PMC5551292_01
Multiple pulmonary nodules. Lesions indicated by arrows were confirmed in adjoining planes in the original CT scan to rule out that they might represent vessels
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F1
The patient was started on cabergoline 0.5 mg 6 cps/week and remained free of progression for 4 years, when in a follow-up chest CT multiple pulmonary nodules with soft tissue density in both lung fields were detected, measuring 0.5-1.2 cm [Figure 1].
(a) Scanned slide of lung biopsy obtained via bronchoscopy, stained with hematoxylin and eosin: Multiple well-defined rounded, strongly basophilic lesions in the lung parenchyma. (b) Cytoplasmic positivity for chromogranin in part of neoplastic cells indicates neurosecretory character
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F2
Ki-67 was positive in approximately 10% of the cells [Figure 2].
Left: 3D PET/CT Ga-68 DOTATATE showing moderate uptake in large pituitary lesion (SUV = 4.4). Right: Scintigraphy after Tc-99 HYNIC-octreotide showing no abnormal uptake in sellar region. The mild radiotracer uptake in the nasopharynx may be considered nonspecific
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F3
Despite a normal chromogranin dosage and of whole body scintigraphy after Tc-99m HYNIC-octreotide injection showing no abnormal uptake in sellar region, the 3D PET/CT Ga-68 DOTATATE images showed moderate uptake in large pituitary lesion (SUV 4.4) and very mild uptake in some of the lung lesions; however, no increased tracer uptake was detected in the liver, pancreas, and right kidney lesions [Figures 3-5].
3D images after F-18 FDG injection show physiologic brain uptake and markedly increased uptake in the pituitary and in multiple lung and liver lesions (left). Ga-68 DOTATATE show less impressive sellar uptake and very mild uptake in lung lesions (right)
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F4
Despite a normal chromogranin dosage and of whole body scintigraphy after Tc-99m HYNIC-octreotide injection showing no abnormal uptake in sellar region, the 3D PET/CT Ga-68 DOTATATE images showed moderate uptake in large pituitary lesion (SUV 4.4) and very mild uptake in some of the lung lesions; however, no increased tracer uptake was detected in the liver, pancreas, and right kidney lesions [Figures 3-5].
CT, PET, PET/CT and 3D-PET transaxial images. Superior row: F-18 FDG images show intense tracer uptake in the pituitary lesion (SUV33, black arrow). Inferior row: Ga-68 DOTATATE images show much less uptake with peripheral enhancement in the lesion (SUV4.4)
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F5
Despite a normal chromogranin dosage and of whole body scintigraphy after Tc-99m HYNIC-octreotide injection showing no abnormal uptake in sellar region, the 3D PET/CT Ga-68 DOTATATE images showed moderate uptake in large pituitary lesion (SUV 4.4) and very mild uptake in some of the lung lesions; however, no increased tracer uptake was detected in the liver, pancreas, and right kidney lesions [Figures 3-5].
MRI after enlargement of the lesion: Solid lobulated lesion with hyperintense components on T1 without gadolinium (hemorrhage) (a) and on T2-weighted (b). Heterogeneous enhancement on T1-weighted after gadolinium (c) with extension to both cavernous sinuses and right temporal lobe
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F6
HE (a) Pituitary tumor at first Surgery: Regular small cells in solid arrangement. Absence of mitosis or necrosis. (b) Second surgery: Nuclear atypia and hyperchromasia are more pronounced. (c) Extensive areas of coagulation necrosis, not observed in the original sample
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F7
The extensive necrotic areas in the pituitary tumor also supported the diagnosis of malignancy [Figure 7].