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Detection of primary tumor in paraneoplastic cerebellar degeneration by FDG-PET.

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Detection of Primary Tumor in Paraneoplastic
Cerebellar Degeneration by FDG-PET
Yukito Shinohara, MD, Youichi Ohnuki, MD,
Fumihito Yoshii, MD, Wakou Takahashi, MD,
Kuichiro Onoe, MD, and Shigeharu Takagi, MD
Paraneoplastic cerebellar degeneration (PCD) is a paraneoplastic neurological syndrome encountered in patients with
malignant tumors. Underlying tumors that are frequently detected include small cell lung cancer, gynecological cancers,
breast cancers, and malignant lymphoma.' We describe here
a patient with PCD in whom no underlying tumor could be
detected despite extensive exploration until finally the occult
tumor was visualized by positron emission tomography with
"F-fluorodeoxyglucose (FDG-PET). After surgical removal
of the tumor, progression of cerebellar ataxia ceased and the
anti-Yo antibody titer decreased.
A 71-year-old woman had been transferred to our hospital
with rapidly progressive dysarthria and ataxia. Results of
physical examinations were normal. Neurological examinations showed horizontal gaze nystagmus, ataxic dysarthria,
and marked limb and truncal ataxia. Deep tendon reflexes
were normal with no motor or sensory impairment, but bilateral Chaddock reflexes were positive. Blood analysis was
normal and tumor markers, carcinoembryonic antigen,
a-fetoprotein, CA19-9 and CA125, were all within normal
ranges. Chest radiography was unremarkable, and head magnetic resonance imaging showed atrophy of the posterior
fossa structures, especially the vermis. Serum anti-Yo antibody titer measured by enzyme-linked immunosorbent assay2
was high at 0.481 (control, 0.056 2 0.008). Western blot
analysis of rat cerebellar homogenate incubated with the patient's serum IgG revealed a 58-kd band. Immunohistochemistry showed that the patient's serum IgG strongly reacted
with Purkinje cell cytoplasm of the rat.
Paraneoplastic cerebellar degeneration was suspected, but
lung computed tomography, abdominal computed tomography, intrapelvic computed tomography, abdominal echography, gastrointestinal endoscopy, vesicography, gallium scan,
and gynecological examinations revealed no evidence of tumors. Finally, whole-body positron emission tomography
(ECAT-EXACT, Siemens) for 40 minutes from 45 minutes
after intravenous injection of FDG (7 mCi) revealed localized accumulation in the caudal portion of the lower pole of
the left kidney (Fig). The standardized uptake value3 was
high at 4.54 (control for nonmalignant material, 1.01 L
0.26, n = lo), a value that ruled out an inflammatory lesion.
Abdominal angiography confirmed a vascular-rich tumor;
and at surgical operation, a 28 X 22-mm undifferentiated
adenocarcinoma at the omentum, rich in tubular structure,
was removed. After the operation, progression of cerebellar
ataxia ceased. Anti-Yo antibody titer declined to 0.304 and
showed no increase 8 months later.
In paraneoplastic cerebellar degeneration, neurological
signs and symptoms often precede those of malignancy.*
However, early detection of the primary tumor is often difficult, although critically i m p ~ r t a n tW
. ~e suggest that, in patients with elevated anti-Yo antibody, in whom paraneoplastic syndrome is suspected, FDG-PET can be useful to detect
the occult tumor.
We thank Drs. Keiko Tanaka and Takashi Inuzuka, Ni-
Fig. FDG-PET picture showing the localized accumulation in
the caudal portion of the lower pole of the lefi kidney (arrow).
igata University, for anti-Yo antibody measurement and immunostaining. These results were briefly presented at the 1996
Kanto regional meeting of the Japan Neurological Society.
Department of Neurology, Tokai University, School o f
Medicine, Isehara, Kanagawa, japan
1. Dalmau J, Posner JB. Neurologic paraneoplastic antibodies (antiYo; anti-Hu; anti-Ri): the case for a nomenclature based on antibody and antigen specificity. Neurology 1994;44:2241-2246
2. Tanaka K, Tanaka M , Igarashi S, et al. Long term course of
change in anti-Yo antibody content in paraneoplastic cerebellar
degeneration. J Neurol Neurosurg Psychiatry 1995;58:256-257
3. Strauss LG, Conti PS. The applications of PET in clinical oncology. J Nucl Med 1991;32:623-648
4. Peterson K, Rosenblum MK, Kotanides H, Posner JB. Paraneoplastic cerebellar degeneration: I. A clinical analysis of 55 anti-Yo
antibody-positive patients. Neurology 1992;42:193 1-1937
5. Tanaka K, Igarashi S, Yamazaki M, et al. Paraneoplastic cerebellar degeneration: Successful early detection and treatment of cancer through characterization of the anti-Purkinje cell antibody.
Intern Med 1992;31:1339-1342
HTLV-I-Associated Facial Nerve Palsy in Africans
and People of African Descent
Pierre-Marie Preux, MSc, MD,*
Waruingi Macharia, MBChB,*
Jean-Claude Vernant, MD, PhD,t
FranGois Denis, MD, PhD,$ Michel Dumas, MD, PhD,*
and Research Group in Tropical Neurology
A possible association between human T-cell lymphotropic
virus type I (HTLV-I) and lower motor neuron facial nerve
Copyright 0 1998 by the American Neurological Association
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cerebellar, detection, degeneration, fdg, primary, paraneoplastic, pet, tumors
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