11C-methionine- and 18F-FDG-PET double-negative metastatic brain tumor from lung adenocarcinoma with paradoxical high 18F-FDG uptake: A case report
- Department of Neurosurgery, Nagoya University Graduate School of Medicine,
- Division of Molecular Oncology, Aichi Cancer Center Research Institute,
- Department of Neurosurgery, Nagoya Central Hospital,
- Nagoya Radiosurgery Center, Nagoya Kyoritsu Hospital,
- Department of Pathology and Laboratory Medicine, Nagoya University Graduate School of Medicine, Nagoya, Japan,
- Department of Respiratory Medicine, Nagoya University Graduate School of Medicine, Nagoya, Japan.
Dr. Kuniaki Tanahashi, Department of Neurosurgery, Nagoya University Graduate School of Medicine, Nagoya, Japan.
DOI:10.25259/SNI_264_2022Copyright: © 2022 Surgical Neurology International This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, transform, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.
How to cite this article: Kuniaki Tanahashi1, Masaki Hirano1,2, Lushun Chalise3, Takahiko Tsugawa4, Yuka Okumura5, Tetsunari Hase6, Fumiharu Ohka1, Kazuya Motomura1, Kazuhito Takeuchi1, Yuichi Nagata1, Norimoto Nakahara3, Naozumi Hashimoto6, Ryuta Saito1. 11C-methionine- and 18F-FDG-PET double-negative metastatic brain tumor from lung adenocarcinoma with paradoxical high 18F-FDG uptake: A case report. 19-Aug-2022;13:372
How to cite this URL: Kuniaki Tanahashi1, Masaki Hirano1,2, Lushun Chalise3, Takahiko Tsugawa4, Yuka Okumura5, Tetsunari Hase6, Fumiharu Ohka1, Kazuya Motomura1, Kazuhito Takeuchi1, Yuichi Nagata1, Norimoto Nakahara3, Naozumi Hashimoto6, Ryuta Saito1. 11C-methionine- and 18F-FDG-PET double-negative metastatic brain tumor from lung adenocarcinoma with paradoxical high 18F-FDG uptake: A case report. 19-Aug-2022;13:372. Available from: https://surgicalneurologyint.com/surgicalint-articles/11804/
Background: Imaging with 18F-fluorodeoxyglucose (FDG)-positron emission tomography (PET) and 11C-methionine (MET)-PET can delineate primary and metastatic brain tumors. Lesion size affects the sensitivity of both scans and histopathological features can also influence FDG-PET, but the effects on MET-PET have not been elucidated.
Case Description: We report an unusual case of metastatic brain tumors without accumulation of FDG or MET, contrasting with high FDG uptake in the primary lung lesion. The brain lesions were identified as adenocarcinoma with a more mucus-rich background, contributing to the indistinct accumulation of both FDG and MET.
Conclusion: Histopathological characteristics can affect both MET and FDG accumulation, leading to findings contradicting those of the primary lesion.
Keywords: 11C-methionine-PET, 18F-fluorodeoxyglucose-PET, Lung adenocarcinoma, Metastatic brain tumor, Mucus
Tissue metabolism can be reflected by 18F-fluorodeoxyglucose (FDG)-positron emission tomography (PET) and 11C-methionine (MET)-PET, making these imaging modalities useful for delineating and assessing both primary and metastatic brain tumors.[
A 63-year-old man with the left deafness due to a small left acoustic neurinoma presented with a 1-month history of dizziness and gait disorder. Contrast-enhanced magnetic resonance imaging (MRI) demonstrated multiple tumors in the right cerebellar hemisphere, right cerebellar peduncle, and right parietal lobe [
(a-c) Gadolinium-enhanced magnetic resonance imaging of the brain at the initial visit. Two enhanced lesions are apparent in the right cerebellar hemisphere (31 × 19-mm solid component with 24 × 14-mm cystic part; 10 × 10-mm cystic tumor, arrows), one in the right cerebellar peduncle (22 × 18 mm, arrowhead) (a and b), and one in the right parietal lobe (5 × 4 mm, arrow) (c). (d) Computed tomography of the lung at the initial visit. A mass lesion is seen in the inferior lobe of the left lung.
Positron emission tomography (PET) of the brain and lung. (a and b) Images of brain PETs. Neither 18F-fluorodeoxyglucose (FDG)-PET (a) nor 11C-methionine-PET (b) shows significant uptake in the areas identified on gadolinium-enhanced magnetic resonance imaging [Figure 1] compared to surrounding normal brain tissue. (c) Image of lung FDG-PET. A high-uptake lesion is seen in the inferior lobe of the left lung.
Histopathological examinations of the lung and cerebellar lesions. (a and b) Acinar and cribriform patterns of tumor cells with increased chromatin and some mucin are invading the lung, showing moderately differentiated adenocarcinoma. Bar = 100 μm (a), Bar = 50 μm (b). (c) Columnar mucinous cells containing moderate cytological atypia and clear cytoplasm are forming a lepidic pattern in a mucin-rich background. The diagnosis is corresponding to the metastasis of lung adenocarcinoma. Bar = 100 μm.
Under general anesthesia, the lesions in the right cerebellar hemisphere were completely resected through a right suboccipital craniotomy in a prone position, with the lesion in the right cerebellar peduncle left untouched. The resected specimens were submitted for histopathological examination.
The postoperative course was uneventful and symptoms ameliorated. Histopathological examination revealed that the cerebellar lesions represented adenocarcinoma consistent with the lung lesion. However, more mucus-rich components were observed in the cerebellar lesions [
Gadolinium-enhanced magnetic resonance imaging of the brain after treatment. (a and b) The two cerebellar lesions are resected, and fractionated stereotactic radiosurgery (SRS) is administered to the lesions in the right cerebellar peduncle and right parietal lobe. No evidence of recurrence is demonstrated in the right cerebellar hemisphere (arrows). The lesion in the right cerebellar peduncle shows slight shrinkage 3 months after the completion of SRS (arrowhead) (a). The lesion in the right parietal lobe is stable (dashed arrow) (b). (c) The lesion in the right cerebellar peduncle shows marked shrinkage 4 years and 5 months after the completion of SRS (arrowhead) with no recurrence of the other lesions.
FDG-PET is well known to be useful for delineating malignant tumors by assessing metabolic activity.[
The negative rate of FDG-PET has been reported as 32–39% in metastatic brain tumors detectable on CT or MRI.[
The histological class of “colloid/mucinous/lepidic” in the international multidisciplinary classification of lung adenocarcinoma[
In addition to lesion size, histopathological features of metastatic brain tumors could be associated with negative findings on MET-PET as well as FDG-PET, which can contradict findings from the primary lesion. Proper assessment of results from PET studies is important when deciding on treatment strategies for metastatic brain tumors.
Institutional Review Board (IRB) permission obtained for the study.
This work was supported by a Grant-in-Aid for Early-Career Scientists awarded to K.T. (no. 20K17928) from the Japan Society for the Promotion of Science (JSPS).
There are no conflicts of interest.
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