Inguinal Herniation of the Bladder Mimicking Malignancy in FDG PET/CT: Original Image

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o sit ron emis si on to mog raphy com bi ned with com pu te ri zed to mog

ra-phy (PET/CT) is a use ful to ol in can cer pa ti ents for di ag no sis, sta ging,

res ta ging and as sess ment res pon se to the rapy.

1

_{Ho we ver, be nign}

con-di ti ons co uld be a so ur ce of mi sin ter pre ta ti on of the ima ges.

2-4

_{We pre sen}

-ted an ori gi nal ima ge of a po ten ti al ra re so ur ce of the fal se po si ti ve re sult in

the in gu i nal re gi on.

Turkiye Klinikleri J Med Sci 2012;32(3)

895

Inguinal Herniation of the

Bladder Mimicking Malignancy in

FDG PET/CT: Original Image

ABS TRACT Who le body po sit ron emis si on to mog raphy /com pu ted to mog raphy (PET/CT) was re-qu es ted for res ta ging in a 73-ye ar-old ma le who un der went wed ge re sec ti on and ra di ot he rapy for lung can cer. Whi le the re was no pat ho lo gi cal flu de oxy glu co se (FDG) up ta ke at the ope ra ti on si te, in the me di as ti nal lymph no des, and in the bi la te ral sur re nal re gi ons, a mass li ke fo cal in ten se FDG up ta ke was no ted in the left in gu i nal re gi on. The dif fe ren ti al di ag no sis inc lu ded a se cond pri mary tu mor, me tas ta tic lympha de no pathy, stran gu la ted her ni a of the bo wel, blad der di ver ti cu lum or in-gu i nal her ni a ti on of the uri nary blad der. A de la yed PET/CT exam of the pel vic re gi on af ter fil ling the blad der was per for med. A full blad der co uld not be ac hi e ved des pi te well hydra ti on, but de la -yed ima ges sho wed so me ex pan si on of the FDG ac cu mu la ti on at the left in gu i nal re gi on. On CT and fu sed ima ges, we got the im pres si on that the re was an ana to mi cal con nec ti on bet we en the blad der and the hyper me ta bo lic fo cus. Blad der her ni a ti on was con si de red ba sed on the CT and fu sed ima -ges. Ul tra so und exa mi na ti on con fir med the di ag no sis. In conc lu si on, fil ling the pa ti ents’ blad der may help to dif fe ren ti a te this be nign con di ti on from ma lig nan ci es.

Key Words: Positron-emission tomography; hernia, inguinal; urinary bladder

ÖZET Ak ci ğer kan se ri ne de niy le ka ma re zek si yo nu ve rad yo te ra pi uy gu la nan 73 ya şın da er kek has ta dan ye ni den ev re le me için tüm vü cut po zit ron emis yon to mog ra fi si/bil gi sa yar lı to mog ra fi (PET/BT) is ten di. Ame li yat böl ge sin de, me di as ti nal lenf dü ğüm le rin de ve her iki sür re nal böl ge de pa to lo jik flu de ok sig lu koz (FDG) tu tu lu mu yok ken, sol in gu i nal böl ge de kit le ben ze ri fo kal yo ğun FDG tu tu lu mu göz len di. Ayı rı cı ta nı da se kon der pri mer tü mör, me tas ta tik len fa de no pa ti, ba ğır sa-ğın bo ğul muş her ni si, me sa ne di ver tü kü lü ve ya me sa ne nin in gu i nal her ni as yo nu dü şü nül dü. Me-sa ne dol du rul duk tan son ra pel vik böl ge nin ge cik me li PET/BT in ce le me si ya pıl dı. İyi hid ras yo na rağ men me sa ne tam ola rak dol du ru la ma dı; fa kat ge cik me li gö rün tü ler, sol in gu i nal böl ge de FDG bi-ri ki mi nin bi raz ge niş le di ği ni gös ter di. BT ve bir leş miş gö rün tü ler de, me sa ne ile hi per me ta bo lik odak ara sın da ana to mik bir bağ lan tı ol du ğu iz le ni mi edi nil di. BT ve bir leş miş gö rün tü ler de me sa -ne her ni as yo nu dü şü nül dü. Ul tra son mu a ye -ne si ta nı yı doğ ru la dı. So nuç ola rak, has ta nın me sa - ne-si ni dol dur mak iyi huy lu ve kö tü huy lu du rum la rın ay rı mın da fay da lı ola bi lir.

Anah tar Ke li me ler: Pozitron emisyon tomografi; fıtık, inguinal; mesane

Turkiye Klinikleri J Med Sci 2012;32(3):895-7 M. Engin ERKAN, MD, Assis.Prof.,a

Sabire YILMAZ, MD,b

Zübeyde Rana KAYA, MD,b

Said SAGER, MD, Assis.Prof.,b

Yusuf Ziya TAN, MD, Msc,c

Metin HALAÇ, MD, Assoc.Prof.,b

Fatih KANTARCI, MD, Assoc.Prof.,d

İlhami USLU, MD, Prof.b

a_{Department of Nuclear Medicine,} Düzce University Faculty of Medicine, Düzce

Departments of b_{Nuclear Medicine,} d_Radiology,

İstanbul University Cerrahpaşa Faculty of Medicine, c_{Clinic of Nuclear Medicine,} İstanbul Göztepe Training and Research Hospital, İstanbul Ge liş Ta ri hi/Re ce i ved: 17.04.2011 Ka bul Ta ri hi/Ac cep ted: 13.10.2011 Ya zış ma Ad re si/Cor res pon den ce: M. Engin ERKAN, MD, Assis.Prof. Düzce University Faculty of Medicine, Department of Nuclear Medicine, Düzce, TÜRKİYE/TURKEY

melihenginerkan@yahoo.com

doi: 10.5336/medsci.2011-24353

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Who le body PET/CT was re qu es ted for res ta

g-ing in a 73-ye ar-old ma le who un der went wed ge

re sec ti on and ra di ot he rapy for lung can cer. The

im-a ges we re im-ac qu i red 60 min im-af ter the in trim-a ve no us

in-jec ti on of flu de oxy glu co se (FDG). Whi le the re was

no pat ho lo gi cal FDG up ta ke at the ope ra ti on si te, in

the me di as ti nal lymph no des and in the bi la te ral

sur re nal re gi ons, a mass li ke fo cal in ten se FDG

up-ta ke was no ted in the left in gu i nal re gi on. The

dif-fe ren ti al di ag no sis inc lu ded a se cond pri mary

tu mor, me tas ta tic lympha de no pathy, stran gu la ted

her ni a of the bo wel or in gu i nal her ni a ti on of the

uri nary blad der. In or der to fill the blad der with

uri ne, we ad vi sed the pa ti ent to drink wa ter. A

de-la yed PET/CT exam of the pel vic re gi on was

per-for med. Alt ho ugh the blad der fil ling was

in comp le te, the de la yed ima ges sho wed so me in cre

-a se in the si ze of FDG -ac cu mu l-a ti on in the left

in-gu i nal re gi on. On CT and fu sed ima ges, we got the

im pres si on that the re was an ana to mi cal con nec ti

on bet we en the blad der and the hyper me ta bo lic fo

-cus (Fi gu re 1). Blad der her ni a ti on was con si de red

ba sed on the CT and fu sed ima ges. Ul tra so und exa

-mi na ti on con fir med the di ag no sis (Fi gu re 2).

Blad der her ni as ac co unt for 0.5% and 3% of all

lo wer ab do mi nal her ni as and 1% to 4% of in gu i nal

her ni as.

5,6

_{They are com mon in men aged 50 to 70}

ye ars.

6

_{Alt ho ugh this con di ti on may ca u se se ri o us}

comp li ca ti ons such as acu te re nal fa i lu re du e to

ob-s truc ti on, rup tu re, in fec ti on, car ci no ma, ve ob-si co cu

ta-ne o us fis tu la and cal cu lus, cli ni cal symptoms are

ra re.

7

_{Be si des, it fre qu ently be co mes evi dent in}

im-a ging pro ce du res im-and du ring sur gery. The cli ni cim-al

symptoms are two-pha se or do ub le mic tu ri ti on.

8,9

De mons tra ting the di rect com mu ni ca ti on of the

ingu i nal cystic le si on with the blad der, si mi lar ec ho

-ge ni city of the blad der and the her ni a ted seg ment

on CT and so nog rap hic mo da li ti es help to di ag no se

this con di ti on as well as pro vi ding in for ma ti on abo

-ut comp li ca ti ons such as nec ro sis, cal cu lus etc.

10

_Ak

-kaş BE et al. con fir med the di ag no sis by

Technetium-99m-labeled Diethylene Triamine

Penta-Acetic Acid (Tc99m-DTPA) re nal scin tig

ra-phy in a si mi lar ca se.

11

_{We pre fer red ul tra so und for}

the de fi ni ti ve di ag no sis of this be nign con di ti on sin

-ce it is easy to per form and do es not ne -ces si ta te

addi ti o nal io ni zing ra addi a ti on. Uri nary blad der addi ver ti

-cu lum is de fi ned as a prot ru si on of blad der mu co sa

thro ugh its mus cu lar la yer which do es not con ta in a

mus cu lar la yer.

12

_{In our ca se, all la yers of the}

blad-Turkiye Klinikleri J Med Sci 2012;32(3)

896

Erkan ve ark. Nükleer Tıp

FIGURE 1: A. Axial and sagittal FDG PET/CT images demonstrate a hyper-metabolic focus in the left inguinal region (long arrows). B. Delayed FDG PET/CT images show some enlargement of this FDG accumulation. Sagittal images also reveal the association between the focal activity in the inguinal region (long arrows) and the bladder (short arrows).

FIGURE 2: Ultrasonographic examination shows a direct fluid-filled commu-nication (white arrows) between the herniated inguinal segment (asterisk) and the bladder (BL). At the lower right of the image is a magnified view of the herniated segment (asterisk) showing the hyperechoic bladder mucosa (white arrowheads) and the hypoechoic muscularis layer (open white arrow).

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der, inc lu ding blad der mu co sa and mus cu lar la yers

we re pre sent at the her ni a ted seg ment, which exc

-lu des blad der di ver ti cu -lum. In conc -lu si on, alt ho ugh

in gu i nal her ni a ti on of the blad der is a ra re be nign

di se a se, it co uld mi mic ma lig nant pat ho lo gi es in

FDG PET ima ges.

13

_{Fil ling the pa ti ents’ blad der with}

uri ne by oral hydra ti on may help to dif fe ren ti a te

this be nign con di ti on from ma lig nan ci es.

Turkiye Klinikleri J Med Sci 2012;32(3)

897

Nuclear Medicine Erkan et al.

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