Cristina Nanni Stefano Fanti. PET-CT: Rare Findings and Diseases

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2 Cristina Nanni Stefano Fanti PET-CT: Rare Findings and Diseases

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4 Cristina Nanni Stefano Fanti PET-CT: Rare Findings and Diseases

5 Dr. Cristina Nanni Ospedale S. Orsola-Malpighi Dept. of Nuclear Medicine Via Massarenti Bologna Italy cristina.nanni@aosp.bo.it Prof. Dr. Stefano Fanti Univ. Bologna Policlinico S.Orsola-Malpighi Dipto. Medicina Nucleare Via Massarenti Bologna Italy fanti@orsola-malpighi.med.unibo.it ISBN: e-isbn: DOI: / Library of Congress Control Number: Springer-Verlag Berlin Heidelberg This work is subject to copyright. All rights are reserved, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilm or in any other way, and storage in data banks. Duplication of this publication or parts thereof is permitted only under the provisions of the German Copyright Law of September 9, 1965, in its current version, and permission for use must always be obtained from Springer. Violations are liable to prosecution under the German Copyright Law. The use of general descriptive names, registered names, trademarks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. Product liability: The publishers cannot guarantee the accuracy of any information about dosage and application contained in this book. In every individual case the user must check such information by consulting the relevant literature. Printed on acid-free paper Springer is part of Springer Science + Business Media (

6 Acknowledgments Cristina Nanni would like to thank Prof. Stefano Fanti for his trust and brilliant vision in the field of PET imaging and the staff of the PET Centre in Bologna (particularly Dr. Vincenzo Allegri, Dr. Paolo Castellucci, Dr. Giancarlo Montini, Dr. Valentina Ambrosini and all the residents) for great work and help in documenting interesting cases. She also thanks Riccardo and Francesca, mum and dad, for a great patience, practical support and constant encouragement. Stefano Fanti would like to thank Dr. Cristina Nanni for her expertise, dedication and attitude: indeed she did all the work, and not only concerning the present book. He also thanks Maddalena, Raffaele and Anita for the great daily joy. v

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8 Contents Chapter 1 FDG: Rare Diseases Chapter 2 11C-Choline: Rare Diseases Chapter 3 11C-Methionine: Rare Diseases Chapter 4 68Ga-Somatostatine Analogs: Rare Diseases Chapter 5 FDG: Rare Findings Chapter 6 11C-Choline: Rare Findings Chapter 7 68Ga-Somatostatine Analogs: Rare Findings Index vii

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10 Introduction Positron Emission Tomography (PET) is an emerging functional imaging technique particularly useful in the diagnostic flow chart of oncological patients. FDG is by far the most employed tracer, providing high accuracy for the detection of most malignancies. Other emerging tracers proven to have a significant impact on patient management are 11C-methionine, 11C-choline and 68Ga-somatostatine analogues. The increasing use of integrated functional (PET) and morphological (CT) imaging and the growing number of patients undergoing these procedures lead to the need for a great deal of experience in image interpretation, since incidental findings and comorbidities can cause misreading of images. This can also be enhanced by the nonspecificity of FDG and, to a lesser extent, other tracers. In these cases, experience, complete patient clinical history and interpretation of co-registered CT images can be crucial for providing correct results to clinicians and for reaching conclusive reports, which are usually expected from a second level imaging procedure such as PET/CT. The aim of this atlas is, therefore, to provide concrete help for reading PET/CT images, presenting several cases characterized by unusual (but still quite common) incidental findings that can come to the attention of PET doctors during routine practice. Cases of rare diseases evaluated with PET are also included, in consideration of the constantly increasing number of clinical indications for PET imaging. Each case is briefly described in a few lines, and the PET result is clarified with multiple images including MIP. In addition, axial, sagittal and coronal sections of CT and fused images centered on the finding of interest are provided. Furthermore, a brief description of the pathological condition under evaluation is reported, including references from the scientific literature when necessary. In conclusion, this atlas is aimed at helping physicians read PET/CT scans in their daily clinical practice. In our experience the key reason for a successful relationship with referring clinicians is reports of outstanding quality. This requires great expertise, but also the capability of recognizing unusual findings, as well as the knowledge of uncommon diseases that may be evaluated by PET scans. Our goal was to provide practical support for such situations. ix

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12 Chapter 1 FDG: Rare Diseases Case 1 Case 2 Clinical Diagnosis: Giant Cell Tumor (GCT) Clinical Diagnosis: Pulmonary Amyloidosis Cases 3 4 Clinical Diagnosis: Pneumoconiosis Case 5 Case 6 Case 7 Case 8 Case 9 Case 10 Case 11 Clinical Diagnosis: Pulmonary Aspergillosis Clinical Diagnosis: Pulmonary Scar Cancer Clinical Diagnosis: HIV-Related Pneumonia Clinical Diagnosis: Pulmonary Sarcoidosis Clinical Diagnosis: Varicella Pneumonia Clinical Diagnosis: Castleman s Disease Clinical Diagnosis: Perivalvular Abscess Case 12 Clinical Diagnosis: Hepatic Abscess Case 13 Case 14 Case 15 Clinical Diagnosis: Pediatric Hepatic Hilar Abscess Clinical Diagnosis: Basal-Cell Carcinoma Clinical Diagnosis: Graves-Basedow Disease C. Nanni, S. Fanti, PET-CT: Rare Findings and Diseases, DOI / _1, Springer-Verlag Berlin Heidelberg

13 1 FDG: Rare Diseases Case 16 Clinical Diagnosis: Erysipelas Case 17 Clinical Diagnosis: Initial Stage Discitis Case 18 Clinical Diagnosis: Erdheim-Chester Disease Case 19 Clinical Diagnosis: Necrotizing Fasciitis Case 20 Clinical Diagnosis: Vaquez Disease Case 21 Clinical Diagnosis: Peritoneal Catheter Infection Case 22 Clinical Diagnosis: Implantable Cardiac Device Infection Case 23 Clinical Diagnosis: Thoracic Aortic Graft Infection Case 24 Clinical Diagnosis: Rheumatoid Arthritis Case 25 Clinical Diagnosis: Idiopathic Mediastinal Fibrosis Case 26 Clinical Diagnosis: Spinal Disc Herniation Case 27 Clinical Diagnosis: Mesenteritis Case 28 Clinical Diagnosis: Osteomyelitis of the Foot Case 29 Clinical Diagnosis: Peritoneal Mesothelioma Case 30 Clinical Diagnosis: Lymphoma of the Brain Case 31 Clinical Diagnosis: Pilonidal Cyst Cases Clinical Diagnosis: Osteomyelitis of the Sternum Cases Clinical Diagnosis: Paget s Disease Cases Clinical Diagnosis: Postsurgical Bone Infection Cases Clinical Diagnosis: Pigmented Villonodular Synovitis Case 41 Clinical Diagnosis: Vascular Graft Infection Case 42 Clinical Diagnosis: Atrial Sarcoma Case 43 Clinical Diagnosis: Avascular Necrosis of Bones Case 44 Clinical Diagnosis: Malignant Otitis Case 45 Clinical Diagnosis: Bone Sarcoidosis

14 FDG: Rare Diseases 1 Case 46 Clinical Diagnosis: Polydermatomyositis Case 47 Clinical Diagnosis: RS3PE Cases Clinical Diagnosis: Tuberculosis Case 50 Clinical Diagnosis: Sacroiliitis Case 51 Clinical Diagnosis: Pulmonary MALT Lymphoma Case 52 Clinical Diagnosis: Fibrosarcoma Case 53 Clinical Diagnosis: Large Soft Tissue Sarcoma Case 54 Clinical Diagnosis: Stump Appendicitis Case 55 Clinical Diagnosis: Bowel Transplantation with EBV Infection Case 56 Clinical Diagnosis: Von Recklinghausen Disease Case 57 Clinical Diagnosis: Wilms Tumor Case 58 Clinical Diagnosis: Microcystic Tumor of the Pancreas Cases Clinical Diagnosis: Epilepsy Case 61 Clinical Diagnosis: Spindle Cell Carcinoma of the Prostate Suggested Reading

15 1 Case 1 Clinical Diagnosis: Giant Cell Tumor (GCT) Fig. 1.1 FDG PET/CT demonstrated several positive areas. A differential diagnosis between infection and tumor persistence was not possible 4 Fig. 1.2 FDG PET/CT demonstrated persistence of positive areas, increased in terms of extension. The final diagnosis was tumor in local progression