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High-Risk Melanoma: Accuracy of FDG PET/CT with Added CT Morphologic Information for Detection of Metastases¹

¹ From the Division of Nuclear Medicine, Department of Medical Radiology (K.S., D.B.H., M.P.L., T.F.H., H.C.S.), and Department of Dermatology (R.D.), University Hospital Zurich, Raemistr 100, 8091 Zurich, Switzerland. Received June 26, 2006; revision requested August 30; revision received September 15; accepted October 25; final version accepted December 11. Supported in part by the Bonizzi-Theler Foundation. Address correspondence to K.S. (e-mail: klaus.strobel{at}usz.ch).

View larger version (17K): [in this window] [in a new window] [Download PPT slide]   Figure 1: Flow diagram of study patients.

View larger version (109K): [in this window] [in a new window] [Download PPT slide]   Figure 2a: (a–c) Images in 50-year-old man. PET/CT was performed 7 months after resection of an ulcerating nodular malignant melanoma of scalp (Breslow thickness, 5.0 mm; Clark level, IV or V); there were negative findings at sentinel node biopsy. (a) Transverse fused PET/CT image shows two pulmonary nodules (arrows) in lower lobes. (b) Corresponding transverse PET image and (c) coronal maximum intensity projection show no FDG uptake. MR imaging (results not shown) was performed 3 days after brain metastases were detected at initial PET/CT; palliative radiation therapy was started. (d–f) Images obtained 6 months later. (d) Transverse fused PET/CT image shows progression of pulmonary nodules (arrows) in size and number. (e) Corresponding transverse PET image and (f) coronal maximum intensity projection show increased FDG uptake in several lung nodules (arrows).

View larger version (68K): [in this window] [in a new window] [Download PPT slide]   Figure 2b: (a–c) Images in 50-year-old man. PET/CT was performed 7 months after resection of an ulcerating nodular malignant melanoma of scalp (Breslow thickness, 5.0 mm; Clark level, IV or V); there were negative findings at sentinel node biopsy. (a) Transverse fused PET/CT image shows two pulmonary nodules (arrows) in lower lobes. (b) Corresponding transverse PET image and (c) coronal maximum intensity projection show no FDG uptake. MR imaging (results not shown) was performed 3 days after brain metastases were detected at initial PET/CT; palliative radiation therapy was started. (d–f) Images obtained 6 months later. (d) Transverse fused PET/CT image shows progression of pulmonary nodules (arrows) in size and number. (e) Corresponding transverse PET image and (f) coronal maximum intensity projection show increased FDG uptake in several lung nodules (arrows).

View larger version (66K): [in this window] [in a new window] [Download PPT slide]   Figure 2c: (a–c) Images in 50-year-old man. PET/CT was performed 7 months after resection of an ulcerating nodular malignant melanoma of scalp (Breslow thickness, 5.0 mm; Clark level, IV or V); there were negative findings at sentinel node biopsy. (a) Transverse fused PET/CT image shows two pulmonary nodules (arrows) in lower lobes. (b) Corresponding transverse PET image and (c) coronal maximum intensity projection show no FDG uptake. MR imaging (results not shown) was performed 3 days after brain metastases were detected at initial PET/CT; palliative radiation therapy was started. (d–f) Images obtained 6 months later. (d) Transverse fused PET/CT image shows progression of pulmonary nodules (arrows) in size and number. (e) Corresponding transverse PET image and (f) coronal maximum intensity projection show increased FDG uptake in several lung nodules (arrows).

View larger version (111K): [in this window] [in a new window] [Download PPT slide]   Figure 2d: (a–c) Images in 50-year-old man. PET/CT was performed 7 months after resection of an ulcerating nodular malignant melanoma of scalp (Breslow thickness, 5.0 mm; Clark level, IV or V); there were negative findings at sentinel node biopsy. (a) Transverse fused PET/CT image shows two pulmonary nodules (arrows) in lower lobes. (b) Corresponding transverse PET image and (c) coronal maximum intensity projection show no FDG uptake. MR imaging (results not shown) was performed 3 days after brain metastases were detected at initial PET/CT; palliative radiation therapy was started. (d–f) Images obtained 6 months later. (d) Transverse fused PET/CT image shows progression of pulmonary nodules (arrows) in size and number. (e) Corresponding transverse PET image and (f) coronal maximum intensity projection show increased FDG uptake in several lung nodules (arrows).

View larger version (88K): [in this window] [in a new window] [Download PPT slide]   Figure 2e: (a–c) Images in 50-year-old man. PET/CT was performed 7 months after resection of an ulcerating nodular malignant melanoma of scalp (Breslow thickness, 5.0 mm; Clark level, IV or V); there were negative findings at sentinel node biopsy. (a) Transverse fused PET/CT image shows two pulmonary nodules (arrows) in lower lobes. (b) Corresponding transverse PET image and (c) coronal maximum intensity projection show no FDG uptake. MR imaging (results not shown) was performed 3 days after brain metastases were detected at initial PET/CT; palliative radiation therapy was started. (d–f) Images obtained 6 months later. (d) Transverse fused PET/CT image shows progression of pulmonary nodules (arrows) in size and number. (e) Corresponding transverse PET image and (f) coronal maximum intensity projection show increased FDG uptake in several lung nodules (arrows).

View larger version (59K): [in this window] [in a new window] [Download PPT slide]   Figure 2f: (a–c) Images in 50-year-old man. PET/CT was performed 7 months after resection of an ulcerating nodular malignant melanoma of scalp (Breslow thickness, 5.0 mm; Clark level, IV or V); there were negative findings at sentinel node biopsy. (a) Transverse fused PET/CT image shows two pulmonary nodules (arrows) in lower lobes. (b) Corresponding transverse PET image and (c) coronal maximum intensity projection show no FDG uptake. MR imaging (results not shown) was performed 3 days after brain metastases were detected at initial PET/CT; palliative radiation therapy was started. (d–f) Images obtained 6 months later. (d) Transverse fused PET/CT image shows progression of pulmonary nodules (arrows) in size and number. (e) Corresponding transverse PET image and (f) coronal maximum intensity projection show increased FDG uptake in several lung nodules (arrows).

View larger version (99K): [in this window] [in a new window] [Download PPT slide]   Figure 3a: (a–c) Images in 36-year-old woman 6 years after resection of malignant melanoma on abdominal wall (Breslow thickness, 1.0 mm; Clark level, IV). After resection and radiation therapy of axillary and supraclavicular lymph node metastases on right side 1 year before, PET/CT follow-up was performed. (a) Transverse fused PET/CT image shows small lesion (arrow) in gluteal subcutaneous fatty tissue on right side. (b) Corresponding transverse PET and (c) coronal maximum intensity projection show no FDG uptake by this lesion. (d–f) Images obtained 3 months later. (d) Transverse PET/CT fused image shows growth of subcutaneous lesion (arrow). (e) Transverse PET image shows pathologic focal FDG uptake by lesion (arrow). (f) Coronal PET image shows, in addition to gluteal metastasis (long arrow), two new focal lesions: supraclavicular lymph node (upper short arrow) and paraaortal lymph node (lower short arrow). Note physiologic FDG uptake in ovaries (arrowheads). Patient died of bleeding brain metastasis 2 weeks after follow-up PET/CT scan.

View larger version (38K): [in this window] [in a new window] [Download PPT slide]   Figure 3b: (a–c) Images in 36-year-old woman 6 years after resection of malignant melanoma on abdominal wall (Breslow thickness, 1.0 mm; Clark level, IV). After resection and radiation therapy of axillary and supraclavicular lymph node metastases on right side 1 year before, PET/CT follow-up was performed. (a) Transverse fused PET/CT image shows small lesion (arrow) in gluteal subcutaneous fatty tissue on right side. (b) Corresponding transverse PET and (c) coronal maximum intensity projection show no FDG uptake by this lesion. (d–f) Images obtained 3 months later. (d) Transverse PET/CT fused image shows growth of subcutaneous lesion (arrow). (e) Transverse PET image shows pathologic focal FDG uptake by lesion (arrow). (f) Coronal PET image shows, in addition to gluteal metastasis (long arrow), two new focal lesions: supraclavicular lymph node (upper short arrow) and paraaortal lymph node (lower short arrow). Note physiologic FDG uptake in ovaries (arrowheads). Patient died of bleeding brain metastasis 2 weeks after follow-up PET/CT scan.

View larger version (20K): [in this window] [in a new window] [Download PPT slide]   Figure 3c: (a–c) Images in 36-year-old woman 6 years after resection of malignant melanoma on abdominal wall (Breslow thickness, 1.0 mm; Clark level, IV). After resection and radiation therapy of axillary and supraclavicular lymph node metastases on right side 1 year before, PET/CT follow-up was performed. (a) Transverse fused PET/CT image shows small lesion (arrow) in gluteal subcutaneous fatty tissue on right side. (b) Corresponding transverse PET and (c) coronal maximum intensity projection show no FDG uptake by this lesion. (d–f) Images obtained 3 months later. (d) Transverse PET/CT fused image shows growth of subcutaneous lesion (arrow). (e) Transverse PET image shows pathologic focal FDG uptake by lesion (arrow). (f) Coronal PET image shows, in addition to gluteal metastasis (long arrow), two new focal lesions: supraclavicular lymph node (upper short arrow) and paraaortal lymph node (lower short arrow). Note physiologic FDG uptake in ovaries (arrowheads). Patient died of bleeding brain metastasis 2 weeks after follow-up PET/CT scan.

View larger version (110K): [in this window] [in a new window] [Download PPT slide]   Figure 3d: (a–c) Images in 36-year-old woman 6 years after resection of malignant melanoma on abdominal wall (Breslow thickness, 1.0 mm; Clark level, IV). After resection and radiation therapy of axillary and supraclavicular lymph node metastases on right side 1 year before, PET/CT follow-up was performed. (a) Transverse fused PET/CT image shows small lesion (arrow) in gluteal subcutaneous fatty tissue on right side. (b) Corresponding transverse PET and (c) coronal maximum intensity projection show no FDG uptake by this lesion. (d–f) Images obtained 3 months later. (d) Transverse PET/CT fused image shows growth of subcutaneous lesion (arrow). (e) Transverse PET image shows pathologic focal FDG uptake by lesion (arrow). (f) Coronal PET image shows, in addition to gluteal metastasis (long arrow), two new focal lesions: supraclavicular lymph node (upper short arrow) and paraaortal lymph node (lower short arrow). Note physiologic FDG uptake in ovaries (arrowheads). Patient died of bleeding brain metastasis 2 weeks after follow-up PET/CT scan.

View larger version (84K): [in this window] [in a new window] [Download PPT slide]   Figure 3e: (a–c) Images in 36-year-old woman 6 years after resection of malignant melanoma on abdominal wall (Breslow thickness, 1.0 mm; Clark level, IV). After resection and radiation therapy of axillary and supraclavicular lymph node metastases on right side 1 year before, PET/CT follow-up was performed. (a) Transverse fused PET/CT image shows small lesion (arrow) in gluteal subcutaneous fatty tissue on right side. (b) Corresponding transverse PET and (c) coronal maximum intensity projection show no FDG uptake by this lesion. (d–f) Images obtained 3 months later. (d) Transverse PET/CT fused image shows growth of subcutaneous lesion (arrow). (e) Transverse PET image shows pathologic focal FDG uptake by lesion (arrow). (f) Coronal PET image shows, in addition to gluteal metastasis (long arrow), two new focal lesions: supraclavicular lymph node (upper short arrow) and paraaortal lymph node (lower short arrow). Note physiologic FDG uptake in ovaries (arrowheads). Patient died of bleeding brain metastasis 2 weeks after follow-up PET/CT scan.

View larger version (60K): [in this window] [in a new window] [Download PPT slide]   Figure 3f: (a–c) Images in 36-year-old woman 6 years after resection of malignant melanoma on abdominal wall (Breslow thickness, 1.0 mm; Clark level, IV). After resection and radiation therapy of axillary and supraclavicular lymph node metastases on right side 1 year before, PET/CT follow-up was performed. (a) Transverse fused PET/CT image shows small lesion (arrow) in gluteal subcutaneous fatty tissue on right side. (b) Corresponding transverse PET and (c) coronal maximum intensity projection show no FDG uptake by this lesion. (d–f) Images obtained 3 months later. (d) Transverse PET/CT fused image shows growth of subcutaneous lesion (arrow). (e) Transverse PET image shows pathologic focal FDG uptake by lesion (arrow). (f) Coronal PET image shows, in addition to gluteal metastasis (long arrow), two new focal lesions: supraclavicular lymph node (upper short arrow) and paraaortal lymph node (lower short arrow). Note physiologic FDG uptake in ovaries (arrowheads). Patient died of bleeding brain metastasis 2 weeks after follow-up PET/CT scan.