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Incidental detection of axillary lymph node metastasis from carcinoma breast during technetium-99m methoxyisobutylisonitrile parathyroid scintigraphy Sir, We describe a suspected case of primary hyperparathyroidism with brown tumors where on parathyroid scintigraphy, an incidental finding of hyper‑metabolic lesion in the right axilla, was noticed which was later on confirmed to be metastasis from breast cancer. A 61‑year‑old‑female patient presented with back pain for 6 months duration. She had hypercalcemia and elevated serum alkaline phosphatase levels. X‑ray of the skull and pelvis showed multiple lytic lesions which raised the suspicion of primary hyperparathyroidism with brown tumors. Technetium99m methoxyisobutylisonitrile (MIBI) parathyroid scintigraphy [Figure 1a and b] was negative for parathyroid adenoma; however, a hypermetabolic lesion in right axilla was noted. Single photon emission computed tomography/computed tomography (SPECT/CT) localized the uptake to the right axillary lymph node (arrows on CT and SPECT/CT images). It also showed multiple lytic lesions in cervico‑dorsal vertebrae. Scintigraphic impression of metastatic right axillary nodal involvement was made. Keeping the probability of primary malignancy in breast, she was further subjected to mammography which on Breast Imaging‑Reporting and Data System (BIRADS) showed BIRADS 5 on right side and BIRADS 2 on left side. Ultrasound of the breast revealed a heterogenous hyperechoic lesion of size 9 mm × 5 mm which was not palpable on clinical examination. Ultrasound guided fine needle aspiration cytology reported
a
c
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lesion in right breast as carcinoma infiltrating duct and from right axillary lymph nodes as metastasis. Whole body bone scan with technetium-99m methylene diphosphonate (MDP) revealed increased osteoblastic activity in multiple bones suggestive of wide spread skeletal metastasis [Figure 1e and f]. The uptake mechanism of Tc99m‑MIBI involves passive diffusion across plasma and mitochondrial membranes and at equilibrium it is sequestered within mitochondria by the large negative transmembrane potentials.[1] Studies have confirmed the relationship between cellular uptake of MIBI and mitochondrial activity or density.[2] The multi‑drug‑resistant P‑glycoprotein system uses MIBI as a substrate and effectively transports it out of tumor cell.[3] The overall concentration of Tc99m MIBI in tumors is a function of many variables including factors that affect the rate of uptake and that determine wash out or excretion from the cell.[4] Tc99m‑MIBI uptake in axillary lymph nodes could be due to involvement of lymphoma,[5] metastases of breast malignancy,[6] and extravasated radioactivity in the ipsilateral upper limb.[7] There have been studies evaluating the role of scintimammography using Tc99m MIBI for evaluation of primary carcinoma of breast and axillary lymph node metastasis.[8,9] Hypermetabolic lesion in axilla as an incidental finding in planar parathyroid scintigraphy with localization to lymph nodes on SPECT/CT in this suspected case of primary
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Figure 1: Technetium-99m methoxyisobutylisonitrile parathyroid scintigraphy [(a) early image; (b) washout image] negative for parathyroid adenoma showing a hypermetabolic lesion in right axilla. Single photon emission computed tomography/computed tomography (SPECT/CT) localized the uptake to the right axillary lymph node (arrows on CT (c) and SPECT/CT (d) images). Technetium-99m MDP whole body bone scan (e and f) revealed increased osteoblastic activity in multiple bones suggestive of wide spread skeletal metastases
Indian Journal of Nuclear Medicine | Vol. 27: Issue 2 | April-June, 2012
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hyperparathyroidism with brown tumors has helped in further evaluation for breast cancer. Subsequently, it was confirmed to be a case of breast carcinoma with axillary lymph nodal and bone metastases with hypercalcemia of malignancy. The findings had essentially changed the diagnosis and hence the management of the patient.
3. 4. 5. 6.
Sasikumar Arun, Ashwani Sood, Anish Bhattacharya, Bhagwant Rai Mittal
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Department of Nuclear Medicine and PET, Postgraduate Institute of Medical Education and Research, Chandigarh, India
8.
Address for correspondence: Dr. Bhagwant Rai Mittal, Department of Nuclear Medicine and PET, PGIMER, Chandigarh ‑ 160 012, India. E‑mail:
[email protected]
REFERENCES 1.
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Piwnica‑Worms D, Kronauge JF, Chiu ML. Uptake and retention of hexakis (2‑methoxyisobutyl isonitrile) technetium (I) in cultured chick myocardial cells. Mitochondrial and plasma membrane potential dependence. Circulation 1990;82:1826‑38. Delmon‑Moingeon LI, Piwnica‑Worms D, Van den Abbeele AD, Holman BL, Davison A, Jones AG. Uptake of the cation hexakis (2‑methoxyisobutylisonitrile)‑technetium‑99m by human carcinoma cell
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DOI: 10.4103/0972-3919.110706
F‑18 fluorodeoxyglucose positron emission tomography/computed tomography scan imaging in sarcoidosis involving multiple lymph nodes, lung parenchyma, liver and skeleton Sir, Sarcoidosis is a granulomatous disease of unknown etiology usually involving mediastinum. Extrathoracic involvement can be seen in one or more organs. Disseminated systemic involvement is rare. We report a patient with systemic sarcoidosis involving many intrathoracic and extrathoracic organs including multiple lymph nodes, lung parenchyma, liver and skeleton detected by F‑18 fluorodeoxyglucose (FDG) positron emission tomography (PET)/computed tomography (CT) imaging. F‑18 FDG PET/ CT was useful in this patient demonstrating the systemic involvement including liver and skeleton. A 63 year‑old woman who developed dsypnea 2 weeks ago was referred to Nuclear Medicine Department for PET/CT imaging due to a mass lesion in the middle lobe of the right lung and infiltration in the lower lobe of the left lung detected on CT scan [Figure 1]. 134
A PET scan with non‑diagnostic CT studywas performed. The blood glucose level was 98 mg/dL before injection of 333 MBq of F‑18 FDG. The images were obtained using Siemens Biograph Duo PET/CT after a 60 min uptake period. Three minutes per bed position was used for data acquisition. F‑18 FDG PET scans demonstrating multiple foci of increased uptake throughout the body. PET/CT images revealed foci of increased F‑18 FDG accumulation in the right cervical, supraclavicular and upper paratracheal, bilateral hilar, subcarinal and broncho‑pulmonary, and bilateral inguinal lymph nodes. Pathological F‑18 FDG uptake was observed in the middle lobe of right lung and infiltration in the lower lobe of left lung. PET/CT images demonstrating focally increased F‑18 FDG uptake in right lateral process of T6 vertebrae, inferior portion of the left scapula, spinous process of T11 vertebrae, left lamina of L3 vertebrae, main body of the right pubic bone and multiple irregular lesions in the liver [Figure 2]. Indian Journal of Nuclear Medicine | Vol. 27: Issue 2 | April-June, 2012
