Physiological Variations of FDG

Distribution and Pitfalls of

Interpretation of PET-CT
Dominique Delbeke, MD, PhD
Vanderbilt University Medical Center
Nashville, Tennessee

VUMC PET conference August 2009

Outline
FDG distribution

Neck: glandular, lymphoid, muscular

Muscular system
GI
GU
GYN

Therapy-related changes
Inflammatory processes
PET technical artifacts
PET/CT technical artifacts
SNM PET/CT guidelines
Preparation of the patient
Reporting

Normal Distribution of FDG

Brain: high uptake in the gray matter
Myocardium: variable uptake
Lungs: low uptake
Mediastinum: low uptake
Liver: low uptake
GI tract: variable activity (esophagus,
stomach, colon)
Urinary tract: excretes FDG
Muscular system: low uptake at rest
Cook GJR, et al: Semin Nucl Med 1996;26:308-314

Physiological Variations of FDG Distribution

Neck:
Glandular tissue
Lymphoid tissue
Muscles
Brown fat

Laryngeal muscles:
vocalis and crico-arytenoid

Parotid glands

Oculomotor muscles

Oculomotor muscles
nasopharynx

Parotid glands

Tonsils
Sublingual gland
and myelohyoid
muscles
Submandibular
glands
Laryngeal
muscles

Patient with lymphoma in remission 6 months earlier

Uptake in
masseter muscles
due to chewing

Initial staging lung cancer

Uptake in R masseter and pterygoid

67 year-old female with medullary thyroid ca and rising calcitonin

Left vocal cord paralysis

16 year old female with lymphoma s/p therapy

Brown fat

Physiological Variations of FDG Distribution

FDG uptake in both

the thyroid gland
and laryngeal
muscles

Hashimoto Thyroiditis

From: Delbeke D et al (eds): Practical FDG Imaging: A teaching File Springer-Verlag 2002.

Physiological Variations of FDG Distribution

Muscular system:
Under tension or after exercise (e.g. chewing, talking,
swallowing, eye movement, hyperventilating, walking..)
Insulin endogenous or exogenous

Exercise

Endogenous insulin

51 year-old male with relapse Hodgkins lymphoma S/P chemotherapy

36 year-old man s/p lung transplant for hypersensitivity

pneumonitis, now lung nodules
other patient with lung cancer

Respiratory
insufficiency

28 year-old male with Hodgkins lymphoma and suspected recurrence

Nausea and vomiting

Weight lifting

22 year-old female with DLBCL s/p completion of therapy

Honeymoon effect

Physiological Variations of FDG Distribution: GI

GI tract:

Lymphoid tissue
Smooth muscle activity
Stools
Metformin
Inflammatory disease

Crohns disease
Lung cancer and colitis
From: Delbeke D et al (eds): Practical FDG Imaging: A teaching File Springer-Verlag 2002.

67 year-old female presents for initial staging of laryngeal cancer

Metformin

Gontier E et al. Eur J Nucl Med Mol Imaging 2008;35(1):95-99

Physiological Variations of FDG Distribution: GI

45-year-old man who
completed chemo and
radiation therapy for
SCC of the larynx
presents with
dysphagia

Esophagitis

65year-old female with

NSCLC referred for initial
staging

1) RUL NSCLC
2) Hepatic
metastases
3) Hiatal hernia
From: Delbeke D et al (eds): Practical FDG Imaging: A teaching File Springer-Verlag 2002.

Physiological Variations of FDG Distribution: GU

Patient evaluated for suspected
recurrent colorectal cancer

Right pelvic kidney

Renal transplant

55-year-old male s/p resection abdominal sarcoma 8 months

ago, presenting with suspicion of recurrence on CT

abdominal recurrent sarcoma and horseshoe kidney

Physiological Variation of FDG Distribution: GU/GYN

36 year old female with a 1 cm SPN

Horseshoe kidney and fibroids

Physiological Variation of FDG Distribution: GYN

33 year-old female just diagnosed with breast cancer

Uterus in a menstruating female

17 year-old female with HD in the neck and chest s/p completion of therapy

Ovaries benign

Lerman H et al. J Nucl Med 2004;45:266-271.

Physiological Variations of FDG Distribution: GYN

Dense breast

Lactating breasts

Vranjesevic D wet al. J Nucl Med 2003;44(8):1238-1242

Monitoring Response to Therapy with FDG PET:

Timing in Relation to Surgical Therapy

Surgery:
~ 2 months for surgical site
Anytime for staging elsewhere.

58 year old man s/p mediastinoscopy

1 week earlier demonstrating NSCLC

62 year-old male s/p resection of recurrent lymphoma of

the small bowel 2 weeks earlier.

Diagnosis: postoperative changes

45 year-old female with anaplastic lymphoma S/P therapy

evaluated for bone marrow transplant
July 05

Bone marrow biopsy L iliac crest

Monitoring Response to Therapy with FDG PET:

Timing in Relation to Radiation Therapy
More than 6 months after completion of radiation:
FDG uptake indicates tumor recurrence
Early after radiation (within 2 monthsup to..):
FDG uptake matching the radiation port due to
inflammatory changes
Recommendations:
Wait as long as possible after radiation before performing
FDG PET
Comparison to baseline PET is helpful
Knowledge of radiation ports is helpful.

48 year-old man with HD diagnosed in 2003

48 year old man with lymphoma

diagnosed 1 year earlier and
treated with XRT to left axilla. He
recurred 2 months earlier and
was treated with chemotherapy.

57 year old male diagnosed with esophageal cancer in

July and treated with chemoradiation completed two
weeks before his follow-up PET scan
July 29

Oct 19

61 year-old female with T-cell lymphoma of left breast and mediastinum

s/p chemo and radiation

Radiation esophagitis

33 year-old male with DLBCL s/p chemo and radiation therapy to mediastinum
2 year earlier and referred for restaging

Radiation pneumonitis

81-year-old male with large

cell carcinoma treated with
radiation therapy

Radiation pneumonitis
From: Delbeke D et al (eds): Practical FDG Imaging: A teaching File Springer-Verlag 2002.

Monitoring Response to Therapy with FDG PET:

Timing in Relation to Chemotherapy
Physiological uptake in response to therapy
For 2-4 weeks: Bone marrow and spleen due to regenerating
bone marrow (hyperplasia)
Worse if bone marrow stimulating factors have been
administered with chemotherapy (e.g. G-CSF, neupogen)
Possible transient cellular stunning
Possible inflammatory response: metabolic flare
Recommendation:
At least 2 weeks after last chemotherapy or just before next
cycle
2-months after completion of therapy

1 day post G-CSF

A 42-year-old
female who
underwent a left
mastectomy for
breast carcinoma
followed by
chemotherapy
presented with
rising tumor
2 weeks later
markers

Diagnosis: Severe bone

marrow uptake related to
administration of G-CSF the
day before

Thymic hyperplasia

Benign Diseases that Can Mimick Malignancy

Granulomatous lesions: e.g. tuberculosis, fungi,
sarcoidosis.
Other inflammatory processes
Hyperplasia/dysplasia
42-year-old male after completion of therapy for SCC of the
oropharynx

Sarcoidosis
From: Delbeke D et al (eds): Practical FDG Imaging: A teaching File Springer-Verlag 2002.

55 year old female with recurrent melanoma

1) Recurrent
melanoma in left
axilla
2) Vaccine injection
in right axilla and
bilateral groins

76 year-old male with pulmonary nodule

Pericarditis

76 year-old male with pulmonary nodule

Recent laminectomy

72-year-old female with weight

loss, fatigue, fevers and chills and
a lesion in the caudate lobe of
the liver on CT

Diagnosis: Surgery: Acute

gangrenous and hemorrhagic
cholecystitis with abscess
formation extending in the right
colon

Suspicion of Klatskin

Acute pancreatitis

43 year old s/p thyroidectomy for papillary thyroid cancer

presenting with borderline elevation of Tg, has Tg Ab and a
negative I-131 scan at time of previous recurrence.

Bx: granulomatous disease

Nocardia abscess

A 80 year-old male with a history of amyloidosis presented

for evaluation of SPN

Amyloidosis

64-year-old
male with
recurrent
left neck
lymphoma
post-stem
cell
transplant

From Vitola JV and Delbeke D. Nuclear Cardiology & Correlative Imaging, Springer-Verlag, 2004

60 year old male with NSCLC 2 years earlier presenting with

SVC syndrome

Thrombus in SVC

68-year-old male with mantle cell lymphoma with multiple LN in

the neck and abdomen

Diagnosis:
1) False low grade lymphoma
2) Fem-Fem graft

PET Technical Artifacts

Malfunctioning detector
Injection site
Indwelling catheter
Sentinel lymph node visualization

57-year-old male with a history of lung cancer believed to

be in remission and referred for follow-up

Diagnosis: Malfunctioning detector

34-year-old female presents with persistent lympadenopathy in the

porta hepatis after completion of therapy for lymphoma

Diagnosis: FDG injection in port and visualization of indwelling catheter

From: Delbeke D et al (eds): Practical FDG Imaging: A teaching File Springer-Verlag 2002.

A 65-year-old male with a history of prostate cancer was

referred for evaluation of a pulmonary nodule.

Arterial injection

60 year old male with multiple

relapse of lymphoma, now new
1 cm mediastinal LN

Dose infiltration and FDG

uptake in sentinel LN

Artifacts on CT-attenuated PET images

Inaccurate co-registration due to: Random motion
less likely with short transmission scan

Artifacts on CT-attenuated PET images

Inaccurate co-registration due to: Respiratory motion
Inaccurate localization of lesion in the region of diaphragm
(dome of liver versus lung bases) in 2% of patients
Curvilinear cold artifacts along diaphragm
65 year-old with lung
cancer s/p XRT to
mediastinum 1 week
earlier
Radiation esophagitis

Goerres GW et al. Radiology 2003;226:906-910.

Osman MM et al. Eur J Nucl Med 2003;30:603-606.
Osman MM et al. J Nucl Med 2003;44:240-243.

Artifacts on CT-attenuated PET images

Hot spots due to over-correction related to:
IV contrast
Focal accumulation of oral contrast
Metallic implants (dental, hardware)
Overestimation of SUV values by up to 10% compared to Ge68 based attenuation correction.

Antoch G et al.J Nucl Med 2002;43:1339-1342. No correction

Cohade C et al. J Nucl Med 2003;44:412-416.
Goerres GW et al. Eur J Nucl Med Molec Imag 2002;29:367-370.
Nakamoto Y et al. J Nucl Med 2002;43:1137-1143.
Antoch G et al. J Nucl Med 2004: 45 (Suppl): 56S.

standard

Thank you!

Brazil 2004