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Lymph Nodal Plasmacytoma Detected on Myocardial Perfusion Imaging. Revisiting the Past
Address for correspondence: Dr. Girish Kumar Parida, Department of Nuclear Medicine, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India. E-mail: grissh135@gmail.com
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Received: ,
Accepted: ,
This article was originally published by Wolters Kluwer - Medknow and was migrated to Scientific Scholar after the change of Publisher.
Abstract
Stress myocardial perfusion imaging (MPI) is a commonly performed imaging to detect stress-induced perfusion defects. However, it can, at times, detect incidental ominous pathologies such as breast cancer, lung cancer, plasmacytoma, or multiple myeloma. Here, we report the case of a 54-year-old man incidentally detected to have plasmacytoma on 99mTc-Sestamibi (2-methoxyisobutylisonitrile) MPI.
Keywords
99mTc sestamibi
myocardial perfusion imaging
plasmacytoma
Introduction
99mTc-sestamibi is a lipophilic cation and has an affinity for tissues exhibiting high mitochondrial content and negative plasma membrane potential.[1] It is classically used for myocardial perfusion imaging (MPI) as its distribution mimics myocardial blood flow. In addition, 99mTc-sestamibi serves as a radiopharmaceutical in scintimammography, parathyroid scans, and occasionally for imaging plasmacytoma or multiple myeloma.[2] Here, we report the case of a 54-year-old man incidentally detected to have plasmacytoma on 99mTc-sestamibi MPI.
Case
A 54-year-old man with a history of shortness of breath for 3 months underwent 99mTc-sestamibi MPI. The rest electrocardiogram was suggestive of right bundle branch block and left anterior fascicular block. The patient also had normal echocardiography with a left ventricular (LV) ejection fraction of 64%. There was no history of hypertension, diabetes mellitus, asthma, or any other significant family history. Stress MPI revealed normal tracer uptake in all walls of the LV myocardium [Figure 1]. In addition, the image showed a focal area of extracardiac tracer uptake in the left cervical region [Figure 1]. On local examination, the patient was found to have a firm swelling in the left cervical region. Subsequently, contrast-enhanced computed tomography (CT) neck was performed, which revealed a large heterogeneously enhancing lesion at the left cervical level III lymph nodal station [Figure 2]. In suspicion of malignancy, an incisional biopsy was performed, and histopathology examination revealed kappa-restricted plasmacytoma with immunohistochemistry markers positive for CD138 and CD38, variably positive for MUM-1, CD20, and negative for CD3, thus confirming the diagnosis of plasmacytoma [Figure 3].
Discussion
MPI with 99mTc-sestamibi is a commonly performed procedure for the detection of stress-induced myocardial perfusion defects. Apart from MPI, it can also be used for parathyroid imaging, scintimammography, and tumor imaging. In our patient, myocardial perfusion images incidentally revealed a prominent 99mTc-sestamibi uptake in the left side of the neck, found to be a plasmacytoma on further evaluation. This highlights the importance of thoroughly reviewing and reporting not only cardiac but also pertinent extracardiac findings in all acquired images.[34]
When 18F-fluorodeoxyglucose positron emission tomography-CT is unavailable or impractical, whole-body 99mTc-sestamibi imaging with single photon emission CT (SPECT)-CT has proven useful in differentiating active from treated myeloma and assessing disease extent.[5] In addition, it serves as a transport substrate for P-glycoprotein, which is also a mechanism for multidrug resistance. A rapid washout of 99mTc-sestamibi is associated with high expression of P-glycoprotein, which is an indicator of multidrug resistance in multiple myeloma.[6] Notably, with SPECT-CT MPI, incidental findings may be associated with poor outcomes, including an increase in cancer-specific mortality.[78]
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Conflicts of interest
There are no conflicts of interest.
Nil.
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