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Improved Detection and Characterization of Adrenal Disease with PET-CT¹

¹ From the Department of Radiology, Massachusetts General Hospital, FND 216, 55 Fruit St, Boston, MA 02114 (A.B.E., S.K.S., V.M.C., D.V.S., G.W.B., M.M.M., J.T.S., P.R.M., M.A.B.); and the Department of Medicine, Division of Endocrinology, St Elizabeth’s Medical Center, Boston, Mass (A.T.S.). Recipient of a Certificate of Merit award for an education exhibit at the 2004 RSNA Annual Meeting. Received March 1, 2005; revision requested April 4; final revision received June 20, 2006; accepted August 1. All authors have no financial relationships to disclose.

View larger version (158K): [in this window] [in a new window] [Download PPT slide]   Figure 1a.  Normal gastric uptake as a potential pitfall in PET interpretation. The patient was a 55-year-old woman with a history of non-Hodgkin lymphoma. Axial (a–c) and coronal (d–f) CT (a, d), PET (b, e), and fused PET-CT (c, f) images show the gastric fundus (arrow). The gastric fundus may normally be mildly FDG—2-[fluorine 18]fluoro-2-deoxy-D-glucose—avid and can be confused with adrenal disease in the absence of CT correlation with adequate coregistration.

 

View larger version (82K): [in this window] [in a new window] [Download PPT slide]   Figure 1b.  Normal gastric uptake as a potential pitfall in PET interpretation. The patient was a 55-year-old woman with a history of non-Hodgkin lymphoma. Axial (a–c) and coronal (d–f) CT (a, d), PET (b, e), and fused PET-CT (c, f) images show the gastric fundus (arrow). The gastric fundus may normally be mildly FDG—2-[fluorine 18]fluoro-2-deoxy-D-glucose—avid and can be confused with adrenal disease in the absence of CT correlation with adequate coregistration.

 

View larger version (129K): [in this window] [in a new window] [Download PPT slide]   Figure 1c.  Normal gastric uptake as a potential pitfall in PET interpretation. The patient was a 55-year-old woman with a history of non-Hodgkin lymphoma. Axial (a–c) and coronal (d–f) CT (a, d), PET (b, e), and fused PET-CT (c, f) images show the gastric fundus (arrow). The gastric fundus may normally be mildly FDG—2-[fluorine 18]fluoro-2-deoxy-D-glucose—avid and can be confused with adrenal disease in the absence of CT correlation with adequate coregistration.

 

View larger version (124K): [in this window] [in a new window] [Download PPT slide]   Figure 1d.  Normal gastric uptake as a potential pitfall in PET interpretation. The patient was a 55-year-old woman with a history of non-Hodgkin lymphoma. Axial (a–c) and coronal (d–f) CT (a, d), PET (b, e), and fused PET-CT (c, f) images show the gastric fundus (arrow). The gastric fundus may normally be mildly FDG—2-[fluorine 18]fluoro-2-deoxy-D-glucose—avid and can be confused with adrenal disease in the absence of CT correlation with adequate coregistration.

 

View larger version (103K): [in this window] [in a new window] [Download PPT slide]   Figure 1e.  Normal gastric uptake as a potential pitfall in PET interpretation. The patient was a 55-year-old woman with a history of non-Hodgkin lymphoma. Axial (a–c) and coronal (d–f) CT (a, d), PET (b, e), and fused PET-CT (c, f) images show the gastric fundus (arrow). The gastric fundus may normally be mildly FDG—2-[fluorine 18]fluoro-2-deoxy-D-glucose—avid and can be confused with adrenal disease in the absence of CT correlation with adequate coregistration.

 

View larger version (125K): [in this window] [in a new window] [Download PPT slide]   Figure 1f.  Normal gastric uptake as a potential pitfall in PET interpretation. The patient was a 55-year-old woman with a history of non-Hodgkin lymphoma. Axial (a–c) and coronal (d–f) CT (a, d), PET (b, e), and fused PET-CT (c, f) images show the gastric fundus (arrow). The gastric fundus may normally be mildly FDG—2-[fluorine 18]fluoro-2-deoxy-D-glucose—avid and can be confused with adrenal disease in the absence of CT correlation with adequate coregistration.

 

View larger version (141K): [in this window] [in a new window] [Download PPT slide]   Figure 2a.  Normal renal uptake as a potential pitfall in PET interpretation. The patient was a 57-year-old woman with a history of breast cancer. Axial CT (a), PET (b), and fused PET-CT (c) images show urinary FDG excretion involving the upper renal pole (arrow), a finding that may be confused with adrenal disease in the absence of CT correlation with adequate coregistration.

 

View larger version (84K): [in this window] [in a new window] [Download PPT slide]   Figure 2b.  Normal renal uptake as a potential pitfall in PET interpretation. The patient was a 57-year-old woman with a history of breast cancer. Axial CT (a), PET (b), and fused PET-CT (c) images show urinary FDG excretion involving the upper renal pole (arrow), a finding that may be confused with adrenal disease in the absence of CT correlation with adequate coregistration.

 

View larger version (106K): [in this window] [in a new window] [Download PPT slide]   Figure 2c.  Normal renal uptake as a potential pitfall in PET interpretation. The patient was a 57-year-old woman with a history of breast cancer. Axial CT (a), PET (b), and fused PET-CT (c) images show urinary FDG excretion involving the upper renal pole (arrow), a finding that may be confused with adrenal disease in the absence of CT correlation with adequate coregistration.

 

View larger version (145K): [in this window] [in a new window] [Download PPT slide]   Figure 3a.  Adrenal adenoma in a 63-year-old woman with a history of mucosa-associated lymphoid tissue lymphoma. Previous CT images had shown a 1.4-cm left adrenal nodule. Axial (a–c) and coronal (d–f) CT (a, d), PET (b, e), and fused PET-CT (c, f) images show an area with minimally increased FDG uptake (arrow) relative to the liver, a finding that corresponds to a left adrenal mass. The unenhanced CT attenuation value of the mass (0 HU) was consistent with an adenoma. The patient remains disease free in other anatomic locations. A minimal degree of FDG uptake can be seen in adenomas, whose incidental detection is a relatively common occurrence. In patients with a history of known malignancy and equivocal CT findings (especially with lipid-poor adenomas), fusion PET-CT is valuable in differentiating adenomas from other neoplasms given the usual lack of significant FDG avidity in adenomas.

 

View larger version (79K): [in this window] [in a new window] [Download PPT slide]   Figure 3b.  Adrenal adenoma in a 63-year-old woman with a history of mucosa-associated lymphoid tissue lymphoma. Previous CT images had shown a 1.4-cm left adrenal nodule. Axial (a–c) and coronal (d–f) CT (a, d), PET (b, e), and fused PET-CT (c, f) images show an area with minimally increased FDG uptake (arrow) relative to the liver, a finding that corresponds to a left adrenal mass. The unenhanced CT attenuation value of the mass (0 HU) was consistent with an adenoma. The patient remains disease free in other anatomic locations. A minimal degree of FDG uptake can be seen in adenomas, whose incidental detection is a relatively common occurrence. In patients with a history of known malignancy and equivocal CT findings (especially with lipid-poor adenomas), fusion PET-CT is valuable in differentiating adenomas from other neoplasms given the usual lack of significant FDG avidity in adenomas.

 

View larger version (120K): [in this window] [in a new window] [Download PPT slide]   Figure 3c.  Adrenal adenoma in a 63-year-old woman with a history of mucosa-associated lymphoid tissue lymphoma. Previous CT images had shown a 1.4-cm left adrenal nodule. Axial (a–c) and coronal (d–f) CT (a, d), PET (b, e), and fused PET-CT (c, f) images show an area with minimally increased FDG uptake (arrow) relative to the liver, a finding that corresponds to a left adrenal mass. The unenhanced CT attenuation value of the mass (0 HU) was consistent with an adenoma. The patient remains disease free in other anatomic locations. A minimal degree of FDG uptake can be seen in adenomas, whose incidental detection is a relatively common occurrence. In patients with a history of known malignancy and equivocal CT findings (especially with lipid-poor adenomas), fusion PET-CT is valuable in differentiating adenomas from other neoplasms given the usual lack of significant FDG avidity in adenomas.

 

View larger version (138K): [in this window] [in a new window] [Download PPT slide]   Figure 3d.  Adrenal adenoma in a 63-year-old woman with a history of mucosa-associated lymphoid tissue lymphoma. Previous CT images had shown a 1.4-cm left adrenal nodule. Axial (a–c) and coronal (d–f) CT (a, d), PET (b, e), and fused PET-CT (c, f) images show an area with minimally increased FDG uptake (arrow) relative to the liver, a finding that corresponds to a left adrenal mass. The unenhanced CT attenuation value of the mass (0 HU) was consistent with an adenoma. The patient remains disease free in other anatomic locations. A minimal degree of FDG uptake can be seen in adenomas, whose incidental detection is a relatively common occurrence. In patients with a history of known malignancy and equivocal CT findings (especially with lipid-poor adenomas), fusion PET-CT is valuable in differentiating adenomas from other neoplasms given the usual lack of significant FDG avidity in adenomas.

 

View larger version (94K): [in this window] [in a new window] [Download PPT slide]   Figure 3e.  Adrenal adenoma in a 63-year-old woman with a history of mucosa-associated lymphoid tissue lymphoma. Previous CT images had shown a 1.4-cm left adrenal nodule. Axial (a–c) and coronal (d–f) CT (a, d), PET (b, e), and fused PET-CT (c, f) images show an area with minimally increased FDG uptake (arrow) relative to the liver, a finding that corresponds to a left adrenal mass. The unenhanced CT attenuation value of the mass (0 HU) was consistent with an adenoma. The patient remains disease free in other anatomic locations. A minimal degree of FDG uptake can be seen in adenomas, whose incidental detection is a relatively common occurrence. In patients with a history of known malignancy and equivocal CT findings (especially with lipid-poor adenomas), fusion PET-CT is valuable in differentiating adenomas from other neoplasms given the usual lack of significant FDG avidity in adenomas.

 

View larger version (116K): [in this window] [in a new window] [Download PPT slide]   Figure 3f.  Adrenal adenoma in a 63-year-old woman with a history of mucosa-associated lymphoid tissue lymphoma. Previous CT images had shown a 1.4-cm left adrenal nodule. Axial (a–c) and coronal (d–f) CT (a, d), PET (b, e), and fused PET-CT (c, f) images show an area with minimally increased FDG uptake (arrow) relative to the liver, a finding that corresponds to a left adrenal mass. The unenhanced CT attenuation value of the mass (0 HU) was consistent with an adenoma. The patient remains disease free in other anatomic locations. A minimal degree of FDG uptake can be seen in adenomas, whose incidental detection is a relatively common occurrence. In patients with a history of known malignancy and equivocal CT findings (especially with lipid-poor adenomas), fusion PET-CT is valuable in differentiating adenomas from other neoplasms given the usual lack of significant FDG avidity in adenomas.

 

View larger version (151K): [in this window] [in a new window] [Download PPT slide]   Figure 4a.  Myelolipoma in a 72-year-old woman with a history of metastatic endometrial carcinoma. Axial (a–c) and coronal (d–f) CT (a, d), PET (b, e), and fused PET-CT (c, f) images show a left adrenal mass (arrow). At CT, the mass measured 7.6 x 5.6 cm and was seen to contain macroscopic fat (internal attenuation of –32 HU), a finding that is most consistent with a myelolipoma. However, a collision tumor (coexistent myelolipoma and metastasis) was difficult to fully exclude with CT alone. Fused PET-CT images revealed no evidence of significantly increased FDG uptake in the left adrenal gland to suggest the presence of malignancy. The majority of myelolipomas are not FDG avid. Certain rare cases of increased avidity have been reported when adenomatous and hematopoietic elements predominate. In patients with a history of malignancy, fusion PET-CT is helpful in recognizing myelolipoma and excluding concomitant metastatic adrenal involvement (collision tumors).

 

View larger version (87K): [in this window] [in a new window] [Download PPT slide]   Figure 4b.  Myelolipoma in a 72-year-old woman with a history of metastatic endometrial carcinoma. Axial (a–c) and coronal (d–f) CT (a, d), PET (b, e), and fused PET-CT (c, f) images show a left adrenal mass (arrow). At CT, the mass measured 7.6 x 5.6 cm and was seen to contain macroscopic fat (internal attenuation of –32 HU), a finding that is most consistent with a myelolipoma. However, a collision tumor (coexistent myelolipoma and metastasis) was difficult to fully exclude with CT alone. Fused PET-CT images revealed no evidence of significantly increased FDG uptake in the left adrenal gland to suggest the presence of malignancy. The majority of myelolipomas are not FDG avid. Certain rare cases of increased avidity have been reported when adenomatous and hematopoietic elements predominate. In patients with a history of malignancy, fusion PET-CT is helpful in recognizing myelolipoma and excluding concomitant metastatic adrenal involvement (collision tumors).

 

View larger version (118K): [in this window] [in a new window] [Download PPT slide]   Figure 4c.  Myelolipoma in a 72-year-old woman with a history of metastatic endometrial carcinoma. Axial (a–c) and coronal (d–f) CT (a, d), PET (b, e), and fused PET-CT (c, f) images show a left adrenal mass (arrow). At CT, the mass measured 7.6 x 5.6 cm and was seen to contain macroscopic fat (internal attenuation of –32 HU), a finding that is most consistent with a myelolipoma. However, a collision tumor (coexistent myelolipoma and metastasis) was difficult to fully exclude with CT alone. Fused PET-CT images revealed no evidence of significantly increased FDG uptake in the left adrenal gland to suggest the presence of malignancy. The majority of myelolipomas are not FDG avid. Certain rare cases of increased avidity have been reported when adenomatous and hematopoietic elements predominate. In patients with a history of malignancy, fusion PET-CT is helpful in recognizing myelolipoma and excluding concomitant metastatic adrenal involvement (collision tumors).

 

View larger version (108K): [in this window] [in a new window] [Download PPT slide]   Figure 4d.  Myelolipoma in a 72-year-old woman with a history of metastatic endometrial carcinoma. Axial (a–c) and coronal (d–f) CT (a, d), PET (b, e), and fused PET-CT (c, f) images show a left adrenal mass (arrow). At CT, the mass measured 7.6 x 5.6 cm and was seen to contain macroscopic fat (internal attenuation of –32 HU), a finding that is most consistent with a myelolipoma. However, a collision tumor (coexistent myelolipoma and metastasis) was difficult to fully exclude with CT alone. Fused PET-CT images revealed no evidence of significantly increased FDG uptake in the left adrenal gland to suggest the presence of malignancy. The majority of myelolipomas are not FDG avid. Certain rare cases of increased avidity have been reported when adenomatous and hematopoietic elements predominate. In patients with a history of malignancy, fusion PET-CT is helpful in recognizing myelolipoma and excluding concomitant metastatic adrenal involvement (collision tumors).

 

View larger version (71K): [in this window] [in a new window] [Download PPT slide]   Figure 4e.  Myelolipoma in a 72-year-old woman with a history of metastatic endometrial carcinoma. Axial (a–c) and coronal (d–f) CT (a, d), PET (b, e), and fused PET-CT (c, f) images show a left adrenal mass (arrow). At CT, the mass measured 7.6 x 5.6 cm and was seen to contain macroscopic fat (internal attenuation of –32 HU), a finding that is most consistent with a myelolipoma. However, a collision tumor (coexistent myelolipoma and metastasis) was difficult to fully exclude with CT alone. Fused PET-CT images revealed no evidence of significantly increased FDG uptake in the left adrenal gland to suggest the presence of malignancy. The majority of myelolipomas are not FDG avid. Certain rare cases of increased avidity have been reported when adenomatous and hematopoietic elements predominate. In patients with a history of malignancy, fusion PET-CT is helpful in recognizing myelolipoma and excluding concomitant metastatic adrenal involvement (collision tumors).

 

View larger version (121K): [in this window] [in a new window] [Download PPT slide]   Figure 4f.  Myelolipoma in a 72-year-old woman with a history of metastatic endometrial carcinoma. Axial (a–c) and coronal (d–f) CT (a, d), PET (b, e), and fused PET-CT (c, f) images show a left adrenal mass (arrow). At CT, the mass measured 7.6 x 5.6 cm and was seen to contain macroscopic fat (internal attenuation of –32 HU), a finding that is most consistent with a myelolipoma. However, a collision tumor (coexistent myelolipoma and metastasis) was difficult to fully exclude with CT alone. Fused PET-CT images revealed no evidence of significantly increased FDG uptake in the left adrenal gland to suggest the presence of malignancy. The majority of myelolipomas are not FDG avid. Certain rare cases of increased avidity have been reported when adenomatous and hematopoietic elements predominate. In patients with a history of malignancy, fusion PET-CT is helpful in recognizing myelolipoma and excluding concomitant metastatic adrenal involvement (collision tumors).

 

View larger version (157K): [in this window] [in a new window] [Download PPT slide]   Figure 5a.  Metastatic disease in an 86-year-old man with metastatic melanoma and a history of prostate cancer. The patient presented with multiple lung nodules. Axial (a) and coronal (d) CT scans demonstrate minimal thickening of the right adrenal gland (arrow) with no discrete mass; axial (b) and coronal (e) PET scans and axial (c) and coronal (f) fused PET-CT images reveal mildly increased FDG uptake in the right adrenal gland (arrow) as well as increased uptake in other locations in the chest and abdomen, findings that are consistent with metastatic disease. An adrenal metastasis was confirmed on the basis of interval growth seen at subsequent CT evaluation. This case illustrates the potential usefulness of fusion PET-CT in the evaluation of subtle metastatic disease in the adrenal gland, which in rare cases may be missed with anatomic imaging (CT) alone. In patients with a history of known malignancy, maintenance of the adreniform shape of one or both adrenal glands is not a guarantee of benignity.

 

View larger version (86K): [in this window] [in a new window] [Download PPT slide]   Figure 5b.  Metastatic disease in an 86-year-old man with metastatic melanoma and a history of prostate cancer. The patient presented with multiple lung nodules. Axial (a) and coronal (d) CT scans demonstrate minimal thickening of the right adrenal gland (arrow) with no discrete mass; axial (b) and coronal (e) PET scans and axial (c) and coronal (f) fused PET-CT images reveal mildly increased FDG uptake in the right adrenal gland (arrow) as well as increased uptake in other locations in the chest and abdomen, findings that are consistent with metastatic disease. An adrenal metastasis was confirmed on the basis of interval growth seen at subsequent CT evaluation. This case illustrates the potential usefulness of fusion PET-CT in the evaluation of subtle metastatic disease in the adrenal gland, which in rare cases may be missed with anatomic imaging (CT) alone. In patients with a history of known malignancy, maintenance of the adreniform shape of one or both adrenal glands is not a guarantee of benignity.

 

View larger version (139K): [in this window] [in a new window] [Download PPT slide]   Figure 5c.  Metastatic disease in an 86-year-old man with metastatic melanoma and a history of prostate cancer. The patient presented with multiple lung nodules. Axial (a) and coronal (d) CT scans demonstrate minimal thickening of the right adrenal gland (arrow) with no discrete mass; axial (b) and coronal (e) PET scans and axial (c) and coronal (f) fused PET-CT images reveal mildly increased FDG uptake in the right adrenal gland (arrow) as well as increased uptake in other locations in the chest and abdomen, findings that are consistent with metastatic disease. An adrenal metastasis was confirmed on the basis of interval growth seen at subsequent CT evaluation. This case illustrates the potential usefulness of fusion PET-CT in the evaluation of subtle metastatic disease in the adrenal gland, which in rare cases may be missed with anatomic imaging (CT) alone. In patients with a history of known malignancy, maintenance of the adreniform shape of one or both adrenal glands is not a guarantee of benignity.

 

View larger version (109K): [in this window] [in a new window] [Download PPT slide]   Figure 5d.  Metastatic disease in an 86-year-old man with metastatic melanoma and a history of prostate cancer. The patient presented with multiple lung nodules. Axial (a) and coronal (d) CT scans demonstrate minimal thickening of the right adrenal gland (arrow) with no discrete mass; axial (b) and coronal (e) PET scans and axial (c) and coronal (f) fused PET-CT images reveal mildly increased FDG uptake in the right adrenal gland (arrow) as well as increased uptake in other locations in the chest and abdomen, findings that are consistent with metastatic disease. An adrenal metastasis was confirmed on the basis of interval growth seen at subsequent CT evaluation. This case illustrates the potential usefulness of fusion PET-CT in the evaluation of subtle metastatic disease in the adrenal gland, which in rare cases may be missed with anatomic imaging (CT) alone. In patients with a history of known malignancy, maintenance of the adreniform shape of one or both adrenal glands is not a guarantee of benignity.

 

View larger version (85K): [in this window] [in a new window] [Download PPT slide]   Figure 5e.  Metastatic disease in an 86-year-old man with metastatic melanoma and a history of prostate cancer. The patient presented with multiple lung nodules. Axial (a) and coronal (d) CT scans demonstrate minimal thickening of the right adrenal gland (arrow) with no discrete mass; axial (b) and coronal (e) PET scans and axial (c) and coronal (f) fused PET-CT images reveal mildly increased FDG uptake in the right adrenal gland (arrow) as well as increased uptake in other locations in the chest and abdomen, findings that are consistent with metastatic disease. An adrenal metastasis was confirmed on the basis of interval growth seen at subsequent CT evaluation. This case illustrates the potential usefulness of fusion PET-CT in the evaluation of subtle metastatic disease in the adrenal gland, which in rare cases may be missed with anatomic imaging (CT) alone. In patients with a history of known malignancy, maintenance of the adreniform shape of one or both adrenal glands is not a guarantee of benignity.

 

View larger version (105K): [in this window] [in a new window] [Download PPT slide]   Figure 5f.  Metastatic disease in an 86-year-old man with metastatic melanoma and a history of prostate cancer. The patient presented with multiple lung nodules. Axial (a) and coronal (d) CT scans demonstrate minimal thickening of the right adrenal gland (arrow) with no discrete mass; axial (b) and coronal (e) PET scans and axial (c) and coronal (f) fused PET-CT images reveal mildly increased FDG uptake in the right adrenal gland (arrow) as well as increased uptake in other locations in the chest and abdomen, findings that are consistent with metastatic disease. An adrenal metastasis was confirmed on the basis of interval growth seen at subsequent CT evaluation. This case illustrates the potential usefulness of fusion PET-CT in the evaluation of subtle metastatic disease in the adrenal gland, which in rare cases may be missed with anatomic imaging (CT) alone. In patients with a history of known malignancy, maintenance of the adreniform shape of one or both adrenal glands is not a guarantee of benignity.

 

View larger version (175K): [in this window] [in a new window] [Download PPT slide]   Figure 6a.  Metastatic disease in a 62-year-old man with a history of melanoma. (a) CT scan shows a new right adrenal nodule (arrow). The nodule measures 19 mm and has indeterminate attenuation characteristics. (b) PET scan reveals an area of increased FDG uptake (arrow), a finding that is most consistent with metastatic disease. Because this was the only known site of disease in the chest, abdomen, or pelvis and the patient’s cardiac history precluded surgery, radiofrequency ablation of the lesion was performed. (c) PET scan from a PET-CT study performed 1 month after ablation shows no remaining FDG avidity in the right adrenal gland (arrow), a finding that indicates a successful treatment outcome. In patients who have undergone treatment for malignancy involving the adrenal gland, PET-CT can assist in assessing for a complete response to treatment when CT findings alone remain equivocal.

 

View larger version (76K): [in this window] [in a new window] [Download PPT slide]   Figure 6b.  Metastatic disease in a 62-year-old man with a history of melanoma. (a) CT scan shows a new right adrenal nodule (arrow). The nodule measures 19 mm and has indeterminate attenuation characteristics. (b) PET scan reveals an area of increased FDG uptake (arrow), a finding that is most consistent with metastatic disease. Because this was the only known site of disease in the chest, abdomen, or pelvis and the patient’s cardiac history precluded surgery, radiofrequency ablation of the lesion was performed. (c) PET scan from a PET-CT study performed 1 month after ablation shows no remaining FDG avidity in the right adrenal gland (arrow), a finding that indicates a successful treatment outcome. In patients who have undergone treatment for malignancy involving the adrenal gland, PET-CT can assist in assessing for a complete response to treatment when CT findings alone remain equivocal.

 

View larger version (87K): [in this window] [in a new window] [Download PPT slide]   Figure 6c.  Metastatic disease in a 62-year-old man with a history of melanoma. (a) CT scan shows a new right adrenal nodule (arrow). The nodule measures 19 mm and has indeterminate attenuation characteristics. (b) PET scan reveals an area of increased FDG uptake (arrow), a finding that is most consistent with metastatic disease. Because this was the only known site of disease in the chest, abdomen, or pelvis and the patient’s cardiac history precluded surgery, radiofrequency ablation of the lesion was performed. (c) PET scan from a PET-CT study performed 1 month after ablation shows no remaining FDG avidity in the right adrenal gland (arrow), a finding that indicates a successful treatment outcome. In patients who have undergone treatment for malignancy involving the adrenal gland, PET-CT can assist in assessing for a complete response to treatment when CT findings alone remain equivocal.

 

View larger version (129K): [in this window] [in a new window] [Download PPT slide]   Figure 7a.  Lymphomatous adrenal gland involvement in a 23-year-old woman with Burkitt lymphoma of the left breast. Axial (a–c) and coronal (d–f) CT (a, d), PET (b, e), and fused PET-CT (c, f) images show a 2 x 1-cm mass in the right adrenal gland (arrow) with an unenhanced CT attenuation of 49 HU, an indeterminate finding that is nonetheless suspicious for malignancy. Mild FDG uptake due to an early adrenal metastasis is also seen in the left adrenal gland. Follow-up PET-CT was performed at an outside institution 3 months after the initiation of chemotherapy and revealed subsequent resolution of these PET and CT findings, indicating successfully treated lymphomatous adrenal gland involvement. Fusion PET-CT may be of value in lymphoma patients with equivocal CT findings, either before or after treatment.

 

View larger version (91K): [in this window] [in a new window] [Download PPT slide]   Figure 7b.  Lymphomatous adrenal gland involvement in a 23-year-old woman with Burkitt lymphoma of the left breast. Axial (a–c) and coronal (d–f) CT (a, d), PET (b, e), and fused PET-CT (c, f) images show a 2 x 1-cm mass in the right adrenal gland (arrow) with an unenhanced CT attenuation of 49 HU, an indeterminate finding that is nonetheless suspicious for malignancy. Mild FDG uptake due to an early adrenal metastasis is also seen in the left adrenal gland. Follow-up PET-CT was performed at an outside institution 3 months after the initiation of chemotherapy and revealed subsequent resolution of these PET and CT findings, indicating successfully treated lymphomatous adrenal gland involvement. Fusion PET-CT may be of value in lymphoma patients with equivocal CT findings, either before or after treatment.

 

View larger version (113K): [in this window] [in a new window] [Download PPT slide]   Figure 7c.  Lymphomatous adrenal gland involvement in a 23-year-old woman with Burkitt lymphoma of the left breast. Axial (a–c) and coronal (d–f) CT (a, d), PET (b, e), and fused PET-CT (c, f) images show a 2 x 1-cm mass in the right adrenal gland (arrow) with an unenhanced CT attenuation of 49 HU, an indeterminate finding that is nonetheless suspicious for malignancy. Mild FDG uptake due to an early adrenal metastasis is also seen in the left adrenal gland. Follow-up PET-CT was performed at an outside institution 3 months after the initiation of chemotherapy and revealed subsequent resolution of these PET and CT findings, indicating successfully treated lymphomatous adrenal gland involvement. Fusion PET-CT may be of value in lymphoma patients with equivocal CT findings, either before or after treatment.

 

View larger version (119K): [in this window] [in a new window] [Download PPT slide]   Figure 7d.  Lymphomatous adrenal gland involvement in a 23-year-old woman with Burkitt lymphoma of the left breast. Axial (a–c) and coronal (d–f) CT (a, d), PET (b, e), and fused PET-CT (c, f) images show a 2 x 1-cm mass in the right adrenal gland (arrow) with an unenhanced CT attenuation of 49 HU, an indeterminate finding that is nonetheless suspicious for malignancy. Mild FDG uptake due to an early adrenal metastasis is also seen in the left adrenal gland. Follow-up PET-CT was performed at an outside institution 3 months after the initiation of chemotherapy and revealed subsequent resolution of these PET and CT findings, indicating successfully treated lymphomatous adrenal gland involvement. Fusion PET-CT may be of value in lymphoma patients with equivocal CT findings, either before or after treatment.

 

View larger version (97K): [in this window] [in a new window] [Download PPT slide]   Figure 7e.  Lymphomatous adrenal gland involvement in a 23-year-old woman with Burkitt lymphoma of the left breast. Axial (a–c) and coronal (d–f) CT (a, d), PET (b, e), and fused PET-CT (c, f) images show a 2 x 1-cm mass in the right adrenal gland (arrow) with an unenhanced CT attenuation of 49 HU, an indeterminate finding that is nonetheless suspicious for malignancy. Mild FDG uptake due to an early adrenal metastasis is also seen in the left adrenal gland. Follow-up PET-CT was performed at an outside institution 3 months after the initiation of chemotherapy and revealed subsequent resolution of these PET and CT findings, indicating successfully treated lymphomatous adrenal gland involvement. Fusion PET-CT may be of value in lymphoma patients with equivocal CT findings, either before or after treatment.

 

View larger version (67K): [in this window] [in a new window] [Download PPT slide]   Figure 7f.  Lymphomatous adrenal gland involvement in a 23-year-old woman with Burkitt lymphoma of the left breast. Axial (a–c) and coronal (d–f) CT (a, d), PET (b, e), and fused PET-CT (c, f) images show a 2 x 1-cm mass in the right adrenal gland (arrow) with an unenhanced CT attenuation of 49 HU, an indeterminate finding that is nonetheless suspicious for malignancy. Mild FDG uptake due to an early adrenal metastasis is also seen in the left adrenal gland. Follow-up PET-CT was performed at an outside institution 3 months after the initiation of chemotherapy and revealed subsequent resolution of these PET and CT findings, indicating successfully treated lymphomatous adrenal gland involvement. Fusion PET-CT may be of value in lymphoma patients with equivocal CT findings, either before or after treatment.

 

View larger version (137K): [in this window] [in a new window] [Download PPT slide]   Figure 8a.  Collision tumors in a 46-year-old man with a history of high-grade leiomyosarcoma of the right spermatic cord. (a–f) Axial (a–c) and coronal (d–f) unenhanced CT (a, d), PET (b, e), and fused PET-CT (c, f) images show a well-circumscribed 25-mm mass in the superior portion of the left adrenal gland at CT and PET-CT (arrow in a, c, d, and f) without concordant FDG avidity (arrow in b and e). The mass had an attenuation of 4 HU at CT, a finding that, together with the size and well-defined margins of the mass, is consistent with an adenoma by established CT criteria. (g–l) On axial (g–i) and coronal (j–l) un-enhanced CT (g, j), PET (h, k), and fused PET-CT (i, l) images, the inferior left limb of the gland has subtle thickening but higher attenuation at CT and intensely increased uptake at PET, and is shown to be the source of the increased uptake at PET-CT (arrow). Specimens obtained from the superior and inferior limbs at fine-needle aspiration biopsy and core biopsy helped confirm the coexistence of an adenoma in the superior gland that was not FDG avid and a metastasis in the inferior limb that accounted for the focus of increased FDG avidity.

 

View larger version (81K): [in this window] [in a new window] [Download PPT slide]   Figure 8b.  Collision tumors in a 46-year-old man with a history of high-grade leiomyosarcoma of the right spermatic cord. (a–f) Axial (a–c) and coronal (d–f) unenhanced CT (a, d), PET (b, e), and fused PET-CT (c, f) images show a well-circumscribed 25-mm mass in the superior portion of the left adrenal gland at CT and PET-CT (arrow in a, c, d, and f) without concordant FDG avidity (arrow in b and e). The mass had an attenuation of 4 HU at CT, a finding that, together with the size and well-defined margins of the mass, is consistent with an adenoma by established CT criteria. (g–l) On axial (g–i) and coronal (j–l) un-enhanced CT (g, j), PET (h, k), and fused PET-CT (i, l) images, the inferior left limb of the gland has subtle thickening but higher attenuation at CT and intensely increased uptake at PET, and is shown to be the source of the increased uptake at PET-CT (arrow). Specimens obtained from the superior and inferior limbs at fine-needle aspiration biopsy and core biopsy helped confirm the coexistence of an adenoma in the superior gland that was not FDG avid and a metastasis in the inferior limb that accounted for the focus of increased FDG avidity.

 

View larger version (122K): [in this window] [in a new window] [Download PPT slide]   Figure 8c.  Collision tumors in a 46-year-old man with a history of high-grade leiomyosarcoma of the right spermatic cord. (a–f) Axial (a–c) and coronal (d–f) unenhanced CT (a, d), PET (b, e), and fused PET-CT (c, f) images show a well-circumscribed 25-mm mass in the superior portion of the left adrenal gland at CT and PET-CT (arrow in a, c, d, and f) without concordant FDG avidity (arrow in b and e). The mass had an attenuation of 4 HU at CT, a finding that, together with the size and well-defined margins of the mass, is consistent with an adenoma by established CT criteria. (g–l) On axial (g–i) and coronal (j–l) un-enhanced CT (g, j), PET (h, k), and fused PET-CT (i, l) images, the inferior left limb of the gland has subtle thickening but higher attenuation at CT and intensely increased uptake at PET, and is shown to be the source of the increased uptake at PET-CT (arrow). Specimens obtained from the superior and inferior limbs at fine-needle aspiration biopsy and core biopsy helped confirm the coexistence of an adenoma in the superior gland that was not FDG avid and a metastasis in the inferior limb that accounted for the focus of increased FDG avidity.

 

View larger version (134K): [in this window] [in a new window] [Download PPT slide]   Figure 8d.  Collision tumors in a 46-year-old man with a history of high-grade leiomyosarcoma of the right spermatic cord. (a–f) Axial (a–c) and coronal (d–f) unenhanced CT (a, d), PET (b, e), and fused PET-CT (c, f) images show a well-circumscribed 25-mm mass in the superior portion of the left adrenal gland at CT and PET-CT (arrow in a, c, d, and f) without concordant FDG avidity (arrow in b and e). The mass had an attenuation of 4 HU at CT, a finding that, together with the size and well-defined margins of the mass, is consistent with an adenoma by established CT criteria. (g–l) On axial (g–i) and coronal (j–l) un-enhanced CT (g, j), PET (h, k), and fused PET-CT (i, l) images, the inferior left limb of the gland has subtle thickening but higher attenuation at CT and intensely increased uptake at PET, and is shown to be the source of the increased uptake at PET-CT (arrow). Specimens obtained from the superior and inferior limbs at fine-needle aspiration biopsy and core biopsy helped confirm the coexistence of an adenoma in the superior gland that was not FDG avid and a metastasis in the inferior limb that accounted for the focus of increased FDG avidity.

 

View larger version (108K): [in this window] [in a new window] [Download PPT slide]   Figure 8e.  Collision tumors in a 46-year-old man with a history of high-grade leiomyosarcoma of the right spermatic cord. (a–f) Axial (a–c) and coronal (d–f) unenhanced CT (a, d), PET (b, e), and fused PET-CT (c, f) images show a well-circumscribed 25-mm mass in the superior portion of the left adrenal gland at CT and PET-CT (arrow in a, c, d, and f) without concordant FDG avidity (arrow in b and e). The mass had an attenuation of 4 HU at CT, a finding that, together with the size and well-defined margins of the mass, is consistent with an adenoma by established CT criteria. (g–l) On axial (g–i) and coronal (j–l) un-enhanced CT (g, j), PET (h, k), and fused PET-CT (i, l) images, the inferior left limb of the gland has subtle thickening but higher attenuation at CT and intensely increased uptake at PET, and is shown to be the source of the increased uptake at PET-CT (arrow). Specimens obtained from the superior and inferior limbs at fine-needle aspiration biopsy and core biopsy helped confirm the coexistence of an adenoma in the superior gland that was not FDG avid and a metastasis in the inferior limb that accounted for the focus of increased FDG avidity.

 

View larger version (74K): [in this window] [in a new window] [Download PPT slide]   Figure 8f.  Collision tumors in a 46-year-old man with a history of high-grade leiomyosarcoma of the right spermatic cord. (a–f) Axial (a–c) and coronal (d–f) unenhanced CT (a, d), PET (b, e), and fused PET-CT (c, f) images show a well-circumscribed 25-mm mass in the superior portion of the left adrenal gland at CT and PET-CT (arrow in a, c, d, and f) without concordant FDG avidity (arrow in b and e). The mass had an attenuation of 4 HU at CT, a finding that, together with the size and well-defined margins of the mass, is consistent with an adenoma by established CT criteria. (g–l) On axial (g–i) and coronal (j–l) un-enhanced CT (g, j), PET (h, k), and fused PET-CT (i, l) images, the inferior left limb of the gland has subtle thickening but higher attenuation at CT and intensely increased uptake at PET, and is shown to be the source of the increased uptake at PET-CT (arrow). Specimens obtained from the superior and inferior limbs at fine-needle aspiration biopsy and core biopsy helped confirm the coexistence of an adenoma in the superior gland that was not FDG avid and a metastasis in the inferior limb that accounted for the focus of increased FDG avidity.

 

View larger version (130K): [in this window] [in a new window] [Download PPT slide]   Figure 8g.  Collision tumors in a 46-year-old man with a history of high-grade leiomyosarcoma of the right spermatic cord. (a–f) Axial (a–c) and coronal (d–f) unenhanced CT (a, d), PET (b, e), and fused PET-CT (c, f) images show a well-circumscribed 25-mm mass in the superior portion of the left adrenal gland at CT and PET-CT (arrow in a, c, d, and f) without concordant FDG avidity (arrow in b and e). The mass had an attenuation of 4 HU at CT, a finding that, together with the size and well-defined margins of the mass, is consistent with an adenoma by established CT criteria. (g–l) On axial (g–i) and coronal (j–l) un-enhanced CT (g, j), PET (h, k), and fused PET-CT (i, l) images, the inferior left limb of the gland has subtle thickening but higher attenuation at CT and intensely increased uptake at PET, and is shown to be the source of the increased uptake at PET-CT (arrow). Specimens obtained from the superior and inferior limbs at fine-needle aspiration biopsy and core biopsy helped confirm the coexistence of an adenoma in the superior gland that was not FDG avid and a metastasis in the inferior limb that accounted for the focus of increased FDG avidity.

 

View larger version (87K): [in this window] [in a new window] [Download PPT slide]   Figure 8h.  Collision tumors in a 46-year-old man with a history of high-grade leiomyosarcoma of the right spermatic cord. (a–f) Axial (a–c) and coronal (d–f) unenhanced CT (a, d), PET (b, e), and fused PET-CT (c, f) images show a well-circumscribed 25-mm mass in the superior portion of the left adrenal gland at CT and PET-CT (arrow in a, c, d, and f) without concordant FDG avidity (arrow in b and e). The mass had an attenuation of 4 HU at CT, a finding that, together with the size and well-defined margins of the mass, is consistent with an adenoma by established CT criteria. (g–l) On axial (g–i) and coronal (j–l) un-enhanced CT (g, j), PET (h, k), and fused PET-CT (i, l) images, the inferior left limb of the gland has subtle thickening but higher attenuation at CT and intensely increased uptake at PET, and is shown to be the source of the increased uptake at PET-CT (arrow). Specimens obtained from the superior and inferior limbs at fine-needle aspiration biopsy and core biopsy helped confirm the coexistence of an adenoma in the superior gland that was not FDG avid and a metastasis in the inferior limb that accounted for the focus of increased FDG avidity.

 

View larger version (114K): [in this window] [in a new window] [Download PPT slide]   Figure 8i.  Collision tumors in a 46-year-old man with a history of high-grade leiomyosarcoma of the right spermatic cord. (a–f) Axial (a–c) and coronal (d–f) unenhanced CT (a, d), PET (b, e), and fused PET-CT (c, f) images show a well-circumscribed 25-mm mass in the superior portion of the left adrenal gland at CT and PET-CT (arrow in a, c, d, and f) without concordant FDG avidity (arrow in b and e). The mass had an attenuation of 4 HU at CT, a finding that, together with the size and well-defined margins of the mass, is consistent with an adenoma by established CT criteria. (g–l) On axial (g–i) and coronal (j–l) un-enhanced CT (g, j), PET (h, k), and fused PET-CT (i, l) images, the inferior left limb of the gland has subtle thickening but higher attenuation at CT and intensely increased uptake at PET, and is shown to be the source of the increased uptake at PET-CT (arrow). Specimens obtained from the superior and inferior limbs at fine-needle aspiration biopsy and core biopsy helped confirm the coexistence of an adenoma in the superior gland that was not FDG avid and a metastasis in the inferior limb that accounted for the focus of increased FDG avidity.

 

View larger version (128K): [in this window] [in a new window] [Download PPT slide]   Figure 8j.  Collision tumors in a 46-year-old man with a history of high-grade leiomyosarcoma of the right spermatic cord. (a–f) Axial (a–c) and coronal (d–f) unenhanced CT (a, d), PET (b, e), and fused PET-CT (c, f) images show a well-circumscribed 25-mm mass in the superior portion of the left adrenal gland at CT and PET-CT (arrow in a, c, d, and f) without concordant FDG avidity (arrow in b and e). The mass had an attenuation of 4 HU at CT, a finding that, together with the size and well-defined margins of the mass, is consistent with an adenoma by established CT criteria. (g–l) On axial (g–i) and coronal (j–l) un-enhanced CT (g, j), PET (h, k), and fused PET-CT (i, l) images, the inferior left limb of the gland has subtle thickening but higher attenuation at CT and intensely increased uptake at PET, and is shown to be the source of the increased uptake at PET-CT (arrow). Specimens obtained from the superior and inferior limbs at fine-needle aspiration biopsy and core biopsy helped confirm the coexistence of an adenoma in the superior gland that was not FDG avid and a metastasis in the inferior limb that accounted for the focus of increased FDG avidity.

 

View larger version (109K): [in this window] [in a new window] [Download PPT slide]   Figure 8k.  Collision tumors in a 46-year-old man with a history of high-grade leiomyosarcoma of the right spermatic cord. (a–f) Axial (a–c) and coronal (d–f) unenhanced CT (a, d), PET (b, e), and fused PET-CT (c, f) images show a well-circumscribed 25-mm mass in the superior portion of the left adrenal gland at CT and PET-CT (arrow in a, c, d, and f) without concordant FDG avidity (arrow in b and e). The mass had an attenuation of 4 HU at CT, a finding that, together with the size and well-defined margins of the mass, is consistent with an adenoma by established CT criteria. (g–l) On axial (g–i) and coronal (j–l) un-enhanced CT (g, j), PET (h, k), and fused PET-CT (i, l) images, the inferior left limb of the gland has subtle thickening but higher attenuation at CT and intensely increased uptake at PET, and is shown to be the source of the increased uptake at PET-CT (arrow). Specimens obtained from the superior and inferior limbs at fine-needle aspiration biopsy and core biopsy helped confirm the coexistence of an adenoma in the superior gland that was not FDG avid and a metastasis in the inferior limb that accounted for the focus of increased FDG avidity.

 

View larger version (122K): [in this window] [in a new window] [Download PPT slide]   Figure 8l.  Collision tumors in a 46-year-old man with a history of high-grade leiomyosarcoma of the right spermatic cord. (a–f) Axial (a–c) and coronal (d–f) unenhanced CT (a, d), PET (b, e), and fused PET-CT (c, f) images show a well-circumscribed 25-mm mass in the superior portion of the left adrenal gland at CT and PET-CT (arrow in a, c, d, and f) without concordant FDG avidity (arrow in b and e). The mass had an attenuation of 4 HU at CT, a finding that, together with the size and well-defined margins of the mass, is consistent with an adenoma by established CT criteria. (g–l) On axial (g–i) and coronal (j–l) un-enhanced CT (g, j), PET (h, k), and fused PET-CT (i, l) images, the inferior left limb of the gland has subtle thickening but higher attenuation at CT and intensely increased uptake at PET, and is shown to be the source of the increased uptake at PET-CT (arrow). Specimens obtained from the superior and inferior limbs at fine-needle aspiration biopsy and core biopsy helped confirm the coexistence of an adenoma in the superior gland that was not FDG avid and a metastasis in the inferior limb that accounted for the focus of increased FDG avidity.

 

View larger version (125K): [in this window] [in a new window] [Download PPT slide]   Figure 9a.  Pheochromocytoma in a 42-year-old man with hypertension. The patient had a contraindication to MR imaging, and PET-CT was performed to assess for possible metastatic disease elsewhere versus adrenal pheochromocytoma. CT (a) and PET (b) scans show a left adrenal mass (arrow). The mass is indeterminate by CT criteria but demonstrates avid FDG uptake on the PET scan, a finding that suggests that the lesion is not an adenoma. The mass was the only focus of significant uptake; no other sites of abnormal uptake were seen that would suggest metastatic disease. Results of laboratory studies were equivocal but suggested pheochromocytoma, a diagnosis that was confirmed at pathologic analysis of the surgical specimen.

 

View larger version (93K): [in this window] [in a new window] [Download PPT slide]   Figure 9b.  Pheochromocytoma in a 42-year-old man with hypertension. The patient had a contraindication to MR imaging, and PET-CT was performed to assess for possible metastatic disease elsewhere versus adrenal pheochromocytoma. CT (a) and PET (b) scans show a left adrenal mass (arrow). The mass is indeterminate by CT criteria but demonstrates avid FDG uptake on the PET scan, a finding that suggests that the lesion is not an adenoma. The mass was the only focus of significant uptake; no other sites of abnormal uptake were seen that would suggest metastatic disease. Results of laboratory studies were equivocal but suggested pheochromocytoma, a diagnosis that was confirmed at pathologic analysis of the surgical specimen.

 

View larger version (138K): [in this window] [in a new window] [Download PPT slide]   Figure 10a.  Brown fat deposition in a 36-year-old woman with a history of breast cancer. (a–f) Axial (a–c) and coronal (d–f) CT (a, d), PET (b, e), and fused PET-CT (c, f) images show cervical foci of avid FDG uptake (arrowheads in d–f), as well as foci of uptake in the right periadrenal fat (arrow) with no abnormal uptake in the adrenal glands proper, a pattern that is consistent with brown fat deposition. (g–l) Axial (g–i) and coronal (j–l) CT (g, j), PET (h, k), and fused PET-CT (i, l) images show similar findings in the left periadrenal fat (arrow) with no abnormal uptake in the adrenal glands.

 

View larger version (74K): [in this window] [in a new window] [Download PPT slide]   Figure 10b.  Brown fat deposition in a 36-year-old woman with a history of breast cancer. (a–f) Axial (a–c) and coronal (d–f) CT (a, d), PET (b, e), and fused PET-CT (c, f) images show cervical foci of avid FDG uptake (arrowheads in d–f), as well as foci of uptake in the right periadrenal fat (arrow) with no abnormal uptake in the adrenal glands proper, a pattern that is consistent with brown fat deposition. (g–l) Axial (g–i) and coronal (j–l) CT (g, j), PET (h, k), and fused PET-CT (i, l) images show similar findings in the left periadrenal fat (arrow) with no abnormal uptake in the adrenal glands.

 

View larger version (113K): [in this window] [in a new window] [Download PPT slide]   Figure 10c.  Brown fat deposition in a 36-year-old woman with a history of breast cancer. (a–f) Axial (a–c) and coronal (d–f) CT (a, d), PET (b, e), and fused PET-CT (c, f) images show cervical foci of avid FDG uptake (arrowheads in d–f), as well as foci of uptake in the right periadrenal fat (arrow) with no abnormal uptake in the adrenal glands proper, a pattern that is consistent with brown fat deposition. (g–l) Axial (g–i) and coronal (j–l) CT (g, j), PET (h, k), and fused PET-CT (i, l) images show similar findings in the left periadrenal fat (arrow) with no abnormal uptake in the adrenal glands.

 

View larger version (122K): [in this window] [in a new window] [Download PPT slide]   Figure 10d.  Brown fat deposition in a 36-year-old woman with a history of breast cancer. (a–f) Axial (a–c) and coronal (d–f) CT (a, d), PET (b, e), and fused PET-CT (c, f) images show cervical foci of avid FDG uptake (arrowheads in d–f), as well as foci of uptake in the right periadrenal fat (arrow) with no abnormal uptake in the adrenal glands proper, a pattern that is consistent with brown fat deposition. (g–l) Axial (g–i) and coronal (j–l) CT (g, j), PET (h, k), and fused PET-CT (i, l) images show similar findings in the left periadrenal fat (arrow) with no abnormal uptake in the adrenal glands.

 

View larger version (94K): [in this window] [in a new window] [Download PPT slide]   Figure 10e.  Brown fat deposition in a 36-year-old woman with a history of breast cancer. (a–f) Axial (a–c) and coronal (d–f) CT (a, d), PET (b, e), and fused PET-CT (c, f) images show cervical foci of avid FDG uptake (arrowheads in d–f), as well as foci of uptake in the right periadrenal fat (arrow) with no abnormal uptake in the adrenal glands proper, a pattern that is consistent with brown fat deposition. (g–l) Axial (g–i) and coronal (j–l) CT (g, j), PET (h, k), and fused PET-CT (i, l) images show similar findings in the left periadrenal fat (arrow) with no abnormal uptake in the adrenal glands.