Table Of ContentJ. Czernin, M. Dahlbom, O. Ratib, C. Schiepers
Atlas of PET/CT Imaging in Oncology
Springer-Verlag Berlin Heidelberg GmbH
J. Czernin, M. Dahlbom
O. Ratib, C. Schiepers
Atlas of PET/CT
Imaging
in Oncology
With a Foreword by Michael E. Phelps
With 647 Figures and 13Tab1es
Springer
Authors ISBN 978-3-642-62141-3 ISBN 978-3-642-18517-5 (eBook)
DOI 1IO0..1I(0)()0771</j97788-3-3-6-6~24-21-81581571-57-5
J. Czernin,MD
M.Dahlbom,MD LibraryofCongressControl umber:2004102323
C.Schiepers,MD.PhD This work is subjcct to copyright. AII rights are reserved,
DepartmentofMolecularandMedicalPharmacology whetherthewholeorpartofthematerialisconcerned,specifi
callytherightsoftranslation,reprinting.reuscof illustrations.
DavidGeffenSchoolofMedicineatUCLA
recitation, broadcasting,reproductionon microfilmor inany
10833 LeConteAvenue,AR-I44 CHS
otherway,andstorageindatabanks.Duplicationofthispubli
LosAngeles,CA90095-6942
cationorpartsthereofispermittedonlyunderthcprovisionsof
USA theGermanCopyrightLawofSeptember9.1965.inilscurrent
version,andpermissionforusemUSI alwaysbcobtained from
O.Ratib.MD.PhD.FAHA Springer-Verlag.Violationsareliableforprosecutionunderthe
GermanCopyrightLaw.
DepartmentofRadiologicalSciences
DavidGeffenSchoolofMedicineat UCLA
100MedicalPlaza,Suite 100 ©Springer-VerlagBerlinHeidelberg2004
Room 1-403 Originallypublishedby Springer-Verlag BerlinHeidclbergNewYorkin2004
LosAngeles,CA90095 Softcover reprintofthchardcovcr Istedition 2004
USA
Theuseofgeneraldescriptivenarncs,registerednamcs,trude
marks, etc. in this publication does not imply. even in the
absenceofaspecificstatcmcnt,tha;suchnamesarccxcmptfrom
Contributors therelevantprotective lawsandregulationsandthereforefree
forgeneraluse.
T.Beyer
ProducIliability:Thepublisherscannotguaranteetheaccuracy
M.Seltzer
ofany infonnationaboutdosageand applicationcontained in
D.Townsend
this book. Ineveryindividualcase the uscr mustchecksuch
C.Yap informationbyconsultingthcrelevantliterature.
Editor:UteHeilmann,Heidelbcrg
Deskeditor:WiJmaMcHugh.Heidelberg
Productioneditor:BemdWieland,Heidelbcrg
Coverdesign:F.Steinen,eStudioCalarnar,Spain
Dataconversion:AM-productionsGmbll,Wiesloch
21/3111-5 4 32 1 SPI 11414264
Printedonacid-frecpaper
Preface
Michael E. Phelps
The positron emission tomography (PET) andalsoestablishedascientificbasisforthemolecu
scannerwasdevelopedtoprovidea molecularimag larimagingproceduresemployedinPET.
ingtechnologyforexamining the biologyof normal In about 2 millionclinical PET studies there
cellular functionand its transformationto disease in has notbeenone reported complication.This results
the living subject.This is achieved by selectingtar primarilyfrom the factthat PETemployees a radio
getsofnormaltissueanddisease(proteins,RNAand tracer technique in which the probe concentrations
DNA)ofbiochemicalprocessesof interestandlabel aretypicallyintherangeoffemtomolespergramtis
ing a molecularprobeselectivefor the target witha sue so there are little to no significant mass effects
positron emitting radionuclide (e.g., F-18, C-II , N exertedonbiochemicalorbiologicalprocess.
13,0-15,1-124,Cu-64,Ga-68). Twoexamplesrele While the scientific foundation of PET was
vant to cancer illustratethis.The first is 2-deoxy-2 being built there were also dramatic events taking
IF-18]fluorodeoxy-D-glucose (FDG)thattargetsthe placeinbiologyinwhichdisciplineswereshiftingto
glucose transporter protein and the enzyme hexoki "molecular"- molecularbiology,moleculargenetics,
nase that phosphorylatesglucose as the first step in molecularpharmacology,bio-and nanotechnologies,
the glycolytic pathway. FDG is a competitive sub genomics,proteomicsandsystemsbiologythatwere
stratewithglucoseandprovidesthe meansto image all accompaniedand enabled by revolutionarytech
the rate of glycolosis throughoutthe body.The sec nologydevelopmentsthatmadethenewsciencepos
ond probe is 3'-IF-18] fluoro-3'-deoxythymidine sible.These efforts beganto change the way people
(FLT) that targets the pyrimidine transporter and thought about and performed science and began
thymidinekinasethat phosporylates thymidine. FLT building a new knowledge and technology base of
isa competitivesubstratewiththymidineto provide moleculardiagnostics and molecular therapeutics to
the means to image DNA replication and thus cell establishtheprinciplesandpracticesofanewmolec
proliferation. Both glycolosis and DNA replication ularmedicine.
arehighlyamplifiedinneoplasticdegeneration. This new molecular world placed more
SincePETisaquantitativeimagingtechnique emphasis on imagingproving an in vivo link in the
thatcanmeasurethetissueconcentrationoftheimag discoverypathwaytobringthenewknowledgeofthe
ingprobeovertime,itprovidesthemeanstotranslate molecular basis of disease to the care of patients.
biochemistry,biology and pharmacology laboratory From this came a growing discipline of molecular
assaysintotheexaminationsinlivingsubjects.While imaging,withPETina leadershiproleinthe invivo
x-raycomputedtomography(CT) movedquickly to applications.Many other imagingtechnologieshave
clinical applications after its invention, the first 15 gatheredaroundthisthemetoprovidemolecularand
yearsofPETwerefocusedonresearch.Thisinvolved structure information, including optical imaging,
translating and validating a wide array of in vitro magnetic resonance imaging (MRI), single photon
molecularassaysintoinvivoonesandusingthemto computed tomography(SPECT),CT and ultrasound
buildabiologicalbridgebetweeninvitroandinvivo imaging. Molecular imaging is now becoming a
biologicalsciences.Inaddition,PETwasusedtodis robustfieldofitsown.
cover many aspects of normal biological functions As partof thischange manyin vivo imaging
andthoseofdiseaseinlivinganimalsandtheultimate technologiesanddisciplineswerealso beingmerged
laboratoryto study human disease, the patient.This atthe instrument(e.g.,PET/CT)or probelevel(PET
built a scientific foundation for PETbased on well andopticalreportergenesinthesamegeneconstruct)
established principles of biochemistry and biology togaintheadvantageofboth.Thegoalistocombine
Preface V
molecularassaysfrom different technologies,as well PET/CTalso provides advantages inthe drug
as combining biological and anatomical information. discovery processinevaluatingpharmacokineticsand
Further, molecular diagnostics and molecular thera pharmacodynamicswith PET withCT betterdefining
peutics were merging together with common disease the anatomical structures inwhich drugs actions take
targets and building molecular probes (therapeutic place, both at the disease target and throughout the
and imaging) together to assist each other in the dis organ systems of the body.These discovery-oriented
covery processand inthecare of patients. studies will also define and evolve into new practice
PET/CT in cancer, the subject of this Atlas, approaches in the way molecular diagnostics and
illustrates many featuresof the evolutionary and rev therapeuticsareemployed togethertoimprovepatient
olutionary changes occurring. PET using FOG to selection through a more biologically informative
image glycolosis reached a point incancerwhere the pictureofthepatient,direct determination therapeutic
literature showed that it was from 9 to 43% more doses and therapeutic outcomes.
accurate than anatomical imaging for diagnosing, This Atlas provides a thoughtful and well
staging, restaging and assessing therapeutic respons illustrated educationalapproach fordefining the prin
es in a large numberof differentcancers and that the ciplesandgood practices ofPET/CT. The additionof
inclusion of PET in the clinical evaluation changed the CD-ROM allows teachers and studentsto manip
treatment in 15 to 50% of patients,depending on the ulateand navigate throughimagesaswellasblending
clinical question. There are,however,specific cases anatomical and biological information or concealing
where each technique isbetter than theother. Inaddi information to provide flexibility inindividualteach
tion, PET/CT presents a picture of human anatomy ing methods.The Atlassystematically provides clini
upon which biological information within structures cal presentations of the cancers of the various organ
of the body is added. This combined information systems from diagnosis to staging, recurrent disease
allowsbetterdelineationofdisease within orbetween and therapeutic response to help design the best
structures, as well as guiding surgical and radiation patient management. It provides a comprehensive
planning and biopsyby using both structureand biol educationaltoolforradiologistsandnuclearmedicine
ogy identification and characterization. Therefore, it specialists who want to learn about molecular
became clear that PET/CT is better than PET or CT PET/CTimaging.
alone.
VI Atlas of PETleT Imaging in Oncology
Table of Contents
Part 1: Clinical and Technical Principles Chapter 3:
Anatomical Masses vs. Viable Tumor . 99
Introduction . . . . . . . . . . . 1
Cases:
Principles of PET/CTImaging . 3 3.1 EccentricTumorViability . 100
3.2 TumorViability 102
Afuture for PETtCT. . . . . . . 12
3.3 LiverCyst. . . . 104
PETtCTImageAcquisition Protocols
3.4 TumorViability . 106
and Imaging OataWorkflow . . 21
3.5 TumorNecrosis. 108
Acquisition Schemes 3.6 PartiallyNecroticNasopharyngeal
for Combined 18F-FOG-PET/CT . . . .. 30 CarcinomaMetastasis . . . . . . 110
3.7 PartiallyNecroticLungMetastasis
From FOG-PETto FOG-PETtCT Imaging 46
ofGlioblastomaMultiforme . . . . 112
Normal Pattern and Common Pitfalls
of FOG-PET Image Interpretation . . . . 54 Chapter 4: Cancers of Headand Neck 117
Cases:
4.1 SquamousCellCarcinoma
Part 2: Atlas oftheTongue . . . . . . . . . . . . . . 118
4.2. ThyroidCancer . . . . . . . . . . . . 120
Chapter 1: PET/CTImageArtifacts 63
4.3 NeuroendocrineTumor. . . . . . . . 122
Cases:
4.4 TonsillarSquamousCellCarcinoma . 124
1.1 CardiacPacemaker 66
4.5 SalivaryDuctCarcinoma. . 126
1.2 HipProsthesis . . . 68
4.6 SquamousCellCarcinoma. . . . . . 128
1.3 DentalArtifact . . . 70
1.4 PermanentCentralIntravenous
Chapter 5: Solitary Pulmonary Nodules 133
LineArtifact. . . . . . . . . 72
Cases:
1.5 Respiratory MotionArtifact. . . 74
5.1 SolitaryPulmonaryNodule . 134
5.2 SolitaryPulmonaryNodule. 136
Chapter 2: Physiological Variants 79
5.3 Hamartoma....... .. 138
Cases:
5.4 Coccidiomycosis . . . . . . 140
2.1 BrownFat . . . . . . . . . . 80
5.5 SolitaryPulmonaryNodule . 142
2.2 Vocal CordActivity. . . . . . 82
2.3 Rebound ThymicHyperplasia 84
2.4 BloodPoolActivity . . . . . . 86
2.5 ThyroidUptake. . . . . . . . . 88
2.6 Post-SurgicallyAlteredAnatomy. 90
2.7 Post-Surgical Variant. 92
2.8 PancreaticMass . . . . . . . . . 94
Table of Contents VII
Chapter6: Lung Cancer 147 Chapter9: Cancers of the Skin 229
Cases: Cases:
6.1 Lung Cancer . . . . 148 9.1 Melanoma 230
6.2 Lung Cancer . . . . 150 9.2 Melanoma 232
6.3 Mucin-Producing Adenocarcinoma 9.3 Restaging Melanoma. 234
of the Lung . . . . . . . . . . . 152 9.4 Metastatic Melanoma 236
6.4 Lung Cancer and Granuloma. . 154 9.5 Ocular Melanoma .. 238
6.5 Malignant and Benign Diseases 156
6.6 Carcinoid...... ..... 158 Chapter10: Breast Cancer. 243
6.7 Status post Pneumonectomy . 160 Cases:
6.8 PleuralCarcinomatosis. 162 10.1 Extensive Metastatic Disease 244
6.9 Mesothelioma ...... ... 164 10.2 Lung and Bone Metastases 246
10.3 Metastatic Breast Cancer. . . 248
Chapter7: 10.4 Internal Mammary LymphNodes. 250
Cancers of the Gastrointestinal Tract . 169 10.5 Breast Implants. . . . . . . . . 252
Cases: 10.6 Inflammatory Breast Cancer . . 254
7.1 Cholangiocarcinoma.. 170 10.7 Benign and Malignant Masses. 256
7.2 Esophageal Cancer. . . 172 10.8 Two PrimaryCancers. . . . . . 258
7.3 Esophageal Carcinoma. 174
7.4 Rectal Cancer. . . . . . 176 Chapter 11:Gynecological Cancers . 263
7.5 Gallbladder and Pancreatic Cancer 178 Cases
7.6 ResidualTumor Viability . . . . . 180 11.1 FallopianTubeCarcinoma . . . . 264
7.7 Gastro-Esophageal Cancer 11.2 Widespread Metastatic Ovarian Cancer 266
with Unexpected Distant Disease 182 11.3 Metastatic Ovarian Cancer . 268
7.8 Metastatic Rectal Carcinoma . . . 184 11.4 Cervical Cancer. 270
7.9 Colon and Hepatocellular Cancer 186 11.5 Ovarian Cancer. 272
7.10 Pancreatid Cancer . . . . . 188 11.6 Uterine Cancer . 274
7.11 Gastric Cancer . . . . . . . 190
7.12 Carcinoma of theAppendix 192 Chapter 12:
7.13 Small Liver Metastasis Cancers of the Genito-Urinary System 279
from Colon Cancer . . . . 194 Cases:
7.14 Recurrent and Metastatic 12.1 Prostate Cancer . . . 282
Colon Cancer. . . . . . 196 12.2 Renal Cell Carcinoma 284
7.15 Rectal Carcinoma. . . . 198 12.3 Renal Cell Carcinoma 286
7.16 Sigmoid Colon Cancer . 200 12.4 Bladder Cancer . . . . 288
12.5 Testicular Cancer. . . 290
Chapter 8: Lymphoma 205 12.6 Transitional Cell Cancer 292
Cases:
8.1 Lymphoma . ... 206 Chapter 13: Benign Diseases 297
8.2 Chronic Myelogenous Leukemia . 208 Cases:
8.3 Hodgkins's Lymphoma . . . . . . 210 13.1 Osteopoikilosis . . . . . 298
8.4 Treatment Response . . . . . . . 212 13.2 Inflammation, Infection . 300
8.5 Localization of Malignant LymphNode 214 13.3 Foreign Body Reaction . 302
8.6 Lymphoma. .... . . .. 216 13.4 Uterine Fibroid 304
8.7 Non-Hodgkin's Lymphoma . 218 13.5 Fistula 306
8.8 Lymphoma Staging . . 220 13.6 Sarcoidosis . . . . 308
8.9 Contrast PET/CT 13.7 TubularAdenoma 310
of Hodgkins's Disease 222 13.8 Fibrous Displasia . 312
8.10 Hodgkin's Lymphoma 224 13.9 Pneumonia. . . . 314
VIII Atlas of PETtCT Imaging in Oncology
Introduction
J. Czernin, M. Dahlbom, O. Ratib, C. Schiepers, C. Yap
Positron Emission Tomography. introduced consists of a brief didactic portion and an extensive
almost three decades ago by Phelps and Hoffman,' selection of interesting and challenging case exam
hasonlyrecentlybeenacceptedasthemostimportant ples.
and innovative tool forcancer imaging.The diagnos The didactic portion of the book includes a
tic and prognostic accuracy of PET imaging with F reviewofthetechnicalprinciplesofPETandPETICT
18 deoxyglucose (FDG) ranges from 80-90% for imaging by M. Dahlbom and C.Schiepers who also
many cancers?and issuperior toanatomical imaging. discuss differences in PET and CT technology
However, PET imaging is limited in its ability to between different commercially available systems.
assignmolecularabnormalitiestospecificanatomical D. Townsend,' who introduced the PETICT
structures. This limitation has been recently over technology provides in chapter 3 the outlook for the
come by the introduction of "in-line", "hybrid" futureofdual modality imaging.
PETICT systems- that have dramatically increased Different opinions have been voiced regard
the visibility of molecular imaging within the radiol ing the optimal imaging protocols. One school of
ogy and oncology community. PETICT has intro thought believes that CT should only be used for
duced radiologists to the concept and importance of attenuation correction and lesion localization while
molecular imaging and helps to conceptualize the others demand that the most elaborate contrast and
inherent limitations of size criteria for defining high-resolution studies should be performed. In any
anatomicalabnormalitiesas malignantorbenign.The event, many of these debates have not resulted in a
molecular informationprovided byPETenablesradi consensus and it appears likely that the specific
ologists for the first time to clearly characterize expertise ofthe users will at least initially determine
anatomicalabnormalitiesascancerous or not. On the the implementationofspecific imaging protocols.O.
other hand, molecular imaging benefits from the Ratib and T. Beyer will also discuss this and other
anatomical framework provided by CT. Hyper-meta issues related to image interpretation and navigation.
boliclesionscannowbeassignedto specificanatom J.Czerninsummarizes the clinical experience
ical structures. and research studies examining the impact and use
Sales figures for PETICT have surpassed fulness ofPETICT.A large number of abstracts thus
those of"stand alone" PET systems and itis predict far addressed the additional value of PETICT over
ed that more than 90%ofPET will be PETICT inthe PET alone for staging and restaging of cancer.
near future. Recently a prospective study was published in the
The introduction ofthis technology results in New EnglandJournalofMedicine>thatcomparedthe
new training requirements for radiologists and diagnostic accuracy of integrated PET andCT to that
nuclear medicine specialists.Radiologists need to be ofPET and CT alone in patients with non-small cell
familiar withthe concept ofmolecular imaging while lung cancer.These and otherstudies are reviewed by
competence in cross-sectional anatomy is required indetailbyJ.Czernin.
from nuclear medicine. A review of the normal FDG distribution in
the human body, the pitfalls and normal variants by
TheAtlas of PETICT Imaging serves anedu M.Seltzer and C.Schiepers ispresented inchapter7
cational purpose and isdesigned to teach radiologists and completesthe didactic section.
and nuclear medicine specialists about important
aspects of molecular imaging and nuclear medicine The Atlas section illustrates the benefits but
specialists aboutthe benefits ofanatomic imaging.It alsopitfallsofcombinedPETICTimaging.Examples
Introduction 1
J. Czernin et al., Atlas of PET/CT Imaging in Oncology
© Springer-Verlag Berlin Heidelberg 2004
of artifacts and physiological variants (brown fat, References
blood pool, thyroid uptake, muscle activity) are pre
sented. The role of PET/CT for imaging cancers of I. Phelps ME, Hoffman EJ,Mullani NA, Ter-Pogossian
the head and neck,solitary pulmonary nodules,lung MM. Application of annihilation coincidence detection to
transaxial reconstruction tomography. J Nucl Med.
cancer, cancers of the gastrointestinal tract, lym
1975;16(3):210-224.
phoma,cancersofthe skin,breastcancer,gynecolog
2. CzeminJ,Phelps ME.Positronemission tomography
icalcancers,andcancersof thegenito-urinarysystem scanning: current and future applications. Annu Rev Med.
is illustrated. Examples of benign diseases include 2002;53:89-112.
inflammation,granuloma and benign tumors. 3. BeyerT,Townsend DW,BrunT,Kinahan PE,Charron
M, Roddy R,Jerin J,Young J, Byars L, Nutt R. A combined
Each case includes a brief history,a specific
PET/CT scanner for clinical oncology. J Nucl Med.
teaching point that emphasizes image findings, and
2000;41(8):1369-1379.
provides relevant clinical follow-up information and 4. Townsend DW, Cherry SR.Combining anatomy and
a brieflistof relevant publications. function: the path to true image fusion. Eur Radiol.
2001;11(10):1968-1974.
5. LardinoisD,WederW,HanyTF,Kamel EM,Korom S,
A special and unique feature of the Atlas,
Seifert B, von Schulthess GK, Steinert He. Staging of non
assembledand designed byO.Ratib,isan interactive
small-celllungcancerwith integrated positron-emissiontomog
CD-ROM that provides the original PET and CT raphy and computed tomography. N Engl J Med.
images of each case in selected planes enabling the 2003;348(25):2500-2507.
users to manually adjust the blending intensity of 6. Israel0,KeidarZ,Bar-Shalom R,GaitiniD,Beck D,
AmitA.Hybrid PET/CT imaging with FDG in management of
eachmodalityinafusedimage. Inaddition,userscan
patientswithgynecologicmalignancies.JNuclMed.2003;44(5
display the clinical history, imaging techniques and
Suppl):I29P.
diagnostic findings of each case as well as the corre 7. AntochG,Stattaus J,NematAT,Mamitz S,Beyer T,
sponding specific teaching point. An "option" button Kuehl H,Bockisch A,Debatin JF,Freudenberg LS.Non-small
allowsturningonandoffgraphicannotationsandleg celllungcancer:dual-modalityPET/CTinpreoperativestaging.
Radiology.2003;229(2):526-533.
ends for each image. The CD is designed to be an
8. CohadeC,OsmanM,LealJ,WahlRL.Directcompar
effective teaching tool through a user-friendly and
ison of 18F-FDG PET and PET/CT in patients withcolorectal
intuitivegraphic interface for navigatingthrough 100 carcinoma.J Nucl Med.2003;44(11):1797-1803.
selected clinical cases covering many frequently 9. FreudenbergLS,AntochG,Schutt P,BeyerT,Jentzen
encountered cancers. W,MullerSP,GorgesR,NowrousianMR,BockischA,Debatin
JF.FDG-PET/CT inre-stagingof patientswithlymphoma. Eur
The CD-ROM is also designed to become a
JNucl Med MolImaging.2003;inpress.
convenient diagnosticcompanionforretrieving refer
10. Hany TF, Steinert HC, Goerres GW, Buck A, von
ence imagesoftypical clinical casesthat maybeused SchulthessGK.PETdiagnosticaccuracy:improvement with in
ascomparativestudiesfordiagnostic interpretationof line PET-CT system: initial results. Radiology.
similarcases inclinical routine. 2002;225(2):575-581.
II. FukuiMB,BlodgettTM,MeltzerCe.PET/CTimaging
in recurrent head and neck cancer. Semin Ultrasound CT MR.
The convincingconceptof merging molecular
2003;24(3):157-163.
with anatomical imaging has driven the clinical
acceptance ofPET/CT. Initial data are emerging that
strongly suggest that PET/CT imaging results in a
higher diagnostic accuracy than PET imaging alone.
4.6-11
The introduction ofPET/CT demands a fresh
lookat the training requirements for specialists inthe
field of molecular-anatomical imaging. It is hoped
that the Atlas of PET/CT imaging results in a better
understanding of the capabilities of PET/CT, and in
tum, to improved care and management of cancer
patients.
2 Atlas of PETteT Imaging inOncology
