DOI: 10.1148/rg.241035078
PET-CT in Recurrent Ovarian Cancer: Initial Observations1
Harpreet K. Pannu, MD,
Robert E. Bristow, MD,
Christian Cohade, MD,
Elliot K. Fishman, MD and
Richard L. Wahl, MD
1 From the Russell H. Morgan Department of Radiology and Radiological Science (H.K.P., C.C., E.K.F., R.L.W.) and the Kelly Gynecologic Oncology Service (R.E.B.), Johns Hopkins Medical Institutions, 600 N Wolfe St, Baltimore, MD 21287. Presented as an education exhibit at the 2002 RSNA scientific assembly. R.L.W. is a stockholder in CTI Molecular Imaging, Knoxville, Tenn; he also has a research agreement with and has received honoraria from GE Medical Systems. Received March 24, 2003; revision requested April 22 and received August 11; accepted August 14. Address correspondence to H.K.P. (e-mail: hpannu1@jhmi.edu).
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Figure 1. Axial fused PET-CT scan shows normal FDG uptake in the left ventricular muscle.
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Figure 2. Coronal fused PET-CT scan shows normal FDG uptake in the renal collecting system. Activity is also seen in the brain, liver, and spleen.
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Figure 3. Coronal fused PET-CT scan shows normal faint activity in the bowel. Activity is also seen in the brain, heart, liver, and bladder.
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Figure 4a. Metastatic disease in a 46-year-old woman with a prior history of micropapillary serous ovarian cancer and an elevated serum CA-125 level (>8,000 U/mL). (a) CT scan demonstrates partially calcified masses in the left side of the pelvis (arrows) near the bowel and superior to the bladder. (b) Fused PET-CT scan shows increased activity in the area of the pelvic masses (arrows), a finding that is compatible with tumor.
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Figure 4b. Metastatic disease in a 46-year-old woman with a prior history of micropapillary serous ovarian cancer and an elevated serum CA-125 level (>8,000 U/mL). (a) CT scan demonstrates partially calcified masses in the left side of the pelvis (arrows) near the bowel and superior to the bladder. (b) Fused PET-CT scan shows increased activity in the area of the pelvic masses (arrows), a finding that is compatible with tumor.
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Figure 5a. Metastatic disease in the same patient as in Figure 4. (a) CT scan shows a calcified liver implant (arrow). (b) Fused PET-CT scan demonstrates an area of FDG uptake (arrow) that corresponds to the implant.
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Figure 5b. Metastatic disease in the same patient as in Figure 4. (a) CT scan shows a calcified liver implant (arrow). (b) Fused PET-CT scan demonstrates an area of FDG uptake (arrow) that corresponds to the implant.
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Figure 6a. Metastatic disease in a 57-year-old woman with a history of moderately differentiated ovarian carcinoma with serous and endometrioid features. (a) CT scan demonstrates a mass (arrow) with cystic central and solid peripheral components. (b) Fused PET-CT scan shows areas of increased activity (arrow) that are compatible with tumor.
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Figure 6b. Metastatic disease in a 57-year-old woman with a history of moderately differentiated ovarian carcinoma with serous and endometrioid features. (a) CT scan demonstrates a mass (arrow) with cystic central and solid peripheral components. (b) Fused PET-CT scan shows areas of increased activity (arrow) that are compatible with tumor.
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Figure 7a. Tumor implants in a 59-year-old woman with a history of moderately differentiated serous carcinoma. (a) CT scan shows small nodules in the sigmoid mesocolon (arrow) but no definite mass in the right side of the pelvis. (b) Fused PET-CT scan shows activity in the sigmoid nodules and superimposed on the cecum (arrows). Surgery revealed tumor at both sites.
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Figure 7b. Tumor implants in a 59-year-old woman with a history of moderately differentiated serous carcinoma. (a) CT scan shows small nodules in the sigmoid mesocolon (arrow) but no definite mass in the right side of the pelvis. (b) Fused PET-CT scan shows activity in the sigmoid nodules and superimposed on the cecum (arrows). Surgery revealed tumor at both sites.
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Figure 8a. Tumor implants in the same patient as in Figure 7. (a) CT scan shows minimal nodularity (arrow) that is adjacent to the unopacified transverse colon and is difficult to distinguish from adjacent bowel. No obvious mass is identified. (b) PET scan shows a small area of increased uptake in the midabdomen (arrow). (c) Fused PET-CT scan helps localize the increased activity seen at PET to the transverse colon (arrow), where small tumor nodules were found at surgery. (Fig 8 reprinted, with permission, from reference 41.)
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Figure 8b. Tumor implants in the same patient as in Figure 7. (a) CT scan shows minimal nodularity (arrow) that is adjacent to the unopacified transverse colon and is difficult to distinguish from adjacent bowel. No obvious mass is identified. (b) PET scan shows a small area of increased uptake in the midabdomen (arrow). (c) Fused PET-CT scan helps localize the increased activity seen at PET to the transverse colon (arrow), where small tumor nodules were found at surgery. (Fig 8 reprinted, with permission, from reference 41.)
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Figure 8c. Tumor implants in the same patient as in Figure 7. (a) CT scan shows minimal nodularity (arrow) that is adjacent to the unopacified transverse colon and is difficult to distinguish from adjacent bowel. No obvious mass is identified. (b) PET scan shows a small area of increased uptake in the midabdomen (arrow). (c) Fused PET-CT scan helps localize the increased activity seen at PET to the transverse colon (arrow), where small tumor nodules were found at surgery. (Fig 8 reprinted, with permission, from reference 41.)
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Figure 9a. Tumor implants in a 55-year-old woman with ovarian cancer and a rising serum CA-125 level. (a) CT scan demonstrates minimal nodularity in the left paracolic gutter (arrow), a finding that is suggestive of implants. (b) PET scan shows a linear area of slightly increased uptake in the same region (arrow) that may represent either normal bowel or implants. (c) Fused PET-CT scan demonstrates an area of increased activity (arrow) that corresponds to the nodules seen at CT and is suggestive of tumor implants.
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Figure 9b. Tumor implants in a 55-year-old woman with ovarian cancer and a rising serum CA-125 level. (a) CT scan demonstrates minimal nodularity in the left paracolic gutter (arrow), a finding that is suggestive of implants. (b) PET scan shows a linear area of slightly increased uptake in the same region (arrow) that may represent either normal bowel or implants. (c) Fused PET-CT scan demonstrates an area of increased activity (arrow) that corresponds to the nodules seen at CT and is suggestive of tumor implants.
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Figure 9c. Tumor implants in a 55-year-old woman with ovarian cancer and a rising serum CA-125 level. (a) CT scan demonstrates minimal nodularity in the left paracolic gutter (arrow), a finding that is suggestive of implants. (b) PET scan shows a linear area of slightly increased uptake in the same region (arrow) that may represent either normal bowel or implants. (c) Fused PET-CT scan demonstrates an area of increased activity (arrow) that corresponds to the nodules seen at CT and is suggestive of tumor implants.
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Figure 10a. Midabdominal tumor in a 46-year-old woman with a history of micropapillary serous ovarian cancer and an elevated serum CA-125 level (same patient as in Fig 4). (a) CT scan shows inhomogeneous distribution of oral contrast material, resulting in some small bowel loops being unopacified. (b) PET scan demonstrates an abdominal mass with increased uptake (arrow). (c) Fused PET-CT scan helps localize the mass (arrow) and allows differentiation of the tumor from adjacent bowel loops.
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Figure 10b. Midabdominal tumor in a 46-year-old woman with a history of micropapillary serous ovarian cancer and an elevated serum CA-125 level (same patient as in Fig 4). (a) CT scan shows inhomogeneous distribution of oral contrast material, resulting in some small bowel loops being unopacified. (b) PET scan demonstrates an abdominal mass with increased uptake (arrow). (c) Fused PET-CT scan helps localize the mass (arrow) and allows differentiation of the tumor from adjacent bowel loops.
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Figure 10c. Midabdominal tumor in a 46-year-old woman with a history of micropapillary serous ovarian cancer and an elevated serum CA-125 level (same patient as in Fig 4). (a) CT scan shows inhomogeneous distribution of oral contrast material, resulting in some small bowel loops being unopacified. (b) PET scan demonstrates an abdominal mass with increased uptake (arrow). (c) Fused PET-CT scan helps localize the mass (arrow) and allows differentiation of the tumor from adjacent bowel loops.
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Figure 11a. Metastatic disease to the chest in a 46-year-old woman with a history of micropapillary serous ovarian cancer and an elevated serum CA-125 level (same patient as in Fig 4). (a) CT scan shows a small right-sided pleural effusion and pleural thickening (arrow). (b) Fused PET-CT scan shows increased uptake in the right-sided pleura (arrow), a finding that is suggestive of malignancy.
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Figure 11b. Metastatic disease to the chest in a 46-year-old woman with a history of micropapillary serous ovarian cancer and an elevated serum CA-125 level (same patient as in Fig 4). (a) CT scan shows a small right-sided pleural effusion and pleural thickening (arrow). (b) Fused PET-CT scan shows increased uptake in the right-sided pleura (arrow), a finding that is suggestive of malignancy.
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Figure 12a. Metastatic mediastinal adenopathy in a 59-year-old woman with a history of poorly differentiated ovarian carcinoma with serous features. Fused PET-CT scans demonstrate enlarged nodes with increased uptake in the right paratracheal, bilateral hilar, subcarinal, and prevascular regions (arrows). The patient also had increasing abdominal disease at CT and a rising serum CA-125 level.
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Figure 12b. Metastatic mediastinal adenopathy in a 59-year-old woman with a history of poorly differentiated ovarian carcinoma with serous features. Fused PET-CT scans demonstrate enlarged nodes with increased uptake in the right paratracheal, bilateral hilar, subcarinal, and prevascular regions (arrows). The patient also had increasing abdominal disease at CT and a rising serum CA-125 level.
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Figure 13a. Malignant iliac nodes in a 46-year-old woman with a history of micropapillary serous ovarian cancer (same patient as in Fig 4). (a) PET scan shows increased uptake in the left side of the pelvis (arrow) that may represent either a bowel implant or a node. (b) CT scan demonstrates enlarged left iliac nodes (arrow). (c) Fused PET-CT scan shows activity in the left iliac nodes (arrow), which proved to be malignant at surgery. Note the misregistration due to bladder activity in the right side of the pelvis.
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Figure 13b. Malignant iliac nodes in a 46-year-old woman with a history of micropapillary serous ovarian cancer (same patient as in Fig 4). (a) PET scan shows increased uptake in the left side of the pelvis (arrow) that may represent either a bowel implant or a node. (b) CT scan demonstrates enlarged left iliac nodes (arrow). (c) Fused PET-CT scan shows activity in the left iliac nodes (arrow), which proved to be malignant at surgery. Note the misregistration due to bladder activity in the right side of the pelvis.
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Figure 13c. Malignant iliac nodes in a 46-year-old woman with a history of micropapillary serous ovarian cancer (same patient as in Fig 4). (a) PET scan shows increased uptake in the left side of the pelvis (arrow) that may represent either a bowel implant or a node. (b) CT scan demonstrates enlarged left iliac nodes (arrow). (c) Fused PET-CT scan shows activity in the left iliac nodes (arrow), which proved to be malignant at surgery. Note the misregistration due to bladder activity in the right side of the pelvis.
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Figure 14a. Increased uptake in a surgical incision in a 73-year-old woman who had undergone primary surgery for adenosarcoma of the ovary 4 weeks earlier. (a) CT scan demonstrates a surgical scar in the abdominal wall (arrow). (b, c) Axial (b) and sagittal (c) fused PET-CT scans demonstrate increased uptake in the abdominal wall (arrow), a finding that corresponds to the scar seen at CT. The increased activity is due to inflammatory change secondary to surgery.
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Figure 14b. Increased uptake in a surgical incision in a 73-year-old woman who had undergone primary surgery for adenosarcoma of the ovary 4 weeks earlier. (a) CT scan demonstrates a surgical scar in the abdominal wall (arrow). (b, c) Axial (b) and sagittal (c) fused PET-CT scans demonstrate increased uptake in the abdominal wall (arrow), a finding that corresponds to the scar seen at CT. The increased activity is due to inflammatory change secondary to surgery.
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Figure 14c. Increased uptake in a surgical incision in a 73-year-old woman who had undergone primary surgery for adenosarcoma of the ovary 4 weeks earlier. (a) CT scan demonstrates a surgical scar in the abdominal wall (arrow). (b, c) Axial (b) and sagittal (c) fused PET-CT scans demonstrate increased uptake in the abdominal wall (arrow), a finding that corresponds to the scar seen at CT. The increased activity is due to inflammatory change secondary to surgery.
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Figure 15a. Misregistration due to physiologic activity in a 57-year-old woman with a history of moderately differentiated ovarian carcinoma with serous and endometrioid features (same patient as in Fig 6). (a) PET scan shows increased uptake in the left side of the abdomen (arrow). (b) CT scan shows a small peritoneal implant in the left paracolic gutter (arrow). (c) Fused PET-CT scan shows activity superimposed on the stomach (arrow) and just medial to the actual location of the implant (arrowhead). The misregistration is due to peristalsis or respiratory motion. Activity in the right kidney is normal.
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Figure 15b. Misregistration due to physiologic activity in a 57-year-old woman with a history of moderately differentiated ovarian carcinoma with serous and endometrioid features (same patient as in Fig 6). (a) PET scan shows increased uptake in the left side of the abdomen (arrow). (b) CT scan shows a small peritoneal implant in the left paracolic gutter (arrow). (c) Fused PET-CT scan shows activity superimposed on the stomach (arrow) and just medial to the actual location of the implant (arrowhead). The misregistration is due to peristalsis or respiratory motion. Activity in the right kidney is normal.
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Figure 15c. Misregistration due to physiologic activity in a 57-year-old woman with a history of moderately differentiated ovarian carcinoma with serous and endometrioid features (same patient as in Fig 6). (a) PET scan shows increased uptake in the left side of the abdomen (arrow). (b) CT scan shows a small peritoneal implant in the left paracolic gutter (arrow). (c) Fused PET-CT scan shows activity superimposed on the stomach (arrow) and just medial to the actual location of the implant (arrowhead). The misregistration is due to peristalsis or respiratory motion. Activity in the right kidney is normal.
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Figure 16a. Misregistration due to physiologic bladder activity in a 58-year-old woman with intermediate to poorly differentiated Sertoli-Leydig cell tumor with heterologous elements. (a) CT scan shows a cystic mass in the left side of the pelvis (arrow). (b) Fused PET-CT scan shows activity in the right side of the pelvis (arrow). (c) CT scan obtained inferior to a reveals that the pelvic activity seen in b represents bladder activity secondary to misregistration due to respiratory motion and bladder filling (arrow). The lesion in the left side of the pelvis (cf a) represents a postoperative fluid collection and shows no activity.
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Figure 16b. Misregistration due to physiologic bladder activity in a 58-year-old woman with intermediate to poorly differentiated Sertoli-Leydig cell tumor with heterologous elements. (a) CT scan shows a cystic mass in the left side of the pelvis (arrow). (b) Fused PET-CT scan shows activity in the right side of the pelvis (arrow). (c) CT scan obtained inferior to a reveals that the pelvic activity seen in b represents bladder activity secondary to misregistration due to respiratory motion and bladder filling (arrow). The lesion in the left side of the pelvis (cf a) represents a postoperative fluid collection and shows no activity.
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Figure 16c. Misregistration due to physiologic bladder activity in a 58-year-old woman with intermediate to poorly differentiated Sertoli-Leydig cell tumor with heterologous elements. (a) CT scan shows a cystic mass in the left side of the pelvis (arrow). (b) Fused PET-CT scan shows activity in the right side of the pelvis (arrow). (c) CT scan obtained inferior to a reveals that the pelvic activity seen in b represents bladder activity secondary to misregistration due to respiratory motion and bladder filling (arrow). The lesion in the left side of the pelvis (cf a) represents a postoperative fluid collection and shows no activity.
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Figure 17a. Ureteral "enlargement" at PET. (a) On a CT scan, both ureters are normal in size (arrows). (b) PET scan shows intense but normal activity in the ureters (arrows), which causes the ureters to appear larger than they really are. (c) Fused PET-CT scan shows ureteric activity superimposed on the left psoas muscle (arrow).
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Figure 17b. Ureteral "enlargement" at PET. (a) On a CT scan, both ureters are normal in size (arrows). (b) PET scan shows intense but normal activity in the ureters (arrows), which causes the ureters to appear larger than they really are. (c) Fused PET-CT scan shows ureteric activity superimposed on the left psoas muscle (arrow).
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Figure 17c. Ureteral "enlargement" at PET. (a) On a CT scan, both ureters are normal in size (arrows). (b) PET scan shows intense but normal activity in the ureters (arrows), which causes the ureters to appear larger than they really are. (c) Fused PET-CT scan shows ureteric activity superimposed on the left psoas muscle (arrow).
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Copyright © 2004 by the Radiological Society of North America.
