INTERESTING IMAGE
Title: Bilateral Breast Uptake Demonstrated on FDG PET/CT Scans in 3 Male Patients With Hepatocellular Carcinomas
Authors: Yu-ChinWu,MD,*†Te-ChunHsieh,MD,†‡Shung-ShungSun,MD,†‡Kuo-YangYen,BS,†‡andChia-HungKao,MD†§
Abstract:We reported 3 male patients with hepatocellular carcinoma who underwent FDG PET/CT for systemic survey before liver transplantation. All of their scans demonstrated obvious FDG uptake in bilateral breasts. These uptakes might be owing to gynecomastia caused by an increase in free estrogen related to the cirrhotic liver.
KeyWords:FDG PET/CT, hepatocellular carcinoma, liver transplantation, gynecomastia, liver cirrhosis.
From the *Department of Nuclear Medicine, National Taiwan University Hospital, Hsin-Chu Branch, Hsin-Hsin-Chu, Taiwan; †Department of Nuclear Medicine and PET Center, China Medical University Hospital, Taichung, Taiwan; ‡Departmentof Biomedical Imaging and Radiological Science, China Medical University, Taichung, Taiwan; and §School of Medicine, China Medical University, Taichung, Taiwan.
T.-C.H. and C.-H.K. contributed equally to this work.
Conflicts of interest and sources of funding: none declared.
Reprints: Chia-Hung Kao, MD, Department of Nuclear Medicine and PET Center, China Medical University Hospital, No. 2, Yuh-Der Rd, Taichung 404, Taiwan. E-mail:
FIGURE1. We reported 3 male hepatitis B virus carriers with a history of hepatocellular carcinoma (HCC) after treatment. Patient 1 (58 years old) had been treated with partial hepatectomy and transcatheter arterial chemoembolization. Patient 2 (56 years old) had been treated with radiofrequency ablation. Patient 3 (55 years old) had been treated with transcatheterarterial chemoembolization and radiofrequency ablation. They underwent 18F-FDG PET/CT for systemic survey before the subsequent liver transplantation. All of their scans demonstrated obvious uptake of FDG in bilateral anterior chest wall regions without any other extrahepatic FDG-avid abnormality. FDG-avid findings seemed to be in breast regions (arrows) and the quantity of breast tissues seemed unusually abundant in male subjects. In patient 1, maximum standardized uptak evalue (SUVmax) of the right/left breast is 2.17/2.13. In patient 2, SUVmax of the right/left breast is 2.13/2.04. In patient 3, SUVmax of the right/left breast is 1.73/1.52.
It is well-known that whole-body FDG PET/CT is widely applied for cancer staging, including malignancies of head/neck, lung cancer, breast, colon/rectum, lymphoma, etc.1
Though FDG PET/CT is relatively more limited in the evaluation of primary HCC than previously mentioned cancers because of the physiologic liver uptake of FDG, it still
plays an important role in the evaluation of tumor aggressiveness and detection of metastatic disease/extrahepatic lesion.2–6 Some studies proved the usefulness of FDG
PET/CT for HCC patients before and after liver transplantation. In these studies, FDG PET/CT could help to select candidate, predict tumor recurrence, and predict
microvascular tumor invasion before transplantation.7–10 Also, these studies presented the
ability of FDG PET/CT to detect recurrence of HCC after transplantation.11,12 Therefore,
our patients underwent FDG PET/CT, a routine in our hospital, before liver
transplantation. If there was no abnormal FDG uptake found outside the liver, the patient was considered to be free of distant metastases and could proceed to the liver
transplantation subsequently. Thus, to differentiate malignancy from benign lesion in the extrahepatic area was extremely important. Unfamiliar pattern of benign FDG-avid finding may be a source of misdiagnosis and should be well recognized.
In these patients, the breast uptake of FDG might be considered as gynecomastia. Gynecomastia, proliferation of the glandular tissue of the male breast, is caused by imbalance between free estrogen and free androgen.13 In other words, an increase in the
free estrogen-to-free androgen ratio resulted in gynecomastia. Moreover, the estrogen sensitivity and androgen insensitivity, even the estrogen-like effect caused by drug, also resulted in gynecomastia.14,15 The frequent cause of gynecomastia was hepatic cirrhosis.
In cirrhotic patients, the prevalence of gynecomastia is as high as 67%, and the pathogenesis of gynecomastia was considered as increased estrogen due to excess androgens converting to estrogens.16,17 Accordingly, it was reasonably presumed that our
patients had gynecomastia, owing to an increase in free estrogen related to their liver cirrhosis caused by hepatitis B virus, as demonstrated on FDG PET/CT. As a result, these
patients underwent subsequent liver transplantations and remained free of tumor recurrence postoperatively.
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