Pitfalls in Oncologic Diagnosis with PET CT. Nononcologic Hypermetabolic Findings
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1 Pitfalls in Oncologic Diagnosis with PET CT. Nononcologic Hypermetabolic Findings Poster No.: C-1359 Congress: ECR 2012 Type: Educational Exhibit Authors: J. Rossi 1, C. A. Mariluis 1, E. Delgado 1, R. Choba 1, C. M. Vietti 1, C. Keywords: DOI: Bruno 2 ; 1 Buenos Aires/AR, 2 Lomas de Zamora/AR Inflammation, elearning, Diagnostic procedure, PET-CT, Nuclear medicine, Oncology, Neoplasia /ecr2012/C-1359 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 16
2 Learning objectives To describe our experience in benign pathologic FDG uptake in PET CT. To characterise lesions representing pitfalls that could be confused with malignant neoplasms. Page 2 of 16
3 Background Accurate anatomic localization of functional abnormalities seen with PET is known to be problematic. Combining PET with a high-resolution anatomic imaging modality such as CT can resolve the localization issue (1). PET CT is a reference diagnostic method to detect cancer with glucose analogue tracer 2-(fluorine-18) fluoro-2-deoxy-d-glucose (FDG) (2). Generally, tumour findings are hypermetabolic and FDG-avid; however, in the daily practice, FDG uptake also occurs in benign causes. These pitfalls are benign pathologic FDG uptake and physiologic FDG uptake (3-6). In this exhibit we will describe our experience with those hypermetabolic pitfalls in PET CT, and their potential to mimic malignant lesions. Physiologic variants and findings due to normal distribution of the tracer (myocardium, bone marrow, digestive and genitourinary tract) will be excluded. Page 3 of 16
4 Imaging findings OR Procedure details Between December 2010 and November 2011, a PET CT was performed for 339 patients with a history of oncologic disease. Non-tumour hypermetabolic findings were reported in 119 subjects. Imaging Findings Of all patients with benign pathologic FDG uptake (n= 119), 37% (n=45) presented muscle contractures (Fig. 1 on page 6); 29.4% (n=35) ostheoarticular inflammatory processes (Fig. 2 on page 6); 9.2% (n=11) enthesopathies (Fig. 3 on page 7); 9.2% (n=11) microinvasive therapeutic procedures (Fig. 4 on page 8); 8.4% (n=10) brown fat (Fig. 5 on page 9); 6.72% (n=8) elastofibroma dorsi (Fig. 6 on page 10); 5.8% (n=7) thymic rebound (Fig. 7 on page 11); 5% (n=6) odontogenic inflammatory process (Fig. 8 on page 12); 4.2% (n=5) sinusitis; 4.2% (n=5) traumatism; and 3.36% (n=4) colostomy site. FDG accumulation in the body is based on glucose metabolism that, in the normal state, can be variable. When FDG accumulation becomes asymmetric or focal, careful evaluation is necessary to distinguish abnormal from normal variation in FDG distribution. Muscle Contractures: Undesirably increased muscle uptake is frequently encountered on 18 F-FDG PET scans as a result of muscle contracture. It is prudent to instruct the patient to avoid any excessive physical activity at least 48 h before injection (7). Ostheoarticular inflammatory processes and enthesopathies: FDG uptake often is found at sites of intraarticular and extraarticular musculoskeletal structures as the result of inflammatory and degenerative changes. The uptake can be asymmetric and could be misinterpreted as a primary or metastatic osseous neoplasm (4). Brown Fat: FDG uptake in hypermetabolic brown fat can occur as glucose transporters have been shown in brown adipose tissue. Because hypermetabolic brown fat is typically bilateral, symmetric, and elongated in the supraclavicular area on PET, the appearance is seldom confused with malignancy (8). Elastofibroma dorsi: Elastofibromas are benign and common lesions characteristically located in the subscapular region. Elastofibromas are FDG uptake pseudotumorous lesions characterized by fibroblastic proliferation and accumulation of abnormal elastic fibers (9). Page 4 of 16
5 Thymic Rebound: Moderate to high FDG uptake is noted in patients with thymic rebound and should not be confused with asymmetric uptake due to lymphoma in this location (10). Page 5 of 16
6 Images for this section: Fig. 1: Patient with lung cancer. Coronal CT (a), PET/CT (b), and PET (c). Fusion PET/CT shows FDG uptake in Psoas muscle (arrow) due to muscle contracture. Note physiological FDG uptake in myocardial and ascending colon. FUNDACION CIENTIFICA DEL SUR - Buenos Aires/AR Page 6 of 16
7 Fig. 2: 70 year-old patient. CT (a), PET/CT (b), and PET (c). PET/CT image shows nononcologic FDG uptake due to bilateral coxartrosis (arrows). Note physiologic FDG distribution in the bladder because of the normal excretory route of FDG. FUNDACION CIENTIFICA DEL SUR - Buenos Aires/AR Page 7 of 16
8 Fig. 3: 62 year-old patient with lung cancer and hepatic metastases (note hepatic FDG uptake). Coronal CT (a), PET/CT (b), and PET (c). PET/CT fusion shows FDG uptake associated with trochanter enthesopathy (arrow). FUNDACION CIENTIFICA DEL SUR - Buenos Aires/AR Page 8 of 16
9 Fig. 4: Axial CT (a), PET/CT (b), and PET (c). Focal FDG uptake in microinvasive therapeutic procedure (intramuscular injection) associated with inflammatory process (arrow). FUNDACION CIENTIFICA DEL SUR - Buenos Aires/AR Page 9 of 16
10 Fig. 5: 59 year-old woman with ovarian cancer. Axial images of TC (a), PET/CT (b), and PET (c), shows increased FDG uptake in bilateral, symmetric and elongated pattern in neck and shoulders that is consistent with uptake in brown fat (arrows). FUNDACION CIENTIFICA DEL SUR - Buenos Aires/AR Page 10 of 16
11 Fig. 6: 67-year-old man with lung cancer (note lung FDG uptake). Axial CT (a), PET/CT (b), and PET (c) reveal focus of FDG uptake in right subescapular region corresponding to hypermetabolic elastofibroma dorsi (arrow). FUNDACION CIENTIFICA DEL SUR - Buenos Aires/AR Page 11 of 16
12 Fig. 7: Thymic rebound in a 30-year-old woman with a history of Hodgkin disease. Axial CT (a), PET/CT (b), and PET (c) reveal a symmetric hypermetabolic focus (arrow) that corresponds to the thymus. FUNDACION CIENTIFICA DEL SUR - Buenos Aires/AR Page 12 of 16
13 Fig. 8: FDG uptake associated with infection. Axial CT (a), PET/CT (b), and PET (c) show diffuse FDG uptake due to odontogenic inflammatory process (arrow). FUNDACION CIENTIFICA DEL SUR - Buenos Aires/AR Page 13 of 16
14 Conclusion It is essential to identify nononcologic hypermetabolic pitfalls of PET CT, so as not to make mistakes at the time of performing a radiologic diagnosis. Muscle contractures, ostheoarticular inflammatory processes and enthesopathies were some of the most frequent findings. Page 14 of 16
15 Personal Information Page 15 of 16
16 References 1. Schoder H, Erdi Y, Larson S, Yeung H. PET/CT: A new imaging technology in nuclear medicine. Eur J Nucl Med Mol Imaging 2003;30: Townsend D, Carney J, Yap J, Hall N. PET/CT Today and Tomorrow. J Nucl Med 2004;45:4S-14S. 3. Brigid G, Flanagan F, Dehdashti F. Whole Body Positron emission tomography: normal variations, pitfalls, and technical considerations. AJR 1997;169: Sheve P, Anzai Y, Wahl R. Pitfalls in Oncologic diagnosis with FDG PET Imaging: Physiologic and Benign variants. RadioGraphics 1999;19: Cook G, Fogleman I, Maisey M. Normal physiological and benign pathological variants of 18-fluoro-2-deoxyglucose positron-emission tomography scanning: Potential for error in interpretation. Semin Nucl Med 1996;26: Strauss L. Fluorine-18 deoxyglucose and false-positive results: a major problem in the diagnostics of oncological patients. Eur J Nucl Med 1996;23: Jackson R, Schlarman T, Hubble W, Osman M. Prevalence and Patterns of Physiologic Muscle Uptake Detected with Whole-Body 18 F-FDG PET. J Nucl Med Technol 2006;34: Truong M, Erasmus J, Munden R, Marom E, Sabloff B, Gladish G, et al. Focal FDG Uptake in Mediastinal Brown Fat Mimicking Malignancy: A Potential Pitfall Resolved on PET/CT. AJR 2004;183: Pierce J, Henderson R. Case report. Hypermetabolism of Elastofibroma Dorsi on PET- CT. AJR 2004;183: Kostakoglu L, Hardoff R, Mirtcheva R, Goldsmith S. PET-CT Fusion Imaging in Differentiating Physiologic from Pathologic FDG Uptake. RadioGraphics 2004; 24: Page 16 of 16
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