Positron Emission Tomography with Fluorine-18-Fluorodeoxyglucose ...

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soft-tissue sarcoma to demonstrate how FDG PET can evaluate the outcome of this treatmentmodality. CASE REPORT. A 50-yr-oldwomanpresentedwith a high- ...

Positron Emission Tomography with Fluorine- 18-Fluorodeoxyglucose for the Evaluation of Therapeutic Isolated Regional Limb Perfusion in a Patient with Soft Tissue Sarcoma Omgo E. Nieweg, Jan Pruim, Harald J. Hoekstra, Anne M.J. Paans, Willem Vaalburg, Jan Oldhoff and Heimen Schraffordt Koops Department [email protected], Divirion [email protected] [email protected] and National PETResearch [email protected] The Netherlands

Mthods: The treatment of a patient with soft-tissue sarcoma was evaluated [email protected] FDG-PET. A [email protected] rernis sion of a locally advanced liposarcoma of the left thigh was achieved with isolated regional perfusionof the limb with tumor necrosis factor alpha, interferon gamma and meiphalan. R suits: PET with 18F-FDGbefore perfusionshowed high glucose

Center, University Hospital [email protected]

lated regional limb perfusion (HILP) with cytostatic drugs for limb-savingtreatmentin patientswith locally advanced lesions (9). The recent addition of tumor necrosis factor alpha to the HILP regimen offers a new and exciting treat ment option (10). We present a case of a locally advanced soft-tissue sarcoma to demonstrate how FDG PET can evaluate the outcome of this treatment modality.

consumptionin the tumor.Afterperfusion,glucosemetabolism in the tumorwasabsent Subsequentexcisionconfirmedcorn plate necrosisof the tumor.Conclusion: FDG-PETmay be CASE REPORT useful in evaluatingthe results of isolateralreglonal limb perfu A 50-yr-oldwomanpresentedwith a high-grademyxoidlipo sionfor soft-tissuesarcomas. sarcomaon thedorsalaspectof theleftthigh(Fig. 1).Thelesion Key Words: fluodne-18-fiuorodeoxyglucose; positron emIssIon tomography; glucose metabolIsm; Isolated lImb


was 20 cm in diameter. The size and proximity of the tumor to the

vessels (Fig.2A)preventedlocalexcisionwithan adequatemar gin. HILP with tumornecrosis factoralpha,interferongammaand

melphalanwas performedin an attempt to save the leg. PETstudieswere performedbeforeandafterHILPin a dy namicandrectilinearfashion.An i.v. dose of 8 mCi(296MBq)

J NuciMed1994;35:90-92

FDO was administered. A Siemens ECAT 951/31 camera was

used. The pretreatmentPET study showeda highlevelof glucose he potential of positron emission tomography (PET) consumptionin the tumor (Fig. 3A). In all planes, a region of with ‘8F-fluoro-2-deoxy-D-glucose (FDG) to visualize var interest was defined around the tumor using a contour analysis ious types of tumors is now well established (1,2). It has technique. The counts within the tumor were averaged per unit of volume for all planes. A Patlak analysis was performedand glu been suggested that PET with FDO may be used to eval cose consumption in the tumor was calculated, assuming a uate the response of a malignant tumor to chemotherapy lumpedconstant of 0.42 (11,12).The glucose consumptionwas and radiotherapy, since a decrease in tissue viability will 41.3 .unole/100g/min. result in a decrease of FDG accumulation (3—5). This po A rectilinearPET study 11 days afterHILPdemonstrateda tential applicationof PET may be of value in the manage coldspotatthesiteofthe tumor(Fig.3B).FDGuptakeintherest ment of patients with soft-tissue sarcoma. Preoperative chemotherapy in patients with localized

of the leg was increased, presumably due to the inflammatory


showed the tumor as a similar cold spot. Calculation of tracer


is the subject

of current


(6-8). Experience has been gained with hyperthermic iso

response caused by the HILP. A PET study 2 mo after HILP uptakedemonstratedno glucoseconsumptionin the lesion. In contrast to the PET study, repeat MIII showed only minor changes in comparison to the pretreatment

Received May27,1993; revIsion accepted Sept29,1993. Forcorrespondence [email protected] [email protected] O.E.Nisweg,TheNethedands Ca' cerInstitute, AntonivanLeeuwenhoek [email protected] Plesmanlaan 121,1066CXAmst& dan, TheNethedands.


MRI (Fig. 2B). The

tumormasswas locallyexcisedthe nextday(Fig.4). Pathologic examinationof the specimenrevealednecrosis; no viable tumor cells were found.

TheJournalofNuclearMedicine • Vol.35 • No.I • Janua,y1994




@. [email protected]

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FiGURE 3. Rectllk'iear FDG PET studies,anterkwvisws,before and 11 days after HILPof the left leg. Beforetreatment,increased glucoseconsumptionin the liposarcomaof the left leg is demon strated(A).After HILP,glucosemetabolismin the tumor is absent


a large liposarcofria (B). The friflammatoiy response in the treated leg is reflected by a


on [email protected] In the ensuing months, the patientdeveloped metastases in the lungs, the left breast, a lymph node in the neck and the 11th thoracic vertebra. She died 9 mo after HILP with widely metas tasized disease but without local recurrenceof the sarcoma. DISCUSSION This case illustrates that FDG-PET can suggest com

diffuseincreasein glucoseconsumptioncomparedto the otherleg.

necessary and when local excision with a limited mar gin—or perhaps even abstaining from excision—isjusti fled. Such studies should take into account the limited

spatial resolution ofPETascompared toMRI.Thepartial volume


due to this limited




underestimate FDG-uptake, especially in smaller tumors. plete remission of a soft-tissue sarcoma after HILP. The Consequently, it is possible that FDG-PET overestimates PET result was confirmed by surgical excision and histo the reductionof glucose consumption as induced by HILP. Another subject of concern in oncology studies with logic examination of the tumor. A few patients with soft-tissue sarcoma have a locally FDG, is the variability of uptake of FDG with fluctuating advanced tumor that threatens the limb. HILP with tumor blood glucose levels as was recently shown for bronchial necrosis factor alpha, interferon gamma and melphalan can carcinomas (13). To overcome this problem, all our patients help to save the extremity in a substantialnumberof these are studied after 6 hr of fasting. In diabetic patients, a nor moglycemic glucose clamp technique is applied. Since ef cases (10). Further studies will be needed to demonstrate whether PET with FDG is indeed able to discriminate fects on dynamic quantification using the Patlak approach between no response to chemotherapy, a partialresponse are less dependenton the plasma glucose levels, this is the and a complete remission. If the present result is con method of choice when reproducibility is needed (13). Approximately 40% of the patients with soft-tissue sar firmed, PET may be able to indicate when amputation is


MRI before HILP illustrates

the largesizeof the lesionand ftsproximfty

tothevessels(A). MRl2moafterHlLP showsa slightdecreasein tumorsizeand vascularity(B).

Chemotherapy Evaluationwfth PET and FDG • Nieweg at al.


2. StraussLG, ContiPS.Theapplications of PETin clinicaloncology.JNucl Med 1991;32:623—648.

3. MinnH, SemiI. Fluorine-18-fluorodeoxyglucose scintigraphyin diagnosis andfollowupof treatment in advanced breastcancer.Em'I NuciMed 1989;15:61—66. 4. HawkinsPA, HohC,DahlbomM, etal.PETcancerevaluationswith FDO. INuciMed


5. IchiyaY, KuwabaraY, OtsukaM, et al.Assessment of response to cancer therapyusingfluorine-18-fluorodeoxyglucose andpositmnemissiontomog raphy. INuciMed


6. Hoekstra JU,Schraffordt KoopsH,Molenaar WM,etal.A combination of intraarterial chemotherapy, preoperative and postoperative radiotherapy,

andsurgery aslimb-saving treatment of primarilyunresectable high-grade softtissuesarcomas of theextremities.Cancer1989;63:59-62. 7. EilberFR,MortonDL, EckardtJ, GrantT, Weisenburger T. Limbsalvage for skeletaland soft tissuesarosmas.Maltidisciplioaiypreoperativether amy.Cancer 1984;53:2579-2584.



@[email protected]__


FiGURE 4. Transection ofthesurgicalspecimenafterlimb-say ing [email protected] the entire

tumorwasnecrotic. coma die with distant metastases. With systemic chemo therapy, remission can be obtained in approximately 40% of these patients (14). A noninvasive technique to predict the outcome of chemotherapy in an early phase will be of value for patient management. In theory, PET has that potential. This study shows that research in this direction may be fruitful.

1. BeanyRP.Positron emission tomography in thestudyof humantumors.


sarcoma.I Cli,t Oncol 1992;10:52-60.

11. Patlakcs, Blasberg RG,FenstermacherJD. Graphical evaluation ofblood [email protected] CerebBlood Flow Metal, 1983;3:1—7.

12.Patlakc:s,Blasberg RG.Graphical evaluation of blood-to-brain transfer oonsthntsfrom multiple-time uptake data Generalizations.I Cereb Blood Flow Metab 1985;5:584-590.

13. Langen K-J,BraunU, RotaKopsE, etal.Theinfluence ofplasma glucose levels on fluotine-18-fluorodeoxyglucose uptake in bronchial carcinomas. I NuciMed 1993;34:355-359.

14.ChangAE, Rosenberg SA, GlatsteinEl, AntmanKH. Sarcomasof soft tissues.In: DeVitaJr VF, Hellinan5, Rosenberg SA,eds.Cancer.Pthzci

REFERENCES Semiii Nuci Med 1984;14:324—341.

8. PezziCM, PollockRE, EvansHL, et a!.Preoperative chemotherapy for soft-tissuesarcomasof the extremities.Ann Swg 1990;211:476-481. 9. HoekstraHJ,Schraffordt KoopsH, Molenaar WM, OldhoffJ. Results of isolatedregionalperfusionin thetreatmentof malignantsofttissuetumorof theextremities.Cancer1987;60:1703—1707. 10. LienardD, Ewalenko P, Delmotte J-J,RenardN, LejeuneFJ.High-dose recombinanttumornecrosisfactor alphain combinationwith interferon gammaandmelphalanin isolationperfusionof thelimbsfor melanoma and

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TheJournalof NuclearMedicine• Vol.35 • No. 1 • January1994

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