Clinical cases and pitfalls using FDG-PET. François Jamar Université Catholique de Louvain, Brussels, Belgium
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1 Clinical cases and pitfalls using FDG-PET François Jamar Université Catholique de Louvain, Brussels, Belgium
2 Case history (1) sepsis 60 yr old female Diabetes (1)- hypertension, alcohol Renal failure, previous septic sacroiliitis Fever of unknow origin Diffuse back pain Liver failure
3 Case history (1) - sepsis Post views 99m Tc-colloid 111 In-WBC
4 Case history (1) - sepsis
5 Case history (1) - sepsis
6 Case history (1) - sepsis Final diagnosis: atypical discitis with muscle and epidural infiltrates (Staph. Aureus)
7 Case history (2) - sepsis 12 yr old girl Osteoblastic osteosarcoma Resection and femur allograft Last chemotherapy May 2007 June 07: cutaneous infection and scar desunion CRP 2 mg/dl WBC raise from 2720/µl (6/6) to 12410/µl (17/6)
8 Case history (2) - sepsis PET-CT (6/6)
9 Case history (2) - sepsis 99m Tc-colloid Bone scan (18/6) 111 In-WBC (20/6)
10 Case History (3) Sepsis Find the culprit Male 64 yr old Unremarkable history except for surgery for left inguinal hernia Recent sigmoid diverticulitis Sepsis E Coli CT scan negative
11 Case History (3) Sepsis Find the culprit Initial scan FU scan
12 Case History (3) Sepsis Find the culprit Male 64 yr old Unremarkable history except for surgery for left inguinal hernia Recent sigmoid diverticulitis Sepsis E Coli CT scan negative KEEP IT SIMPLE WHEN IT IS SIMPLE
13 Case History (4) An infected baby G. Depas Univ of Liège Term born baby scanned at day 24 for unexplained fever and CRP mother s vaginal swab positive for Strept. B Final diagnosis: osteomyelitis of right tibia Note unusual FDG distribution
14 Case History (5) Another infected baby G. Depas Univ of Liège Term born baby scanned at day 72 for infection of exogenous material. Underwent neo-natal ventriculo-peritoneal derivation subsequently infected without localization of a reservoir. Final diagnosis: parietal peritoneal collection (Staph. Epid.)
15 Case (6) Endocarditis and septic emboli J. Van Riet, KU Leuven
16 Case (6) Endocarditis and septic emboli J. Van Riet, KU Leuven
17 Case (6) Endocarditis and septic emboli J. Van Riet, KU Leuven
18 Case (7) Arterial prosthetic graft infection G. Namur U Liège Bifemoral prosthetic graft infection Supposed origin : abscess of the small bowel (arrow)
19 Arterial Case (7b) prosthetic graft infection G. Namur U Liège Infection of an ilio-femoral crossover bypass
20 Case history (8) - sepsis Girl 18y Massive NHL with superior vena cava syndrome Hyperthermia after 1 st chemo cycle FDG injection through femoral cath. Final diagnosis: catheter infection!
21 Messages heart/vascular infections For endocarditis, fasting is essential Avoid injection through old catheters Look for septic emboli Contribution of CT (with contrast?) Advantage over WBC: no platelet contamination
22 Cases (10) PUO in HIV+ pts C. Castaigne, M. Dusart, P. Flamen, M. Tondeur, ULB Tuberculosis Kaposi s sarcoma
23 Message in PUO 1/3 infection 1/3 cancer 1/3 systemic disease
24 Case History (11) - PUO Male 42 yr old No relevant previous history Fever (up to 38 8) for the last 3 weeks Arthralgias, headache, insomnia Chest Xray, Abdominal US, BS (-) CRP raised, normal leukocytes
25 Case History (11) - PUO At the time of PET-CT, patient reports anterior neck pain TSH < 0.02 FT4 2.8
26 Case History (11) - PUO Presentation Recovery Final diagnosis: de Quervain s thyroiditis recovery ( 99m Tc scan) after 3 months
27 Case History (12) FUO Giant cell arteritis
28 Case History (12b) FUO Giant cell arteritis Presentation After R/
29 Message: Giant cell arteritis Noninvasive, can substitute temporal biopsy Perform PET before steroid trial Fasting for aortic involvement
30 Case History (13) PUO immunosuppression Male 28 yr old Treated for Behçet s disease Immunosuppression Asthenia, fever, weight loss Diffuse bone pain Cancer???
31 Case History (13) PUO immunosuppression
32 Case History (13) PUO immunosuppression T1 T1 gado T2
33 Case History (13) PUO immunosuppression Final diagnosis: Miliary tuberculosis in immunocompromised patient with vertebral osteomyelitis Message: consider everything and exploit CT as much as possible
34 Case history (14) PET vs PET-CT (G. Moulin-Romsee KULeuven) Male 62 y Medical history: NHL St.III => R/ CHOP-R 6 cycles CR in 2006 at end of 1 line treatment Clinical deterioration feb Suspicion recurrence NHL Referred for PET-CT
35 Case history (14) -PET
36 Case history (14) PET-CT CT shows big tissular mass encompassing the retroperitoneum and all its structures. This mass has a hypodense centre with a contrast enhanced wall. Final diagnosis: mycotic AAA
37 Message A final diagnosis could not have been obtained without a CT (with contrast). In high probability patients, PET-CT is most helpful, hence, mandatory Never believe the most likely diagnosis
38 Case History (15) Sepsis Cancer or infection? Male 56 yr old AD hepato-renal polycystic disease Renal transplant with right nephrectomy Bile duct carcinoid tumor with liver metastasis Vertebral osteomyelitis 2001 Septic shock (E Coli), biliary or renal origin?
39 Case History (15) Sepsis Cancer or infection?
40 Case History (15) Sepsis Cancer or infection? Infected renal cyst and liver metastasis
41 Case History (15) Sepsis Cancer or infection? The diagnosis was ascertained already using an 111 In-WBC scintigraphy
42 Message: sepsis Cancer or infection? In pyogenic infection, PET-(CT) lacks specificity ( 111 In)-WBC scintigraphy remains to be considered Cave: many cancer patients may have infection
43 Case History (16) Cancer Find the diagnosis 19 yr old girl with history of agressive thyroid carcinoma (left lobe) Many times I131 but currently considered in remission Rapidly evolving left adenopathy (> 4 cm) FNAB (-) but Tg (+) Final diagnosis: chronic EBV infection
44 Case History (17) Cancer Find the diagnosis Male 72 yr old Right lung nodules Asthenia and mild fever Tobacco and alcohol Right lung Tbc Left lung: legionella Arthritis right wrist NEVER BELIEVE IT S SIMPLE
45 Conclusions FDG-PET in infection PET is not specific! Cave in cancer patients PET-CT clearly better than PET alone Clinical judgment Privilege preparation on basis of patient s condition
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