Severe Pulmonary Emphysema with Secondary

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肺氣腫之正子造影. PET of pulmonary emphysema. 核子醫誌 2005;18:121-125. 2005年6月 18卷2期. 123. Figure 4. CT of the chest with lung window (left) shows ...
Severe Pulmonary Emphysema with Secondary Pulmonary Hypertension: 18F-FDG PET Abnormalities Ching-Yuan Chen1, Wei-Jen Shih2, Wen-Sheng Huang1, Hong-Ming Zhuang3, Primo Milan4, Daniel Hong-Yuan Shen1, Yu-Ming Fan1, Shiou-Chi Cherng1 1

Department of Nuclear Medicine, Tri-Service General Hospital, Taipei, Taiwan, Nuclear Medicine Service, Veterans Administration Medical Center; Department of Diagnostic Radiology, College of Medicine, University of Kentucky, Lexington, KY, USA 3 Division of Nuclear Medicine, Department of Radiology, University of Pennsylvania Hospital, Philadelphia, PA, USA 4 Department of Diagnostic Radiology, College of Medicine, University of Kentucky, Lexington, KY, USA 2

A 60-year-old male presented with a solitary pulmonary

detection of unexpected cardiac abnormalities by FDG-

nodule (SPN) in the right upper lobe by computed

PET in patient evaluated for SPN.

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tomography (CT) of the chest. He was referred for Ffluorodeoxyglucose positron emission tomography

Key words: solitary pulmonary nodule (SPN), 18F-fluo-

(FDG-PET) to evaluate the nature of the nodule. FDG-

rodeoxyglucose positron emission tomography (FDG-

PET images showed downward displacement of both

PET), emphysematous changes of both lungs, enlarge-

diaphragms with flattened upper boarder of the liver,

ment of both ventricles

elongated vertical dimension of the thoracic cavity, and increased radioactivity in the region of the stomach,

Ann Nucl Med Sci 2005;18:121-125

while there was no definite lesion with increased FDG metabolism in the lungs. In addition, the following cardiac chamber abnormalities were found: thickened

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F-fluorodeoxyglucose positron emission tomography

inter-ventricular septum, well visualization of the right

(FDG-PET) has been used to measure the increased glucose

and left ventricles - thicken free walls of the left and

metabolism in tumor cells [1], which has a high rate of glu-

right ventricles. Follow-up chest radiography showed

cose consumption under both aerobic and anaerobic condi-

downward displacement of both diaphragms with elon-

tions. The FDG-PET has reached widespread application in

gation of vertical dimension of both lungs, consistent

the assessment of solitary pulmonary nodule (SPN) [2]. The

with emphysematous changes. CT of the chest with

goal of FDG metabolic evaluation of a SPN is to distinguish

lung window demonstrated emphysematous changes of

between benign and malignant disease [2]. Most of SPNs are

both lungs, consistent with pulmonary emphysema and

benign, only one-three is malignant lung cancer. Currently

enlargement of both ventricles, corresponding to sec-

plain radiography and computed tomography (CT) are most

ondary pulmonary hypertension with ventricular abnor-

commonly used modalities [3]. However, most noncalcified

malities. In summary, we discovered that incidental

SPNs may remain indeterminate on the basis of results at plain radiography and CT. The authors present that incidental detection of unexpected cardiac abnormalities by FDG-PET

Received 12/6/2004; revised 3/3/2005; accepted 3/5/2005. For correspondence or reprints contact: Shiou-Chi Cherng, M.D., Department of Nuclear Medicine, Tri-Service General Hospital, 325 Section 2, Cheng-Kung Road, Nei-Hu, Taipei 114, Taiwan, ROC. Tel: (886)2-87927374, Fax: (886)287927217, E-mail: [email protected]

in patient evaluated for SPN.

ౘᇉ̮ ඈ Chen CY et al

Case Report A 60-year-old male smoker presented with a long-term history of dry cough. CT of the chest disclosed a SPN in the right upper lobe (Figure 1). He was referred for FDG-PET to evaluate the nature of the nodule. Nuclear Medicine and Related Studies Coronal section of PET images showed downward dis-

Figure 3. Follow-up chest radiography shows downward displacement of both diaphragms with elongation of vertical dimension of both lungs, consistent with emphysematous changes. Figure 1. A CT image shows a nodule in the right upper lobe (arrow) of the lungs.

placement of both diaphragms with flattened upper boarder of the liver, elongated vertical dimension of the thoracic cavity, and increased radioactivity in the region of the stomach, while there was no definite lesion with increased FDG metabolism in the lungs. In addition, the following cardiac chamber abnormalities were found: thickened inter-ventricular septum, well visualization of the right and left ventricles?thicken free walls of the left and right ventricles (Figure 2). Follow-up chest radiography showed downward displacement of both diaphragms with elongation of vertical dimension of both lungs, consistent with emphysematous changes (Figure 3). CT of the chest with lung window demonstrated emphysematous changes of both lungs and enlargement of both ventricles (Figure 4). Diagnosis

Figure 2. Coronal section of 18F-FDG PET images show downward displacement of both hemi-diaphragms with flattened upper boarder of the liver, elongated vertical dimension of the thoracic cavity, and increased radioactivity in the region of the stomach (arrowhead). In addition, thickened inter-ventricular septum and well visualization of the right and left ventricles-thicken free walls of the left and right ventricles are noted.

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1. Severe Pulmonary Emphysema with secondary pulmonary hypertension 2. Enlargement of both ventricles

Discussion Increased FDG uptake in the right cardiac chambers in

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۱ঈཚ̝ϒ̄ౄᇆ PET of pulmonary emphysema

Figure 4. CT of the chest with lung window (left) shows emphysematous changes of both lungs and enlargement of both ventricles; mediastinal window (right) also shows enlargement of both ventricles. R: right ventricle, L: left ventricle.

a patient with pulmonary emphysema has been reported [3-

2. Fischer BM, Mortensen J, Dirksen A, et al. Positron

5]. However, our patient is different in describing symmetri-

emission tomography of incidentally detected small pul-

cal downward displacement of both diaphragms, elongated

monary nodules. Nucl Med Comm 2004;25:3-6.

vertical dimension of the thoracic cavity, and increased FDG

3. Gupta NC, Frank AR, Dewan NA, et al. Solitary pul-

uptake in inter-ventricular septum and both ventricles. We

monary nodules: Detection of malignancy with PET with

emphasize that visualization of downward displacement of

2-[F-18]-fluoro-deoxy-d-glucose. Radiology 1992;184:

both diaphragms and flattened upper boarder of the liver

441-444.

seen on FDG-PET is a sign of emphysematous changes of

4. Duarte PS, Zhuang H, Machado C, Aldighieri F, Martins

the lungs, which were well revealed on follow-up chest radi-

LR, Alonso G. Increased FDG uptake in the right cardiac

ography and CT images; consequence of pulmonary emphy-

chambers in a patient with pulmonary emphysema. Clin

sema results in pulmonary hypertension and right ventricle

Nucl Med 2002;27:605-606.

overload leading to enlargement of the right and left ventri-

5. Fujii H, Ide M, Yasuda S, Takahashi W, Shohtsu A,

cles, especially in inter-ventricular septum. In summary, it

Kubo A. Increased FDG uptake in the wall of the right

has been demonstrated that incidental detection of an unex-

atrium in people who participated in a cancer screening

pected malignant and/or pre-malignant tumor by FDG-PET

program with whole-body PET. Ann Nucl Med

in patients evaluated for SPN [6-11]. Variation in cardiac

1999;13:55-59.

activity resulting from coexisting heart diseases, such as car-

6. Otani H, Kagaya Y, Yamane Y, et al. Long-term right

diomyopathy or pulmonary hypertension, may be also noted,

ventricular volume overload increases myocardial fluo-

when reviewing the whole body studies of FDG-PET

rodeoxyglucose uptake in the interventricular septum in

obtained for oncology purpose.

patients with atrial septal defect. Circulation 2000;101:1686-1692.

References 1. Wahl. RL, Hutchins GD, Buchsboaum DJ, et al. 18F-2deoxy-2-fluror-deoxyglucose uptake into human xenografts. Cancer 1991;67:1544-1550.

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7. Agress H Jr, Cooper BZ. Detection of clinically unexpected malignant and premalignant tumors with wholebody FDG PET: histopathologic comparison. Radiology 2004;230:417-422.

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positron emission tomographic scans may represent a

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8.

emission tomography imaging to cancer screening. Br J

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