British Journal of Radiology (2004) 77, 74-75
© 2004 British Institute of Radiology
doi: 10.1259/bjr/19323466
Tumour vaccine associated lymphadenopathy and false positive positron emission tomography scan changes
R L Jones, BSc, MRCP1,
D Cunningham, MD, FRCP1,
G Cook, MD, FRCP, FRCR2 and
P J Ell, MD, PhD, FRCP, FRCR3
1 Gastrointestinal and 2 Nuclear Medicine Departments, Royal Marsden Hospital, Down's Road, Sutton, Surrey SM2 5PT and 3 Institute of Nuclear Medicine, UCL, The Middlesex Hospital, Mortimer Street, London W1T 3AA, UK
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Abstract
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A patient receiving intradermal injections of vaccine directed towards carcinoembryonic antigen-bearing metastases from colorectal cancer showed uptake of 18F-fluorodeoxyglucose in local draining lymph nodes during the course of treatment. This appearance should be considered as a possible false positive in patients undergoing such treatment who are being investigated with PET scans.
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Introduction
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Carcinoembryonic antigen (CEA) is a tumour-associated antigen present on neoplasms of the gastrointestinal tract as well as other adenocarcinomas. The majority of colorectal cancers (90%) express CEA on their cell surfaces. Immmunological treatment directed towards CEA-bearing tumours has been developed using a tumour vaccine (CeaVac) [1] given intradermally.
[18F] fluorodeoxyglucose (FDG) positron emission tomography (PET) has been shown to be of significant clinical use in colorectal cancer, particularly in patients with increased CEA [2], but a number of potential imaging pitfalls have also been described [3].
We describe the first case of benign lymphadenitis associated with the use of the CEA vaccine, CeaVac, in the treatment of advanced colorectal carcinoma. The case displayed false positive increased uptake on PET scanning into regional lymph nodes draining the CeaVac injection site.
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Case report
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The patient is a 63-year-old man who had an anterior resection for a Dukes C adenocarcinoma of the rectosigmoid junction. The radial margin was clear and 1 out of 22 lymph nodes contained tumour. He had no past medical history apart from previous exposure to asbestos, as evidenced by pleural plaques on the plain chest radiograph.
A CT scan revealed three liver lesions suspicious of metastatic disease. Subsequent MRI scanning revealed these lesions to be cysts. PET scanning revealed no obvious uptake in the liver and abnormal uptake in the right hilar region. His CEA level was 2 µg l-1 (normal range <5 µg l-1).
He was commenced on an advanced disease protocol consisting of 5-FU/folinic acid/CeaVac 6 weeks following surgery. A PET scan performed 2 months after starting CeaVac revealed FDG avid disease in the right hilum and right axillary region. Repeat PET scanning after a further 2 months demonstrated a new focus in the liver and continued right axillary and hilar uptake (Figure 1a
).
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Figure 1. (a) Coronal 18FDG PET slice showing abnormal uptake in the liver, right hilum and right axilla during treatment with CeaVac injections into the right deltoid. (b) Coronal 18FDG PET slice 1 month after completion of CeaVac showing continued abnormal activity in the liver and right hilum but no further abnormality in the right axilla.
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After a further 2 months he had completed 8 cycles of 5-FU/folinic acid/CeaVac. Further follow-up CT confirmed a new solitary metastasis in the liver. At this time it was decided to change chemotherapy to capecitabine and oxaliplatin.
A subsequent PET scan performed 1 month after stopping CeaVac revealed a normal right axilla but continued uptake in right hilum and liver (Figure 1b
).
The most likely cause of the right axillary lymphadenopathy was as a secondary response to CeaVac treatment recently given intradermally in the right deltoid region. The time course of axillary uptake corresponding to CeaVac treatment and the presence of progressive disease in the liver whilst axillary uptake disappeared, support this. In addition, there was no clinical evidence of local skin disease or peripheral inflammation that might have caused reactive lymph nodes. This case is the first reported of false positive PET scanning associated with the use of CeaVac in colorectal cancer. This is an important finding as management could be altered on the basis of the PET scan result. PET positive isolated lymphadenopathy should be reviewed in patients receiving CeaVac treatment for colorectal cancer, particularly when it occurs at a site not commonly associated with metastatic spread from this cancer. A full history from the patient at the time of scanning and discussion of all relevant clinical details and treatment at multidisciplinary meetings are also steps that may help prevent similar potential imaging pitfalls.
Received for publication July 18, 2002.
Revision received March 13, 2003.
Accepted for publication April 24, 2003.
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References
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- Foon KA, John WJ, Chakraborty M, Das R, Teitelbaum A, Garrison J, et al. Clinical and immune responses in resected colon cancer patients treated with anti-idiotype monoclonal antibody vaccine that mimics the carcinoembryonic antigen. J Clin Oncol 1999;17:2889–95.[Abstract/Free Full Text]
- Valk PE, Abella-Columna E, Haseman MK, Pounds TR, Tesar RD, Myers RW, et al. Whole-body PET imaging with [18F] fluorodeoxyglucose in management of recurrent colorectal cancer. Arch Surg 1999;134:503–11.[Abstract/Free Full Text]
- Cook GJR, Fogelman I, Maisey MN. Normal physiological and benign pathological variants of 18-FDG PET scanning: potential for error in interpretation. Sem Nucl Med 1996;26:308–14.[CrossRef][Medline]
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