INTERESTING IMAGE
Malignant Peritoneal Mesothelioma With Lower Extremity Metastasis PET/CT Imaging Bryan B. Le and Ba D. Nguyen, MD Abstract: Malignant peritoneal mesothelioma is usually confined to the abdomen and pelvis. Extra-abdominal and extrapelvic dissemination is very uncommon mostly at advanced stages of the disease. This rare clinical event may be related to contiguous spread through connecting pathways linking the abdomen and pelvis to the thorax and proximal lower extremity. The authors present a case of advanced malignant peritoneal mesothelioma with contiguous dissemination to the right thigh and proximal leg documented and monitored by 18F-FDG PET/ CT imaging. Key Words: malignant peritoneal mesothelioma, lower extremity, PET (Clin Nucl Med 2015;40: e68Ye70)
Received for publication September 16, 2013; revision accepted February 21, 2014. From the Department of Radiology, Mayo Clinic, Scottsdale, AZ. Conflicts of interest and sources of funding: none declared. Reprints: Ba D. Nguyen, MD, Department of Radiology, Mayo Clinic, 13400 E. Shea Blvd, Scottsdale, AZ 85259. E-mail: [email protected]. Copyright * 2014 by Lippincott Williams & Wilkins ISSN: 0363-9762/15/4001Ye68
e68
www.nuclearmed.com
REFERENCES 1. Bridda A, Frego M, Mencarelli R, et al. Peritoneal mesothelioma: a review. MedGenMed. 2007;9:32. 2. Munkholm-Larsen S, Cao CQ, Yan TD. Malignant peritoneal mesothelioma. World J Gastrointest Surg. 2009;1:38Y48. 3. Boffetta P. Epidemiology of peritoneal mesothelioma: a review. Ann Oncol. 2007;18:985Y990. 4. Park JY, Kim KW, Kwon HJ, et al. Peritoneal mesotheliomas: clinicopathologic features, CT findings, and differential diagnosis. AJR Am J Roentgenol. 2008;191:814Y825. 5. Souza FF, Jagganathan J, Ramayia N, et al. Recurrent malignant peritoneal mesothelioma: radiological manifestations. Abdom Imaging. 2010;35:315Y321. 6. Baratti D, Kusamura S, Cabras AD, et al. Lymph node metastases in diffuse malignant peritoneal mesothelioma. Ann Surg Oncol. 2010;17:45Y53. 7. Tan CH, Vikram R, Boonsirikamchai P, et al. Pathways of extrapelvic spread of pelvic disease: imaging findings. Radiographics. 2011;31:117Y133. 8. Yan TD, Deraco M, Elias D, et al. A novel tumor-node-metastasis (TNM) staging system of diffuse malignant peritoneal mesothelioma using outcome analysis of a multi-institutional database. Cancer. 2011;117:1855Y1863. 9. Hommell-Fontaine J, Isaac S, Passot G, et al. Malignant peritoneal mesothelioma treated by cytoreductive surgery and hyperthermic intraperitoneal chemotherapy: is GLUT1 expression a major prognostic factor? A preliminary study. Ann Surg Oncol. 2013;20:3892Y3898. 10. Cao Q, Lu M, Heath J, et al. 18F-FDG PET/CT in a recurrent diffuse malignant peritoneal mesothelioma. Clin Nucl Med. 2012;37:492Y494. 11. Eade TN, Fulham MJ, Constable CJ. Primary malignant peritoneal mesothelioma: appearance on F-18 FDG positron emission tomographic images. Clin Nucl Med. 2002;27:924Y925. 12. Yamaguchi S, Asao T, Tsutsumi S, et al. Effectiveness of intraperitoneal hyperthermo-chemotherapy for malignant peritoneal mesothelioma and estimation of its effect by repeated FDG-PET: a case report. Hepatogastroenterology. 2011;58:861Y864. 13. Mirarabshahii P, Pillai K, Chua TC, et al. Diffuse malignant peritoneal mesotheliomaVan update on treatment. Cancer Treat Rev. 2012;38:605Y612.
Clinical Nuclear Medicine
& Volume 40, Number 1, January 2015
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Clinical Nuclear Medicine
& Volume 40, Number 1, January 2015
MPM With Lower Extremity Metastasis
FIGURE 1. The 71-year-old woman presented with a sudden onset of right thigh swelling. An outside medical evaluation with CT imaging raised the possibility of pelvic malignancy. Subsequently, she consulted our institution for worsening symptoms with nausea, vomiting, and diarrhea. Her past clinical history was remarkable for treated breast cancer and hepatocellular carcinoma, and lack of exposure to asbestos. A repeat CT scan showed an edematous and infiltrative process involving the musculature and soft tissues of the right abdomen, pelvis, and proximal right thigh. In addition, CT found a possible 9-cm fibroid at the uterine fundus. Exploratory laparotomy confirmed the uterine fibroid and detected widespread mesothelioma of epithelial type involving the mesentery of the terminal ileum, omentum, right colic gutter, and right anterior abdominal wall. Composite PET/CT and maximum intensity projection images showed abnormal uptake (SUV, 4.7Y7.4) of the biopsy-proven mesothelioma with sheetlike features along the right lower anterior abdominal wall, subhepatic space, omentum, lower anterior abdominal wall musculature, anterior pelvic wall musculature, perineum, right labia, right thigh, and right medial upper calf superficial tissues.
* 2014 Lippincott Williams & Wilkins
www.nuclearmed.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
e69
Clinical Nuclear Medicine
Le and Nguyen
& Volume 40, Number 1, January 2015
FIGURE 2. Posttherapeutic PET/CT whole-body maximum intensity projection images (A, before therapy; B, after therapy), after 4 cycles of carboplatin and pemetrexed, showed partial improvement with decreased tracer uptake of the diffuse lesions of the abdomen, pelvis, and right lower extremity. Malignant peritoneal mesothelioma (MPM) is second to pleural mesothelioma in occurrence rate and accounts for up 15% to 30% of all cases.1,2 The risk factors of MPM include exposure to asbestos, thorotrast, erionite, therapeutic radiation, familial Mediterranean fever, and other causes of chronic peritonitis.2,3 Its recorded incidences are 0.5 to 3 cases per million among the male population and 0.2 to 2 cases per million among women.3 Malignant peritoneal mesothelioma has essentially 3 histological types in decreasing order of frequency; these are as follows: epithelioid, sarcomatoid, and mixed or biphasic.1,2 Imaging features consist of focal or confluent peritoneal nodules or infiltrative masses with potential encasement of the mesenteric vasculature, mass effect on the abdominopelvic organs, and presence of ascites.4,5 At advanced stages, MPM may mimic carcinomatosis from other types of abdominal and pelvic malignancies. The imaging demonstration of nodal metastasis and extra-abdominopelvic dissemination signals a poor prognosis and outcome of MPM.2,6 Cutaneous and muscles involvement of lower extremity has not been reported. The MPM spread to the thigh and leg could be from contiguous metastasis through pathways of communication between the pelvis and proximal thigh.7 Efforts to stage MPM with TNM classification and glucose transporter GLUT-1 expression have been attempted to provide clinicians with an appropriate patient selection for cytoreductive surgery and hyperthermic intraperitoneal chemotherapy.8,9 Because PET/CT relies on tumor expression of GLUT and is able to provide a comprehensive whole-body functional evaluation, it is a valuable imaging tool for MPM staging and posttherapeutic monitoring.10Y12 Our patient, a nonsurgical candidate due to widespread MPM, showed on PET/CT partial lesion improvement with carboplatin and pemetrexed therapy.13
e70
www.nuclearmed.com
* 2014 Lippincott Williams & Wilkins
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Malignant Peritoneal Mesothelioma With Lower Extremity Metastasis PET/CT Imaging Bryan B. Le and Ba D. Nguyen, MD Abstract: Malignant peritoneal mesothelioma is usually confined to the abdomen and pelvis. Extra-abdominal and extrapelvic dissemination is very uncommon mostly at advanced stages of the disease. This rare clinical event may be related to contiguous spread through connecting pathways linking the abdomen and pelvis to the thorax and proximal lower extremity. The authors present a case of advanced malignant peritoneal mesothelioma with contiguous dissemination to the right thigh and proximal leg documented and monitored by 18F-FDG PET/ CT imaging. Key Words: malignant peritoneal mesothelioma, lower extremity, PET (Clin Nucl Med 2015;40: e68Ye70)
Received for publication September 16, 2013; revision accepted February 21, 2014. From the Department of Radiology, Mayo Clinic, Scottsdale, AZ. Conflicts of interest and sources of funding: none declared. Reprints: Ba D. Nguyen, MD, Department of Radiology, Mayo Clinic, 13400 E. Shea Blvd, Scottsdale, AZ 85259. E-mail: [email protected]. Copyright * 2014 by Lippincott Williams & Wilkins ISSN: 0363-9762/15/4001Ye68
e68
www.nuclearmed.com
REFERENCES 1. Bridda A, Frego M, Mencarelli R, et al. Peritoneal mesothelioma: a review. MedGenMed. 2007;9:32. 2. Munkholm-Larsen S, Cao CQ, Yan TD. Malignant peritoneal mesothelioma. World J Gastrointest Surg. 2009;1:38Y48. 3. Boffetta P. Epidemiology of peritoneal mesothelioma: a review. Ann Oncol. 2007;18:985Y990. 4. Park JY, Kim KW, Kwon HJ, et al. Peritoneal mesotheliomas: clinicopathologic features, CT findings, and differential diagnosis. AJR Am J Roentgenol. 2008;191:814Y825. 5. Souza FF, Jagganathan J, Ramayia N, et al. Recurrent malignant peritoneal mesothelioma: radiological manifestations. Abdom Imaging. 2010;35:315Y321. 6. Baratti D, Kusamura S, Cabras AD, et al. Lymph node metastases in diffuse malignant peritoneal mesothelioma. Ann Surg Oncol. 2010;17:45Y53. 7. Tan CH, Vikram R, Boonsirikamchai P, et al. Pathways of extrapelvic spread of pelvic disease: imaging findings. Radiographics. 2011;31:117Y133. 8. Yan TD, Deraco M, Elias D, et al. A novel tumor-node-metastasis (TNM) staging system of diffuse malignant peritoneal mesothelioma using outcome analysis of a multi-institutional database. Cancer. 2011;117:1855Y1863. 9. Hommell-Fontaine J, Isaac S, Passot G, et al. Malignant peritoneal mesothelioma treated by cytoreductive surgery and hyperthermic intraperitoneal chemotherapy: is GLUT1 expression a major prognostic factor? A preliminary study. Ann Surg Oncol. 2013;20:3892Y3898. 10. Cao Q, Lu M, Heath J, et al. 18F-FDG PET/CT in a recurrent diffuse malignant peritoneal mesothelioma. Clin Nucl Med. 2012;37:492Y494. 11. Eade TN, Fulham MJ, Constable CJ. Primary malignant peritoneal mesothelioma: appearance on F-18 FDG positron emission tomographic images. Clin Nucl Med. 2002;27:924Y925. 12. Yamaguchi S, Asao T, Tsutsumi S, et al. Effectiveness of intraperitoneal hyperthermo-chemotherapy for malignant peritoneal mesothelioma and estimation of its effect by repeated FDG-PET: a case report. Hepatogastroenterology. 2011;58:861Y864. 13. Mirarabshahii P, Pillai K, Chua TC, et al. Diffuse malignant peritoneal mesotheliomaVan update on treatment. Cancer Treat Rev. 2012;38:605Y612.
Clinical Nuclear Medicine
& Volume 40, Number 1, January 2015
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Clinical Nuclear Medicine
& Volume 40, Number 1, January 2015
MPM With Lower Extremity Metastasis
FIGURE 1. The 71-year-old woman presented with a sudden onset of right thigh swelling. An outside medical evaluation with CT imaging raised the possibility of pelvic malignancy. Subsequently, she consulted our institution for worsening symptoms with nausea, vomiting, and diarrhea. Her past clinical history was remarkable for treated breast cancer and hepatocellular carcinoma, and lack of exposure to asbestos. A repeat CT scan showed an edematous and infiltrative process involving the musculature and soft tissues of the right abdomen, pelvis, and proximal right thigh. In addition, CT found a possible 9-cm fibroid at the uterine fundus. Exploratory laparotomy confirmed the uterine fibroid and detected widespread mesothelioma of epithelial type involving the mesentery of the terminal ileum, omentum, right colic gutter, and right anterior abdominal wall. Composite PET/CT and maximum intensity projection images showed abnormal uptake (SUV, 4.7Y7.4) of the biopsy-proven mesothelioma with sheetlike features along the right lower anterior abdominal wall, subhepatic space, omentum, lower anterior abdominal wall musculature, anterior pelvic wall musculature, perineum, right labia, right thigh, and right medial upper calf superficial tissues.
* 2014 Lippincott Williams & Wilkins
www.nuclearmed.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
e69
Clinical Nuclear Medicine
Le and Nguyen
& Volume 40, Number 1, January 2015
FIGURE 2. Posttherapeutic PET/CT whole-body maximum intensity projection images (A, before therapy; B, after therapy), after 4 cycles of carboplatin and pemetrexed, showed partial improvement with decreased tracer uptake of the diffuse lesions of the abdomen, pelvis, and right lower extremity. Malignant peritoneal mesothelioma (MPM) is second to pleural mesothelioma in occurrence rate and accounts for up 15% to 30% of all cases.1,2 The risk factors of MPM include exposure to asbestos, thorotrast, erionite, therapeutic radiation, familial Mediterranean fever, and other causes of chronic peritonitis.2,3 Its recorded incidences are 0.5 to 3 cases per million among the male population and 0.2 to 2 cases per million among women.3 Malignant peritoneal mesothelioma has essentially 3 histological types in decreasing order of frequency; these are as follows: epithelioid, sarcomatoid, and mixed or biphasic.1,2 Imaging features consist of focal or confluent peritoneal nodules or infiltrative masses with potential encasement of the mesenteric vasculature, mass effect on the abdominopelvic organs, and presence of ascites.4,5 At advanced stages, MPM may mimic carcinomatosis from other types of abdominal and pelvic malignancies. The imaging demonstration of nodal metastasis and extra-abdominopelvic dissemination signals a poor prognosis and outcome of MPM.2,6 Cutaneous and muscles involvement of lower extremity has not been reported. The MPM spread to the thigh and leg could be from contiguous metastasis through pathways of communication between the pelvis and proximal thigh.7 Efforts to stage MPM with TNM classification and glucose transporter GLUT-1 expression have been attempted to provide clinicians with an appropriate patient selection for cytoreductive surgery and hyperthermic intraperitoneal chemotherapy.8,9 Because PET/CT relies on tumor expression of GLUT and is able to provide a comprehensive whole-body functional evaluation, it is a valuable imaging tool for MPM staging and posttherapeutic monitoring.10Y12 Our patient, a nonsurgical candidate due to widespread MPM, showed on PET/CT partial lesion improvement with carboplatin and pemetrexed therapy.13
e70
www.nuclearmed.com
* 2014 Lippincott Williams & Wilkins
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
