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Pitfalls in Cancer Evaluation in Case of Chronic Superior Vena Cava Obstruction: Vertebral Enhancement and Hot Quadrate Sign in the Liver

Published:November 26, 2021DOI:https://doi.org/10.1016/j.jtho.2021.11.011
      A 42-year-old man suffering from superior vena cava (SVC) syndrome was diagnosed with having locally advanced lung adenocarcinoma (Fig. 1A). He was treated with radiochemotherapy followed by maintenance therapy with durvalumab leading to a partial response partial response on follow-up computed tomography (CT) (Fig. 1B). Although there were no secondary bone lesions on baseline CT (Fig. 1C), follow-up contrast-enhanced CT revealed the apparition of a densification affecting the left side of the fifth, sixth, and seventh thoracic vertebrae (Fig. 1D, arrow), raising suspicion of a metastatic evolution. The dissociated mediastinal and bone evolution, the topography of the bone features, and the identification of several venous collateral pathways on enhanced CT (Fig. 1E, arrow head) lead to explore these lesions with metabolic imaging. Fluorodeoxyglucose positron emission tomography (FDG PET)/CT was performed 5 weeks after (Fig. 1F, fusion image, axial slice) revealing no vertebral pathologic uptake. Furthermore, unenhanced CT revealed no vertebral lesion, reinforcing the diagnosis of vertebral venous congestion secondary to SVC obstruction. Surprisingly, lung perfusion single-photon emission CT (SPECT)/CT (4 wks after CT) did not reveal any pathologic bone uptake either (Fig. 1G).
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      Figure 1Baseline contrast-enhanced chest CT revealing (A) a locally advanced mediastinal mass and (C) no vertebral lesion with (B) a partial response to radiochemotherapy. Follow-up contrast-enhanced CT reveals (D) the apparition of densifications on the left side of the fifth, sixth, and seventh vertebrae and (E, arrow head) enhanced venous collateral pathways. (F) FDG PET/CT and SPECT/CT reveal no vertebral pathologic uptake. CT, computed tomography; FDG PET, fluorodeoxyglucose positron emission tomography; SPECT, single-photon emission computed tomography.
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