Multimodality imaging of malignant pheochromocytoma

Pheochromocytomas offer the opportunity to explore multiple pathophysiological mechanisms through functional imaging. MIBG scintigraphy and PET scanning with tracers of the sympathetic nervous system are based on uptake of catecholamines and catecholamine-like compounds by hNET, the human norepinephrine transporter. In-111 pentetreotide scanning involves the imaging of somatostatin receptors on the cellular surface of tissues. FDG PET scanning examines the transport and incorporation of FDG into cells. We present a patient with malignant pheochromocytoma who underwent multitracer imaging to characterize the tumor and probe its pathophysiology to direct a therapeutic approach. This case underscores the inherent difficulties in the diagnosis and localization of malignant pheochromocytomas. Multiple approaches to functional and anatomic imaging may be required to fully delineate the extent of disease and similarly to direct radionuclide-based therapy.