Positive Positron Emission Tomography/Computed ...

Lee et al

REFERENCES 1. Roberts C, Batstone PJ, Goodlad JR: Lymphadenopathy and lymph node infarction as a result of gold injections. J Clin Pathol 54:562-564, 2001 2. Maurer R, Schmid U, Davies JD, et al: Lymph-node infarction and malignant lymphoma: A multicentre survey of European, English and American cases. Histopathology 10:571-588, 1986 3. Brehaut LE, Anderson LH, Taylor DA: Extraskeletal Ewing’s sarcoma: Diagnosis of a case by fine needle aspiration cytology. Acta Cytol 30:683-687, 1986 4. Hense HW, Ahrens S, Paulussen M, et al: Descriptive epidemiology of Ewing’s tumor–analysis of German patients from (EI)CESS 1980-1997 [in German]. Klin Padiatr 211:271-275, 1999 5. Batziou C, Stathopoulos GP, Petraki K, et al: Primitive neurectodermal tumors: A case of extraosseous Ewing’s sarcoma of the small intestine and review of the literature. J Buon 11:519-522, 2006 6. Chow E, Merchant TE, Pappo A, et al: Cutaneous and subcutaneous Ewing’s sarcoma: An indolent disease. Int J Radiat Oncol Biol Phys 46:433-438, 2000 7. Kara G: Spinal cord Ewing’s sarcoma metastasis: Presentation of one case. Ann Nucl Med 18:623-626, 2004 8. Moodley M, Jordaan A: Ewing’s sarcoma of the vulva–a case report. Int J Gynecol Cancer 15:1177-1178, 2005 9. Moustafellos P, Gourgiotis S, Athanasopoulos G, et al: A spontaneously ruptured primitive neuroectodermal tumor/extraosseous Ewing’s sarcoma of the kidney with renal vein tumor thrombus. Int Urol Nephrol 39:393-395, 2007 10. Pekala JS, Gururangan S, Provenzale JM, et al: Central nervous system extraosseous Ewing sarcoma: Radiologic manifestations of this newly defined pathologic entity. Am J Neuroradiol 27:580-583, 2006 11. Baldini EH, Demetri GD, Fletcher CD, et al: Adults with Ewing’s sarcoma/ primitive neuroectodermal tumor: Adverse effect of older age and primary extraosseous disease on outcome. Ann Surg 230:79-86, 1999 12. Bacci G, Balladelli A, Forni C, et al: Adjuvant and neoadjuvant chemotherapy for Ewing sarcoma family tumors in patients aged between 40 and 60: Report

of 35 cases and comparison of results with 586 younger patients treated with the same protocols in the same years. Cancer 109:780-786, 2007 13. Bacci G, Forni C, Longhi A, et al: Long-term outcome for patients with non-metastatic Ewing’s sarcoma treated with adjuvant and neoadjuvant chemotherapies: 402 patients treated at Rizzoli between 1972 and 1992. Eur J Cancer 40:73-83, 2004 14. Bacci G, Picci P, Ferrari S, et al: Neoadjuvant chemotherapy for Ewing’s sarcoma of bone: No benefit observed after adding ifosfamide and etoposide to vincristine, actinomycin, cyclophosphamide, and doxorubicin in the maintenance phase–results of two sequential studies. Cancer 82:1174-1183, 1998 15. Bacci G, Ferrari S, Longhi A, et al: Therapy and survival after recurrence of Ewing’s tumors: The Rizzoli experience in 195 patients treated with adjuvant and neoadjuvant chemotherapy from 1979 to 1997. Ann Oncol 14:1654-1659, 2003 16. Nesbit ME Jr, Gehan EA, Burgert EO Jr, et al: Multimodal therapy for the management of primary, nonmetastatic Ewing’s sarcoma of bone: A long-term follow-up of the First Intergroup study. J Clin Oncol 8:1664-1674, 1990 17. Rosen G, Caparros B, Nirenberg A, et al: Ewing’s sarcoma: Ten-year experience with adjuvant chemotherapy. Cancer 47:2204-2213, 1981 18. Burgert EO Jr, Nesbit ME, Garnsey LA, et al: Multimodal therapy for the management of nonpelvic, localized Ewing’s sarcoma of bone: Intergroup study IESS-II. J Clin Oncol 8:1514-1524, 1990 19. Kolb EA, Kushner BH, Gorlick R, et al: Long-term event-free survival after intensive chemotherapy for Ewing’s family of tumors in children and young adults. J Clin Oncol 21:3423-3430, 2003 20. Smith MA, Ungerleider RS, Horowitz ME, et al: Influence of doxorubicin dose intensity on response and outcome for patients with osteogenic sarcoma and Ewing’s sarcoma. J Natl Cancer Inst 83:1460-1470, 1991 21. Paulussen M, Ahrens S, Dunst J, et al: Localized Ewing tumor of bone: Final results of the cooperative Ewing’s Sarcoma Study CESS 86. J Clin Oncol 19:1818-1829, 2001

DOI: 10.1200/JCO.2007.13.0930

■ ■ ■

Positive Positron Emission Tomography/Computed Tomography in Early Inverted Papilloma of the Maxillary Sinus A 62-year-old man had an elective [18F]fluorodeoxyglucose (FDG) positron emission tomography (PET)/computed tomography (CT) scan during his annual health examination by his own preference and expense at a local general hospital. The examination was carried out using a Siemens Biograph 6 PET/CT camera (CTI, Knoxville, TN) with a full-width at half-maximum of 4.5 mm and an axial field of view of 15 cm. Intravenous 370 MBq of FDG was used. Spiral CT was performed first, followed by dual-phase FDGPET. Reconstruction was performed by using ordered subset maximum likelihood expectation maximization. Unexpectedly, [18F]FDG PET-CT images at 1 hour after injection revealed a marked focal area of increased radioactivity uptake at the anterior inferior part of the patient’s left maxillary sinus (Figs 1 and 2). Maximal standardized uptake values (SUV) of the lesion were 9.0 at 1 hour and 18.1 at 2 hours after injection. Transaxial CT image showed a soft tissue lesion in the inferior aspect of his left maxillary sinus without evidence of bony destruction. The asymptomatic patient was referred to our tertiary teaching hospital. During endoscopic exploratory antrostomy, a well-defined, slightly bluish red mass (2.3 ⫻ 2.0 ⫻ 0.8 cm) that had a mildly granular surface was found at the anterior inferior part of his left maxillary sinus (Fig 3). Frozen section revealed inverted papilloma. Complete removal of the tumor together with all sinus mucosa was carried out easily and a nasoantral window was created to facilitate drainage and 4848

ventilation of the sinus, leaving the mucosa around the natural ostium undisturbed. Pathology report confirmed the diagnosis of inverted papilloma. Microscopically, the tumor showed an inverted growth pattern consisted of markedly thickened squamous epithelium, growing downward into the underlying stroma. The epithelium was composed of squamous, transitional, and columnar cells with marked chronic inflammatory cell infiltrate without evidence of concurrent malignancy (Fig 4). Immunohistochemical study showed low expression of Ki-67 in the lesion, indicating a low level of proliferative activity (Fig 5). We report what is, to the best of our knowledge, the first case of early inverted papilloma having very high SUVs that are indistinguishable from those of malignant diseases of the maxillary sinus. For different types of malignancy, or even for the same type of cancer of the paranasal sinuses, FDG uptakes may have a wider range than those of the benign diseases. A previous report showed that two cases of poorly differentiated squamous cell carcinoma of the maxillary sinus could have markedly different levels of FDG uptake (20.67 and 7.56, respectively) that may be attributed to the presence or absence of inflammatory cell infiltration such as lymphocytes inside the lesion.1 Another group reported three cases of inverted papilloma of the paranasal sinuses (two maxillary and one ethmoid).2 In their series, the SUV of FDG-PET for inverted papilloma ranged from 1.98 to 4.65, and the median value was 3.49. These values were lower than those from malignant tumors (SUV ranged from 1.78 to 19.36; median SUV, 12.6) in this region, although no statistical significance was found. On the contrary, our patient showed an exceptionally high SUV, which may be explained at least in part by the marked inflammatory response found JOURNAL OF CLINICAL ONCOLOGY

Downloaded from jco.ascopubs.org on December 30, 2011. For personal use only. No other uses without permission. Copyright © 2007 American Society of Clinical Oncology. All rights reserved.

Diagnosis in Oncology

Fig 1.

inside the lesion. Inverted papillomas are pathologically benign but clinically aggressive tumors most often occur within sinonasal cavities of the head and neck region. Overall concurrent malignancy is about 9%. For our patient, the value of [18F]FDG PET-CT is that the high uptake value has drawn our attention to perform an immediate exploration for the sinus lesion, otherwise a diagnosis of antral polyp or cyst should have been made by conventional CT. Early diagnosis of inverted papilloma, as for any malignant tumors, is also important in order to facilitate adequate treatment for this disease and to avoid recurrence. Other benign maxillary sinus conditions that may exhibit high SUV of [18F]FDG-PET include invasive aspergillosis infection of the paranasal sinuses3 and plasmacyte-rich chronic paranasal sinusitis.4

Among the armaments we have nowadays, [18F]FDG-PET has been considered to have a relatively higher sensitivity and specificity for cancer detection. However, to avoid misinterpretation, one must know the limitations and conditions in which false-negatives and false-positives could exist.5 Coregistered PET-CT has the advantage of better localization of the targets of interest by combining the structural information of CT with the functional information of PET. As yet, additional cost-effectiveness studies are ongoing for the role of PET-CT in initial investigation for pretreatment staging, as well as treatment result evaluation and post-treatment follow-up studies for metastasis, recurrences, and second primary.

Fig 2.

Fig 3. 4849

www.jco.org


Lee et al

Fig 4.

Fig 5.

In summary, our patient has shown that very high SUVs of [ F]FDG PET-CT can be detected even in small, asymptomatic inverted papilloma. These high uptakes were indistinguishable from those of maxillary sinus cancers, and were probably due to the presence of inflammatory infiltrates within the lesion. This is a previously unreported benign maxillary sinus tumor showing very high SUVs of [18F]FDG PET-CT. 18

Chang-Shen Lin Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan © 2007 by American Society of Clinical Oncology

AUTHORS’ DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST

The author(s) indicated no potential conflicts of interest. REFERENCES

Ka-Wo Lee and Wen-Rei Kuo Department of Otolaryngology, Faculty of Medicine, College of Medicine, Kaohsiung Medical University; and the Department of Otolaryngology, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan

Cheng-Chien Tsai Department of Nuclear Medicine, Yuan’s General Hospital, Kaohsiung, Taiwan

Yu-Wen Chen Department of Nuclear Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan

Chee-Yin Chai and Yue-Chiu Su Department of Pathology, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan

1. Kawabe J, Higashiyama S, Torii K, et al: Two cases of maxillary cancer with a similar clinical course and imaging findings but markedly different levels of FDG uptake. Clin Nucl Med 30:810-812, 2005 2. Ninomiya H, Oriuchi N, Kahn N, et al: Diagnosis of tumor in the nasal cavity and paranasal sinuses with (11C)choline PET: Comparative study with 2-(18F)fluoro-2-deoxy-D-glucose (FDG) PET. Ann Nucl Med 18:29-34, 2004 3. Kawabe J, Okamura T, Koyama K, et al: Relatively high F-18 fluorodeoxyglucose uptake in paranasal sinus aspergillosis: A PET study. Ann Nucl Med 12:145-146, 1998 4. Yasuda S, Shohtsu A, Ide M, et al: Elevated F-18 FDG uptake in plasmacyterich chronic maxillary sinusitis. Clin Nucl Med 23:176-178, 1998 5. Bakheet SM, Powe J: Benign causes of 18-FDG uptake on whole body imaging. Semin Nucl Med 28:352-358, 1998

DOI: 10.1200/JCO.2007.13.1540 ■ ■ ■

4850

JOURNAL OF CLINICAL ONCOLOGY
