the 8 snowmass 2017: pet/ct & nuclear medicine in clinical practice · 2017-01-31 · director...
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The 8 th | Snowmass 2017:
PET/CT & Nuclear Medicine in Clinical Practice
Thursday, February 23, 2017Westin Snowmass Resort • Snowmass Village, Colorado
Educational Symposia
TABLE OF CONTENTSTHURSDAY, FEBRUARY 23, 2017
Sentinel Node Scintigraphy (Kevin J. Donohoe, M.D.) ..................................................................................................... 159
PET/CT of Lymphoma (Kevin L. Berger, M.D.)............................................................................................................... 175
Challenging Chest PET/CT Cases (Don C. Yoo, M.D.) .................................................................................................. 189
The False Positive Problem with FDG PET: Improving Specificity with PET/CT (Paul Shreve, M.D.) ............................... 195
Challenging Abdomen and Pelvis PET/CT Cases (Don C. Yoo, M.D.) ........................................................................... 215
SAVE THE DATES - 2018 Winter Symposia
159
160
Lymphoscintigraphy - Sentinel Node
Imaging
Clinical Nuclear Medicine 2017
Kevin Donohoe M.D.
Division of Nuclear Medicine
Beth Israel Deaconess Medical Center
Harvard Medical School
Boston, MA
Conflict of Interest
• I have no conflict of interest.
Take Home Points
• Breast cancer injections should include peri-
tumoral injections
• Tilmanocept is better tolerated by patients
than sulfur colloid
• SPECT/CT is an important tool for specific
patient populations
Lymphoscintigraphy - Sentinel Node
• Melanoma
• Squamous Cell Carcinoma
• Breast Cancer
• Prostate Cancer
• Penile
• Colon
• Etc .
Lymphoscintigraphy - Sentinel Node
• Melanoma
– Superficial Spreading
– Acral Lentiginoid
– Lentigo Maligna
– Nodular
Signs of Melanoma – A,B,C,D
• Asymmetry
• Border (irregular)
• Color (multiple shades of brown, red, or black)
• Diameter (>6 mm)
161
Superficial Spreading Melanoma
• Upper Back in men, lower legs in women
• Age at diagnosis: 40 - 50
• Shades of brown, bluish red with palpable borders
• 70% of melanomas
Superficial Spreading Melanoma
Acral Lentiginous Melanoma
• Seen on the extremities - palms, soles, nail beds
• Starts as a light brown spot on the lateral nail fold or
a vertical brown streak running the length of the
nail. When such a change is noted, a nail fold or
matrix biopsy is indicated.
Acral Lentiginous Melanoma
Lentigo Maligna
• Usually the best prognosis
• A slowly enlarging dark brown or black freckle on
the cheek of an elderly patient
• Microscopically is malignant melanoma, but which
clinically runs an essentially benign course for years
(up to 25) until eventually invasive malignant
melanoma supervenes.
Lentigo Maligna
162
Nodular Melanoma
• Seen at any site
• Age: 40-50
• Reddish purple, blue or black mixed with brown
• Poor prognosis - prominent vertical growth phase
Nodular Melanoma
Melanoma - Risk Factors
• High risk (>50 times nl population)
– Persistently changing mole
– Atypical moles in patient with two family members with
melanoma
– Adulthood
– > 50 nevi > 2mm
• Intermediate risk (10 fold increase)
– Family history of melanoma
– Sporadic atypical moles
– Congenital nevi (?)
– Caucasian
– Personal history of prior melanoma
• Low risk (2 to 4 time normal)
– Immunosuppression
– Sun sensitivity or excess exposure
Melanoma Staging
Clark Level
I Confined to epidermis
II Invades but does not fill papillary dermis
III Through papillary dermis to reticular dermis
IV Reticular dermis
V Subcutaneous fat
Melanoma Staging
Thickness (mm) Overall MCCG*
< 0.76 96 99
0.76 – 1.49 87 95
1.50 – 2.49 75 84
2.50 – 3.99 66 70
>4.00 47 44
% Survival Breslow
* Melanoma Clinical Cooperative Group
163
RGP
VGP
Clinical-Pathological Correlation between RGP and VGP Melanoma in a Lesion where VGP Nodules Are Arising in RGP of the Superficial Spreading Type
From Robbin’s Pathologic Basis of Disease; Chapter: The Skin
When Should Sentinel Node Study Be Done in Patients with Melanoma?
• When I get a request to do one.
• ASCO Guideline (2012)
– http://jco.ascopubs.org/content/30/23/2912
– Melanoma > 1mm; < 4mm Breslow thickness
– Melanoma < 1mm if risk other factors are present
• Lympho-vascular invasion
• Mitotic rate ≥ 1/mm2
• Vertical growth phase
• Ulceration
• Clark Level
164
Sentinel Node Logistics - Melanoma
• EANM practice guidelines for lymphoscintigraphy and
sentinel lymph node biopsy in melanoma
– October 2015
– Endorsed by SNMMI
Injectate
• Tracer
– Filtered sulfur colloid
• 0.22 micron filter
– Unfiltered sulfur colloid
– Tilmanocept
– Microcolloid
– Nanocolloid
• Antimony sulfide colloid
– Albumen
• Dye
– Methylene blue
– Lymphazurin blue
– Isosulfan blue
• Can decrease pulse oximetry > 2% in 33% of patients
Colloids Buffering the Colloid
• Check pH of colloid from your
radiopharmacy.
Tilmanocept (Lymphoseek)
• Multiple mannose units
– Attach to CD 206 receptors
– Macrophages
– Dendritic cells
• 7 nanometers
Injection Technique
• Inject within 1.5 cm of lesion
• Intradermal injection
• Surround lesion
165
Imaging
• Flow Images
– Depends on tracer, location
• Delayed images
– 10 minutes
– Transmission views
• Mark skin
– Co-57 spot marker
• Surgery same day (usually)
Gamma Probe
Breast Cancer
• Disease
• Who gets sentinel node study
• Comments on sentinel node studies in
general
Breast Cancer - Staging
Node Category Overall Survival Without Recurrence
All patients 60 47
Nodes negative 82 72
Nodes positive 40 25
1-3 nodes 54 34
4+ nodes 26 16
When Should Sentinel Node Study Be Done in Patients with Breast CA?
• When I get a request to do one.
• EANM/SNMMI Guideline
– http://snmmi.files.cms-plus.com/docs/
Final%20Breast%20Sentinel%20Node%20Guideline.
• Women with invasive or microinvasive primary
and clinically negative axilla
• Exceptions:
– Women >70 y/o with <2cm primary lesion that is ER+
– When sentinel node status will not change Rx
Sentinel Node Scintigraphy
• Albertini - 62 pts with invasive BC (‘96 Florida)
– Blue dye and filtered SC injected around tumor
– Sentinel node removed
– Complete axillary node dissection carried out
– 92% of SLNs identified
– SC increased sentinel node detection from 73%
to 92%
– No pts with negative SLNs had positive non-SLN
nodes
166
Sentinel Node Scintigraphy
• Paganelli, Veronesi Milan 1998
– Used various colloids
– Intradermal and peritumoral injections
– Found fewer nodes in patients with larger colloid
(200 - 1000 nm)
Injection
• Intradermal
– Small volume (0.1 ml)
– Low activity (100 uCi)
– 25 ga needle
– 2 sites around areola
• Parenchymal (breast)
– Larger volume (0.3 ml???)
– Activity????
– 25 ga needle
– 4 sites around lesion (in lesion???)
– ? Cold packs
Lymphatic Drainage of the Breast L Breast Cancer
Sentinel Node Imaging – Breast Cancer Sentinel Node Imaging – Breast Cancer
Anterior
167
Sentinel Node Imaging – Breast Cancer
LAO
Sentinel Node Imaging – Breast Cancer
Anterior
Sentinel Node Imaging – Breast Cancer
Left Lateral
Sentinel Node Imaging – Breast Cancer
Right Lateral
Tc-99m Co-57 Combined
Sentinel Node Imaging – Melanoma
168
Sentinel Node Imaging – Melanoma Sentinel Node Imaging – Melanoma
Sentinel Node
• Uren – J Nucl Med 1993 – 203 patients –
Scintingraphy and clinical palpation identified
sentinel nodes in 98% of patients with melanoma.
– 22 patients showed drainage to 3 or more node groups.
– Multiple lymphatic pathways seen in several patients.
Static
SPECT Head and Neck Issues
• Proximity of injection to node bed
– Inject smaller volume (0.05 cc)
– Inject close to biopsy site
• SPECT/CT imaging
– Helps identify obscured nodes
– Helps localize depth of nodes
• Resect injection site first
• Multiple node bed drainage
• 30% of the time positive nodes seen
in more than one node bed
169
Cervical Nodes
SPECT/CT
Sentinel Node – Lower Extremity Melanoma
170
SPECT/CT SPECT/CT
SPECT/CT
• How useful is it?
– Tumor
• Site
• Cell type
– Surgeon
– How can you get information to the
surgeon
SPECT/CT
• Better localization of sentinel lymph nodes
– Small study in bladder cancer showed more sentinel
nodes with SPECT CT than with planar imaging.
– Squamous Cell CA of head and neck – 40 patients -
Denmark
• 38% of patients showed additional relevant nodes with
additional planar and SPECT images
• 10% of patients had extra contralateral nodes identified
– Breast cancer – 157 patients – Israel
• Planar images alone negative for nodal visualization in 15%
of pts.
• SPECT/CT alone was negative in 10% of pts.
– Prostate cancer – Germany
• SPECT/CT used to localize sentinel nodes for radiotherapy
• 4 of 6 patients would have had a “geographical miss” of
therapy to nodes in the perirectal area.
171
Hard Copy Communication Issues
• Keep good relationship with the
surgeons
– Be aware of what they are doing with the
information you are providing to them
• Images
• Markings
– With probe
– ?Join them for surgery
• Verify melanoma injection site with
surgeon if there is any doubt
Tumors
• Vulvar cancer
• Cervical cancer
• Penile cancer
• Head and neck cancer
• GI tumors
• Prostate cancer
• Lung cancer
• Thyroid (Italy - April
2006)
Problems With Other Tumors
• Injection technique
– Site
– Timing
– Invasiveness
• Lymphatic drainage
• Imaging, skin marking
172
173
174
175
176
PET Imaging of Lymphoma
Kevin L. Berger, MD
Director of PET/CT
PET/CT and Nuclear Medicine in Clinical Practice
Incidence of Cancer in the
United States*
Prostate 29%
Lung and bronchus 15%
Colon and rectum 10%
Urinary bladder 7%
Non-Hodgkin s
lymphoma
4%
Melanoma of the skin 4%
Kidney and renal pelvis 4%
Leukemia 3%
Oral cavity and pharynx 3%
Pancreas 2%
All other sites 19%
Women
678,060
Men
766,860
26% Breast
15% Lung and bronchus
11% Colon and rectum
6% Uterine corpus
4% Non-Hodgkin s
lymphoma
4% Melanoma of the skin
4% Thyroid
3% Ovary
3% Kidney and renal pelvis
3% Leukemia
21% All other sites
American Cancer Society. Cancer Facts & Figures 2007. Atlanta, GA: American Cancer Society; 2007.
Cancer Mortality in the
United States*
Lung and bronchus 31%
Prostate 9%
Colon and rectum 9%
Pancreas 6%
Leukemia 4%
Hepatobiliary 4%
Esophagus 4%
Urinary bladder 3%
Non-Hodgkin s
lymphoma
3%
Kidney and renal pelvis 3%
All other sites 24%
26% Lung and bronchus
15% Breast
10% Colon and rectum
6% Pancreas
6% Ovary
4% Leukemia
3% Non-Hodgkin s
lymphoma
3% Uterine corpus
2% CNS
2% Hepatobiliary
23% All other sites
Women
270,100
Men
289,550
American Cancer Society. Cancer Facts & Figures 2007. Atlanta, GA: American Cancer Society; 2007.
WHO Classification B-cell
• Precursor B-cell neoplasms
– B-acute lymphoblastic leukemia (B-ALL)
– Lymphoblastic lymphoma (LBL)
• Peripheral B-cell neoplasms
– B-cell chronic lymphocytic leukemia/small lymphocytic lymphoma
– B-cell prolymphocytic leukemia
– Lymphoplasmacytic lymphoma/immunocytoma
– Mantle cell lymphoma
– Follicular lymphoma
– Extranodal marginal zone B-cell lymphoma of MALT type
– Nodal marginal zone B-cell lymphoma
– Splenic marginal zone lymphoma
– Hairy cell leukemia
– Plasmacytoma/plasma cell myeloma
– Diffuse large B-cell lymphoma
– Burkitt s lymphoma
REAL/WHO Classifications
for B-Cell Neoplasms Indolent
(Low Risk)
Aggressive
(Intermediate Risk)
Very Aggressive
(High Risk)
• CLL/SLL
• LPL
• HCL
• MZL
– Extranodal
– Nodal
– Splenic
• Follicular lymphoma
• PLL
• Plasmacytoma/plasma cell
myeloma
• MCL
• DLBCL
– Mediastinal large B-
cell lymphoma
– Primary effusion
lymphoma
• Precursor
B-lymphoblastic
lymphoma/leukemia
• Burkitt s lymphoma/
Burkitt s cell
leukemia
Variable Behavior
Abbreviations: CLL, chronic lymphocytic leukemia; SLL, small lymphocytic lymphoma; MCL, mantle cell lymphoma;
HCL, hair cell leukemia; LPL, lymphoplasmacytic lymphoma; MZL, marginal zone lymphoma; FCL, follicular cell
lymphoma.
Clinical Course of NHL subclasses
(WHO Classification)
6
MZ
L
SLL
*/C
LL
FL*
DL
BC
L*
MCL PMLBCL ALCL
PTCL
BLL
LL
Oth
er
22%
Indolent
(low grade)
Aggressive
(intermediate grade)
Highly aggressive
(high grade)
• Slowly progressive • Rapid clinical course • Grows rapidly
31%
6%
2%
2%
6%
2%
2%
6%
5%
16%
Grades I, II- Indolent
Grade III- Agressive
Su
rviv
al if u
ntre
ate
d
Years Months Weeks
6%
MC
L
177
Hodgkin s Lymphoma
• Clinically and biologically distinct
• Bimodal distribution
• About 8220 cases in the US
• NHL:HL ratio of 8:1
Metabolic Phenotype Wong et al. JNM 2005
4317 357N =
Aggressive Behaviour of the Disease
AggressiveIndolent
60
50
40
30
20
10
0
-10
GROUP
Hodgkins Disease
NHL
58
95
99
2836
CMS Evidence Determination
• Increased glycolytic metabolism is a fundamental
property of cancer cells, and thus there is really not any
cancer that is not FDG-avid. However, in general, low-
grade tumors that grow more slowly tend to be less FDG
avid than do their higher grade counterparts within a
given tumor cell type. Examples where this has been
demonstrated included low-grade sarcomas,
lymphomas, and gliomas.
– http://www1.cms.hhs.gov/mcd/viewdraftdecisionmemo.asp?
from2=viewdraftdecisionmemo.asp&id=218&
Lymphoma Metabolic Phenotypes Wong CYO et al, MIB 2006
178
SUV limitations
• SUV varies depending on partial
volume effects
• SUV dependent on plasma glucose
concentration
• SUV measurements are dependent
on reconstruction algorithms, uptake
time and scanner hardware
SUVpvc
SUV dependence on glucose
concentration • EORTC(99): SUV change < -25% => Response
• Scan 1: SUV=3; Glu=90
• Scan 2: SUV=2; Glu=150
• SUV change is -33% (significant change)
• But 3/2 is similar to (90/150) -0.84
• So change in SUV can be explained by change in
glucose level.
Courtesy of Oliver Wong, MD
Standardized Uptake Value
• Recommend maintaining scan paradigms
(uptake time, reconstruction algorithm,
manufacture scanner type, etc.) for optimal
assessment of response.
• Per ACR accreditation standards, report
glucose level, uptake time, injection dose,
etc. in technique
Lymphoma
• We will review through a case illustration approach that
lymphoma presents with multiple different phenotypes:
small cell, follicular, marginal cell, diffuse large B-cell,
Hodgkin s, etc.
• The FDG PET imaging characteristics reflect the
different phenotypes, and the clinical utility of FDG PET
is maximized by understanding the biologic behavior of
these different phenotypes.
Hodgkin s Lymphoma
• 29-year-old
• Enlarged supraclavicular LN
• Biopsy: classical HL, NS
• B symptoms
179
HL, NS subtype
Low Power
Medium Power
Reed-Sternberg Cell
High Power
Hodgkin s Lymphoma Hodgkin s Lymphoma
Hodgkin s Lymphoma Hodgkin s Lymphoma
• CT: stage IIB
• PET/CT
– Stage IIIB
– IPS= 3
180
Does FDG-PET Add Additional Prognostic Information to
CT Staging in Lymphoma (NHL and HL) Patients
• NHL = 110, HL + 26 patients
• CT and FDG-PET were discordant in
30 %
– In half of them PET showed change of
stage.
Blanca Sanchez-Gonzalez et al, Blood (ASH Annual Meeting Abstracts), Nov 2008; 112: 4949.
Optimizing PET/CT • Restaging of patients with lymphoma. Comparison of low dose CT (20 mAs) with
contrast enhanced diagnostic CT in combined [18F]-FDG PET/CT.
la Fougère C, Pfluger T, Schneider V, Hacker M, Bröckel N, Morhard D,
Hundt W, Bartenstein P, Becker C, Tiling R. Nuklearmedizin. 2008;47(1):37-42
and
• J Nucl Med. 2007; 48 (Supplement 2):183P
•
45 patients with non-Hodgkin lymphoma (n=35) and Hodgkin's disease (n=10)
were included into this study. Sensitivity/Specificity/PPV/NPV
• LD-CT 66%/93%/76%/88%
• CE-CT 87%/91%/78%/95%
• PET 95%/96%/90%/98%
• PET/LD-CT 94%/99%/97%/98%
• PET/CE-CT 96%/99%/99%/99%
• PET/CE-CT yielded a more precise lesion delineation than PET/LD-CT. This
was due to the improved image quality of CE-CT, increasing accuracy.
PET/CT Treatment Monitoring
• Treatment with systemic chemo
– 2 cycles of ABVD
– No RT
Early PET Treatment Monitoring
Hodgkin s Lymphoma-Treatment Monitoring
– 2 months later Hodgkin s Lymphoma
181
Hodgkin s
Lymphoma
Early Interim 2-PET Scan Is Prognostically
Superior to International Prognostic Score
in Advanced-Stage Hodgkin's Lymphoma
Andrea Gallamini et al
Journal of Clinical Oncology, Vol 25, No 24
(August 20), 2007: pp. 3746-3752
Gallamini, A. et al. J Clin Oncol; 25:3746-3752 2007
Clinical outcome for patients according to International
Prognostic Score (IPS) group and PET results after two
cycles of ABVD
Gallamini, A. et al. J Clin Oncol; 25:3746-3752 2007
progression-free survival according to International
Prognostic Score (IPS) group
Gallamini, A. et al. J Clin Oncol; 25:3746-3752 2007
Progression-free survival according to IPS group and PET
results after two cycles of ABVD NHL-Follicular Grade 1
• 67-year-old
• Left submandibular mass
182
PET
PET
SUV=5.4
SUVm=7.9
Biopsy: follicular NHL, grade 1
Follicular Lymphoma
Grade 1
Grade 1: 0-5 centroblasts/hpf; centrocytes
CD20 Bcl-2
Ki-67 Bcl-6
IHC NHL-Follicular Grade 1
• Stage I
• Received IFRT
• Achieved CR
183
NHL-Restaging
• Patient presents 2 years later with left
axillary mass
• Restaging PET/CT
Restaging PET 3 years later
Restaging PET 3 years later
SUVm=15.9 Biopsy: Follicular NHL, grade 2
Follicular Lymphoma
Grade 2
Grade 2: 6-15 centroblasts/hpf
NHL-Restaging
• Biopsy: Follicular NHL, grade 2,
• Stage I
• Received RT
• No evidence of disease currently
184
PET- Subsequent therapy 4
months later
PET- Subsequent therapy 4
months later
End of therapy PET/CT status
correlates strongly with PFS
Amanda Cashen Blood (ASH Annual Meeting Abstracts), Nov 2008; 112: 371
NHL
• 66-year-old
• Mesentric LN biopsy in 2003
• Follicular NHL, grade 1
• Treated with CVP
• Restaging PET January, 2004
Follicular Transformed DLBCL Follicular Transformed DLBCL
SUVm=31.3
185
Follicular Transformed DLBCL
• Biopsy showed transformed DLBCL
• Treated with R-CHOP
• Relapsed in 9/06
• Liver biopsy: DLBCL
• Treatment with R-ICE
Marginal Zone Lymphoma
(MZL)
59 year-old
Splenic MZL in 2001
Rituxan
Splenectomy in 2006
Splenic MZL MZL - Restaging
• Large SQ mass in the right shoulder
area
PET MZL Transformed DLBC PET- Restaging, SUVm=16.1
• 3-9-07 on 226226
186
Pathology: Large Cell
Transformation Treatment
• R-CHOP
• Myeloid growth factors (pegfilgrastim)
was used during therapy
Restaging PET 4 months later PET Summary
• Use of attenuation-corrected PET is strongly encouraged,
and the use of optimized PET/CT protocols.
• Beware of potential pitfalls: brown fat activation, neck
muscle uptake, inflammation, G-CSF effect, etc.
• Visual assessment alone is adequate for interpreting PET
findings as positive or negative though knowledge of
semiquantitative uptake may be valuable for recognizing
transformation or possible understaging secondary to
biopsy sampling error.
• Mediastinal blood pool activity is recommended as the
reference background activity to define PET positivity for a
residual mass ≥ 2 cm regardless of its location.
PET Summary
• Initial Diagnosis/Staging PET may direct biopsy and helps
characterize phenotype of lymphoma.
• PET offers important prognostic information with regard to
response to therapy and is useful for characterizing a
mass as residual disease versus fibrosis.
187
188
189
190
191
192
193
194
195
196
False Positive Problem in FDG PET:
Improving Specificity with PET/CT
Paul Shreve, M.D.Advanced Radiology Services, P.C Spectrum Health Lemmen-Holten Cancer CenterGrand Rapids, MI USA
PET/CT & Nuclear Medicine in Clinical Practice 2017Smowmass, CO February 23, 2017
• Reimbursement/pre-authorization • Limited adoption in clinical practice guidelines
(such as National Cancer Care Network)• Referring physician confidence in clinical usefulness• Bad reads/reports• Few local champions
What is Holding FDG PET Back?
The Usual Suspects
6th Best Practices in PET/CT Symposium, Sonoma, CA Oct 3-5, 2013
• Most common critique of FDG PET is FALSE POSITIVE findings
• Reports do not address clinical question• Lack of correlation with other/prior
imaging studies in interpretation/report
What is Holding FDG PET Back?
Bad reads/reports
Cheson , B. The case against heavy PETing. J Clin Onc 2009; 1742-1743.
Whole Body FDG PET Imaging
• Concentrated in tissues proportional to glucose transport and metabolism
• Undergoes urinary excretion
2-Deoxy-2-[F-18]fluoro-D-glucose : FDG
FDG PhysiologicTracerDistribution
• Most cancers are hypermetabolic• So…. hot spots bad• Just identify hot spots not reflecting normal
organs/tissues• Report hot spots as cancer/possible cancer
Whole Body FDG PET Imaging
What Could Be Simpler
197
• Identifying hot spots on the FDG PET images is fairly easy
• It is figuring out what the hot spots are that is the challenge
• The advent of PET-CT has made the task much easier, but not foolproof
• There is always a balance between sensitivity and specificity
Whole Body FDG PET Imaging
But…all “hot spots” are not cancer
Shreve P, Anzai Y., Wahl R.L. Pitfalls in oncologic diagnosis with FDG PET
imaging: Physiologic and benign variants. Radiographics 1999; 19:61-77.
• Reconstruction artifacts• Benign sources of focal FDG
tracer uptake
False Positives in FDG
PET-CT Imaging
Benign Sources of Increased FDG Tracer Activity
4 iterations with 8 subsets
gaussian filter 5
2 iterations with 4 subsets
gaussian filter 7
Concentrated barium in rectosigmoid colon from prior upper GI series
causing extensive spurious apparent FDG uptake on attenuation corrected
PET images (used CT as attenuation map). No artifact on non-AC images
attenuation corrected non-attenuation corrected
198
Attenuation corrected OSEM
using contrast CT attenuation Non-attenuation corrected FBP
Subclavian vein contrast artifact can occur
when CT scanning protocol is not properly
optimized for whole body scanning
Contrast CT
• Inflammation• Skeletal muscle• Brown fat• Benign soft tissue and bone tumors• Isolated urinary tracer • Bowel activity• Injection emboli
Whole Body FDG PET Imaging
Benign Sources of Increased FDG
Re-staging of head and neck cancer
using PET/CT circa 2001
Abnormal soft tissue in right neck on recent CT
Patient post surgery and chemotherapy
Re-staging of head and neck cancer
Abnormal soft tissue on CT (arrowhead) has no corresponding
FDG uptake. Region of abnormal FDG uptake corresponds to
post- operative fistulous tract on CT scan (arrows)
• Activated leukocytes have elevated glycolytic metabolism
• Infection and aseptic inflammation are associated with elevated FDG uptake
• FDG uptake typically moderate, but active granulomatous infection can be very hot
Infection and Inflammation
Whole Body PET-CT Imaging
• Read the CT! (pssst…it is not just a “localization scan”, never was)
• Priors, priors, priors! (PACS is here)• Clinical history, clinical history.• Take the time to do it right (easier
said than done these days)
FDG PET-CT Imaging
How to avoid benign hot spot false positive
199
Small focal pneumonia in left upper lobe
2010
2004
Diverticulitis
Diverticulitis with abscessSinus tract
200
Sarcoid Ovary
Hemorrhagic ovarian cyst
Pseudocyst at tail of the pancreas
Shreve , P. Focal fluorine-18 flouorodeoxyglucose accumulation in
inflammatory pancreatic disease. Euro J Nucl Med 1998; 25:259-264.
SUVmax = 6.8
HU = 18
201
SUVmax (of rim) = 3.8
HU = 26
Six weeks prior
FDG-PET: NSCLC, Mediastinal false positives
Caseating Granulomatous Infection
202
• False positive rate for lymph nodes in the mediastinum and neck as high as 10-15%
• False positive rate lower for abdominal/pelvic lymph nodes, appears to be < 5%.
• Tissue diagnosis should be obtained when possible to confirm a positive PET finding that substantially changes management
False Positive Lymph Nodes on FDG PET
Whole Body PET-CT Imaging
• Talc pleurodesis• Subcutaneous fat and
intramuscular injection
Other inflammation related false positives
Whole Body PET-CT Imaging
203
• Healing fractures can have modest FDG uptake, which can persist for weeks
• Degenerative joints, and certain joints such as sternoclavicular jointsand AC joints can show modest focal uptake
• Osteophytes rarely can have FDG uptake • Vertebroplasty• Myositis ossificans
Skeletal Inflammatory Uptake of FDG
Whole Body PET-CT Imaging
Minimal FDG uptake in left AC joint due to degenerative change
Rib fracture
Sacral insufficiency fracture in patient being staged for non-small cell lung cancer
Multiple vertebralplasties and insufficiency fractures
Breast cancer with left hip pain
204
Attenuation corrected Non-attenuation corrected Myositis Ossificans
• Inflammation• Skeletal muscle• Brown fat• Benign soft tissue and bone tumors• Isolated urinary tracer • Bowel activity
Whole Body FDG PET Imaging
Benign Sources of Increased FDG
209
Insulineffect on FDGmuscle uptake
Skeletal muscle physiologic FDG uptake
205
• Inflammation• Skeletal muscle• Brown fat• Benign soft tissue and bone tumors• Isolated urinary tracer • Bowel activity
Whole Body FDG PET Imaging
Benign Sources of Increased FDG
Functional Anatomy - Brown Fat Uptake
Whole Body PET-CT Imaging
• Brown adipose tissue is thought to be involved in mammalian thermal regulation
• Adrenergic stimulation causes rapid glucose uptake and metabolism to generate heat
• FDG uptake is seen in residual adult brown fat in response to cold or adrenergic output
• Brown fat FDG uptake is most commonly seen in fat at the base of the neck and shoulders, thoracic paraspinous fat, but can be present in mediastinal and upper abdominal fat as well Physiologic brown adipose tissue FDG uptake
at neck and shoulders in young anxious patient
206
Physiologic brown adipose tissue FDG uptake at typical location of base of neck and shoulders
Physiologic brown adipose tissue FDG uptake in paraspinous fat along thoracic spine
Physiologic brown adipose tissue FDG uptakein less common location of upper abdomen
Physiologic brown adipose tissue FDG uptake at the neck and shoulders and mediastinal lymphoma
Functional Anatomy – Hibridomas
Whole Body PET-CT Imaging
• Benign brown fat tumors have been know to pathologists
• Rare, usually seen at shoulder, knees• Are very hot but have typical CT appearance• FDG uptake can vary over time • Liposarcoma is in the differential
hiberdoma
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• Inflammation• Skeletal muscle• Brown fat• Benign soft tissue and bone tumors• Isolated urinary tracer • Bowel activity
Whole Body FDG PET Imaging
Benign Sources of Increased FDG
• Warthin’s tumor in parotid gland• Benign pituitary adenomas can very hot• Benign bone lesions including histiocytic/giant
cell containing lesions
Benign Tumors
Whole Body PET-CT Imaging
Aoki J, et. al. Radiology 2001; 219:774-777
Warthin s tumor of leftparotidgland
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May 2011 September 2010
May 2011 September 2010
Pituitary Adenoma Pituitary Adenoma
Normal palatine tonsil FDG uptake Normal adenoid FDG uptake in a 16 year old
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• Adrenal nodules are common (5% on CT)• 80% nodules are adenomas• 40%-57% adrenal nodules benign in patients
with known malignancy• Adrenal also fairly common site of metastasis
(lung, breast , melanoma, renal, colon, thyroid)• Primary adrenal cancers rare
Adrenal Masses
Whole Body PET-CT Imaging
Benign adrenal adenoma
• Benign adrenal adenomas can exhibit low FDG tracer activity, sometimes greater than liver
• CT criteria for adrenal adenoma (HU < 10) can be helpful
• Gets difficult with small nodules with modest uptake in setting where adrenal metastasis possible (ie lung cancer) – prior CTs if available
Adrenal Masses
Whole Body PET-CT Imaging
Blake MA, et al. PET/CT for Adrenal Assessment. AJR 2009; 195: W91-W95Anatomically normal adrenals with FDG uptake
• Inflammation• Skeletal muscle• Brown fat• Benign soft tissue and bone tumors• Isolated urinary tracer • Bowel activity
Whole Body FDG PET Imaging
Benign Sources of Increased FDG
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Focal FDG uptake in retroperitoneum Normal urinary FDG in ureter
Ureter identified on CT confirms focal FDG uptake is due
to urinary tracer, not an abnormal lymph node
Bilateral bladder diverticula urinary FDG tracer activity Bilateral bladder diverticula urinary FDG tracer activity
• Inflammation• Skeletal muscle• Brown fat• Benign soft tissue and bone tumors• Isolated urinary tracer • Bowel activity
Whole Body FDG PET Imaging
Benign Sources of Increased FDG
Right and transverse colon physiologic FDG uptake
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Right and transverse colon physiologic FDG uptake
• An isolated intense focus of FDG uptake in the colon warrants further investigation (colonoscopy) as this is associated with villous adenomas and carcinomas generally > 1 cm in size
• CT may not be revealing, although occasionally a nodule or mass is seen
Focal Intense FDG Tracer Uptake in Colon
Whole Body PET-CT Imaging
Incidental adenocarcinoma of the sigmoid colon
• Same as with other nuclear medicine exams
• Remember registration in axial planes between PET images and CT images may not be perfect
Whole Body FDG PET Imaging
Injection blood clot emboli artifact
• False positive findings can be reduced by careful attention to CT findings, prior imaging studies, and clinical history
• Inflammation, particularly of lymph nodes, is a source of unavoidable non-specificity
• A close working relationship with referring clinicians is key to reducing the fall-out of false positive and false negative FDG PET-CT interpretation and reporting
False Positive Findings on
FDG PET-CT
Conclusions
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