Letters to Editor 2. 3.
4.
5. 6.
Valenta LJ, Treadwell T, Berry R, Elias AN. Idiopathic thrombocytopenic purpura and Graves disease. Am J Hematol 1982;12:69‑72. Kurata Y, Nishioeda Y, Tsubakio T, Kitani T. Thrombocytopenia in Graves’ disease: Effect of T3 on platelet kinetics. Acta Haematol 1980;63:185‑90. Cordiano I, Betterle C, Spadaccino CA, Soini B, Girolami A, Fabris F. Autoimmune thrombocytopenia (AITP) and thyroid autoimmune disease (TAD): Overlapping syndromes? Clin Exp Immunol 1998;113:373‑8. Cheung E, Liebman HA. Thyroid disease in patients with immune thrombocytopenia. Hematol Oncol Clin North Am 2009;23:1251‑60. Gill H, Hwang YY, Tse E. Primary immune thrombocytopenia responding to antithyroid treatment in a patient with Graves’ disease. Ann Hematol 2011;90:223‑4.
7. 8.
Hofbauer LC, Spitzweg C, Schmauss S, Heufelder AE. Graves disease associated with autoimmune thrombocytopenic purpura. Arch Intern Med 1997;157:1033‑6. Bartalena L, Bogazzi F, Martino E. Adverse effects of thyroid hormone preparations and antithyroid drugs. Drug Saf 1996;15:53‑63. Access this article online Quick Response Code: Website: www.ijnm.in
DOI: 10.4103/0972-3919.136602
Malignant melanoma with cavitary pulmonary metastasis: Diagnostic dilemma resolved by FDG PET/CT guided biopsy Sir, We present a case of a 70‑year‑old male patient who was operated 5 years back for a malignant melanoma of right big toe. He was again operated 3 years ago for the recurrence in his right thigh. Patient was in complete remission and on regular follow up since then. Patient was apparently normal till 3 months back when he presented with two episodes of hemoptysis. Chest X‑ray revealed a left lung upper lobe thick walled cavitary lesion. Computed tomography (CT) revealed the same findings along with hemorrhage in the surrounding area. From the above findings, it could not be ascertained whether the mass was infective or metastatic in nature. Therefore, a CT‑guided biopsy was done which revealed it to be infective in nature (resolving pneumonia). But even after 3 weeks of appropriate antibiotic coverage, the mass neither resolved nor decreased in size. Repeat CT‑guided biopsy revealed necrotic tissue but could not pinpoint the diagnosis. It was then that the patient was referred for the 18F FDG PET/CT, which revealed a cavitary lesion in left lung upper lobe with increased uptake of the radiotracer along its margins [Figure 1a‑c; arrows]. But the clinical query was still unanswered, so a PET/CT‑guided biopsy was undertaken. PET/CT‑guided biopsy from the lung mass [Figure 1d and e] revealed malignant melanoma cells which were positive for HMB‑45 and S‑100 and were negative for cytokeratin. So, PET/CT‑guided biopsy from the margins of the cavitary lesion showing increased uptake aided in the accurate diagnosis of pulmonary metastasis from malignant melanoma. To the best of our knowledge, this is the first case of malignant melanoma with isolated cavitary lung metastases.
to choose between adequate resection and preservation of limb function.[1] Melanomas which metastasize beyond its locoregional site generally predict a poor outcome with a mean survival of around 6 months only.[2] Patients with melanoma metastases to lung have a median survival of 1 year, while those to sites other than lung have a median survival of around 18 months.[3] Cavitary lung metastases are extremely rare and represent only 4% of cases of lung metastases and usually arise from squamous cell carcinoma (especially of the head and neck), adenocarcinomas, and sarcomas.[4] FDG PET is useful in the initial staging of patients with cutaneous malignant melanoma to help detect soft tissue, lymph node, and visceral metastases.[5] In a meta‑analysis comparing ultrasonography (USG), CT, and PET/CT for staging and surveillance of melanoma patients, USG was found superior for the detection of lymph node metastases while PET/CT was found superior for distant metastases.[6] The proper guideline‑based or targeted therapy for a patient can only be administered after proper histopathological diagnosis of the tumor site or site of metastases, which at times can be difficult due to prior chemotherapy or radiation therapy changes.[7] FDG PET/CT can visualize vital areas of the tumor with increased metabolic activity and can pin‑point the tissues from which biopsy can be taken. This increases its diagnostic value.[8] In this case, PET/CT‑guided biopsy helped to pin‑point the diagnosis of cavitary metastases to the lung which originated from the malignant melanoma of the right toe and hence helped in changing the treatment plan of the patient.
Foot melanoma comprises 3 to 5% of all melanoma cases and presents a challenge to the treating physician who has
Partha Sarathi Chakraborty, Varun Singh Dhull, Sellam Karunanithi, Satyavrat Verma, Rakesh Kumar
196
Indian Journal of Nuclear Medicine | Vol. 29: Issue 3 | July-September, 2014
Letters to Editor
a
b
c
d
e
Figure 1: 18F FDG PET/CT revealing a cavitary lesion in left lung upper lobe with increased uptake of the radiotracer along its margins (a‑c; arrows). A PET/CT‑guided biopsy was performed from the lung mass along the margins where intense uptake was noted (d and e)
Department of Nuclear Medicine, All India Institute of Medical Sciences, New Delhi, India Address for correspondence: Dr. Rakesh Kumar, Department of Nuclear Medicine and Positron Emission Tomography (PET), All India Institute of Medical Sciences, New Delhi ‑ 110 029, India. E‑mail: [email protected]
5. 6.
7. 8.
REFERENCES 1. 2.
3. 4.
Rashid OM, Schaum JC, Wolfe LG, Brinster NK, Neifeld JP. Prognostic variables and surgical management of foot melanoma: Review of a 25‑year institutional experience. ISRN Dermatol 2011;2011:384729. Chua TC, Scolyer RA, Kennedy CW, Yan TD, McCaughan BC, Thompson JF. Surgical management of melanoma lung metastasis: An analysis of survival outcomes in 292 consecutive patients. Ann Surg Oncol 2012;19:1774‑81. Tas F. Metastatic behavior in melanoma: Timing, pattern, survival, and influencing factors. J Oncol 2012;2012:647684. Raissouni S, Ghizlane R, Mouzount H, Saoussane K, Khadija S, Zouaidia F, et al. Unusual case of cavitary lung metastasis from squamous cell carcinoma
of the uterine cervix. Pan Afr Med J 2013;14:37. Krug B, Crott R, Lonneux M, Baurain JF, Pirson AS, Vander Borght T. Role of PET in the initial staging of cutaneous malignant melanoma: Systematic review. Radiology 2008;249:836‑44. Xing Y, Bronstein Y, Ross MI, Askew RL, Lee JE, Gershenwald JE, et al. Contemporary diagnostic imaging modalities for the staging and surveillance of melanoma patients: A meta‑analysis. J Natl Cancer Inst 2011;103:129‑42. Werner MK, Aschoff P, Reimold M, Pfannenberg C. FDG‑PET/CT‑guided biopsy of bone metastases sets a new course in patient management after extensive imaging and multiple futile biopsies. Br J Radiol 2011;84:e65‑7. Klaeser B, Mueller MD, Schmid RA, Guevara C, Krause T, Wiskirchen J. PET‑CT‑guided interventions in the management of FDG‑positive lesions in patients suffering from solid malignancies: Initial experiences. Eur Radiol 2009;19:1780‑5. Access this article online Quick Response Code: Website: www.ijnm.in
DOI: 10.4103/0972-3919.136604
Extra‑renal malignant rhabdoid tumor of head and neck region: Characteristics of tracer uptake on FDG PET/CT in tumor with rare histology Sir, A 40‑year‑old female presented with complaints of diminished vision and deviation of eyes since 15 days, with a single episode of convulsion. CT scan of head and neck showed a large mass arising from the sphenoid sinus, eroding the skull base. Endoscopy
guided biopsy was done elsewhere which was suggestive of myoepithelial tumor. Since the extent of lesion made it inoperable, patient was referred to our Institution for whole body F‑18 Fluorodeoxyglucose Positron Emission Tomography/Computed Tomography (FDG PET/CT) study, for staging, prior to definitive
Indian Journal of Nuclear Medicine | Vol. 29: Issue 3 | July-September, 2014
197
Copyright of Indian Journal of Nuclear Medicine is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
4.
5. 6.
Valenta LJ, Treadwell T, Berry R, Elias AN. Idiopathic thrombocytopenic purpura and Graves disease. Am J Hematol 1982;12:69‑72. Kurata Y, Nishioeda Y, Tsubakio T, Kitani T. Thrombocytopenia in Graves’ disease: Effect of T3 on platelet kinetics. Acta Haematol 1980;63:185‑90. Cordiano I, Betterle C, Spadaccino CA, Soini B, Girolami A, Fabris F. Autoimmune thrombocytopenia (AITP) and thyroid autoimmune disease (TAD): Overlapping syndromes? Clin Exp Immunol 1998;113:373‑8. Cheung E, Liebman HA. Thyroid disease in patients with immune thrombocytopenia. Hematol Oncol Clin North Am 2009;23:1251‑60. Gill H, Hwang YY, Tse E. Primary immune thrombocytopenia responding to antithyroid treatment in a patient with Graves’ disease. Ann Hematol 2011;90:223‑4.
7. 8.
Hofbauer LC, Spitzweg C, Schmauss S, Heufelder AE. Graves disease associated with autoimmune thrombocytopenic purpura. Arch Intern Med 1997;157:1033‑6. Bartalena L, Bogazzi F, Martino E. Adverse effects of thyroid hormone preparations and antithyroid drugs. Drug Saf 1996;15:53‑63. Access this article online Quick Response Code: Website: www.ijnm.in
DOI: 10.4103/0972-3919.136602
Malignant melanoma with cavitary pulmonary metastasis: Diagnostic dilemma resolved by FDG PET/CT guided biopsy Sir, We present a case of a 70‑year‑old male patient who was operated 5 years back for a malignant melanoma of right big toe. He was again operated 3 years ago for the recurrence in his right thigh. Patient was in complete remission and on regular follow up since then. Patient was apparently normal till 3 months back when he presented with two episodes of hemoptysis. Chest X‑ray revealed a left lung upper lobe thick walled cavitary lesion. Computed tomography (CT) revealed the same findings along with hemorrhage in the surrounding area. From the above findings, it could not be ascertained whether the mass was infective or metastatic in nature. Therefore, a CT‑guided biopsy was done which revealed it to be infective in nature (resolving pneumonia). But even after 3 weeks of appropriate antibiotic coverage, the mass neither resolved nor decreased in size. Repeat CT‑guided biopsy revealed necrotic tissue but could not pinpoint the diagnosis. It was then that the patient was referred for the 18F FDG PET/CT, which revealed a cavitary lesion in left lung upper lobe with increased uptake of the radiotracer along its margins [Figure 1a‑c; arrows]. But the clinical query was still unanswered, so a PET/CT‑guided biopsy was undertaken. PET/CT‑guided biopsy from the lung mass [Figure 1d and e] revealed malignant melanoma cells which were positive for HMB‑45 and S‑100 and were negative for cytokeratin. So, PET/CT‑guided biopsy from the margins of the cavitary lesion showing increased uptake aided in the accurate diagnosis of pulmonary metastasis from malignant melanoma. To the best of our knowledge, this is the first case of malignant melanoma with isolated cavitary lung metastases.
to choose between adequate resection and preservation of limb function.[1] Melanomas which metastasize beyond its locoregional site generally predict a poor outcome with a mean survival of around 6 months only.[2] Patients with melanoma metastases to lung have a median survival of 1 year, while those to sites other than lung have a median survival of around 18 months.[3] Cavitary lung metastases are extremely rare and represent only 4% of cases of lung metastases and usually arise from squamous cell carcinoma (especially of the head and neck), adenocarcinomas, and sarcomas.[4] FDG PET is useful in the initial staging of patients with cutaneous malignant melanoma to help detect soft tissue, lymph node, and visceral metastases.[5] In a meta‑analysis comparing ultrasonography (USG), CT, and PET/CT for staging and surveillance of melanoma patients, USG was found superior for the detection of lymph node metastases while PET/CT was found superior for distant metastases.[6] The proper guideline‑based or targeted therapy for a patient can only be administered after proper histopathological diagnosis of the tumor site or site of metastases, which at times can be difficult due to prior chemotherapy or radiation therapy changes.[7] FDG PET/CT can visualize vital areas of the tumor with increased metabolic activity and can pin‑point the tissues from which biopsy can be taken. This increases its diagnostic value.[8] In this case, PET/CT‑guided biopsy helped to pin‑point the diagnosis of cavitary metastases to the lung which originated from the malignant melanoma of the right toe and hence helped in changing the treatment plan of the patient.
Foot melanoma comprises 3 to 5% of all melanoma cases and presents a challenge to the treating physician who has
Partha Sarathi Chakraborty, Varun Singh Dhull, Sellam Karunanithi, Satyavrat Verma, Rakesh Kumar
196
Indian Journal of Nuclear Medicine | Vol. 29: Issue 3 | July-September, 2014
Letters to Editor
a
b
c
d
e
Figure 1: 18F FDG PET/CT revealing a cavitary lesion in left lung upper lobe with increased uptake of the radiotracer along its margins (a‑c; arrows). A PET/CT‑guided biopsy was performed from the lung mass along the margins where intense uptake was noted (d and e)
Department of Nuclear Medicine, All India Institute of Medical Sciences, New Delhi, India Address for correspondence: Dr. Rakesh Kumar, Department of Nuclear Medicine and Positron Emission Tomography (PET), All India Institute of Medical Sciences, New Delhi ‑ 110 029, India. E‑mail: [email protected]
5. 6.
7. 8.
REFERENCES 1. 2.
3. 4.
Rashid OM, Schaum JC, Wolfe LG, Brinster NK, Neifeld JP. Prognostic variables and surgical management of foot melanoma: Review of a 25‑year institutional experience. ISRN Dermatol 2011;2011:384729. Chua TC, Scolyer RA, Kennedy CW, Yan TD, McCaughan BC, Thompson JF. Surgical management of melanoma lung metastasis: An analysis of survival outcomes in 292 consecutive patients. Ann Surg Oncol 2012;19:1774‑81. Tas F. Metastatic behavior in melanoma: Timing, pattern, survival, and influencing factors. J Oncol 2012;2012:647684. Raissouni S, Ghizlane R, Mouzount H, Saoussane K, Khadija S, Zouaidia F, et al. Unusual case of cavitary lung metastasis from squamous cell carcinoma
of the uterine cervix. Pan Afr Med J 2013;14:37. Krug B, Crott R, Lonneux M, Baurain JF, Pirson AS, Vander Borght T. Role of PET in the initial staging of cutaneous malignant melanoma: Systematic review. Radiology 2008;249:836‑44. Xing Y, Bronstein Y, Ross MI, Askew RL, Lee JE, Gershenwald JE, et al. Contemporary diagnostic imaging modalities for the staging and surveillance of melanoma patients: A meta‑analysis. J Natl Cancer Inst 2011;103:129‑42. Werner MK, Aschoff P, Reimold M, Pfannenberg C. FDG‑PET/CT‑guided biopsy of bone metastases sets a new course in patient management after extensive imaging and multiple futile biopsies. Br J Radiol 2011;84:e65‑7. Klaeser B, Mueller MD, Schmid RA, Guevara C, Krause T, Wiskirchen J. PET‑CT‑guided interventions in the management of FDG‑positive lesions in patients suffering from solid malignancies: Initial experiences. Eur Radiol 2009;19:1780‑5. Access this article online Quick Response Code: Website: www.ijnm.in
DOI: 10.4103/0972-3919.136604
Extra‑renal malignant rhabdoid tumor of head and neck region: Characteristics of tracer uptake on FDG PET/CT in tumor with rare histology Sir, A 40‑year‑old female presented with complaints of diminished vision and deviation of eyes since 15 days, with a single episode of convulsion. CT scan of head and neck showed a large mass arising from the sphenoid sinus, eroding the skull base. Endoscopy
guided biopsy was done elsewhere which was suggestive of myoepithelial tumor. Since the extent of lesion made it inoperable, patient was referred to our Institution for whole body F‑18 Fluorodeoxyglucose Positron Emission Tomography/Computed Tomography (FDG PET/CT) study, for staging, prior to definitive
Indian Journal of Nuclear Medicine | Vol. 29: Issue 3 | July-September, 2014
197
Copyright of Indian Journal of Nuclear Medicine is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
