A Case of Triple Primary Malignancies Including the Breast, Pancreas, and Lung: The Role of 18 F-FDG PET/CT

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1 A Cse of Triple Primry Mlignncies Including the Brest, Pncres, nd Lung: The Role of 18 F-FDG PET/CT Filiz HATİPOĞLU, Serp KARAARSLAN, İnnç KARAPOLAT, Atill ÇÖKMEZ c Deprtment of Nucler Medicine, Deprtment of Pthology, c Deprtment of Generl Surgery, Sif University Fculty of Medicine, İzmir Ge liş T ri hi/re ce i ved: K ul T ri hi/ac cep ted: Y zış m Ad re si/cor res pon den ce: A.Filiz HATİPOĞLU Sif University Fculty of Medicine, Deprtment of Nucler Medicine, İzmir, TÜRKiYE/ TURKEY krgozfiliz@yhoo.com ABSTRACT Brest cncer is the most common mlignncy in women nd survivl rtes increse thnks to erly dignosis nd tretment options. Secondry mlignncies my develop in these cses with incresed survivl. On the other hnd, the cses in which two distinct synchronous orgn mlignncies develop esides rest cncer re quite rrely found in the literture. In this cse presenttion, s fr s we know, we hve reported the first cse previously dignosed with rest cncer in whom development of synchronous lung nd pncres mlignncies ws detected y 18 F-FDG PET/CT performed during follow-up period. Our cse is interesting ecuse of crrying synchronous nd metchronous 3 distinct mlignncies lltogether nd it presents the importnce of interprettion of the 18 F-FDG PET/CT imgings performed during follow-up of primry tumor nd histopthologicl confirmtion with respect to surgicl tretment possiility. Key Words: Neoplsms, multiple primry; positron-emission tomogrphy/ computed tomogrphy ÖZET Meme knseri kdınlrd en sık görülen mlignite olup erken tnı ve tedvi seçenekleri syesinde sğklım ornlrı rtmktdır. Artn sğklım ile irlikte u olgulrd sekonder mligniteler gelişeilmektedir. Bun krşın litertürde meme mlignitesi ynınd senkron iki frklı orgn mlignitesi orty çıkn olgulr oldukç z rstlnılmktdır. Biz u olgu sunumund meme mlignitesi tnısı lmış, izlem sırsınd ypıln 18 F-FDG PET/BT görüntüleme ile frk edilen senkron kciğer ve pnkres mlignitesi gelişen ilk olguyu rpor etmekteyiz. Olgumuz senkron ve metkron üç frklı mligniteyi ünyesinde tşımsı nedeniyle ilginç olup, primer ir tümör vrlığınd tkip sırsınd ypıln 18 F-FDG PET/BT görüntülerinin yorumlnmsı ve histoptolojik konfirms yonun cerrhi tedvi şnsı çısındn önemini orty koymktdır. Anhtr Kelimeler: Neoplziler, çoklu primer; pozitron-emisyon tomogrfi/ ilgisyrlı tomogrfi Turkiye Klinikleri J Cse Rep 2016;24(4):301-5 doi: /cserep Cop yright 2016 y Tür ki ye Kli nik le ri hen multipl neoplsms develop in the sme person the tumors re defined s synchronous (within 6 months fter the first tumor) nd metchronous (fter 6 months from the first tumor) ccording to the time etween the occurence. The tumors tht developed distinctly nd synchronously or metchronously in n identicl ptient re nmed s multiple primry tumors nd reported to hve n incidence of % in the literture. 1 The incidence of multiple primry mlignncies, is rising ecuse of improved survivl rtes due to erly dignosis nd newly developed tretment options. 2 Turkiye Klinikleri J Cse Rep 2016;24(4) 301

2 Htipoğlu ve rk. In the cses with mlignncies; possiility of surgicl tretment for secondry mlignncies tht my develop during follow-up period hs gret importnce with respect to survivl. Consequently, it should e kept in mind tht newly developed hypermetolic lesions encountered y 18 F-FDG PET/ CT during follow-up periods of the ptients found with primry mlignncy should e evluted for secondry mlignncies s well s possile metsttic sites. In our mnuscript, we hve presented cse who ws operted for rest mlignncy nd found to hve hypermetolic lesions in the pncretic ody nd upper loe of left lung with 18 F- FDG PET/CT performed two yers lter nd histopthologiclly dignosed with rrely oserved synchronous lung nd pncretic mlignncies. CASE REPORT A 44-yer-old femle ptient ws operted for mlignnt cytology in her right rest ccompnied y frozen section iopsy. She ws dignosed with mlignnt phyllodes tumor of rest nd rective lymph nodes ccording to the pthologicl evlution (Figure 1). Whole ody PET/CT imging performed for primry stging nd ccording to PET/CT, our ptient ws ssessed s T1N0M0 stge nd followed-up without tretment. Whole ody PET/CT imging performed during the follow-up period encountered moderte-degree hypermetolic (mximum stndrd uptke vlue (SU- Vmx)= 2.6) nodulr prenchyml lesion locted t Nükleer Tıp FIGURE 1: Mlignnt phyllodes tumor field including pleomorphic nd spordiclly spindle cells in the strom etween norml rest duct (H&Ex100). left upper loe picoposterior segment with n irregulr contour nd pproximte size of 1.4x1.0 cm (Figure 2) nd moderte-degree hypermetolic (SUVmx=2.5) pncretic lesion in dimeter of 2.5 cm locted t the ody of pncres (Figure 2). The moderte-degree hypermetolic lesion encountered in the ody of the pncres ws evluted s highly likely to e mlignnt wheres the nodulr lesion with n irregulr contour locted t left upper loe picoposterior segment ws interpreted s either metstsis of one of the previously existing mlignncies (mlignncy of rest or pncres) or second primry cncer of lung nd thus histopthologicl correltion ws recommended for differentil dignosis. Morphologicl nd immunohistochemicl fetures (positive TTF1 nd cytokertin 7 nd negtive cytokertin 20 of tru-cut iopsy FIGURE 2: ) Trnsxil PET-CT imges showed moderte-degree hypermetolic (mximum stndrd uptke vlue (SUVmx)= 2.6) nodulr prenchyml lesion locted t left lung upper loe picoposterior segment with n pproximte size of 1.4x1.0 cm (rrow). ) Trnsxil PET-CT imges showed modertedegree hypermetolic (SUVmx=2.5) pncretic lesion in dimeter of 2.5 cm locted t the ody of pncres (rrow). SUV is n index of trcer uptke tht is defined s follows: SUV= ctivity concentrtion in the tissue (MBq/ml)/dministered ctivity (MBq/ptient wight (kg)) Turkiye Klinikleri J Cse Rep 2016;24(4) 302

3 Htipoğlu et l. Nucler Medicine FIGURE 3: ) Adenocrcinom fields including smll ppillry formtions nd glndulr structures in the lung tru-cut iopsy specimen (H&Ex100). ) TTF1 positivity in the lung tru-cut iopsy specimen (TTF1x100). Its pthologicl exmintion resulted its dignosis in fvor of ductl denocrcinom (Figure 4 ). Metstsis ws encountered in two of the 19 lymph nodules dissected from surrounding pncres (Figure 4 ). The ptient, who ws performed six cures of chemotherpy following surgicl opertion nd received the lst cure t Novemer 2012, hs undergone whole ody PET/CT in Decemer 2012 nd no pthologicl uptke of 18F-FDG ws found in pncres nd left lung fter surgery (Figure 5). No relpse, metstsis nd nother mlignncy ws encountered in the ptient during three yer of follow-up fter the dministered tretment procedures nd lso vi thorcic nd whole ody CT imging performed in specimen otined from the lesion locted t left upper loe picoposterior segment supported mlignncy of primry lung (non-smll cell lung crcinom) (Figure 3, ). Similrly with tru-cut iopsy, wedge mteril specimen reveled 1.5 cm-dimeter tumor. On the histopthologicl exmintion of lymph nodes with tissue smples of 5th, 6th nd 9th sttions rective hyperplsi were dignosed. No dditionl tretment ws given ccording to these findings. A short time lter, the lesion locted t the ody region of pncres ws eveluted y cytologicl exmintion for differentil dignosis. The smers tht reveled cytomorphologiclly mlignnt fetures were inter preted in fvor of denocrcinom. Whipple procedure ws performed ccording to these results. FIGURE 4: ) Tumor cells with findings of mlignncy tht formed glndulr structures in vrious dimeter mesurements in the pncres opertion mteril (H&Ex50). ) Focus of norml residul lymph nodules in the lymph nodules dissected from peripncretic region (gren rrow), typicl metsttic denocrcinom fields locted s sucpsulr sinuses (red rrow) nd fields composed of gint cells (H&Ex50). Turkiye Klinikleri J Cse Rep 2016;24(4) 303

4 Htipoğlu ve rk. Nükleer Tıp FIGURE 5: ) Trnsxil fused PET/CT imges showed the chnges secondry to opertion t the level of left upper loe picoposterior segment. ) Body nd til regions of the pncres couldn t e encountered secondry to the opertion on sgittl fused PET/CT. DISCUSSION Thnks to technologicl improvements in the present time, rte of erly dignosis in the mlignncies progressively increses nd survivl durtions of the cses hve prolonged due to dditionl modern tretment options. As consequence of ll these improvements, potentil of secondry mlignncies in these cses increses. 2 Crcinogenic effects due to tretment nd genetic predisposition of the ptient my e responsile s reson of this issue. 3 Our cses ws not given n dditionl tretment regimen. Therefore, tumors my e considered to e ssocited with genetic predisposition. The ptient reported in her medicl history tht one of her silings ws exitus due to tongue mlignncy while her other siling ws operted for rest mlignncy. However, no detiled informtion on sutype of the tumor couldn t e otined nd this present chrcteristic supports our hypothesis. A study on 40 cses hs reported tht secondry mlignncy develops within 1 to 22 months fter the primry mlignncy nd lung cncer is found in 5% of the secondry mlignncies tht developed in the cses with mlignncy of rest in study. 4,5 In our cse presenttion, lung crcinom developed two yers fter s stted in the literture in ddition with synchronous pncretic ductl denocrcinom. In cse series of 149 ptients, possiility of newly-developed lung nodule to e secondry mlignncy of lung ws found higher in the cses with mlignncy of hed-neck, rest, cervix, gllldder, esophgus, ovry, prostte nd stomch wheres metsttic potentil ws found higher in the cses with melnom, srcom nd testiculr crcinom. 6 18F-FDG hs the cpility to detect multiple coexisting cncers. 7,8 There re mny studies tht hve investigted dvntge of 18F-FDG PET or PET/CT in detecting multiple primry tumors with respect to reveling metolic chnges in contrst to conventionl ntomicl imgings. 9 As fr s we hve investigted in the literture, this is the first reported cse in whom secondrily developed primry mlignncies of pncres nd lung detected vi 18 F-FDG PET/CT imging performed during follow-up periods of the cses with primry mlignncy of rest. Even though, it is known tht multiple primry mlignncies hve worse progression, our cse hs een followed-up without detecting ny relpse or metstsis thnks to erly dignosis otined y PET/CT nd histopthologicl confirmtion. In our report FDG PET/CT hs plyed n importnt role in detection of secondry primry mlignncies of lung nd pncres tht developed synchronously nd in the mngement of the ptient providing n opportunity for surgicl resection ccompnied y histopthologicl dignosis. For this reson in ptients with known mlignncy, the msses which re recognised y imging modlities such s FDG PET/CT during follow-up Turkiye Klinikleri J Cse Rep 2016;24(4) 304

5 Htipoğlu et l. periods of the cses should mke us consider metchronous tumor s well s metsttic involvement. Imging modlities nd chievement of Nucler Medicine pthologicl evlution cretes the chnce of erly resection nd crries the critic importnce on survivl nd prognosis. 1. Demndnte CG, Troyer DA, Miles TP. Multiple primry mlignnt neoplsms: cse report nd comprehensive review of the literture. Am J Clin Oncol 2003;26(1): Hemminki K, Boffett P. Multiple primry cncers s clues to environmentl nd heritle cuses of cncer nd mechnisms of crcinogenesis. IARC Sci Pul 2004;(157): Vn Leeuwen FE, Trvis LB. Second Cncer. In: De Vit VT, Hellmn S, Rosenerg SA, eds. Cncer: Principles nd Prctice of Oncology. 6 th ed. Phildelphi: Lippincott Willims nd Wilkins; p REFERENCES 4. Girdini R, Mrtelli G, Rilke F, Pilott S. Dignostic prolems of second primry mlignncies detected y fine-needle spirtion cytology. Cncer 1993;72(9): Mriotto AB, Rowlnd JH, Ries LA, Scopp S, Feuer EJ. Multiple cncer prevlence: growing chllenge in long-term survivorship. Cncer Epidemiol Biomrkers Prev 2007;16(3): Quint LE, Prk CH, Innettoni MD. Solitry pulmonry nodules in ptients with ekstrpulmonry neoplsms. Rdiology 2000;217(1): Gjendr S, Shrm R, Shoo MK. Triple cncer: chronic lymphocytic leukemi with ldder nd prostte crcinom. Mlys J Pthol 2015;37(2): Srm M, Borde C, Surmnym P, Shnmug Sundrm P. Rndom synchronous mlignncy in mle rest: cse report. J Brest Cncer 2013;16(4): Even-Spir E, Keidr Z, Br-Shlom R. Hyrid imging (SPECT/CT nd PET/CT)- improving the dignostic ccurcy of functionl/ metolic nd ntomic im ging. Semin Nucl Med 2009;39(4): Turkiye Klinikleri J Cse Rep 2016;24(4) 305