A Concomitant False-Negative 18F-FDG PET Imaging in an Adrenocortical Carcinoma and a High Uptake in a Corresponding Liver Metastasis
Cécile Ghander,* Frédérique Tissier,* Florence Tenenbaum,* Stéphane Silvera, Bruno Ragazzon, Jérôme Bertherat, Xavier Bertagna, Bertrand Dousset, Bruno Richard, Paul Legmann, and Lionel Groussin
Institut National de la Santé et de la Recherche Médiale Unité 1016, Centre National de la Recherche Scientifique Unité Mixte de Recherche 8104, Institut Cochin, Department of Endocrinology, Metabolism and Cancer (F.Ti., B.Ra., J.B., X.B., B.D., L.G.), 75014 Paris, France; Université Paris Descartes, Sorbonne Paris Cité, Faculté de Médecine (C.G., F.Ti., J.B., X.B., B.D., B.Ri., P.L., L.G.), 75006 Paris, France; and Assistance Publique des Hôpitaux de Paris, Hôpital Cochin, Department of Endocrinology, Center for Rare Adrenal Diseases (C.G., J.B., X.B, L.G.), INCa Comete Network (F.Ti., J.B., B.D., X.B.), and Departments of Pathology (F.Ti.), Radiology (S.S., P.L.), Digestive and Endocrine Surgery (B.D.), and Nuclear Medicine (F.Te., B.Ri.), 75014 Paris, France
A 55-yr-old woman with a 1.5-month history of worsening diabetes and hypertension, pro- nounced hypokalemia, muscle weakness, hirsutism, and 10-kg weight gain was diagnosed with ACTH-inde- pendent Cushing’s syndrome (urinary free cortisol, 2910 nmol/24 h; normal range, 80-250). An adreno- cortical carcinoma (ACC) was suspected because of high plasma dehydroepiandrosterone and testosterone levels.
Computed tomography (CT) imaging showed a het- erogeneous right adrenal mass (55 × 40 mm) with a liver tumor (67 × 46 mm) located in segment VII (Fig. 1A).
Positron emission tomography (PET) scanning with 18F- fluorodeoxyglucose (FDG) did not show any pathological im- age for the adrenal lesion, but there was a high uptake in the liver tumor (Fig. 1B). A [60-131I]iodomethyl-19 nor- cholesterol (NP-59) scintigraphy showed a mirror image with a heterogeneous uptake confined to the adrenal lesion (Fig. 1C), thereby suggesting an adrenocortical origin.
Pathology confirmed the adrenocortical nature of the adrenal lesion, which was diagnosed as an ACC (Weiss score = 6). The liver tumor was a corresponding metas- tasis (Fig. 2, A-D).
Previously, we showed that a 18F-FDG PET uptake, with an adrenal to liver maximum standardized uptake value ratio above 1.45, has a 100% sensitivity to diag- nose ACC (1). An ACC without 18F-FDG uptake seems to be rare (2) but should certainly be considered as il- lustrated by this case. The second originality of this imaging procedure is by contrast the strong 18F-FDG uptake in the liver metastasis. The metastasis may have become metabolically active due to the occurrence of a hexokinase-II overexpression (Fig. 2, E and F) (no dif- ference in glucose transporter 1 immunostaining be- tween the metastasis and the primary cancer was ob- served) (3). Moreover, this patient illustrates the capability of NP-59 scans to visualize a functioning ACC with a loss of uptake in the liver tumor, maybe because of a nonfunctional metastasis (4, 5).
Acknowledgments
Address all correspondence and requests for reprints to: Pr. Lionel Groussin, Service d’Endocrinologie et Maladies Mé- taboliques, Hôpital Cochin, 27, rue du Faubourg St Jacques, 75014 Paris, France. E-mail: lionel.groussin@cch.aphp.fr.
Printed in U.S.A.
Copyright @ 2012 by The Endocrine Society
doi: 10.1210/jc.2011-3039 Received November 5, 2011. Accepted January 5, 2012.
First Published Online February 8, 2012
* C.G., F.Ti., and F.Te. contributed equally to this work.
Abbreviations: ACC, Adrenocortical carcinoma; CT, computed tomography; FDG, fluoro- deoxyglucose; PET, positron emission tomography.
CT scan
18F-FDG PET-CT
131I nor-cholesterol SPECT-CT
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This work was supported by the Conny-Maeva Charitable Foundation.
Disclosure Summary: The authors have nothing to disclose.
References
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