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INTERESTING CASES
Year : 2021  |  Volume : 20  |  Issue : 3  |  Page : 324-326

Somatostatin-receptor avidity of pancreatic neuroendocrine tumor thrombus in porto-caval venous systems on 99mTc-Octreotide and posttherapeutic 177Lu-DOTA-TATE scans


1 Department of Nuclear Medicine, School of Medicine, Shahid Beheshti University of Medical sciences, Tehran, Iran
2 Department of Nuclear Medicine and Molecular Imaging, Farshchian Heart Center, School of Medicine, Hamadan University of Medical Sciences, Hamadan, Iran

Date of Submission16-Mar-2021
Date of Decision07-May-2021
Date of Acceptance24-May-2021
Date of Web Publication20-Aug-2021

Correspondence Address:
Dr. Mohsen Qutbi
Department of Nuclear Medicine, Taleghani Hospital, Yaman Street, Velenjak, Tehran 1985711151
Iran
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DOI: 10.4103/wjnm.wjnm_35_21

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   Abstract 

A 62-year-old woman with a history of abdominal pain presented with multiple hepatic lesions and dilatation of portal, splenic and superior mesenteric veins on the magnetic resonance imaging referred for a 99mTc-octreotide scan. Accordingly, similar octreotide-avid lesions were found as well as an uptake in the epigastric region conforming to the anatomy of the portocaval venous system, compatible with a tumor thrombosis. Then, the patient underwent two cycles of therapy with 177Lu-DOTA-TATE, on that the same appearance was observed. The uptake in the tumor thrombus remained somewhat unchanged, but clinically, a significant improvement of the intractable ascites was achieved.

Keywords: 177Lu-DOTA-TATE, 99mTc-Octreotide, pancreatic neuroendocrine tumor, somatostatin-receptor, tumor thrombosis


How to cite this article:
Amoui M, Ahmadi R, Qutbi M, Asli IN. Somatostatin-receptor avidity of pancreatic neuroendocrine tumor thrombus in porto-caval venous systems on 99mTc-Octreotide and posttherapeutic 177Lu-DOTA-TATE scans. World J Nucl Med 2021;20:324-6

How to cite this URL:
Amoui M, Ahmadi R, Qutbi M, Asli IN. Somatostatin-receptor avidity of pancreatic neuroendocrine tumor thrombus in porto-caval venous systems on 99mTc-Octreotide and posttherapeutic 177Lu-DOTA-TATE scans. World J Nucl Med [serial online] 2021 [cited 2021 Sep 25];20:324-6. Available from: http://www.wjnm.org/text.asp?2021/20/3/324/324172

A 62-year-old woman with a history of abdominal pain, episodes of hypotension, and syncope presented for a 99mTc-octreotide scan. On the ultrasonography (USG) performed before, there were multiple heterogeneous and hypoechoic masses in hepatic parenchyma and significant dilatation and intraluminal thrombosis of the portal and splenic veins. Doppler USG also showed intrathrombotic vascular components suggestive of tumor thrombosis. The patient then underwent a gadolinium-enhanced magnetic resonance imaging (MRI) of the abdomen which confirmed multiple hypointense lesions in the liver and portal, splenic and superior mesenteric venous dilatation with heterogenous enhancement [Figure 1]. After receiving an informed consent, whole-body 99mTc-octreotide scan [Figure 2] was performed that demonstrated multiple octreotide-avid lesions in the liver as well as a less intense uptake in the epigastric region conforming to the anatomy of the portal and the splenic venous system as those found on the MRI. Afterward, the patient underwent a liver biopsy. Poorly differentiated neuroendocrine carcinoma of pancreatic origin was confirmed on histopathologic examination. The patient was on Sandostatin LAR treatment for several months before being referred for a radiopeptide therapy with 177Lu-DOTA-TATE as a result of exacerbation of the symptoms and developing intractable ascites. On post-therapeutic whole-body scan one day following intravenous administration of 5550 MBq [150 mCi] of 177Lu-DOTA-TATE [Figure 3]a, the same findings were observed as those on the 99mTc-octreotide scan. The patient received another dose of 177Lu-DOTA-TATE therapy 6 months later [Figure 3]b. The ascites improved remarkably by clinical assessment thereafter, but other lesions remained unchanged. Neuroendocrine tumors of pancreatic origin are among the tumors with a predilection for involvement of the portal and caval venous systems through the direct intraluminal extension of malignant tumoral cells. This mechanism is other than the predisposition toward the hypercoagulable state, i.e. venous thrombosis, induced by cancer. The former seems to be prognostically less favorable, because of predictably less response to anticoagulation therapy.[1],[2],[3] Unfortunately, since the uptake can be attributed to radiotracer accumulation either in the activated leukocytes trapped in the clot or malignant tumoral cells, octreotide-based scans seem not to be able to reliably differentiate the two conditions, but CT and MRI are more useful by demonstrating different enhancing patterns.[4],[5] The octreotide avidity of tumor thrombus has been shown in previous reports on 68Ga-DOTA-TATE/NOC positron emission tomography scans,[6],[7],[8],[9] but the response to 177Lu-DOTA-TATE therapy is yet to be investigated. Currently, the effective therapeutic method is surgical resection of the thrombus to alleviate the unpleasant symptoms.[10] In our case, because of the patient's refusal, surgical thrombectomy was not performed, but despite octreotide avidity of the thrombus, two cycles of 177Lu-DOTA-TATE therapy were not remarkably effective. However, a considerable clinical improvement in ascites has been observed, and therefore, this achievement, i.e. symptom alleviation, can be of notable importance. Taken together, further investigations are required to assess the effectiveness of radiopeptide therapy in resolving tumor thrombus from neuroendocrine tumors.
Figure 1: Transverse (a and b) and coronal (c) slices of a gadolinium-enhanced magnetic resonance image show hepatic lesions, ascites (small arrowheads) and dilatation of the portal (small arrow), superior mesenteric (large arrowhead) and splenic (large arrow) veins as well as intraluminal tumor thrombosis

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Figure 2: Whole-body (a), tomographic slices (b-d) of the 99mTc-octreotide scan demonstrate multiple octreotide-avid lesion in the liver as well as uptake matching the anatomy of portal and splenic venous system

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Figure 3: Posttherapeutic 177Lu-DOTA-TATE scans of first (a) and second (b) cycles of therapy shows similar finding as those observed on 99mTc-octreotide scan

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Conflicts of interest

There are no conflicts of interest.

 
   References Top

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Kawakami H, Kuwatani M, Hirano S, Kondo S, Nakanishi Y, Itoh T, et al. Pancreatic endocrine tumors with intraductal growth into the main pancreatic duct and tumor thrombus within the portal vein: A case report and review of the literature. Intern Med 2007;46:273-7.  Back to cited text no. 1
    
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Naswa N, Kumar R, Bal C, Malhotra A. Vascular thrombosis as a cause of abdominal pain in a patient with neuroendocrine carcinoma of pancreas: Findings on (68) Ga-DOTANOC PET/CT. Indian J Nucl Med 2012;27:35-7.  Back to cited text no. 7
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Nguyen BD. Pancreatic neuroendocrine tumor with portal vein tumor thrombus: PET demonstration. Clin Nucl Med 2005;30:628-9.  Back to cited text no. 8
    
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Lim TC, Tan EH, Zaheer S. Use of Ga-68 DOTATATE PET/CT to confirm portal vein tumor thrombosis in a patient with pancreatic neuroendocrine tumor. Clin Nucl Med 2011;36:498-9.  Back to cited text no. 9
    
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Prakash L, Lee JE, Yao J, Bhosale P, Balachandran A, Wang H, et al. Role and operative technique of portal venous tumor thrombectomy in patients with pancreatic neuroendocrine tumors. J Gastrointest Surg 2015;19:2011-8.  Back to cited text no. 10
    


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  [Figure 1], [Figure 2], [Figure 3]



 

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