TEDDY PET/CT AT THE U OF U READY FOR THE UNCLEAR MEDICINE? Case #1. Case #1 60 y/o male with MGUS, PET/CT to evaluate for active multiple myeloma

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1 PET/CT AT THE U OF U READY FOR THE UNCLEAR MEDICINE? STOP DICTATING SO LOUD OR I WILL EAT YOU TEDDY Case #1 60 y/o male with MGUS, PET/CT to evaluate for active multiple myeloma Case #1 1.5 cm midline infrahyoid cystic lesion at the level of the thyroid cartilage; enhancing rim Focal hypermetabolic activity associated with this lesion 1

2 Case #1 Thyroglossal duct cyst (potentially infected) Remnant of TGD Location: between foramen cecum at tongue base & thyroid bed in infrahyoid neck 20-25% suprahyoid neck About 50% at hyoid bone level 25% infrahyoid neck Infected wall enhancement, PET positive Thyroid cancer (<1%) nodularity, chunky calcification, PET positive (asymmetry) History of papillary thyroid cancer s/p thyroidectomy I-131 ablation incidental finding Companion case Case #2 47 year old male with history of NHL, originally isolated within the abdomen What ducts are involved? What canal/foramen is involved? Case #2 47 year old male with history of NHL, originally isolated within the abdomen Bilateral parotid ducts Right greater palatine canal Case #2 Lymphoma infiltration Case #2 Lymphoma infiltration Most inferior slice Most superior slice Greater palatine canal: starts at inferior aspect of PPF & traverses maxilla and palatine bones to the palate Transmits descending palatine artery, vein, and greater/lesser palatine nerves between the PPF and the oral cavity Parotid ducts: pass anteriorly along the masseter musculature through the buccopharyngeal fascia and buccinator muscle opening into the vestibule of mouth courses to parotid ampulla near second maxillary molars 2

3 Case #2 Lymphoma infiltration Case #3 45 male with vague history of weight loss POST- TREATMENT Case #3 45 male with vague history of weight loss FINDINGS: Prominent left lateral pharyngeal recess uptake; differential of inflammatory uptake or tumor (NPC?) Case #3 MALT Lymphoma Extranodal marginal zone B cell lymphoma About 7-8% of all NHL (Of NHLs arising from Waldeyer s ring, tonsil is their most frequent site, followed by the nasopharynx, base of tongue, and the soft palate) Most commonly involves the stomach (approximately 70%) Non-gastric involvement: salivary glands, orbit, thyroid, lungs Nasopharyngeal involvement is rare Companion case MALT lymphoma of lacrimal gland Case #4 Younger female with anemia 3

4 Case #4 Younger female with anemia Extramedullary hematopoiesis obliterates sinuses Marrow expansion Case #4 Younger female with anemia Case #4 Thalassemia major Hemoglobinopathy increased RBC destruction and increased marrow production of RBCs Case #5 75 year old female with lung cancer High-risk regions (Southeast Asia, Northeast India, Mediterranean) Severe anemia marrow repopulation Expansion of medullary cavity, extramedullary hematopoiesis (MC paraspinal), osteopenia Treatment: blood transfusions, iron chelation therapy Case #5 75 year old female with lung cancer Inflammation related to biting the tip of their tongue prior to PET/CT Case #5 The Hot Parotid Lesion BMT WARTHINS MECa Hypermetabolic parotid mass ALL PAROTID TUMORS CAN BE HOT (BENIGN OR MALIGNANT) Don t forget metastatic lymph nodes 4

5 Case #6 Middle aged patient with pain, erythema and swelling of right cheek after eating Case #6 Middle aged patient with pain, erythema and swelling of right cheek after eating Hypermetabolic parotid mass Auriculotemporal perineural spread Foramen ovale involvement Case #6 Poorly differentiated parotid carcinoma Auriculotemporal nerve (sensory branch of posterior division of V3) pierces parotid fascia communicating rami join the facial nerve within the parotid gland Case #7 Young female patient with hoarseness Expected course on PET/CT: parallel to posterior border of mandibular condyle Case #7 Young female patient with hoarseness Case #7 Vocal cord paralysis Absent FDG uptake in a denervated vocal cord Hypometabolic paramedian left vocal cord anteromedial arytenoid rotation ballooning of laryngeal ventricle Mass involving the left recurrent laryngeal nerve Common pitfall in the era of PET without CT Do not interpret contralateral normal uptake as pathologic Teflon injection thyroplasty incites granulomatous reaction that may take up FDG 5

6 Case #8 Known lung carcinoid tumor Case #8 Known lung carcinoid tumor Carcinoid Carotid body paraganglioma Not FDG-PET Case #8 68Ga-DOTATATE PET imaging Newer radiotracer : 68Ga DOTATATE Somatostatin analogue imaging Superiority in NET lesion detection compared to Octreoscan, MIBG scintigraphy, and MRI Companion case Carotid Body Paraganglioma Another lesion PET/CT for staging metastatic paraganglioma Recommended this particular patient to be genetically tested for SDHx mutations given two separate neuroendocrine-like tumors INITIAL 4 YEAR F/U Lutetium-177 Dotatate (Lutathera ) therapy Case #9 Patient with history of fibroblastic osteosarcoma PRRT: Peptide receptor radionuclide therapy Recently FDA approved Treatment of gastroenteropancreatic neuroendocrine tumors (GEP-NETs) Findings: Bilateral maxillectomy; fat packing at left anterior maxilla; asymmetric nodular enhancement on MRI and calcification on PET/CT at right maxillary surgical bed adjacent to ptyergoids (not all that hot but still suspicious for local recurrence) 6

7 Case #9 Patient with history of fibroblastic osteosarcoma Case #9 Ossified pulmonary met Isolated finding: Calcified/ossified 9 mm new pulmonary nodule SUV 1.2 FNA Interpretation LUNG, LEFT LOWER LOBE NODULE, CT- GUIDED BIOPSY WITH TOUCH PREPARATIONS: - Metastatic osteosarcoma. If you see any appreciable metabolic activity in a lung lesion less than 1 cm suspicious for malignancy Sarcomas can t trust on PET/CT in regards to metabolic activity (can be low) Case #10 Prostate CA metastasis ISOLATED PROSTATE MET Case #10 Fluciclovine PET/CT Just be aware of this new radiotracer in setting of head/neck metastasis Axumin (Blue Earth Diagnostics, Inc.) FDA approved for biochemical recurrence/persistence of prostate cancer following definitive treatment Is this a Head/Neck conference or a Urology conference? Synthetic L-leucine amino acid analog Transported across cell membranes by amino acid transporters (LAT-1, ACST2) Upregulated in prostate cancer cells Case #11 Non-keratinizing NPC Case #11 PET/CT for staging NO DISTANT METS 7

8 Case #11 Complete metabolic and anatomic treatment response (chemo/radiosensitive) Case #11 Follow-up PET/CT 4 MONTHS LATER 6 MONTHS LATER AFTER CHEMORADIATION Case #11 Underwent bone scan Case #11 Biopsy results High grade malignant epithelial neoplasm most consistent with metastatic nasopharyngeal carcinoma Case #12 55 year old with sore throat/hoarseness; ENT PET/CT referral Case #12 Biopsy results Stage II squamous cell carcinoma of the left vocal cord Stage IIB adenocarcinoma of the lung PET/CT changing management by finding second primary lesion 8

9 Case #13 Thyroid Lymphoma Most common DLBCL, non-hodgkin Corollary thyroid cases, more commonly DIFFUSE THYROID UPTAKE FOCAL THYROID UPTAKE 80% - solitary, homogeneous thyroid mass 20% - multiple masses or diffuse infiltration Hashimoto s has 70x increased risk for this MC: Hashimoto s thyroiditis 25-50% reported malignancy Case #14 GI Cancer f/u; My tooth hurts doc Case #14 GI Cancer f/u; My tooth hurts doc INCIDENTAL ODONTOGENIC ABSCESS Conclusion: Adding the high energy 511 kev photons can add a lot of value in head/neck imaging THANK YOU 9