DOI:10.2214/AJR.05.0441
AJR 2007; 188:W503-W505
© American Roentgen Ray Society
Gastric Linitis Plastica from Metastatic Breast Carcinoma: FDG and FES PET Appearances
Jeffrey P. Kanne1,2,
David A. Mankoff3,
Geoffrey S. Baird4,
Satoshi Minoshima3 and
Robert B. Livingston5
1 Department of Radiology, University of Washington, Seattle, WA
98195-7115.
2 Present address: Division of Radiology, Cleveland Clinic, 9500 Euclid Ave.,
Hbb, Cleveland, OH 44195.
3 Division of Nuclear Medicine, University of Washington, Seattle, WA.
4 Department of Pathology, University of Washington, Seattle, WA.
5 Division of Hematology and Oncology, University of Washington, Seattle Cancer
Care Alliance, Seattle, WA.
Received March 14, 2005;
accepted after revision July 10, 2005.
Address correspondence to J. P. Kanne
(kannej{at}ccf.org).
WEB This is a Web exclusive article.
Keywords: breast cancer • FDG PET • FES PET • gastric linitis plastica • oncologic imaging • PET • radioisotopes
Introduction
Gastric linitis plastica is defined as diffuse thickening and rigidity of
the gastric wall resulting from inflammation and fibrosis. The most common
cause is gastric adenocarcinoma infiltrating the submucosa and muscularis
propria and the desmoplastic reaction it incites
[1]. Although rare,
hematogenous dissemination of infiltrating lobular carcinoma of the breast is
the most common metastatic cause of gastric linitis plastica
[1,
2].
PET using 2-[18F]fluoro-2-deoxy-D-glucose (FDG) has
become an important tool for staging breast carcinoma and monitoring response
to therapy
[3–5].
In addition, PET of estrogen receptor (ER)–positive breast neoplasms
with 16
-[18F]-17ß-fluoroestradiol (FES) has shown
promise as an investigational approach for measuring regional ER expression
and changes in estradiol binding in response to hormonal therapy
[3,
4,
6].
We present a case of gastric linitis plastica resulting from metastatic
lobular carcinoma of the breast with FDG and FES PET findings.
Case Report
A 79-year-old woman with metastatic breast carcinoma presented to her
medical oncologist with new complaints of early satiety, epigastric fullness,
and belching. Seven years earlier, she had undergone left lumpectomy, axillary
dissection, and locoregional radiation therapy for ER-positive infiltrating
lobular carcinoma of the breast with metastases to the ipsilateral axillary
lymph nodes. She was subsequently treated with a standard systemic
chemotherapeutic regimen followed by continuous hormonal therapy. Five and a
half years after her initial diagnosis, she developed scattered osseous
metastases.
Because of the patient's new abdominal symptoms, contrast-enhanced CT of
the abdomen and pelvis was performed and showed diffuse thickening of the
gastric wall (Fig. 1A,
1B,
1C,
1D,
1E,
1F). This examination was
followed by upper endoscopy, which revealed thickened, mildly nodular,
indurated, and erythematous gastric mucosa extending from the gastric fundus
to the distal body. Endoscopic biopsy revealed infiltrating lobular carcinoma
of the breast that stained positive for ER on immunohistochemical studies.
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Fig. 1A —79-year-old woman with gastric linitis plastica from
metastatic lobular carcinoma of breast. Contrast-enhanced CT images of upper
abdomen show diffuse gastric wall thickening (arrows). There are also
numerous hepatic metastases.
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Fig. 1B —79-year-old woman with gastric linitis plastica from
metastatic lobular carcinoma of breast. Contrast-enhanced CT images of upper
abdomen show diffuse gastric wall thickening (arrows). There are also
numerous hepatic metastases.
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Fig. 1C —79-year-old woman with gastric linitis plastica from
metastatic lobular carcinoma of breast. Attenuation-corrected image from FDG
PET shows increased FDG uptake in stomach (arrow), with maximum
standardized uptake value (SUV) of 4.4.
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Fig. 1D —79-year-old woman with gastric linitis plastica from
metastatic lobular carcinoma of breast. Attenuation-corrected image from
16-[18F]-17ß-fluoroestradiol (FES) PET shows increased
uptake in stomach (arrow), with maximum SUV of 7.0. Physiologic
uptake is present in liver (asterisk).
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Fig. 1E —79-year-old woman with gastric linitis plastica from
metastatic lobular carcinoma of breast. Photomicrograph of gastric biopsy
specimen shows infiltrate of incohesive cells surrounding gastric glands,
which is compatible with metastatic carcinoma. (H and E, x400)
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Fig. 1F —79-year-old woman with gastric linitis plastica from
metastatic lobular carcinoma of breast. Photomicrograph shows strong nuclear
staining of neoplastic cells with estrogen receptor, which is consistent with
lobular breast carcinoma. (estrogen-receptor immunohistochemical stain,
x400)
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Further restaging was performed with FDG PET (Advanced Tomographic, GE
Healthcare). A dose of 10.8 mCi (400 MBq) of FDG was injected IV 45 minutes
before scanning. The patient had undergone a 6-hour fast before scanning, and
her blood glucose level was 96 mg/dL at the time of injection. The patient's
body weight was 68 kg, and height was 1.7 m. Imaging consisted of five
adjacent 15-cm axial fields of view from the neck to pelvis with 7-minute
emission scans and 3-minute 511-keV transmission scans per field. Images were
acquired two-dimensionally and were corrected for attenuation using the
segmented transmission scans and were reconstructed by filtered
backprojection. The standardized uptake value (SUV) was calculated as tissue
activity (µCi/mL) divided by injected dose per patient's body weight
(mCi/kg). FDG PET showed unusually prominent and thickened gastric uptake,
with a maximum SUV of 4.4, in addition to several hypermetabolic foci in the
axial skeleton.
The patient also underwent FES PET as part of an ongoing research study
evaluating regional estradiol binding in metastatic breast cancer and changes
in response to hormonal treatment. This study was performed with the approval
of the University of Washington's institutional review board and the
Radioactive Drug Research Committee, and the patient signed informed consent
before the study.
FES imaging is considered experimental and is not used to direct patient
care; however, FES PET results are interesting in the context of this case.
After a short transmission scan, 5.0 mCi (185 MBq) of FES was injected IV over
2 minutes and was followed by dynamic emission imaging over the upper abdomen
from the time of the injection to 60 minutes. Data obtained from 30 to 60
minutes after injection were summed and reconstructed as described for FDG
PET. This was followed by a torso survey, consisting of five fields of view,
similar to FDG PET. The SUV was calculated as described for FDG PET; body
weight and height were unchanged from the prior FDG PET scan. FES PET showed
intense gastric uptake (maximum SUV = 7.0), correlating to the CT, FDG PET,
endoscopic, and histologic findings and suggesting high ER expression.
Discussion
The survival rate after detecting gastric metastases in patients with
breast carcinoma is 23% at 2 years, with a median survival of 10 months.
Favorable prognostic features include lobular subtype, ER positivity, and
simultaneous osseous metastases. A high number of prior treatment regimens is
an unfavorable prognostic indicator
[1].
The diagnosis of gastric metastases can be difficult because the signs and
symptoms are nonspecific. These include early satiety, nausea and vomiting,
epigastric pain, and weight loss. Moreover, other complications of breast
carcinoma, such as liver metastases, hypercalcemia, nonneoplastic gastritis,
and side effects of therapy, may produce similar clinical symptoms
[1]. Imaging findings of
gastric linitis plastica include rigidity and mural thickening on fluoroscopic
barium studies and diffuse mural thickening on CT
[2]. Findings on endoscopy can
mimic benign hypertrophic gastritis or primary infiltrating gastric
adenocarcinoma, and the sensitivity of endoscopic biopsy is limited by
extensive fibrosis and the depth of neoplastic cells within the gastric wall
[1].
FDG PET is a useful imaging tool for staging breast cancer in patients with
locoregional or metastatic recurrence when used in conjunction with CT, MRI,
and bone scintigraphy, particularly in the setting of osseous and regional
lymph node metastases [7]. In
addition, FDG PET can help determine and monitor response to systemic therapy
[3–5].
FDG uptake in the stomach can be physiologic, resulting from smooth-muscle
activity, or may be the result of nonneoplastic inflammation. One study of 763
patients showed that in patients without a specific history of esophagogastric
disease, a maximum SUV of < 4.0 in the stomach on FDG PET was generally not
associated with esophagogastric neoplasia and did not require further
evaluation [8].
Quantifying ER expression in both primary and recurrent breast neoplasms is
critical because ER-positive tumors are associated with longer disease-free
and overall survival than ER-negative breast tumors
[9]. Importantly, ER expression
also predicts the likelihood of response to hormonal therapy, which is often
preferred in patients with metastatic breast cancer
[8]. Immunohistochemical
staining of biopsy material is the reference standard for determining hormone
receptor expression in breast tumors; however, particularly in metastatic
disease, ER expression can be heterogeneous, and an assay of ER expression
from biopsy material can be prone to sampling error.
FES PET has shown promise in assessing ER expression in vivo, and measures
of FES uptake in primary tumors correlate with in vitro assays of ER
expression [6]. As such, FES
PET may also predict the likelihood of response to hormonal therapy
[4]. Although part of an
experimental study and not used to direct care in this case, FES PET showed
estradiol binding in a region that does not normally express ER—namely,
the stomach wall—and provided specific evidence of ectopic estradiol
binding that was consistent with disease spread as suggested by nonspecific
abnormalities seen on CT and FDG PET.
Although rare, gastric linitis plastica is an important complication of
metastatic breast cancer because the signs and symptoms may contribute to
patient discomfort and weight loss, potentially limiting treatment with
chemotherapy. In this case, endoscopic biopsy was diagnostic. However, in up
to 30% of patients with gastric linitis plastica, endoscopic biopsy may be
negative because the neoplastic cells usually infiltrate the deep layers of
the gastric wall [1]. In light
of the fact that gastric uptake of FDG can be nonspecific, additional imaging
with more specific agents may help identify metastatic tumor in patients with
negative or nondiagnostic endoscopic biopsies, especially when clinical
suspicion for gastric linitis plastica remains high. In this case, detection
of estradiol trapping in the stomach on FES PET showed the potential of tumor
receptor imaging for specific identification of metastasis.
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Introduction
Case Report
