MR PET Imaging of Inflammation

in Paediatric Oncology Patients

Dr Timothy Cain

Paediatric Radiologist and Nuclear Medicine Specialist

The Royal Children’s Hospital Melbourne, Victoria, Australia

RCH Medical Imaging has a research collaboration

with Siemens Healthineers through the Murdoch

Children’s Research Institute

RCH MR PET is a global reference site for Siemens

Healthineers

Declarations

Objectives

• Be aware of MR PET for paediatric Imaging

• Demonstrate how MR PET can be used like PET CT for

investigation of inflammation

• Be aware of high frequency of incidental findings

• Be aware of benefits of MR for correlation with PET

Indications for FDG MR PET Imaging

Infection/inflammation

• Oncology

• Febrile neutropaenia – diagnosis of infective and non-infective causes

• Prior to bone marrow transplantation - screening

• Assessment of infection treatment success or recurrence

• Non-oncologic

• PUO – especially immune deficiency syndromes

• Arthralgia/Autoimmune/Vasculitis

RCH MR PET Imaging statistics

• 982 MR PET imaging studies were performed at the

RCH between April 2016 and December 2018

• 612 of these studies performed on oncology patients

• 28 oncology patients had imaging specifically to assess

inflammation

• febrile neutropenia

• assess response to treatment for infection.

Febrile Neutropaenia

• 15 yo male with

relapsed AML

• Febrile neutropenia

• Previous lung infection

with worsening fevers

despite appropriate

therapy – infection

elsewhere?

Febrile Neutropaenia

• LZ 5 yo female

• ALL - delayed consolidation

chemotherapy because of

candida sepsis

• FDG PET to determine

extent of disease

Persistent Fevers post BMT

• 9 yo male

• Persistent

unexplained high-

grade fever for over

1 week following

bone marrow

transplant

• Pancreatitis post

BMT

MR PET Inflammation

• 17 yo male T-cell ALL

• Febrile 6 days, hypotension

• Findings consistent with diffuse

inflammatory process involving

joints and muscles

• No focal source of infection or

inflammation demonstrated

RCH MR PET Findings

Incidental inflammation common

• Lung – pneumonia and anaesthesia related atelectasis

• Gastrointestinal tract – oesophagus, stomach, bowel

• Lymphoid tissue – cervical, axillary, inguinal

• Other

• Injection sites, muscle inflammation, skin inflammation

• Central line, surgical scar

MR PET Unexpected Lung uptake

Oct 2016 Nov 2017 Feb 2018

• 6 yo female

• Spitz naevus of left upper

arm; unknown potential

(Malignant melanoma?)

• Asymptomatic at time of

all studies

• MR imaging showed

unexpected RUL

collapse and RML

consolidation

MR PET Unexpected lung Inflammation

9 yo male with

Hodgkins Lymphoma

Unexpected Right

basal lung lesion on

late assessment PET

scan

Nov 2017 Jan 2018 May 2018

Initial staging early & late response assessment

MR PET ‘Incidental’ Inflammation

9 yo male with

Hodgkins

Lymphoma

Unexpected

Right basal

lung lesion

MR PET Reactive lymph nodes

• 12 yo Female with

incomplete excision of

fibrohistiocytic tumour

from left hand

• Enlarged and isotope

avid lymph nodes

• Biopsy proven reactive

nodes – post

immunisation left deltoid

muscle

MR PET – CVC related Inflammation

• 16 yo male Hodgkins

Lymphoma

• Good response post

treatment

• Focal uptake right

atrium – line tip related

inflammation

Baseline scan End of treatment

Sep 2107 Mar 2018

CT Mar 2018 (inspiration)

MR PET Mar 2018 (expiration)

MR PET - MSK Inflammation

• 7-year-old with Burkitt's lymphoma - primary in mandible

• Bilateral greater trochanter uptake

• Right infraspinatus (rotator cuff) tendinitis – high T2

signal in muscle

MR PET Bowel activity

• 7 yo male

• f/up PTLD post cardiac transplantation

• Recent diarrhoea suspicious of small bowel

PTLD recurrence

• RLL uptake unexpected pulmonary infection

• Lt deltoid recent immunisation (no uptake

on right side bilateral injections

• Colonic uptake suspicious of PTLD

recurrence

• Colonic biopsy –ve

MR PET in paediatric Infection and Inflammation

• Useful to identify source of infection in febrile patients

• Can be used to assess treatment response

• Detects a wide range of infective and inflammatory conditions

• Incidental or unexpected signs of inflammation are common,

but not all are significant

• Simultaneous MR often provides anatomical correlation that CT

would not be expected to provide

Acknowledgements…..

• RCH Foundation and Good Friday

Appeal

• Michael Kean and MR Technologists

• Duncan Veysey and Nuc Med

Technologists

• Peter Francis and MID imaging

specialists

• MID Nurses and Clerical staff

• Anaesthetists & Anaesthetic

technologists

• RCH Clinicians

• Simon Harvey and epilepsy team

• Michael Sullivan and oncology colleagues

• Child Life Therapists

Interested in Paediatric Imaging? Come to AOSPR 2019

Thank you for your attention

Dr Timothy Cain

Paediatric Radiologist and Nuclear Medicine Specialist

The Royal Children’s Hospital Melbourne, Australia