Diffuse fluorodeoxyglucose-positron uptake in the bone marrow of a patient with granulocyte colony-stimulating factor-producing pleomorphic carcinoma of the lung: A case report

Abstract

Abstract. The current study presents the case of a 66-year-old male presenting with fever and chest pain. Chest enhanced computed tomography scanning revealed a mass shadow in the right upper lobe with chest wall invasion. 18-Fluorodeoxyglucose-positron emission tomography (FDG-PET) identified the localized uptake of the mass lesion in the right upper lobe, in addition to diffuse uptake by the bone marrow. The laboratory data on admission revealed marked leukocytosis and an elevated C-reactive protein level (CRP). Serum concentrations of granulocyte colony-stimulating factor (G-CSF) and interleukin 6 were increased. Based on a clinical diagnosis of non-small cell lung cancer (c-T3N0M0 stage IIB), the patient underwent right upper lobectomy with chest wall resection. The histological examination showed a pulmonary pleomorphic carcinoma. Immunohistochemical analysis of the resected tumor tissues revealed positive staining for G-CSF. The patient's high-grade fever, leukocytosis, and elevated CRP level rapidly subsided following the resection. This confirmed that the tumor was a G-CSF-producing pulmonary pleomorphic carcinoma. Five months after the resection, the diffuse FDG uptake in the bone marrow was absent, even with the presence of a small pulmonary metastasis and marginal serum G-CSF elevation. Diffuse FDG uptake in bone marrow induced by G-CSF producing pleomorphic carcinoma must be taken into consideration, in order for it not to be misinterpreted as diffuse bone marrow metastases or hematologic malignancy. IntroductionThere have been several previous studies reporting that various cytokines, including granulocyte colony-stimulating factor (G-CSF) and interleukin 6 (IL-6), are produced by lung carcinomas, particularly pleomorphic carcinomas previously diagnosed as large cell carcinomas (1-7). G-CSF production by cancer cells has been associated with the rapid progression of the disease and with the poor prognosis.Pleomorphic carcinoma of lung was first classified in 1999 by the World Health Organization as a subset of sarcomatoid carcinoma. This type of tumor is rare, accounting for 2-3% of all cancer cases in a previous surgical series, but for <1% in epidemiological studies (8). Pleomorphic carcinoma is a poorly-differentiated non-small cell lung carcinoma, which may consist of a squamous cell carcinoma, adenocarcinoma or undifferentiated non-small cell carcinoma that contains ≥10% spindle and/or giant cells or a carcinoma consisting only of spindle and giant cells. Pleomorphic carcinoma of the lung has been reported to have aggressive clinical course with a poor response to chemotherapy and radiotherapy (8). The prognosis is significantly poorer than that of most other subsets of non-small cell lung cancer, even in early-stage disease.G-CSF causes hyper metabolic uptake of bone marrow in positron emission tomography (PET) using F-18-fluorodeoxyglucose (FDG) (9,10). The current case encountered diffuse FDG uptake in the bone marrow by G-CSF-producing pleomorphic carcinoma prior to the tumor resection, and...

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“…Furthermore, the present case had a diffuse fluorodeoxyglucose uptake in the bone marrow before pembrolizumab treatment, which is suggested to have occurred due to bone marrow hyperplasia induced by G‐CSF produced by recurrent UTUC. G‐CSF‐producing tumors typically show diffuse accumulation of 18F‐ fluorodeoxyglucose in the bone marrow on PET scans, indicating enhanced glucose metabolism by promoting hematopoietic capacity 5,6 . In the present case, only weak positives for G‐CSF immunostaining of cancer cells in nephroureterectomy specimens were found (Fig.…”

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“…In the present case, diffuse uptake in the bone marrow was observed in the first FDG-PET. Increased FDG uptake in the bone marrow without bone metastasis was previously reported in patients with G–CSF–producing tumors [ 7 ]. The same findings were described in patients who received G-CSF as an adjunct to chemotherapy [ 8 ].…”

“…The same findings were described in patients who received G-CSF as an adjunct to chemotherapy [ 8 ]. This is thought to be because hematopoiesis promoted by G-CSF abnormally increases marrow glucose metabolism [ 7 ]. As for the uptake in the bone marrow of patients with G–CSF–producing tumors or on G-CSF administration, cautious interpretation is necessary to avoid misdiagnosing bone metastasis.…”

Advanced G‐CSF‐producing non‐small cell lung cancer‐not otherwise specified, with favourable response to pembrolizumab monotherapy

“…In this case, leucocytosis and elevated serum G‐CSF activity without infection or other diseases were observed on admission. In addition, typical examination of G‐CSF‐producing tumours showed a diffuse accumulation of 18 F‐FDG in the bone marrow in the PET scan, indicating glucose metabolism was enhanced with the promotion of haematopoietic ability [2]. Therefore, we clinically diagnosed the patient with GCF‐producing lung tumour.…”