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LETTER TO THE EDITOR
Year : 2011  |  Volume : 7  |  Issue : 2  |  Page : 231-233

FDG avid "abdominal band" representing omental cake in mucinous adenocarcinoma of the appendix: Potential implications for disease monitoring with FDG-PET in this setting


1 Radiation Medicine Centre, Bhabha Atomic Research Centre, Tata Memorial Hospital Annexe, Mumbai, Maharashtra, India
2 Department of Pathology, Tata Memorial Hospital, Mumbai, Maharashtra, India

Date of Web Publication12-Jul-2011

Correspondence Address:
Sandip Basu
Radiation Medicine Centre (BARC), Tata Memorial Hospital Annexe, Jerbai Wadia Road, Parel, Mumbai - 400 012, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0973-1482.82939

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How to cite this article:
Basu S, Shet T. FDG avid "abdominal band" representing omental cake in mucinous adenocarcinoma of the appendix: Potential implications for disease monitoring with FDG-PET in this setting . J Can Res Ther 2011;7:231-3

How to cite this URL:
Basu S, Shet T. FDG avid "abdominal band" representing omental cake in mucinous adenocarcinoma of the appendix: Potential implications for disease monitoring with FDG-PET in this setting . J Can Res Ther [serial online] 2011 [cited 2019 Sep 21];7:231-3. Available from: http://www.cancerjournal.net/text.asp?2011/7/2/231/82939

Sir,

We herein report a case of a 61-year-old male who was diagnosed recently with moderately differentiated mucin-secreting adenocarcinoma of the appendix. On colonoscopy, it appeared as an ulcerated friable appendicular mass from which multiple biopsies were taken that was suggestive of this diagnosis [Figure 1]. He had undergone Fluorodeoxyglucose Positron Emission Tomography (FDG-PET) imaging with this referral diagnosis for a whole body disease survey. The whole body FDG-PET demonstrated an unusual broad and prominent FDG avid abdominal band. Also, there were certain discrete foci, which suggest peritoneal seeding by the disease and irregular FDG uptake superior and lateral surface of the liver [Figure 2]. The contrast-enhanced CT scan of the abdomen (undertaken in a different diagnostic center subsequently) reported diffuse thickening, stranding, and nodularity of the omentum forming an "omental cake" and also there was evidence of subcapsular hepatic deposits. The peritoneal biopsy proved this to be due to metastatic deposits of well-differentiated mucin-secreting adenocarcinoma consistent with the primary from the appendix [Figure 3]a and b.
Figure 1: Sections from the appendix tumor. The image shows dysplastic gland and signet ring cells in lamina propria (HandE, ×20)


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Figure 2: Whole body 18F-FDG-PET scan. (a) maximum image projection (MIP) images and (b) coronal images, done 60 min after the intravenous injection of 300 MBq of 18F-FDG, show diffuse and relatively intense FDG uptake in the form of a sheet or band noted in the upper abdomen. Also noted are certain discrete foci, which suggest peritoneal seeding by the disease. These were consistent with contrast-enhanced computed tomography (CECT) impression of omental involvement in the form of an "omental cake" by the disease. The irregular foci observed at the lateral and superior surface of the liver was consistent with the fi nding of subcapsular hepatic deposits in the CECT scan


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Figure 3: (a) Biopsy from peritoneum reveals moderately differentiated adenocarcinoma infi ltrating adipose tissue with fibrosis (HandE, 2); and (b) demonstrates the higher power view of the same (HandE, 10)


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Diffuse peritoneal infiltration (omental cake) occurs most commonly as secondary to intraperitoneal tumor spread. Other less common causes of the peritoneal infiltration include inflammatory conditions, such as tuberculosis, Crohn's disease, phlegmonous pancreatitis, granulomatous enterocolitis, and others. However, it most commonly results in ovarian or gastrointestinal cancer. The diagnosis has to be interpreted in a given clinical setting and the patient history and diagnosis. [1],[2] In our cursory experience, the peritoneal involvement by tuberculosis is usually characterized by a relatively low-grade diffuse uptake all over the abdomen, giving an appearance of enhanced background. We believe, however, a standardized uptake value (SUV) cutoff cannot be taken as confirmatory of a diagnosis, and the gold standard for diagnosis continues to be biopsy. The discussion of more cases like this will significantly help in developing an evidence base for noninvasive diagnosis with PET and will enhance its role and reliability in this setting.

The message and the learning points in the presented case are the following: (a) Recognizing the pattern of tracer uptake is of critical importance in the interpretation of PET imaging. The present case illustrates a very striking uptake pattern in the setting of peritoneal carcinomatosis. (b) The present case is interesting due to the fact that it depicts the role of FDG-PET in peritoneal metastatic deposits of well-differentiated mucin-secreting adenocarcinoma of the appendix, which is contrary to the common belief that it has a limited role in the evaluation of mucinous tumors, particularly in hypocellular lesions with abundant mucin. It has been reported that the sensitivity of FDG-PET imaging for the detection of mucinous carcinoma is significantly lower than in nonmucinous carcinoma. However, it should be remembered that the FDG uptake in a tumor is influenced by multiple factors, such as mitotic activity, tumor grade, Ki 67 index, and overall tumor biology. In a particular tumor type, high grades can be encountered that would predict aggressive biology and FDG uptake can be a surrogate biomarker for this. The present observation also raises the potential of this modality in these variants for noninvasive disease characterization and monitoring and image-guided biopsy in this setting.

 
 > References Top

1.Rodríguez E, Pombo F. Peritoneal tuberculosis versus peritoneal carcinomatosis: Distinction based on CT findings. J Comput Assist Tomogr 1996;20:269-72.  Back to cited text no. 1
    
2.Ha HK, Jung JI, Lee MS, Choi BG, Lee MG, Kim YH, et al. CT differentiation of tuberculous peritonitis and peritoneal carcinomatosis. AJR Am J Roentgenol 1996;167:743-8.  Back to cited text no. 2
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]


This article has been cited by
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Annals of Coloproctology. 2014; 30(2): 93
[Pubmed] | [DOI]



 

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