{"paper_id":"6af64956-e66c-4864-a9c1-eece3e1e2df8","body_text":"IMAGE OF THE MONTH\n18F-FDG simultaneous PET/MR findings of a malignant\ntransformation and metastases of abdominal wall endometriosis\nHaiyan Wang1 & Qiaoyi Xue2 & Yi Shou 1 & Xing Chen 1 & Zhiwen You1 & Jianmin Yuan2 & Jinli Gao 3 & Jun Zhao 1\nReceived: 11 February 2020 / Accepted: 4 March 2020\n# The Author(s) 2020\nAbdominal wall endometriosis (AWE) arising from a surgical\nscar of cesarean delivery or other abdominopelvic operation, is a\nrare event with an incidence of 0.03 to 2% [ 1, 2]. Malignant\ntransformation of AWE is an extremely rare disease, with few\ncases reported in the literature [ 3–5], and the atypical mecha-\nnism for progression to carcinoma remains unknown. The most\nfrequent histological type of malignancy developing from\nextraovarian endometriosis is clear cell adenocarcinoma, follow-\ned by endometrioid adenocarcinoma [2, 6, 7]. Surgery and ad-\njuvant chemotherapy are the primary treatment options. High\nmortality rate was found up to 50 months following diagnosis,\nwith median survival time of 42 months after the diagnosis.\nRoutine CT and MRI imaging are not sensitive in detecting\nmalignancy and there is no specific clinical marker for malignant\ntransformation. Whole-body 18F-fluorodeoxyglucose positron\nemission tomography/computed tomography (18F-FDG PET/\nCT) has been demonstrated to be a sensitive and well-\nestablished imaging modality for detection, staging/re-staging,\nand evaluation of therapy response of solid tumors.\nSimultaneous 18F-FDG positron emission tomography/\nmagnetic resonance (PET/MR) has the potential to play an im-\nportant role in identifying the malignancy and the evaluation of\nclinical staging because MRI has higher soft tissue contrast and\nno ionizing radiation exposure compared to CT.\nWe herein report a case of a 43-year-old woman with clear\ncell adenocarcinoma arising from malignant transformation of\nAWE 19 years after cesarean section. She was initially hospi-\ntalized for abdominal wall mass 3 months ago. The 10 × 5 cm\nof mass was palpated in the right lower abdomen. The mass\nwas firm, tenacious, indolent to palpation, and had poor mo-\nbility. Abdominal needle biopsy was performed, and the his-\ntopathological results confirmed adenocarcinoma. Cancer an-\ntigen (CA) 125 level before the surgery was 26.20 IU/ml.\nThe patient was then sent for whole-body Fluorine-18 FDG\npositron emission tomography magnetic resonance (18F-FDG\nPET/MR) assessment for preoperative staging. A hybrid 3.0 T\nPET/MR scanner (uPMR 790, UIH, Shanghai, China) was\nused. Default clinical MRI sequences including T1w and\nT2w were scanned. 18F-FDG PET/MR imaging revealed a\n9.4 × 4.6 × 4.8 cm solid, heterogenic mass in the abdominal\nwall on its exterior part, partially involving the right rectus\nabdominal muscle, with significantly increased FDG uptake\n(SUVmax = 9.61). Several enlarged retroperitoneal lymph\nnodes and left inguinal lymph nodes with high FDG uptake\nwere also found in PET/MR-fused images (SUVmax = 4.25).\nThere was no abnormal 18F-FDG uptake in the uterus and\nbilateral ovaries.\nAn extensive resection with bilateral appendectomy of\nuterus, pelvic lymph node cleaning, and reconstruction of\nthe abdominal wall was performed. During the operation, a\nmass of 10 × 5 × 5 cm was found in the lower right rectus\nabdominis and between the peritoneum. The mass was firmly\nattached to the rectus abdominis, and it was difficult to sepa-\nrate it from healthy tissue. Multiple enlargement and fused\nlymph nodes were found in the bilateral iliac blood vessels\nand around the retroperitoneum. No obvious mass was found\nin the uterus and bilateral ovaries, and no effusion/infiltration\nwas found in the abdominal and pelvic cavity.\nHistopathological diagnosis was a stage IIIc clear cell ade-\nnocarcinoma originated in ectopic endometrial tissue, and 51\nlymph nodes out of 69 ones was positive. Chemotherapy with\ntaxol and carboplatin was then initiated.\nHaiyan Wang and Qiaoyi Xue contributed equally to this work.\nThis article is part of the Topical Collection on Image of the Month\n* Jinli Gao\ngaojinli.ok@163.com\n* Jun Zhao\npetcenter@126.com\n1 Department of Nuclear Medicine, Shanghai East Hospital, Tongji\nUniversity School of Medicine, Shanghai, China\n2 Central Research Institute, UIH Group, Shanghai, China\n3 Department of Pathology, Shanghai East Hospital, Tongji University\nSchool of Medicine, Shanghai, China\nhttps://doi.org/10.1007/s00259-020-04761-7\n/ Published online: 25 April 2020\nEuropean Journal of Nuclear Medicine and Molecular Imaging (2020) 47:3190–3191\n\n\nAcknowledgments We thank Dr. Lingzhi Hu, Ph.D.(Director of PET/MR,\nUnited Imaging Healthcare) who provided imaging technological support.\nFunding information T h i ss t u d yw a sf u n d e db yt h eK e yS p e c i a l t y\nConstruction Project of Pudong Health and Family Planning\nCommission of Shanghai, PWZzk2017-24.\nCompliance with ethical standards\nConflict of interest The authors declare that they have no conflict of\ninterest.\nEthical approval All procedures performed in studies involving human\nparticipants were in accordance with the ethical standards of the institu-\ntional and/or national research committee and with the principles of the\n1964 Declaration of Helsinki and its later amendments or comparable\nethical standards.\nInformed consent Informed consent was obtained from the patient for\nthe anonymous use of her clinical, imaging, and histologic data for\npublication.\nOpen Access This article is licensed under a Creative Commons\nAttribution 4.0 International License, which permits use, sharing, adap-\ntation, distribution and reproduction in any medium or format, as long as\nyou give appropriate credit to the original author(s) and the source, pro-\nvide a link to the Creative Commons licence, and indicate if changes were\nmade. The images or other third party material in this article are included\nin the article's Creative Commons licence, unless indicated otherwise in a\ncredit line to the material. If material is not included in the article's\nCreative Commons licence and your intended use is not permitted by\nstatutory regulation or exceeds the permitted use, you will need to obtain\npermission directly from the copyright holder. To view a copy of this\nlicence, visit http://creativecommons.org/licenses/by/4.0/.\nReferences\n1. Bektas H, Bilsel Y , Sari YS, et al. Abdominal wall endometrioma: a\n10-year experience and brief review of the literature. J Surg Res.\n2010;164:e77–81.\n2. Mihailovici A, Rottenstreich M, Kovel S, et al. Endometriosis-associated\nmalignant transformation in abdominal surgical scar: a PRISMA-\ncompliant systematic review. Medicine. 2017;96(49):e9136.\n3. Djakovic I, Vukovic A, Bolanca I, et al. Abdominal wall endometri-\nosis eleven years after cesarean section: case report. Acta Clin Croat.\n2017;56:162–5.\n4. Bats AS, Zafrani Y , Pautier P , et al. Malignant transformation of\nabdominal wall endometriosis to clear cell carcinoma: case report\nand review of the literature. Fertil Steril. 2008;90:1197.e13–6.\n5. Jiang M, Chen P , Sun L, et al. 18F-FDG PET/CT finding of a recur-\nrent adenocarcinoma arising from malignant transformation of ab-\ndominal wall endometriosis. Clin Nucl Med. 2015;40:184–5.\n6. Sosa-Duran EF, Aboharp-Hasan Z, Mendoza-Morales RC, et al.\nClear cell adenocarcinoma arising from abdominal wall endometri-\nosis. Cirugia y Cirujanos. 2016;84(3):245–9.\n7. Marchand E, Hequet D, Thoury A, et al. Malignant transformation of\nsuperficial peritoneal endometriosis lesion. BMJ Case Rep. 2013.\nhttps://doi.org/10.1136/bcr-2012-007730.\nPublisher’sn o t eSpringer Nature remains neutral with regard to jurisdic-\ntional claims in published maps and institutional affiliations.\n3191Eur J Nucl Med Mol Imaging  (2020) 47:3190–3191","source_license":"CC0","license_restricted":false}