Case Author(s): Gregg Schubach, M.D./Keith Fischer, M.D. , 8/8/95 . Rating: #D3, #Q3

Diagnosis: Carcinoid Tumor

Brief history:

69-year old smoker with atypical chest pain. There is no significant past medical history.

Images:

Top: Exercise sestamibi images Bottom: Rest thallium images(delayed 18 hrs) All SPECT projection images.

View main image(mi) in a separate image viewer

View second image(xr). Chest Radiograph (contrast adjusted to highlight finding)

View third image(ct). Axial CT images

Full history/Diagnosis is available below

Diagnosis: Carcinoid Tumor

Full history:

The myocardial perfusion scintigraphy was performed using the dual isotope technique. The top row of images, which were performed using Tc-99m sestamibi during exercise, demonstrate an area of radiopharmaceutical uptake in the right upper lung medially. The bottom row, which are rest Tl-201 chloride images, demonstrate no abnormal pulmonary uptake. The chest radiograph obtained two days prior to the nuclear medicine examination demonstrates an ill-defined pulmonary nodule in the right upper lung zone medially. A CT scan of the chest obtained two days after the nuclear medicine examination demonstrates a noncalcified nodule in the right upper lobe.

Findings:

The myocardial perfusion scintigraphy was performed using the dual isotope technique. The top row of images, which were performed using Tc-99m sestamibi during exercise, demonstrate an area of radiopharmaceutical uptake in the right upper lung medially. The bottom row, which are rest Tl-201 chloride images, demonstrate no abnormal pulmonary uptake. The chest radiograph obtained two days prior to the nuclear medicine examination demonstrates an ill-defined pulmonary nodule in the right upper lung zone medially. A CT scan of the chest obtained two days after the nuclear medicine examination demonstrates a noncalcified nodule in the right upper lobe.

Discussion:

Although sestamibi is an excellent agent for evaluating myocardial perfusion, multiple reports indicate uptake in many malignancies. Indeed, sestamibi is currently being investigated as a potential diagnostic tool in the evaluation of breast masses. The pulmonary nodule may have been identified on the Tl-201 images, had the images been obtained immediately following the thallium administration. The rest images were obtained approximately 18 hours after Tl-201 administration.

Followup:

Subsequent bronchoscopy and biopsy report carcinoid tumor.

Major teaching point(s):

(1) This case highlights the importance of reviewing the projection images in addition to the SPECT images. The finding would have been undiagnosed had the projection images not been reviewed. (2) The radiographic features of carcinoid tumor of the lung include central location (80%) as is seen in this case. 90% of these malignancies are characterized as low grade with a ten year survival rate approaching 85% following surgery.

Differential Diagnosis List

Bronchogenic carcinoma is the most likely diagnosis of this sestamibi-avid pulmonary nodule in this 69-year old smoker.

ACR Codes and Keywords:

References and General Discussion of Myocardial Imaging (Anatomic field:Lung, Mediastinum, and Pleura, Category:Neoplasm, Neoplastic-like condition)

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Case number: mi007

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