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Clinical Applications of PET in Oncology¹

¹ From the Department of Radiology, Duke University Medical Center, Rm 1410, Duke North, Erwin Rd, Durham, NC 27710 (T.G.T., R.E.C.); and the Department of Radiology, Mayo Clinic, Rochester, Minn (E.M.R.). Received September 17, 2002; revision requested November 13; revision received April 14, 2003; accepted May 1. Address correspondence to R.E.C. (e-mail: colem010@mc.duke.edu).

View larger version (7K): [in a new window]   Figure 1. Diagram shows positron annihilation resulting in back-to-back photons. Photons are detected in detectors on each side. The location of the annihilation is limited to the shaded column. e+ = positron, e– = electron, = photon.

View larger version (35K): [in a new window]   Figure 2. Schematic of a simple PET scanner detecting an event. The radiotracer molecule leading to this event must have been in the central gray area. The ring of rectangles represents the detectors.

View larger version (25K): [in a new window]   Figure 3. Schematic shows factors that degrade PET images. Top: Random event. Middle: Scattered events in transaxial plane (left) and out of plane (right). Bottom: Attenuation event, in which one of the photons never reaches its detector.

View larger version (42K): [in a new window]   Figure 4. Attenuation effects. PET emission images were obtained with (left) and without (right) attenuation correction. Artifacts on the noncorrected image (right) include the outer bright rim, artificially bright lungs, and elongation of the intense lesion.

View larger version (127K): [in a new window]   Figure 5. Frontal (left) and left lateral (right) maximum intensity projections from FDG PET scan in an 80-year-old man referred for diagnosis of lung carcinoma. Newly discovered right lower lobe pulmonary nodule (arrows) is intensely hypermetabolic, with SUV of 12. Subsequent biopsy demonstrated non-small cell carcinoma.

View larger version (94K): [in a new window]   Figure 6a. FDG PET images in a 69-year-old man referred for diagnosis of lung carcinoma, with a newly-discovered left lung nodule. (a) Frontal maximum intensity projection is normal, with no hypermetabolic abnormality present. (b) Coronal sections from attenuation-corrected emission (left) and segmented transmission (right) scans. Transmission image demonstrates large nodule (arrow) in the posterior aspect of left lung. Only low-grade FDG activity is seen in this region on the emission scan (arrowhead). At patient’s request, the nodule was removed surgically and proved to be pulmonary hamartoma.

View larger version (103K): [in a new window]   Figure 6b. FDG PET images in a 69-year-old man referred for diagnosis of lung carcinoma, with a newly-discovered left lung nodule. (a) Frontal maximum intensity projection is normal, with no hypermetabolic abnormality present. (b) Coronal sections from attenuation-corrected emission (left) and segmented transmission (right) scans. Transmission image demonstrates large nodule (arrow) in the posterior aspect of left lung. Only low-grade FDG activity is seen in this region on the emission scan (arrowhead). At patient’s request, the nodule was removed surgically and proved to be pulmonary hamartoma.

View larger version (114K): [in a new window]   Figure 7. Frontal maximum intensity projection from FDG PET scan in a 75-year-old man with newly diagnosed non-small cell lung cancer, who was referred for initial staging of lung carcinoma, shows large metabolic mass in the middle portion of left lung (large arrow), with central photopenia suggestive of necrosis. Metastases to left hilar and mediastinal lymph nodes (large arrowheads), right adrenal gland (small arrow), and bilateral perinephric spaces (small arrowheads) are present.

View larger version (89K): [in a new window]   Figure 8a. FDG PET images in a 62-year-old man with a history of non-small cell lung cancer. Patient had undergone right upper lobectomy and presented with increasing right upper extremity pain; he was referred for restaging of lung carcinoma. (a) Frontal maximum intensity projection demonstrates increased FDG uptake in apicomedial portion of right hemithorax (arrow). Normal laryngeal activity is seen in the midline of the neck (arrowhead). (b) Coronal image confirms hypermetabolic tumor adjacent to superior mediastinum and extending superiorly into the region of the brachial plexus on the right (arrow).

View larger version (84K): [in a new window]   Figure 8b. FDG PET images in a 62-year-old man with a history of non-small cell lung cancer. Patient had undergone right upper lobectomy and presented with increasing right upper extremity pain; he was referred for restaging of lung carcinoma. (a) Frontal maximum intensity projection demonstrates increased FDG uptake in apicomedial portion of right hemithorax (arrow). Normal laryngeal activity is seen in the midline of the neck (arrowhead). (b) Coronal image confirms hypermetabolic tumor adjacent to superior mediastinum and extending superiorly into the region of the brachial plexus on the right (arrow).

View larger version (79K): [in a new window]   Figure 9. Frontal maximum intensity projection from FDG PET scan in a 70-year-old woman with newly diagnosed adenocarcinoma of transverse colon who was referred for initial staging of colorectal cancer. Intense FDG uptake is shown (arrow) in left midabdomen, in the region of the patient’s known malignancy. No metastases are seen.

View larger version (121K): [in a new window]   Figure 10a. FDG PET images in a 56-year-old man with newly discovered pulmonary nodule and incidental discovery of colonic adenoma. (a) Frontal (left) and lateral (right) maximum intensity projections demonstrate nodule (arrows) in middle portion of right lung nodule to be hypermetabolic (SUV = 9.0). Subsequent resection demonstrated squamous cell carcinoma of the lung. Also noted is hypermetabolic (arrowheads) focus in right upper abdomen. (b) Axial image demonstrates that hypermetabolic (SUV = 6.5) lesion (arrow) is located anteriorly, possibly contiguous with transverse colon (arrowheads). Subsequent colonoscopy demonstrated 3-cm tubulovillous adenoma, with no evidence of malignancy.

View larger version (61K): [in a new window]   Figure 10b. FDG PET images in a 56-year-old man with newly discovered pulmonary nodule and incidental discovery of colonic adenoma. (a) Frontal (left) and lateral (right) maximum intensity projections demonstrate nodule (arrows) in middle portion of right lung nodule to be hypermetabolic (SUV = 9.0). Subsequent resection demonstrated squamous cell carcinoma of the lung. Also noted is hypermetabolic (arrowheads) focus in right upper abdomen. (b) Axial image demonstrates that hypermetabolic (SUV = 6.5) lesion (arrow) is located anteriorly, possibly contiguous with transverse colon (arrowheads). Subsequent colonoscopy demonstrated 3-cm tubulovillous adenoma, with no evidence of malignancy.

View larger version (87K): [in a new window]   Figure 11. Frontal maximum intensity projection from FDG PET scan in a 59-year-old woman with recent surgical resection of colon carcinoma, referred for initial staging of colorectal cancer prior to additional therapy. Numerous hypermetabolic lesions in the liver (arrows) and retroperitoneum (large arrowheads) are shown. Findings are compatible with metastases. A subtle focus of activity in right pulmonary hilum (small arrowhead) was thought to be inflammatory.

View larger version (109K): [in a new window]   Figure 12. Frontal (left) and left lateral (right) maximum intensity projections from FDG PET scan in a 67-year-old man with history of rectal carcinoma who was referred for restaging of colorectal cancer. FDG PET was performed after low anterior resection. Locally recurrent disease in presacral space at the site of anastomosis (thick arrow), hepatic metastases involving right and left hepatic lobes (arrowheads), and solitary pulmonary metastasis (thin arrow) are visible.

View larger version (85K): [in a new window]   Figure 13. Frontal maximum intensity projection from FDG PET scan in an 80-year-old man after recent excision of melanoma from the left ear. The patient was referred for initial staging of melanoma. Two discrete hypermetabolic foci (arrows) in left supraclavicular fossa, compatible with regional nodal metastases, are shown. At surgery, patient was found to have micrometastatic disease to a third node that was not visible at PET.

View larger version (92K): [in a new window]   Figure 14. Frontal maximum intensity projection from FDG PET scan in a 46-year-old woman with malignant melanoma of unknown primary who was referred for restaging of melanoma. Innumerable metastases are shown, including cutaneous or subcutaneous, nodal, hepatic, splenic, and pulmonary sites of disease.

View larger version (119K): [in a new window]   Figure 15. Frontal (left) and left lateral (right) maximum intensity projections from FDG PET scan in a 46-year-old man with history of melanoma removed from left upper back who then presented with pigmented cutaneous lesions extending from biopsy site to left axilla. Patient was referred for restaging of melanoma. Multiple sites of disease are visible, including local recurrence at biopsy site with in-transit cutaneous metastases (large arrows), left axillary metastases (small arrows), retrosternal metastasis (large arrowhead), and splenic and hepatic metastases (small arrowheads).

View larger version (79K): [in a new window]   Figure 16. Frontal maximum intensity projection from FDG PET scan in a 67-year-old woman with newly diagnosed T-cell lymphoma. Patient was referred for initial staging of lymphoma. Widespread nodal disease is shown above and below the diaphragm. Spleen (arrowheads) is diffusely hypermetabolic, suggesting lymphomatous involvement.

View larger version (100K): [in a new window]   Figure 17. Frontal maximum intensity projection from FDG PET scan in a 46-year-old man with metastatic adenocarcinoma of unknown primary. The patient was referred for evaluation subsequent to high-dose chemotherapy. Increased FDG uptake is seen in marrow of axial and proximal appendicular skeleton, and homogeneous FDG uptake is seen in spleen. This pattern is consistent with effects of marrow stimulation with colony-stimulating factors. On investigation, it was determined that patient had been receiving a marrow-stimulating agent up to the time of PET.

View larger version (78K): [in a new window]   Figure 18a. Frontal maximum intensity projections from FDG PET scans in a 68-year-old woman with B-cell lymphoma. (a) Image obtained shortly after diagnosis and prior to initiation of therapy shows large lymphoma masses (arrow) in abdomen and small focus of disease (arrowhead) in superior mediastinum. (b) Second image obtained 10 weeks later, after chemotherapy, shows complete resolution of FDG uptake, with no metabolically active disease.

View larger version (77K): [in a new window]   Figure 18b. Frontal maximum intensity projections from FDG PET scans in a 68-year-old woman with B-cell lymphoma. (a) Image obtained shortly after diagnosis and prior to initiation of therapy shows large lymphoma masses (arrow) in abdomen and small focus of disease (arrowhead) in superior mediastinum. (b) Second image obtained 10 weeks later, after chemotherapy, shows complete resolution of FDG uptake, with no metabolically active disease.

View larger version (89K): [in a new window]   Figure 19a. FDG PET images in a 57-year-old man with newly diagnosed esophageal carcinoma. Patient was referred for initial staging of esophageal cancer. (a) Frontal maximum intensity projection shows hypermetabolic lesion (arrow) in middle portion of the esophagus, corresponding to patient’s known esophageal tumor. In addition, there is a small hypermetabolic focus (arrowhead) in the superior mediastinum, located in the paratracheal space. (b) Axial image shows metastatic focus (arrowhead) in small left paratracheal lymph node.

View larger version (45K): [in a new window]   Figure 19b. FDG PET images in a 57-year-old man with newly diagnosed esophageal carcinoma. Patient was referred for initial staging of esophageal cancer. (a) Frontal maximum intensity projection shows hypermetabolic lesion (arrow) in middle portion of the esophagus, corresponding to patient’s known esophageal tumor. In addition, there is a small hypermetabolic focus (arrowhead) in the superior mediastinum, located in the paratracheal space. (b) Axial image shows metastatic focus (arrowhead) in small left paratracheal lymph node.

View larger version (73K): [in a new window]   Figure 20a. FDG PET images in a 54-year-old woman with right neck swelling who was found to have metastatic squamous cell carcinoma to a right cervical lymph node. The patient was referred for diagnosis of head and neck cancer. (a) Frontal maximum intensity projection shows focal FDG uptake (arrow) in a right cervical lymph node, consistent with known metastatic disease. A second focus of uptake (arrowhead) is present superiorly and medially. (b) Axial image shows the two foci of uptake. Nodal disease is seen in right cervical chain (arrow), and second focus of uptake is seen to lie in the region of the right oropharynx (arrowhead). On the basis of PET findings, directed examination and biopsy of the right oropharyngeal region were performed and revealed squamous cell carcinoma arising in the right tonsil.

View larger version (71K): [in a new window]   Figure 20b. FDG PET images in a 54-year-old woman with right neck swelling who was found to have metastatic squamous cell carcinoma to a right cervical lymph node. The patient was referred for diagnosis of head and neck cancer. (a) Frontal maximum intensity projection shows focal FDG uptake (arrow) in a right cervical lymph node, consistent with known metastatic disease. A second focus of uptake (arrowhead) is present superiorly and medially. (b) Axial image shows the two foci of uptake. Nodal disease is seen in right cervical chain (arrow), and second focus of uptake is seen to lie in the region of the right oropharynx (arrowhead). On the basis of PET findings, directed examination and biopsy of the right oropharyngeal region were performed and revealed squamous cell carcinoma arising in the right tonsil.

View larger version (76K): [in a new window]   Figure 21a. FDG PET images obtained after radiation therapy in a 43-year-old man with prior laryngeal carcinoma. Patient was referred for restaging of head and neck cancer. (a) Frontal (left) and left lateral (right) maximum intensity projections show focal FDG accumulation (arrow) in the neck, in the region of the larynx. (b) Axial image confirms focal FDG activity (arrow) in larynx, which is worrisome for recurrent tumor. Laryngoscopy and biopsy results confirmed presence of viable tumor.

View larger version (46K): [in a new window]   Figure 21b. FDG PET images obtained after radiation therapy in a 43-year-old man with prior laryngeal carcinoma. Patient was referred for restaging of head and neck cancer. (a) Frontal (left) and left lateral (right) maximum intensity projections show focal FDG accumulation (arrow) in the neck, in the region of the larynx. (b) Axial image confirms focal FDG activity (arrow) in larynx, which is worrisome for recurrent tumor. Laryngoscopy and biopsy results confirmed presence of viable tumor.

View larger version (84K): [in a new window]   Figure 22. Frontal maximum intensity projection from FDG PET scan in a 46-year-old woman with a large mass in left breast. The patient was referred for initial staging of breast cancer. Large hypermetabolic mass (thick arrow) in left breast is visible. Enlarged hypermetabolic nodes (arrowheads) in left axilla are compatible with axillary metastases. Two additional foci of FDG uptake are seen projecting over the abdomen (thin arrows); on further investigation, these were determined to be osseous metastases to spine.

View larger version (80K): [in a new window]   Figure 23. Frontal maximum intensity projection from FDG PET scan in a 50-year-old woman with history of papillary thyroid cancer. Patient presented with abdominal pain. Innumerable metastatic lesions are seen, including hepatic, pulmonary, nodal, and peritoneal sites of disease.

View larger version (85K): [in a new window]   Figure 24a. FDG PET images in a 53-year-old woman with history of mucosal-associated lymphoid tissue lymphoma. Patient was referred for restaging after therapy. (a) Frontal maximum intensity projection shows tiny hypermetabolic focus (arrow) on the right side of the neck. PET scan is otherwise normal. (b) Axial image through base of the neck shows focal activity (arrow) to lie in the region of the thyroid. Thyroid US and biopsy revealed well-differentiated papillary thyroid cancer.

View larger version (32K): [in a new window]   Figure 24b. FDG PET images in a 53-year-old woman with history of mucosal-associated lymphoid tissue lymphoma. Patient was referred for restaging after therapy. (a) Frontal maximum intensity projection shows tiny hypermetabolic focus (arrow) on the right side of the neck. PET scan is otherwise normal. (b) Axial image through base of the neck shows focal activity (arrow) to lie in the region of the thyroid. Thyroid US and biopsy revealed well-differentiated papillary thyroid cancer.