IMAGES THAT TEACH Isolated cardiac metastasis in a patient with neuroendocrine carcinoma of pancreas discovered on 68 Ga-DOTANOC PET/CT Bangkim Chandra Khangembam, MD, Niraj Naswa, MD, Punit Sharma, MD, Chandrasekhar Bal, MD, Arun Malhotra, MD, PhD, and Rakesh Kumar, MD, PhD We present an interesting image that demonstrates utility of 68 Ga-DOTANOC PET/CT for demonstrating rare metastatic sites of neuroendocrime tumor. Key Words: Neuroendocrine tumor Æ 68 Ga-DOTANOC Æ PET/CT Æ metastasis INTRODUCTION Metastatic tumors to the heart occur comparatively more frequently than primary cardiac tumors although the overall event is very rare. Myocardial metastasis from neuroendocrine tumors (NET) is very rare with a reported incidence of\ 1%. 1 68 Ga-labeled [1-,4-,7-,10-tetraazacyclo- dodecane-1-,4-,7-,10-tetraacetic acid]-1-NaI 3 -octreotide ( 68 Ga-DOTANOC) is a positron emission tomography- computed tomography (PET/CT) tracer for somatostatin receptor scintigraphy and very useful for staging and restaging NETs. 2 We present images of a case of pancreatic NET patient in whom an isolated cardiac metastasis was detected on 68 Ga-DOTANOC PET/CT. Interestingly, the primary pancreatic tumor had a low somatostatin receptor (SSTR) expression and hence low 68 Ga-DOTANOC avidity, while the cardiac metastasis was intensely 68 Ga-DOTANOC avid (high SSTR expression). 3 CASE SUMMARY A 47-year-old male presented with a nine-month history of repeated episodes of flushing, nausea, and diarrhea. Biochemical analysis showed elevated levels of serum Chromogranin-A (538.84 pg/dL). The patient did not have any cardiac symptoms, and baseline EKG was normal. A contrast-enhanced computed tomogra- phy (CECT) of the abdomen was done, which revealed a partially exophytic soft tissue mass lesion arising from the body of pancreas, suggesting a diagnosis of pancreatic NET. Hence, a staging 68 Ga-labeled 68 Ga-DOTANOC PET/CT was performed. It revealed mild 68 Ga-DOTANOC uptake in the pancreatic mass (Figure 1A-C) along with another intense focus in the right atrium (Figure 1A, D, E). To characterize the cardiac lesion, a CECT of thorax was done which revealed a large hypodense lesion in the right atrium (Figure 2), suspected to be a myocardial deposit. Endo- myocardial biopsy from the cardiac mass was consistent with NET with a mitotic index of 2/10 HPF and immunoreactivity for Chromogranin A and synapto- physin. Biopsy from pancreatic mass also revealed NET. The primary pancreatic tumor was resected, and the patient was put on long-acting somatostatin analogues for cardiac metastasis. From the Department of Nuclear Medicine, All India Institute of Medical Sciences, New Delhi, India No funding received from any organization for this study. Reprint requests: Rakesh Kumar, MD, PhD, Department of Nuclear Medicine, All India Institute of Medical Sciences, E-81, Ansari Nagar (East), AIIMS Campus, New Delhi 110029, India; rkphulia@ yahoo.com. J Nucl Cardiol 1071-3581/$34.00 Copyright Ó 2012 American Society of Nuclear Cardiology. doi:10.1007/s12350-012-9563-4