Case Author(s): Jayson R. St. Jacques,M.D. and Henry D. Royal,M.D. , . Rating: #D3, #Q4
Diagnosis: Myocardial ischemia
Brief history:
66 year old woman with history of non-small cell lung cancer
Images:
Coronal PET images from neck to proximal thigh are shown.
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View second image(mi).
Myocardial imaging with one day Thalium-201/Tc-99m-Sestamibi protocol are shown.
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Myocardial imaging with one day Thalium-201/Tc-99m-Sestamibi bullseye target views are shown.
Full history/Diagnosis is available below
Diagnosis: Myocardial ischemia
Full history:
66 year old woman with history of non-small cell lung cancer, post radiation, undergoing chemotherapy. PET study requested for evaluation of recurrence.
Radiopharmaceutical:
12.0 mCi F-18 Flurodeoxyglucose (PET imaging)
2.5 mCi Thallium-201 chloride i.v. (myocardial study-rest)
21.6 mCi Technectium-99m sestamibi i.v. (myocardial study-exercise)
Findings:
PET study demonstrated no evidence of tumor recurrence. The study was compared to previous PET performed 4 months previously. Left lung apex activity consistent with post radiation changes, unchanged from prior exam. New finding of decreased activity in the lateral wall of the heart. At the time this was felt to represent infarct of the lateral wall or ischemia of the septal wall.
Rest and exercise stress myocardial imaging performed nine days later demonstated marked ischemia in the apex, anteroseptal wall, and septum. The patient had positive electrocardiographic changes of ischemia during the exercise stress component of the exam. The patient was assymtomatic during rest.
Discussion:
Interpretation of FDG cardiac uptake is complicated. In normal fasting patients, decreased septal uptake can be seen. In this case the decreased uptake was in the lateral wall. Decreased uptake could be due to infarction (decreased glucose metabolism) or septal ischemia (increased glucose metabolism seen with ischemia). With ischemia the myocardium decreases its utilization of fatty acids and increases its use of glucose.
Followup:
The patient underwent cardiac catherization 5 days after the thallium/sestamibi stress test. A complex 95% stenotic ostial left anterior descending artery lesion adjoining a large diagonal branch was identified. Patient underwent successful bifurcation stenting of the ostial left anterior descending artery.
ACR Codes and Keywords:
References and General Discussion of PET Tumor Imaging Studies (Anatomic field:Heart and Great Vessels, Category:Organ specific)
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Case number: pt081
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