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Clinical Role of FDG PET in Evaluation of Cancer Patients¹

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

	Abstract

Top Abstract LEARNING OBJECTIVES FOR TEST... Introduction Normal Distribution of FDG Solitary Pulmonary Nodules Lung Cancer Colorectal Cancer Lymphoma Esophageal Cancer Malignant Melanoma Head and Neck Cancer Breast Cancer PET-CT Fusion Imaging Conclusions References

 
Positron emission tomography (PET) is a diagnostic imaging technique that allows identification of biochemical and physiologic alterations in tumors. Use of PET performed with 2-[fluorine-18]fluoro-2-deoxy-D-glucose (FDG) significantly improves the accuracy of tumor imaging. In terms of oncologic applications, FDG PET has already gained widespread acceptance in the initial staging of cancer, management of recurrent cancer, and monitoring the response to therapy. With conventional imaging modalities, size criteria are used to distinguish between benign and malignant disease in lymph nodes; conversely, FDG PET is based on identification of fundamental aspects of tumor metabolism. FDG uptake in tumors is proportional to the metabolic rate of viable tumor cells, which have an increased demand for glucose. The high sensitivity and high negative predictive value of FDG PET in most malignant tumors enable this technique to play an even greater role in tumor management at initial staging and follow-up.

© RSNA, 2003

Index Terms: Fluorine, radioactive • Neoplasms, PET, _**.12163², _**.30 • Neoplasms, staging • Positron emission tomography (PET), _**.12163

	LEARNING OBJECTIVES FOR TEST 2

Top Abstract LEARNING OBJECTIVES FOR TEST... Introduction Normal Distribution of FDG Solitary Pulmonary Nodules Lung Cancer Colorectal Cancer Lymphoma Esophageal Cancer Malignant Melanoma Head and Neck Cancer Breast Cancer PET-CT Fusion Imaging Conclusions References

 
After reading this article and taking the test, the reader will be able to:

• Discuss the value of FDG PET in comparison with those of conventional imaging modalities in initial staging and restaging of cancers.
  
• Describe the advantages of FDG PET over conventional imaging modalities in predicting therapy outcome or monitoring response to therapy.
  
• Identify the pitfalls of FDG PET in staging and in monitoring response to therapy.
  

	Introduction

Top Abstract LEARNING OBJECTIVES FOR TEST... Introduction Normal Distribution of FDG Solitary Pulmonary Nodules Lung Cancer Colorectal Cancer Lymphoma Esophageal Cancer Malignant Melanoma Head and Neck Cancer Breast Cancer PET-CT Fusion Imaging Conclusions References

 
Positron emission tomography (PET) is an advanced imaging tool for diagnosis, staging, and restaging of cancer. The method is based on identifying the increased glycolytic activity in malignant cells, in which glucose is preferentially concentrated due to an increase in membrane glucose transporters as well as to an increase in some of the principal enzymes, such as hexokinase, responsible for phosphorylation of glucose (1,2). 2-[fluorine-18]fluoro-2-deoxy-D-glucose (FDG) is transported into tumor cells, similarly to glucose, by means of glucose transporter proteins known as GLUT transporters and subsequently phosphorylated by hexokinase to FDG 6-phosphate. FDG 6-phosphate is not efficiently metabolized further and therefore accumulates within the cell. This process of "metabolic trapping" of FDG in the cell constitutes the basis for imaging the in vivo distribution of the tracer with FDG PET. It is possible to image the entire body in a single session, increasing the opportunity for finding unsuspected disease sites.

At present, the Centers for Medicare and Medicaid Services (formerly the Health Care Financing Administration) has approved expanded Medicare coverage for FDG PET for the following indications: diagnosis, initial staging, and restaging of non–small cell lung cancer, colorectal cancer, Hodgkin and non-Hodgkin lymphoma, esophageal cancer, melanoma, head and neck cancers, and breast cancer as well as characterization of solitary pulmonary nodules (Table). However, the current Medicare coverage does not include central nervous system, thyroid, hepatocellular, pancreatic, and genitourinary neoplasms.

	Normal Distribution of FDG

Top Abstract LEARNING OBJECTIVES FOR TEST... Introduction Normal Distribution of FDG Solitary Pulmonary Nodules Lung Cancer Colorectal Cancer Lymphoma Esophageal Cancer Malignant Melanoma Head and Neck Cancer Breast Cancer PET-CT Fusion Imaging Conclusions References

 
There are several sites of normal physiologic accumulation of FDG, hence FDG distribution is not limited to neoplastic tissues (Fig 1). The brain uses glucose as its primary substrate; consequently, accumulation is physiologically high in the cortex, basal ganglia, thalamus, and cerebellum. Although the myocardium uses free fatty acids as its primary substrate, it also uses glucose as an alternate substrate; up to 4% of the injected dose can accumulate within the myocardium depending on the relative availability of free fatty acids versus glucose. The biodistribution of FDG can be affected by blood glucose levels via the competitive displacement of FDG by the circulating glucose. There is no agreement as to adjusting glucose levels in diabetic patients. In type I diabetes, insulin is not recommended and FDG PET should be performed in the morning after an overnight fast. In type II diabetes, insulin may be used to manipulate glucose levels, although this requires patient monitoring and exaggerates physiologic muscle uptake. All patients should fast for at least 4–6 hours prior to the study to enhance and standardize tumor FDG uptake as well as to avoid the interference of the cardiac uptake for lesions in the chest.

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

In this review, potential sources of false-positive and false-negative findings are discussed under each disease category.

Quantitative evaluation of FDG PET images: FDG PET also provides quantitative data in the form of the standardized uptake value (SUV) or standardized uptake ratio (SUR). This is an uptake measurement that provides a means of comparison of FDG uptake between different lesions. Measurement of SUV requires attenuation correction to avoid the variability in FDG uptake due to the differences in tumor depth within the body. This value normalizes the tumor FDG uptake with the injected activity (Q_inj) and the body weight (W) (SUV = Q x W/Q_inj). However, SUV is dependent on the body weight. Therefore, correction with the lean body mass (SUV_LBM) is required to avoid erroneous comparisons that can stem from changes in pre- and posttherapy body weight in the same patient. In calculating SUVs, the administered dose, corrected for residual activity in the syringe and tubing, must also be accurately determined and the dose must be decay corrected to the time of imaging.

	Solitary Pulmonary Nodules

Top Abstract LEARNING OBJECTIVES FOR TEST... Introduction Normal Distribution of FDG Solitary Pulmonary Nodules Lung Cancer Colorectal Cancer Lymphoma Esophageal Cancer Malignant Melanoma Head and Neck Cancer Breast Cancer PET-CT Fusion Imaging Conclusions References

 
There is no size criterion that allows reliable distinction of benign from malignant solitary pulmonary nodules. Although 80% of benign solitary pulmonary nodules are less than 2 cm in diameter, small size is not consistent with benignity, since approximately 42% of malignant nodules are less than 2 cm in diameter (6). The overall sensitivity and specificity of FDG PET are 92% and 90%, respectively, for detection of malignancy in nodules between 0.7 and 4 cm in diameter (7) (Fig 2). FDG PET has been approved by the Centers for Medicare and Medicaid Services as a substitute for CT-directed needle biopsy. In a recent meta-analysis, FDG PET was reported to have a sensitivity of 97% and a specificity of 78% in characterizing solitary pulmonary nodules (8). In this analysis, no difference was found in the accuracy of FDG PET between nodules 1 cm in diameter and those larger than 1 cm, although few data exist for nodules smaller than 1 cm. Notwithstanding the controversial views, SUVs of 2.5 or greater have been used as a cutoff value indicative of malignancy (7,9). In brief, evaluation of solitary pulmonary nodules with FDG PET allows patients to be followed up with sequential imaging rather than invasive procedures.

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

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

	Lung Cancer

Top Abstract LEARNING OBJECTIVES FOR TEST... Introduction Normal Distribution of FDG Solitary Pulmonary Nodules Lung Cancer Colorectal Cancer Lymphoma Esophageal Cancer Malignant Melanoma Head and Neck Cancer Breast Cancer PET-CT Fusion Imaging Conclusions References

Initial Staging of NSCLC
In the staging of NSCLC, FDG PET is not recommended for determination of tumor size or invasion into adjacent tissues (T3 status of the tumor). However, FDG PET has been successfully used in mediastinal nodal staging and detection of distant metastases (Fig 3). Staging with CT and magnetic resonance (MR) imaging has been reported to have a sensitivity of 50%–60%, whereas mediastinoscopy has a sensitivity and specificity of 87% and 91%, respectively (10,11). A recent comprehensive study reported a sensitivity of 93% and specificity of 99% for FDG PET versus 72% and 94% for CT, respectively (12). The sensitivity and specificity of FDG PET for nodal involvement are comparable with those of mediastinoscopy; however, its sensitivity is limited for micrometastases, which require tissue biopsy (13). Owing to its high negative predictive value (approximately 94%), FDG PET combined with chest CT preoperatively may alleviate the need for surgical staging in FDG PET–negative cases. However, with a positive FDG PET result, further diagnostic procedures should still be pursued to avoid overstaging.

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

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

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

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

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

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

FDG PET can demonstrate changes in metabolism after treatment and may be a better indicator of a favorable response to therapy than the decrease in tumor size determined with CT. However, it has been suggested that a relative decrease in FDG uptake may indicate only a partial response resulting from destruction of cells sensitive to chemotherapy while resistant cells continue to grow (18). Nevertheless, normalization of FDG uptake after treatment appears to be an indicator of a good prognosis (19) (Fig 5). In a recent study, all patients with negative posttherapy FDG PET scans were alive 2 years after the completion of treatment, whereas 50% of patients with residual FDG uptake did not survive within that same period (16,17,19) (Fig 6).

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

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

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

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

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

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

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

Tumors with low metabolic activity such as bronchioloalveolar carcinoma and carcinoid tumors can give rise to false-negative results. Occasionally, well-differentiated adenocarcinomas have relatively less intense FDG accumulation, particularly lesions smaller than 1.0 cm in diameter.

	Colorectal Cancer

Top Abstract LEARNING OBJECTIVES FOR TEST... Introduction Normal Distribution of FDG Solitary Pulmonary Nodules Lung Cancer Colorectal Cancer Lymphoma Esophageal Cancer Malignant Melanoma Head and Neck Cancer Breast Cancer PET-CT Fusion Imaging Conclusions References

 
Adenocarcinoma of the large intestine is the third most common malignancy in the United States, representing 15% of all cancers. If diagnosed in its early stage, this common malignancy is highly curable with surgical treatment.

Initial Staging of Colorectal Cancer
FDG PET is sensitive for primary colorectal carcinoma; however, it does not supplant the current morphologic imaging modalities at initial staging, as FDG PET scanners lack the resolution required to evaluate the depth of tumor penetration through the bowel wall. At the primary site, the negative predictive value of FDG PET is greater than the positive predictive value (100% vs 90%) due to the false-positive FDG PET findings of inflammatory processes (22).

The main role of FDG PET in staging colorectal cancer is the assessment of regional lymph node involvement and distal metastases. In a recent study, the sensitivity of both FDG PET and CT in detecting involved regional lymph nodes was 29%, whereas the specificity of FDG PET was higher (96% vs 85%) (22,23). False-negative findings in regional metastatic lymph nodes are usually due to the intense FDG uptake by the primary site, which obscures the adjacent structures. At initial surgery for primary colorectal carcinoma, hepatic metastases are present in 10%–25% of patients (24). FDG PET is superior to CT for identification of hepatic metastases, with a sensitivity of 88% versus 38% and a specificity of 100% versus 97% (22).

Recurrent Colon Cancer and Evaluation of Response to Therapy
The recurrence rate after curative resection of the primary tumor is 10%–40% (25). Approximately 25% of first colorectal cancer recurrences are isolated locoregional failures. An additional 15%–20% are detected as metastatic deposits and are potentially resectable for cure (26). Despite the convenience of CT in the detection of pelvic recurrences, this technique is limited by low specificity (27). The use of T1- and T2-weighted MR imaging may help differentiate local recurrences from scar tissue, although there are still limitations with respect to the tumor size and specificity (28). A correlation has been observed between reduction of the tumor FDG metabolism 5 weeks after systemic treatment and therapy outcome, with sensitivities of 100% and 75%, respectively (29,30). In patients treated with novel therapies such as radio-frequency ablation or a combination of cryotherapy and hepatic artery chemotherapy, FDG PET may be more accurate than CT in distinguishing posttherapy changes from recurrent or residual tumor (31) (Fig 8).

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

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

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

Local-Pelvic Recurrence.— FDG PET accurately demonstrates recurrent colorectal cancer in patients who have indeterminate findings at CT or MR imaging (32–35) (Fig 9). In a meta-analysis of 366 patients, the sensitivity and specificity of FDG PET for local-pelvic recurrences were 95% and 97%, respectively (36). Nonetheless, correlation with CT is recommended to avoid misinterpretations in cases of inflammatory lesions and bladder diverticula.

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

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

In patients suspected of having recurrent colorectal cancer, FDG PET can favorably influence therapeutic management in up to 31% of patients by indicating a change in the surgical decision (38).

Hepatic and Abdominal Metastases.— Surgical resection is the only potential cure in patients with intrahepatic metastases, whereas extrahepatic disease excludes curative surgery. FDG PET has a greater sensitivity and specificity than conventional imaging modalities in depicting hepatic and extrahepatic recurrent colorectal cancer (33,39). The sensitivity and specificity of FDG PET in detection of recurrences in the liver are 96% and 97%, respectively (Fig 10). FDG PET may reveal unexpected extrahepatic metastases leading to patient treatment changes in 18%–43%of patients with suspected recurrent or metastatic colorectal cancer (33,37).

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

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

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

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

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

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

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

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

False-negative FDG PET results may occur in lesions smaller than 1 cm in diameter, particularly in the liver (47). MR imaging techniques such as breath-hold contrast material–enhanced arterial phase imaging may demonstrate subtle metastases undetected with FDG PET. Also, false-negative results in metastatic lymph nodes appear to stem from the lesser extent of the involvement (micrometastases) and the proximity of the involved lymph node to the primary site.

	Lymphoma

Top Abstract LEARNING OBJECTIVES FOR TEST... Introduction Normal Distribution of FDG Solitary Pulmonary Nodules Lung Cancer Colorectal Cancer Lymphoma Esophageal Cancer Malignant Melanoma Head and Neck Cancer Breast Cancer PET-CT Fusion Imaging Conclusions References

 
Non-Hodgkin lymphomas are the sixth most common cause of cancer-related deaths in the United States. Non-Hodgkin lymphomas are more than five times as common as Hodgkin disease. Both types of lymphoma are potentially curable, and treatment options vary greatly with the initial stage of the disease.

Initial Staging of Lymphoma
Nodal Involvement.— FDG PET demonstrates disease sites equally in both non-Hodgkin lymphoma and Hodgkin disease (48–55). FDG PET has a high sensitivity for detecting nodal disease regardless of the lesion site and size (48). FDG uptake is usually comparable in all grades of non-Hodgkin lymphoma. However, low-grade lymphomas may have a lower degree of FDG uptake compared with high-grade lymphomas. Qualitative interpretation is sufficient for staging, whereas quantitative analysis may be useful in determining the malignancy grade in non-Hodgkin lymphoma (55).

The diagnostic efficiency of FDG PET is equivalent or superior to that of CT in staging malignant lymphoma prior to therapy (56). FDG PET may "upstage" patients by revealing additional disease sites. FDG PET has been reported to demonstrate significantly more lesions than gallium-67 single photon emission CT, indicating higher sensitivity for FDG PET (48).

Extranodal Involvement.— In 20%–30% of patients, infradiaphragmatic disease (mainly splenic) is diagnosed only at staging laparotomy (57). The sensitivity of CT is 15%–37% for splenic infiltration and 19%–33% for liver infiltration (57). Ga-67 imaging is limited in evaluation of the abdomen due to the physiologic bowel uptake. Despite the physiologic FDG accumulation in the liver, FDG PET is able to demonstrate liver lesions (58). Several studies have illustrated the superiority of FDG PET over CT in the detection of hepatic and splenic extranodal lesions (55,59).

Central nervous system lymphomas have considerably high FDG uptake compared with the adjacent gray matter. FDG PET can be used to differentiate primary central nervous system lymphoma from infectious lesions associated with acquired immunodeficiency syndrome (59).

Detection of bone marrow involvement with FDG PET is controversial. Physiologic bone marrow uptake can be observed on FDG PET images. Diffusely increased uptake is not specific to bone marrow involvement and is usually observed in reactive bone marrow, particularly following chemotherapy and administration of growth factor (eg, granulocyte colony-stimulating factor) (5,60,61) (Fig 13). In addition, in patients with limited involvement of the bone marrow, FDG PET findings may be false-negative.

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

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

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

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

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

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

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

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

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

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

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

	Esophageal Cancer

Top Abstract LEARNING OBJECTIVES FOR TEST... Introduction Normal Distribution of FDG Solitary Pulmonary Nodules Lung Cancer Colorectal Cancer Lymphoma Esophageal Cancer Malignant Melanoma Head and Neck Cancer Breast Cancer PET-CT Fusion Imaging Conclusions References

Initial Staging of Esophageal Cancer
FDG PET is sensitive for detection of both primary squamous cell carcinoma as well as adenocarcinoma of the esophagus (71–75). Squamous cell carcinomas usually originate from the proximal esophagus, whereas adenocarcinomas occur in the distal esophagus near the gastroesophageal junction (Fig 18). The sensitivity of FDG PET is not adequate in small T1 tumors and in detecting local invasion due to its limited resolution. Staging with endoscopic ultrasonography (US) is highly effective for evaluation of locoregional invasion and discrimination of stages T1 and T2 from stages T3 and T4 for distal esophageal carcinomas (76).

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

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

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

FDG PET is more accurate than combined CT and endoscopic US for detection of stage IV disease, and the results affect surgical management in approximately 22% of patients (71,72, 74). In esophageal cancer, involvement of the supraclavicular, cervical, and celiac nodes is considered distant metastasis and precludes curative surgery. In 9%–28% of patients, distant metastases can be detected only with FDG PET (71,72,74) (Fig 19). Hence, FDG PET is helpful in distinguishing between resectable and unresectable disease and thereby avoiding unnecessary surgery. The use of FDG PET in patients with esophageal cancer leads to more accurate staging and allows more accurate stratification of patients into surgical and multimodality protocols.

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

False-positive and False-negative Findings
Gastric mucosa may demonstrate significant FDG uptake, posing potential confusion in tumors of the gastroesophageal junction. Mild FDG uptake may be seen in the normal esophagus, possibly due to smooth muscle activity or reflux esophagitis. In patients who have undergone recent radiation therapy, 8–12 weeks should elapse before an FDG PET study to avoid false-positive findings of radiation-induced esophagitis. Surgery performed 4 weeks prior to scanning may result in false-positive FDG uptake in areas of resolving inflammation.

When disease is located near the sites of physiologic uptake (heart, bladder, kidney, liver), FDG PET should be complemented by other imaging modalities to minimize false-negative findings.

	Malignant Melanoma

Top Abstract LEARNING OBJECTIVES FOR TEST... Introduction Normal Distribution of FDG Solitary Pulmonary Nodules Lung Cancer Colorectal Cancer Lymphoma Esophageal Cancer Malignant Melanoma Head and Neck Cancer Breast Cancer PET-CT Fusion Imaging Conclusions References

 
Melanoma is becoming a more common disease, with a 12% increase in incidence since 1995. The death rate for melanoma has also doubled in the past 35 years, with increases of approximately 5% per year in the older white population.

Initial Staging of Melanoma
FDG PET is most useful in evaluation of high-risk (thickness > 1.5 mm) or advanced-stage melanoma. Accurate identification of locoregional and distant metastases is important in determining the most appropriate therapeutic intervention. FDG PET has sensitivity rates of 91%–96% for areas of known melanoma, but the sensitivity decreases when the tumor size is less than 5 mm (77). The sensitivity of FDG PET is only 17% in detecting locoregional metastases in stage I and II disease (78–80). Such cases of minimal tumor volumes are more accurately staged with sentinel node scintigraphy with intraoperative probing and biopsy, which has a sensitivity of 94% and specificity of 100% (79). Acland et al (80) reported that FDG PET could not demonstrate metastatic disease identified with sentinel node biopsy in patients with melanoma less than 1.5 mm thick. In early-stage melanoma, however, CT may yield false-positive results in up to 22% of cases; hence, FDG PET can complement CT in this group of patients (81).

FDG PET is superior to morphologic imaging modalities for detection of metastatic melanoma in patients with high-risk melanoma (82). FDG PET and CT have site sensitivities of 94% versus 55% and specificities of 94% versus 84%, respectively (83,84) (Fig 20). Although metastases can be detected with FDG PET earlier than with conventional imaging, CT may be more sensitive than FDG PET for small pulmonary lesions (82,83).

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

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

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

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

Small lesions (<0.5 cm in diameter) with no mass effect and cerebral metastases may be false-negative at FDG PET.

	Head and Neck Cancer

Top Abstract LEARNING OBJECTIVES FOR TEST... Introduction Normal Distribution of FDG Solitary Pulmonary Nodules Lung Cancer Colorectal Cancer Lymphoma Esophageal Cancer Malignant Melanoma Head and Neck Cancer Breast Cancer PET-CT Fusion Imaging Conclusions References

 
Head and neck cancers represent 2%–3% of cancer cases in the United States and primarily consist of squamous cell carcinomas of the nasopharynx, oral cavity, and larynx. Accurate identification of distant disease in head and neck carcinoma patients is critical to determine the appropriate therapeutic approach and prognosis. FDG PET is not reimbursable for central nervous system and thyroid neoplasms at this time.

Initial Staging of Head and Neck Cancer
Accurate pretherapy lymph node staging is essential for planning surgical strategy in patients with resectable head and neck squamous cell carcinoma (Fig 22). In patients with nonresectable disease, individualized radiation therapy also requires precise definition of metastatic involvement. CT and MR imaging lack sensitivity and specificity in evaluation of the locoregional lymph nodes due to their dependence on size criteria. Lymph node staging of head and neck squamous cell carcinomas with FDG PET is more accurate than with conventional imaging modalities (85–88). The diagnostic accuracy of FDG PET for detecting lymph node metastases is superior to those of conventional modalities, with a sensitivity and a specificity of up to 90% and 94%, respectively, compared with CT values of up to 82% and 85%, respectively, and MR imaging values of up to 88% and 79%, respectively, obtained in various studies (87,88). For example, an enlarged or borderline node at CT may represent a benign reactive process, and a negative FDG PET scan in the corresponding region may spare the patient an unnecessary neck dissection. Conversely, a small node that is FDG PET positive may warrant additional surgical exploration.

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

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

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

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

Recurrent Head and Neck Cancer and Evaluation of Response to Therapy
After radiation therapy and surgery, distortion of anatomic structures limits the ability of MR imaging and CT to demonstrate residual or recurrent disease. Accurate detection of residual disease or early recurrence with FDG PET allows a change in patient treatment. The sensitivity of FDG PET in detecting residual or recurrent disease at the primary site (86) is comparable with those of CT and MR imaging (88%–100% vs 70%–92%), but its specificity is superior (75%–100% vs 50%–57%) (90–92) (Fig 23). In assessment of posttreatment nodal status, FDG PET is also more specific than CT or MR imaging in detecting residual or recurrent lymph node metastases (91,92).

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

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

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

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

FDG PET is less useful than conventional diagnostic methods in classifying salivary gland tumors as benign or malignant (97).

False-positive and False-negative Findings
Postsurgical inflammatory changes particularly in the oral mucosa, paranasal sinuses, palatine tonsils, reactive inflammatory cervical lymph nodes, and laryngeal muscles due to vocalization may cause false-positive results. In addition, asymmetry of laryngeal muscle activity may occur due to local paralysis of the vocal cord (Fig 7).

FDG PET performed earlier than 4 months after completion of radiation therapy, necrotic tumors, and small tumors (<0.5 cm in diameter) may cause false-negative results (94).

	Breast Cancer

Top Abstract LEARNING OBJECTIVES FOR TEST... Introduction Normal Distribution of FDG Solitary Pulmonary Nodules Lung Cancer Colorectal Cancer Lymphoma Esophageal Cancer Malignant Melanoma Head and Neck Cancer Breast Cancer PET-CT Fusion Imaging Conclusions References

 
Breast cancer is the most common malignancy in women in the United States. The main role of FDG PET in breast cancer is determination of metastatic disease. FDG PET is also useful in patients with nonpalpable lesions or dense breasts, after mammaplasty, and after mammography with equivocal results. The sensitivity and specificity of FDG PET in detection of primary breast carcinoma both range from 80% to 100% (98–102). FDG PET has not been shown to be useful in estimating tumor biologic behavior such as histologic tumor type (ductal vs lobular), microscopic tumor growth pattern (nodular vs diffuse), cell proliferation, and axillary lymph node status (103).

Initial Staging of Breast Cancer
The most important advantage of FDG PET at initial staging is the detection of unsuspected distant metastases in a single scanning session (Fig 25). FDG PET also allows detection of metastases of the internal mammary lymph nodes, which are not routinely sampled under the current standard of care (104).

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

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

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

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

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

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

Hathaway et al (110) demonstrated the benefit of combined FDG PET and MR imaging for determination of axillary recurrence in patients treated with axillary lymph node dissection.

In a study of 75 patients, Bender et al (111) found that FDG PET demonstrated six local recurrences and eight nodal and seven bone metastases not seen at CT or MR imaging. In a study of 57 patients, the sensitivity and specificity of FDG PET in detecting recurrence were 93% and 79%, respectively (112). Cook and Fogelman (113) compared FDG PET with bone scintigraphy in 23 patients with skeletal metastases from breast cancer. They concluded that FDG PET was superior to bone scintigraphy in detecting osteolytic metastases.

FDG PET is most beneficial as a monitoring tool in patients with locally advanced breast cancer who are undergoing induction therapy for advanced disease. Administration of chemotherapy before surgery in patients with locally advanced breast cancer is intended to "downstage" the primary tumor and eliminate occult distant metastases. Preliminary reports indicate that FDG PET may allow differentiation of responders from nonresponders (114,115) (Fig 27). In two studies of 22 and 30 patients, FDG PET allowed identification of responders to chemotherapy with a high sensitivity and accuracy even after the first and second cycles of therapy (115,116). If these data were confirmed, predicting the tumor response to therapy would alter management at an earlier stage.

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

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

False-negative results can occur when lesions are less than 1 cm in diameter or when the tumor is well differentiated, such as tubular carcinoma and carcinoma in situ. A high rate of false-negative findings has also been reported in lobular carcinomas (117).

	PET-CT Fusion Imaging

Top Abstract LEARNING OBJECTIVES FOR TEST... Introduction Normal Distribution of FDG Solitary Pulmonary Nodules Lung Cancer Colorectal Cancer Lymphoma Esophageal Cancer Malignant Melanoma Head and Neck Cancer Breast Cancer PET-CT Fusion Imaging Conclusions References

 
We cannot stress enough the value of new imaging systems combining two essential and complementary imaging modalities, PET and multisection CT, to create one integrated unit that allows both functional and anatomic imaging in a single study. These diversified units allow PET and CT image fusion for more accurate tumor localization and viability assessment. FDG is taken up by nonmalignant conditions such as infectious or inflammatory processes, particularly in the posttherapy setting. With registered imaging, one has the ability to precisely differentiate areas of physiologic or nonmalignant FDG uptake from those of malignant origin. PET-CT fusion changes impressions and increases diagnostic confidence. The precise identification of pathologic foci may substantially change patient treatment subsequent to changes in staging and prognostication.

In our experience, PET-CT fusion data led to a significant change in impression in 20% of oncologic cases. Even in cases where no change in impression occurred, there was greater diagnostic confidence. Among cases where PET-CT provided more confidence or changed the impression, most were in the abdomen and pelvis. CT fusion with PET increased sensitivity and specificity in 6% and 12% of patients, respectively (S.J.G., unpublished data, 2002). Charron et al (118) compared combined PET and CT images of different cancers with PET images alone. In 31% of cases, areas with variable amounts of normal physiologic FDG uptake were distinguished from potential uptake of FDG in a nearby neoplastic lesion. Consequently, combined PET-CT images are more effective than PET images alone in precisely localizing neoplastic lesions and in distinguishing normal variants from juxtaposed neoplastic lesions. Hence, PET-CT may affect patient treatment significantly and improve specificity more than sensitivity.

	Conclusions

Top Abstract LEARNING OBJECTIVES FOR TEST... Introduction Normal Distribution of FDG Solitary Pulmonary Nodules Lung Cancer Colorectal Cancer Lymphoma Esophageal Cancer Malignant Melanoma Head and Neck Cancer Breast Cancer PET-CT Fusion Imaging Conclusions References

 
Metabolic imaging with FDG PET is rapidly becoming an integral component in the management of oncologic disease. FDG PET and anatomic imaging modalities, such as CT or MR imaging, play complementary roles in allowing a more accurate overall evaluation of malignant processes. This is particularly valid in specific situations, such as differential diagnosis of indeterminate lesions at CT, differentiation of posttreatment changes from recurrent tumor, and monitoring the response to therapy. The most frequent use of FDG PET currently is in the staging of malignancies for which it is categorized as reimbursable by Medicare. FDG PET has also proved to be an accurate diagnostic tool in the early identification of refractory cancers, which can provide a basis for alternative treatment strategies in selected tumors. Finally, FDG PET decidedly contributes to management of other malignancies, such as central nervous system tumors and thyroid cancer as well as genitourinary tumors, and identification of the primary site in patients with unknown primary tumors. Widespread use of FDG PET for these broader indications awaits further evaluation.

The role of PET in tumor imaging will continue to expand as more indications are approved and newer more tumor-specific radiopharmaceutical agents are developed.

	Acknowledgments

 
We thank Michael Petrenko, RT(N)(R), Gordon Tellefsen, RT(N), George Nuviola, and Paul Lizotte for their kind assistance in supervising the FDG PET and correlative imaging studies and archiving the images. We also thank David Panush, MD, and Robert Krutman, MD, for their assistance in reviewing the manuscript.

	Footnotes

 
²_**. Multiple body systems

Abbreviations: FDG = 2-[F-18]fluoro-2-deoxy-D-glucose, NSCLC = non–small cell lung cancer, PET = positron emission tomography, SUV = standardized uptake value

	References

Top Abstract LEARNING OBJECTIVES FOR TEST... Introduction Normal Distribution of FDG Solitary Pulmonary Nodules Lung Cancer Colorectal Cancer Lymphoma Esophageal Cancer Malignant Melanoma Head and Neck Cancer Breast Cancer PET-CT Fusion Imaging Conclusions References

 

1. McGowan KM, Long SD, Pekala PH. Glucose transporter gene expression: regulation of transcription and mRNA stability. Pharmacol Ther 1995; 66:465-505.[CrossRef][Medline]
2. Wahl RL. Targeting glucose transporters for tumor imaging: "sweet" idea, "sour" result. J Nucl Med 1996; 37:1038-1041.[Free Full Text]
3. Kostakoglu L, Wong JCH, Barrington SF, et al. Speech-related visualization of laryngeal muscles with fluorine-18-FDG. J Nucl Med 1996; 37:1771-1773.[Abstract/Free Full Text]
4. Shreve PD, Anzai Y, Wahl RL. Pitfalls in oncologic diagnosis with FDG PET imaging: physiologic and benign variants. RadioGraphics 1999; 19:61-77.[Abstract/Free Full Text]
5. Abdel-Dayem HM, Rosen G, El-Zeftawy H, et al. Fluorine-18 fluorodeoxyglucose splenic uptake from extramedullary hematopoiesis after granulocyte colony-stimulating factor stimulation. Clin Nucl Med 1999; 24:319-322.[CrossRef][Medline]
6. Leef JL, Klein JS. The solitary pulmonary nodule. Radiol Clin North Am 2002; 40:123-143.[CrossRef][Medline]
7. Lowe VJ, Duhaylongsod FG, Patz EF, et al. Pulmonary abnormalities and PET data analysis: a retrospective study. Radiology 1997; 202:435-439.[Abstract/Free Full Text]
8. Gould MK, MacLean CC, Kuschner WG, et al. Accuracy of positron emission tomography for diagnosis of pulmonary nodules and mass lesions. JAMA 2001; 285:914-924.[Abstract/Free Full Text]
9. Lowe VJ, Fletcher JW, Gobar L, et al. Prospective investigation of PET in lung nodules. J Clin Oncol 1998; 16:1075-1084.[Abstract]
10. Webb WR, Gatsonis C, Zerhouni EA, et al. CT and MR imaging in staging non-small cell bronchogenic carcinoma: report of the Radiologic Diagnostic Oncology Group. Radiology 1991; 178:705-713.[Abstract/Free Full Text]
11. Gdeedo A, Van SP, Corthouts B, et al. Prospective evaluation of computed tomography and mediastinoscopy in mediastinal lymph node staging. Eur Respir J 1997; 10:1547-1551.[Abstract]
12. Steinert HC, Hauser M, Allemann F, et al. Non-small cell lung cancer: nodal staging with FDG PET versus CT with correlative lymph node mapping and sampling. Radiology 1997; 202:441-446.[Abstract/Free Full Text]
13. Poncelet AJ, Lonneux M, Coche E, Weynand B, Noirhomme P. PET-FDG scan enhances but does not replace preoperative surgical staging in non-small cell lung carcinoma. Eur J Cardiothorac Surg 2001; 20:468-474; discussion 474–475.[Abstract/Free Full Text]
14. Bury T, Dowlati A, Paulus P, et al. Evaluation of the solitary pulmonary nodule by positron emission tomography imaging. Eur Respir J 1996; 9:410-414.[Abstract]
15. Valk PE, Pounds TR, Hopkins DM, et al. Staging non-small cell lung cancer by whole-body positron emission tomographic imaging. Ann Thorac Surg 1995; 60:1573-1581.[Abstract/Free Full Text]
16. Hicks RJ, Kalff V, MacManus MP, et al. (18)F-FDG PET provides high-impact and powerful prognostic stratification in staging newly diagnosed non-small cell lung cancer. J Nucl Med 2001; 42:1596-1604.[Abstract/Free Full Text]
17. Hicks RJ, Kalff V, MacManus MP, et al. The utility of (18)F-FDG PET for suspected recurrent non-small cell lung cancer after potentially curative therapy: impact on management and prognostic stratification. J Nucl Med 2001; 42:1605-1613.[Abstract/Free Full Text]
18. Ichiya Y, Kuwabara Y, Otsuka M, et al. Assessment of response to cancer therapy using fluorine-18-fluorodeoxyglucose and positron emission tomography. J Nucl Med 1991; 32:1655-1660.[Abstract/Free Full Text]
19. Hebert ME, Lowe VJ, Hoffman JM, et al. Positron emission tomography in the pretreatment evaluation and follow-up of non-small cell lung cancer patients treated with radiotherapy: preliminary findings. Am J Clin Oncol 1996; 19:416-421.[CrossRef][Medline]
20. Patz EJ, Lowe VJ, Hoffman JM, et al. Persistent or recurrent bronchogenic carcinoma: detection with PET and 2-[F-18]-2-deoxy-D-glucose. Radiology 1994; 191:379-382.[Abstract/Free Full Text]
21. Goldsmith SJ, Kostakoglu L. Nuclear medicine imaging of lung cancer. Radiol Clin North Am 2000; 38:511-524.[CrossRef][Medline]
22. Abdel-Nabi H, Doerr RJ, Lamonica DM, et al. Staging of primary colorectal carcinomas with fluorine-18 fluorodeoxyglucose whole-body PET: correlation with histopathologic and CT findings. Radiology 1998; 206:755-760.[Abstract/Free Full Text]
23. Mukai M, Sadahiro S, Yasuda S, et al. Preoperative evaluation by whole-body 18F-fluorodeoxyglucose positron emission tomography in patients with primary colorectal cancer. Oncol Rep 2000; 7:85-87.[Medline]
24. Adson MA. Resection of liver metastases: when is it worthwhile? World J Surg 1987; 11:511-520.[CrossRef][Medline]
25. Philips RKS, Hittinger R, Blesovsky L, Fry JS, Fielding LP. Local recurrence following curative surgery for large bowel cancer. II. The rectum and rectosigmoid. Br J Surg 1984; 71:17-20.
26. August DA, Ottow RT, Sugarbaker PH. Clinical perspective of human colorectal cancer metastasis. Cancer Metastasis Rev 1984; 3:303-324.[CrossRef][Medline]
27. Moss AA. Imaging of colorectal carcinoma. Radiology 1989; 170:308-310.[Free Full Text]
28. Ito K, Kato T, Tadokoro M, et al. Recurrent rectal cancer and scar: differentiation with PET and MR imaging. Radiology 1992; 182:549-552.[Abstract/Free Full Text]
29. Findlay M, Young H, Cunningham D, et al. Noninvasive monitoring of tumor metabolism using fluorodeoxyglucose and positron emission tomography in colorectal cancer liver metastases: correlation with tumor response to fluorouracil NTS. J Clin Oncol 1996; 14:700-708.[Abstract/Free Full Text]
30. Guillem JG, Puig-La Calle J, Jr, Akhurst T, et al. Prospective assessment of primary rectal cancer response to preoperative radiation and chemotherapy using 18-fluorodeoxyglucose positron emission tomography. Dis Colon Rectum 2000; 43:18-24.[CrossRef][Medline]
31. Akhurst T, Larson S, Maccapinlac H, et al. Fluorodeoxyglucose (FDG) positron emission tomography (PET) immediately post-hepatic cryotherapy predicts recurrence of tumor in the liver (abstr). Proceedings of the annual meeting of the American Society of Clinical Oncology. Alexandria, Va: American Society of Clinical Oncology, 1999; 625.
32. Krestin GP, Steinbrich W, Friedman G. Recurrent rectal cancer: diagnosis with MR imaging versus CT. Radiology 1988; 168:307-311.[Abstract/Free Full Text]
33. Ogunbiyi OA, Flanagan FL, Dehdashti F, et al. Detection of recurrent and metastatic colorectal cancer: comparison of positron emission tomography and computed tomography. Ann Surg Oncol 1997; 4:613-620.[Abstract]
34. Flamen P, Stroobants S, Van Cutsem E, et al. Additional value of whole-body positron emission tomography with fluorine-18-2-deoxy-D-glucose in recurrent colorectal cancer. J Clin Oncol 1999; 17:894-901.[Abstract/Free Full Text]
35. Takeuchi O, Saito N, Koda K, Sarashina H, Nakajima N. Clinical assessment of positron emission tomography for the diagnosis of local recurrence in colorectal cancer. Br J Surg 1999; 86:932-937.[CrossRef][Medline]
36. Huebner RF, Park KC, Shepherd JE, Schwimmer J, Czernin J. A meta-analysis of the literature for whole-body FDG-PET detection of recurrent colorectal cancer. J Nucl Med 2000; 41:1177-1189.[Abstract/Free Full Text]
37. Schiepers C, Penninckx F, De Vadder N, et al. Contribution of PET in the diagnosis of recurrent colorectal cancer: comparison with conventional imaging. Eur J Surg Oncol 1995; 21:517-522.[CrossRef][Medline]
38. Hustinx R, Paulus P, Daenen F, et al. Clinical value of positron emission tomography in the detection and staging of recurrent colorectal cancer. Gastroenterol Clin Biol 1999; 23:323-329.[Medline]
39. Boykin KN, Zibari GB, Lilien DL, McMillan RW, Aultman DF, McDonald JC. The use of FDG-positron emission tomography for the evaluation of colorectal metastases of the liver. Am Surg 1999; 65:1183-1185.[Medline]
40. Lai DT, Fulham M, Stephen MS, et al. The role of whole-body positron emission tomography with F18-fluorodeoxyglucose in identifying operable colorectal cancer metastases to the liver. Arch Surg 1996; 131:703-707.[Abstract/Free Full Text]
41. Valk PE, Abella-Columna E, Haseman MK, et al. Whole-body PET imaging with [18F]fluorodeoxyglucose in management of recurrent colorectal cancer. Arch Surg 1999; 134:503-511; discussion 511–513.[Abstract/Free Full Text]
42. Ruhlmann J, Schomburg A, Bender H, et al. Fluorodeoxyglucose whole-body positron emission tomography in colorectal cancer patients studied in routine daily practice. Dis Colon Rectum 1997; 40:1195-1204.[CrossRef][Medline]
43. Cohen A, Minsky BD, Schilsky RL. Cancer of the colon. In: DeVita VT, Jr, Hellman S, Rosenberg SA, eds. Cancer: principles and practice of oncology. 5th ed. Philadelphia, Pa: Lippincott, 1997; 1144-1184.
44. Flanagan FL, Dehdashti F, Ogunbiyi OA, Kodner IJ, Siegel BA. Utility of FDG-PET for investigating unexplained plasma CEA elevation in patients with colorectal cancer. Ann Surg 1998; 227:319-323.[CrossRef][Medline]
45. Kubota R, Yamada S, Kubota K, et al. Intratumoral distribution of F18-fluoro-deoxyglucose in vivo: high accumulation in macrophages and granulation tissues studied by micro-autoradiography. J Nucl Med 1992; 33:1972-1980.[Abstract/Free Full Text]
46. Haberkorn U, Strauss LG, Dimitrakopoulou A, et al. PET studies for fluorodeoxyglucose metabolism in patients with recurrent colorectal tumors receiving radiotherapy. J Nucl Med 1991; 32:1485-1490.[Abstract/Free Full Text]
47. Ruers TJ, Langenhoff BS, Neeleman N, et al. Value of positron emission tomography with [F-18]fluorodeoxyglucose in patients with colorectal liver metastases: a prospective study. J Clin Oncol 2002; 20:388-395.[Abstract/Free Full Text]
48. Kostakoglu L, Leonard JP, Kuji I, Coleman M, Vallabhajosula S, Goldsmith SJ. Comparison of fluorine-18 fluorodeoxyglucose positron emission tomography and Ga-67 scintigraphy in lymphoma. Cancer 2002; 94:879-888.[CrossRef][Medline]
49. Moog F, Bangerter M, Diederichs CG, et al. Lymphoma: role of whole-body 2-deoxy-2-[F-18]fluoro-D-glucose (FDG) PET in nodal staging. Radiology 1997; 203:795-800.[Abstract/Free Full Text]
50. Cremerius U, Fabry U, Neuerburg J, Zimny M, Osieka R, Buell U. Positron emission tomography with 18F-FDG to detect residual disease after therapy for malignant lymphoma. Nucl Med Commun 1998; 19:1055-1063.[Medline]
51. Stumpe KD, Urbinelli M, Steinert HC, Glanzmann C, Buck A, von Schulthess GK. Whole-body positron emission tomography using fluorodeoxyglucose for staging of lymphoma: effectiveness and comparison with computed tomography. Eur J Nucl Med 1998; 25:721-728.[CrossRef][Medline]
52. Jerusalem G, Beguin Y, Fassotte MF, et al. Whole-body positron emission tomography using 18F-fluorodeoxyglucose for post-treatment evaluation in Hodgkin’s disease and non-Hodgkin’s lymphoma has higher diagnostic and prognostic value than classical computed tomography scan imaging. Blood 1999; 94:429-433.[Abstract/Free Full Text]
53. Mainolfi C, Maurea S, Varrella P, et al. Positron emission tomography with fluorine-18-deoxyglucose in the staging and control of patients with lymphoma: comparison with clinico-radiologic assessment. Radiol Med 1998; 95:98-104.
54. Bangerter M, Kotzerke J, Griesshammer M, Elsner K, Reske SN, Bergmann L. Positron emission tomography with 18-fluorodeoxyglucose in the staging and follow-up of lymphoma in the chest. Acta Oncol 1999; 38:799-804.[CrossRef][Medline]
55. Thill R, Neuerburg J, Fabry U, et al. Comparison of findings with 18-FDG PET and CT in pretherapeutic staging of malignant lymphoma. Nuklearmedizin 1997; 36:234-239. [German].[Medline]
56. Kostakoglu L, Goldsmith SJ. [F-18] fluorodeoxyglucose positron emission tomography in staging and follow-up of lymphoma: is it time to shift gears? Eur J Nucl Med 2000; 27:1564- 1578.[CrossRef][Medline]
57. Munker R, Stengel A, Stabler A, et al. Diagnostic accuracy of ultrasound and computed tomography in the staging of Hodgkin’s disease. Cancer 1995; 76:1460-1466.[CrossRef][Medline]
58. Bangerter M, Moog F, Griesshammer M, et al. Usefulness of FDG-PET in diagnosing primary lymphoma of the liver. Int J Hematol 1997; 66:517-520.[CrossRef][Medline]
59. Heald AE, Hoffman JM, Bartlett JA, Waskin HA. Differentiation of central nervous system lesions in AIDS patients using positron emission tomography (PET). Int J STD AIDS 1996; 7:337-346.[Abstract/Free Full Text]
60. Carr R, Barrington SF, Madan B, et al. Detection of lymphoma in bone marrow by whole-body positron emission tomography. Blood 1998; 91:3340-3346.[Abstract/Free Full Text]
61. Moog F, Bangerter M, Kotzerke J, Guhlman A, Frickhofen N, Reske SN. 18-F-fluorodeoxyglucose-positron emission tomography as a new approach to detect lymphomatous bone marrow. J Clin Oncol 1998; 16:603-609.[Abstract]
62. Surbone A, Longo DL, DeVita VT, et al. Residual abdominal masses in aggressive non-Hodgkin’s lymphoma after combination chemotherapy: significance and management. J Clin Oncol 1988; 6:1832-1837.[Abstract]
63. Front D, Bar-Shalom R, Mor M, et al. Aggressive non-Hodgkin lymphoma: early prediction of outcome with 67Ga scintigraphy. Radiology 2000; 214:253-257.[Abstract/Free Full Text]
64. Front D, Bar-Shalom R, Mor M, et al. Hodgkin disease: prediction of outcome with 67Ga scintigraphy after one cycle of chemotherapy. Radiology 1999; 210:487-491.[Abstract/Free Full Text]
65. Cremerius U, Fabry U, Kroll U, et al. Clinical value of FDG PET for therapy monitoring of malignant lymphoma: results of a retrospective study in 72 patients. Nuklearmedizin 1999; 38:24-30. [German].[Medline]
66. Romer W, Hanauske A, Ziegler S, et al. Positron emission tomography in non-Hodgkin’s lymphoma: assessment of chemotherapy with fluorodeoxyglucose. Blood 1998; 91:4464-4471.[Abstract/Free Full Text]
67. Spaepen K, Stroobants S, Dupont P, et al. Prognostic value of positron emission tomography (PET) with fluorine-18 fluorodeoxyglucose ([18F]FDG) after first line chemotherapy in non-Hodgkin’s lymphoma: Is [18F]FDG PET a valid alternative to conventional diagnostic methods? J Clin Oncol 2001; 19:414-419.[Abstract/Free Full Text]
68. Kostakoglu L, Coleman M, Leonard JP, Kuji I, Zoe H, Goldsmith SJ. Positron emission tomography predicts prognosis after one cycle of chemotherapy in aggressive lymphoma and Hodgkin’s disease. J Nucl Med 2002; 43:1018-1027.[Abstract/Free Full Text]
69. Hoffmann M, Kletter K, Diemling M, et al. Positron emission tomography with fluorine-18-2-fluoro-2-deoxy-D-glucose (F18-FDG) does not visualize extranodal B-cell lymphoma of the mucosa-associated lymphoid tissue (MALT)-type. Ann Oncol 1999; 10:1185-1189.[Abstract/Free Full Text]
70. Rankin SC. Oesophageal cancer. In: Husband JES, Reznek RH, eds. Imaging in oncology. Oxford, England: Isis Medical Media, 1998; 93-110.
71. Flanagan FL, Dehdashti F, Siegel BA, et al. Staging of esophageal cancer with 18F-fluorodeoxyglucose positron emission tomography. AJR Am J Roentgenol 1997; 168:417-424.[Abstract/Free Full Text]
72. Rankin SC, Taylor H, Cook GJ, Mason R. Computed tomography and positron emission tomography in the pre-operative staging of oesophageal carcinoma. Clin Radiol 1998; 53:659-665.[CrossRef][Medline]
73. Skehan SJ, Brown A, Thompson M, et al. Imaging features of primary and recurrent esophageal cancer at FDG PET. RadioGraphics 2000; 20:713-723.[Abstract/Free Full Text]
74. Brucher B, Weber W, Bauer M, et al. Neoadjuvant therapy of esophageal squamous cell carcinoma: response to therapy evaluation by positron emission tomography. Ann Surg 2001; 233:300-309.[CrossRef][Medline]
75. Kim K, Park SJ, Kim BT, Lee KS, Shim YM. Evaluation of lymph node metastases in squamous cell carcinoma of the esophagus with positron emission tomography. Ann Thorac Surg 2001; 71:290-294.[Abstract/Free Full Text]
76. Kelly S, Harris KM, Berry E, et al. A systematic review of the staging performance of endoscopic ultrasound in gastro-oesophageal carcinoma. Gut 2001; 49:534-539.[Abstract/Free Full Text]
77. Tyler DS, Onaitis M, Kherani A, et al. Positron emission tomography scanning in malignant melanoma: clinical utility in patients with stage III disease. Cancer 2000; 89:1019-1025.[CrossRef][Medline]
78. Minjnhout SG, Hoekstra OS, van Tulder MW, Teule GJJ, Deville WLJM. Systemic review of the diagnostic accuracy of F-18 fluorodeoxyglucose positron emission tomography in melanoma patients. Cancer 2001; 91:1530-1542.[CrossRef][Medline]
79. Wagner JD, Schauwecker D, Davidson D, et al. Prospective study of fluorodeoxyglucose-positron emission tomography imaging of lymph node basins in melanoma patients undergoing sentinel node biopsy. J Clin Oncol 1999; 17:1508-1515.[Abstract/Free Full Text]
80. Acland KM, Healy C, Calonje E, et al. Comparison of positron emission tomography scanning and sentinel node biopsy in the detection of micrometastases of primary cutaneous malignant melanoma. J Clin Oncol 2001; 19:2674-2678.[Abstract/Free Full Text]
81. Kuvshinoff BW, Kurtz C, Coit DG. Computed tomography in evaluation of patients with stage III melanoma. Ann Surg Oncol 1997; 4:396-402.[Abstract]
82. Krug B, Dietlein M, Groth W, et al. Fluor-18-fluorodeoxyglucose positron emission tomography (FDG-PET) in malignant melanoma: diagnostic comparison with conventional imaging methods. Acta Radiol 2000; 41:446-452.[CrossRef][Medline]
83. Rinne D, Baum RP, Hor G, et al. Primary staging and follow-up of high risk melanoma patients with whole-body 18F-fluorodeoxyglucose positron emission tomography: results of a prospective study of 100 patients. Cancer 1998; 82:1664-1671.[CrossRef][Medline]
84. Holder WD, Jr, White RL, Jr, Zuger JH, et al. Effectiveness of positron emission tomography for the detection of melanoma metastases. Ann Surg 1998; 227:764-769.[CrossRef][Medline]
85. Hollenbeak CS, Lowe VJ, Stack BC. The cost-effectiveness of fluorodeoxyglucose 18-F positron emission tomography in the N0 neck. Cancer 2001; 92:2341-2348.[CrossRef][Medline]
86. Davis JP, Maisey NM, Chevreton EB. Positron emission tomography: a useful imaging technique for otolaryngology, head and neck surgery? J Laryngol Otol 1998; 112:125-127.[Medline]
87. Adams S, Baum RP, Stuckensen T, et al. Prospective comparison of 18F-FDG PET with conventional imaging modalities (CT, MRI, US) in lymph node staging of head and neck cancer. Eur J Nucl Med 1998; 25:1255-1260.[CrossRef][Medline]
88. Kau RJ, Alexiou C, Laubenbacher C, Werner M, Schwaiger M, Arnold W. Lymph node detection of head and neck squamous cell carcinomas by positron emission tomography with fluorodeoxyglucose F 18 in a routine clinical setting. Arch Otolaryngol Head Neck Surg 1999; 125:1322-1328.[Abstract/Free Full Text]
89. Braams JW, Pruim J, Kole AC, et al. Detection of unknown primary head and neck tumors by positron emission tomography. Int J Oral Maxillofac Surg 1997; 26:112-115.[Medline]
90. Fischbein NJ, AAssar OS, Caputo GR, et al. Clinical utility of positron emission tomography with 18F-fluorodeoxyglucose in detecting residual/recurrent squamous cell carcinoma of the head and neck. AJNR Am J Neuroradiol 1998; 19:1189-1196.[Abstract]
91. Anzai Y, Carroll WR, Quint DJ, et al. Recurrence of head and neck cancer after surgery or irradiation: prospective comparison of 2-deoxy-2-[F-18]fluoro-D-glucose PET and MR imaging diagnoses. Radiology 1996; 200:135-141.[Abstract/Free Full Text]
92. Wong WL, Chevretton EB, McGurk M, et al. A prospective study of PET-FDG imaging for the assessment of head and neck squamous cell carcinoma. Clin Otolaryngol 1997; 22:209-214.[CrossRef][Medline]
93. McGuirt WF, Greven KM, Keyes JW, Jr, et al. Positron emission tomography in the evaluation of laryngeal carcinoma. Ann Otol Rhinol Laryngol 1995; 104:274-278.[Medline]
94. Greven KM, Williams DW, 3rd, Keyes JW, Jr, et al. Positron emission tomography of patients with head and neck carcinoma before and after high dose irradiation. Cancer 1994; 4:1355-1359.
95. Lowe VJ, Boyd JH, Dunphy FR, et al. Surveillance for recurrent head and neck cancer using positron emission tomography. J Clin Oncol 2000; 18:651-658.[Abstract/Free Full Text]
96. Lowe VJ, Dunphy FR, Varvares M, et al. Evaluation of chemotherapy response in patients with advanced head and neck cancer using [F-18]fluorodeoxyglucose positron emission tomography. Head Neck 1997; 19:666-674.[CrossRef][Medline]
97. McGuirt WF, Keyes JW, Jr, Greven KM, et al. Preoperative identification of benign versus malignant parotid masses: a comparative study including positron emission tomography. Laryngoscope 1995; 105:579-584.[Medline]
98. Wahl RL, Cody R, Hutchins GD, et al. Primary and metastatic breast carcinoma: initial clinical evaluation with PET with the radiolabeled glucose analogue 2-[F-18]-fluoro-2-deoxy-D-glucose. Radiology 1991; 179:765-770.[Abstract/Free Full Text]
99. Schiedhauer K, Scharl A, Pietrzyk U, et al. Qualitative [18F]FDG positron emission tomography in primary breast cancer: clinical relevance and practicability. Eur J Nucl Med 1996; 23:618-623.[CrossRef][Medline]
100. Smith IC, Ogston KN, Whitford P, et al. Staging of the axilla in breast cancer: an accurate in vivo assessment using positron emission tomography with 2-(fluorine-18)-fluoro-2-deoxy-D-glucose. Ann Surg 1998; 228:220-227.[CrossRef][Medline]
101. Crippa F, Agresti R, Seregni E, et al. Prospective evaluation of fluorine-18-FDG PET in presurgical staging of the axilla in breast cancer. J Nucl Med 1998; 39:4-8.[Abstract/Free Full Text]
102. Utech CI, Young CS, Winter PP. Prospective evaluation of fluorine-18 fluorodeoxyglucose positron emission tomography in breast cancer for staging of the axilla related to surgery and immunocytochemistry. Eur J Nucl Med 1996; 23:1588-1593.[CrossRef][Medline]
103. Avril N, Menzel M, Dose J, et al. Glucose metabolism of breast cancer assessed by 18F-FDG PET: histologic and immunohistochemical tissue analysis. J Nucl Med 2001; 42:9-16.[Abstract/Free Full Text]
104. Eubank WB, Mankoff DA, Takasugi J, et al. 18fluorodeoxyglucose positron emission tomography to detect mediastinal or internal mammary metastases in breast cancer. J Clin Oncol 2001; 19:3516-3523.[Abstract/Free Full Text]
105. Adler LP, Faulhaber PF, Schnur KC, et al. Axillary lymph node metastases: screening with [F-18]2-deoxy-2-fluoro-D-glucose (FDG) PET. Radiology 1997; 203:323-327.[Abstract/Free Full Text]
106. Avril N, Dose J, Janicke F, et al. Metabolic characterization of breast tumors with positron emission tomography using F-18 fluorodeoxyglucose. J Clin Oncol 1996; 14:1848-1857.[Abstract/Free Full Text]
107. Mariani G, Moresco L, Viale G, et al. Radioguided sentinel lymph node biopsy in breast cancer surgery. J Nucl Med 2001; 42:1198-1215.[Abstract/Free Full Text]
108. Noguchi M, Ohta N, Thomas M, et al. Risk of internal mammary lymph node metastases and its prognostic value in breast cancer patients. J Surg Oncol 1993; 52:26-30.[Medline]
109. Katz A, Strom EA, Buchholz TA, et al. Locoregional recurrence patterns after mastectomy and doxorubicin-based chemotherapy: implications for postoperative irradiation. J Clin Oncol 2000; 18:2817-2827.[Abstract/Free Full Text]
110. Hathaway PB, Mankoff DA, Maravilla KR, et al. Value of combined FDG PET and MR imaging in the evaluation of suspected recurrent local-regional breast cancer: preliminary experience. Radiology 1999; 210:807-814.[Abstract/Free Full Text]
111. Bender H, Kirst J, Palmedo H, et al. Value of 18fluoro-deoxyglucose positron emission tomography in the staging of recurrent breast carcinoma. Anticancer Res 1997; 17:1687-1692.[Medline]
112. Moon DP, Maddahi J, Silverman DHS, et al. Accuracy of whole-body fluorine-18-FDG PET for the detection of recurrent or metastatic breast carcinoma. J Nucl Med 1998; 39:431-435.[Abstract/Free Full Text]
113. Cook GJ, Fogelman I. The role of positron emission tomography in the management of bone metastases. Cancer 2000; 88:2927-2933.[CrossRef][Medline]
114. Jansson T, Westlin JE, Ahlstrom H, et al. Positron emission tomography studies in patients with locally advanced and/or metastatic breast cancer: a method for early therapy evaluation? J Clin Oncol 1995; 13:1470-1477.[Abstract]
115. Schelling M, Avril N, Nahrig J, et al. Positron emission tomography using [(18)F]fluorodeoxyglucose for monitoring primary chemotherapy in breast cancer. J Clin Oncol 2000; 18:1689-1695.[Abstract/Free Full Text]
116. Mallard J, Welch AE, Hutcheon AW, et al. Positron emission tomography using [(18)F]-fluorodeoxy-D-glucose to predict the pathologic response of breast cancer to primary chemotherapy. J Clin Oncol 2000; 18:1676-1688.[Abstract/Free Full Text]
117. Avril N, Rose CA, Schelling M, et al. Breast imaging with positron emission tomography and fluorine-18 fluorodeoxyglucose: use and limitations. J Clin Oncol 2000; 18:3495-3502.[Abstract/Free Full Text]
118. Charron M, Beyer T, Bohnen NN, et al. Image analysis in patients with cancer studied with a combined PET and CT scanner. Clin Nucl Med 2000; 25:905-910.[CrossRef][Medline]

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