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Revista Española de Enfermedades Digestivas

Print version ISSN 1130-0108

Rev. esp. enferm. dig. vol.106 n.1 Madrid Jan. 2014

http://dx.doi.org/10.4321/S1130-01082014000100016 

LETTERS TO THE EDITOR

 

Use of an oral effervescent agent in the diagnostic of gastric carcinoma with 18F-FDG PET/CT

Empleo de un agente oral efervescente en el diagnóstico del cáncer gástrico mediante PET-TAC con 18F-FDG

 


Palabras clave: Cáncer gástrico. PET-TAC. Gastroscopia virtual.

Key words: Gastric carcinoma. PET/CT. Virtual gastroscopy.


 

Dear Editor,

A 76-year-old man with a history of lung cancer IV E (T4N0M0) and pulmonary lobectomy (left lung upper lobe) performed 4 years ago was treated with four chemotherapy cycles of cisplatine-vinorelbine (CDDP-VNR) and radiotherapy. Thenceforth in complete remission.

PET/CT study was required for suspected space-occupying lesion (SOL) in liver region after the last control with CT, where recurrence at lung and six hepatic hypodense SOL, suspicious of metastasis, were reported. When the patient arrived to our department he was being treated with antihypertensive, dyslipidemic, NSAIDs and proton pump inhibitors, presenting evidence of mucocutaneous jaundice, generalized weakness, dyspepsia, weight loss and microcytic anemia (MCV 75.1 fl and MCHC 30.9 g/dL).

PET/CT study with fluorine-18-fluorodeoxyglucose (18F-FDG) (Philips Gemini TF16) showed a suprahilar left mass (diagnosed as recurrence in the last CT scan) with high glucose uptake, standard uptake value (SUVmax) of 13.6, an elevated gastric glucose metabolism (SUVmax 8.6) in a collapsed stomach and a hypermetabolic reservoir in sigma (SUVmax 12.9) without demonstrating alterations in liver tracer binding. We decided to make a late acquisition of abdomino-pelvic region to accurate the limits of gastric lesion (Fig. 1) at 180 minutes postinjection using fruit salt to distend the stomach (1-3), showing an excrescent mass uptake in its lesser curvature, increasing SUVmax values by 18 % over the initial, suggesting malignancy and increasing the suspected diagnosis to gastric carcinoma (GC). Through image processing, virtual gastroscopy was performed (9) which showed a second aspect polypoid tumor of 5 mm (Fig. 2) in the pyloric antrum, undetected in the multiplanar images.

 

 

 

The sigma deposit also rose by 42 % in SUVmax which was also oriented to malignancy.

Both gastric lesions were biopsied by endoscopic guidance, demonstrating the histopathological examination of the polypoid lesion a tubular adenoma with high-grade dysplasia without invasion of the epithelium. The mass of the lesser curvature was diagnosed as initial intestinal type adenocarcinoma. It was not identified the presence of Helicobacter pylori (HP) in the samples. Biopsy of colon (sigma) by colonoscopy proved to be a moderately differentiated adenocarcinoma infiltrating and ulcerated.

 

Discussion

The concomitance of three synchronous primary tumors in the lung, stomach and colon is a rare find and it also difficult the therapeutic management of the patient.

The uptake of 18F-FDG at gastric carcinoma is not unique, having to make a differential diagnosis with benign entities such as gastritis (with or without HP), or malignant entities such as ring cell carcinoma, diffuse B-cell lymphoma, MALT lymphoma, mediastinal B-cell lymphoma, gastrointestinal stromal tumors or gastric metastases (4-8).

The oral administration of an effervescent agent allows more accurate assessment of the gastric wall by reducing false positives of gastric collapse and better delineation of the extent of lesions. Furthermore, the possibility of virtual gastroscopy by software (9,10) gives a value-added to this technique.

 

Raúl Sánchez-Jurado, José Ferrer-Rebolleda, M.a del Puig Cózar-Santiago,
José Enrique Aguilar-Barrios, Manuel Devis-Saiz and Rut Sanz-Llorens

ERESA-Nuclear Medicine Department. Consorcio Hospital General Universitario de Valencia.
Valencia, Spain

 

References

1. Ma Q, Xin J, Zhao Z, Guo Q, Yu S, Xu W,et al. Value of 18F-FDG PET/CT in the diagnosis of primary gastric cancer via stomach distension. Eur J Radiol (in press) doi: 10.1016/j.ejrad.2013.01.021.         [ Links ]

2. Yun M, Choi HS, Yoo E, Bong JK, Ryu YH, Lee JD. The role of gastric distention in differentiating recurrent tumor from physiologic uptake in the remnant stomach on 18F-FDG PET. J Nucl Med 2005;46:953-7.         [ Links ]

3. Yamada T, Inoue Y, Asano Y, Nippashi Y, Woodhams R, Matsunaga K, et al. Use of an oral effervescent agent in the evaluation of gastric 67Ga uptake. Ann Nucl Med 2012;26:192-6.         [ Links ]

4. Fu L, Li H, Wang H, Xu B, Fan Y, Tian J. SUVmax/THKmax as a biomarker for distinguishing advanced gastric carcinoma from primary gastric lymphoma. PLos One 2012;7:e50914.         [ Links ]

5. Valls-Ferrusola E, García-Garzón JR, Ponce-López A, Soler-Peter M, Fuertes-Cabero S, Moragas-Solanes M, et al. Patterns of extension of gastrointestinal stromal tumors (GIST) treated with imatinib (Gleevec)Ò by 18F-FDG PET/CT. Rev Esp Enferm Dig 2012;104:360-6.         [ Links ]

6. Lim JS, Yun MJ, Hyung WJ, Park MS, Choi JY, Lee JD, et al. CT and PET in stomach cancer: Preoperative staging and monitoring of response to therapy. Radiographics 2006;26:143-56.         [ Links ]

7. Makis W, Ciarallo A, Hickeson M, Lisbona R. Gastric recurrence of a primary colon plasmacytoma: Staging and evaluating response to therapy with 18F-FDG PET/CT. Br J Radiol 2012;85:e4-9.         [ Links ]

8. Ruiz-Hernández G, Delgado-Bolton RC, Rubio-Pérez MJ, Jiménez-Vicioso A, Pérez-Castejón MJ, Carreras-Delgado JL. Recurrencia de un carcinoma gástrico de células en anillo de sello demostrada por PET-FDG. Rev Esp Med Nucl 2005;24:326-30.         [ Links ]

9. Moschetta M, Scardapane A, Telegrafo M, Lorusso V, Angelelli G, Stabile Ianora AA. Differential diagnosis between benign and malignant ulcers: 320-row CT virtual gastroscopy. Abdom Imaging 2012;37:1066-73.         [ Links ]

10. Kim JH, Eun HW, Hong SS, Kim YJ, Han JK, Choi BI. Gastric cancer detection using MDCT compared with 2D axial CT: Diagnostic accuracy of three different reconstruction techniques. Abdom Imaging 2012;37:541-8.         [ Links ]

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