Scintigraphic Detection of Hepatic Metastases with 1311-Labeled Steroid in Recurrent Adrenal Carcinoma: Case Report
K. Watanabe, I. Kamoi, C. Nakayama, I. Koga, and K. Matsuura Kyushu University School of Medicine, Fukuoka, Japan
Abdominal scintigraphy using a new 1311-labeled steroid agent was per- formed on a 40-year-old woman proven by surgery to have adrenocortical carcinoma. Considerable accumulations were observed at the sites of liver metastasis. Hepatic scintigraphy and autopsy findings revealed that the ac- cumulation was more marked at the active cancer cells and only slight in the central necrotic tissue. Adrenal scintigraphy is valuable in the study of metastatic hormone-producing adrenal carcinoma. J Nucl Med 17: 904-906, 1976
Adrenal scintigraphy with 131I-iodocholesterol is of recognized value in the diagnosis of Cushing’s syndrome and primary aldosteronism attributable to adrenocortical adenoma (1-3). When symptoms of overproduction of adrenocortical hormone due to adrenocortical carcinoma are present, however, the diagnostic value of adrenal scintigraphy is thought to be low, because the uptake of 131I-iodocholesterol in the foci is small. Hardly any cases of adrenocor- tical carcinoma with adequate uptake of 131I-iodo- cholesterol have been reported, with the exception of Forman et al. (4), who were able to visualize localized recurrence and lymph node metastases in a postoperative case of adrenal carcinoma with Cushing’s syndrome.
Imaging with 1311-6-NCL,* a new steroid agent with a much higher adrenal uptake than 131I-iodo- cholesterol (5,6), we were able to visualize hepatic metastases in a postoperative case of adrenocortical carcinoma with Cushing’s syndrome.
CASE REPORT
A 40-year-old woman had a 5-year history of palpitations, headache, and dizziness on exertion. In July 1972 she was hospitalized for detailed exami- nation and treatment. Physical examination on ad-
mission revealed such characteristic findings of Cush- ing’s syndrome as moon face, truncal obesity, and purple striae. Her blood pressure was high (160/110 mm Hg). Biochemical tests showed urinary levels of 17-KS of 57.3 mg/day and 17-OHCS of 40.0 mg/ day, both being high. Blood cortisol was 33.0 µg/dl at 9 am, 29.4 mg/dl at 5 pm, and 31.5 mg/dl at 9 pm, all being high. Circadian rhythm was not ob- served. The response to a rapid suppression test with 4 mg of dexamethasone was negative. An ACTH-stimulation test was also negative and find- ings suggestive of autonomous hormonal produc- tion were obtained. Pneumoperitoneum and adrenal venography revealed a left adrenal tumor. In Sep- tember 1972, left total adrenectomy, left partial ne- phrectomy, and splenectomy were performed. The excised tumor measured 17 × 11 × 8 cm and weighed 1,450 gm. The histologic diagnosis was adrenocortical carcinoma. Cobalt teletherapy was given postoperatively and the course thereafter was good.
However, the patient was readmitted in January 1974, complaining of abdominal distension, ano- rexia, and right upper quadrant pain. Temporary subjective improvement occurred, but there was ag- gravation of the Cushing-like symptoms. Biochemical
* Iodine-131-68-iodomethyl-19-norcholest-5(10)-en-38-ol, manufactured by the Daiichi Radioisotope Co., Tokyo, Japan.
tests showed blood cortisol of 24.0 µg/dl, urinary 17-OHCS of 12.5 mg/day, and 17-KS of 45.4 mg/ day, these values all being markedly elevated. The liver was enlarged and palpable. Hepatic scintigraphy (Fig. 1A), after the intravenous injection of 3 mCi of 99mTc-sulfur colloid, revealed numerous defects in the enlarged liver, and the diagnosis of hepatic me- tastases was made. Thereafter, 700 Ci of 1311-6- NCL was intravenously administered, and 8 days later scintigraphy of the upper abdominal region was done. The anterior view (Fig. 1B) showed multifocal abnormal accumulation in the upper abdominal re- gion. The sites of abnormal accumulation of 1311-6- NCL clearly corresponded with the defects observed with 99mTe-sulfur colloid. These findings, the clinical symptoms, and the biochemical tests all provided the strong suspicion of hepatic metastasis of the adrenal carcinoma, with metastatic production of adrenocortical hormone. The patient was placed on methotrexate therapy, but there was no improvement and she died 1 year and 10 months after the opera- tion, with general prostration and cardiac insuffi- ciency.
At autopsy, the metastatic foci were found in the liver, lumbar vertebrae, and lymph nodes near the left renal artery. The right adrenal gland showed pronounced atrophy. The liver was markedly en- larged, measuring 36 × 33 × 12 cm. Many nodular metastatic foci, having sharp margins and diameters of 4-10 cm, were found in the liver. The smaller metastases were solid, but the centers of the larger nodules showed necrosis. Histologically, the meta- static foci were similar to adrenocortical cells, which is consistent with the histologic picture of the pri- mary focus.
DISCUSSION
Adrenal scintigraphy with 131I-iodocholesterol has been recognized as valuable for the localized diag- nosis of hormone-producing adrenal tumor (1-3) and for the recognition of hyperplasia of the adrenal cortex (7,8). In recurrent cases of Cushing’s syn- drome after total adrenectomy, this procedure is also of value in studying the remaining functional adrenal tissue (9). Because adrenocortical carcinoma is rarer than benign adrenocortical tumor, the value of ad- renal scintigraphy for the diagnosis of adrenocortical carcinoma has not yet been fully explored. How- ever, since the uptake of 131I-iodocholesterol per gram of cancer tissue is small, its diagnostic value is generally considered unimpressive (3). Only For- man et al. have claimed its value in the detection of metastatic foci from adrenocortical carcinoma (4). In their case report, small lymph node metastases were detected by scintigraphy, and the uptake of
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131I-jodocholesterol in the primary carcinoma was not necessarily small. The level of uptake of 131]- iodocholesterol in the tumor is probably largely de- pendent on hormone production in the cancer tissue.
In the present case, hepatic metastases of adreno- cortical carcinoma were detected by scintigraphy with 1311-6-NCL. Because 131I-labeled steroids, such as 131I-jodocholesterol and 1311-6-NCL, are excreted into the alimentary tract through the liver, liver ac- cumulation is typically high. In our case, activity higher than that of the normal liver background was observed in the metastatic foci of the adrenocortical carcinoma. When the 99mTc-sulfur colloid and 131]- 6-NCL scans are compared, it is seen that, if a defect in the former is comparatively small, uptake in the latter is usually good. On the other hand, when the defect is large, the uptake of 1311-6-NCL is better around the periphery and weak in the center. This agrees with our autopsy findings, which show central necrosis in the larger metastases, with adrenocortical- like cells around the periphery. The carcinoma cells concentrating 1311-6-NCL are clearly like the parent cells in .the primary tumor and can still produce adrenocortical hormone. We find a parallel situation in well-differentiated thyroid cancers and their metas- tases, which secrete thyroid hormones and concen- trate radioactive iodide.
The case reported by Forman et al. and our case suggest that 131I-jodocholesterol and 1311-6-NCL can be used in the diagnosis of metastases of adreno- cortical carcinoma. The accumulation of 1311-6-NCL in the adrenal cortex, compared with that in the liver, is about ten times the corresponding ratio for 131I-jodocholesterol. Thus, the former is promising for diagnostic purposes. In our case, adrenal scin- tigraphy proved useful in examining metastases of adrenocortical carcinoma that retained their hor- mone-producing function.
REFERENCES
1. CONN JW, BEIERWALTES WH, LIEBERMAN LM, et al .: Primary aldosteronism: Preoperative tumor visualization by scintillation scanning. J Clin Endocrinol Metab 33: 713-716, 1971
2. CONN JW, MORITA R, COHEN EL, et al .: Primary aldosteronism: Photoscanning of tumors after administra- tion of 1311-19-iodocholesterol. Arch Intern Med 129: 417- 425, 1972
3. LIEBERMAN LM, BEIERWALTES WH, CONN JW, et al .: Diagnosis of adrenal disease by visualization of human adrenal glands with 11I-19-iodocholesterol. N Engl J Med 285: 1387-1393, 1971
4. FORMAN BH, ANTAR MA, TOULOUKIAN RJ, et al .:
Localization of a metastatic adrenal carcinoma using 1311- 19-iodocholesterol. J Nucl Med 15: 332-334, 1974
5. KOJIMA M, MAEDA M, OGAWA H, et al .: Homo- allylic rearrangement of 19-iodocholesterol. JCS Chem Comm: 47, 1975
6. KOJIMA M, MAEDA M, OGAWA H, et al .: New adrenal- scanning agent. J Nucl Med 16: 666-668, 1975
7. BEIERWALTES WH, LIEBERMAN LM, ANSARI AN, et al .: Visualization of human adrenal glands in vivo by scintillation scanning. JAMA 216: 275-277, 1971
8. MATSUURA K, KAMOI I, WATANABE K, et al .: Adrenal scintigraphy using 11I-aldosterol. Radioisotopes 24: 780- 785, 1975
9. SCHTEINGART DE, CONN JW, LIEBERMAN LM, et al .: Persistent or recurrent Cushing’s syndrome after “total adrenalectomy.” Arch Intern Med 130: 384-387, 1972
CENTRAL CHAPTER SOCIETY OF NUCLEAR MEDICINE ANNUAL FALL MEETING
October 9-10, 1976
Madison, Wisconsin
Data Processing in Nuclear Medicine: An Assessment of Cost and Effort vs. Benefit
The versatility of available data-processing equipment is well established, but have patient and labora- tory benefits been well enough established to warrant purchasing the required specialized equipment in a community hospital setting? And if so, what kind of equipment should be purchased-a simple or a more sophisticated (and more expensive) system; hardwired, hybrid, or programmable computer? How much train- ing, particularly on the part of nuclear physicians and technologist staff, is needed to drive such systems effectively?
The faculty for this meeting will address itself to these topics in the course of a program intended to sur- vey established and imminent applications of data-processing systems.
Further information may be obtained by contacting:
Robert E. Polcyn, M.D., Director, Section of Nuclear Medicine, Department of Radiology, University of Wisconsin Hospitals, 1300 University Ave., Madison, WI 53706.