G Model REMNIM-752; No. of Pages 3
ARTICLE IN PRESS Rev Esp Med Nucl Imagen Mol. 2015;xxx(xx):xxx–xxx
Clinical note 18
F-FDG PET/CT versus bone scintigraphy in the follow-up of gastric cancer M. Sollini a,∗ , L. Calabrese a , B. Zangheri a , P.A. Erba b , A. Gramaglia c , M. Gasparini a a
Nuclear Medicine Unit, IRCCS MultiMedica, Via Milanese 300, 20099 Sesto San Giovanni (MI), Italy Regional Center of Nuclear Medicine, University of Pisa, Via Savi 10, 56125 Pisa, Italy c Radiation Oncology Unit, Policlinico di Monza, Via Amati 111, 20900 Monza, Italy b
a r t i c l e
i n f o
Article history: Received 9 July 2015 Accepted 19 October 2015 Available online xxx Keywords: Gastric cancer 2-Deoxy-2-(18 F)fluoro-d-glucose positron emission tomography/computed tomography Bone scintigraphy
a b s t r a c t A 53-year-old patient underwent a positron emission tomography/computed tomography with 2-fluoro2-deoxy-d-glucose (18 F-FDG PET/CT) in the suspicious of gastric tumor recurrence (mediastinal and abdominal lymph nodes). PET/CT identified only an area of 18 F-FDGuptake in the twelfth thoracic vertebrae. Unexpectedly, a bone scintigraphy revealed many “hot” spots changing the diagnosis (single metastasis versus plurimetastatic disease) and impacting on patient’s management. © 2015 Elsevier España, S.L.U. and SEMNIM. All rights reserved.
18
F-FDG PET/TC en comparación con la gammagrafía ósea en el seguimento del cancer gástrico r e s u m e n Palabras clave: Cáncer de estómago Tomografía por emisión de positrones-tomografía computarizada con 18 F-2-fluoro-2 deoxi-d-glucosa Gammagrafía ósea
˜ Un paciente de 53 anos fue sometido a una tomografía por emisión de positrones-tomografía computarizada con 18 F-2-fluoro-2 deoxi-d-glucosa (18 F-FDG PET/TC) ante la sospecha de recidiva de cáncer de estómago (nódulos linfáticos en mediastino y abdomen). El PET/TC identificó únicamente una zona de captación de 18 F-FDG en la duodécima vértebra torácica. Sorpresivamente, la gammagrafía ósea reveló muchas imágenes hipercaptantes que modificaron el diagnóstico (metástasis única en lugar de metástasis múltiples) con el consiguiente impacto en el tratamiento del paciente. © 2015 Elsevier España, S.L.U. y SEMNIM. Todos los derechos reservados.
Introduction Gastric cancer is the sixth commonest cancer diagnosed and the fourth commonest cause of cancer-related death (107,000 deaths, 6.1%).1 Imaging plays a crucial role to stage patients and to ensure an appropriate patients selection for treatment interventions, whereas its role during the follow-up period remains controversial.2 Bone metastasis rarely occurs in gastric cancer (incidence of 1–20%) and have bad prognosis.1,3 Bone scintigraphy is the commonest nuclear medicine technique used in oncology to identify bone metastases, although growing evidences on the usefulness of positron emission tomography/computed tomography with 2fluoro-2-deoxy-d-glucose (18 F-FDG PET/CT) have been reported in literature. Recent studies compared the diagnostic performances of 18 F-FDG PET/CT to bone scan in gastric cancer reporting
∗ Corresponding author. E-mail addresses: [email protected], [email protected] (M. Sollini).
discordant results. According to Ma et al.3 18 F-FDG PET/CT and bone scan have similar effectiveness for the detection of metachronous bone metastases. Ahn et al.4 reported that bone scintigraphy is more useful compared to 18 F-FDG PET/CT in both the initial stage and in the post-surgical setting.
Clinical case In March 2012 a 51-year-old man underwent partial gastrectomy followed by triplet chemotherapy (epirubicin, oxaliplatin and capecitabine) for a gastric cancer (pT3N2). Radiological followup was negative until October 2014 when an enhanced-CT scan resulted suspected for tumor recurrence (increase in mediastinal and abdominal lymph nodes size), thus a 18 F-FDG PET/CT was required to re-stage disease. PET/CT showed no tracer uptake in lymph nodes but revealed an area of 18 F-FDG uptake (SUVmax = 4.2) in the twelfth thoracic vertebrae (Fig. 1a) as confirmed by axial lowdose CT and fused PET/CT images (Fig. 1b and Fig. 1c). This finding was considered suggestive for bone metastasis. The patient was completely asymptomatic, laboratory exams were normal, and all
http://dx.doi.org/10.1016/j.remn.2015.10.002 2253-654X/© 2015 Elsevier España, S.L.U. and SEMNIM. All rights reserved.
Please cite this article in press as: Sollini M, et al. 18 F-FDG PET/CT versus bone scintigraphy in the follow-up of gastric cancer. Rev Esp Med Nucl Imagen Mol. 2015. http://dx.doi.org/10.1016/j.remn.2015.10.002
G Model REMNIM-752; No. of Pages 3 2
ARTICLE IN PRESS M. Sollini et al. / Rev Esp Med Nucl Imagen Mol. 2015;xxx(xx):xxx–xxx
Fig. 1. MIP image (a) shows an area of 18 F-FDG uptake in the twelfth thoracic vertebra (arrow). Axial low CT (top) and fused PET/CT (bottom) images using abdominal- (b) and bone-window (c) confirm the focal 18 F-FDG uptake in the right part of the vertebral body associated to a bone alteration visible on the CT component of the images.
Fig. 2. Low- (a) and high-intensity (b) bone scintigraphy. Images show many areas of radiopharmaceutical uptake involving mainly the skull, both the clavicles, the right scapula, the sternum, the ribs, the spine, and the pelvis.
Please cite this article in press as: Sollini M, et al. 18 F-FDG PET/CT versus bone scintigraphy in the follow-up of gastric cancer. Rev Esp Med Nucl Imagen Mol. 2015. http://dx.doi.org/10.1016/j.remn.2015.10.002
G Model REMNIM-752; No. of Pages 3
ARTICLE IN PRESS M. Sollini et al. / Rev Esp Med Nucl Imagen Mol. 2015;xxx(xx):xxx–xxx
tumor markers (including PSA and CEA) were negative. Oncologist required a bone scan to confirm or exclude PET/CT finding. Bone scintigraphy, performed 3 weeks later, revealed many “hot” spots in addition to PET/CT finding, as shown by Fig. 2. Magnetic resonance imaging of the spine (not shown) confirmed the presence of bone metastases (which appeared as low-signal and high-signal intensity lesions using T1-weighted and STIR sequences, respectively) excluding spinal cord compression. Based on these findings he started a second-line chemotherapy. The appearance of bone pain required external beam radiotherapy with palliative intent on right iliac bone (total dose of 30 Gy). Nonetheless disease was rapidly progressive and patient died in March 2015. Discussion The primary interest of this case is the mismatch between PET/CT and bone scintigraphy. In fact, the therapeutic management of cancer patients may be completely different in case of a single metastases/oligometastatic disease (i.e. local treatment such as stereotactic body radiotherapy) or in presence of diffuse metastastic disease (i.e. systemic therapy).5 Therefore, although 18 F-FDG PET/CT has already been demonstrated complementary to CT in the follow-up of gastric cancer,6 our findings suggest 18 F-FDG
3
that also bone scan should be performed since it may drastically impact patients’ management (oligometastatic versus plurimetastic disease). Conflict of interest The authors declare no conflict of interest. References 1. Ferlay J, Steliarova-Foucher E, Lortet-Tieulent J, Rosso S, Coebergh JW, Comber H, et al. Cancer incidence and mortality patterns in Europe: estimates for 40 countries in 2012. Eur J Cancer. 2013;49:1374–403. 2. Waddell T, Verheij M, Allum W, Cunningham D, Cervantes A, Arnold D. European Society for Medical Oncology (ESMO); European Society of Surgical Oncology (ESSO); European Society of Radiotherapy and Oncology (ESTRO) Gastric cancer: ESMO-ESSO-ESTRO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol. 2013;24:vi57–63. 3. Ma DW, Kim JH, Jeon TJ, Lee YC, Yun M, Youn YH, et al. 18 F-fluorodeoxyglucose positron emission tomography-computed tomography for the evaluation of bone metastasis in patients with gastric cancer. Dig Liver Dis. 2013;45:769–75. 4. Ahn JB, Ha TK, Kwon SJ. Bone metastasis in gastric cancer patients. J Gastric Cancer. 2011;11:38–45. 5. Reyes DK, Pienta KJ. The biology and treatment of oligometastatic cancer. Oncotarget. 2015;6:8491–524. 6. Ozkan E, Araz M, Soydal C, Kucuk ON. The role of 18 F-FDG-PET/CT in the preoperative staging and posttherapy follow up of gastric cancer: comparison with spiral CT. World J Surg Oncol. 2011;9:75.
Please cite this article in press as: Sollini M, et al. 18 F-FDG PET/CT versus bone scintigraphy in the follow-up of gastric cancer. Rev Esp Med Nucl Imagen Mol. 2015. http://dx.doi.org/10.1016/j.remn.2015.10.002
ARTICLE IN PRESS Rev Esp Med Nucl Imagen Mol. 2015;xxx(xx):xxx–xxx
Clinical note 18
F-FDG PET/CT versus bone scintigraphy in the follow-up of gastric cancer M. Sollini a,∗ , L. Calabrese a , B. Zangheri a , P.A. Erba b , A. Gramaglia c , M. Gasparini a a
Nuclear Medicine Unit, IRCCS MultiMedica, Via Milanese 300, 20099 Sesto San Giovanni (MI), Italy Regional Center of Nuclear Medicine, University of Pisa, Via Savi 10, 56125 Pisa, Italy c Radiation Oncology Unit, Policlinico di Monza, Via Amati 111, 20900 Monza, Italy b
a r t i c l e
i n f o
Article history: Received 9 July 2015 Accepted 19 October 2015 Available online xxx Keywords: Gastric cancer 2-Deoxy-2-(18 F)fluoro-d-glucose positron emission tomography/computed tomography Bone scintigraphy
a b s t r a c t A 53-year-old patient underwent a positron emission tomography/computed tomography with 2-fluoro2-deoxy-d-glucose (18 F-FDG PET/CT) in the suspicious of gastric tumor recurrence (mediastinal and abdominal lymph nodes). PET/CT identified only an area of 18 F-FDGuptake in the twelfth thoracic vertebrae. Unexpectedly, a bone scintigraphy revealed many “hot” spots changing the diagnosis (single metastasis versus plurimetastatic disease) and impacting on patient’s management. © 2015 Elsevier España, S.L.U. and SEMNIM. All rights reserved.
18
F-FDG PET/TC en comparación con la gammagrafía ósea en el seguimento del cancer gástrico r e s u m e n Palabras clave: Cáncer de estómago Tomografía por emisión de positrones-tomografía computarizada con 18 F-2-fluoro-2 deoxi-d-glucosa Gammagrafía ósea
˜ Un paciente de 53 anos fue sometido a una tomografía por emisión de positrones-tomografía computarizada con 18 F-2-fluoro-2 deoxi-d-glucosa (18 F-FDG PET/TC) ante la sospecha de recidiva de cáncer de estómago (nódulos linfáticos en mediastino y abdomen). El PET/TC identificó únicamente una zona de captación de 18 F-FDG en la duodécima vértebra torácica. Sorpresivamente, la gammagrafía ósea reveló muchas imágenes hipercaptantes que modificaron el diagnóstico (metástasis única en lugar de metástasis múltiples) con el consiguiente impacto en el tratamiento del paciente. © 2015 Elsevier España, S.L.U. y SEMNIM. Todos los derechos reservados.
Introduction Gastric cancer is the sixth commonest cancer diagnosed and the fourth commonest cause of cancer-related death (107,000 deaths, 6.1%).1 Imaging plays a crucial role to stage patients and to ensure an appropriate patients selection for treatment interventions, whereas its role during the follow-up period remains controversial.2 Bone metastasis rarely occurs in gastric cancer (incidence of 1–20%) and have bad prognosis.1,3 Bone scintigraphy is the commonest nuclear medicine technique used in oncology to identify bone metastases, although growing evidences on the usefulness of positron emission tomography/computed tomography with 2fluoro-2-deoxy-d-glucose (18 F-FDG PET/CT) have been reported in literature. Recent studies compared the diagnostic performances of 18 F-FDG PET/CT to bone scan in gastric cancer reporting
∗ Corresponding author. E-mail addresses: [email protected], [email protected] (M. Sollini).
discordant results. According to Ma et al.3 18 F-FDG PET/CT and bone scan have similar effectiveness for the detection of metachronous bone metastases. Ahn et al.4 reported that bone scintigraphy is more useful compared to 18 F-FDG PET/CT in both the initial stage and in the post-surgical setting.
Clinical case In March 2012 a 51-year-old man underwent partial gastrectomy followed by triplet chemotherapy (epirubicin, oxaliplatin and capecitabine) for a gastric cancer (pT3N2). Radiological followup was negative until October 2014 when an enhanced-CT scan resulted suspected for tumor recurrence (increase in mediastinal and abdominal lymph nodes size), thus a 18 F-FDG PET/CT was required to re-stage disease. PET/CT showed no tracer uptake in lymph nodes but revealed an area of 18 F-FDG uptake (SUVmax = 4.2) in the twelfth thoracic vertebrae (Fig. 1a) as confirmed by axial lowdose CT and fused PET/CT images (Fig. 1b and Fig. 1c). This finding was considered suggestive for bone metastasis. The patient was completely asymptomatic, laboratory exams were normal, and all
http://dx.doi.org/10.1016/j.remn.2015.10.002 2253-654X/© 2015 Elsevier España, S.L.U. and SEMNIM. All rights reserved.
Please cite this article in press as: Sollini M, et al. 18 F-FDG PET/CT versus bone scintigraphy in the follow-up of gastric cancer. Rev Esp Med Nucl Imagen Mol. 2015. http://dx.doi.org/10.1016/j.remn.2015.10.002
G Model REMNIM-752; No. of Pages 3 2
ARTICLE IN PRESS M. Sollini et al. / Rev Esp Med Nucl Imagen Mol. 2015;xxx(xx):xxx–xxx
Fig. 1. MIP image (a) shows an area of 18 F-FDG uptake in the twelfth thoracic vertebra (arrow). Axial low CT (top) and fused PET/CT (bottom) images using abdominal- (b) and bone-window (c) confirm the focal 18 F-FDG uptake in the right part of the vertebral body associated to a bone alteration visible on the CT component of the images.
Fig. 2. Low- (a) and high-intensity (b) bone scintigraphy. Images show many areas of radiopharmaceutical uptake involving mainly the skull, both the clavicles, the right scapula, the sternum, the ribs, the spine, and the pelvis.
Please cite this article in press as: Sollini M, et al. 18 F-FDG PET/CT versus bone scintigraphy in the follow-up of gastric cancer. Rev Esp Med Nucl Imagen Mol. 2015. http://dx.doi.org/10.1016/j.remn.2015.10.002
G Model REMNIM-752; No. of Pages 3
ARTICLE IN PRESS M. Sollini et al. / Rev Esp Med Nucl Imagen Mol. 2015;xxx(xx):xxx–xxx
tumor markers (including PSA and CEA) were negative. Oncologist required a bone scan to confirm or exclude PET/CT finding. Bone scintigraphy, performed 3 weeks later, revealed many “hot” spots in addition to PET/CT finding, as shown by Fig. 2. Magnetic resonance imaging of the spine (not shown) confirmed the presence of bone metastases (which appeared as low-signal and high-signal intensity lesions using T1-weighted and STIR sequences, respectively) excluding spinal cord compression. Based on these findings he started a second-line chemotherapy. The appearance of bone pain required external beam radiotherapy with palliative intent on right iliac bone (total dose of 30 Gy). Nonetheless disease was rapidly progressive and patient died in March 2015. Discussion The primary interest of this case is the mismatch between PET/CT and bone scintigraphy. In fact, the therapeutic management of cancer patients may be completely different in case of a single metastases/oligometastatic disease (i.e. local treatment such as stereotactic body radiotherapy) or in presence of diffuse metastastic disease (i.e. systemic therapy).5 Therefore, although 18 F-FDG PET/CT has already been demonstrated complementary to CT in the follow-up of gastric cancer,6 our findings suggest 18 F-FDG
3
that also bone scan should be performed since it may drastically impact patients’ management (oligometastatic versus plurimetastic disease). Conflict of interest The authors declare no conflict of interest. References 1. Ferlay J, Steliarova-Foucher E, Lortet-Tieulent J, Rosso S, Coebergh JW, Comber H, et al. Cancer incidence and mortality patterns in Europe: estimates for 40 countries in 2012. Eur J Cancer. 2013;49:1374–403. 2. Waddell T, Verheij M, Allum W, Cunningham D, Cervantes A, Arnold D. European Society for Medical Oncology (ESMO); European Society of Surgical Oncology (ESSO); European Society of Radiotherapy and Oncology (ESTRO) Gastric cancer: ESMO-ESSO-ESTRO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol. 2013;24:vi57–63. 3. Ma DW, Kim JH, Jeon TJ, Lee YC, Yun M, Youn YH, et al. 18 F-fluorodeoxyglucose positron emission tomography-computed tomography for the evaluation of bone metastasis in patients with gastric cancer. Dig Liver Dis. 2013;45:769–75. 4. Ahn JB, Ha TK, Kwon SJ. Bone metastasis in gastric cancer patients. J Gastric Cancer. 2011;11:38–45. 5. Reyes DK, Pienta KJ. The biology and treatment of oligometastatic cancer. Oncotarget. 2015;6:8491–524. 6. Ozkan E, Araz M, Soydal C, Kucuk ON. The role of 18 F-FDG-PET/CT in the preoperative staging and posttherapy follow up of gastric cancer: comparison with spiral CT. World J Surg Oncol. 2011;9:75.
Please cite this article in press as: Sollini M, et al. 18 F-FDG PET/CT versus bone scintigraphy in the follow-up of gastric cancer. Rev Esp Med Nucl Imagen Mol. 2015. http://dx.doi.org/10.1016/j.remn.2015.10.002
