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Pitfalls in Oncologic Diagnosis with FDG PET Imaging: Physiologic and Benign Variants¹

¹ Department of Internal Medicine, Division of Nuclear Medicine (P.D.S., R.L.W.)
² Department of Radiology (Y.A.), B1G412 University Hospital, University of Michigan Medical Center, 1500 E Medical Center Dr, Ann Arbor, MI 48109
³ Department of Nuclear Medicine, Veterans Affairs Medical Center, Ann Arbor, Mich (P.D.S.).

View larger version (77K): [in a new window]   Figure 1.  Normal distribution of FDG. Anterior reprojection emission FDG PET image shows the normal distribution of FDG 1 hour after intravenous administration. Intense activity is present in the brain (straight solid arrows) and the bladder (curved arrow). Lower-level activity is present in the liver (open arrow) and kidneys (arrowheads). i = site of FDG injection.

View larger version (81K): [in a new window]   Figure 2a.  Normal distribution of FDG. Anterior reprojection attenuation-corrected FDG PET images of the chest and upper abdomen in patients who had fasted show minimal (a) and intense (b) myocardial FDG uptake. With attenuation correction, lung tracer activity is nearly absent and low-level tracer activity is present in the mediastinum and heart cavity due to the blood pool. Low-level hepatic and renal activity is also present. Arrowheads indicate abnormal FDG uptake in small bronchogenic carcinomas.

View larger version (79K): [in a new window]   Figure 2b.  Normal distribution of FDG. Anterior reprojection attenuation-corrected FDG PET images of the chest and upper abdomen in patients who had fasted show minimal (a) and intense (b) myocardial FDG uptake. With attenuation correction, lung tracer activity is nearly absent and low-level tracer activity is present in the mediastinum and heart cavity due to the blood pool. Low-level hepatic and renal activity is also present. Arrowheads indicate abnormal FDG uptake in small bronchogenic carcinomas.

View larger version (41K): [in a new window]   Figure 3a.  FDG uptake in the stomach. (a, b) Axial (a) and coronal (b) FDG PET images show that FDG uptake in the stomach wall (arrows in b) is readily identified in the presence of gaseous distention. (c) Axial FDG PET image shows that FDG uptake in the stomach wall is readily identified in the presence of a contracted stomach that maintains a gastric configuration. (d, e) Axial FDG PET images show that a laterally situated (d) or medially situated (e) contracted stomach (arrow) can appear as a discrete focal abnormality. In both d and e, there is no other region of FDG uptake to suggest a gastric configuration. i in e = injection site, r = normal renal tracer activity. (f) Axial FDG PET image shows that inhomogeneous FDG uptake in the stomach wall (arrow) can simulate an FDG-avid mass. The faint outline of the stomach is discernible (arrowhead), but the stomach is laterally displaced by hepatomegaly. (g) Axial FDG PET image shows that primary gastric carcinoma (arrow) can also produce inhomogeneous FDG uptake, as can gastric lymphoma. (h) Axial FDG PET image shows that focal, inhomogeneous stomach wall uptake can be simulated by a metastatic lesion of the adjacent left adrenal gland (arrow).

View larger version (92K): [in a new window]   Figure 3b.  FDG uptake in the stomach. (a, b) Axial (a) and coronal (b) FDG PET images show that FDG uptake in the stomach wall (arrows in b) is readily identified in the presence of gaseous distention. (c) Axial FDG PET image shows that FDG uptake in the stomach wall is readily identified in the presence of a contracted stomach that maintains a gastric configuration. (d, e) Axial FDG PET images show that a laterally situated (d) or medially situated (e) contracted stomach (arrow) can appear as a discrete focal abnormality. In both d and e, there is no other region of FDG uptake to suggest a gastric configuration. i in e = injection site, r = normal renal tracer activity. (f) Axial FDG PET image shows that inhomogeneous FDG uptake in the stomach wall (arrow) can simulate an FDG-avid mass. The faint outline of the stomach is discernible (arrowhead), but the stomach is laterally displaced by hepatomegaly. (g) Axial FDG PET image shows that primary gastric carcinoma (arrow) can also produce inhomogeneous FDG uptake, as can gastric lymphoma. (h) Axial FDG PET image shows that focal, inhomogeneous stomach wall uptake can be simulated by a metastatic lesion of the adjacent left adrenal gland (arrow).

View larger version (76K): [in a new window]   Figure 3c.  FDG uptake in the stomach. (a, b) Axial (a) and coronal (b) FDG PET images show that FDG uptake in the stomach wall (arrows in b) is readily identified in the presence of gaseous distention. (c) Axial FDG PET image shows that FDG uptake in the stomach wall is readily identified in the presence of a contracted stomach that maintains a gastric configuration. (d, e) Axial FDG PET images show that a laterally situated (d) or medially situated (e) contracted stomach (arrow) can appear as a discrete focal abnormality. In both d and e, there is no other region of FDG uptake to suggest a gastric configuration. i in e = injection site, r = normal renal tracer activity. (f) Axial FDG PET image shows that inhomogeneous FDG uptake in the stomach wall (arrow) can simulate an FDG-avid mass. The faint outline of the stomach is discernible (arrowhead), but the stomach is laterally displaced by hepatomegaly. (g) Axial FDG PET image shows that primary gastric carcinoma (arrow) can also produce inhomogeneous FDG uptake, as can gastric lymphoma. (h) Axial FDG PET image shows that focal, inhomogeneous stomach wall uptake can be simulated by a metastatic lesion of the adjacent left adrenal gland (arrow).

View larger version (71K): [in a new window]   Figure 3d.  FDG uptake in the stomach. (a, b) Axial (a) and coronal (b) FDG PET images show that FDG uptake in the stomach wall (arrows in b) is readily identified in the presence of gaseous distention. (c) Axial FDG PET image shows that FDG uptake in the stomach wall is readily identified in the presence of a contracted stomach that maintains a gastric configuration. (d, e) Axial FDG PET images show that a laterally situated (d) or medially situated (e) contracted stomach (arrow) can appear as a discrete focal abnormality. In both d and e, there is no other region of FDG uptake to suggest a gastric configuration. i in e = injection site, r = normal renal tracer activity. (f) Axial FDG PET image shows that inhomogeneous FDG uptake in the stomach wall (arrow) can simulate an FDG-avid mass. The faint outline of the stomach is discernible (arrowhead), but the stomach is laterally displaced by hepatomegaly. (g) Axial FDG PET image shows that primary gastric carcinoma (arrow) can also produce inhomogeneous FDG uptake, as can gastric lymphoma. (h) Axial FDG PET image shows that focal, inhomogeneous stomach wall uptake can be simulated by a metastatic lesion of the adjacent left adrenal gland (arrow).

View larger version (68K): [in a new window]   Figure 3e.  FDG uptake in the stomach. (a, b) Axial (a) and coronal (b) FDG PET images show that FDG uptake in the stomach wall (arrows in b) is readily identified in the presence of gaseous distention. (c) Axial FDG PET image shows that FDG uptake in the stomach wall is readily identified in the presence of a contracted stomach that maintains a gastric configuration. (d, e) Axial FDG PET images show that a laterally situated (d) or medially situated (e) contracted stomach (arrow) can appear as a discrete focal abnormality. In both d and e, there is no other region of FDG uptake to suggest a gastric configuration. i in e = injection site, r = normal renal tracer activity. (f) Axial FDG PET image shows that inhomogeneous FDG uptake in the stomach wall (arrow) can simulate an FDG-avid mass. The faint outline of the stomach is discernible (arrowhead), but the stomach is laterally displaced by hepatomegaly. (g) Axial FDG PET image shows that primary gastric carcinoma (arrow) can also produce inhomogeneous FDG uptake, as can gastric lymphoma. (h) Axial FDG PET image shows that focal, inhomogeneous stomach wall uptake can be simulated by a metastatic lesion of the adjacent left adrenal gland (arrow).

View larger version (74K): [in a new window]   Figure 3f.  FDG uptake in the stomach. (a, b) Axial (a) and coronal (b) FDG PET images show that FDG uptake in the stomach wall (arrows in b) is readily identified in the presence of gaseous distention. (c) Axial FDG PET image shows that FDG uptake in the stomach wall is readily identified in the presence of a contracted stomach that maintains a gastric configuration. (d, e) Axial FDG PET images show that a laterally situated (d) or medially situated (e) contracted stomach (arrow) can appear as a discrete focal abnormality. In both d and e, there is no other region of FDG uptake to suggest a gastric configuration. i in e = injection site, r = normal renal tracer activity. (f) Axial FDG PET image shows that inhomogeneous FDG uptake in the stomach wall (arrow) can simulate an FDG-avid mass. The faint outline of the stomach is discernible (arrowhead), but the stomach is laterally displaced by hepatomegaly. (g) Axial FDG PET image shows that primary gastric carcinoma (arrow) can also produce inhomogeneous FDG uptake, as can gastric lymphoma. (h) Axial FDG PET image shows that focal, inhomogeneous stomach wall uptake can be simulated by a metastatic lesion of the adjacent left adrenal gland (arrow).

View larger version (78K): [in a new window]   Figure 3g.  FDG uptake in the stomach. (a, b) Axial (a) and coronal (b) FDG PET images show that FDG uptake in the stomach wall (arrows in b) is readily identified in the presence of gaseous distention. (c) Axial FDG PET image shows that FDG uptake in the stomach wall is readily identified in the presence of a contracted stomach that maintains a gastric configuration. (d, e) Axial FDG PET images show that a laterally situated (d) or medially situated (e) contracted stomach (arrow) can appear as a discrete focal abnormality. In both d and e, there is no other region of FDG uptake to suggest a gastric configuration. i in e = injection site, r = normal renal tracer activity. (f) Axial FDG PET image shows that inhomogeneous FDG uptake in the stomach wall (arrow) can simulate an FDG-avid mass. The faint outline of the stomach is discernible (arrowhead), but the stomach is laterally displaced by hepatomegaly. (g) Axial FDG PET image shows that primary gastric carcinoma (arrow) can also produce inhomogeneous FDG uptake, as can gastric lymphoma. (h) Axial FDG PET image shows that focal, inhomogeneous stomach wall uptake can be simulated by a metastatic lesion of the adjacent left adrenal gland (arrow).

View larger version (75K): [in a new window]   Figure 3h.  FDG uptake in the stomach. (a, b) Axial (a) and coronal (b) FDG PET images show that FDG uptake in the stomach wall (arrows in b) is readily identified in the presence of gaseous distention. (c) Axial FDG PET image shows that FDG uptake in the stomach wall is readily identified in the presence of a contracted stomach that maintains a gastric configuration. (d, e) Axial FDG PET images show that a laterally situated (d) or medially situated (e) contracted stomach (arrow) can appear as a discrete focal abnormality. In both d and e, there is no other region of FDG uptake to suggest a gastric configuration. i in e = injection site, r = normal renal tracer activity. (f) Axial FDG PET image shows that inhomogeneous FDG uptake in the stomach wall (arrow) can simulate an FDG-avid mass. The faint outline of the stomach is discernible (arrowhead), but the stomach is laterally displaced by hepatomegaly. (g) Axial FDG PET image shows that primary gastric carcinoma (arrow) can also produce inhomogeneous FDG uptake, as can gastric lymphoma. (h) Axial FDG PET image shows that focal, inhomogeneous stomach wall uptake can be simulated by a metastatic lesion of the adjacent left adrenal gland (arrow).

View larger version (32K): [in a new window]   Figure 4a.  FDG uptake in the large intestine. (a, b) Axial (a) and coronal (b) FDG PET images show extensive uptake in the transverse colon (left image in a, right image in b) and cecum (right image in a, left image in b). The inhomogeneity of the FDG accumulation in the transverse colon results in discrete focal abnormalities on the reconstructed images. When isolated, intense focal FDG uptake in the cecum, as in other segments of the colon, can be misinterpreted as an abnormal FDG-avid mass in the abdomen. (c) Axial FDG PET image shows that when the colon is filled with gas, a region of FDG uptake can resemble peritoneal or mesenteric carcinomatosis. (d) Axial FDG PET image of the chest obtained at the lower extent of the field of view shows how a limited field of view can complicate identification of physiologic FDG uptake in the intestine. There is FDG uptake in the hepatic flexure with colonic interposition (arrow), which could be misdiagnosed as a neoplasm in the hepatic dome or costophrenic sulcus. (e, f) Coronal FDG PET image (e) and correlative CT scan (f) clearly show the colon (arrows). This example emphasizes the importance of anatomic correlation with PET results.

View larger version (82K): [in a new window]   Figure 4bxy.  FDG uptake in the large intestine. (a, b) Axial (a) and coronal (b) FDG PET images show extensive uptake in the transverse colon (left image in a, right image in b) and cecum (right image in a, left image in b). The inhomogeneity of the FDG accumulation in the transverse colon results in discrete focal abnormalities on the reconstructed images. When isolated, intense focal FDG uptake in the cecum, as in other segments of the colon, can be misinterpreted as an abnormal FDG-avid mass in the abdomen. (c) Axial FDG PET image shows that when the colon is filled with gas, a region of FDG uptake can resemble peritoneal or mesenteric carcinomatosis. (d) Axial FDG PET image of the chest obtained at the lower extent of the field of view shows how a limited field of view can complicate identification of physiologic FDG uptake in the intestine. There is FDG uptake in the hepatic flexure with colonic interposition (arrow), which could be misdiagnosed as a neoplasm in the hepatic dome or costophrenic sulcus. (e, f) Coronal FDG PET image (e) and correlative CT scan (f) clearly show the colon (arrows). This example emphasizes the importance of anatomic correlation with PET results.

View larger version (57K): [in a new window]   Figure 4c.  FDG uptake in the large intestine. (a, b) Axial (a) and coronal (b) FDG PET images show extensive uptake in the transverse colon (left image in a, right image in b) and cecum (right image in a, left image in b). The inhomogeneity of the FDG accumulation in the transverse colon results in discrete focal abnormalities on the reconstructed images. When isolated, intense focal FDG uptake in the cecum, as in other segments of the colon, can be misinterpreted as an abnormal FDG-avid mass in the abdomen. (c) Axial FDG PET image shows that when the colon is filled with gas, a region of FDG uptake can resemble peritoneal or mesenteric carcinomatosis. (d) Axial FDG PET image of the chest obtained at the lower extent of the field of view shows how a limited field of view can complicate identification of physiologic FDG uptake in the intestine. There is FDG uptake in the hepatic flexure with colonic interposition (arrow), which could be misdiagnosed as a neoplasm in the hepatic dome or costophrenic sulcus. (e, f) Coronal FDG PET image (e) and correlative CT scan (f) clearly show the colon (arrows). This example emphasizes the importance of anatomic correlation with PET results.

View larger version (49K): [in a new window]   Figure 4d.  FDG uptake in the large intestine. (a, b) Axial (a) and coronal (b) FDG PET images show extensive uptake in the transverse colon (left image in a, right image in b) and cecum (right image in a, left image in b). The inhomogeneity of the FDG accumulation in the transverse colon results in discrete focal abnormalities on the reconstructed images. When isolated, intense focal FDG uptake in the cecum, as in other segments of the colon, can be misinterpreted as an abnormal FDG-avid mass in the abdomen. (c) Axial FDG PET image shows that when the colon is filled with gas, a region of FDG uptake can resemble peritoneal or mesenteric carcinomatosis. (d) Axial FDG PET image of the chest obtained at the lower extent of the field of view shows how a limited field of view can complicate identification of physiologic FDG uptake in the intestine. There is FDG uptake in the hepatic flexure with colonic interposition (arrow), which could be misdiagnosed as a neoplasm in the hepatic dome or costophrenic sulcus. (e, f) Coronal FDG PET image (e) and correlative CT scan (f) clearly show the colon (arrows). This example emphasizes the importance of anatomic correlation with PET results.

View larger version (45K): [in a new window]   Figure 4e.  FDG uptake in the large intestine. (a, b) Axial (a) and coronal (b) FDG PET images show extensive uptake in the transverse colon (left image in a, right image in b) and cecum (right image in a, left image in b). The inhomogeneity of the FDG accumulation in the transverse colon results in discrete focal abnormalities on the reconstructed images. When isolated, intense focal FDG uptake in the cecum, as in other segments of the colon, can be misinterpreted as an abnormal FDG-avid mass in the abdomen. (c) Axial FDG PET image shows that when the colon is filled with gas, a region of FDG uptake can resemble peritoneal or mesenteric carcinomatosis. (d) Axial FDG PET image of the chest obtained at the lower extent of the field of view shows how a limited field of view can complicate identification of physiologic FDG uptake in the intestine. There is FDG uptake in the hepatic flexure with colonic interposition (arrow), which could be misdiagnosed as a neoplasm in the hepatic dome or costophrenic sulcus. (e, f) Coronal FDG PET image (e) and correlative CT scan (f) clearly show the colon (arrows). This example emphasizes the importance of anatomic correlation with PET results.

View larger version (130K): [in a new window]   Figure 4f.  FDG uptake in the large intestine. (a, b) Axial (a) and coronal (b) FDG PET images show extensive uptake in the transverse colon (left image in a, right image in b) and cecum (right image in a, left image in b). The inhomogeneity of the FDG accumulation in the transverse colon results in discrete focal abnormalities on the reconstructed images. When isolated, intense focal FDG uptake in the cecum, as in other segments of the colon, can be misinterpreted as an abnormal FDG-avid mass in the abdomen. (c) Axial FDG PET image shows that when the colon is filled with gas, a region of FDG uptake can resemble peritoneal or mesenteric carcinomatosis. (d) Axial FDG PET image of the chest obtained at the lower extent of the field of view shows how a limited field of view can complicate identification of physiologic FDG uptake in the intestine. There is FDG uptake in the hepatic flexure with colonic interposition (arrow), which could be misdiagnosed as a neoplasm in the hepatic dome or costophrenic sulcus. (e, f) Coronal FDG PET image (e) and correlative CT scan (f) clearly show the colon (arrows). This example emphasizes the importance of anatomic correlation with PET results.

View larger version (39K): [in a new window]   Figure 5a.  FDG uptake in the small intestine. (a) Axial FDG PET images (left image obtained at a higher level than right image) show typical segmental FDG uptake in the ileum. FDG uptake is not present elsewhere in the intestine. (b) Axial FDG PET image shows FDG uptake in the terminal ileum and cecum (arrow) with additional isolated foci of uptake in segments of the small intestine (arrowheads); these foci could be mistaken for mesenteric lymph node metastases.

View larger version (31K): [in a new window]   Figure 5b.  FDG uptake in the small intestine. (a) Axial FDG PET images (left image obtained at a higher level than right image) show typical segmental FDG uptake in the ileum. FDG uptake is not present elsewhere in the intestine. (b) Axial FDG PET image shows FDG uptake in the terminal ileum and cecum (arrow) with additional isolated foci of uptake in segments of the small intestine (arrowheads); these foci could be mistaken for mesenteric lymph node metastases.

View larger version (19K): [in a new window]   Figure 6a.  FDG uptake in the thyroid gland in a nongoitrous, euthyroid patient. Sequential axial FDG PET images (shown from superior [left] to inferior [right]) (a), coronal FDG PET image (left image in b), and sagittal FDG PET image (right image in b) show relatively intense FDG uptake in the thyroid gland.

View larger version (17K): [in a new window]   Figure 6b.  FDG uptake in the thyroid gland in a nongoitrous, euthyroid patient. Sequential axial FDG PET images (shown from superior [left] to inferior [right]) (a), coronal FDG PET image (left image in b), and sagittal FDG PET image (right image in b) show relatively intense FDG uptake in the thyroid gland.

View larger version (66K): [in a new window]   Figure 7.  FDG uptake in skeletal muscle due to muscle contraction during the FDG uptake phase. Posterior reprojection FDG PET image of a patient who was allowed a short walk after FDG administration shows intense FDG accumulation in the gluteal musculature (arrows).

View larger version (11K): [in a new window]   Figure 8.  FDG uptake in skeletal muscle. Coronal FDG PET images of the neck (shown from anterior [left] to posterior [right]) show intense and relatively symmetric FDG activity in portions of the sternocleidomastoid and trapezius muscles (arrowheads).

View larger version (85K): [in a new window]   Figure 9a.  Asymmetric or isolated FDG uptake in skeletal muscle. (a) Coronal FDG PET image of a patient who used his left arm before FDG injection reveals FDG uptake in only a small portion of the left trapezius muscle (arrow). (b) Axial FDG PET image of the same patient shows FDG uptake (arrowhead) with an appearance suggestive of a large metastatic or primary neoplasm of the chest wall. (c) Axial FDG PET image shows FDG uptake in the left pterygoid muscle (arrow) in a patient who underwent contralateral neck surgery. Although the patient did not speak during the FDG uptake phase, muscle imbalance due to loss of the contralateral musculature resulted in the FDG uptake, which could be misinterpreted as a neoplasm of the skull base. c = normal cerebellar tracer uptake.

View larger version (21K): [in a new window]   Figure 9b.  Asymmetric or isolated FDG uptake in skeletal muscle. (a) Coronal FDG PET image of a patient who used his left arm before FDG injection reveals FDG uptake in only a small portion of the left trapezius muscle (arrow). (b) Axial FDG PET image of the same patient shows FDG uptake (arrowhead) with an appearance suggestive of a large metastatic or primary neoplasm of the chest wall. (c) Axial FDG PET image shows FDG uptake in the left pterygoid muscle (arrow) in a patient who underwent contralateral neck surgery. Although the patient did not speak during the FDG uptake phase, muscle imbalance due to loss of the contralateral musculature resulted in the FDG uptake, which could be misinterpreted as a neoplasm of the skull base. c = normal cerebellar tracer uptake.

View larger version (46K): [in a new window]   Figure 9c.  Asymmetric or isolated FDG uptake in skeletal muscle. (a) Coronal FDG PET image of a patient who used his left arm before FDG injection reveals FDG uptake in only a small portion of the left trapezius muscle (arrow). (b) Axial FDG PET image of the same patient shows FDG uptake (arrowhead) with an appearance suggestive of a large metastatic or primary neoplasm of the chest wall. (c) Axial FDG PET image shows FDG uptake in the left pterygoid muscle (arrow) in a patient who underwent contralateral neck surgery. Although the patient did not speak during the FDG uptake phase, muscle imbalance due to loss of the contralateral musculature resulted in the FDG uptake, which could be misinterpreted as a neoplasm of the skull base. c = normal cerebellar tracer uptake.

View larger version (44K): [in a new window]   Figure 10xy.  Irregular myocardial FDG uptake in a patient who had fasted for 12 hours before FDG injection. Axial FDG PET images of the chest (shown from superior [top left] to inferior [bottom right]) show the outlines of the left and right ventricles. There are discrete foci of intense FDG activity (arrows), which could be mistaken for mediastinal lymph nodes at the base of the heart.

View larger version (44K): [in a new window]   Figure 11axy.  FDG uptake in bone marrow. (a) Axial FDG PET images (shown from superior [top left] to inferior [bottom center]) show normal FDG activity in the marrow of the vertebral bodies (arrows). Sagittal FDG PET image (bottom right) clearly shows the modest FDG uptake at each vertebral body. (b) Axial FDG PET images (shown from superior [top left] to inferior [bottom center]) of a patient with lung cancer show metastases to the marrow spaces of the vertebral bodies (arrowheads) and left pedicle (arrow). Sagittal FDG PET image (bottom right) shows the irregular intensity and nonuniform distribution of the FDG uptake in the metastases. Metastases are also present in the left rib and sternum.

View larger version (41K): [in a new window]   Figure 11bxy.  FDG uptake in bone marrow. (a) Axial FDG PET images (shown from superior [top left] to inferior [bottom center]) show normal FDG activity in the marrow of the vertebral bodies (arrows). Sagittal FDG PET image (bottom right) clearly shows the modest FDG uptake at each vertebral body. (b) Axial FDG PET images (shown from superior [top left] to inferior [bottom center]) of a patient with lung cancer show metastases to the marrow spaces of the vertebral bodies (arrowheads) and left pedicle (arrow). Sagittal FDG PET image (bottom right) shows the irregular intensity and nonuniform distribution of the FDG uptake in the metastases. Metastases are also present in the left rib and sternum.

View larger version (31K): [in a new window]   Figure 12xy.  FDG uptake in bone marrow in a patient treated with granulocyte colony-stimulating factor. Axial FDG PET images (shown from superior [top left] to inferior [bottom center]) and a sagittal FDG PET image (bottom right) show intense FDG uptake in the vertebral bodies and sternum. The intense uptake resulted from expansion of the bone marrow due to the granulocyte colony-stimulating factor. Marrow activity in the ribs, scapula, and proximal humeri is also evident.

View larger version (41K): [in a new window]   Figure 13a.  Urinary excretion of FDG. (a) Axial FDG PET images (left image obtained at a higher level than right image) show the common finding of focal urinary FDG activity in the upper-pole calix of the left kidney (arrowhead). (b) Consecutive axial FDG PET images (shown from superior [top left] to inferior [bottom right]) of a patient with lung cancer show focal urinary FDG activity in the upper-pole calix of the left kidney (arrows) and a metastasis to the left adrenal gland (arrowheads). (c) CT scan of the same patient as in b clearly shows the relationship between the left adrenal mass and the left upper-pole calix. (d, e) Axial FDG PET images (shown from superior [top left] to inferior [bottom right]) (d) and a coronal FDG PET image (e) show isolated urinary FDG activity in a small extrarenal pelvis (arrows). This finding could be misinterpreted as FDG-avid paraaortic or renal hilar lymph nodes if the relationship to the kidney is not clearly demonstrated. (f) Correlative CT scan shows intrapelvic fat with a small, medially displaced ureter (arrow).

View larger version (46K): [in a new window]   Figure 13bxy.  Urinary excretion of FDG. (a) Axial FDG PET images (left image obtained at a higher level than right image) show the common finding of focal urinary FDG activity in the upper-pole calix of the left kidney (arrowhead). (b) Consecutive axial FDG PET images (shown from superior [top left] to inferior [bottom right]) of a patient with lung cancer show focal urinary FDG activity in the upper-pole calix of the left kidney (arrows) and a metastasis to the left adrenal gland (arrowheads). (c) CT scan of the same patient as in b clearly shows the relationship between the left adrenal mass and the left upper-pole calix. (d, e) Axial FDG PET images (shown from superior [top left] to inferior [bottom right]) (d) and a coronal FDG PET image (e) show isolated urinary FDG activity in a small extrarenal pelvis (arrows). This finding could be misinterpreted as FDG-avid paraaortic or renal hilar lymph nodes if the relationship to the kidney is not clearly demonstrated. (f) Correlative CT scan shows intrapelvic fat with a small, medially displaced ureter (arrow).

View larger version (135K): [in a new window]   Figure 13c.  Urinary excretion of FDG. (a) Axial FDG PET images (left image obtained at a higher level than right image) show the common finding of focal urinary FDG activity in the upper-pole calix of the left kidney (arrowhead). (b) Consecutive axial FDG PET images (shown from superior [top left] to inferior [bottom right]) of a patient with lung cancer show focal urinary FDG activity in the upper-pole calix of the left kidney (arrows) and a metastasis to the left adrenal gland (arrowheads). (c) CT scan of the same patient as in b clearly shows the relationship between the left adrenal mass and the left upper-pole calix. (d, e) Axial FDG PET images (shown from superior [top left] to inferior [bottom right]) (d) and a coronal FDG PET image (e) show isolated urinary FDG activity in a small extrarenal pelvis (arrows). This finding could be misinterpreted as FDG-avid paraaortic or renal hilar lymph nodes if the relationship to the kidney is not clearly demonstrated. (f) Correlative CT scan shows intrapelvic fat with a small, medially displaced ureter (arrow).

View larger version (65K): [in a new window]   Figure 13dwxyz.  Urinary excretion of FDG. (a) Axial FDG PET images (left image obtained at a higher level than right image) show the common finding of focal urinary FDG activity in the upper-pole calix of the left kidney (arrowhead). (b) Consecutive axial FDG PET images (shown from superior [top left] to inferior [bottom right]) of a patient with lung cancer show focal urinary FDG activity in the upper-pole calix of the left kidney (arrows) and a metastasis to the left adrenal gland (arrowheads). (c) CT scan of the same patient as in b clearly shows the relationship between the left adrenal mass and the left upper-pole calix. (d, e) Axial FDG PET images (shown from superior [top left] to inferior [bottom right]) (d) and a coronal FDG PET image (e) show isolated urinary FDG activity in a small extrarenal pelvis (arrows). This finding could be misinterpreted as FDG-avid paraaortic or renal hilar lymph nodes if the relationship to the kidney is not clearly demonstrated. (f) Correlative CT scan shows intrapelvic fat with a small, medially displaced ureter (arrow).

View larger version (73K): [in a new window]   Figure 13e.  Urinary excretion of FDG. (a) Axial FDG PET images (left image obtained at a higher level than right image) show the common finding of focal urinary FDG activity in the upper-pole calix of the left kidney (arrowhead). (b) Consecutive axial FDG PET images (shown from superior [top left] to inferior [bottom right]) of a patient with lung cancer show focal urinary FDG activity in the upper-pole calix of the left kidney (arrows) and a metastasis to the left adrenal gland (arrowheads). (c) CT scan of the same patient as in b clearly shows the relationship between the left adrenal mass and the left upper-pole calix. (d, e) Axial FDG PET images (shown from superior [top left] to inferior [bottom right]) (d) and a coronal FDG PET image (e) show isolated urinary FDG activity in a small extrarenal pelvis (arrows). This finding could be misinterpreted as FDG-avid paraaortic or renal hilar lymph nodes if the relationship to the kidney is not clearly demonstrated. (f) Correlative CT scan shows intrapelvic fat with a small, medially displaced ureter (arrow).

View larger version (121K): [in a new window]   Figure 13f.  Urinary excretion of FDG. (a) Axial FDG PET images (left image obtained at a higher level than right image) show the common finding of focal urinary FDG activity in the upper-pole calix of the left kidney (arrowhead). (b) Consecutive axial FDG PET images (shown from superior [top left] to inferior [bottom right]) of a patient with lung cancer show focal urinary FDG activity in the upper-pole calix of the left kidney (arrows) and a metastasis to the left adrenal gland (arrowheads). (c) CT scan of the same patient as in b clearly shows the relationship between the left adrenal mass and the left upper-pole calix. (d, e) Axial FDG PET images (shown from superior [top left] to inferior [bottom right]) (d) and a coronal FDG PET image (e) show isolated urinary FDG activity in a small extrarenal pelvis (arrows). This finding could be misinterpreted as FDG-avid paraaortic or renal hilar lymph nodes if the relationship to the kidney is not clearly demonstrated. (f) Correlative CT scan shows intrapelvic fat with a small, medially displaced ureter (arrow).

View larger version (30K): [in a new window]   Figure 14.  FDG uptake in the testes. Axial FDG PET image shows physiologic FDG uptake in the testes.

View larger version (73K): [in a new window]   Figure 15awxyz.  FDG uptake in healing bone. (a, b) Axial FDG PET images (shown from superior [top left] to inferior [bottom right]) (a) and a sagittal FDG PET image (b) obtained 6 weeks after cardiac surgery show FDG uptake (SUV = 3.3) in a healing sternum. (c) Axial FDG PET images (left image obtained at a higher level than right image) of a patient who experienced lateral fractures of two right ribs 3 weeks before imaging show FDG uptake (SUV = 2.3) in the healing fractures (arrows). Six weeks later, FDG uptake in the fractures had diminished slightly (SUV = 2.1).

View larger version (109K): [in a new window]   Figure 15b.  FDG uptake in healing bone. (a, b) Axial FDG PET images (shown from superior [top left] to inferior [bottom right]) (a) and a sagittal FDG PET image (b) obtained 6 weeks after cardiac surgery show FDG uptake (SUV = 3.3) in a healing sternum. (c) Axial FDG PET images (left image obtained at a higher level than right image) of a patient who experienced lateral fractures of two right ribs 3 weeks before imaging show FDG uptake (SUV = 2.3) in the healing fractures (arrows). Six weeks later, FDG uptake in the fractures had diminished slightly (SUV = 2.1).

View larger version (51K): [in a new window]   Figure 15c.  FDG uptake in healing bone. (a, b) Axial FDG PET images (shown from superior [top left] to inferior [bottom right]) (a) and a sagittal FDG PET image (b) obtained 6 weeks after cardiac surgery show FDG uptake (SUV = 3.3) in a healing sternum. (c) Axial FDG PET images (left image obtained at a higher level than right image) of a patient who experienced lateral fractures of two right ribs 3 weeks before imaging show FDG uptake (SUV = 2.3) in the healing fractures (arrows). Six weeks later, FDG uptake in the fractures had diminished slightly (SUV = 2.1).

View larger version (47K): [in a new window]   Figure 16a.  FDG uptake in noncancerous lymph nodes. (a) Axial FDG PET image of a patient with a treated lung abscess shows FDG uptake in intrapulmonary lymph nodes (arrows). Even though the lung abscess is no longer FDG avid, the inflammatory response in the regional lymph nodes and the associated FDG uptake remain. (b) Axial FDG PET images (shown from superior [top left] to inferior [bottom right]) of a patient with a cavitating primary lung neoplasm (open arrow) and adjacent organized pneumonia show FDG uptake in paratracheal and precarinal lymph nodes (solid arrows). The FDG-avid nodes did not harbor metastases but rather an inflammatory response to the regional pneumonia. Note the FDG uptake along the tract formed by a previously placed chest tube (arrowheads). (c) Contrast material–enhanced CT scan of the same patient as in b shows an enlarged precarinal lymph node (solid arrow) and the chest tube tract (open arrow).

View larger version (54K): [in a new window]   Figure 16bxy.  FDG uptake in noncancerous lymph nodes. (a) Axial FDG PET image of a patient with a treated lung abscess shows FDG uptake in intrapulmonary lymph nodes (arrows). Even though the lung abscess is no longer FDG avid, the inflammatory response in the regional lymph nodes and the associated FDG uptake remain. (b) Axial FDG PET images (shown from superior [top left] to inferior [bottom right]) of a patient with a cavitating primary lung neoplasm (open arrow) and adjacent organized pneumonia show FDG uptake in paratracheal and precarinal lymph nodes (solid arrows). The FDG-avid nodes did not harbor metastases but rather an inflammatory response to the regional pneumonia. Note the FDG uptake along the tract formed by a previously placed chest tube (arrowheads). (c) Contrast material–enhanced CT scan of the same patient as in b shows an enlarged precarinal lymph node (solid arrow) and the chest tube tract (open arrow).

View larger version (81K): [in a new window]   Figure 16c.  FDG uptake in noncancerous lymph nodes. (a) Axial FDG PET image of a patient with a treated lung abscess shows FDG uptake in intrapulmonary lymph nodes (arrows). Even though the lung abscess is no longer FDG avid, the inflammatory response in the regional lymph nodes and the associated FDG uptake remain. (b) Axial FDG PET images (shown from superior [top left] to inferior [bottom right]) of a patient with a cavitating primary lung neoplasm (open arrow) and adjacent organized pneumonia show FDG uptake in paratracheal and precarinal lymph nodes (solid arrows). The FDG-avid nodes did not harbor metastases but rather an inflammatory response to the regional pneumonia. Note the FDG uptake along the tract formed by a previously placed chest tube (arrowheads). (c) Contrast material–enhanced CT scan of the same patient as in b shows an enlarged precarinal lymph node (solid arrow) and the chest tube tract (open arrow).

View larger version (29K): [in a new window]   Figure 17.  FDG uptake in a normal lymph node. Axial FDG PET image shows FDG accumulation in a normal axillary lymph node (arrow) secondary to extravasation of the tracer at the injection site, which was in the ipsilateral arm.

View larger version (86K): [in a new window]   Figure 18a.  FDG uptake in joints. (a) Axial FDG PET image of a patient with no clinical or radiographic evidence of abnormal sternoclavicular joints shows focal FDG uptake in the sternoclavicular joints (arrows). (b) Axial FDG PET images (shown from superior [left] to inferior [right]) show elevated FDG uptake in the anterior rib ends (arrows). Arrowheads = vertebral body metastasis.

View larger version (21K): [in a new window]   Figure 18b.  FDG uptake in joints. (a) Axial FDG PET image of a patient with no clinical or radiographic evidence of abnormal sternoclavicular joints shows focal FDG uptake in the sternoclavicular joints (arrows). (b) Axial FDG PET images (shown from superior [left] to inferior [right]) show elevated FDG uptake in the anterior rib ends (arrows). Arrowheads = vertebral body metastasis.

View larger version (43K): [in a new window]   Figure 19a.  FDG uptake in joints. (a) Axial FDG PET image shows symmetric focal FDG uptake (SUV = 3.2) in the inferior glenohumeral joints (arrows). (b, c) Axial (b) and coronal (c) FDG PET images show isolated focal FDG uptake (SUV = 3.0) (arrowhead), which mimics an osseous metastasis.

View larger version (73K): [in a new window]   Figure 19b.  FDG uptake in joints. (a) Axial FDG PET image shows symmetric focal FDG uptake (SUV = 3.2) in the inferior glenohumeral joints (arrows). (b, c) Axial (b) and coronal (c) FDG PET images show isolated focal FDG uptake (SUV = 3.0) (arrowhead), which mimics an osseous metastasis.

View larger version (44K): [in a new window]   Figure 19c.  FDG uptake in joints. (a) Axial FDG PET image shows symmetric focal FDG uptake (SUV = 3.2) in the inferior glenohumeral joints (arrows). (b, c) Axial (b) and coronal (c) FDG PET images show isolated focal FDG uptake (SUV = 3.0) (arrowhead), which mimics an osseous metastasis.

View larger version (65K): [in a new window]   Figure 20a.  FDG uptake associated with infection. (a, b) Coronal (a) and axial (b) FDG PET images of a patient with pneumonia in the right middle lobe show diffuse FDG uptake (arrow). The configuration and uniformity of the uptake are typical of uncomplicated alveolar pneumonia. (c) Correlative CT scan shows the alveolar pneumonia. (d, e) Coronal (d) and axial (e) FDG PET images of a patient with cavitating pneumonia show focal, intense FDG uptake (arrow). (f) Correlative CT scan shows the cavitating pneumonia.

View larger version (40K): [in a new window]   Figure 20b.  FDG uptake associated with infection. (a, b) Coronal (a) and axial (b) FDG PET images of a patient with pneumonia in the right middle lobe show diffuse FDG uptake (arrow). The configuration and uniformity of the uptake are typical of uncomplicated alveolar pneumonia. (c) Correlative CT scan shows the alveolar pneumonia. (d, e) Coronal (d) and axial (e) FDG PET images of a patient with cavitating pneumonia show focal, intense FDG uptake (arrow). (f) Correlative CT scan shows the cavitating pneumonia.

View larger version (98K): [in a new window]   Figure 20c.  FDG uptake associated with infection. (a, b) Coronal (a) and axial (b) FDG PET images of a patient with pneumonia in the right middle lobe show diffuse FDG uptake (arrow). The configuration and uniformity of the uptake are typical of uncomplicated alveolar pneumonia. (c) Correlative CT scan shows the alveolar pneumonia. (d, e) Coronal (d) and axial (e) FDG PET images of a patient with cavitating pneumonia show focal, intense FDG uptake (arrow). (f) Correlative CT scan shows the cavitating pneumonia.

View larger version (57K): [in a new window]   Figure 20d.  FDG uptake associated with infection. (a, b) Coronal (a) and axial (b) FDG PET images of a patient with pneumonia in the right middle lobe show diffuse FDG uptake (arrow). The configuration and uniformity of the uptake are typical of uncomplicated alveolar pneumonia. (c) Correlative CT scan shows the alveolar pneumonia. (d, e) Coronal (d) and axial (e) FDG PET images of a patient with cavitating pneumonia show focal, intense FDG uptake (arrow). (f) Correlative CT scan shows the cavitating pneumonia.

View larger version (44K): [in a new window]   Figure 20e.  FDG uptake associated with infection. (a, b) Coronal (a) and axial (b) FDG PET images of a patient with pneumonia in the right middle lobe show diffuse FDG uptake (arrow). The configuration and uniformity of the uptake are typical of uncomplicated alveolar pneumonia. (c) Correlative CT scan shows the alveolar pneumonia. (d, e) Coronal (d) and axial (e) FDG PET images of a patient with cavitating pneumonia show focal, intense FDG uptake (arrow). (f) Correlative CT scan shows the cavitating pneumonia.

View larger version (119K): [in a new window]   Figure 20f.  FDG uptake associated with infection. (a, b) Coronal (a) and axial (b) FDG PET images of a patient with pneumonia in the right middle lobe show diffuse FDG uptake (arrow). The configuration and uniformity of the uptake are typical of uncomplicated alveolar pneumonia. (c) Correlative CT scan shows the alveolar pneumonia. (d, e) Coronal (d) and axial (e) FDG PET images of a patient with cavitating pneumonia show focal, intense FDG uptake (arrow). (f) Correlative CT scan shows the cavitating pneumonia.

View larger version (25K): [in a new window]   Figure 21.  FDG uptake associated with ostomy. Axial FDG PET image shows FDG uptake at the exposed mucosa of a healing tracheostomy owing to a normal inflammatory response.

View larger version (43K): [in a new window]   Figure 22a.  FDG uptake associated with granulation tissue. (a) Axial FDG PET image of a patient with a resolving sterile hematoma in the right breast due to lumpectomy shows a rim of FDG uptake (arrows). (b) Axial FDG PET image of a patient with a resolving thromboembolism of the left main pulmonary artery shows modest FDG activity (arrow).

View larger version (27K): [in a new window]   Figure 22b.  FDG uptake associated with granulation tissue. (a) Axial FDG PET image of a patient with a resolving sterile hematoma in the right breast due to lumpectomy shows a rim of FDG uptake (arrows). (b) Axial FDG PET image of a patient with a resolving thromboembolism of the left main pulmonary artery shows modest FDG activity (arrow).