objectives Pitfalls and Pearls in PET/CT imaging Kevin Robinson, DO Assistant Professor Department of Radiology Michigan State University

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1 objectives Pitfalls and Pearls in PET/CT imaging Kevin Robinson, DO Assistant Professor Department of Radiology Michigan State University To determine the regions of physiologic activity To understand the limitations of PET imaging uptake that is not malignant lack of uptake can be malignant Pitfalls Anatomically While PET has revolutionized evaluation of diagnosing, staging and re-staging neoplasms, pitfalls remain physiologic activity abnormal activity mimicking neoplasm e.g. infection and inflammation no activity when neoplasm is present Diffuse Head and neck Chest Abdomen and Pelvis e.g. micrometastasis Anatomically abnormal activity in neck Diffuse Head and neck Chest Abdomen and Pelvis 1

2 Brown Fat s/p chemotherapy Brown fat almost unheard of prior to PET imaging seen in abundance in hibernating animals complex mechanism ways to reduce controlled temperature (warm up the patient) prior to injection diazepam propanolol diffuse activity seen throughout the axial skeleton no focal activity homogenous Imperative to know if this patient has received chemotherapy recently Bone Marrow Stimulating agents can persist for up to 4 weeks after administration of the agent typically appears in the axial skeleton more than appendicular diffuse and homogenous if nodular and heterogenous, suspect neoplastic involvement Hx of recently diagnosed NHL. No treatment given large spleen same patient - bone activity History of SLE. PET scan to r/o malignancy Inhomogeneous bone activity. Has the patient received chemotx? bone marrow stimulating agent marrow hyperplasia - seen in the post-treatment setting lymphomatous involvement Focal activity more worrisome than diffuse homogenous activity glucose = 90 mg/dl appropriate fasting taking immunosuppressive meds for SLE 2

3 abnormal uptake from coughing Anatomically Diffuse Head and neck Chest Abdomen and Pelvis physiologic activity head and neck muscle activity in general, symmetric activity is physiologic muscles of mastication orbital muscles soft tissues thyroid - not typically FDG avid diffuse - thyroiditis focal - cant exclude malignancy - (30-40% chance if assd with intense activity) history of colon cancer Tongue mass Known tongue mass proven to be squamous cell carcinoma Only one hyper metabolic lymph node seen on PET Several other sub centimeter lymph nodes seen on PET without activity 3

4 Hx of tongue carcinoma Anatomically Lymph node dissection found 5 more lymph nodes in the neck positive for malignancy PET failed to find these lymph nodes due to the small size of tumor within the lymph nodes PET cannot replace lymph node dissection in the evaluation of micro metastasis Diffuse Head and neck Chest Abdomen and Pelvis Tumors with low uptake Lung Non-lung primaries lung nodule discovered on CXR Carcinoid Well differentiated Adenocarcinoma bronchoalveolar carcinoma in situ Bronchial tumors (rare) mucoepidermoid adenoid cystic MALT - marginal zone lymphoma Metastasis Renal Cell carcinoma more common for RCC mets in lung to show low activity than high activity mucinous tumors colon breast ovary suv = 1.9 DX: pulmonary carcinoid Bronchoalveolar Carcinoma least common of the lung cancers 70 y/o with known ovarian CA and elevated CA-125 notoriously shows low uptake on PET scan, with uptake less than mediastinal background. Why? combination of factors slow tumor cellularity > low demand for glucose large amount of non-glucose containing fibrous stroma with slow growth rate history of talc pleurodesis several years prior 4

5 Talc pleurodesis malignant mesothelioma seen inpatients with thoracic malignancies, such as with malignant effusion or mesothelioma fluid drained, pleurodesis performed to prevent effusion from coming back can be very hyper metabolic due to marked inflammatory foreign body reaction (SUV 7-12) persistent over many years, and can increase or decrease with time CT shows density or calcification is key finding Calcifications similar to talc pleurodesis - however, calcifications are photopenic left lung opacity Left Lung Mass Post obstructive lung Bronchial lesion seen on bronchoscopy lung mass post obstructive atelectasis DX: leiomyoma sarcoid like reaction sarcoid appearance seen on PET symmetric bilateral hilar lymph nodes and mediastinal LN appear in the presence of responding tumor not common - occurs in 1% of cancer patients mixed response occurs not typically seen early in the course of disease represents an inflammatory response can watch and wait, but biopsy may be necessary. 5

6 62 y/o female with Fatigue and cough False positives in PET/CT of the lung PET is actually positive, Radiologist interpretation is false infection bacterial - SUV can be quite high e.g fungal mycobacterium viral inflammatory radiation pneumonitis post obstructive BOOP Sarcoid BIOPSY SOMETIMES NEEDED REGARDLESS dx: sarcoid SPN in a 77 y/o male known primary malignancy known history of lymphoma silicone granuloma Cryptococcus known history of liposarcoma Hx of throat CA PET scan shows no evidence of recurrence small focal density in the left breast with minimal activity no known biopsy no prior mammograms DX: invasive ductal carcinoma Diffuse Head and neck Chest Abdomen and Pelvis Anatomically 6

7 kidneys bladder bowel physiologic activity bowel activity physiologic bowel activity very common long segment of colonic activity typically normal ddx: inflammatory bowel disease focal segments of activity must be interpreted with caution Colon CA and PET not indicated for diagnosing colon carcinoma limited by small tumor size physiologic uptake in the colon PET can detect colon CA, which can be an incidental finding hx of esophageal CA presents for re-staging esophageal carcinoma normal liver activity Focal activity in the ileocecal valve. Dx: normal activity 7

8 PET 6 months later Hx of colon CA with resection 2 years ago. Elevated serum tumor markers mild focal activity (SUV = 4)at the site of anastomosis benign or tumor recurrence? DX: recurrent tumor Attenuation Correction Artifact from suture material normal activity activity in collecting system can obscure underlying lesions ureteral activity continuous segmental focal hypodensity in the left kidney photopenia of the left kidney confirms benign process renal cyst Renal carcinoma Renal and Bladder carcinomas activity is variable about 50% of RCC have sufficient activity FDG excreted can mask underlying tumor within the kidney and bladder Therefore, FDG not recommended in detection of RCC and bladder cancers 8

9 ectopic kidney Remote history of nasopharyngeal carcinoma. PET scan for disease surveillence Prostate known malignancy Prostate PET/CT FDG not recommended for detection FDG poor in detection (50% sensitive) aggressive tumors can be negative well differentiated or slow growing cells no glucose receptors bladder activity can obscure tumors not specific BPH, scarring and cancer can all demonstrate activity carcinoid 65 y/o with ovarian CA history of total hysterectomy complains of abdominal discomfort PET showing no obvious abnormal uptake 9

10 peritoneal mets conclusion peritoneal mets from stage III ovarian carcinoma CT is helpful in assessing bowel many pitfalls of PET imaging knowing regions of physiologic activity is imperative false positives may not be false uptake, but false interpretation negative PET scan does not indicate absence of disease routes of metastasis are important to know 10

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