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CASE REPORT
Year : 2012  |  Volume : 27  |  Issue : 1  |  Page : 35-37  

Vascular thrombosis as a cause of abdominal pain in a patient with neuroendocrine carcinoma of pancreas: Findings on 68 Ga-DOTANOC PET/CT


Department of Nuclear Medicine, All India Institute of Medical Sciences, New Delhi, India

Date of Web Publication15-Mar-2013

Correspondence Address:
Rakesh Kumar
Department of Nuclear Medicine, All India Institute of Medical Sciences, Ansari Nagar, New Delhi - 110 029
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0972-3919.108847

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   Abstract 

Neuroendocrine tumors of pancreas are relatively rare neoplasms and are classified as either functioning or non-functioning tumors. A 55-year-old female diagnosed with a large, well-differentiated, non-functional neuroendocrine carcinoma of pancreas, presented with abdominal pain of increasing severity. A contrast-enhanced examination of the abdomen was performed to reveal a large, diffuse, enhancing pancreatic mass with multiple filling defects within the mesenteric vasculature. We present findings on 68 Ga-labeled [1,4,7,10-tetraazacyclododecane-1,4,7,10-tetraacetic acid]-1-NaI 3 -Octreotide, positron emission tomography-computed tomography ( 68 Ga-DOTANOC PET/CT) and the importance of somatostatin receptor-based PET imaging in such patients.

Keywords: 68 Ga-DOTANOC, neuroendocrine tumor, pancreas, PET/CT, thrombosis


How to cite this article:
Naswa N, Kumar R, Bal C, Malhotra A. Vascular thrombosis as a cause of abdominal pain in a patient with neuroendocrine carcinoma of pancreas: Findings on 68 Ga-DOTANOC PET/CT. Indian J Nucl Med 2012;27:35-7

How to cite this URL:
Naswa N, Kumar R, Bal C, Malhotra A. Vascular thrombosis as a cause of abdominal pain in a patient with neuroendocrine carcinoma of pancreas: Findings on 68 Ga-DOTANOC PET/CT. Indian J Nucl Med [serial online] 2012 [cited 2022 Jan 22];27:35-7. Available from: https://www.ijnm.in/text.asp?2012/27/1/35/108847


   Introduction Top


Endocrine tumors of the pancreas (EPTs) are rare tumors with an incidence of approximately 4-12 per million in a given population. [1] They are classified mainly into two distinct entities. The functional pancreatic tumors are usually small and present with clinical symptoms of hormonal excess coupled with biochemical evidence of the same. [2] In contrast, the non-functioning tumors are usually silent and present later in the course with large masses producing symptoms arising mainly from the tumor bulk. [3] Different imaging modalities have been used in the diagnosis and detection of such neoplasms. Role of somatostatin receptor imaging using the single photon emission computed tomography (SPECT) agent 111 In-octreotide is well-established in these tumors. [4] However, they are increasingly being replaced with PET imaging using the novel isotope 68 Ga labeled with different octreotide analogs, providing superior anatomical information and image resolution. [5] We present here the findings of a case of non-functioning neuroendocrine tumor of pancreas imaged with 68 Ga-labeled [1, 4, 7, 10-tetraazacyclododecane-1, 4, 7, 10-tetraacetic acid]-1-NaI 3 ?Octreotide?(-Octreotide ( 68 Ga-DOTANOC) PET/CT.


   Case Report Top


A 53-year-old female was diagnosed with a pancreatic tumor when she initially presented with anorexia and weight loss. Contrast-enhanced CT (CECT) examination at that time revealed a large, homogenous enhancing mass involving almost the entire pancreas with no evidence of local invasion or nodal involvement. A biopsy examination of pancreatic tissue revealed features of a well-differentiated tumor of neuroendocrine origin (neuroendocrine carcinoma proliferating index, 4%). In view of extensive disease involving pancreas, surgery was deferred and the patient was put on octreotide therapy. The patient was apparently well for a period of 4 months when she started having abdominal pains, which progressed in severity over the next month. A repeat contrast-enhanced examination of the abdomen revealed no significant alterations of the primary pancreatic mass, but showed numerous filling defects within the mesenteric vasculature. In view of the disease progression, a staging PET/CT using 68 Ga-DOTANOC was performed [Figure 1]. Intense radiotracer uptake was noted in the primary tumor (SUV max -53). Also seen was an arborizing area of abnormal tracer uptake within the abdomen, which was subsequently traced to mesenteric vessels [Figure 2]. Thus, 68 Ga-DOTANOC PET/CT helped confirm the presence of mesenteric vascular thrombosis and localize the cause of abdominal pain to be the same. In addition, the whole body examination revealed no other areas of abnormal uptake that could suggest presence of other metastatic sites.
Figure 1: Whole body 68Ga-DOTANOC PET MIP (maximum intensity projection) image of a 53-year-old female diagnosed with a primary neuroendocrine tumor of the pancreas, showing area of intense radiotracer uptake within the abdomen (bold arrow). Also noted are areas of abnormal tracer uptake in an arborizing fashion distal to the area of primary abnormality (arrows)

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Figure 2: Sequential unenhanced CT, 68Ga-DOTANOC PET, and fused PET/CT images are shown. Upper row images display the primary pancreatic mass, which is homogenously enlarged and bulky, (a) and shows intense tracer avidity (b, SUVmax-53). Fused PET/CT image shows the tumor with uptake compatible with a pancreatic neuroendocrine tumor (c). Middle row images are axial sections to define the abnormal arborizing uptake seen on the MIP image. CT image shows enlarged mesenteric vessels (d, arrow) although a contrast-enhanced examination was not performed. Increased tracer uptake is noted in the area corresponding to enlarged blood vessels (e). Axial PET/CT section reveals enlarged primary inferior mesenteric vessels and its branches showing intense tracer uptake suggestive of tumor thrombus (f). Lower row images represent distal sections of the vasculature with similar findings (g-i). No areas of nodal of visceral tracer uptake were identified that may suggest metastatic disease. Hence, a diagnosis of primary pancreatic neuroendocrine tumor with mesenteric vessel thrombosis could be confirmed with 68Ga-DOTANOC PET/CT imaging

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   Discussion Top


Tumor thrombosis of blood vessels have been most commonly described in association with hepatocellular and renal cell carcinomas. [6] Tumor thrombosis in pancreatic adenocarinomas has also been frequently described in the literature. [7] Presence of tumor-induced vascular thrombosis usually implies a less favorable prognosis and has a direct bearing on management and treatment outcomes. However, a similar association in context of pancreatic neuroendocrine tumor (NET) is exceedingly rare and only few case reports have demonstrated this association in the past. [8] Tumor thrombosis by a pancreatic NET has also been described previously on fluorodeoxyglucose (FDG) PET imaging. [9] Two previous reports also demonstrate tumor thrombosis on somatostatin receptor PET/CT imaging using the radiotracers DOTATATE, where 68 Ga-DOTATATE was used to confirm the presence of tumor thrombosis within inferior mesenteric vessels. [10],[11] However, role of 68 Ga-labeled tracer DOTANOC to detect tumor thrombosis in pancreatic NETs have not been described in the past, which has a broader spectrum of receptor affinity as compared to other octreotide analogs. [12] 68 Ga-DOTANOC PET/CT can play additional roles besides confirming the presence of tumor thrombosis and localizing it as the source of abdominal pain. Intense tracer uptake by tumor tissue (SUV max as in this case) is an in vivo demonstration of presence of somatostatin receptors on tumor cell surface in a high density. This can be exploited for therapy purpose using peptide-based radionuclide therapy using 90Y- or 177Lu-labeled octreotide analogs. [13] Also, the candidate can be followed up further using sequential imaging to either monitor the response to therapy or evidence of progression.

 
   References Top

1.Modlin IM, Lye KD, Kidd M. A 5-decade analysis of 13,715 carcinoid tumors. Cancer 2003;97:934-59.  Back to cited text no. 1
    
2.Dixon E, Pasieka JL. Functioning and nonfunctioning neuroendocrine tumors of the pancreas. Curr Opin Oncol 2007;19:30-5.  Back to cited text no. 2
    
3.Eckhauser FE, Cheung PS, Vinik AI, Strodel WE, Lloyd RV, Thompson NW. Nonfunctioning malignant neuroendocrine tumors of the pancreas. Surgery 1986;100:978-88.  Back to cited text no. 3
    
4.Krenning EP, Kwekkeboom DJ, Bakker WH, Breeman WA, Kooij PP, Oei HY, et al. Somatostatin receptor scintigraphy with [ 111 In-DTPA-D-Phe1]- and [123I-Tyr3]-octreotide: The Rotterdam experience with more than 1000 patients. Eur J Nucl Med 1993;20:716-31.  Back to cited text no. 4
    
5.Gabriel M, Decristoforo C, Kendler D, Dobrozemsky G, Heute D, Uprimny C, et al. 68Ga-DOTA-Tyr3-octreotide PET in neuroendocrine tumors: Comparison with somatostatin receptor scintigraphy and CT. J Nucl Med 2007;48:508-18.  Back to cited text no. 5
    
6.Sharma P, Kumar R, Jeph S, Karunanithi S, Naswa N, Gupta A, et al. 18F-FDG PET-CT in the diagnosis of tumor thrombus: Can it be differentiated from benign thrombus? Nucl Med Commun 2011;32:782-8.  Back to cited text no. 6
    
7.Price LH, Nguyen MB, Picozzi VJ, Kozarek RA. Portal vein thrombosis in pancreatic cancer: Natural history, risk factors, and implications for patient management. ASCO 2010 Gastrointestinal Cancers Symposium 2010;22-4.  Back to cited text no. 7
    
8.Kawakami H, Kuwatani M, Hirano S, Kondo S, Nakanishi Y, Itoh T, et al. Pancreatic endocrine tumors with intraductal growth into the main pancreatic duct and tumor thrombus within the portal vein: A case report and review of the literature. Intern Med 2007;46:273-7.  Back to cited text no. 8
    
9.Nguyen BD. Pancreatic neuroendocrine tumor with portal vein tumor thrombus: PET demonstration. Clin Nucl Med 2005;30:628-9.  Back to cited text no. 9
    
10.Sainz-Esteban A, Prasad V, Baum RP. Pancreatic neuroendocrine tumor with involvement of the inferior mesenteric vein diagnosed by Ga-68 DOTA-TATE PET/CT. Clin Nucl Med 2010;35:40-1.  Back to cited text no. 10
    
11.Lim TC, Tan EH, Zaheer S. Use of Ga-68 DOTATATE PET/CT to confirm portal vein tumor thrombosis in a patient with pancreatic neuroendocrine tumor. Clin Nucl Med 2011;36:498-9.  Back to cited text no. 11
    
12.Reubi JC, Schar JC, Waser B, Wenger S, Heppeler A, Schmitt JS, et al. Affinity profiles for human somatostatin receptor subtypes SST1-SST5 of somatostatin radiotracers selected for scintigraphic and radiotherapeutic use. Eur J Nucl Med 2000;27:273-82.  Back to cited text no. 12
    
13.Lamberts SW, Krenning EP, Reubi JC. The role of somatostatin and its analogs in the diagnosis and treatment of tumors. Endocr Rev 1991;12:450-82.  Back to cited text no. 13
    


    Figures

  [Figure 1], [Figure 2]


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[Pubmed] | [DOI]



 

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