Rationale and Objectives
The purpose of this retrospective study was to evaluate the incidence of totally implantable venous access devices, also called ports, implantation and the associated abnormalities in 2-[ 18 F]-fluoro-2-deoxy-D-glucose (FDG) positron emission tomography-computed tomography (PET-CT) images for patients with cancer, and to determine the percentage of abnormalities identified in the original reports.
Materials and Methods
The study aimed to perform a retrospective review of all FDG PET-CT imaging in a 3-year period. Cases of port-associated abnormalities found on the FDG PET-CT images were identified and then correlated with X-ray reports and clinical treatment or follow-up.
Results
In total, 2442 FDG PET-CT scans were retrospectively reviewed. Among them, 897 (897 of 2442, 36.7%) demonstrated port implantation. Abnormalities, including 22 port fractures (22 of 897, 2.45%), 14 malposition (1.56%), one infection (0.11%), and one embraced by a fibrin sheath or tumor (0.11%) were found. Only the infectious one had clinical symptoms. Among the 22 fractured ports, eight fractured catheters migrated and became dislodged. All of the malpositioned ports, except two in the contralateral subclavian vein, were found in the ipsilateral jugular vein. Both the port infection and the port embraced by a fibrin sheath or tumor occurred at the tips of the devices, which demonstrated FDG uptake in the mediastinal region. Only seven of the 38 (18.42%) images of port abnormalities had been identified in the original reports.
Conclusions
Based on this study, we recommend that the interpretation of FDG PET-CT scans should include a checklist to record all metallic device implantations and to interpret the whole-body X-ray topography as a standard part of PET-CT image report.
Introduction
The use of totally implantable venous access devices, also called ports, provides long-term administration of chemotherapy agents to patients with cancer . The port consists of a radiopaque injection port and a silicon or polyurethane catheter; therefore, the integrity and the position of the catheter can be traced through a chest X-ray. It has been reported that port catheter fractures with fragment dislodgement occurred in 0.2%–2.1% of implantations . Port fractures may be asymptomatic, but they can be fatal in some cases. Other serious port complications that have been reported in the literature include infection, venous thrombosis, catheter leakage, pulmonary embolism, arrhythmia, cardiac arrest, and cardiac perforation.
In the past 10 years, coverage of 2-[ 18 F]-fluoro-2-deoxy-D-glucose (FDG) positron emission tomography-computed tomography (PET-CT) procedures by health insurance companies and the commercial availability of FDG accelerated the prevalence of FDG PET-CT use for both cancer treatment monitoring and recurrent restaging. In the proposed FDG PET-CT procedure guidelines, the integrated PET-CT report should include any detected incidental findings from the CT scan that are relevant to patient care, even in the cases where the PET scans are negative .
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Materials and Methods
Patients
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FDG PET-CT Acquisition
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Imaging Analysis
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Data Analysis
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Results
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Table 1
Patient Characteristics, FDG PET-CT Images, and Port Fracture Complications
Image-based Patient-based Total number 2442 1714 Sex (M/F) 1368/1074 1001/713 Age (y) 56.2 ± 12.6 56.7 ± 13.0 Port implantation 897 519 Location of fracture 22 18 Connection 16 12 Proximal 1/3 6 6 Fracture after implantation (y) Unknown 2 1 0.5–1.0 1 1 1.0–2.0 3 3 2.0–3.0 4 3 >3.0 12 10
CT, computed tomography; FDG, 2-[ 18 F]-fluoro-2-deoxy-D-glucose; PET, positron emission tomography.
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Table 2
The Types and Frequencies of Cancer and Related Complications
Cancer Types or Characteristics Head and Neck Cancer Breast Cancer Lung Cancer Colorectal Cancer Lymphoma Others Cancers Total Image-based PET-CT scan 1048 527 184 403 119 161 2442 Port implantation (%) 272 (26.0%) 297 (56.4%) 55 (29.9%) 172 (42.7%) 61 (51.3%) 40 (24.8%) 897 (36.7%) Abnormalities Fracture 9 10 1 1 1 0 22 Malpositioned 4 3 4 3 0 0 14 Infection 0 1 0 0 0 0 1 Tumor-embraced or fibrin sheath 0 0 0 0 1 0 1 Patient-based PET-CT scan 758 312 150 283 70 141 1714 Port implantation (%) 165 (21.8%) 172 (55.1%) 29 (19.3%) 98 (34.6%) 23 (32.9%) 32 (22.7%) 519 (30.3%) Fracture 6 9 1 1 1 0 18 Malpositioned 4 2 3 3 0 0 12
CT, computed tomography; PET, positron emission tomography.
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![Figure 1, ( a-d ) The serial transverse 2-[ 18 F]-fluoro-2-deoxy-D-glucose (FDG) positron emission tomography-computed tomography (PET-CT) fusion images of a 65-year-old man with stage III rectal cancer showed high-attenuation foci in the lower right lung field. ( e ) The three-dimensional volume-rendering CT display, with 5 cm thickness of the attenuation CT, revealed a segment of metallic device extending from the right lung hilum to the lower lung field. ( f ) Angiogram and percutaneous endovascular removal of the dislodged port catheter in the right pulmonary artery was attempted but failed. The patient maintained regular follow-ups for 3 years and all were uneventful.](https://storage.googleapis.com/dl.dentistrykey.com/clinical/TheIncidenceofTotallyImplantableVenousAccessDevicesInsertionandtheAssociatedAbnormalitiesinPatientsWithCancerRevealedin18FFDGPETCTImaging/0_1s20S1076633217303082.jpg)
![Figure 2, ( a-c ) The serial coronal 2-[ 18 F]-fluoro-2-deoxy-D-glucose (FDG) positron emission tomography-computed tomography (PET-CT) fusion images of a 64-year-old man with lip cancer showed increased FDG uptake at the mediastinal and axillary lymph nodes. A linear segment of a metallic device, a fractured port catheter, was found extending from the superior vena cava to the right ventricle. ( d ) The three-dimensional volume-rendering CT display, with 5 cm thickness of the attenuation CT, 2 years prior revealed a port fracture at the anastomosis between the injection port and the catheter, with no distal segment migration. ( e ) The distal segment of the fractured port lodged in the right ventricle. Angiogram and percutaneous endovascular removal of the dislodged catheter were successful.](https://storage.googleapis.com/dl.dentistrykey.com/clinical/TheIncidenceofTotallyImplantableVenousAccessDevicesInsertionandtheAssociatedAbnormalitiesinPatientsWithCancerRevealedin18FFDGPETCTImaging/1_1s20S1076633217303082.jpg)
![Figure 3, ( a ) The transverse and ( b ) the coronal views of the 2-[ 18 F]-fluoro-2-deoxy-D-glucose (FDG) positron emission tomography-computed tomography (PET-CT) fusion images of a 34-year-old man with anaplastic T-cell lymphoma showed dislodgment of a fractured port distal segment in the pulmonary artery. ( c ) The three-dimensional volume-rendering CT display, with 5 cm thickness of the attenuation CT, demonstrated the fractured port segment transversely dislodged in the pulmonary artery. Angiogram and percutaneous endovascular removal of the dislodged catheter were successful.](https://storage.googleapis.com/dl.dentistrykey.com/clinical/TheIncidenceofTotallyImplantableVenousAccessDevicesInsertionandtheAssociatedAbnormalitiesinPatientsWithCancerRevealedin18FFDGPETCTImaging/2_1s20S1076633217303082.jpg)
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![Figure 4, ( a ) The coronal 2-[ 18 F]-fluoro-2-deoxy-D-glucose (FDG) positron emission tomography-computed tomography (PET-CT) fusion image and ( b ) the three-dimensional volume-rendering CT display, with 5 cm thickness of the attenuation CT, of a 76-year-old woman with non–small cell lung cancer showed port misplacement into the right jugular vein.](https://storage.googleapis.com/dl.dentistrykey.com/clinical/TheIncidenceofTotallyImplantableVenousAccessDevicesInsertionandtheAssociatedAbnormalitiesinPatientsWithCancerRevealedin18FFDGPETCTImaging/3_1s20S1076633217303082.jpg)
![Figure 5, ( a, b ) The serial coronal 2-[ 18 F]-fluoro-2-deoxy-D-glucose (FDG) positron emission tomography-computed tomography (PET-CT) fusion images and ( c ) the three-dimensional volume-rendering CT display, with 5 cm thickness of the attenuation CT, of a 44-year-old woman with sigmoid colon cancer revealed a linear metallic device running from the right shoulder region to below the right clavicle and into the left subclavian vein. In a follow-up FDG PET-CT image 9 months later, the tip of the port spontaneously moved into the superior vena cava (not shown).](https://storage.googleapis.com/dl.dentistrykey.com/clinical/TheIncidenceofTotallyImplantableVenousAccessDevicesInsertionandtheAssociatedAbnormalitiesinPatientsWithCancerRevealedin18FFDGPETCTImaging/4_1s20S1076633217303082.jpg)
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Discussion
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![Figure 6, ( a ) The maximal intensity projection (MIP) images of a 42-year-old woman with breast cancer and nasopharyngeal cancer showed a linear focus of intense 2-[ 18 F]-fluoro-2-deoxy-D-glucose (FDG) activity in the upper chest region. The transverse section of ( c ) the computed tomography (CT), ( d ) the FDG positron emission tomography (PET), and ( e ) the FDG PET-CT fusion images revealed that the FDG uptake lesion corresponded to the location of the distal part of the central venous catheter in the left brachiocephalic vein. The port was removed, and the tip and blood cultures revealed Staphylococcus infection. The patient developed mediastinal lymph node metastasis 3 years later. ( b ) The MIP image of the mediastinal lymph node metastasis looks similar to the previous image showing the catheter tip infection ( a ), but the PET-CT fusion images differentiate between ( c-e ) the catheter infection and ( f–h ) the mediastinal lymph node metastasis.](https://storage.googleapis.com/dl.dentistrykey.com/clinical/TheIncidenceofTotallyImplantableVenousAccessDevicesInsertionandtheAssociatedAbnormalitiesinPatientsWithCancerRevealedin18FFDGPETCTImaging/5_1s20S1076633217303082.jpg)
![Figure 7, The coronal section of ( a ) the computed tomography (CT) and ( b ) the 2-[ 18 F]-fluoro-2-deoxy-D-glucose (FDG) positron emission tomography (PET)-CT images of a 68-year-old woman with diffuse large B-cell lymphoma revealed multiple intra-abdominal and a superior vena cava-to-right ventricle FDG-positive lesions. The transverse section of ( c ) the CT and ( d ) the FDG PET-CT images revealed that the tip of the catheter was embraced by the FDG uptake lesion in the superior vena cava. The FDG PET-CT was performed 2 days after the port implantation (the patient had a cardiac sonography the morning of the port implantation) and revealed normal wall motion, with no chamber dilatation and no evidence of thrombus or vegetation formation in the heart. The FDG uptake at the tip of the port was considered as either catheter embraced by a tumor or catheter in a fibrin sheath.](https://storage.googleapis.com/dl.dentistrykey.com/clinical/TheIncidenceofTotallyImplantableVenousAccessDevicesInsertionandtheAssociatedAbnormalitiesinPatientsWithCancerRevealedin18FFDGPETCTImaging/6_1s20S1076633217303082.jpg)
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Conclusion
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Acknowledgment
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