|
HISTORY: A 54 year old woman presented
with hypercalcemia, renal failure, and severe back pain. She
was diagnosed with multiple myeloma, stage III-B in July 2004.
After undergoing a bone marrow transplant, she presents today for
restaging of multiple myeloma.
RADIOPHARMACEUTICAL: 16.5 mCi F-18, FDG, IV, via right hand vein.
COMMENT: Patient's blood sugar at time of injection of the
radioisotope was 87 mg percent with the patient height being 5 feet
6 inches and patient weight 138 pounds.
PROCEDURE: Following injection of the radioisotope, imaging was
performed from the top of the head to the hips 90 minutes following
injection of the radioisotope. Emission and transmission imaging was
performed with attenuation correction. Correction was obtained for
random events. Iterative reconstructions were performed with axial,
coronal, and sagittal reconstructions as well as with 3D volume
rendering. Emission imaging of the lower extremities was performed
from the hips to the toes also with axial, coronal, and sagittal
reconstructions with 3D imaging. Additionally, noncontrasted,
nondiagnostic CT imaging was performed from the vertex to the feet
for anatomic location and attenuation correction only.
REVIEW OF PREVIOUS EXAMINATIONS: Previous PET scan 12/28/04
demonstrated two focal lesions of bone, right ilium, SUV 6.7, and
left proximal femur, SUV 3.9. There was severe heterogeneous uptake
in the red marrow distribution with an SUV of 5.0. Abnormal uptake
was present in the right lung associated with an area of infiltrate
with an SUV of 2.3 compatible with pneumonia.
Several rib fractures were noted.
Antecedent vertebroplasty was present at several levels in the
vertebral column.
Myelomatous changes of the bones were identified.
CT examination of the abdomen and pelvis 2/8/05 was worrisome for
thickening of the wall of the cecum and ascending colon as well as
descending colon, with fluid about the distal pancreas and third or
fourth portion of the duodenum. These findings were worrisome for
bowel infection.
MRI of the dorsal spine and lumbar spine 1/26/05 at UAMS
demonstrated hypo to isointense marrow on STIR-weighting, improved
from isointense on the prior study of 12/30/04, diffusely
hypointense on T1-weighting, with multiple compression fractures
identified but with no focal lesions. Vertebroplasties were seen at
T6, T8, and T11 as well as L1 and L2 with compression fractures also
involving T2, T3, T5, T11, and L3 through L5.
CURRENT PET CT SCAN FINDINGS: The current PET CT examination reveals
improvement in terms of myeloma with no focal lesions identified.
There is improving red marrow uptake, moderate and homogeneous, SUV
2.2, compared to severe and heterogeneous, SUV 5.0, as seen on the
prior study.
There is no extramedullary disease. There is, however, new
development with abnormal increased uptake in the gallbladder wall
and with a particularly prominent focal region of uptake in the
gallbladder neck, SUV 5.6 based on lean body mass. This is not seen
normally. Primary diagnostic consideration is acute cholecystitis.
There is questionably a minimal amount of pericholecystic fluid. The
gallbladder wall appears slightly thickened since the gallbladder is
distended, with the gallbladder wall measuring about 2 mm in
thickness. Gallbladder wall thickness where the gallbladder measures
8.3 cm and 3.7 cm transverse would be less than 2 cm.
There is also abnormal uptake in the left lung involving the left
lower lobe adjacent to a moderate sized pleural effusion, SUV 3.1,
worrisome for infection.
There is a moderate to large size right pleural effusion. There is a
subapical infiltrate on the right with an SUV of 2.0, suggesting
focal pneumonia.
The myelomatous changes of the bones are again noted but without
evidence of active focal lesions identified.
The patient has a gastrostomy tube in place extending to the second
portion of the duodenum.
IMPRESSION:
1. IMPROVEMENT IN TERMS OF MYELOMA WITH LOSS OF FOCAL LESIONS AND
DECREASE IN DIFFUSE UPTAKE.
2. FINDINGS WORRISOME FOR ACUTE CHOLECYSTITIS WITH DIFFERENTIAL
CONSIDERATIONS TO BE EXTRAMEDULLARY TUMOR, UNLIKELY, OR CHRONIC
CHOLECYSTITIS, ALSO UNLIKELY, SINCE IN OVER 3,000 PET SCANS
PERFORMED FOR MULTIPLE MYELOMA, THE GALLBLADDER HAS NOT BEEN
PREVIOUSLY SEEN AT THIS FACILITY. SINCE A PRIOR PET SCAN AT THIS
INSTITUTION DID NOT REVEAL GALLBLADDER UPTAKE, PRIMARY CARCINOMA OF
THE GALLBLADDER IS ESSENTIALLY EXCLUDED. 3. BILATERAL PLEURAL
EFFUSIONS, WITH ABNORMAL UPTAKE IN THE SUBAPICAL RIGHT LUNG AND IN
THE LEFT LOWER LOBE WORRISOME FOR INFECTION.
4. THE ABNORMAL APPEARANCE OF THE BOWEL ON THE PRIOR CT REVIEWED
ABOVE APPEARS SIGNIFICANTLY IMPROVED WITH LITTLE PERICOLONIC
INFLAMMATORY CHANGE AND ONLY MINIMAL RESIDUAL WALL THICKENING IN THE
CECUM AND ASCENDING COLON.
COMMENT: INCIDENTALLY NOTED IS INCREASED UPTAKE IN THE SPLEEN
COMPARED TO THE LIVER. BOTH ORGANS ARE NORMAL IN SIZE. SPLENIC SUV
BY LEAN BODY MASS IS 2.9, WITH UPTAKE IN THE LIVER MEASURING AN SUV
OF 2.0. TYPICALLY THE SPLEEN DEMONSTRATES LESS UPTAKE THAN THE
LIVER. HOWEVER, BOTH ORGANS ARE NORMAL IN SIZE, THIS MAY REPRESENT
EFFECTS OF BONE MARROW STIMULATING TREATMENT, REACTIVE CHANGE, OR,
THEORETICALLY, EXTRAMEDULLARY TUMOR OR EXTRAMEDULLARY HEMATOPOIESIS.
PLEASE CORRELATE.
BACK
© 2005 Nuclear Education Online
- Images courtesy of University
of Arkansas for Medical Sciences Dept of Nuclear Medicine.
|
