Clinical PET and PET/CT

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2 Clinical PET and PET/CT

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4 E. Edmund Kim Myung-Chul Lee Tomio Inoue Wai-Hoi Wong Editors Clinical PET and PET/CT Principles and Applications Second Edition

5 Editors E. Edmund Kim Departments of Nuclear Medicine and Diagnostic Radiology The University of Texas Houston, TX, USA Tomio Inoue Department of Radiology Yokohama City University Graduate School of Medicine Yokohama, Kanagawa Japan Myung-Chul Lee Department of Nuclear Medicine Gachon University School of Medicine Namdong-Gu, Incheon Korea, Republic of (South Korea) Wai-Hoi Wong Department of Experimental Diagnostic Imaging The University of Texas MD Anderson Cancer Center Houston, TX, USA ISBN ISBN (ebook) DOI / Springer New York Heidelberg Dordrecht London Library of Congress Control Number: Springer Science+Business Media New York 2004, 2013 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, speci fi cally the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on micro fi lms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. Exempted from this legal reservation are brief excerpts in connection with reviews or scholarly analysis or material supplied speci fi cally for the purpose of being entered and executed on a computer system, for exclusive use by the purchaser of the work. Duplication of this publication or parts thereof is permitted only under the provisions of the Copyright Law of the Publisher s location, in its current version, and permission for use must always be obtained from Springer. Permissions for use may be obtained through RightsLink at the Copyright Clearance Center. Violations are liable to prosecution under the respective Copyright Law. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a speci fi c statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. While the advice and information in this book are believed to be true and accurate at the date of publication, neither the authors nor the editors nor the publisher can accept any legal responsibility for any errors or omissions that may be made. The publisher makes no warranty, express or implied, with respect to the material contained herein. Printed on acid-free paper Springer is part of Springer Science+Business Media (

6 This book is dedicated to our wives and children.

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8 Preface Since the fi rst edition of Clinical PET, PET/CT has been increasingly utilized as an effective imaging technique for managing patients with tumors, neurodegenerative diseases, and cardiovascular disorders. PET demonstrates the functional processes of metabolic rates, receptor expression, cell-tissue interaction, or events at the molecular level. Many new promising target-speci fi c radioligands have emerged in the clinical research and await its translation for clinical use. CT shows precise localization and characterization of increased tracer uptake and also shows small additional lesions. Reimbursement of high technology imaging cost has led to a growing acceptance of PET/CT in the clinical setting and its full integration into clinical practice. This second edition has been updated to re fl ect advances that have occurred since the fi rst edition. Two chapters related to radiation dosimetry in FDG PET and current status of PET/CT have been added to Part I of Basic Principles. The cardiology section in Part II of Clinical Applications has three new chapters dealing with coronary, myocardial, and atherosclerotic diseases. There are fi ve additional new chapters discussing primary unknown tumor, infection and in fl ammation, PET/CT in radiation treatment, evidence-based PET/CT, and PET/MRI. These advances offer better diagnosis and staging of the diseases, prediction, and evaluation of therapeutic responses as well as risk assessment. Again, this textbook covers the full range of PET and PET/ CT applications in oncology, neurology, and cardiology. These chapters were written by experienced experts in the fi eld of nuclear medicine and PET in the United States, Korea, and Japan. We hope that this new edition will continue to serve as a valuable reference source for both practitioners and trainees in the fi eld of nuclear medicine, radiology, oncology, neurology, and cardiology in utilizing PET and PET/CT in their clinical practice as well as understanding their basic principles. --E. Edmund Kim, MD vii

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10 Preface to the 1st Edition Positron emission tomography (PET) has been around long enough that it is hard to think of it as being anything special. It has been a valuable research tool in academic institutions since the 1970s, but its move into clinical practice in community hospitals has just begun. Those who are now working with PET, or have made the decision to do so, understand just how different a perspective on disease this modality provides. For most patients in whom it is indicated, PET provides earlier and more sensitive detection. It is special, but not in ways that are immediately evident. It requires a shift in the diagnostic paradigm and adjustments in patient management to capture the advantages of early diagnosis. Questions remain on how and when payment will be made for PET studies, but as with so much else in medicine, once patients and referring physicians know what PET can do for them, it will not be denied. Given time, it will eventually be documented that PET saves money overall by eliminating unnecessary and futile interventions in patients with advanced disease. That s the power of imaging the body s biochemistry. The momentum toward the use of PET is expected to grow with the advent of molecular imaging. The sequencing of the genome and proteomes is establishing the fundamental molecular basis of how cells function. Molecules can now be designed to stop the disease or to prevent it from occurring. Imaging of gene expression could eventually provide the basis for developing therapeutic strategies individualized to a patient s genetic characteristics. Biology and genetics have been merged with medicine to produce the new fi eld of molecular medicine which created the need for an imaging technology that looks at the biology of a disease. As drug company research and molecular imaging converge, imaging probes will be used to select patients for treatment with speci fi c drugs. The main impact of PET on community practice now, and likely for several years to come, is on oncology. Whole-body PET in cancer patients enables clinicians to identify malignant diseases in their early stages, differentiate benign from malignant tumors, examine the entire body for metastases, and determine the effectiveness of cancer therapeutics. It has been predicted that PET would undergo spectacular growth in the twenty- fi rst century as molecular medicine becomes central to the analysis of disease. The burgeoning world of PET is re fl ected in recent scienti fi c meetings including those of the Radiological Society of North America (RSNA) and the Society of Nuclear Medicine (SNM). ix

11 x Preface to the 1st Edition This book provides comprehensive information on the basic principles and clinical applications of PET. Emphasis is placed on the familiarization of normal distribution, artifacts, and pitfalls of common agents such as fl uorodeoxyglucose (FDG) in conjunction with computed tomography (CT), magnetic resonance imaging (MRI), or ultrasound to establish the clinical effectiveness of PET. Practical understanding of updated PET scanners, cyclotron, image process, and quanti fi cation is also stressed. This book is therefore divided into two parts: the fi rst part discusses the basic principles of PET, such as instrumentation, image process, fusion, radiopharmaceuticals, radiosynthesis, safety, and economics. The second part discusses the clinical applications of the technique in neurology, cardiology, infection, and oncology. We hope this book meets the growing needs of diagnostic radiologists, nuclear physicians, and clinicians for understanding the basic principles and clinical applications of PET.

12 Acknowledgments I am very appreciative and indebted to all of the contributors for their good work, and also to Mr. Andrew Moyer at Springer in New York for his support and patience during the creation of this book. E. Edmund Kim, MD The University of Texas MD Anderson Cancer Center Houston, TX, USA xi

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14 Contents Part I Basic Principles 1 Principles of Positron Emission Tomography Imaging... 3 Hossain Baghaei, Wai-Hoi (Gary) Wong, and Hongdi Li 2 Production of Isotopes Carlos González Lepera and Wai-Hoi Wong 3 From PET to PET/CT Osama Mawlawi, Richard Wendt III, and Wai-Hoi Gary Wong 4 Radiopharmaceuticals David J. Yang, Tomio Inoue, and E. Edmund Kim 5 Automated Synthesis of Radiopharmaceuticals David J. Yang, I. Hong Shih, and E. Edmund Kim 6 Cost Analysis and Effectiveness of PET and PET/CT E. Edmund Kim and Franklin C.L. Wong 7 Technical Principles, Radiation Safety, and Image Interpretation E. Edmund Kim and Franklin C.L. Wong 8 Normal and Variable Patterns in PET Ho-Young Lee, Myung-Chul Lee, and E. Edmund Kim 9 Artifacts in FDG PET and PET/CT Masashi Kawaguchi, Ukihide Tateishi, Tomio Inoue, and E. Edmund Kim 10 Radiation Dosimetry in 18 F-FDG PET/CT Eunkyung (Angela) Park 11 Current Status of PET in the World Seok-Ki Kim, Keon W. Kang, and Myung-Chul Lee Part II Clinical Applications 12 Epilepsy Dong Soo Lee, So Won Oh, and Myung-Chul Lee xiii

15 xiv Contents 13 Neurodegenerative Diseases Sang Eun Kim, Jong Jin Lee, and Yoo Sung Song 14 Cerebrovascular Disease and PET Hidehiko Okazawa and Yu-Kyeong Kim 15 Brain Tumors Franklin C.L. Wong, Xiaoyi Duan, and E. Edmund Kim 16 Head and Neck Tumors Franklin C.L. Wong, Xiaoyi Duan, and E. Edmund Kim 17 Lung and Pleural Cancers E. Edmund Kim and Franklin C.L. Wong 18 Breast Cancer E. Edmund Kim and Masashi Yukihiro 19 Coronary Artery Disease Won Woo Lee, Dong Soo Lee, and Myung-Chul Lee 20 Myocardial Viability Won Jun Kang 21 Atherosclerosis Jin-Chul Paeng 22 Esophageal, Gastric, and Pancreatic Cancers Chang Woon Choi, Tomio Inoue, Nobukazu Takahashi, and E. Edmund Kim 23 Hepatobiliary and Small Bowel Cancers Byung-Tae Kim and E. Edmund Kim 24 Colorectal Cancer Hirofumi Shibata, Ukihide Tateishi, and Tomio Inoue 25 Urologic Cancer Tomio Inoue, Nobukazu Takahashi, Tetsuya Higuchi, and E. Edmund Kim 26 Gynecologic Cancers Seok-Ki Kim, Sung-Eun Kim, June-Key Chung, and E. Edmund Kim 27 Lymphoma E. Edmund Kim and Franklin C.L. Wong 28 Melanoma, Myeloma, and Sarcoma E. Edmund Kim and Franklin C.L. Wong 29 Carcinoma of Unknown Primary Gi-Jeong Cheon