Resolution Positron Emission Tomography Research Articles

The Effect of Magnetic Field on Positron Range and Spatial Resolution in an Integrated Whole-Body Time-Of-Flight PET/MRI System.

Simultaneous imaging systems combining positron emission tomography (PET) and magnetic resonance imaging (MRI) have been actively investigated. A PET/MR imaging system (GE Healthcare) comprised of a time-of-flight (TOF) PET system utilizing silicon photomultipliers (SiPMs) and 3-tesla (3T) MRI was recently installed at our institution. The small-ring (60 cm diameter) TOF PET subsystem of this PET/MRI system can generate images with higher spatial resolution compared with conventional PET systems. We have examined theoretically and experimentally the effect of uniform magnetic fields on the spatial resolution for high-energy positron emitters. Positron emitters including 18F, 124I, and 68Ga were simulated in water using the Geant4 Monte Carlo toolkit in the presence of a uniform magnetic field (0, 3, and 7 Tesla). The positron annihilation position was tracked to determine the 3D spatial distribution of the 511-keV gammy ray emission. The full-width at tenth maximum (FWTM) of the positron point spread function (PSF) was determined. Experimentally, 18F and 68Ga line source phantoms in air and water were imaged with an investigational PET/MRI system and a PET/CT system to investigate the effect of magnetic field on the spatial resolution of PET. The full-width half maximum (FWHM) of the line spread function (LSF) from the line source was determined as the system spatial resolution. Simulations and experimental results show that the in-plane spatial resolution was slightly improved at field strength as low as 3 Tesla, especially when resolving signal from high-energy positron emitters in the air-tissue boundary.

Performance measurement of PSF modeling reconstruction (True X) on Siemens Biograph TruePoint TrueV PET/CT

The Siemens Biograph TruePoint TrueV (B-TPTV) positron emission tomography (PET) scanner performs 3D PET reconstruction using a system matrix with point spread function (PSF) modeling (called the True X reconstruction). PET resolution was dramatically improved with the True X method. In this study, we assessed the spatial resolution and image quality on a B-TPTV PET scanner. In addition, we assessed the feasibility of animal imaging with a B-TPTV PET and compared it with a microPET R4 scanner. Spatial resolution was measured at center and at 8 cm offset from the center in transverse plane with warm background activity. True X, ordered subset expectation maximization (OSEM) without PSF modeling, and filtered back-projection (FBP) reconstruction methods were used. Percent contrast (% contrast) and percent background variability (% BV) were assessed according to NEMA NU2-2007. The recovery coefficient (RC), non-uniformity, spill-over ratio (SOR), and PET imaging of the Micro Deluxe Phantom were assessed to compare image quality of B-TPTV PET with that of the microPET R4. When True X reconstruction was used, spatial resolution was <3.65 mm with warm background activity. % contrast and % BV with True X reconstruction were higher than those with the OSEM reconstruction algorithm without PSF modeling. In addition, the RC with True X reconstruction was higher than that with the FBP method and the OSEM without PSF modeling method on the microPET R4. The non-uniformity with True X reconstruction was higher than that with FBP and OSEM without PSF modeling on microPET R4. SOR with True X reconstruction was better than that with FBP or OSEM without PSF modeling on the microPET R4. This study assessed the performance of the True X reconstruction. Spatial resolution with True X reconstruction was improved by 45 % and its % contrast was significantly improved compared to those with the conventional OSEM without PSF modeling reconstruction algorithm. The noise level was higher than that with the other reconstruction algorithm. Therefore, True X reconstruction should be used with caution when quantifying PET data.

Inhomogeneous Computed Tomographic Densities in Lungs in Acute Respiratory Distress Syndrome: Stress Multipliers Leading to Ventilator-induced Injury?

Inhomogeneous Computed Tomographic Densities in Lungs in Acute Respiratory Distress Syndrome: Stress Multipliers Leading to Ventilator-induced Injury?

Impact of point spread function correction in standardized uptake value quantitation for positron emission tomography images: a study based on phantom experiments and clinical images

While point spread function (PSF)-based positron emission tomography (PET) reconstruction effectively improves the spatial resolution and image quality of PET, it may damage its quantitative properties by producing edge artifacts, or Gibbs artifacts, which appear to cause overestimation of regional radioactivity concentration. In this report, we investigated how edge artifacts produce negative effects on the quantitative properties of PET. Experiments with a National Electrical Manufacturers Association (NEMA) phantom, containing radioactive spheres of a variety of sizes and background filled with cold air or water, or radioactive solutions, showed that profiles modified by edge artifacts were reproducible regardless of background μ values, and the effects of edge artifacts increased with increasing sphere-to-background radioactivity concentration ratio (S/B ratio). Profiles were also affected by edge artifacts in complex fashion in response to variable combinations of sphere sizes and S/B ratios; and central single-peak overestimation up to 50% was occasionally noted in relatively small spheres with high S/B ratios. Effects of edge artifacts were obscured in spheres with low S/B ratios. In patient images with a variety of focal lesions, areas of higher radioactivity accumulation were generally more enhanced by edge artifacts, but the effects were variable depending on the size of and accumulation in the lesion. PET images generated using PSF-based reconstruction are therefore not appropriate for the evaluation of SUV.

Region-Based Partial Volume Correction Techniques for PET Imaging: Sinogram Implementation and Robustness

Background/Purpose. Limited spatial resolution of positron emission tomography (PET) requires partial volume correction (PVC). Region-based PVC methods are based on geometric transfer matrix implemented either in image-space (GTM) or sinogram-space (GTMo), both with similar performance. Although GTMo is slower, it more closely simulates the 3D PET image acquisition, accounts for local variations of point spread function, and can be implemented for iterative reconstructions. A recent image-based symmetric GTM (sGTM) has shown improvement in noise characteristics and robustness to misregistration over GTM. This study implements the sGTM method in sinogram space (sGTMo), validates it, and evaluates its performance. Methods. Two 3D sphere and brain digital phantoms and a physical sphere phantom were used. All four region-based PVC methods (GTM, GTMo, sGTM, and sGTMo) were implemented and their performance was evaluated. Results. All four PVC methods had similar accuracies. Both noise propagation and robustness of the sGTMo method were similar to those of sGTM method while they were better than those of GTMo method especially for smaller objects. Conclusion. The sGTMo was implemented and validated. The performance of the sGTMo in terms of noise characteristics and robustness to misregistration is similar to that of the sGTM method and improved compared to the GTMo method.

Analysis for Distinctive Activation Patterns of Pain and Itchy in the Human Brain Cortex Measured Using Near Infrared Spectroscopy (NIRS)

Pain and itch are closely related sensations, yet qualitatively quite distinct. Despite recent advances in brain imaging techniques, identifying the differences between pain and itch signals in the brain cortex is difficult due to continuous temporal and spatial changes in the signals. The high spatial resolution of positron emission tomography (PET) and functional magnetic resonance imaging (fMRI) has substantially advanced research of pain and itch, but these are uncomfortable because of expensiveness, importability and the limited operation in the shielded room. Here, we used near infrared spectroscopy (NIRS), which has more conventional usability. NIRS can be used to visualize dynamic changes in oxygenated hemoglobin and deoxyhemoglobin concentrations in the capillary networks near activated neural circuits in real-time as well as fMRI. We observed distinct activation patterns in the frontal cortex for acute pain and histamine-induced itch. The prefrontal cortex exhibited a pain-related and itch-related activation pattern of blood flow in each subject. Although it looked as though that activation pattern for pain and itching was different in each subject, further cross correlation analysis of NIRS signals between each channels showed an overall agreement with regard to prefrontal area involvement. As a result, pain-related and itch-related blood flow responses (delayed responses in prefrontal area) were found to be clearly different between pain (τ = +18.7 sec) and itch (τ = +0.63 sec) stimulation. This is the first pilot study to demonstrate the temporal and spatial separation of a pain-induced blood flow and an itch-induced blood flow in human cortex during information processing.

Feasibility of Using Distal Endpoints for In-Room PET Range Verification of Proton Therapy

In an effort to verify the dose delivery in proton therapy, positron emission tomography (PET) scans have been employed to measure the distribution of β+ radioactivity produced from nuclear reactions of the protons with native nuclei. Since the dose and PET distributions are difficult to compare directly, the range verification is currently carried out by comparing measured and Monte Carlo (MC) simulation predicted PET distributions. In order to reduce the reliance on MC, simulated PET (simPET) and dose distal endpoints were compared to explore the feasibility of using distal endpoints for in-room PET range verification. MC simulations were generated for six head and neck patients with corrections for radiological decay, biological washout, and PET resolution. One-dimensional profiles of the dose and simPET were examined along the direction of the beam and covering the cross section of the beam. The chosen endpoints of the simPET (x-intercept of the linear fit to the distal falloff) and planned dose (20%-50% of maximum dose) correspond to where most of the protons are below the threshold energy for the nuclear reactions. The difference in endpoint range between the distal surfaces of the dose and MC-PET were compared and the spread of range differences was assessed. Among the six patients, the mean difference between MC-PET and dose depth was found to be -1.6 mm to +0.5 mm between patients, with a standard deviation of 1.1 to 4.0 mm across the individual beams. In clinical practice, regions with deviations beyond the safety margin need to be examined more closely and can potentially lead to adjustments to the treatment plan.

Routine Production of 89Zr Using an Automated Module

89Zr has emerged as a useful radioisotope for targeted molecular imaging via positron emission tomography (PET) in both animal models and humans. This isotope is particularly attractive for cancer research because its half-life (t1/2 = 3.27 days) is well-suited for in vivo targeting of macromolecules and nanoparticles to cell surface antigens expressed by cancer cells. Furthermore, 89Zr emits a low-energy positron (Eβ+,mean = 0.40 MeV), which is favorable for high spatial resolution in PET, with an adequate branching ratio for positron emission (BR = 23%). The demand for 89Zr for research purposes is increasing; however, 89Zr also emits significant gamma radiation (Γ15 keV = 6.6 R×cm2/mCi×h), which makes producing large amounts of this isotope by hand unrealistic from a radiation safety standpoint. Fortunately, a straightforward method exists for production of 89Zr by bombarding a natural Y target in a biomedical cyclotron and then separation of 89Zr from the target material by column chromatography. The chemical separation in this method lends itself to remote processing using an automated module placed inside a hot cell. In this work, we have designed, built and commissioned a module that has performed the chemical separation of 89Zr safely and routinely, at activities in excess of 50 mCi, with radionuclidic purity &gt; 99.9% and satisfactory effective specific activity (ESA).

Optimal co-segmentation of tumor in PET-CT images with context information.

Positron emission tomography (PET)-computed tomography (CT) images have been widely used in clinical practice for radiotherapy treatment planning of the radiotherapy. Many existing segmentation approaches only work for a single imaging modality, which suffer from the low spatial resolution in PET or low contrast in CT. In this work, we propose a novel method for the co-segmentation of the tumor in both PET and CT images, which makes use of advantages from each modality: the functionality information from PET and the anatomical structure information from CT. The approach formulates the segmentation problem as a minimization problem of a Markov random field model, which encodes the information from both modalities. The optimization is solved using a graph-cut based method. Two sub-graphs are constructed for the segmentation of the PET and the CT images, respectively. To achieve consistent results in two modalities, an adaptive context cost is enforced by adding context arcs between the two sub-graphs. An optimal solution can be obtained by solving a single maximum flow problem, which leads to simultaneous segmentation of the tumor volumes in both modalities. The proposed algorithm was validated in robust delineation of lung tumors on 23 PET-CT datasets and two head-and-neck cancer subjects. Both qualitative and quantitative results show significant improvement compared to the graph cut methods solely using PET or CT.

Evaluation of a timing integrated circuit architecture for continuous crystal and SiPM based PET systems

Improving timing resolution in positron emission tomography (PET), thus having fine time information of the detected pulses, is important to increase the reconstructed images signal to noise ratio (SNR) [1]. In the present work, an integrated circuit topology for time extraction of the incoming pulses is evaluated. An accurate simulation including the detector physics and the electronics with different configurations has been developed. The selected architecture is intended for a PET system based on a continuous scintillation crystal attached to a SiPM array. The integrated circuit extracts the time stamp from the first few photons generated when the gamma-ray interacts with the scintillator, thus obtaining the best time resolution. To get the time stamp from the detected pulses, a time to digital converter (TDC) array based architecture has been proposed as in [2] or [3]. The TDC input stage uses a current comparator to transform the analog signal into a digital signal. Individually configurable trigger levels allow us to avoid false triggers due to signal noise. Using a TDC per SiPM configuration results in a very area consuming integrated circuit. One solution to this problem is to join several SiPM outputs to one TDC. This reduces the number of TDCs but, on the other hand, the first photons will be more difficult to be detected. For this reason, it is important to simulate how the time resolution is degraded when the number of TDCs is reduced. Following this criteria, the best configuration will be selected considering the trade-off between achievable time resolution and the cost per chip. A simulation is presented that uses Geant4 for simulation of the physics process and, for the electronic blocks, spice and Matlab. The Geant4 stage simulates the gamma-ray interaction with the scintillator, the photon shower generation and the first stages of the SiPM. The electronics simulation includes an electrical model of the SiPM array and all the integrated circuitry that generates the time stamps. Time resolution results are analyzed using Matlab. The goal is to analyze the best resolution achievable with the SiPM and its degradation due to different circuitry configurations.

Beta-Cell Imaging: Call for Evidence-Based and Scientific Approach

Advances in positron emission tomography (PET) imaging have provided opportunities to develop radiotracers specific for imaging insulin-producing pancreatic β-cells. However, a host of lingering questions should be addressed before these radiotracers are advocated for noninvasive quantification of β-cell mass (BCM) in vivo in the native pancreas. We provide an overview of tetrabenazine-based PET tracers developed to image and quantify BCM and discuss several theoretical, technical, and biological limitations of applying these tracers in clinical practice. VMAT2, a transporter protein expressed on pancreatic β-cells, has been advocated as a promising target for PET imaging tracers, such as dihydrotetrabenazine. However, the lack of radiotracer specificity for these proteins hampers their clinical application. Another important argument against their use is a striking discrepancy between radiotracer uptake and BCM in subjects with type I diabetes mellitus and healthy controls. Additionally, technical issues, such as the finite spatial resolution of PET, partial volume effects, and movement of the pancreas during respiration, impede PET imaging as a viable option for BCM quantification in the foreseeable future. The assertion that BCM can be accurately quantified by tetrabenazine derived β-cell-specific radiotracers as density per unit volume of pancreatic tissue is not justifiable at this time. The fallacy of these claims can be explained by technical as well as biological facts that have been disregarded and ignored in the literature.

LuYAP/LSO Phoswich Detectors for High Resolution Positron Emission Tomography

The spatial resolution in positron emission tomography (PET) can be improved by the addition of depth-of-interaction (DOI) information. This can be achieved by using the phoswich approach in which depth identification relies on differences in scintillation decay time and pulse shape discrimination techniques. In this paper we have looked at a special phoswich combination LuAP/LSO or LuYAP/LSO. This combination of scintillators is especially interesting since LuAP and LuYAP have emission in the excitation band of LSO, which may have an impact on the timing resolution of the detector. As will be shown in this paper, the phoswich concept based on these two scintillators can be utilized, however, with some limitations. This paper is an extension of our previous phoswich investigation [3].

Application of FDG-PET/CT in Radiation Oncology

Positron emission tomography (PET)/computed tomography (CT), which combines the advantages of high sensitivity and specificity of PET and high resolution of CT, is a unique tool for cancer management. PET/CT has been widely used in cancer diagnosis and treatment. The article reviews the recent applications of PET/CT in radiation oncology, with a focus on 18F-fluorodeoxyglucose (FDG)-PET/CT, addressing the applications in treatment planning and treatment response assessment of radiation therapy.

A mass conservation‐based optical flow method for cardiac motion correction in 3D‐PET

Cardiac positron emission tomography (PET) images usually show two kinds of artifacts: the limited resolution of PET leads to partial volume effects and the motion of the heart induces blurring. These phenomena degrade the PET images and induce errors in the quantification. One method of reducing this problem is to use gated PET data. However, the reduction of information per phase leads to an increase in noise on the reconstructed images. Alternatively, the PET data have to be corrected for motion and partial volume effects. Optical flow methods have been shown to accurately estimate the motion between PET image frames. These methods assume that the brightness of the objects remains constant between the frames. This condition is not fulfilled in cardiac PET data because the brightness of the cardiac muscle tissue (myocardium) is not accurately resolved due to the partial volume effect. Therefore, the use of a newly developed optical flow method based upon the conservation of mass condition is proposed to correct the cardiac PET data. Mass conservation is applicable to PET images as the total activity in the field of view may be assumed to remain almost constant, if the data are precorrected for radioactive decay. Two variants of the method using the quadratic and the nonquadratic penalization are presented. The methods were evaluated with respect to correlation coefficient, myocardial thickness and the blood pool activity in the left ventricle on phantom data and on 14 patient image volumes. The proposed methods showed that the cardiac motion can be efficiently corrected despite partial volume effects. The correlation coefficient between the image volumes increased from 0.87 to 0.98 on average. The change in myocardial thickness was reduced from 28% to 3%. The variation in blood pool activity was reduced from 80% to 8%. The algorithm needed only about 4 s for execution. A mass preserving optical flow method of cardiac motion correction in 3D PET data has been presented and tested on phantom as well as patient data. The results show that the motion was corrected for all datasets effectively.

Symmetric geometric transfer matrix partial volume correction for PET imaging: principle, validation and robustness

Limited spatial resolution of positron emission tomography (PET) often requires partial volume correction (PVC) to improve the accuracy of quantitative PET studies. Conventional region-based PVC methods use co-registered high resolution anatomical images (e.g. computed tomography (CT) or magnetic resonance images) to identify regions of interest. Spill-over between regions is accounted for by calculating regional spread functions (RSFs) in a geometric transfer matrix (GTM) framework. This paper describes a new analytically derived symmetric GTM (sGTM) method that relies on spill-over between RSFs rather than between regions. It is shown that the sGTM is mathematically equivalent to Labbe's method; however it is a region-based method rather than a voxel-based method and it avoids handling large matrices. The sGTM method was validated using two three-dimensional (3D) digital phantoms and one physical phantom. A 3D digital sphere phantom with sphere diameters ranging from 5 to 30 mm and a sphere-to-background uptake ratio of 3-to-1 was used. A 3D digital brain phantom was used with four different anatomical regions and a background region with different activities assigned to each region. A physical sphere phantom with the same geometry and uptake as the digital sphere phantom was manufactured and PET-CT images were acquired. Using these three phantoms, the performance of the sGTM method was assessed against that of the GTM method in terms of accuracy, precision, noise propagation and robustness. The robustness was assessed by applying mis-registration errors and errors in estimates of PET point spread function (PSF). In all three phantoms, the results showed that the sGTM method has accuracy similar to that of the GTM method and within 5%. However, the sGTM method showed better precision and noise propagation than the GTM method, especially for spheres smaller than 13 mm. Moreover, the sGTM method was more robust than the GTM method when mis-registration errors or errors in estimates of PSF occur. The improved robustness was more pronounced for smaller objects. In conclusion, the sGTM method was analytically derived and validated. The noise characteristics and robustness of the sGTM method were better than the conventional GTM method.

Simulation Study of Tissue-Specific Positron Range Correction for the New Biograph mMR Whole-Body PET/MR System

Positron range is a limiting factor in spatial resolution of positron emission tomography (PET) imaging. In this work we investigated the tissue-dependent nature of positron range and its effect on imaging with the new Biograph mMR 3 T whole-body PET/MR system. Positron range simulations were performed for Rb-82 and Ga-68 in homogeneous and non-homogeneous configurations of soft and lung tissue using Geant4. In addition, a 3D MLEM reconstruction framework was extended to incorporate correction kernels that compensate for the effect of positron range. We developed methods for selecting and adapting such correction kernels based on the MR-derived attenuation map and pre-simulated positron range data. The methods were evaluated using Monte Carlo (MC) simulation data on a model of the mMR system including the 3 T magnetic field (MF) and the MR body coil. The results prove that the use of tissue-specific positron range kernels results in better spatial resolution. Especially, the application of generalized kernels at the borders of different tissue types has the potential to provide better contrast and lesion localization.

Evaluation of the co-registration capabilities of a MRI/PET compatible bed in an Experimental autoimmune encephalomyelitis (EAE) model

Positron Emission Tomography (PET) with 18F-FDG is a promising tool for the detection and evaluation of active inflammation in animal models of neuroinflammation. MRI is a complementary imaging technique with high resolution and contrast suitable to obtain the anatomical data required to analyze PET data. To combine PET and MRI modalities, we developed a support bed system compatible for both scanners that allowed to perform imaging exams without animal repositioning. With this approach, MRI and PET data were acquired in mice with Experimental autoimmune encephalomyelitis (EAE). In this model, it was possible to measure a variation of 18F-FDG uptake proportional to the degree of disease severity which is mainly related to Central Nervous System (CNS) inflammation. Against the low resolved PET images, the co-registered MRI/PET images allowed to distinguish the different brain structures and to obtain a more accurate tracer evaluation. This is essential in particular for brain regions whose size is of the order of the spatial resolution of PET.

Recommendations for the Use of Radiotherapy in Nodal Lymphoma

These guidelines have been developed to define the use of radiotherapy for lymphoma in the current era of combined modality treatment taking into account increasing concern over the late side-effects associated with previous radiotherapy. The role of reduced volume and reduced doses is addressed, integrating modern imaging with three-dimensional planning and advanced techniques of treatment delivery. Both wide-field and involved-field techniques have now been supplanted by the use of defined volumes based on node involvement shown on computed tomography (CT) and positron emission tomography (PET) imaging and applying the International Commission on Radiation Units and Measurements concepts of gross tumour volume (GTV), clinical target volume (CTV) and planning target volume (PTV). The planning of lymphoma patients for radical radiotherapy should now be based upon contrast enhanced 3 mm contiguous CT with three-dimensional definition of volumes using the convention of GTV, CTV and PTV. The involved-site radiotherapy concept defines the CTV based on the PET-defined pre-chemotherapy sites of involvement with an expansion in the cranio-caudal direction of lymphatic spread by 1.5 cm, constrained to tissue planes such as bone, muscle and air cavities. The margin allows for uncertainties in PET resolution, image registration and changes in patient positioning and shape. There is increasing evidence in both Hodgkin and non-Hodgkin lymphoma that traditional doses are higher than necessary for disease control and related to the incidence of late effects. No more than 30 Gy for Hodgkin and aggressive non-Hodgkin lymphoma and 24 Gy for indolent lymphomas is recommended; lower doses of 20 Gy in combination therapy for early-stage low-risk Hodgkin lymphoma may be sufficient. As yet there are no large datasets validating the use of involved-site radiotherapy; these will emerge from the current generation of clinical trials. Radiotherapy remains the most effective single modality in the treatment of lymphoma. A reduction in both treatment volume and overall treatment dose should now be considered to minimise the risks of late sequelae. However, it is important that this is not at the expense of the excellent disease control currently achieved.

Small-Animal PET Imaging of Amyloid-Beta Plaques with [11C]PiB and Its Multi-Modal Validation in an APP/PS1 Mouse Model of Alzheimer's Disease

In vivo imaging and quantification of amyloid-β plaque (Aβ) burden in small-animal models of Alzheimer's disease (AD) is a valuable tool for translational research such as developing specific imaging markers and monitoring new therapy approaches. Methodological constraints such as image resolution of positron emission tomography (PET) and lack of suitable AD models have limited the feasibility of PET in mice. In this study, we evaluated a feasible protocol for PET imaging of Aβ in mouse brain with [11C]PiB and specific activities commonly used in human studies. In vivo mouse brain MRI for anatomical reference was acquired with a clinical 1.5 T system. A recently characterized APP/PS1 mouse was employed to measure Aβ at different disease stages in homozygous and hemizygous animals. We performed multi-modal cross-validations for the PET results with ex vivo and in vitro methodologies, including regional brain biodistribution, multi-label digital autoradiography, protein quantification with ELISA, fluorescence microscopy, semi-automated histological quantification and radioligand binding assays. Specific [11C]PiB uptake in individual brain regions with Aβ deposition was demonstrated and validated in all animals of the study cohort including homozygous AD animals as young as nine months. Corresponding to the extent of Aβ pathology, old homozygous AD animals (21 months) showed the highest uptake followed by old hemizygous (23 months) and young homozygous mice (9 months). In all AD age groups the cerebellum was shown to be suitable as an intracerebral reference region. PET results were cross-validated and consistent with all applied ex vivo and in vitro methodologies. The results confirm that the experimental setup for non-invasive [11C]PiB imaging of Aβ in the APP/PS1 mice provides a feasible, reproducible and robust protocol for small-animal Aβ imaging. It allows longitudinal imaging studies with follow-up periods of approximately one and a half years and provides a foundation for translational Alzheimer neuroimaging in transgenic mice.

P197 PET-FDG staging for lung cancer: outcome of high uptake FDG at extrathoracic sites

<h3>Background</h3> Positron Emission Tomography (PET) scanning withF-18 2-fluoro-2-deoxy-D-Glucose (FDG) is pivotal in staging lung carcinoma where curative intent is proposed and increasingly is being evaluated in measuring response to therapy as well as in detecting recurrent disease. Staging nodal disease in the mediastinum apart, PET has also been reported to improve the non-invasive detection of unsuspected extra thoracic disease in upto 10% and may alter management in up to 40% of cases [McLoud TC, Cancer Imaging 2003]. The limited resolution of PET, however, results in subsequent investigations and to quantify this further we have reviewed our experiences. <h3>Methods</h3> Over a 2-year period to end 2010, 236 patients were identified as investigated by PET scan after an initial discussion of all lung cancer patients at multi-disciplinary meeting (MDT). Of these, 21 (11%) had high uptake FDG with potential evidence of extra thoracic disease not previously identified. Mean (range) age for this group was 69 (54–82) years with13 male and eight female. <h3>Results</h3> Of the 21 patients, 13 included high uptake in the bowel with two in each of breast, thyroid, and musculo-skeletal and one in stomach and parotid. 4 patients were then not investigated further; these included one where PET-FDG findings were ignored after further MDT discussion, one was too unwell to investigate and died shortly thereafter, and two who refused further investigation. Of the remainder, 12 had high uptake FDG in the bowel but all were found to be benign after subsequent investigation, and five confirmed malignant disease of which two had thyroid cancer, two-breast cancer, and one had a prior history of bowel cancer. Over this 2-year time period none of the initially PET negative cases subsequently developed radiological malignancy. <h3>Conclusion</h3> For extra thoracic disease, our experience with PET-FDG potentially reports sensitivity and a negative predictive power of 100% with a specificity of 95% and a positive predictive value of 29%. Although among our cases 11% had the suggestion of positive extra thoracic disease, the majority (71%) were then found to be benign with a concentration particularly at bowel. Further work will probably be needed to guide future investigation of potentially false positive metabolic or inflammatory findings at this site, but uptake at the other sites, potentially a concurrent primary malignancy or metastases, cannot be ignored.