case_images: PMC6159203_01
case_images: A 43-year-old woman with metastatic breast disease.18F-Fludeoxyglucose (FDG) PET/CT maximum intensity projection shows 18F-FDG-avid uptake in the lung, mediastinum and bone (a). Coronal PET/CT slice shows a 17 mm-pulmonary nodule localized at the posterior basal segment of the lower side of the left lobe with SUVmax of 10.7 (b). The patient was subject to another PET/CT study using 18F-fluoroestradiol (c). The maximum intensity projection shows focal uptake sites in the lung (d). Consistent with the metabolic response seen in panel (b), the same focus had an increased response by using 68Ga-DTPA anti-HER2 (SUVmax = 3.3) (e, f).
case_images: bjrcr.20160136.g001.jpg
case_images: PMC6159203_01_bjrcr.20160136.g001.jpg
case_images: f1
case_images: The PET/CT revealed increased 18F-FDG uptake in the lungs, bones and axillary lymph nodes (Figure 1a). Thus, a parallel study using 68Ga-DTPA anti-HER2 and 18F-16alpha-17beta-fluoroestradiol (18F-FES) was subsequently conducted (Figure 1b,c).
case_images: Images of the patient showing an infiltrating canalicular carcinoma with strong positive staining for oestrogen receptors in the breast (a), lymph node (b) and lung (c), with histological scores of 140, 120 and 130, respectively. Progesterone receptor expression with histological scores of 70, 40 and 5 in the breast, lymph node and lung (d-f) respectively. An indeterminate staining for HER2 analysis was visualized at the primary tumour (g) and both metastatic sites (h: lymph node; i: lung) by using immunohistochemistry (IHC; 2+ for all tissues). The expression of HER2 was corroborated by using fluorescence microscopy and in situ hybridization. The results were found as follows: Breast (j) not amplified (ERBB2:Cen17 ratio = 1.00) Nuclear in situ Hybridization (D17Z 1 x 2, ERBB2 x 2~17)[35]. Lymph node (k) amplified (ERBB2:Cen17 ratio = 4.08) Nuclear in situ Hybridization (D17Z 1 x 2, ERBB2 x 2~17)[60]. Lung (l) amplified (ERBB2:Cen17 ratio = 3.19) Nuclear in situ Hybridization (D17Z 1 x 2, ERBB2 x 2~17)[60].
case_images: bjrcr.20160136.g002.jpg
case_images: PMC6159203_01_bjrcr.20160136.g002.jpg
case_images: f2
case_images: HER2 was negative in the breast (Figure 2g) and indeterminate (2+) in both metastatic sites (Figure 2h,i). However, using fluorescence microscopy and in situ hybridization (FISH), HER2 overexpression was confirmed in the lymph node (4.18) as well as in the lung (3.19) (Figure 2k,l), whereas the primary tumour remained negative (Figure 2j).