Case of the Quarter - 2015 Q2

This case can be downloaded and read as an PDF or read on this page below. An interactive website with Hermes Medical Software that shows this case's PET and CT images can be seen by clicking the below button.

Clinical History

A 64 year-old female with a newly diagnosed melanoma of the left nostril was referred for a staging PET-CT.

Findings

Dedicated views of the head and neck and half body were acquired after injection of FDG. Low dose CT scans were used for attenuation correction and image fusion.

No abnormal uptake is seen in the region of the left nostril. There are no sites of abnormal lymph node activity in the head and neck region.

On low dose CT, there is a well-defined soft tissue mass measuring 12 x 8 mm, within the distal left main bronchus/ extending into the superior segmental bronchus of the lingual, which shows low grade FDG uptake (SUV max = 1.7). No other endobronchial or intraparenchymal pulmonary lesions are seen. No mediastinal or hilar adenopathy identified.

Tracer distribution is otherwise unremarkable and no other significant CT abnormality is identified.

Interpretation

Left main bronchus/superior lingula endobronchial soft tissue lesion with low grade FDG uptake. Melanoma is known to metastasise to the site, but typically would be expected to be more FDG avid. The differential diagnosis includes an endobronchial carcinoid. Respiratory referral with a view to bronchoscopic sampling is recommended.

Follow-up

A bronchoscopic biopsy was performed which demonstrated a typical carcinoid. The patient subsequently had a left thoracotomy and upper lobectomy with the final histology confirming a typical carcinoid with a low mitotic rate.

Key Teaching points and Discussion

References

Quaedvlieg PF, Visser O, Lamers CB, Janssen-Heijen ML, Taal BG. Epidemiology and survival in patients with carcinoid disease in The Netherlands. An epidemiological study with 2391 patients. Ann Oncol. 2001;12(9):1295

Modlin IM, Lye KD, Kidd M. A 5-decade analysis of 13,715 carcinoid tumors. Cancer. 2003;97(4):934

Lococo F, Cesario A, Paci M, Filice A, Versari A, Rapicetta C, Ricchetti T, Sgarbi G, Alifano M, Cavazza A, Treglia G. PET/CT assessment of neuroendocrine tumors of the lung with special emphasis on bronchial carcinoids. Tumour Biol. 2014 Sep;35(9):8369-77