A 64-year-old woman with a background of recurrent serous adenocarcinoma ovarian cancer underwent half-body (skull base to midthigh) 18-fluorodeoxyglucose positron emission tomography with computed tomography ([18F]FDG PET/CT) restaging in large part due to her chronic kidney disease and inability to have a contrast-enhanced restaging CT, as might be expected as the standard of care. This was in the context of an asymptomatic rapid rise in cancer antigen 125 (Ca-125) from 18 to 184 units/mL (normal range 0–35 units/mL) over 4 months whilst on maintenance rucaparib therapy. Axial CT, [18F]FDG PET and fused [18F]FDG PET/CT of the pelvis (Figure 1A–C); showed multiple avid tumour deposits close to the vaginal stump from a previous total abdominal hysterectomy (TAH) and bilateral salpingo-oophorectomy (BSO). The deposits were closely applied to the bladder, rectum and mesorectum.

Figure 1. Axial CT (A), [18F]FDG PET (B) and fused [18F]FDG PET/CT (C) of the pelvis show multiple avid tumour deposits close to the vaginal stump from a previous total abdominal hysterectomy and bilateral salpingo-oophorectomy

Maximal intensity projection [18F]FDG PET, axial CT, [18F]FDG PET and fused [18F]FDG PET/CT of the upper abdomen (Figure 2A–D) and axial CT, [18F]FDG PET and fused [18F]FDG PET/CT of the lower abdomen/pelvis (Figure 2E–G) demonstrate intensely avid peritoneal deposits coating the peritoneal surfaces of the liver, spleen and small bowel respectively, with a heavier burden of deposits in the right of the abdomen. These appearances illustrate the deposition of disease according to peritoneal flow from the pelvis to the upper abdomen with preferential flow on the right, reflected in a higher burden of disease on the subdiaphragmatic surface and pelvic peritoneum here.

Figure 2. Maximal intensity projection [18F]FDG PET (A), axial CT (B), [18F]FDG PET (C) and fused [18F]FDG PET/CT (D) of the upper abdomen demonstrate intensely avid peritoneal deposits along the peritoneal surfaces with a heavier burden of deposits in the right of the abdomen. Axial CT (E), [18F]FDG PET (F) and fused [18F]FDG PET/CT (G) of the lower abdomen/ pelvis show avid disease coating the small bowel mesentery

In addition, axial CT, [18F]FDG PET and fused [18F]FDG PET/CT of the mid-abdomen (Figure 3A–C) and sagittal CT, [18F]FDG PET and fused [18F]FDG PET/CT of the abdomen (Figure 3D–F); show an avid umbilical lesion in continuity with the diffuse peritoneal carcinomatosis. This illustrates the eponymously known Sister Mary Joseph nodule (SMJN), which is an umbilical nodule resulting from the metastatic spread of an abdominal or pelvic malignancy. These lesions are comparatively rare, estimated to occur in only 1–3% of abdominopelvic malignancies but are associated with a bad prognosis. Studies and case series have shown that compared to conventional contrast-enhanced CT, [18F]FDG PET/CT offers a higher sensitivity in depicting the disease burden and distribution of peritoneal carcinomatosis, enabling an appreciation of the extent of disease, including rare manifestations such as SMJN as demonstrated in this case.

Figure 3. Axial CT (A), [18F]FDG PET (B) and fused [18F]FDG PET/CT (C) and respective sagittal images (D–F) show an avid umbilical eponymously known Sister Mary Joseph nodule (SMJN)

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Acknowledgements

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Author contributions

ER — drafted the manuscript and revised the manuscript; AN — conceived the design, revised the manuscript; JS — PET/CT reading, conceived the design and revised the manuscript; IL — PET/CT reading, conceived the design and revised the manuscript.

Conflict of interest

All authors disclose no conflict of interest.

Ethics statement

Institutional review board approval was not required. Informed consent was obtained from the individual participant.

Funding

No funding was received.

Supplementary material

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