Pancreatic metastases from primary ileal NET only detected by 68Ga-DOTATOC PET/CT
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IMAGE OF THE MONTH
Pancreatic metastases from primary ileal NET only detected by 68Ga-DOTATOC PET/CT P. Mapelli 1,2 & F. Fallanca 2 & A. Franchini 2,3 & L. Albarello 4 & E. G. Vanoli 2 & S. Partelli 1,5 & F. Muffatti 5 & L. Gianolli 2 & M. Falconi 1,5 & M. Picchio 1,2 Received: 21 November 2019 / Accepted: 5 February 2020 # Springer-Verlag GmbH Germany, part of Springer Nature 2020
Pancreatic metastases occurs in approximately 2% of patients with small intestinal neuroendocrine tumours (SI-NETS). [1] 68Ga-DOTATOC PET/CT is a useful tool to evaluate patients with NET, changing therapeutic management and staging in 51% of cases and playing an essential role in treatment planning as reported in the present case. [2–4] A 67-year-old woman was hospitalized for ischemic stroke. Among the investigations carried out to look for possible causes, an abdominal ultranonography incidentally showed a solid pancreatic body lesion (14 mm). Abdominal CT documented Wirsung duct ectasia in pancreatic tail, with no clear visualization of the body lesion. Endoscopic ultrasound confirmed the presence of the lesion, with cytological examination being diagnostic for a NET. To complete preoperative staging, a 68Ga-DOTATOC PET/CT was performed, showing intense tracer uptake at the pancreatic body lesion (a–d). Additionally, a focal intense tracer uptake was detected in the last ileal loop, suggesting the presence of a further neuroendocrine lesion (e– g). Colonoscopy with bioptic sampling was performed, and a primary SI-NET was diagnosed.
This article is part of the Topical Collection on Image of the month * M. Picchio [email protected] 1
Vita-Salute San Raffaele University, Milan, Italy
2
Nuclear Medicine Department, IRCCS San Raffaele Scientific Institute, Milan, Italy
3
University of Milano-Bicocca, Milan, Italy
4
Pathology Department, IRCCS San Raffaele Scientific Institute, Milan, Italy
5
Pancreatic Surgery Unit, Pancreas Translational & Clinical Research Centre, IRCCS San Raffaele Scientific Institute, Milan, Italy
Markers related to SI-NET, such as neuron-specific enolase and urinary 5-hydroxyindoleacetic acid have been measured before surgery and resulted negative. Distal pancreatectomy and splenectomy, ileal resection and lymphadenectomy were then performed. Histological and immunohistochemical assessments confirmed a welldifferentiated SI-NET (10 mm) with nodal metastases (< 10 mm); nodal metastases did not show 68Ga-DOTATOC uptake reasonably because of the small size. Ileal NETs are characterized by intense and diffuse nuclear immunostaining for CDX2 (h, brown reactivity) and intense cytoplasmic immunostaining for serotonin (i) compared to primary pancreatic NET. [5] The pancreatic lesion, showing diffuse and intense immunostaining for CDX2 (l) and serotonin (m), was considered to be a metastatic localization of the primary SI-NET (pT3b pN1 G2 pM1b; ki67 2%). [6]. Six months later, a follow-up 68Ga-DOTATOC PET/CT showed no signs of recurrence. Conventional imaging modalities only detected the pancreatic lesion, po
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