the patient underwent an adrenalectomy on the left side. Histology confirmed the suspicion of an adrenal gland metastasis of the NSCLC. The adrenalectomy was initially scheduled as a minimally invasive procedure, but it needed to be extended interoperatively to a conventional adrenal resection with a left-sided incision. The primary lung tumor was removed by upper lobar resection with adjacent lymphadenectomy (June 2011). An adjuvant chemotherapy regimen was also started. Three months later, the patient presented for follow up with swelling close to the incision site of the adrenalectomy. According to the patient, these nodular lesions appeared almost immediately following surgery and had progressively increased in size. A PET•CT scan performed on the Biograph™ mCT 40 to better characterize those lesions. The Biograph mCT features the industry's finest volumetric resolution of 87mm3,** which generates high quality images and enables accurate localization of lesions. The second 18F FDG PET•CT study (Figure 2), performed 4 months after adrenalectomy and 3 months after pulmonary resection, revealed multiple, 18F FDG avid foci up to 2 cm in diameter in the region of the left adrenal gland adjacent to the diaphragm with subcutaneous spread in the dorsal and dorso-caudal direction. Additional lesions were located next to the descending colon, as well as in the muscles and subcutaneous tissue of the back. The SUVmax of those masses was significantly elevated (SUVmax 24), suggesting malignancy.

 

Comments
The nodular 18F FDG avid lesions correlated exactly with the surgery corridor of the adrenalectomy, indicating the presence of multiple, intraoperatively implanted metastases of the NSCLC, which was confirmed histologically. The more superficially located tumors could be removed surgically. In addition, the patient underwent external radiation and combination chemotherapy. A follow-up PET•CT scan (Figure 3) 6 weeks after termination of the chemotherapy showed only minimal treatment response in few of the metastatic foci, especially in the subcutaneous nodules. However, lesions in the adrenal bed showed progression, along with new lesions in perirenal space and in the caudal pole of the left kidney, which together suggest therapy failure.
 

*Fludeoxyglucose F 18 Injection

 

INDICATIONS AND USAGE
Fludeoxyglucose F 18 injection (18F FDG) is indicated for positron emission tomography (PET) imaging in the following setting:
Oncology: For assessment of abnormal glucose metabolism to assist in the evaluation of malignancy in patients with known or suspected abnormalities found by other testing modalities, or in patients with an existing diagnosis of cancer.


IMPORTANT SAFETY INFORMATION

Radiation Risks
Radiation-emitting products, including fludeoxyglucose F 18 injection, may increase the risk for cancer, especially in pediatric patients. Use the smallest dose necessary for imaging and ensure safe handling to protect the patient and health care worker.

Blood Glucose Abnormalities
In the oncology and neurology setting, suboptimal imaging may occur in patients with inadequately regulated blood glucose levels. In these patients, consider medical therapy and laboratory testing to assure at least two days of normoglycemia prior to fludeoxyglucose F18 injection administration.

Adverse Reactions
Hypersensitivity reactions with pruritus, edema and rash have been reported; have emergency resuscitation equipment and personnel immediately available.

 

Full Prescribing Information for Fludeoxyglucose F 18 Injection

Fludeoxyglucose F 18 Injection is manufactured by Siemens' PETNET Solutions, 810 Innovation Drive, Knoxville, TN 39732

The statements by Siemens customers described herein are based on results that were achieved in the customer's unique setting. Since there is no "typical" hospital and many variables exist (e.g., hospital size, case mix, level of IT adoption) there can be no guarantee that other customers will achieve the same results.