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FDG PET in the Evaluation of Treatment for Lymphoma: Clinical Usefulness and Pitfalls¹

¹ From the Department of Radiology, Chiba University Hospital, 1-8-1 Inohana, Chuo-ku, Chiba 260-8677, Japan (T.K., H.I.); and the Division of Diagnostic Imaging, University of Texas M. D. Anderson Cancer Center, Houston, Tex (T.K., S.C.F., V.V., S.P., H.A.M.). Presented as an education exhibit at the 2003 RSNA Scientific Assembly. Received March 16, 2004; revision requested May 21 and received August 24; accepted August 26. H.A.M. is a member of the speakers’ bureau for Siemens and Cardinal Health and received a grant from GE Medical Systems. All remaining authors have no financial relationships to disclose. Address correspondence to T.K. (e-mail: kazamat@fg7.so-net.ne.jp).

View larger version (117K): [in a new window]   Figure 1a.  Residual mass with FDG uptake in a 76-year-old woman with non-Hodgkin lymphoma who had completed chemotherapy. (a) Chest CT scan shows residual soft-tissue attenuation in the mediastinum and right hilum. (b) Corresponding axial PET scan shows residual FDG uptake in the same location. The patient underwent salvage chemotherapy, but tumor relapse occurred.

View larger version (72K): [in a new window]   Figure 1b.  Residual mass with FDG uptake in a 76-year-old woman with non-Hodgkin lymphoma who had completed chemotherapy. (a) Chest CT scan shows residual soft-tissue attenuation in the mediastinum and right hilum. (b) Corresponding axial PET scan shows residual FDG uptake in the same location. The patient underwent salvage chemotherapy, but tumor relapse occurred.

View larger version (129K): [in a new window]   Figure 2a.  Residual mass without FDG uptake in a 72-year-old man who had just completed chemotherapy. (a) Abdominal CT scan shows residual nodules in the mesentery (arrow). (b) Corresponding axial PET scan shows no FDG uptake in the mesentery; however, physiologic uptake is seen in the intestinal tract (arrows). The patient remains free of disease.

View larger version (64K): [in a new window]   Figure 2b.  Residual mass without FDG uptake in a 72-year-old man who had just completed chemotherapy. (a) Abdominal CT scan shows residual nodules in the mesentery (arrow). (b) Corresponding axial PET scan shows no FDG uptake in the mesentery; however, physiologic uptake is seen in the intestinal tract (arrows). The patient remains free of disease.

View larger version (110K): [in a new window]   Figure 3a.  No increased FDG uptake at early evaluation in a 21-year-old man with Hodgkin disease who had undergone two cycles of chemotherapy. (a) Chest CT scan shows residual mediastinal lymphadenopathies (arrows). (b) Corresponding axial PET scan shows no increased uptake at the site of the mediastinal masses (arrows). Note, however, the uptake in the spine and sternum (arrowheads) due to granulocyte colony-stimulating factor (G-CSF) therapy. The patient remains disease free after completing chemotherapy.

View larger version (86K): [in a new window]   Figure 3b.  No increased FDG uptake at early evaluation in a 21-year-old man with Hodgkin disease who had undergone two cycles of chemotherapy. (a) Chest CT scan shows residual mediastinal lymphadenopathies (arrows). (b) Corresponding axial PET scan shows no increased uptake at the site of the mediastinal masses (arrows). Note, however, the uptake in the spine and sternum (arrowheads) due to granulocyte colony-stimulating factor (G-CSF) therapy. The patient remains disease free after completing chemotherapy.

View larger version (107K): [in a new window]   Figure 4a.  Residual increased FDG uptake at early evaluation in a 33-year-old woman with Hodgkin disease who had undergone one cycle of chemotherapy. (a) Axial CT scan shows a large right paramediastinal lesion. (b) Coronal PET scan shows increased FDG uptake (arrow) corresponding to the lesion seen in a. Note also the physiologic uptake in the myocardium and kidneys. Although the patient underwent intensive treatment, she had a poor prognosis.

View larger version (110K): [in a new window]   Figure 4b.  Residual increased FDG uptake at early evaluation in a 33-year-old woman with Hodgkin disease who had undergone one cycle of chemotherapy. (a) Axial CT scan shows a large right paramediastinal lesion. (b) Coronal PET scan shows increased FDG uptake (arrow) corresponding to the lesion seen in a. Note also the physiologic uptake in the myocardium and kidneys. Although the patient underwent intensive treatment, she had a poor prognosis.

View larger version (175K): [in a new window]   Figure 5a.  Enlarging lymph node without FDG uptake in a 70-year-old woman with non-Hodgkin lymphoma that had been in remission for 3 years. (a, b) Serial CT scans obtained 6 months apart show an enlarging lymph node in the peripancreatic region (arrow). (c) Corresponding axial PET scan shows no increased FDG uptake in the peripancreatic region. Note, however, the physiologic uptake in the kidneys and liver. The patient remains free of disease.

View larger version (176K): [in a new window]   Figure 5b.  Enlarging lymph node without FDG uptake in a 70-year-old woman with non-Hodgkin lymphoma that had been in remission for 3 years. (a, b) Serial CT scans obtained 6 months apart show an enlarging lymph node in the peripancreatic region (arrow). (c) Corresponding axial PET scan shows no increased FDG uptake in the peripancreatic region. Note, however, the physiologic uptake in the kidneys and liver. The patient remains free of disease.

View larger version (104K): [in a new window]   Figure 5c.  Enlarging lymph node without FDG uptake in a 70-year-old woman with non-Hodgkin lymphoma that had been in remission for 3 years. (a, b) Serial CT scans obtained 6 months apart show an enlarging lymph node in the peripancreatic region (arrow). (c) Corresponding axial PET scan shows no increased FDG uptake in the peripancreatic region. Note, however, the physiologic uptake in the kidneys and liver. The patient remains free of disease.

View larger version (128K): [in a new window]   Figure 6a.  Stable lymph nodes with FDG uptake in a 61-year-old man with non-Hodgkin lymphoma in remission. (a) CT scan shows prominent lymph nodes in the region of the right external iliac artery (arrows). (b) Corresponding axial PET scan shows FDG uptake in these nodes (arrows). Note also the physiologic uptake in the sigmoid colon (arrowheads). Results of biopsy confirmed the recurrence of non-Hodgkin lymphoma.

View larger version (81K): [in a new window]   Figure 6b.  Stable lymph nodes with FDG uptake in a 61-year-old man with non-Hodgkin lymphoma in remission. (a) CT scan shows prominent lymph nodes in the region of the right external iliac artery (arrows). (b) Corresponding axial PET scan shows FDG uptake in these nodes (arrows). Note also the physiologic uptake in the sigmoid colon (arrowheads). Results of biopsy confirmed the recurrence of non-Hodgkin lymphoma.

View larger version (126K): [in a new window]   Figure 7a.  Pneumonia in a 72-year-old man with non-Hodgkin lymphoma who was undergoing chemotherapy. (a) Coronal PET scan shows FDG uptake in the right lung base (arrow). Note also the physiologic uptake in the kidneys. (b) Chest CT scan shows consolidation with an air bronchogram in the right lung base.

View larger version (138K): [in a new window]   Figure 7b.  Pneumonia in a 72-year-old man with non-Hodgkin lymphoma who was undergoing chemotherapy. (a) Coronal PET scan shows FDG uptake in the right lung base (arrow). Note also the physiologic uptake in the kidneys. (b) Chest CT scan shows consolidation with an air bronchogram in the right lung base.

View larger version (111K): [in a new window]   Figure 8a.  Cholecystitis in a 47-year-old man with non-Hodgkin lymphoma who was undergoing chemotherapy. (a) Axial PET scan shows FDG accumulation in the gallbladder (arrow). The accumulation in the retroperitoneum (arrowheads) represents lymphoma. (b) Abdominal CT scan shows a gallstone and a fluid collection adjacent to the gallbladder (arrow) as well as retroperitoneal lymphadenopathies (arrowheads).

View larger version (138K): [in a new window]   Figure 8b.  Cholecystitis in a 47-year-old man with non-Hodgkin lymphoma who was undergoing chemotherapy. (a) Axial PET scan shows FDG accumulation in the gallbladder (arrow). The accumulation in the retroperitoneum (arrowheads) represents lymphoma. (b) Abdominal CT scan shows a gallstone and a fluid collection adjacent to the gallbladder (arrow) as well as retroperitoneal lymphadenopathies (arrowheads).

View larger version (88K): [in a new window]   Figure 9.  Colitis in a 45-year-old man with non-Hodgkin lymphoma who had undergone bone marrow transplantation. The patient presented with fever and abdominal cramping. Coronal PET scan shows increased activity in the colon.

View larger version (138K): [in a new window]   Figure 10a.  Probable bleomycin toxicity in a 35-year-old man with Hodgkin disease who was treated with doxorubicin hydrochloride, bleomycin, vinblastine, and dacarbazine. (a) Coronal PET scan shows diffuse increased FDG uptake in the lungs. Note also the physiologic uptake in the myocardium and kidneys and the increased uptake in the bone marrow due to G-CSF therapy. (b) Axial PET scan shows increased FDG uptake at the periphery of the lungs. (c) CT scan shows diffuse ground-glass attenuation.

View larger version (93K): [in a new window]   Figure 10b.  Probable bleomycin toxicity in a 35-year-old man with Hodgkin disease who was treated with doxorubicin hydrochloride, bleomycin, vinblastine, and dacarbazine. (a) Coronal PET scan shows diffuse increased FDG uptake in the lungs. Note also the physiologic uptake in the myocardium and kidneys and the increased uptake in the bone marrow due to G-CSF therapy. (b) Axial PET scan shows increased FDG uptake at the periphery of the lungs. (c) CT scan shows diffuse ground-glass attenuation.

View larger version (118K): [in a new window]   Figure 10c.  Probable bleomycin toxicity in a 35-year-old man with Hodgkin disease who was treated with doxorubicin hydrochloride, bleomycin, vinblastine, and dacarbazine. (a) Coronal PET scan shows diffuse increased FDG uptake in the lungs. Note also the physiologic uptake in the myocardium and kidneys and the increased uptake in the bone marrow due to G-CSF therapy. (b) Axial PET scan shows increased FDG uptake at the periphery of the lungs. (c) CT scan shows diffuse ground-glass attenuation.

View larger version (122K): [in a new window]   Figure 11.  Increased FDG uptake due to G-CSF therapy in a 49-year-old woman with a history of non-Hodgkin lymphoma and bone marrow transplantation. Whole-body PET scan shows diffuse increased FDG uptake in the bone marrow and spleen (arrows).

View larger version (69K): [in a new window]   Figure 12a.  Increased bone marrow uptake due to G-CSF therapy and lymphomatous infiltration in a 45-year-old man with Hodgkin disease. (a) Baseline sagittal PET scan shows focal FDG uptake in the lower thoracic spine (arrowhead). (b) Corresponding sagittal T1-weighted MR image shows a marrow-replacing lesion in the lower thoracic spine (arrowhead). (c) On a sagittal PET scan obtained after completion of chemotherapy, the previously involved spine shows decreased activity (arrowhead), whereas the normal bone marrow shows increased activity due to G-CSF therapy. (d) Corresponding sagittal T1-weighted MR image shows fatty infiltration of the previously involved lower thoracic spine (arrowhead).

View larger version (88K): [in a new window]   Figure 12b.  Increased bone marrow uptake due to G-CSF therapy and lymphomatous infiltration in a 45-year-old man with Hodgkin disease. (a) Baseline sagittal PET scan shows focal FDG uptake in the lower thoracic spine (arrowhead). (b) Corresponding sagittal T1-weighted MR image shows a marrow-replacing lesion in the lower thoracic spine (arrowhead). (c) On a sagittal PET scan obtained after completion of chemotherapy, the previously involved spine shows decreased activity (arrowhead), whereas the normal bone marrow shows increased activity due to G-CSF therapy. (d) Corresponding sagittal T1-weighted MR image shows fatty infiltration of the previously involved lower thoracic spine (arrowhead).

View larger version (69K): [in a new window]   Figure 12c.  Increased bone marrow uptake due to G-CSF therapy and lymphomatous infiltration in a 45-year-old man with Hodgkin disease. (a) Baseline sagittal PET scan shows focal FDG uptake in the lower thoracic spine (arrowhead). (b) Corresponding sagittal T1-weighted MR image shows a marrow-replacing lesion in the lower thoracic spine (arrowhead). (c) On a sagittal PET scan obtained after completion of chemotherapy, the previously involved spine shows decreased activity (arrowhead), whereas the normal bone marrow shows increased activity due to G-CSF therapy. (d) Corresponding sagittal T1-weighted MR image shows fatty infiltration of the previously involved lower thoracic spine (arrowhead).

View larger version (86K): [in a new window]   Figure 12d.  Increased bone marrow uptake due to G-CSF therapy and lymphomatous infiltration in a 45-year-old man with Hodgkin disease. (a) Baseline sagittal PET scan shows focal FDG uptake in the lower thoracic spine (arrowhead). (b) Corresponding sagittal T1-weighted MR image shows a marrow-replacing lesion in the lower thoracic spine (arrowhead). (c) On a sagittal PET scan obtained after completion of chemotherapy, the previously involved spine shows decreased activity (arrowhead), whereas the normal bone marrow shows increased activity due to G-CSF therapy. (d) Corresponding sagittal T1-weighted MR image shows fatty infiltration of the previously involved lower thoracic spine (arrowhead).

View larger version (46K): [in a new window]   Figure 13a.  Increased bone marrow uptake due to G-CSF therapy and lymphomatous infiltration in a 30-year-old woman with relapsed Hodgkin disease. (a) Sagittal PET scan obtained prior to chemotherapy shows heterogeneous intense FDG uptake in the spine (arrows), a finding that suggests lymphomatous involvement. Note the relatively low uptake in the sternum and in several vertebrae (arrowheads). (b) On a sagittal PET scan obtained 2 months after chemotherapy, the previously involved bone marrow demonstrates decreased uptake (arrows), whereas the relatively normal bone marrow shows intense uptake due to G-CSF therapy (arrowheads).

View larger version (56K): [in a new window]   Figure 13b.  Increased bone marrow uptake due to G-CSF therapy and lymphomatous infiltration in a 30-year-old woman with relapsed Hodgkin disease. (a) Sagittal PET scan obtained prior to chemotherapy shows heterogeneous intense FDG uptake in the spine (arrows), a finding that suggests lymphomatous involvement. Note the relatively low uptake in the sternum and in several vertebrae (arrowheads). (b) On a sagittal PET scan obtained 2 months after chemotherapy, the previously involved bone marrow demonstrates decreased uptake (arrows), whereas the relatively normal bone marrow shows intense uptake due to G-CSF therapy (arrowheads).

View larger version (120K): [in a new window]   Figure 14a.  Radiation pneumonitis in a 26-year-old man with non-Hodgkin lymphoma who had undergone radiation therapy 4 months earlier. (a) Coronal PET scan shows intense FDG uptake in the medial chest. Note also the physiologic uptake in the kidneys. (b) Chest CT scan shows consolidation in the paramediastinal lung.

View larger version (137K): [in a new window]   Figure 14b.  Radiation pneumonitis in a 26-year-old man with non-Hodgkin lymphoma who had undergone radiation therapy 4 months earlier. (a) Coronal PET scan shows intense FDG uptake in the medial chest. Note also the physiologic uptake in the kidneys. (b) Chest CT scan shows consolidation in the paramediastinal lung.

View larger version (75K): [in a new window]   Figure 15.  FDG uptake in the sternum and brain in a 17-year-old boy with non-Hodgkin lymphoma who had undergone sternotomy 2 months earlier. Sagittal PET scan shows intense FDG uptake in the sternum (arrowheads) and physiologic uptake in the brain.

View larger version (88K): [in a new window]   Figure 16.  Probable brown fat uptake on the nonirradiated side in a 37-year-old man with non-Hodgkin lymphoma who had undergone chemotherapy and radiation therapy to the left side of the neck. Coronal PET scan shows increased FDG uptake in the right supraclavicular region (arrow); however, no abnormality was seen at CT. Physiologic uptake is seen in the vocal cords (arrowhead), myocardium, liver, and digestive tract. The patient remains disease free. Brown fat (supraclavicular area fat) is adipose tissue whose only function is to generate heat. It usually demonstrates the symmetric uptake pattern shown here and is more common in women and during the winter (35,36).

View larger version (101K): [in a new window]   Figure 17a.  Thrombus at the tip of a central line in a 76-year-old woman. (a) Coronal PET scan shows focal FDG uptake in the right anterior mediastinum (arrowhead). Note also the physiologic uptake in the myocardium, skeletal muscles, and kidneys. (b) Follow-up PET scan obtained 4 hours later after flushing the central line with saline solution shows persistent uptake (arrowhead). (c) CT scan reveals a thrombus at the tip of the central line (arrow). Follow-up PET performed 2 months later after removal of the central line showed resolution of the uptake.

View larger version (102K): [in a new window]   Figure 17b.  Thrombus at the tip of a central line in a 76-year-old woman. (a) Coronal PET scan shows focal FDG uptake in the right anterior mediastinum (arrowhead). Note also the physiologic uptake in the myocardium, skeletal muscles, and kidneys. (b) Follow-up PET scan obtained 4 hours later after flushing the central line with saline solution shows persistent uptake (arrowhead). (c) CT scan reveals a thrombus at the tip of the central line (arrow). Follow-up PET performed 2 months later after removal of the central line showed resolution of the uptake.

View larger version (100K): [in a new window]   Figure 17c.  Thrombus at the tip of a central line in a 76-year-old woman. (a) Coronal PET scan shows focal FDG uptake in the right anterior mediastinum (arrowhead). Note also the physiologic uptake in the myocardium, skeletal muscles, and kidneys. (b) Follow-up PET scan obtained 4 hours later after flushing the central line with saline solution shows persistent uptake (arrowhead). (c) CT scan reveals a thrombus at the tip of the central line (arrow). Follow-up PET performed 2 months later after removal of the central line showed resolution of the uptake.

View larger version (103K): [in a new window]   Figure 18a.  Rib fracture in a 46-year-old man with Hodgkin disease who had completed treatment. (a, b) Coronal (a) and axial (b) PET scans show focal FDG uptake in the posterior chest wall (arrows). Note also the accumulation in both shoulders (arrowheads in a), a finding that may represent degenerative changes, and the physiologic uptake in the myocardium and kidneys. (c) CT scan clearly shows a rib fracture (arrow).

View larger version (77K): [in a new window]   Figure 18b.  Rib fracture in a 46-year-old man with Hodgkin disease who had completed treatment. (a, b) Coronal (a) and axial (b) PET scans show focal FDG uptake in the posterior chest wall (arrows). Note also the accumulation in both shoulders (arrowheads in a), a finding that may represent degenerative changes, and the physiologic uptake in the myocardium and kidneys. (c) CT scan clearly shows a rib fracture (arrow).

View larger version (95K): [in a new window]   Figure 18c.  Rib fracture in a 46-year-old man with Hodgkin disease who had completed treatment. (a, b) Coronal (a) and axial (b) PET scans show focal FDG uptake in the posterior chest wall (arrows). Note also the accumulation in both shoulders (arrowheads in a), a finding that may represent degenerative changes, and the physiologic uptake in the myocardium and kidneys. (c) CT scan clearly shows a rib fracture (arrow).

View larger version (68K): [in a new window]   Figure 19.  Decreased bone marrow activity due to radiation therapy in a 26-year-old man with Hodgkin disease of the mediastinum. Sagittal PET scan shows decreased FDG uptake in the thoracic spine (arrowheads).

View larger version (95K): [in a new window]   Figure 20.  Brown fat in an 18-year-old man with Hodgkin disease who had undergone chemotherapy. Coronal PET scan shows symmetric increased FDG uptake in the shoulders, neck, and paraspinal area. Note also the physiologic uptake in the kidneys.

View larger version (74K): [in a new window]   Figure 21a.  Thymic uptake in a 17-year-old boy with Hodgkin disease. (a) Axial PET scan obtained 4 months after completion of chemotherapy shows increased FDG uptake in the anterior mediastinum (arrow). (b, c) CT scans obtained just after completion of chemotherapy (b) and 4 months later (c) show interval enlargement of the thymus with normal architecture (arrow).

View larger version (63K): [in a new window]   Figure 21b.  Thymic uptake in a 17-year-old boy with Hodgkin disease. (a) Axial PET scan obtained 4 months after completion of chemotherapy shows increased FDG uptake in the anterior mediastinum (arrow). (b, c) CT scans obtained just after completion of chemotherapy (b) and 4 months later (c) show interval enlargement of the thymus with normal architecture (arrow).

View larger version (79K): [in a new window]   Figure 21c.  Thymic uptake in a 17-year-old boy with Hodgkin disease. (a) Axial PET scan obtained 4 months after completion of chemotherapy shows increased FDG uptake in the anterior mediastinum (arrow). (b, c) CT scans obtained just after completion of chemotherapy (b) and 4 months later (c) show interval enlargement of the thymus with normal architecture (arrow).

View larger version (88K): [in a new window]   Figure 22a.  Postsurgical change in a 63-year-old man with Hodgkin disease. A splenic lesion had been found and splenectomy performed 1 month earlier. (a) Sagittal PET scan shows FDG uptake in the anterior abdominal wall (arrowhead) as well as lymphoma lesions of the neck, mediastinum, spine, and retroperitoneum (arrows). (b) Axial PET scan again shows FDG uptake in the anterior abdominal wall (arrow), as well as lymphoma lesions of the pelvis (arrowhead). (c) CT scan shows postsurgical change (arrow) and pelvic lymphadenopathies (arrowhead).

View larger version (94K): [in a new window]   Figure 22b.  Postsurgical change in a 63-year-old man with Hodgkin disease. A splenic lesion had been found and splenectomy performed 1 month earlier. (a) Sagittal PET scan shows FDG uptake in the anterior abdominal wall (arrowhead) as well as lymphoma lesions of the neck, mediastinum, spine, and retroperitoneum (arrows). (b) Axial PET scan again shows FDG uptake in the anterior abdominal wall (arrow), as well as lymphoma lesions of the pelvis (arrowhead). (c) CT scan shows postsurgical change (arrow) and pelvic lymphadenopathies (arrowhead).

View larger version (126K): [in a new window]   Figure 22c.  Postsurgical change in a 63-year-old man with Hodgkin disease. A splenic lesion had been found and splenectomy performed 1 month earlier. (a) Sagittal PET scan shows FDG uptake in the anterior abdominal wall (arrowhead) as well as lymphoma lesions of the neck, mediastinum, spine, and retroperitoneum (arrows). (b) Axial PET scan again shows FDG uptake in the anterior abdominal wall (arrow), as well as lymphoma lesions of the pelvis (arrowhead). (c) CT scan shows postsurgical change (arrow) and pelvic lymphadenopathies (arrowhead).

View larger version (101K): [in a new window]   Figure 23a.  Tracheostomy in a 38-year-old man with non-Hodgkin lymphoma who was undergoing chemotherapy. (a) Sagittal PET scan shows FDG uptake in the lower neck (arrowhead). (b) CT scan of the neck shows a tracheostomy.

View larger version (96K): [in a new window]   Figure 23b.  Tracheostomy in a 38-year-old man with non-Hodgkin lymphoma who was undergoing chemotherapy. (a) Sagittal PET scan shows FDG uptake in the lower neck (arrowhead). (b) CT scan of the neck shows a tracheostomy.

View larger version (111K): [in a new window]   Figure 24.  Axillary uptake due to partial subcutaneous radiotracer injection in a 40-year-old woman with Hodgkin disease in remission. Coronal PET scan shows linear FDG uptake in the left upper arm (arrows) associated with focal uptake in the left axilla (arrowhead). The study was performed with the patient’s arms elevated because of the large amount of radiotracer leakage.