SESSION TITLE: Malignant Disease Global Case Reports
SESSION TYPE: Global Case Report Poster
PRESENTED ON: Tuesday, October 27, 2015 at 01:30 PM - 02:30 PM
INTRODUCTION: Thrombosis in cancer may be manifested as venous thromboembolic disease (VTE) or tumor thrombosis (TT), with VTE being far the most common condition (20% of cancer patients develop VTE) . Preliminary data substantiate that FDG PET/CT is a useful method for assessing VTE, at least for DVT. Although some publications have suggested that only tumoral and infected thrombi show increase of the FDG uptake, some series reported that ordinary thrombus may also show increased uptake as a result of the acute inflammatory phase of aseptic deep venous thrombosis.
CASE PRESENTATION: We report the case of a 72 year old with a previous diagnosis of squamous skin cancer performed at another institution, a year prior to consultation. A routine chest roentgenogram revealed a small opacified shadow over the right upper lung field. A contrast-enhanced computed tomography (CT) scan of the chest revealed a right upper lobe lung ground glass opacity (14 × 11 mm) with no mediastinal lymphadenopathy and no involvement of the chest wall. Final pathology showed a mucinous variant of adenocarcinoma in situ. It was completely resected. All lymph nodes were benign. Follow-up was uneventful and the patient went home on the fifth postoperative day. He returned to his previous activities (including regular long walks) in two weks. On further staging a whole body 18FDG positron emission tomography (PET) scan was performed and it revealed increased focal FDG uptake in the left leg below the knee with a standardized uptake value (SUVmax) 2.6 and in the right chest wall in the area of the fifth rib. He was transferred to our institution. Upon referral , the patient was asymptomatic and there was no spontaneous pain, tenderness, swelling or increased warmth in any of the the areas that showed of increased FDG uptake. Doppler ultrasound of his left leg confirmed extensive deep venous thrombosis involving the distal left femoral vein and left popliteal vein, with features indicating complete occlusion.. An extensive work-up was performed in search of any underlying disorders predisposing to thromboembolism and showed all studies within the normal limits. Extensive staging procedures were also negative for metastatic disease.
DISCUSSION: The overall prevalence of incidental VTE among cancer patients varies, depending on the study population but incidental DVT has been reported in 50% as an incidental finding. 18F-FDG is a glucose analog taken up avidly by metabolically active cells. Those cells include endothelial cells, lymphocytes and also macrophages,. Controversy remains whether FDG PET/CT is capable of differentiating bland thrombosis (BT) from tumor thrombosis (TT), although most authors agree that TT generally has higher FDG uptake than BT
CONCLUSIONS: Our patient had a focal increase of FDG uptake with an SUVmax 2.6. The initially limited disease and the complete resection status (RO) obtained with surgery but mainly, the uneventful followup during 10 months only with anticoagulant treatment, confirm that it was a BT and not a TT.
Reference #1: Khosa F, Otero HJ, Prevedello LM, et al. Imaging presentation of venous thrombosis in patients with cancer. AJR Am J Roentgenol. 2010;194:1099-1108
Reference #2: Faisal Khosa, Hansel J. Otero, et al. Imaging Presentation of Venous Thrombosis in Patients With Cancer. American Journal of Roentgenology 2010; 194:4, 1099-1108.
Reference #3: Lee EY, Khong PL. The value of 18F-FDG PET/contrast-enhanced CT in detection of tumor thrombus. Clin Nucl Med. 2013 Feb;38(2):e60-5.
DISCLOSURE: The following authors have nothing to disclose: Hugo Ruben Andr Karlen, Nicolas Itcovicci, Marco Solis, Vanina Martin, Marcos Hernandez, Silvia Quadrelli
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