Multimodality molecular imaging in the evaluation of pheochromocytoma. A case report.

A 63-year-old woman had gone to the emergency room several times for recurring episodes of headaches, tachycardia with palpitations, anxiety and sweating in the context of hypertensive crisis. High levels of adrenaline, noradrenaline, metanephrine and normetanephrine were found in urine. RM detected a hypervascular 5 cm in size right adrenal mass in contact with the inferior cava vein compatible with pheochromocytoma, associated with a solid exophytic hypervascular hepatic lesion suggestive of metastases at the left liver lobe (LLL) and an hepatic subcapsular hemangioma at the right liver lobe (RLL). For a better characterization and staging, adrenal scintigraphy was recommended.1 Whole-body 131I-MIBG (Fig. 1) showed intense uptake in right adrenal mass concordant with the diagnosis of pheochromocytoma. There was no evidence of focal uptake at the suspicious liver metastases on planar or SPECT images. A later 99mTc-autologous red blood cell (RBC) scintigraphy showed typical imaging of hepatic hemangioma2 located at the LLL (Fig. 2). Due to the disagreement of morphological and functional images, the studies achieved were recovered from PACS and a multimodality 131I MIBG/MR and 99mTc-RBC/MR registration and fusion was performed. The suspicious liver metastases at the LLL according to RM evidenced a high red-cell content (Fig. 3A), while the possible angiomatous lesion at the RLL was negative for it at merged fusion images (Fig. 3B). The final conclusion of the nuclear medicine studies was a right pheochromocytoma without extraadrenal extension. The patient underwent a laparoscopic resection of the right adrenal gland. During the intervention, the surgeons visualized a superficial angioma at the LLL and a smooth subcapsular lesion with benign aspect at the RLL. Pathological analysis revealed a 39 g and 5 cm × 3 cm × 3 cm pheochromocytoma with more than 4 tumor morphological criteria for potentially malignant biological behavior. One year after