Current imaging and possible therapeutic management of glucagonoma tumors: a case report

Glucagonomas, like other neuroendocrine tumors, express somatostatin receptors in more than 80% of cases. Unfortunately, because of the rarity of these tumors, the sensitivity and specificity of somatostatin analog (octreotide) imaging have not been established. Nonetheless, there have been limited reports in the literature supporting the use of indium In-111 DTPA N-terminal D-phenylalanine (D-PHE1) octreotide for glucagonoma imaging and may be most beneficial as an adjuvant to conventional imaging for tumor staging and therapeutic decision making. Current therapeutic applications of octreotide focus on stabilization of disease in tumors expressing somatostatin receptors, and tumor destruction, using beta-emitting isotopes. In this report, imaging of a glucagonoma with In-111 DTPA-D-PHE1 octreotide scintigraphy is described in a 51-year-old woman examined for a large palpable abdominal mass.     

Therapy of neuroendocrine tumors with radiolabeled somatostatin-analogues.

Peptide receptor scintigraphy with the radioactive somatostatin-analogue [111In-DTPA0]octreotide (DTPA = diethylenetriaminepentaacetic acid) is a sensitive and specific technique to show in vivo the presence and abundance of somatostatin receptors on various tumors. With this technique primary tumors and metastases of neuroendocrine cancers as well as of many other cancer types can be localised. A new application is the use of peptide receptor radionuclide therapy, administrating high doses of 111In- or 90Y-labeled octreotide-analogues. PRECLINICAL: We investigated the radiotherapeutic effect of 90Y- and 111In-labeled [DOTA0,Tyr3]octreotide (DOTA = tetraazacyclododecanetetraacetic acid) or [111In-DTPA0]octreotide in Lewis rats bearing the somatostatin receptor-positive rat pancreatic tumor CA20948 in A) the flank or B) in the liver. PATIENTS: Thirty end-stage patients with mostly neuroendocrine progressing tumors were treated with [111In-DTPA0]octreotide, up to a maximal cumulative patient dose of about 74 GBq, in a phase 1 trial. PRECLINICAL RESULTS: A) Flank model: at least two 111MBq injections of [111In-DOTA0,Tyr3]octreotide were needed to reach tumor response, in 40% of the animals complete tumor remission was found after a follow-up period of 10 months. One or two injections of [90Y-DOTA0,Tyr3] octreotide yielded transient stable disease. B) Liver model: we found that peptide receptor radionuclide therapy is only effective if somatostatin receptors are present on the tumors, and is therefore receptor-mediated. High radioactive doses of 370 MBq [111In-DTPA0]octreotide or 93 MBq [90Y-DOTA0,Tyr3]octreotide can inhibit the growth of somatostatin receptor-positive metastases. CLINICAL RESULTS: There were no major clinical side effects after up to 2 years treatment, except that a transient decline in platelet counts and lymphocyte subsets can occur. Promising beneficial effects on clinical symptoms, hormone production and tumor proliferation were found. Of the 21 patients with progressive disease at baseline and who received a cumulative dose of more than 20 GBq [111In-DTPA0]octreotide, 8 patients showed stabilisation of disease and 6 other patients a reduction in size of tumors. There is a tendency towards better results in patients whose tumors have a higher accumulation of the radioligand. CONCLUSION: Radionuclide therapy with octreotide-derivatives is feasible, both with 111In and 90Y as radionuclides.     

111In-DOTA-lanreotide scintigraphy in patients with tumors of the lung.

Imaging with radiolabeled somatostatin (SST) analogs has recently been established for the localization of various human SST receptor (hsstr)-positive tumors, including neuroendocrine tumors, lymphomas, and non-small cell lung cancer (NSCLC). METHODS: 111In-1,4,7,10-tetraazacyclododecane-N,N',N",N"'-tetraacetic acid-lanreotide (DOTA-LAN) scintigraphy (150 MBq; 7 nmol per patient) was performed on 47 patients (28 patients with primary tumors, 19 patients with lung metastases from other tumors) to evaluate the tumor binding in patients with histologically confirmed lung cancer. A group of 27 tumor patients without documented lung lesions served as the control group. Early and delayed planar and SPECT images were acquired. Whole-body scintigraphy was performed at 0.5, 4-6, 24, and 48 h after injection for tumor dose estimation. In addition, hsstr subtype expression and radioligand binding characteristics were studied in vitro using lung tumor samples (n = 15). RESULTS: 111In-DOTA-LAN indicated the primary lung tumor in 16 of 16 NSCLC patients. Lymph node metastases were visualized in 6 of 6 NSCLC patients, and bone metastases were seen in 3 of 3 NSCLC patients. 111In-DOTA-LAN scintigraphy indicated lung carcinoid in 5 of 5 patients and small cell lung cancer lesions in 6 of 6 patients. Multiple lung metastases were shown in all 6 patients with non-Hodgkin's lymphoma and in the 1 patient with Hodgkin's disease, 5 of 5 colorectal adenocarcinoma patients, 4 of 4 carcinoid patients, 2 of 2 neuroendocrine carcinoma (NEC) patients, and 1 of 1 angiosarcoma patient. Pulmonary tumor sites not indicated by CT or MRI were visualized in 6 of 47 tumor patients (i.e., 13%; lung metastases in 1 carcinoid patient and 1 NEC patient, lymph node metastases in 1 carcinoid patient and 2 NSCLC patients, bone metastases in 1 carcinoid patient). The estimated lung tumor dose ranged between 0.2 and 5 mGy/MBq. Focal lung uptake of 111In-DOTA-LAN was not observed in any of the 27 control patients. In vitro binding studies indicated high-affinity binding sites for 111In-DOTA-LAN in NSCLC samples (dissociation constants, 0.5 and 4 nmol/L) with predominant expression of hsstr4. CONCLUSION: 111In-DOTA-LAN yields high tumor binding for various human lung tumors. Consecutively, radiopeptide therapy may offer a potential new treatment alternative for some lung tumor patients.     

Visualization of gallbladder with In-111 labeled octreotide in post prandial state

Somatostatin receptor scintigraphy is widely used in the management of neuroendocrine tumors. Somatostatin receptors are present in both neoplastic and normal tissues, which may lead to misinterpretation of the scans. Here, a patient with lung carcinoid imaged with In-111 octreotide is presented. Imaging was performed 4 and 24 hours after an intravenous injection of 185 MBq In-111 octreotide in the post prandial state. Whole body and SPECT images showed accumulation of radioactivity in the gallbladder. Imaging was repeated after fatty meal ingestion to differentiate abnormal activity and physiological uptake in the gallbladder. The abdominal SPECT studies at 28 hours revealed no uptake in the gallbladder, and the scintigraphic study was reported as normal so further excessive diagnostic procedures were prevented. Gallbladder can be visualized on somatostatin receptor scintigraphy even in the post prandial state. Delayed images after fatty meal administration are important for differential diagnosis.     

Metastatic Neuroendocrine Carcinoma Presenting as a "Superscan" on 68Ga-DOTANOC Somatostatin Receptor PET/CT

ABSTRACT: PET/CT imaging using Ga-labeled somatostatin analogs has become a popular noninvasive diagnostic modality in the workup of patients with neuroendocrine tumors. A 65-year-old man with pancreatic neuroendocrine tumor with confirmed liver metastases on conventional imaging underwent restaging Ga-DOTANOC PET/CT to monitor response to cold octreotide therapy. Previous PET/CT had shown presence of multiple liver and skeletal metastases along with a primary pancreatic tumor showing intense tracer uptake. The present PET/CT study showed an increase in number and uptake of the metastatic lesions suggestive of progressive disease resulting in the appearance of a superscan.     

Early massive accumulation of In-111 pentetreotide in a metastatic liver tumor of islet cell carcinoma

A 62-year-old woman was examined with In-111 pentetreotide and Ga-67 citrate. She had undergone an operation to resect a neuroendocrine tumor of the pancreas and still had masses in the liver. One of her hepatic lesions had been biopsied and acinar cell carcinoma was suspeted. Fluid in the cyst of the tumor, however, contained a high concentration of gastrin and the tumor was strongly suspected of being a metastasis from the neuroendocrine tumor of the pancreas. The hepatic tumors quickly accumulated In-111 pentetreotide immediately after the injection, but there was no Ga-67 citrate uptake in the tumor. Five months after pentetreotide scintigraphy, her hepatic tumors were resected and histologically proven to be metastasis of islet cell carcinoma. In-111 pentetreotide provides information of the somatostatin-receptor status on the tumor and supports the diagnosis made by hormonal survey.     

Imaging of non-small-cell lung cancer with indium-111 pentetreotide

PURPOSE: Lung cancer is the leading cause of cancer deaths in the United States. Non-small-cell lung cancer (NSCLC) accounts for 75% to 85% of lung cancers. CT has been the standard anatomic study for localizing and staging NSCLC, although it is associated only with moderate accuracy. In-111 pentetreotide, a radiolabeled somatostatin analog largely used in the scintigraphic localization of neuroendocrine tumors, has been shown incidentally to identify NSCLC lesions. This observation is important in the workup for metastatic disease for neuroendocrine tumors, because presumed metastatic lesions may actually be second primary tumors of NSCLC. In-111 may also serve as a potentially useful adjunct to CT in the anatomic evaluation of NSCLC. The purpose of this study was to determine the likelihood of detecting and localizing NSCLC using In-111 pentetreotide scintigraphy. MATERIALS AND METHODS: Ten patients with known or possible NSCLC were examined using In-111 pentetreotide. Scans were compared with the patients' previously performed chest radiographs and CT scans. RESULTS: In-111 pentetreotide imaging correctly identified sites of tumor involvement as detected by chest CT and surgery in all 10 patients with NSCLC. CONCLUSION: This study demonstrates the uptake of In-111 pentetreotide by NSCLC. This important observation should be considered in the workup for metastatic disease of neuroendocrine tumors with In-111 pentetreotide, because NSCLC can be a source of false-positive findings. In-111 pentetreotide imaging may also serve as a potentially useful adjunct to CT for identifying obscured or equivocal lesions and as an aid in localizing tissue for biopsy.     

Comparison of In-111 octreotide and Tc-99m (V) DMSA scintigraphy in the detection of medullary thyroid tumor foci in patients with elevated levels of tumor markers after surgery.

PURPOSE: In this retrospective study, the authors evaluated the utility of In-111 octreotide (OctreoScan) and Tc-99m (V) DMSA scintigraphy for the localization of recurrent metastatic tumor foci in patients with medullary thyroid cancer (MTC) and compared the findings with those of conventional radiologic imaging methods. METHODS: The scintigraphic images were compared with computed tomography (CT) and magnetic resonance imaging (MRI) and ultrasonography (US) in 14 patients (8 men, 6 women; age range, 22 to 74 years) with elevated calcitonin and carcinoembryonic antigen levels after total thyroidectomy. All scintigraphic image findings were evaluated qualitatively as mild uptake (+) and moderate to marked uptake (++). RESULTS: In-111 octreotide may be superior to Tc-99m (V) DMSA for the detection of tumor foci of patients with MTC on a patient basis (78.5% versus 57.1%) and on a lesion basis (44.1% versus 30.2%). The sensitivity rate for In-111 octreotide (78.5%) was also similar to that of CT and MRI on a patient basis. Conversely, the combined use of Tc-99m (V) DMSA and In-111 octreotide revealed the best sensitivity rate (85.7%) on a patient basis, whereas the combined use of CT and MRI showed the best sensitivity rate (81.3%) on a lesion basis. CONCLUSIONS: These findings suggest that In-111 octreotide is superior to Tc-99m (V) DMSA and has a similar sensitivity rate to CT and MRI for the diagnosis of recurrent or metastatic MTC. Although the combined use of In-111 octreotide and Tc-99m (V) DMSA was most sensitive, the combined use of CT and MRI with radionuclide imaging methods may better detect more metastatic tumor foci.     

111In-pentetreotide and123I-MIBG for detection and resection of lymph node metastases of a carcinoid not visualized by CT, MRI or FDG-PET

A patient with a history of a jejunal carcinoid and resection of liver metastases underwent CT, MRI and FDG-PET as well as somatostatin receptor scintigraphy using 111In-pentetreotide during follow-up. Octreoscan demonstrated one extrahepatic abdominal lesion with pathologic uptake, while the other imaging modalities failed to show a corresponding abnormality. For verification of this finding 123I-MIBG scintigraphy was performed. The MIBG scan confirmed the octreotide positive lesion and showed an additional abdominal lesion in the SPECT study. According to the scintigraphic results, radioguided surgery (RGS) was implemented using 123I-MIBG. This resulted in the intra-operative detection of two para- and pre-aortic lymph node metastases by the gamma probe and successful resection. An additional preaortal lymph node, suspicious by palpation, was also removed. Histopathology revealed metastases of a carcinoid tumor in all three specimens. In conclusion, the use of RGS facilitates successful removal of carcinoid metastatic lesions despite negative conventional imaging results. Secondly, 123I-MIBG scintigraphy may provide advantages over octreoscan for preoperative localization as well as radio-guided surgery of neuroendocrine metastatic lesions, if the involved site is located in proximity to highly octreotide-avid organs such as the kidneys or spleen.     

111In-octreotide scintigraphy: A tool to select patients with endocrine pancreatic tumors for octreotide treatment?

The results of octreotide scintigraphy, performed in two patients with malignant endocrine pancreatic tumors, were compared with the effect of somatostatin-14 and its analogue octreotide on hormonal levels and clinical outcome. Radiolabeled octreotide failed to demonstrate any tumor localisation in a patient with a malignant insulinoma. Nevertheless, IV injection of somatostatin and octreotide resulted in a significant decrease in peripheral insulin levels. Moreover in this patient, chronic treatment with a high dose of octreotide subcutaneously was able to transiently lower the incidence of hypoglycemic events. In a second patient with metastatic PP-oma,¹¹¹In-octreotide disclosed a pancreatic tumor in the tail of the pancreas and metastatic supraclavicular lymph nodes. In this patient IV administration of somatostatin and octreotide inhibited the hormonal secretion of the tumor but subcutaneous injection of octreotide induced hardly any decrease in plasma PP levels and failed to affect tumor growth. These observations find a possible reason for this in the heterogeneous affinity of the somatostatin receptors in endocrine pancreatic tumors. They indicate that octreotide scintigraphy alone should not be used to select patients with neuroendocrine tumors who can benefit from chronic treatment with the somatostatin analogue.     

Peptide receptor imaging and therapy.

This article reviews the results of somatostatin receptor imaging (SRI) in patients with somatostatin receptor-positive neuroendocrine tumors, such as pituitary tumors, endocrine pancreatic tumors, carcinoids, gastrinomas, and paragangliomas, or other diseases in which somatostatin receptors may also be expressed, like sarcoidosis and autoimmune diseases. [(111)In-DTPA0]octreotide is a radiopharmaceutical that has great potential for helping visualize whether somatostatin receptor-positive tumors have recurred. The overall sensitivity of SRI to localize neuroendocrine tumors is high. In several neuroendocrine tumor types, inclusion of SRI in the localization or staging procedure may be very rewarding in terms of cost effectiveness, patient management, or quality of life. The value of SRI in patients with other tumors, such as breast cancer or malignant lymphomas, or in patients with granulomatous diseases has to be established. The application of radiolabeled peptides may be clinically useful in another way: after the injection of [(111)In-DTPA0]octreotide, surgeons can detect tumor localizations by a probe that is used during the operation. This may be of particular value if small tumors with a high receptor density are present (e.g., gastrinomas). As the success of peptide receptor scintigraphy for tumor visualization became clear, the next logical step was to try to label these peptides with radionuclides emitting alpha or beta particles, or Auger or conversion electrons, and to perform radiotherapy with these radiolabeled peptides. The results of the described studies with 90Y- and (111)In-labeled octreotide show that peptide receptor radionuclide therapy using radionuclides with appropriate particle ranges may become a new treatment modality. One might consider the use of radiolabeled somatostatin analogs first in an adjuvant setting after surgery of somatostatin receptor-positive tumors to eradicate occult metastases and second for cancer treatment at a later stage.     

Detection of bone metastases in patients with endocrine gastroenteropancreatic tumors: bone scintigraphy compared with somatostatin receptor scintigraphy.

Scintigraphy with somatostatin analogs is a sensitive method for the staging and therapeutic management of patients with endocrine gastroenteropancreatic (GEP) tumors. The aim of this study was to compare prospectively somatostatin receptor scintigraphy (SRS) using 111n-pentetreotide with bone scintigraphy using 99mTc-hydroxymethylene diphosphonate for the detection of bone metastases. METHODS: One-hundred-forty-five patients with proven endocrine GEP tumors were investigated. Patients were classified according to the presence of bone metastases as indicated by CT, MRI or histologic data. Group I included 19 patients with confirmed bone metastases, and group II included 126 patients without bone metastases. RESULTS: In group I, SRS was positive in all 19 patients with bone metastases, and bone scintigraphy was positive in 17 patients. Bone metastases were found to occur predominantly in patients with liver metastases. In group 11, 5 patients had recent bone surgery for fracture or arthritis. SRS showed bone uptake in 4 of these patients, and bone scanning showed abnormal uptake in 5. In 7 of the remaining 121 group II patients, SRS was negative and bone scanning showed abnormal bone uptake suggesting bone metastases. The detection of bone metastases was of major prognostic value, because 42% of group 1 patients died during a 2-y follow-up. CONCLUSION: In patients with GEP tumors, the accuracy of SRS appears to be similar to that of bone scintigraphy for the detection of bone metastases.     

Bone metastasis from gastrinoma without hepatic involvement. Utility of the scintigraphy with 111 In-pentetreotide

The case of a 54 year old patient suffering from gastrinoma (within a type I multiple endocrine neoplasm) is presented. In 1990, she underwent a surgical resection. Eight years later, she suffered from a pain in the left thigh. The 99mTc-MDP bone scintigraphy showed bone metastasis. The CT scan did not show any hepatic involvement and the scintigraphy with 111In-Pentetreotide verified bone metastasis of a neuroendocrine tumor as a single expression of the recidive. In this case, the utility of the scintigraphy with octreotide to facilitate the localization and extent of the neuroendocrine tumors is demonstrated.     

Improved visualization of carcinoid liver metastases by indium-111 pentetreotide scintigraphy following treatment with cold somatostatin analogue

Five patients with hepatic metastases of midgut carcinoid underwent somatostatin receptor scintigraphy with indium-111 pentetreotide before and during treatment with octreotide. Octreotide treatment changed the biodistribution of ¹¹¹In-pentetreotide significantly. Whereas the radioactivity in liver, spleen and kidney decreased, hepatic metastases showed increased contrast. In one patient, liver metastases could only be detected during octreotide treatment. These data suggest that the diagnostic reliability of somatostatin receptor scintigraphy in carcinoid liver metastases is not necessarily compromised by octreotide therapy. Because of different biodistributions, the detection of liver metastases may even be improved during octreotide therapy. Correspondence to: U. Dörr     

Colorectal carcinoma: detection with indium-111 anticarcinoembryonic- antigen monoclonal antibody ZCE-025

A phase I and II clinical trial with indium-111-labeled anticarcinoembryonic-antigen monoclonal antibody ZCE-025 (In-111 ZCE-025) was initiated. Fifteen patients with colorectal tumors underwent external scintigraphy following the administration of 5.5 mCi (203.5 MBq) In-111 ZCE-025 at doses of 2.5-80.0 mg. Eighteen of 20 documented tumor sites, excluding those in the liver, were detected with In-111 ZCE-025. Lesions less than 1.5 cm could not be detected. Twenty-five percent of liver metastases exhibited positive accumulation of In-111 ZCE-025 at doses of 40-80 mg. No side effects were encountered. Because of the high detection rate of lymph node metastases from colorectal carcinoma with In-111 ZCE-025, this technique may be helpful in preoperative staging of patients with colorectal tumors, as well as in distinguishing recurrent tumors from postoperative or postradiation changes seen on computed tomography scans or other radiologic images.     

Tc-99m sestamibi and In-111 DTPA octreotide uptake in breast carcinoma with neurendocrine differentiation

Some breast tumors are classified as primary neuroendocrine carcinomas because of argyrophilia and positivity for neuroendocrine markers (chromogranins A and B and neuron-specific enolase), regardless of their cellular rest and cord structures. Tc-99m sestamibi has been widely used to identify epithelial breast carcinoma and lymph node metastases, whereas In-111 DTPA-octreotide has been used to identify primary and secondary neuroendocrine neoplasms specifically. The use of In-111 DTPA-octreotide and Tc-99m sestamibi scintigraphy in a woman with neuroendocrine differentiated cancer of the left breast is reported. Uptake of these radiopharmaceuticals only in the breast tumor permitted identification of a primary breast carcinoma, whereas absence of In-111 DTPA-octreotide uptake in other sites helped to exclude the presence of other neuroendocrine neoplasms in other organs.     

Bone metastases in carcinoid tumors: clinical features, imaging characteristics, and markers of bone metabolism.

The purpose of this study was to describe the clinical presentation of bone metastases in patients with carcinoid tumors and to determine the diagnostic value of imaging techniques and markers of bone metabolism. METHODS: This retrospective study was performed on the entire group of patients with carcinoid tumors treated in our hospital from January 1992 to May 1999. Only patients with metastasized tumors were included. RESULTS: Eleven of 90 patients (12%) (95% confidence interval [CI], 5%-19%) with a metastasized carcinoid tumor had symptomatic bone metastases. All bone metastases occurred in 55 patients with midgut carcinoids (20%; 95% CI, 9%-31%). Plain radiography had a sensitivity of 44% (95% CI, 12%-76%); MRI, 100% (95% CI, 61%-100%); bone scintigraphy, 90% (95% CI, 72%-100%); and octreotide scintigraphy, 60% (95% CI, 35%-93%). In 9 patients, both octreotide scintigraphy and bone scintigraphy were performed. Of 45 bone lesions, 22 (49%) were visualized by both modalities, 13 (29%) were visualized with octreotide scintigraphy but not with bone scintigraphy, and 10 (22%) were visualized with bone scintigraphy but not with octreotide scintigraphy. In 2 patients, octreotide scintigraphy and bone scintigraphy provided complementary results. Markers of bone metabolism could not discriminate carcinoid patients from those without bone metastases. The markers of bone metabolism did not reflect the osteolytic or osteoblastic appearance of metastases. CONCLUSION: Pain is the principal symptom of bone metastases in patients with carcinoid tumors. Plain radiography and markers of bone metabolism do not contribute to the diagnosis of bone metastases. MRI has a high sensitivity for bone metastases. Both bone scintigraphy and octreotide scintigraphy have acceptable sensitivity and can provide complementary results.     

The value of octreotide scintigraphy in patients with lung cancer

We evaluated octreotide scintigraphy in 81 untreated patients who were suspected of having bronchial carcinoma. Octreotide scintigraphy visualized the primary tumour in all of 40 patients with non-smallcell lung carcinoma (non-SCLC), and all of 26 patients with SCLC. In the remaining patients, other bronchial disease and metastases from extrapulmonary carcinomas were also visualized. Mediastinal lymph node involvement and distant metastases were recognized in 5 of 15 and 1 of 7 patients with non-SCLC, respectively. In vitro, none of the non-SCLCs were shown to bear somatostatin receptors. We postulate that the visualization of non-SCLC during octreotide scintigraphy is caused by binding of labelled octreotide to activated leucocytes or to proliferating neuroendocrine cells around the tumours. In patients with SCLC, radiologically suspected lymph node involvement was visualized for 21 of 25 sites. Distant metastases, especially to the liver and abdomen, were missed for 14 of 20 sites, most probably because no laxatives were administered and single photon emission tomography of the abdomen was not performed. The failure to recognize liver metastases is most probably due to a comparable uptake of radioactivity by the surrounding normal liver tissue. In 15 of 26 patients, previously unrecognized tumour sites were suggested during octreotide scintigraphy, leading to a downstaging of 5 of 14 patients with limited disease. Unexpected cerebral metastases were suggested in five patients with either limited or extensive disease. In all four of these for whom follow-up was available, cerebral metastases became manifest 5–8 months after octreotide scintigraphy. We conclude (1) that octreotide scintigraphy is of no use to differentiate SCLC from other lung disease, and (2) that octreotide scintigraphy should be included in the staging procedure of SCLC because it may allow early detection of metastases, especially to the brain.     

Diabetes mellitus and pancreatic tumor

A 68 year old Ecuadorian man was investigated for polyuria, polydipsia and weight loss of 3 kg during the previous two months. Insulin dependent diabetes mellitus was diagnosed 10 year before admission and treated with appropriate diet and insulin (35 U/d). 18 months before was diagnosed in El Ecuador of "multiple liver nodes non-suggestive of malignancy". Physical examination showed a large multinodular petrous hepatomegaly. There was no evidence of skin lesions. Results of laboratory studies included a basal plasma glucose level that ranged between 275-367 mg/dl (N=60-100), glycosylated haemoglobin of 8.9% (N<5) and a serum albumin of 2.8 gr./dl (N=3.4-4.8). At admission non-other laboratory alterations were detected. Computed tomography showed a mass on the head of the pancreas with loco-regional lymph nodes and liver metastases. Tumor markers were normal. Fine-needle aspiration cytology of the liver masses revealed the presence of liver metastases of a non-differentiated malignant tumor. A 111In-DTPAOC scintigraphy revealed the presence of somatostatin receptors in the liver metastases, also detecting the presence of multiple bone metastases in the axial and appendicular skeleton. Plasma glucagon level was 678 pg/ml (N<250). A diagnosis of metastatic glucagonoma was established and therapy with streptozocin, 5-FU, insulin and synthetic somatostatin analogs was initiated. Three months after the therapy initiation the patient was symptom free. Some weeks after the patient suffered from left hip pain, and a control 111In-DTPA scintigraphy showed progression of his bone metastases. In conclusion, glucagonoma must be suspected in all diabetic patients with metastatic liver, even in absence of necrotic migratory erythema. In these circumstances, plasmatic glucagon level and somatostatin receptors scintigraphy will be a useful tool for establishing the final diagnosis.     

Assessment of a neuroendocrine tumour by 111In-pentetreotid scintigraphy and PET with 18FFDOPA and 18F-FDG

We present the case of a 67 year old patient diagnosed of a neuroendocrine carcinoid tumour of the small intestine. The tumour and subsequent metastases were resected previously by surgery, but a new recurrence was suspected. CT showed left adrenal enlargement. 18F-FDG PET was normal and 111In pentetreotide scintigraphy showed liver and left diaphragmatic uptake. 18F-FDOPA PET showed uptake foci in liver and left diaphragm and also in left adrenal gland, retro urinary bladder area and multiple foci in abdominopelvic region, suggesting a peritoneal carcinomatosis. 18F-FDOPA PET was the first imaging modality to assess the extensiveness of the disease that was confirmed six month later by CT. Neuroendocrine tumors are a heterogeneous group of neoplasia. They are studied by conventional radiologic and functional techniques of nuclear medicine. This case illustrates the need to use the different techniques and tracers according to the characteristics of the tumor to be studied to thus improve the diagnostic and prognostic performance.