Cardiovascular Disease: Cardiothoracic Disorders |

FDG-PET Abnormalities Years After Talc Pleurodesis Can Confound Subsequent Lung Cancer Evaluations: A Case Series, Literature Review, and Diagnostic Recommendations FREE TO VIEW

Whittney Warren, DO; William Londeree, MD; Sarah Cantrell, MS; Joel Nations, MD; William Kelly, MD
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Walter Reed National Naval Medical Center, Bethesda, MD

Copyright 2016, American College of Chest Physicians. All Rights Reserved.

Chest. 2016;149(4_S):A68. doi:10.1016/j.chest.2016.02.072
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SESSION TITLE: Cardiothoracic Disorders

SESSION TYPE: Case Report Slide

PRESENTED ON: Saturday, April 16, 2016 at 04:00 PM - 05:00 PM

INTRODUCTION: Talc pleurodesis is a technique commonly used for treatment of recurrent pleural effusions and pneumothoraces. Abnormal pleural FDG-PET avidity following pleurodesis can persist for years and complicate any subsequent diagnostic evaluation of pulmonary nodules or known malignancy later in life.

CASE PRESENTATION: We present 3 patients over a 5 year period that were referred for pulmonary nodule evaluation and underwent past talc pleurodesis for benign disease, usually recurrent pneumothoraces. The SUV of the pleural lesions ranged from 2.1- 9.4. Additionally, the majority of lesions demonstrated pleural thickening with nodularity in patients up to 14 years post procedure. One 76 year old smoker with a history of right sided pleurodesis developed a new left sided 1 cm spiculated nodule with right pleural thickening and nodularity. Pleural PET avidity was 7.2 SUV, while the left nodule had very low level activity and was limited stage adenocarcinoma. Serial imaging has shown stability of the pleural lesion consistent with benign disease. Another patient had right apical pleural thickening with PET avidity of 5.8 SUV prompting biopsy which demonstrated giant cell reaction to polarizable material consistent with his history of talc pleurodesis. Our final case showed PET avidity in the bilateral pleura after bilateral pleurodesis had been performed 14 years prior for recurrent pneumothoraces. The literature, radiographic and clinical clues that suggest benign post-pleurodesis PET uptake are reviewed.

DISCUSSION: Talc pleurodesis is an effective treatment for recurrent pneumothorax or pleural effusion. Due to the non- absorbable nature of the mineral compound, a foreign body granulomatous inflammatory response occurs that can produce thickening and discrete nodularity in the pleura. Granuloma formation has been described in animal models occuring as soon as three weeks after pleurodesis. Persistent PET avidity in these areas has been reported in the literature as many as 48 years after talc was administered. These areas of avidity often correspond to high density plaques on CT scan, and can cause diagnostic dilemma especially in patients sent for evaluation of other parenchymal abnormalities. Serial imaging or biopsy has been recommended but are limited by sampling error and we review diagnostic recommendations.

CONCLUSIONS: Patients with history of talc pleurodesis can develop malignant appearing pleural thickening and nodularity with increased avidity on FDG-PET that persists years after the procedure was performed. These lesions should not distract or defer evaluation of other, potentially resectable parenchymal lesions.

Reference #1: Vandemoortele T, Laroumagne S, Roca E et al. Positive FDG-PET/CT of the pleura twenty years after talc pleurodesis: three cases of benign talcoma. Respiration. 2014;87(3):243-8.

Reference #2: Kwek BH, Aquino SL, Fischman AJ. Fluorodeoxyglucose positron emission tomography and CT after talc pleurodesis. Chest. 2004;125(6):2356-60.

DISCLOSURE: The following authors have nothing to disclose: Whittney Warren, William Londeree, Sarah Cantrell, Joel Nations, William Kelly

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