⁶⁸Ga-DOTANOC PET/CT With Lung Involvement in the Era of COVID-19 Pandemic

Abstract

Patient was a 55-year-old man with history of pancreas neuroendocrine tumor grade 2, Ki-67 index 10%. He was treated with surgical resection. ⁶⁸Ga-DOTANOC PET/CT was performed as part of follow-up of known disease. The images showed opacities in both lungs’ parenchyma with moderate uptake of radiotracer and mediastinal lymph nodes with high uptake suggestive of infection. Two weeks before a high-resolution CT was performed, these findings in the lungs were not present. The patient was asymptomatic and was referred to the emergency department for reverse transcriptase–polymerase chain reaction COVID-19 test, and the result was positive.

FIGURE 1.

A and B, High-resolution CT was performed in a 55-year-old man with pancreas neuroendocrine tumor grade 2 Ki-67 index 10% for follow-up of known disease 2 weeks before the ⁶⁸Ga-DOTANOC PET/CT was performed. The findings were negative for infection or metastases (white arrows). C, Afterward, a ⁶⁸Ga-DOTANOC PET/CT was performed. Maximum intensity projection image shows moderate and diffuse uptake in both lungs (black arrows) and high uptake in mediastinum (black arrowheads). No sites of metastatic disease were found. D and E, PET and PET/CT axial section demonstrates bilateral, multifocal, and peripheral ground-glass opacities with more involvement in both inferior lobes (SUVmax 4.3) and moderate somatostatin receptor expression in the lungs (black arrows) suggestive of COVID-19 infection. These findings were not present in the CT previously. F and G, PET and PET/CT axial section with right hilar, subcarinal, and Aortopulmonary window lymph nodes (white arrowhead), with high radiotracer uptake (SUVmax 5.5) suggestive of inflammatory process and COVID-19 infection. On January 30, 2020, the WHO Director-General Dr Tedros Adhanom Ghebreyesus declared the 2019-nCoV outbreak a public health emergency of international concern. By September 6, 2020, 7:00 pm GMT-5, there were 26,994,442 confirmed cases, 880,994 deaths, and 216 countries affected.¹ In Colombia, by September 6, 2020, 5:00 pm GMT-5, the confirmed cases are 666,521 with 21,412 deaths.² The nuclear medicine departments around the world have had a challenge in facing the pandemic. They did not discontinue their operation. The “COVID-19 Pandemic: Guidance for Nuclear Medicine Departments”³ suggested some recommendations. One of these is the incidental COVID-19 finding in hybrid study that involves a CT of the chest. If COVID-19 findings are detected in the lungs, it must be reported immediately. The image acquisition of ⁶⁸Ga-DOTA peptides PET/CT is from the head to the middle of the upper leg⁴ and includes the chest. Therefore, there may be incidental detection in chest part in asymptomatic but infected cases undergoing scans for other indications.⁵ Moreover, uptake in inflammatory processes is described in ⁶⁸Ga-DOTA peptides because white blood cells including leukocytes and macrophages express somatostatin receptor 2,⁶ and it should be considered in COVID-19 times. There are few cases reported of COVID-19 findings in PET/CT with radiotracers different from ¹⁸F-FDG. Scarlattei et al⁷ reported 5 cases of unknown SARS-CoV-2 pneumonia detected by PET/CT with ¹⁸F-FDG, ¹⁸F-choline, and ⁶⁸Ga-prostate-specific membrane antigen. Stasiak et al⁸ reported 1 case with COVID-19 infection after ⁶⁸Ga–prostate-specific membrane antigen-11 PET/CT imaging in a patient with prostate cancer. Moreover, Vicente and Castrejón⁹ and Olivari et al¹⁰ reported one case with incidental COVID-19 pneumonia on ¹⁸F-choline PET/CT for biochemical recurrence of prostate cancer and COVID-19 pneumonia increased choline uptake with ¹⁸F-choline PET/CT, respectively. However, none of these case reports are with ⁶⁸Ga-DOTA peptides. This case demonstrates findings of COVID-19 in ⁶⁸Ga-DOTANOC PET/CT in an asymptomatic patient with the infection confirmed by reverse transcriptase–polymerase chain reaction.