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Photon-deficient Mass on FDG-PET Scan in Renal Cell Carcinoma: A Case Report.
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PMID:  24179364     Owner:  NLM     Status:  PubMed-not-MEDLINE    
Abstract/OtherAbstract:
F-18 Fluorodeoxyglucose Positron Emission Tomography imaging (F-18 FDG PET) detects malignancies depending on the uptake profile of glycolysis of tumors; however, the role of FDG PET is limited in the evaluation of primary renal malignancy because of low FDG uptake by renal cell carcinoma and also because normal urinary excretion of FDG seen in the images. A patient with renal cell carcinoma whose FDG PET imaging study incidentally shows a photon-deficient mass in the upper pole of the right kidney is present here. The diagnosis is also validated by the histopathological findings of tumor necrosis, hemorrhage, and scars.
Authors:
George Shih; Wei-Jen Shih; Bonnie Mitchell; Primo P Milan
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Publication Detail:
Type:  Journal Article     Date:  2008-12-23
Journal Detail:
Title:  Clinical medicine. Case reports     Volume:  2     ISSN:  1178-6450     ISO Abbreviation:  Clin Med Case Rep     Publication Date:  2008  
Date Detail:
Created Date:  2013-11-01     Completed Date:  2013-11-01     Revised Date:  2014-01-24    
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Nlm Unique ID:  101515695     Medline TA:  Clin Med Case Rep     Country:  New Zealand    
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Languages:  eng     Pagination:  1-4     Citation Subset:  -    
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Journal ID (nlm-ta): Clin Med Case Rep
Journal ID (iso-abbrev): Clin Med Case Rep
ISSN: 1178-6450
Publisher: Libertas Academica
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© 2009 by the authors
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collection publication date: Year: 2009
Electronic publication date: Day: 23 Month: 12 Year: 2008
Volume: 2First Page: 1 Last Page: 4
PubMed Id: 24179364
ID: 3785371
Publisher Id: ccrep-2-2009-001

Photon-deficient Mass on FDG-PET Scan in Renal Cell Carcinoma: A Case Report
George Shih
Wei-Jen Shih
Bonnie Mitchell
Primo P Milan
Department of Radiology, Weill Medical College, Cornell University New York, NY, and Nuclear Medicine Service, Pathology Service and Radiology Service, Lexington VA Medical Center, and Department of Diagnostic Radiology and Department of Pathology, College of Medicine, University of Kentucky, Lexington, Kentucky, U.S.A.
Correspondence: Correspondence: Dr. Wei-Jen Shih, Nuclear Medicine Service, Lexington VA Medical Center, 1101 Veterans Drive, Lexington, KY 40502. Tel: (859) 381-5928; Fax: (859) 381-5934; Email: wshih0@uky.edu

Introduction

It is well established that advances in F-18 FDG PET imaging may lead to early cancer detection, more accurate tumor staging and consequently adequate treatment, better monitoring of the disease and enhanced surveillance for recurrences after treatment. The role of FDG PET is limited in the evaluation of primary renal malignancy because of low FDG uptake by renal cell carcinoma (RCC) and because of the normal urinary excretion of FDG seen in the images.1,2 Here, a photon-deficiency lesion in the right kidney found on FDG PET is reported.


Case Report

A 69-year-old man with a history of having undergone coronary artery bypass graft, cholecystectomy, cerebro-vascular accident with craniotomy and recent hoarseness of voice for eight months had recently invasive squamous cell carcinoma of vocal cord. CT of the neck without contract enhancement showed deformity of the larynx with thickening of the anterior commissure and right vocal cord which are characteristic of a mucosal lesion. He also suffered from new onset of changes in non-specific gastrointestinal symptoms. Therefore he underwent an abdominal CT with contrast medium which incidentally showed a heterogeneously enhancing exophytic mass projecting posteriorly from the upper pole of the right kidney (Fig. 1). Four days later, ultrasonic (U.S.) of kidney showed a solid mass measuring 4-cm in the upper pole of the right kidney. Three weeks later, an MRI with contrast medium showed a 4-cm complex enhancing mass projecting from the posterolateral aspect of the upper pole of the right kidney; the complex mass demonstrated heterogeneous signal internally including a focal hyperintense signal on precontrastT1 weighted sequences; and these areas also showed hyperintense signal postcontrast suggesting hemorrhage, necroses, and scar formation (Fig. 2). F-18 FDG PET images showed two small areas of faintly increased activity in the larynx (not shown); in addition, a photon-deficient area was also seen in the upper border of the right kidney (Fig. 3). Subsequently, a right nephrectomy using hand-assisted laparoscopic nephrectomy directed laparocopy with biopsy and direct laryngoscopy with biopsy were same day resulted in clear renal cell carcinoma with focal papillary features (Figs. 4A and B) an focal capsular invasion approxmimal one-two cell layers short of true transcapular involvement us present. In addition, areas of hemorrhage, tumor necrosis, and scars (4C and D) were noted.


Discussion

A case of a photon-deficient area in the upper pole of the right kidney on FDG PET scan (Fig. 2), which was subsequently confirmed by CT and MRI imaged (Figs. 1 and 2), and diagnosed as RCC as presented here. This finding of “cold” or photon-deficient area in the right kidney seen in FDG PET images (Fig. 3) has not been previously reported. The photon-deficient area in the right kidney of this patient might be partially explained by tumor necrosis, hemorrhage and fibrosis/scar tissue (Fig. 4) which were shown on MR images as well.

RCC is a diagnostic challenge. Among all patients with RCC, 25%–39% are asymptomatic and the diagnosis is made from a radiological study obtained for the reasons.1,2 This patient showed no clinical symptom related to RCC which, was detected serendipitously by abdominal CT imaging (Fig. 1) as part of working up for a new onset of non-specific gastro-intestinal symptoms. Incidentally, CT imaging of the abdomen with contrast medium (Fig. 1) showed the lesion in the upper pole of the right upper. An ultrasonogram confirmed a solid mass in the right upper pole of the kidney; subsequently MRI showed a 4-cm complex mass at the superior-posterior aspect of the right kidney (Fig. 2).

In the study of FDG PET in detection of RCC, Ak and Can reported that F-18 FDG PET may have a role in the diagnosis and evaluation of patients with RCC and primary staging of the disease.3 However, usually FDG is excreted by kidneys and it is difficult to distinguish FDG excreted in the urine from that accumulating in the tumor unless the patient has renal failure with no urine formation. Visualization is difficult in a patient with RCC who has renal failure and is on long-term hemodialysis because FDG is not excreted in the urine.4 Furthermore, the detection rate of RCC by PET is generally as low as 31.5%–60%.5,6 The role of FDG PET in the detection of RCC is limited by low sensitivity7,8 because isometabolism of renal tumors has been reported9 and FDG PET displays poor efficacy in cases of renal cell carcinoma because of low levels or absence of glycolysis in this type of tumor.10 An unusual case of photon-deficiency in renal tumor (RCA) is reported here.

FDG PET is limited in the evaluation of primary urological malignancies including prostate and urinary bladder cancer.11,12 It has been reported that FDG PET does not show primary renal tumors, and is more useful for detecting postoperative local recurrence or distal metastasis than the primary tumor.13 In the evaluation of distant metastases from RCC, FDG PET in not a sensitive imaging modality and may not adequately characterize small metastatic lesion.14 FDG study might demonstrate tumor invasion of the right renal vein and infra-hepatic inferior vena cava.1517

In summary, a patient with renal cell carcinoma, whose FDG PET incidentally showed a photon-deficient mass in the upper pole of the right kidney is presented; this finding can be explained by non- uptake of the tracer by the tumor, and the histopathological findings of tumor necrosis, hemorrhage, and scars.


Notes

fn1-ccrep-2-2009-001Disclosure

The authors report no conflicts of interest.

Acknowledgement

The authors thank Mark Ingram, reference librarian, for his excellent and diligent search of the literature during the preparation of this paper.


References
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2. Vogelzang NJ,Scardino PT,Shipley WU,et al. Comprehesive Textbook of Genitouriary OncologyBaltimore, U.S.AWilliams & WilkinsYear: 1996
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10. Ryzhkova DV,Granov AM,Karelin MI,et al. Positron emission tomography in oncourology, Vestn-Ross-Akad-Med-NaukYear: 20059262
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12. Kumar R,Zhang H,Alavi A. PET in the management of urology malignanciesRadiol Clin North AmYear: 20044211415315488563
13. Ramdave S,Thomas GW,Berlanieri SU,et al. Clinical Role of F-18 FDG PET for detection and manangement of renal cell carcinomaU UrolYear: 200116682530
14. Maljhail NS,Urabain J-L,Albani JM,et al. F-18 FDG PET in evalustion of distant metastases from renal cell carcinomaJ Clin OncolYear: 2003213995400014581422
15. Nguyen BD. Positron emission tomography imaging of renal vein and inferior vena cava tumor thrombus from renal cell carcinomaClin Nucl MedYear: 2005301070915647678
16. Agrawal A,Nair N,Baghel N. F18 FDG PET in Ormond disease in a patient with renal cell carcinomaClin Nucl MedYear: 2007323202217413587
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Article Categories:
  • Case Report

Keywords: renal cell carcinoma, photon-deficiency, F-18 FDG-PET, MR I, CT, U.S., tumor necrosis, glycolysis.

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