PET/CT in the Oncologic Imaging of Nodal Disease: Pearls and Pitfalls - PowerPoint Presentation

Slide1

PET/CT in the Oncologic Imaging of Nodal Disease: Pearls and PitfallsA Resident’s Primer

Kathryn

Wallitt

,

MBBS, BSc, FRCR,

1

Siraj

Yusuf,

BMedSci, MBBS, MRCP, DCH, FRCR,

1

Neil Soneji,

MBBS, BSc, MRCS, FRCR,

1

Sairah

R. Khan,

MBBS, BSc, MRCP, FRCR,

1

Zarni Win

, MBBS, BSc, MSc, MRCP, FRCR,

1

Tara D. Barwick

,

MBChB

, MSc, MRCP, FRCR

1,2

1

Department of Radiology, Imperial College Healthcare NHS Trust, London, England

2

Department of Surgery and Cancer, Imperial College, London, England

Presented as an education exhibit at the 2016 RSNA Annual Meeting (

NM128-ED-X

)

.

All authors have disclosed no relevant relationships.

Address correspondence to: Department of Radiology, Imperial College Healthcare NHS Trust, London W12 0HS, England (email:

kathryn.tran@nhs.net)

Slide2

Key concepts

Positron emission tomography (PET) has an established role in oncologic imaging, of which fluorine 18

fluorodeoxyglucose

(FDG) is the most commonly used tracer.In the majority of cancers, the identification of nodal involvement is crucial to assess and stratify disease status determine appropriate managementFDG PET/computed tomography (CT) is commonly used in the staging, treatment planning, response assessment, and follow-up of a number of cancers, including lung, esophageal, cervical, lymphoma, and head and neck cancers.1,2We have used specific examples to demonstrate pearls and pitfalls in the assessment of nodal disease that can occur in PET/CT studies.

1. NCCN guidelines 2016

2. RCR PET guidelines 2016

Slide3

Learning objectivesAfter viewing this online presentation, participants will be able to:

Illustrate

the methods of assessing for nodal metastatic disease at FDG PET/CT

Review the typical appearances of nodal metastatic disease at FDG PET/CTDescribe the pitfalls of FDG PET/CT in nodal cancer imagingDiscuss the role of FDG PET/CT in nodal staging in some common malignanciesIdentify non-FDG tracers that may improve nodal staging

Slide4

Assessing nodal disease at conventional imaging

Nodal Morphology

Shape: round, elliptical, or oval

Fatty hilumNodal clusteringNodal attenuation (eg, solid, cystic, necrotic, or calcified)Enhancement characteristic after administration of intravenous contrast media (homogeneity or heterogeneity)Size criteria for nodal groupsSiteGroupShort axis (mm)Head and neckCervical8Axilla10MediastinumSubcarinalParacardiacRetrocruralOther128610

Abdomen

Gastrohepatic

Portacaval

Celiac

axis

–renal arteryRenal artery–aortic bifurcation88101012PelvisCommon iliacExternal iliacInternal iliacObturator91078Inguinal10

Adapted and reprinted, with permission, from reference 3, Royal College of Radiologists. Recommendations for Cross-sectional Imaging in Cancer Management. Second edition. 2014.

Nodal Size

Slide5

Features of normal versus abnormal nodes at conventional imaging

NORMAL

ABNORMAL

SizeSmall LargeShapeElliptical or ovalRoundFatty hilumPresentAbsentEnhancement patternHomogeneousHeterogeneous Cystic or necrotic componentsAbsentPresentNodal clusteringAbsentPresent

Slide6

Assessing nodal disease: Pattern of spread

Knowing typical patterns of nodal spread will help to accurately interpret images.

Fig 1. Lung cancer

Left lower lobe primary tumor (blue arrow) with ipsilateral hilar, contralateral mediastinal, and supraclavicular nodes (red arrows).Fig 2. Recurrent breast cancerIpsilateral subpectoral and internal mammary nodes (red arrows).Fig 3. Head and neck cancerRight oropharyngeal tumor (blue arrow) with ipsilateral cervical nodes (red arrows)

MIP

MIP

MIP

Red arrows = lymph node

Blue arrow = primary tumor

Fig 1

Fig 2

Fig 3

MIP = maximum intensity projection

Slide7

Other factors to considerWhen assessing nodal disease at PET, consider

Standardized uptake value

(SUV)

Visual—Level of visualized uptake compared with that of background structuresRatio of uptake—Lymph node activity–to–primary tumor activityOther causes of nodal activity—Infection, inflammationNumber and distribution of nodes—Single node versus chainSize of nodes—Decreased sensitivity if smaller than 8–10 mm

Slide8

Assessing nodal disease: SUV

PET can help quantify radiotracer accumulation of lesions.

SUV is a

semiquantitative measure of normalized radioactivity concentration on PET images, with excellent test-retest repeatability for maximum SUV (SUVmax) and mean SUV (SUVmean), providing that standardized acquisitions and techniques are followed.SUV = Activity in ROI (MBq)/ROI volume (mL)Injected activity (MBq)/patient weight (kg)

SUVmax 10.2

Fused

Slide9

Assessing nodal disease at PET: SUVThere is no SUVmax cutoff between benign and malignant nodes.

4

PET can help target biopsy of the most avid node and also the most avid component of a nodal mass.Fig 1. High-grade transformation of follicular lymphoma. Left cervical node with intense uptake on FDG PET/CT image (blue arrow). Low-level activity in bilateral axillary and inguinal nodes (red arrows), typical of low-grade follicular lymphoma. PET/CT helped to target biopsy at the site of high-grade transformation.Fig 2. Conglomerate mesenteric nodal mass in a patient with high-grade transformation of a low-grade follicular lymphoma (blue arrows). Focal area of high FDG uptake helped target tissue biopsy to the most avid component (red arrow).Fused4. Bella et al. Clin J Cancer 2014

Fig 1

MIP

Fig 2

Slide10

Biological factors affecting SUV

Numerous factors affect SUV, including the following:

5

TechnicalSUV is based on accurate height, weight, and administered activity.PET requires attenuation correction with accompanying low-dose CT.BiologicalInsulin can result in increased soft-tissue and muscle activity. This can be overcome by ensuring adequate time interval from administration of insulin and administration of FDG.6 Brown fat is typically located in the supraclavicular, midaxillary, posterior mediastinal, paraesophageal, and paraspinal regions. It is more commonly found in children and thin adults. Sympathetic stimulation can increase its metabolic activity, such as in cold weather.7 PhysicalStrenuous physical activity shortly prior to administration of FDG can result in increased activity in muscle. MIP5. Boellaard. J Nucl Med 20096. Boellaard et al. Eur J Nucl Med Mol Imaging 20157. Lakhani et al. RadioGraphics 2017

Fig 1.

Increased abdominal muscle uptake in a patient who had been to the gym prior to PET/CT study

.

Fig 1

Slide11

Factors affecting SUV: InsulinFig 1. FDG PET/CT images in a 34-year-old man who is human immunodeficiency virus positive.

Diffuse soft-tissue uptake after recent insulin injection (Fig 1a).

This can result in underestimation of activity at sites of disease. In this case, low-level active borderline enlarged celiac axis and portal nodes are not seen on MIP images (Fig 1b and 1c, blue arrows).

Injection sites can be seen on the CT component (Fig 1d, red arrows).Enzyme-linked immunosorbent spot assay positive; nodes decreased in size after tuberculosis treatment (not shown). Soft-tissue uptake from insulin injection can result in underestimation of activity at sites of disease.MIPFusedFusedCTCT

Fig 1a

Fig 1b

Fig 1c

Fig 1d

Slide12

Factors affecting SUV: Brown fat

Fig 2. Interim MIP and PET/CT images.

Although there is a reduction in volume of mediastinal disease, there is brown fat uptake in the superior mediastinum, mimicking nodal disease (blue arrows).

MIPFig 1. Baseline MIP and PET/CT images in a 24-year-old woman with Hodgkin lymphoma show stage 2 disease with mediastinal nodes (red arrows).MIPFusedBrown fat can mimic sites of nodal disease.

Fused

Fig 1

Fig 2

Slide13

Factors affecting SUV: Brown fat

Fig 1. Oropharyngeal cancer.

Images show metabolically active left oropharyngeal tumor (blue arrows). Adjacent extensive brown fat uptake (red arrows) is masking a metabolically active left cervical node (green arrows), which is suspicious for a metastatic node on contrast material–enhanced

CT image.Brown fat can mask sites of nodal disease.MIPFusedPETContrast-enhanced CT

Slide14

Assessing nodal disease at PET: Visual

Fig 3. End of treatment PET image.

Disease progression with increased activity at original sites of disease (green arrows).

Fig 1. Baseline staging PET image for non-Hodgkin lymphoma.Stage 3 metabolically active nodal disease above and below the diaphragm (red arrows).Fig 2. Interim PET image. Partial metabolic response. Overall reduction in FDG activity but persistent nodal uptake (blue arrows), remains greater than that of mediastinal blood pool.Nodal disease can be visually assessed at baseline and at follow-up imaging for treatment response. In lymphoma, a five-point visual score is used to assess involved sites with interim and end of treatment response criteria at follow-up.8,9

The Deauville criteria uses background mediastinal blood pool and liver activity as reference levels.

MIP

MIP

MIP

8.

Meigan

et al.

Leuk

Lymphoma 2009

9. Barrington et al. J

Clin

Oncol

2014

Fig 1

Fig 2

Fig 3

Slide15

Lymph node–to–primary tumor

SUV

max

ratio is high. N2 nodal disease is likely malignant.Lymph node–to–primary tumor SUVmax ratio is low. N3 nodes may be reactive.

Case 1. Lung cancer staging images.

Right upper lobe primary tumor with satellite nodule (Fig 1a, blue arrows) with similar FDG activity to that of the right hilar (Fig 1a, red arrow) and

pretracheal

(Fig 1a and 1b, green arrows) nodes.

Fused

Case 2. Lung cancer staging images.Right hilar primary tumor (Fig 2a and 2b, blue arrows) demonstrates much more FDG activity than contralateral left hilar node (red arrows) distant from primary tumor. MIPFused

Lymph node–to–primary tumor SUVmax ratio

can be used to assess whether a node is likely to be malignant. A high ratio is more suggestive of malignant nodal disease.

10

Assessing nodal disease at PET: Lymph node–to–primary tumor ratio

10.

Cerfolio

and Bryant. Ann

Thorac

Surg

2007

Fig 1a

Fig 2a

MIP

Fig 1b

Fig 2b

Fig 1a

Fused

Slide16

Pearl: PET has better sensitivity and specificity for nodal disease than CT.

Sensitivity

is the ability of PET/CT to correctly identify sites of nodal disease (true-positive rate).

Specificity is ability of PET/CT to correctly identify nodes that are not involved by disease (true-negative rate).CT is used to evaluate nodal staging of cancers on the basis of size and/or morphology of lymph nodes.PET provides functional information on metabolic activity for improved sensitivity and specificity and more accurate staging.In non–small cell lung cancer, a meta-analysis has shown the sensitivity and specificity of CT and PET/CT in depicting mediastinal nodal disease is 55% and 81% versus 77% and 86%, respectively.11 11.

Silvestri

et al. Chest 2013

Slide17

Fig 1. Images in a 67-year-old man with progressive supranuclear palsy; FDG PET/CT was performed to look for paraneoplastic disease. Solitary, intensely active, borderline enlarged 10-mm right paratracheal node (green arrows) with no other sites of FDG-avid disease. Endobronchial ultrasonographically

(US)–guided biopsy results demonstrated adenocarcinoma.

Pearl

: PET performs better than nodal size criteria and has higher sensitivity and improved specificity (correctly identifying sites of disease) for nodal disease than CT.Pearl: PET has better sensitivity and specificity for nodal disease than CT.

MIP

Fused

CT

Fig 1b

Fig 1c

Fig 1a

The increased sensitivity (depicting tumor in small nodes) and specificity (correctly identifying sites of disease) is subject to the primary tumor being FDG avid. Low-level avid tumors such as prostate cancer may be occult on PET images.

Slide18

PITFALLS

Technical

Size of nodes

Peritumoral nodesTumors with low-level glucose metabolismInflammation and infectionSarcoidlike reaction to malignancyUreteric activity mimicking nodesFalse-negative findings False-positive findings

Slide19

Pitfalls: Misregistration

PET images are acquired over a period of time and are non–breath hold.

Image misregistration may render images difficult to interpret, particularly at the diaphragm.

Fig 1. Focus of activity at the diaphragm could represent a paracardiac node or liver lesion.Fig 2. Contrast-enhanced CT image confirms a focal liver lesion (arrow).FusedPETContrast-enhanced CTFig 1Fig 2

Slide20

Pitfalls: Spatial resolutionA chain of right cervical nodes on iterative (Fig 1) and high-definition (Fig 2) images. High-definition images have better signal-to-noise ratio, and the superior metabolically active node is more conspicuous on high-definition images (red arrows).

Nodes smaller than 1 cm may be falsely negative on PET images because of spatial resolution limitations and partial

voluming

. Iterative reconstructionHigh-definition reconstructionFig 1Fig 2

Slide21

Esophageal

cancer staging: Small

peritumoral

nodesLocal-regional nodes may be missed because of their small size or proximity to the primary tumor. Endoscopic US is best for local-regional nodal staging.12 CTPETFusedCase 1 images show small FDG-avid left gastric node (Fig 1a and 1b, red arrows), which is reliably separated from the adjacent intensely avid primary tumor.

Fused

MIP

Case 2 images show small

peritumoral

nodes masked by proximity to primary tumor (blue arrows).

Fused

CT

Fig 1a

Fig 2

Fig 1b

12.

Marzola

et al.

Eur

J

Radiol

2012

Slide22

Esophageal cancer staging: Distant metastasesFDG has low yield in the early stage (high-grade dysplasia;

invasion into the lamina

propria

, muscularis mucosae, or submucosa) but is good for depicting distant nodal and metastatic disease. Endoscopic US is best for local-regional nodal staging.13Fig 1. FDG PET/CT esophageal cancer (*) staging images.FDG-avid distant nodal disease in the left para-aortic (red arrows) and left gastric (blue arrow) regions. CT images show occult bone metastases in T7 spinous process, L1, and left proximal femur (green arrows).13. You et al. J Thorac Oncol 2013FusedMIP

MIP

*

Fig 1a

Fig 1b

Slide23

Locally advanced cervical cancer nodal staging

No routine role for PET/CT in staging early disease (FIGO stage

≤

IB1), as micrometastases may be missed at PET.7 PET/CT is established in nodal staging of locally advanced disease (FIGO stage ≥ IB2)14,15,2 PET/CT in these patients can help stratify therapeutic approach.Fig 1. Images in a 45-year-old woman with International Federation of Gynecology and Obstetrics (FIGO) stage IIB cervical cancer.PET images demonstrate FDG-avid tumor (✩), bilateral pelvic disease (black arrows), and left para-aortic nodal disease (white arrows). Radiation therapy field extended to include left para-aortic node. Note the supraclavicular brown fat on the MIP image (black arrowheads).7. Lakhani et al. RadioGraphics 201714. SIGN 200815. NCCN 2010 cervical cancer guidelines2. RCR PET guidelines 2016

Fused

MIP

CT

Fig 1a

✩

Fig 1b

Fig 1c

Slide24

Example of using FDG PET/CT for nodal staging to stratify therapeutic approachPELN = pelvic lymph node PALN = paraaortic

lymph node CRT = chemotherapy and radiation therapy

EFT = extended field radiation therapy

Cervical CancerFIGO stage ≥ IB2 PET/CT PELN negativePALN negativePELN positivePALN negativePELN positivePALN positiveCRT

Consider PALN sampling

Offer EFT

Locally advanced cervical cancer nodal staging

14. SIGN 2008

15. NCCN 2010 cervical cancer guidelines

2. RCR PET guidelines 2016

Slide25

Tumor *PELN = pelvic lymph node PALN = paraaortic lymph node CRT = chemotherapy and radiation therapy EFT = extended field radiation therapy

PELN negative

PALN negative

PELN positivePALN negativePELN positivePALN positiveCRTConsider PALN samplingOffer EFT

PELN/PALN negative

*

Locally advanced cervical cancer nodal staging

10. SIGN 2008

11. NCCN 2010 cervical cancer guidelines

2. RCR PET guidelines 2016

PELN positive

*

PALN positive

*

Slide26

Pitfall: Tumors with low-level metabolic activity Images in a 78-year-old man with extensive nodal disease above and below the diaphragm on contrast-enhanced CT image (not shown); lymphoma is suspected.

Nodal disease with low-level avidity on FDG PET images in para-aortic (red arrows, Fig 1) and left external iliac (blue arrows, Fig 2) regions.

Biopsy results of accessible left external iliac lymphadenopathy revealed metastatic prostate carcinoma.FusedPETPETFused

Pitfall

: Tumors with low-level metabolic activity, such as prostate cancer, may be missed at PET.

Fused

Fig 1

Fig 2

Slide27

Fig 1. FDG PET/CT images in a 65-year-old woman with unexplained weight loss. No FDG-avid disease on the MIP image (Fig 1a) Enlarged left gastric lymph nodes demonstrate low-level FDG uptake (blue arrows).

Endoscopic results confirmed adenocarcinoma of the stomach.

Pitfall

: Well-differentiated adenocarcinoma can be missed at FDG PET/CT.MIPFusedCTPET

Pitfall: Tumors with low-level metabolic activity

Fig 1a

Fig 1b

Fig 1c

Fig 1d

Slide28

Patient with intensely avid rectal adenocarcinoma (Fig 1, red arrow).

PET/CT images also demonstrate low-level active pathologically enlarged mesenteric node (Fig 2, blue arrows).

Histologic findings showed primary rectal adenocarcinoma and synchronous carcinoid within mesenteric nodes.

Fused

CT

PET

Fused

Pitfall

: Well-differentiated neuroendocrine tumors such as carcinoid may be missed at FDG PET.

Pitfall: Neuroendocrine tumors

Fig 1

Fig 2

Slide29

Fig 1. Primary rectal mucinous tumor (red arrows) and mesorectal node (blue arrows) with low-level FDG avidity due to their low cellularity and mucin content.16

Fig 2.

Primary oropharyngeal tumor (not shown) and bilateral avid cervical nodes (blue arrows). Additional left cervical necrotic node (green arrows) has only a rim of low-level FDG activity.

FusedPET

Necrotic and/or cystic nodes and tumors can be missed at PET.

PET

Contrast-enhanced CT

False-negative pitfall: Cystic and/or necrotic nodes

16. Berger et al. AJR Am J

Roentgenol

2000

Fig 1

Fig 2

Slide30

Baseline PET staging for biopsy-proved high-grade non-Hodgkin lymphoma. Patient started a high dose of steroids prior to PET because of epidural disease.Left paravertebral soft-tissue (red arrows, Fig 1a and b) and infiltrative mediastinal nodal (green arrows, Fig 2a and b) disease are only low-level avid on PET images, unusual for high-grade lymphoma.

Likely underestimation of level of tracer uptake due to steroids

Steroids can result in underestimation of uptake at sites of nodal disease.

1717. Brepoels et al. J Nuc Med 2007Pitfall: SteroidsFusedContrast-enhanced CT

Fused

Contrast-enhanced CT

Fig 1a

Fig 1b

Fig 2a

Fig 2b

Slide31

Compare these two MIP FDG PET images.

Which demonstrates malignancy?

PET/CT to investigate mediastinal disease

Fig 1Fig 2MIPMIP

Slide32

Case 1: A patient with

lymphoma

shows FDG-avid mediastinal, cervical, and axillary lymph nodes, in addition to increased uptake in the bone marrow (Fig 1). LymphomaPET is nonspecific for malignancy; inflammation can mimic disease.PET/CT to investigate mediastinal diseaseSarcoidCase 2: A different patient with sarcoidosis has FDG uptake in a similar nodal distribution mimicking lymphoma. In addition, this patient has focal splenic and nodal activity below the diaphragm (Fig 2).

Fig 1

Fig 2

MIP

MIP

Slide33

PET/CT to investigate mediastinal disease

Fig 1

MIP

Fig 2MIPCompare these two MIP FDG PET images. Which demonstrates malignancy?

Slide34

Case 1: A patient with a primary lung cancer shows FDG-avid primary tumor in the left hilum (blue arrow, Fig 1) and ipsilateral and contralateral mediastinal lymph nodes (red arrows)—N3 disease.

Lung cancer

PET is nonspecific for malignancy; infection can

mimic disease.PET/CT to investigate mediastinal diseaseTuberculosisCase 2: Renal transplant patient. FDG PET was performed to investigate mediastinal lymphadenopathy. Note FDG-avid bilateral hilar and mediastinal nodes (Fig 2, green arrows) and activity at the right lung apex (purple arrowhead). Differential diagnoses included lung malignancy, posttransplant lymphoproliferative disorder, and infection. Nodal sampling revealed tuberculosis infection.

Fig 1

MIP

Fig 2

MIP

Slide35

Characterized by noncaseating granulomas, without accompanying systemic symptoms and histologically indistinguishable from sarcoidosisSarcoidlike reaction may occur18: Adjacent to the primary tumor

At local drainage nodes

At distant sites, commonly mediastinal and hilar lymphadenopathy

Sarcoidlike reaction can precede, follow, or occur concurrently with both hematologic and solid malignancies.19 Both sarcoidlike reaction to malignancy and nodal metastatic disease are FDG avid and can be difficult to differentiate.Sarcoidlike reaction to malignancy18. Chowdhury et al. Clin Rad 200919. Cohen et al. Clin Dermatol 2007

Slide36

Fig 1. Image from staging FDG PET for primary oropharyngeal tumor (red arrow), with bilateral cervical nodes (blue arrows). Mediastinal and hilar nodes also show increased FDG activity (green arrows) but in an atypical distribution for metastatic disease.Endobronchial US biopsy results demonstrated sarcoidosis.

Sarcoidlike

reaction to malignancy

Fig 2. Posttreatment PET image after chemotherapy and radiation therapy. This demonstrates complete metabolic response in the sites of malignant disease but persistent uptake in mediastinal and hilar nodes, consistent with sarcoidlike reaction to malignancy. New uptake in the right shoulder is due to dermal inflammation.

MIP

Fig 1

MIP

Fig 2

Slide37

Case 1: Nodal disease in cervical cancer.The patient has a 7-mm obturator node (red arrows, Fig 1a and 1b). As FDG is renally excreted, the node is masked by adjacent ureteric activity (blue arrows) in a patient with left hydronephrosis secondary to cervical cancer (*, Fig 1c)

CT

Fused

MIPPitfall: Ureteric FDG activity can mask

nodal disease.

*

Pitfall: Ureteric activity

Fig 1a

Fig 1c

Fig 1b

7. Lakhani et al.

RadioGraphics

2017

Slide38

Case 2: Left upper lobe lung cancer tumor (blue arrow) with a focus of uptake in the left pelvis (red arrow, Fig 1a and 1b). Node or ureteric activity?Correlation with the CT component and fused images confirm the uptake was along the line of the ureter (Fig 1c and 1d). Repeat imaging after the patient empties his or her bladder may show the ureteric activity has resolved.Note the further focus of increased activity (green arrow, Fig 1a) was localized to the bowel and required further correlation with

colonoscopic

findings.

FusedCTPETPitfall: Ureteric activity can mimic nodal disease.MIP

Pitfall: Ureteric activity

Fig 1c

Fig 1d

Fig 1b

Fig 1a

7. Lakhani et al.

RadioGraphics

2017

Slide39

Using PET to triage for biopsy in nodal staging of lung cancer

Case 2: Uncertain N2 or N3 disease:

Left hilar lung cancer (blue arrow, Fig 2) with heterogeneous nodal uptake in ipsilateral and contralateral nodes. This is uncertain for disease or reactive nodes (red arrows, Fig 2). Nodal sampling findings confirmed reactive nodes.

Case 1: Confident N2 disease: Left upper lobe lung cancer (blue arrow, Fig 1) with nodal uptake in multiple ipsilateral hilar nodes of similar metabolic activity (red arrows); have a typical distribution of disease spread (red arrows). No sampling required.MIPFig 1

MIP

Fig 2

Slide40

Nodal assessment with PET in lung cancer to stratify therapeutic approach

Contrast-enhanced CT operable

FDG PET/CT

Negative at PET MediastinumPositive at PET Mediastinum UncertainPositive at PET Mediastinum Definite

PET distant metastases

Surgery

Nodal sampling

Other treatment

20. NICE guidelines, UK

Slide41

Nodal assessment with PET in lung cancer to stratify therapeutic approach

Negative at PET Mediastinum

Positive at PET Mediastinum Uncertain

Positive at PET Mediastinum DefinitePET distant metastasesSurgeryNodal samplingOther treatment

*

? N3

*

Negative Mediastinum

Tumor

*

*

N3 definite

Left Adrenal

L5

*

20. NICE guidelines, UK

Slide42

Other PET tracersOther PET tracers include:Carbon 11 choline, fluorine 18 cholineCell membrane metabolism

Prostate cancer

Gallium 68 prostate-specific membrane antigen (PSMA)

Prostate cancerFluorine 18 fluciclovineSynthetic amino acid analogueProstate cancerGallium 68 tetraazacyclododecane tetraacetic acid peptidesSomatostatin receptor imagingNeuroendocrine tumorsMIPFig 1: Gallium 68 PSMA PET for biochemical relapse prostate cancer. Prostate-specific antigen level of 5.0 ng/mL, 2 years after radical radiation therapy.Uptake in small supraclavicular (green arrow), retrocrural (red arrow), and retroperitoneal (blue arrow) nodes.

Slide43

SummaryPET performs better than nodal size criteria, has high specificity for nodal involvement, and has good sensitivity for some tumors. PET is less sensitive in early stage disease but has a role in high-risk nodal staging (eg

, in esophageal and cervical cancer).

Knowledge of the technical and interpretative pitfalls is essential.

Knowing the typical patterns of nodal spread of tumors is most important for accurate image interpretation.

Slide44

References

National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology

.

2016. https://www.nccn.org/professionals/physician_gls/f_guidelines.aspRoyal College of Radiologists. RCR PET guidelines. 2016. https://www.rcr.ac.uk/system/files/publication/field_publication_files/bfcr163_pet-ct.pdfRoyal College of Radiologists. Recommendations for cross-sectional imaging in cancer management. Second edition 2014.Ela Bella AJ, Zhang YR, Fan W, et al. Maximum standardized uptake value on PET/CT in preoperative assessment of lymph node metastasis from thoracic esophageal squamous cell carcinoma. Chin J Cancer 2014 Apr;33(4):211–217.Boellaard R. Standards for PET image acquisition and quantitative data analysis. J

Nucl

Med 2009;50(

Suppl

1):11S–20S.

Boellaard

R, Delgado-Bolton R, Oyen WJ, et al. FDG PET/CT: EANM procedure guidelines for tumour imaging: version 2.0. Eur J Nucl Med Mol Imaging 2015 Feb;42(2):328–354.Lakhani A, Khan SR, Bharwani N, et al. FDG PET/CT pitfalls in gynecological and genitourinary oncologic imaging. RadioGraphics 2017 37:2;577–594.Meignan M, Gallamini A, Haioun C, et al. Report on the First International Workshop on Interim-PET-Scan in Lymphoma. Leuk Lymphoma 2009 Aug;50(8):1257–1260. Barrington SF, Mikhaeel GN,

Kostakoglu L, et al. Role of imaging in the staging and response assessment of lymphoma: consensus of the International Conference on Malignant Lymphomas Imaging Working Group. J Clin Oncol

2014 Sep 20;32(27):3048–3058.

Cerfolio

RJ, Bryant AS. Ratio of the maximum standardized uptake value on FDG-PET of the mediastinal (N2) lymph nodes to the primary tumor may be a universal predictor of nodal malignancy in patients with non small-cell lung cancer. Ann

Thorac

Surg

 2007; 83:1826–1829.

Silvestri GA, Gonzalez AV,

Jantz

MA, et al. Methods for staging non-small cell lung cancer: diagnosis and management of lung cancer, 3rd

ed

: American College of Chest Physicians evidence-based clinical practice guidelines

.

Chest 2013 May;143(5

Suppl

):e211S–e250S.

Marzola

MC, De Manzoni G,

Grassetto

G, et al. Extended staging of esophageal cancer using FDG-PET: a critical appraisal.

Eur

J

Radiol

2012 Jan;81(1):21–30.

You JJ, Wong RK, Darling G, et al.

Clinical utility of 18F FDG PET/CT in the staging of patients with potentially resectable

esophageal cancer. J Thorac Oncol 2013:8:1563–1569

Scottish Intercollegiate Guidelines Network. Guideline 99: Management of cervical cancer SIGN 2008. http://www.sign.ac.uk/assets/sign99.pdfNational Comprehensive Cancer Network. NCCN Guidelines version 1.2017 Updates Cervical cancer 2010 guidelines. https://www.tri-kobe.org/nccn/guideline/gynecological/english/cervical.pdf

Berger KL, Nicholson SA, Dehdashti F, Siegel BA. FDG PET evaluation of mucinous neoplasms: correlation of FDG uptake with histopathologic features. AJR Am J

Roentgenol

 

2000;174:1005–1008. 

Brepoels

L,

Stroobants

S,

Vandenberghe

P, et al

.

Effect of corticosteroids on 18F-FDG uptake in

tumor

lesions after chemotherapy. J

Nuc

Med 2007 Mar: 48 (3): 390–397.

Chowdhury FU,

Sheerin

F, Bradley KM, Gleeson FV

.

Sarcoid

-like reaction to malignancy on whole-body integrated (18)F-FDG PET/CT: prevalence and disease pattern.

Clin

Radiol

2009 Jul;64(7):675–681.

Cohen PR,

Kurzrock

R. Sarcoidosis and malignancy.

Clin

Dermatol

2007 May-Jun;25(3):326–333.

National Institute for Health and Care Excellence. Diagnosis and staging of lung cancer, NICE guidelines, UK

.

https://www.nice.org.uk/guidance/cg121/ifp/chapter/diagnosing-and-staging-lung-cancer

Slide45

Suggested ReadingsBoellaard R. Standards for PET image acquisition and quantitative data analysis. J Nucl Med 2009;50(suppl 1):11S–20S.

Boellaard

R, Delgado-Bolton R, Oyen WJ, et al

. FDG PET/CT: EANM procedure guidelines for tumour imaging: version 2.0. Eur J Nucl Med Mol Imaging 2015;42(2):328–354.Chowdhury FU, Sheerin F, Bradley KM, Gleeson FV. Sarcoid-like reaction to malignancy on whole-body integrated (18)F-FDG PET/CT: prevalence and disease pattern. Clin Radiol 2009;64(7):675-681.Lakhani A, Khan SR, Bharwani N, et al. FDG PET/CT Pitfalls in Gynecological and Genitourinary Oncologic Imaging. RadioGraphics 2017 37:2;577–594.