HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Abstract Full Text Full Text (PDF) CME Test (opens in a new window) Submit a response Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Kostakoglu, L. Articles by Goldsmith, S. J. Search for Related Content PubMed PubMed Citation Articles by Kostakoglu, L. Articles by Goldsmith, S. J. Related Collections Nuclear Medicine

Clinical Role of FDG PET in Evaluation of Cancer Patients¹

¹ From the Division of Nuclear Medicine, Department of Radiology, New York Presbyterian Hospital, Weill Cornell Medical Center, 525 E 68th St, Starr No. 221, New York, NY 10021 (L.K., S.J.G.); and the Division of Nuclear Medicine, Department of Radiology, Hackensack University Medical Center, Hackensack, NJ (H.A.). Received April 25, 2002; revision requested August 5 and received October 7; accepted October 8. H.A. has given lectures sponsored by CTI (Knoxville, Tenn), PETNET (Knoxville, Tenn), and Alliance Imaging (Anaheim, Calif) on use of PET. Address correspondence to L.K. (e-mail: lak2005@med.cornell.edu).

View larger version (70K): [in a new window]   Figure 1.  Normal distribution of FDG. Coronal FDG PET image shows physiologic uptake in the cerebral cortex, vocal cords (arrow), liver, kidneys, intestine, and urinary bladder. Also note the minimal uptake in the breasts, mediastinum, and bone marrow.

View larger version (100K): [in a new window]   Figure 2a.  Primary carcinoid nodule of the left upper lung. (a) Computed tomographic (CT) scan shows a 1.5-cm-diameter solitary pulmonary nodule (arrow) in the left upper lobe adjacent to the aortic arch. (b) Axial FDG PET image shows hypermetabolism in the lesion (arrow) (mean SUV = 1.9). Histologic evaluation demonstrated that the mass was a pulmonary carcinoid tumor.

View larger version (92K): [in a new window]   Figure 2b.  Primary carcinoid nodule of the left upper lung. (a) Computed tomographic (CT) scan shows a 1.5-cm-diameter solitary pulmonary nodule (arrow) in the left upper lobe adjacent to the aortic arch. (b) Axial FDG PET image shows hypermetabolism in the lesion (arrow) (mean SUV = 1.9). Histologic evaluation demonstrated that the mass was a pulmonary carcinoid tumor.

View larger version (71K): [in a new window]   Figure 3a.  NSCLC of the right upper lobe with metastatic involvement of the ipsilateral hilum, bilateral adrenal glands, and bone. Coronal FDG PET images show intense hypermetabolism in an NSCLC of the right upper lobe. Additional foci are seen in the right hilum (short arrow in b), bilateral adrenal glands (long arrows) (with greater activity in the right gland than in the left), and left acetabulum (arrowhead in b); these foci represent distant metastases.

View larger version (62K): [in a new window]   Figure 3b.  NSCLC of the right upper lobe with metastatic involvement of the ipsilateral hilum, bilateral adrenal glands, and bone. Coronal FDG PET images show intense hypermetabolism in an NSCLC of the right upper lobe. Additional foci are seen in the right hilum (short arrow in b), bilateral adrenal glands (long arrows) (with greater activity in the right gland than in the left), and left acetabulum (arrowhead in b); these foci represent distant metastases.

View larger version (112K): [in a new window]   Figure 4a.  NSCLC of the right upper lobe staged with FDG PET and CT. (a, b) Coronal FDG PET images show intense hypermetabolism in an NSCLC of the right upper lobe, as well as in right hilar, paratracheal, subcarinal, and right supraclavicular (arrow in b) lymph nodes. The original CT report mentioned all of these findings except the right supraclavicular node. (c) CT scan shows a large mass in the right upper lobe. (d) CT scan of the thoracic inlet shows right supraclavicular adenopathy (arrow), which was initially overlooked, thus changing the stage from 3A (potential surgical candidate) before FDG PET to 3B (inoperable disease) after FDG PET.

View larger version (109K): [in a new window]   Figure 4b.  NSCLC of the right upper lobe staged with FDG PET and CT. (a, b) Coronal FDG PET images show intense hypermetabolism in an NSCLC of the right upper lobe, as well as in right hilar, paratracheal, subcarinal, and right supraclavicular (arrow in b) lymph nodes. The original CT report mentioned all of these findings except the right supraclavicular node. (c) CT scan shows a large mass in the right upper lobe. (d) CT scan of the thoracic inlet shows right supraclavicular adenopathy (arrow), which was initially overlooked, thus changing the stage from 3A (potential surgical candidate) before FDG PET to 3B (inoperable disease) after FDG PET.

View larger version (99K): [in a new window]   Figure 4c.  NSCLC of the right upper lobe staged with FDG PET and CT. (a, b) Coronal FDG PET images show intense hypermetabolism in an NSCLC of the right upper lobe, as well as in right hilar, paratracheal, subcarinal, and right supraclavicular (arrow in b) lymph nodes. The original CT report mentioned all of these findings except the right supraclavicular node. (c) CT scan shows a large mass in the right upper lobe. (d) CT scan of the thoracic inlet shows right supraclavicular adenopathy (arrow), which was initially overlooked, thus changing the stage from 3A (potential surgical candidate) before FDG PET to 3B (inoperable disease) after FDG PET.

View larger version (119K): [in a new window]   Figure 4d.  NSCLC of the right upper lobe staged with FDG PET and CT. (a, b) Coronal FDG PET images show intense hypermetabolism in an NSCLC of the right upper lobe, as well as in right hilar, paratracheal, subcarinal, and right supraclavicular (arrow in b) lymph nodes. The original CT report mentioned all of these findings except the right supraclavicular node. (c) CT scan shows a large mass in the right upper lobe. (d) CT scan of the thoracic inlet shows right supraclavicular adenopathy (arrow), which was initially overlooked, thus changing the stage from 3A (potential surgical candidate) before FDG PET to 3B (inoperable disease) after FDG PET.

View larger version (83K): [in a new window]   Figure 5a.  Large cell lung cancer in a 71-year-old woman. (a) Pretherapy coronal FDG PET image shows intense hypermetabolism in a lung neoplasm in the superior segment of the left lower lobe, as well as in the bilateral hilar and mediastinal lymph nodes. (b) FDG PET image obtained 4 months after therapy shows normal FDG distribution with physiologic uptake in the heart, renal collecting system, intestine, and bladder.

View larger version (76K): [in a new window]   Figure 5b.  Large cell lung cancer in a 71-year-old woman. (a) Pretherapy coronal FDG PET image shows intense hypermetabolism in a lung neoplasm in the superior segment of the left lower lobe, as well as in the bilateral hilar and mediastinal lymph nodes. (b) FDG PET image obtained 4 months after therapy shows normal FDG distribution with physiologic uptake in the heart, renal collecting system, intestine, and bladder.

View larger version (81K): [in a new window]   Figure 6a.  NSCLC of the left parahilar region evaluated with FDG PET before and after therapy (left pneumonectomy and radiation therapy). (a) Pretherapy coronal FDG PET image shows left parahilar hypermetabolism in an NSCLC (arrow). (b) FDG PET image obtained 8 months after therapy shows multiple new hypermetabolic foci in the aortopulmonary window, subcarinal, and right-sided lymph nodes, findings consistent with progression of disease.

View larger version (84K): [in a new window]   Figure 6b.  NSCLC of the left parahilar region evaluated with FDG PET before and after therapy (left pneumonectomy and radiation therapy). (a) Pretherapy coronal FDG PET image shows left parahilar hypermetabolism in an NSCLC (arrow). (b) FDG PET image obtained 8 months after therapy shows multiple new hypermetabolic foci in the aortopulmonary window, subcarinal, and right-sided lymph nodes, findings consistent with progression of disease.

View larger version (81K): [in a new window]   Figure 7a.  NSCLC treated with radiation therapy and followed up with posttherapy FDG PET. (a, b) Projection and coronal FDG PET images show midesophageal activity secondary to radiation esophagitis (arrow). In addition, there is asymmetric activity in the laryngeal muscles (arrowhead in a), which is decreased on the left side secondary to paralysis of the vocal cord and disruption of the left recurrent laryngeal nerve. (c) Sagittal FDG PET image shows decreased activity in the marrow of the thoracic spine (arrowheads) secondary to radiation therapy.

View larger version (73K): [in a new window]   Figure 7b.  NSCLC treated with radiation therapy and followed up with posttherapy FDG PET. (a, b) Projection and coronal FDG PET images show midesophageal activity secondary to radiation esophagitis (arrow). In addition, there is asymmetric activity in the laryngeal muscles (arrowhead in a), which is decreased on the left side secondary to paralysis of the vocal cord and disruption of the left recurrent laryngeal nerve. (c) Sagittal FDG PET image shows decreased activity in the marrow of the thoracic spine (arrowheads) secondary to radiation therapy.

View larger version (53K): [in a new window]   Figure 7c.  NSCLC treated with radiation therapy and followed up with posttherapy FDG PET. (a, b) Projection and coronal FDG PET images show midesophageal activity secondary to radiation esophagitis (arrow). In addition, there is asymmetric activity in the laryngeal muscles (arrowhead in a), which is decreased on the left side secondary to paralysis of the vocal cord and disruption of the left recurrent laryngeal nerve. (c) Sagittal FDG PET image shows decreased activity in the marrow of the thoracic spine (arrowheads) secondary to radiation therapy.

View larger version (111K): [in a new window]   Figure 8a.  Colorectal carcinoma with a solitary hepatic metastasis in the left lobe. The metastasis was treated with radio-frequency ablation; FDG PET and CT were performed to evaluate the response to therapy. (a) Posttherapy CT scan shows a low-attenuation lesion with deformity and central increased attenuation (arrow) secondary to the radio-frequency ablation. (b) Baseline FDG PET image shows hypermetabolism in the metastasis (arrow). (c) Posttherapy FDG PET image shows only partial ablation of the lesion medially with residual metabolism noted laterally (arrow).

View larger version (92K): [in a new window]   Figure 8b.  Colorectal carcinoma with a solitary hepatic metastasis in the left lobe. The metastasis was treated with radio-frequency ablation; FDG PET and CT were performed to evaluate the response to therapy. (a) Posttherapy CT scan shows a low-attenuation lesion with deformity and central increased attenuation (arrow) secondary to the radio-frequency ablation. (b) Baseline FDG PET image shows hypermetabolism in the metastasis (arrow). (c) Posttherapy FDG PET image shows only partial ablation of the lesion medially with residual metabolism noted laterally (arrow).

View larger version (89K): [in a new window]   Figure 8c.  Colorectal carcinoma with a solitary hepatic metastasis in the left lobe. The metastasis was treated with radio-frequency ablation; FDG PET and CT were performed to evaluate the response to therapy. (a) Posttherapy CT scan shows a low-attenuation lesion with deformity and central increased attenuation (arrow) secondary to the radio-frequency ablation. (b) Baseline FDG PET image shows hypermetabolism in the metastasis (arrow). (c) Posttherapy FDG PET image shows only partial ablation of the lesion medially with residual metabolism noted laterally (arrow).

View larger version (133K): [in a new window]   Figure 9a.  Colorectal carcinoma in a 78-year-old man who underwent surgical resection. CT and FDG PET were performed for evaluation of recurrence. (a) CT scan shows a presacral soft-tissue mass (arrow), but it is difficult to determine whether this finding represents postoperative fibrosis or tumor recurrence. (b) Axial FDG PET image shows circumferential hypermetabolism in the presacral space (solid arrow), which represents recurrent tumor (proved at biopsy) with central necrosis. Normal bladder activity is noted anteriorly (arrow with dotted tail). FDG PET can help identify the optimal site for biopsy within a mass by highlighting the area of maximum tumor activity.

View larger version (77K): [in a new window]   Figure 9b.  Colorectal carcinoma in a 78-year-old man who underwent surgical resection. CT and FDG PET were performed for evaluation of recurrence. (a) CT scan shows a presacral soft-tissue mass (arrow), but it is difficult to determine whether this finding represents postoperative fibrosis or tumor recurrence. (b) Axial FDG PET image shows circumferential hypermetabolism in the presacral space (solid arrow), which represents recurrent tumor (proved at biopsy) with central necrosis. Normal bladder activity is noted anteriorly (arrow with dotted tail). FDG PET can help identify the optimal site for biopsy within a mass by highlighting the area of maximum tumor activity.

View larger version (102K): [in a new window]   Figure 10a.  Colorectal carcinoma in a 42-year-old man who underwent resection of colon cancer; the patient was undergoing chemotherapy for multiple hepatic metastases. Initial and follow-up FDG PET was performed to evaluate the response to therapy. (a) Pretherapy coronal FDG PET images show new metastases in the right lobe (arrows and small arrowhead) and left lobe (large arrowhead) of the liver. (b) Coronal FDG PET images obtained 5 months after therapy show increased intensity in the right lobe metastases (arrows and arrowhead) and resolution of the left lobe metastasis.

View larger version (98K): [in a new window]   Figure 10b.  Colorectal carcinoma in a 42-year-old man who underwent resection of colon cancer; the patient was undergoing chemotherapy for multiple hepatic metastases. Initial and follow-up FDG PET was performed to evaluate the response to therapy. (a) Pretherapy coronal FDG PET images show new metastases in the right lobe (arrows and small arrowhead) and left lobe (large arrowhead) of the liver. (b) Coronal FDG PET images obtained 5 months after therapy show increased intensity in the right lobe metastases (arrows and arrowhead) and resolution of the left lobe metastasis.

View larger version (130K): [in a new window]   Figure 11a.  Colorectal carcinoma in a 55-year-old man who underwent tumor resection and in whom recurrence was clinically suspected. FDG PET was performed to evaluate the extent of disease; CT showed no evidence of recurrence. (a) Anterior (left) and posterior (right) coronal FDG PET images show intense hypermetabolism in the left side of the midabdomen (solid arrow), a finding consistent with tumor recurrence. In addition, a subtle nonspecific focus is seen in the liver (arrow with dotted tail). (b) Axial FDG PET image shows the focus of intense hypermetabolism in the left side of the abdomen (arrow). (c) CT scan shows soft-tissue attenuation adjacent to the pancreatic tail (arrow) with adjacent stranding, an appearance consistent with tumor recurrence. In retrospect, this appearance corresponded to the FDG PET finding.

View larger version (89K): [in a new window]   Figure 11b.  Colorectal carcinoma in a 55-year-old man who underwent tumor resection and in whom recurrence was clinically suspected. FDG PET was performed to evaluate the extent of disease; CT showed no evidence of recurrence. (a) Anterior (left) and posterior (right) coronal FDG PET images show intense hypermetabolism in the left side of the midabdomen (solid arrow), a finding consistent with tumor recurrence. In addition, a subtle nonspecific focus is seen in the liver (arrow with dotted tail). (b) Axial FDG PET image shows the focus of intense hypermetabolism in the left side of the abdomen (arrow). (c) CT scan shows soft-tissue attenuation adjacent to the pancreatic tail (arrow) with adjacent stranding, an appearance consistent with tumor recurrence. In retrospect, this appearance corresponded to the FDG PET finding.

View larger version (138K): [in a new window]   Figure 11c.  Colorectal carcinoma in a 55-year-old man who underwent tumor resection and in whom recurrence was clinically suspected. FDG PET was performed to evaluate the extent of disease; CT showed no evidence of recurrence. (a) Anterior (left) and posterior (right) coronal FDG PET images show intense hypermetabolism in the left side of the midabdomen (solid arrow), a finding consistent with tumor recurrence. In addition, a subtle nonspecific focus is seen in the liver (arrow with dotted tail). (b) Axial FDG PET image shows the focus of intense hypermetabolism in the left side of the abdomen (arrow). (c) CT scan shows soft-tissue attenuation adjacent to the pancreatic tail (arrow) with adjacent stranding, an appearance consistent with tumor recurrence. In retrospect, this appearance corresponded to the FDG PET finding.

View larger version (93K): [in a new window]   Figure 12a.  Colorectal carcinoma in a 35-year-old man who underwent resection and in whom the level of carcinoembryonic antigen was rising. CT was originally performed, as there was no evidence of metastases. FDG PET was performed to detect a possible site of recurrence. (a, b) Coronal (a) and axial (b) FDG PET images show a subtle focus of hypermetabolism in the left lower quadrant of the abdomen (arrow in a, arrowhead in b). Findings from rotating three-dimensional (cine) images (not shown) strongly suggested extraluminal uptake. (c) CT scan shows subtle increased attenuation in the mesentery (arrow and arrowhead), which was identified only in retrospect after correlation with the FDG PET scan. The surgical decision was based solely on the FDG PET findings. Surgical exploration yielded recurrent metastatic peritoneal implants in the area of FDG uptake. FDG PET in conjunction with anatomic imaging can significantly assist location of early tumor recurrence by guiding exploratory surgery.

View larger version (91K): [in a new window]   Figure 12b.  Colorectal carcinoma in a 35-year-old man who underwent resection and in whom the level of carcinoembryonic antigen was rising. CT was originally performed, as there was no evidence of metastases. FDG PET was performed to detect a possible site of recurrence. (a, b) Coronal (a) and axial (b) FDG PET images show a subtle focus of hypermetabolism in the left lower quadrant of the abdomen (arrow in a, arrowhead in b). Findings from rotating three-dimensional (cine) images (not shown) strongly suggested extraluminal uptake. (c) CT scan shows subtle increased attenuation in the mesentery (arrow and arrowhead), which was identified only in retrospect after correlation with the FDG PET scan. The surgical decision was based solely on the FDG PET findings. Surgical exploration yielded recurrent metastatic peritoneal implants in the area of FDG uptake. FDG PET in conjunction with anatomic imaging can significantly assist location of early tumor recurrence by guiding exploratory surgery.

View larger version (111K): [in a new window]   Figure 12c.  Colorectal carcinoma in a 35-year-old man who underwent resection and in whom the level of carcinoembryonic antigen was rising. CT was originally performed, as there was no evidence of metastases. FDG PET was performed to detect a possible site of recurrence. (a, b) Coronal (a) and axial (b) FDG PET images show a subtle focus of hypermetabolism in the left lower quadrant of the abdomen (arrow in a, arrowhead in b). Findings from rotating three-dimensional (cine) images (not shown) strongly suggested extraluminal uptake. (c) CT scan shows subtle increased attenuation in the mesentery (arrow and arrowhead), which was identified only in retrospect after correlation with the FDG PET scan. The surgical decision was based solely on the FDG PET findings. Surgical exploration yielded recurrent metastatic peritoneal implants in the area of FDG uptake. FDG PET in conjunction with anatomic imaging can significantly assist location of early tumor recurrence by guiding exploratory surgery.

View larger version (74K): [in a new window]   Figure 13.  Hodgkin disease. After chemotherapy, FDG PET was performed to evaluate the response to therapy. Posttherapy coronal FDG PET image shows diffusely increased activity in the marrow of the axial and appendicular skeleton, a finding consistent with reactive bone marrow.

View larger version (97K): [in a new window]   Figure 14a.  Non-Hodgkin lymphoma in the mediastinum in a 29-year-old man. After chemotherapy, FDG PET was performed to evaluate the response to therapy. (a) Posttherapy CT scan shows a residual mediastinal mass (arrow). (b) Coronal FDG PET image shows circumferential hypermetabolism in the region of the mass with central absence of activity (arrows), an appearance consistent with residual lymphoma and central necrosis.

View larger version (104K): [in a new window]   Figure 14b.  Non-Hodgkin lymphoma in the mediastinum in a 29-year-old man. After chemotherapy, FDG PET was performed to evaluate the response to therapy. (a) Posttherapy CT scan shows a residual mediastinal mass (arrow). (b) Coronal FDG PET image shows circumferential hypermetabolism in the region of the mass with central absence of activity (arrows), an appearance consistent with residual lymphoma and central necrosis.

View larger version (93K): [in a new window]   Figure 15a.  Hodgkin disease involving the mediastinal and right cervical lymph nodes. (a, b) CT scans of the neck (a) and chest (b) show marked adenopathy of the right side of the neck and the mediastinum. (c) Coronal FDG PET image shows multiple foci of intense hypermetabolism in the right cervical lymph nodes and mediastinal lymph nodes (with greater activity on the right side than on the left), which represent extensive nodal involvement. (d) CT scan obtained 2 months after chemotherapy shows a persistent right mediastinal mass. It is not possible to determine whether it represents posttherapy fibrosis or residual tumor. (e) Contemporaneous FDG PET image shows resolution of the previously noted intense uptake seen in c, with no evidence of residual tumor.

View larger version (89K): [in a new window]   Figure 15b.  Hodgkin disease involving the mediastinal and right cervical lymph nodes. (a, b) CT scans of the neck (a) and chest (b) show marked adenopathy of the right side of the neck and the mediastinum. (c) Coronal FDG PET image shows multiple foci of intense hypermetabolism in the right cervical lymph nodes and mediastinal lymph nodes (with greater activity on the right side than on the left), which represent extensive nodal involvement. (d) CT scan obtained 2 months after chemotherapy shows a persistent right mediastinal mass. It is not possible to determine whether it represents posttherapy fibrosis or residual tumor. (e) Contemporaneous FDG PET image shows resolution of the previously noted intense uptake seen in c, with no evidence of residual tumor.

View larger version (72K): [in a new window]   Figure 15c.  Hodgkin disease involving the mediastinal and right cervical lymph nodes. (a, b) CT scans of the neck (a) and chest (b) show marked adenopathy of the right side of the neck and the mediastinum. (c) Coronal FDG PET image shows multiple foci of intense hypermetabolism in the right cervical lymph nodes and mediastinal lymph nodes (with greater activity on the right side than on the left), which represent extensive nodal involvement. (d) CT scan obtained 2 months after chemotherapy shows a persistent right mediastinal mass. It is not possible to determine whether it represents posttherapy fibrosis or residual tumor. (e) Contemporaneous FDG PET image shows resolution of the previously noted intense uptake seen in c, with no evidence of residual tumor.

View larger version (88K): [in a new window]   Figure 15d.  Hodgkin disease involving the mediastinal and right cervical lymph nodes. (a, b) CT scans of the neck (a) and chest (b) show marked adenopathy of the right side of the neck and the mediastinum. (c) Coronal FDG PET image shows multiple foci of intense hypermetabolism in the right cervical lymph nodes and mediastinal lymph nodes (with greater activity on the right side than on the left), which represent extensive nodal involvement. (d) CT scan obtained 2 months after chemotherapy shows a persistent right mediastinal mass. It is not possible to determine whether it represents posttherapy fibrosis or residual tumor. (e) Contemporaneous FDG PET image shows resolution of the previously noted intense uptake seen in c, with no evidence of residual tumor.

View larger version (88K): [in a new window]   Figure 15e.  Hodgkin disease involving the mediastinal and right cervical lymph nodes. (a, b) CT scans of the neck (a) and chest (b) show marked adenopathy of the right side of the neck and the mediastinum. (c) Coronal FDG PET image shows multiple foci of intense hypermetabolism in the right cervical lymph nodes and mediastinal lymph nodes (with greater activity on the right side than on the left), which represent extensive nodal involvement. (d) CT scan obtained 2 months after chemotherapy shows a persistent right mediastinal mass. It is not possible to determine whether it represents posttherapy fibrosis or residual tumor. (e) Contemporaneous FDG PET image shows resolution of the previously noted intense uptake seen in c, with no evidence of residual tumor.

View larger version (90K): [in a new window]   Figure 16a.  Non-Hodgkin lymphoma in a 45-year-old woman. FDG PET was performed with a dual-head coincidence camera before and after the first cycle of chemotherapy. (a) Pretherapy coronal FDG PET image shows uptake in right mediastinal lymph nodes (arrows), which is consistent with lymphoma. Note the physiologic uptake in the heart. (b) FDG PET image obtained after one cycle of chemotherapy shows no evidence of residual disease. The patient is still in remission with a progression-free survival of 24 months.

View larger version (85K): [in a new window]   Figure 16b.  Non-Hodgkin lymphoma in a 45-year-old woman. FDG PET was performed with a dual-head coincidence camera before and after the first cycle of chemotherapy. (a) Pretherapy coronal FDG PET image shows uptake in right mediastinal lymph nodes (arrows), which is consistent with lymphoma. Note the physiologic uptake in the heart. (b) FDG PET image obtained after one cycle of chemotherapy shows no evidence of residual disease. The patient is still in remission with a progression-free survival of 24 months.

View larger version (98K): [in a new window]   Figure 17.  Hodgkin disease evaluated with FDG PET after therapy. Coronal FDG PET image shows diffuse, homogeneous, bilobed mediastinal activity in the region of the thymus (arrows), a finding consistent with thymic rebound. The patient is currently free of disease. Tumor involvement is usually more focal and heterogeneous.

View larger version (82K): [in a new window]   Figure 18a.  Adenocarcinoma of the distal esophagus. FDG PET was performed to evaluate the extent of disease. Coronal (a), axial (b), and sagittal (c) FDG PET images show intense hypermetabolism in the distal esophagus (arrow), which corresponds to a malignant tumor. There is no evidence of metastases, although it is difficult to evaluate the locoregional lymph nodes in the vicinity of the primary tumor because of the intense uptake within the tumor.

View larger version (64K): [in a new window]   Figure 18b.  Adenocarcinoma of the distal esophagus. FDG PET was performed to evaluate the extent of disease. Coronal (a), axial (b), and sagittal (c) FDG PET images show intense hypermetabolism in the distal esophagus (arrow), which corresponds to a malignant tumor. There is no evidence of metastases, although it is difficult to evaluate the locoregional lymph nodes in the vicinity of the primary tumor because of the intense uptake within the tumor.

View larger version (83K): [in a new window]   Figure 18c.  Adenocarcinoma of the distal esophagus. FDG PET was performed to evaluate the extent of disease. Coronal (a), axial (b), and sagittal (c) FDG PET images show intense hypermetabolism in the distal esophagus (arrow), which corresponds to a malignant tumor. There is no evidence of metastases, although it is difficult to evaluate the locoregional lymph nodes in the vicinity of the primary tumor because of the intense uptake within the tumor.

View larger version (74K): [in a new window]   Figure 19.  Squamous cell cancer of the midesophagus. Coronal FDG PET images show intense hypermetabolism in the midesophagus (black arrow), which corresponds to the primary tumor. There are extensive metastases in the mediastinal, supraclavicular, and epicardial lymph nodes (white arrows).

View larger version (108K): [in a new window]   Figure 20a.  Primary rectal melanoma in a 68-year-old woman. CT and FDG PET were performed to evaluate the extent of disease. (a) CT scan shows no evidence of metastases. (CT was performed to study the abdomen and pelvis only.) (b) Coronal FDG PET image obtained within 2 weeks of the CT study shows multiple hepatic and bilateral lung metastases.

View larger version (91K): [in a new window]   Figure 20b.  Primary rectal melanoma in a 68-year-old woman. CT and FDG PET were performed to evaluate the extent of disease. (a) CT scan shows no evidence of metastases. (CT was performed to study the abdomen and pelvis only.) (b) Coronal FDG PET image obtained within 2 weeks of the CT study shows multiple hepatic and bilateral lung metastases.

View larger version (70K): [in a new window]   Figure 21a.  Primary vulvar melanoma in a 61-year-old woman who experienced recurrence. Anterior (a) and posterior (b) coronal FDG PET images show multiple foci of hypermetabolism in the left inguinal, pelvic, perineal, and mesenteric lymph nodes, which represent extensive locoregional recurrence of melanoma.

View larger version (74K): [in a new window]   Figure 21b.  Primary vulvar melanoma in a 61-year-old woman who experienced recurrence. Anterior (a) and posterior (b) coronal FDG PET images show multiple foci of hypermetabolism in the left inguinal, pelvic, perineal, and mesenteric lymph nodes, which represent extensive locoregional recurrence of melanoma.

View larger version (108K): [in a new window]   Figure 22a.  Supraglottic cancer in a 66-year-old man with a metastasis in a left cervical lymph node. (a, b) Axial (a) and coronal (b) FDG PET images show hypermetabolism in a supraglottic cancer (white arrow, arrow with dotted tail) and involvement of a level II left cervical lymph node (solid black arrow) with no other evidence of metastases. (c, d) Axial CT scans show the supraglottic mass (c) and the involved lymph node (d).

View larger version (95K): [in a new window]   Figure 22b.  Supraglottic cancer in a 66-year-old man with a metastasis in a left cervical lymph node. (a, b) Axial (a) and coronal (b) FDG PET images show hypermetabolism in a supraglottic cancer (white arrow, arrow with dotted tail) and involvement of a level II left cervical lymph node (solid black arrow) with no other evidence of metastases. (c, d) Axial CT scans show the supraglottic mass (c) and the involved lymph node (d).

View larger version (101K): [in a new window]   Figure 22c.  Supraglottic cancer in a 66-year-old man with a metastasis in a left cervical lymph node. (a, b) Axial (a) and coronal (b) FDG PET images show hypermetabolism in a supraglottic cancer (white arrow, arrow with dotted tail) and involvement of a level II left cervical lymph node (solid black arrow) with no other evidence of metastases. (c, d) Axial CT scans show the supraglottic mass (c) and the involved lymph node (d).

View larger version (133K): [in a new window]   Figure 22d.  Supraglottic cancer in a 66-year-old man with a metastasis in a left cervical lymph node. (a, b) Axial (a) and coronal (b) FDG PET images show hypermetabolism in a supraglottic cancer (white arrow, arrow with dotted tail) and involvement of a level II left cervical lymph node (solid black arrow) with no other evidence of metastases. (c, d) Axial CT scans show the supraglottic mass (c) and the involved lymph node (d).

View larger version (102K): [in a new window]   Figure 23a.  Cancer of the tongue in a 70-year-old man who underwent treatment for locoregional nodal recurrence. FDG PET was performed to evaluate the response to treatment. (a) CT scan shows a low-attenuation lesion in the right submandibular region (arrow). (b) Axial FDG PET image shows circumferential activity with central absence of activity (arrow), findings consistent with tumor recurrence and central necrosis.

View larger version (49K): [in a new window]   Figure 23b.  Cancer of the tongue in a 70-year-old man who underwent treatment for locoregional nodal recurrence. FDG PET was performed to evaluate the response to treatment. (a) CT scan shows a low-attenuation lesion in the right submandibular region (arrow). (b) Axial FDG PET image shows circumferential activity with central absence of activity (arrow), findings consistent with tumor recurrence and central necrosis.

View larger version (74K): [in a new window]   Figure 24a.  Supraglottic cancer in a 66-year-old man with a metastasis in a left cervical lymph node (same patient as in Fig 22). FDG PET was performed before treatment and 7 months after treatment. (a) Initial coronal FDG PET image shows uptake in a supraglottic cancer (arrow with dotted tail) and a left cervical lymph node (solid arrow). (b) Posttherapy FDG PET image shows resolution of focal hypermetabolism in the supraglottic cancer and left cervical lymph node. The mild diffuse and linear activity represents postoperative changes and muscle spasms in the sternocleidomastoid muscles (arrowheads).

View larger version (76K): [in a new window]   Figure 24b.  Supraglottic cancer in a 66-year-old man with a metastasis in a left cervical lymph node (same patient as in Fig 22). FDG PET was performed before treatment and 7 months after treatment. (a) Initial coronal FDG PET image shows uptake in a supraglottic cancer (arrow with dotted tail) and a left cervical lymph node (solid arrow). (b) Posttherapy FDG PET image shows resolution of focal hypermetabolism in the supraglottic cancer and left cervical lymph node. The mild diffuse and linear activity represents postoperative changes and muscle spasms in the sternocleidomastoid muscles (arrowheads).

View larger version (116K): [in a new window]   Figure 25a.  Intraductal carcinoma of the left breast in a 34-year-old woman with biopsy-proved metastases of the left axillary lymph nodes. FDG PET was performed to determine the presence of any extranodal metastases. (a, b) Coronal FDG PET images show mild hypermetabolism in involved left axillary lymph nodes (arrow in a) and more intense hypermetabolism in the right upper thoracic paraspinal region (arrow in b), a finding highly suspicious for a metastasis. No abnormality was reported at staging CT. The patient did not have back pain. (c) Posterior bone scan shows no abnormal uptake in the corresponding region (false-negative finding). (d) Follow-up axial T1-weighted MR image obtained at the level of the FDG uptake shows abnormal signal intensity in the right transverse process of the T3 vertebra (arrow), an appearance consistent with metastatic disease. The patient’s chemotherapy was intensified due to the unexpected FDG PET finding. Correlative imaging of the metastasis to T3 was performed. (e) CT scan shows a subtle area of decreased attenuation in the right transverse process of T3 (arrow), a finding that was initially overlooked. This finding corresponds to the abnormality seen at FDG PET.

View larger version (104K): [in a new window]   Figure 25b.  Intraductal carcinoma of the left breast in a 34-year-old woman with biopsy-proved metastases of the left axillary lymph nodes. FDG PET was performed to determine the presence of any extranodal metastases. (a, b) Coronal FDG PET images show mild hypermetabolism in involved left axillary lymph nodes (arrow in a) and more intense hypermetabolism in the right upper thoracic paraspinal region (arrow in b), a finding highly suspicious for a metastasis. No abnormality was reported at staging CT. The patient did not have back pain. (c) Posterior bone scan shows no abnormal uptake in the corresponding region (false-negative finding). (d) Follow-up axial T1-weighted MR image obtained at the level of the FDG uptake shows abnormal signal intensity in the right transverse process of the T3 vertebra (arrow), an appearance consistent with metastatic disease. The patient’s chemotherapy was intensified due to the unexpected FDG PET finding. Correlative imaging of the metastasis to T3 was performed. (e) CT scan shows a subtle area of decreased attenuation in the right transverse process of T3 (arrow), a finding that was initially overlooked. This finding corresponds to the abnormality seen at FDG PET.

View larger version (115K): [in a new window]   Figure 25c.  Intraductal carcinoma of the left breast in a 34-year-old woman with biopsy-proved metastases of the left axillary lymph nodes. FDG PET was performed to determine the presence of any extranodal metastases. (a, b) Coronal FDG PET images show mild hypermetabolism in involved left axillary lymph nodes (arrow in a) and more intense hypermetabolism in the right upper thoracic paraspinal region (arrow in b), a finding highly suspicious for a metastasis. No abnormality was reported at staging CT. The patient did not have back pain. (c) Posterior bone scan shows no abnormal uptake in the corresponding region (false-negative finding). (d) Follow-up axial T1-weighted MR image obtained at the level of the FDG uptake shows abnormal signal intensity in the right transverse process of the T3 vertebra (arrow), an appearance consistent with metastatic disease. The patient’s chemotherapy was intensified due to the unexpected FDG PET finding. Correlative imaging of the metastasis to T3 was performed. (e) CT scan shows a subtle area of decreased attenuation in the right transverse process of T3 (arrow), a finding that was initially overlooked. This finding corresponds to the abnormality seen at FDG PET.

View larger version (107K): [in a new window]   Figure 25d.  Intraductal carcinoma of the left breast in a 34-year-old woman with biopsy-proved metastases of the left axillary lymph nodes. FDG PET was performed to determine the presence of any extranodal metastases. (a, b) Coronal FDG PET images show mild hypermetabolism in involved left axillary lymph nodes (arrow in a) and more intense hypermetabolism in the right upper thoracic paraspinal region (arrow in b), a finding highly suspicious for a metastasis. No abnormality was reported at staging CT. The patient did not have back pain. (c) Posterior bone scan shows no abnormal uptake in the corresponding region (false-negative finding). (d) Follow-up axial T1-weighted MR image obtained at the level of the FDG uptake shows abnormal signal intensity in the right transverse process of the T3 vertebra (arrow), an appearance consistent with metastatic disease. The patient’s chemotherapy was intensified due to the unexpected FDG PET finding. Correlative imaging of the metastasis to T3 was performed. (e) CT scan shows a subtle area of decreased attenuation in the right transverse process of T3 (arrow), a finding that was initially overlooked. This finding corresponds to the abnormality seen at FDG PET.

View larger version (99K): [in a new window]   Figure 25e.  Intraductal carcinoma of the left breast in a 34-year-old woman with biopsy-proved metastases of the left axillary lymph nodes. FDG PET was performed to determine the presence of any extranodal metastases. (a, b) Coronal FDG PET images show mild hypermetabolism in involved left axillary lymph nodes (arrow in a) and more intense hypermetabolism in the right upper thoracic paraspinal region (arrow in b), a finding highly suspicious for a metastasis. No abnormality was reported at staging CT. The patient did not have back pain. (c) Posterior bone scan shows no abnormal uptake in the corresponding region (false-negative finding). (d) Follow-up axial T1-weighted MR image obtained at the level of the FDG uptake shows abnormal signal intensity in the right transverse process of the T3 vertebra (arrow), an appearance consistent with metastatic disease. The patient’s chemotherapy was intensified due to the unexpected FDG PET finding. Correlative imaging of the metastasis to T3 was performed. (e) CT scan shows a subtle area of decreased attenuation in the right transverse process of T3 (arrow), a finding that was initially overlooked. This finding corresponds to the abnormality seen at FDG PET.

View larger version (46K): [in a new window]   Figure 26.  Intraductal carcinoma of the right breast in a 62-year-old woman with right axillary adenopathy. Axial FDG PET images (presented from anterior [top left] to posterior [bottom right]) show intense hypermetabolism in a large, diffuse carcinoma of the right breast with activity in the right axillary lymph nodes (arrow).

View larger version (91K): [in a new window]   Figure 27a.  Progressive metastatic breast cancer in the mediastinum in a 63-year-old woman with a history of intraductal breast carcinoma. Two FDG PET studies were performed at different times to evaluate the extent of disease. (a) Initial pretherapy follow-up coronal FDG PET image shows a focus of mild hypermetabolism in the right paratracheal region (arrow). (b) Repeat FDG PET image obtained 7 months later shows further increased activity in a right paratracheal lymph node (arrow) and new foci in the right subcarinal and left hilar regions, findings consistent with metastases. Note the variable uptake in the heart in the two images.

View larger version (94K): [in a new window]   Figure 27b.  Progressive metastatic breast cancer in the mediastinum in a 63-year-old woman with a history of intraductal breast carcinoma. Two FDG PET studies were performed at different times to evaluate the extent of disease. (a) Initial pretherapy follow-up coronal FDG PET image shows a focus of mild hypermetabolism in the right paratracheal region (arrow). (b) Repeat FDG PET image obtained 7 months later shows further increased activity in a right paratracheal lymph node (arrow) and new foci in the right subcarinal and left hilar regions, findings consistent with metastases. Note the variable uptake in the heart in the two images.