|
HISTORY:
This is a 66-year-old white man with a
history of multiple myeloma diagnosed in June of 2003 when he
presented with a skin rash and anemia. He has been seen and treated
for his multiple myeloma at the
University of Arkansas Myeloma Institute. The patient has undergone
tandem auto stem cell transplantation, first one in July and second
one in October of 2003. He is in complete remission and no evidence of
disease from a myeloma standpoint. He is scheduled for a planned
consolidation chemotherapy consisting of DT-PACE q. three monthly
times four doses. He was expected to receive this consolidation
therapy within six months of his second auto transplantation.
Following that, the treatment plan was to treat him with maintenance
interferon therapy. During routine followup CT scans, he was found to
have right lower lobe collapse and an endobronchial lesion was
suspected. He underwent a diagnostic bronchoscopy which showed right
endobronchial lesion. A biopsy revealed a possible neuroendocrine
tumor and a Indium-111 Pentetreotide (OctreoScan) study was ordered.
PAST MEDICAL HISTORY:
Multiple myeloma as above.
PAST SURGICAL HISTORY:
Hernia repair, left inguinal repair in 1965.
FAMILY HISTORY:
Father died of lung cancer at 78.
SOCIAL HISTORY:
Two to three cigarettes per day for ten years. Drinks one beer and one
shot of whisky per day. The patient has two grown children. He
is a retired schoolteacher.
REVIEW OF SYSTEMS:
He lost 25 pounds after transplantation. He has normal appetite.
IMAGING:
PET scan shows increased uptake in the right hilum
Nuclear Medicine:
5.4 mCi Indium-111 octreotide infused
intravenously. At a 4 hour delay, planar images were obtained
anteriorly and posteriorly over the thorax, abdomen, and pelvis. SPECT
imaging of the lower thorax and abdomen was performed. Study was
performed on the Hawkeye system with computed tomography attenuation
correction and anatomic localization.
|
CT Image |
OctreoScan
SPECT |
SPECT/CT
Fusion |
Click here to see full image magnified.
In the left upper quadrant just to the left of
midline, a small focal are of increased activity is seen, which is
localized in the bowel. A large mass is seen involving the right
perihilar region, consistent with a known metastatic tumor. A second
focus of increased activity is seen involving the left lateral chest
wall at approximately the level of the seventh rib. Smaller discrete
foci are seen involving the chest wall.
IMPRESSION: INDIUM-111 OCTREOTIDE STUDY DEMONSTRATING FOCAL AREA OF
INCREASED ACTIVITY INVOLVING THE BOWEL IN THE LEFT UPPER QUADRANT. A
LARGE METASTATIC FOCUS IS SEEN IN THE RIGHT HILAR REGION AND A SECOND
SMALLER FOCUS IS SEEN INVOLVING THE LEFT LATERAL CHEST WALL. FINDINGS
MOST CONSISTENT WITH PRIMARY AND METASTATIC CARCINOID.
Hospital Course:
He underwent a right lower lobectomy and right
middle lobectomy. The pathology report indicated a mucinous
adenocarcinoma with prominent neuroendocrine features, most likely
primary. His postoperative pathological diagnosis is consistent
with stage III-A non-small cell adenocarcinoma. One subcarinal node
was involved with malignancy. Hem/Onc is now consulted for
recommendations regarding treatment of stage III-A lung cancer, status
post surgical resection.
RECOMMENDATIONS:
1. We will coordinate with multiple myeloma oncologist to see if the
patient can receive DT-PACE which will serve as an adjuvant
chemotherapy to his lung cancer as well. After his first course of
DT-PACE, we will recommend adjuvant radiation therapy to his chest to
decrease local recurrence. A new adjuvant trial this year shows
4% absolute survival advantage in patients who receive adjuvant
cisplatin based therapy. In that study, many of the patients had
received adjuvant radiation therapy also. In a separate study for
patients with resected stage III-A lesions, adjuvant radiation therapy
decreased local recurrences but did not affect the overall survival.
Taking these studies into account, it is reasonable to recommend
radiation therapy while incorporating his consolidation therapy for
multiple myeloma with DT-PACE.
BACK
© 2004 Nuclear Education Online
- Images courtesy of University
of Arkansas for Medical Sciences Dept of Nuclear Medicine.
|
