Acute Findings on FDG PET/CT: Key Imaging Features and How to Differentiate Them from Malignancy

Establishing local diagnostic reference levels for adult whole-body PET/CT in Malaysia

BACKGROUND

The combination of positron emission tomography (PET) and computed tomography (CT) scanning has significantly transformed the field of nuclear medicine.

PURPOSE

This study aims to establish local diagnostic reference levels (LDRLs) for adult positron emission tomography/computed tomography (PET/CT) scans utilizing three radiotracers:18F-fluorodeoxyglucose (18F-FDG), 68Gallium-prostate-specific-membrane-antigen (68Ga-PSMA), and 68Gallium-etraazacyclododecane-tetraacetic-acid-octreotide (68Ga-DOTATATE).

METHODS

Demographic data, radiation dose information, scanner PET/CT system specifications, and acquisition protocols were collected from the Department of Nuclear Medicine at Penang Hospital in Malaysia. The LDRL was determined by calculating the 50th percentile.

RESULTS

The proposed LDRLs values for whole-body 18F-FDG, 68Ga-PSMA and 68Ga-DOTATATE scans were 264 MBq, 194.07 MBq, and 186.85 MBq, respectively. The proposed LDRL for the diagnostic CT parameters (CTDIvol and DLP) associated with whole-body 18F-FDG PET/CT scans were 4.04 mGy and 412.25 mGy.cm, while proposed LDRL values for 68Ga-PSMA and 68Ga-DOTATATE scans were 4.33 mGy and 452.16 mGy.cm, and 4.51 mGy and 468.69 mGy.cm, respectively.

CONCLUSION

The administered activity of 18F-FDG, 68Ga-PSMA, and 68Ga-DOTATATE examinations can be reduced without compromising or affecting the image quality. The proposed LDRL values for the CT parameters of the whole-body 18F-FDG examinations were the lowest among all compared values, but 68Ga-PSMA and 68Ga-DOTATATE examinations require further studies to optimize patient radiation doses in Malaysia and other regions while maintaining image quality.

Metabolic imaging distinguishes ovarian cancer subtypes and detects their early and variable responses to treatment

High grade serous ovarian cancer displays two metabolic subtypes; a high OXPHOS subtype that shows increased expression of genes encoding electron transport chain components, increased oxygen consumption, and increased chemosensitivity, and a low OXPHOS subtype that exhibits glycolytic metabolism and is more drug resistant. We show here in patient-derived organoids and in the xenografts obtained by their subcutaneous implantation that the low OXPHOS subtype shows higher lactate dehydrogenase activity and monocarboxylate transporter 4 expression than the high OXPHOS subtype and increased lactate labeling in 13C magnetic resonance spectroscopy (MRS) measurements of hyperpolarized [1-13C]pyruvate metabolism. There was no difference between the subtypes in PET measurements of 2-deoxy-2-[fluorine-18]fluoro-D-glucose ([18F]FDG) uptake. Both metabolic imaging techniques could detect the early response to Carboplatin treatment in drug-sensitive high OXPHOS xenografts and no response in drug-resistant in low OXPHOS xenografts. 13C magnetic resonance spectroscopic imaging of hyperpolarized [1-13C]pyruvate metabolism has the potential to be used clinically to distinguish low OXPHOS and high OXPHOS tumor deposits in HGSOC patients and to detect their differential responses to treatment.

Case report: Chest radiotherapy-induced vertebral fractures in lung cancer patients: a case series and literature review

Background

As survival rates for lung cancer (LC) patients continue to rise, the adverse impacts of therapies become more relevant. Radiotherapy is known to negatively affect bone health. However, radiotherapy-induced vertebral fractures in lung cancer patients remain an exceedingly rare and underrecognized condition that could be mistaken for bone metastasis.

Case presentation

We identified three LC patients (all long-term survivors), aged 67 to 81, who developed thoracic vertebral fractures post-chest radiotherapy, within irradiated fields; two had advanced non-small cell lung cancer (NSCLC) and one had extensive small cell lung cancer (SCLC). Baseline imaging confirmed that the fractures occurred after therapy. The median time from radiotherapy to fracture onset was 19 months (range: 1-30 months), with a median follow-up time from the initial fracture of 39 months (range: 37-61 months). All observed fractures were compressive in nature. These patients shared common characteristics, including advanced age, a history of heavy smoking, and high radiation doses. Additionally, hypermetabolic activity at the fracture sites necessitated MRI to differentiate these fractures from bone metastases. Management involved interventional strategies such as vertebroplasty, kyphoplasty, and rhizotomy, along with general and pharmacological measures to prevent subsequent fractures.

Conclusions

Despite their low incidence, radiotherapy-induced vertebral fractures in LC patients are clinically significant and may resemble bone metastases on PET-CT imaging. MRI, alongside risk factors similar to those of osteoporosis, can facilitate prompt identification and differentiation. As survival rates in LC patients improve, the relevance of this adverse effect increases, underscoring the need for implementing bone protective strategies to further enhance patient outcomes and quality of life.

Demonstration of Resolution of Community-Acquired Pneumonia Over a Short Course of Antibiotics on [ 18 F]FDG-PET/CT Undertaken for Suspected Perimyocarditis Evaluation

A 28-year-old male presenting with left-sided pleuritic chest pain, cough, palpitation, and fever with mild ST depression in II, III, and aVF, raised troponin I, troponin T, creatine phosphokinase-MB, and erythrocyte sedimentation rate was referred for F-18 2-fluoro 2-deoxyglucose positron emission tomography with noncontrast computed tomography ([ 18 F]FDG-PET/CT) to rule out perimyocarditis. The first scan revealed incidental finding of [ 18 F]FDG avid left lobar pneumonia and inadequate myocardial suppression, thus perimyocarditis could not be ruled out. The clinician was informed and after counseling, patient consented for a repeat study post-high fat-low carbohydrate diet. A regional [ 18 F]FDG-PET/CT on the 5th day revealed adequate myocardial suppression, ruling out perimyocarditis. However, the metabolic and anatomical resolution of previously noted left lobar pneumonia was also observed in such a span of time with the administered antibiotics.

Nocardia masquerading as pulmonary malignancy in a patient with adult-onset immunodeficiency on 18F-FDG PET/CT

A 77-year-old man with a history of left nephrectomy for renal cell carcinoma and partial hepatectomy for cholangiocarcinoma underwent 18F-FDG PET/CT for assessment of an irregular lung lesion. FDG-PET demonstrated development of an intensely avid spiculated left lower lobe pulmonary lesion and intensely avid left pulmonary hilar nodes, raising suspicion for a malignancy. Eleven days following the PET study, the patient was admitted to hospital with an altered mental state. CT brain revealed diffuse round hyperdensities within the brain parenchyma. Microbiology of the lung lesion was positive for Nocardia Beijingensis and he was subsequently diagnosed with disseminated nocardiosis.

Case series of rhomboid ligament degeneration, mimicking a supraclavicular adenopathy

A case series of 3 different patients showing very rare costoclavicular ligament increased SUV uptake on PET\CT with history of different types of cancer. This finding has not been described before especially that it corresponds to benign degenerative rather than sinister process. This is supported by low SUV and stability over months of follow up. Furthermore, even in degenerative joint diseases we have found very rare cases of such uptake. Experienced radiologists need to be always involved in the multidisciplinary team approach and be very cautious when approaching such findings to avoid any unnecessary medical interventions.

Focal incidental colorectal fluorodeoxyglucose uptake: Should it be spotlighted?

Fluorine-18 fluorodeoxyglucose (F-18 FDG) positron emission tomography/computed tomography (PET/CT) has emerged as a cornerstone in cancer evaluation imaging, with a well-established history spanning several years. This imaging modality, encompassing the examination of the body from the base of the skull to the upper thighs, comprehensively covers the chest and abdominopelvic regions in a singular scan, allowing for a holistic assessment of nearly the entire body, including areas of marginal interest. The inherent advantage of this expansive scan range lies in its potential to unveil unexpected incidental abnormal hypermetabolic areas. The identification of incidental focal FDG uptake within colorectal regions during PET/CT scans is not an uncommon occurrence, albeit fraught with challenges associated with non-specific FDG uptake. The presence of benign colorectal lesions or physiological uptake poses a particular obstacle, as these may manifest with FDG uptake levels that mimic malignancy. Consequently, physicians are confronted with a diagnostic dilemma when encountering abnormal FDG uptake in unexpected colorectal areas. Existing studies have presented divergent results concerning these uptakes. Standardized uptake value and its derivatives have served as pivotal metrics in quantifying FDG uptake in PET images. In this article, we aim to succinctly explore the distinctive characteristics of FDG, delve into imaging findings, and elucidate the clinical significance of incidental focal colorectal uptake. This discussion aims to contribute valuable insights into the nuanced interpretation of such findings, fostering a comprehensive understanding.

Unexpected focal fluorodeoxyglucose uptake in main organs; pass through or pass by?

Since the inception of fluorine-18 fluorodeoxyglucose (F-18 FDG), positron emission tomography/computed tomography (PET/CT) utilizing F-18 FDG has become widely accepted as a valuable imaging modality in the field of oncology, with global prevalence in clinical practice. Given that a single Torso PET/CT scan encompasses the anatomical region from the skull base to the upper thigh, the detection of incidental abnormal focal hypermetabolism in areas of limited clinical interest is both feasible and not uncommon. Numerous investigations have been undertaken to delineate the distinctive features of these findings, yet the outcomes have proven inconclusive. The incongruent results of these studies present a challenge for physicians, leaving them uncertain about the appropriate course of action. This article provides a succinct overview of the characteristics of fluorodeoxyglucose, followed by a comprehensive discussion of the imaging findings and clinical significance associated with incidental focal abnormal F-18 FDG activity in several representative organs. In conclusion, while the prevalence of unrecognized malignancy varies across organs, malignancies account for a substantial proportion, ranging from approximately one-third to over half, of incidental focal uptake. In light of these rates, physicians are urged to exercise vigilance in not disregarding unexpected uptake, facilitating more assured clinical decisions, and advocating for further active evaluation.

Evaluation of Colonoscopic Results of Patients with Incidental Colonic FDG Uptake in PET/CT Imaging

BACKGROUND

Colorectal cancer is a significant global health concern, ranking as the second most deadly and third most common cancer worldwide. Early detection and removal of precancerous lesions play a crucial role in preventing cancer development and reducing mortality. Since FDG uptake is not specific for malignancy, incidental increased FDG uptake in the gastrointestinal tract may be challenging to interpret and may require further colonoscopic examination. This study aimed to investigate the features associated with malignant and premalignant pathology in patients with incidental colonic FDG uptake and determine the necessity of colonoscopy for each FDG uptake.

METHODS

Retrospective analysis was performed on data from patients who underwent colonoscopies between January 2016 and December 2021. Patients with FDG uptake in known colorectal malignancy regions were excluded. The study included 56 patients with incidental colonic FDG uptake. PET/CT images were visually and quantitatively analyzed, and the corresponding colonoscopy and histopathological results were recorded. Statistical analyses were conducted to evaluate the relationship between FDG uptake patterns, SUVmax values, and histopathological diagnoses. Colonoscopic findings were categorized as malignancy, polyps, and non-neoplastic lesions.

RESULTS

Among the 56 patients with incidental colonic FDG uptake, 36 lesions were identified, and histopathology revealed malignancy in 10 (17.9%) patients and premalignant polyps in the 26 (46.4%) cases. Focal FDG uptake with corresponding wall thickening or soft tissue density on CT was associated with a higher likelihood of premalignant or malignant lesions. The SUVmax values demonstrated a significant difference between negative findings and polyps/malignancies. However, no significant difference was observed between malignant and premalignant lesions. A ROC curve analysis was made and assesed a cut-off value of 11.1 SUVmax (sensitivity: 83.3% and specificity: 90%) to distinguish premalignant or malignant lesions from non-malignant lesions.

CONCLUSION

Incidental colonic FDG uptake with a focal pattern and corresponding CT findings were more likely to indicate premalignant or malignant lesions. SUVmax values were helpful in predicting the presence of pathological findings, but histopathological verification remains necessary for a definitive diagnosis. These findings contribute to our understanding of the clinical implications of incidental colonic FDG uptake and highlight the importance of follow-up colonoscopy for further evaluation.

Expert review for clinical and translational imaging actionable imaging findings in the daily PET/CT scenario

Background and aim

The American College of Radiology (ACR) defines "actionable findings" the ones requiring a special communication between radiologists and referring clinicians, suggesting to organize their categorization in a three-degree scale on the basis of the risk for the patient to develop complications. These cases may fall in a grey-zone communication between different care figures with the risk of being underestimated or even not being considered at all. In this paper, our aim is to adapt the ACR categorization to the most frequent actionable findings encountered when reporting PET/CT images in a Nuclear Medicine Department, describing the most frequent and relevant imaging features and presenting the modalities of communication and the related clinical interventions that can be modulated by the prognostic severity of the clinical cases.

Materials and methods

We performed a descriptive, observational and critical analysis of the most relevant literature on the topic of "actionable findings", in particular, starting from the reports of the ACR Actionable Reporting Work Group, we categorised and described, in a narrative review, the most relevant "actionable findings" encountered in the Nuclear Medicine PET/CT daily practice.

Results

To the best of our knowledge, to date there are no clear indications on this selective PET/CT topic, considering that the current recommendations target mainly radiologists and assume a certain level of radiological expertise. We resumed and classified the main imaging conditions under the term of "actionable findings" according to the corresponding anatomical districts, and we described their most relevant imaging features (independently of PET avidity or not). Furthermore, a different communication timing and strategy was suggested on the basis of the findings' urgency.

Conclusion

A systematic categorization of the actionable imaging findings according to their prognostic severity may help the reporting physician to choose how and when to communicate with the referring clinician or to identify cases requiring a prompt clinical evaluation. Effective communication is a critical component of diagnostic imaging: timely receipt of the information is more important than the method of delivery.

Emerging Trends in Radionuclide Imaging of Infection and Inflammation in Pediatrics: Focus on FDG PET/CT and Immune Reactivity

The most common indication for ¹⁸F-FDG PET/CT is tumor imaging, which may be performed for initial diagnosis, staging, therapeutic response monitoring, surveillance, or suspected recurrence. In the routine practice of pediatric nuclear medicine, most infectious, inflammatory, and autoimmune processes that are detected on ¹⁸F-FDG PET/CT imaging - except for imaging in fever or inflammation of unknown origin - are coincidental and not the main indication for image acquisition. However, interpreting these "coincidental" findings is of utmost importance to avoid erroneously attributing these findings to a neoplastic process. We review the recent literature on fever of unknown origin as well as inflammation of unknown origin in pediatrics and then focus on the ¹⁸F FDG PET/CT imaging findings seen in two specific entities with increased immune reactivity: hemophagocytic lymphohistiocytosis syndrome and the immune-related adverse events associated with checkpoint inhibitors. We will subsequently close with two sections highlighting related topics and relevant references for further reading.

Disease severity and status in Stevens–Johnson syndrome and toxic epidermal necrolysis: Key knowledge gaps and research needs

Stevens–Johnson syndrome and toxic epidermal necrolysis (SJS/TEN) are on a spectrum of cutaneous drug reactions characterized by pan-epidermal necrosis with SJS affecting < 10% of body surface area (BSA), TEN > 30%, and SJS/TEN overlap between 10 and 30%. Severity-of-illness score for toxic epidermal necrolysis (SCORTEN) is a validated tool to predict mortality rates based on age, heart rate, BSA, malignancy and serum urea, bicarbonate, and glucose. Despite improved understanding, SJS/TEN mortality remains constant and therapeutic interventions are not universally accepted for a number of reasons, including rarity of SJS/TEN; inconsistent definition of cases, disease severity, and endpoints in studies; low efficacy of interventions; and variations in treatment protocols. Apart from mortality, none of the other endpoints used to evaluate interventions, including duration of hospitalization, is sufficiently standardized to be reproducible across cases and treatment centers. Some of the gaps in SJS/TEN research can be narrowed through international collaboration to harmonize research endpoints. A case is made for an urgent international collaborative effort to develop consensus on definitions of endpoints such as disease status, progression, cessation, and complete re-epithelialization in interventional studies. The deficiencies of using BSA as the sole determinant of SJS/TEN severity, excluding internal organ involvement and extension of skin necrosis beyond the epidermis, are discussed and the role these factors play on time to healing and mortality beyond the acute stage is highlighted. The potential role of artificial intelligence, biomarkers, and PET/CT scan with radiolabeled glucose as markers of disease status, activity, and therapeutic response is also discussed.

Molecular Imaging of Aortic Aneurysm and Its Translational Power for Clinical Risk Assessment

Aortic aneurysms (AAs) are dilations of the aorta, that are often fatal upon rupture. Diagnostic radiological techniques such as ultrasound (US), magnetic resonance imaging (MRI), and computed tomography (CT) are currently used in clinical practice for early diagnosis as well as clinical follow-up for preemptive surgery of AA and prevention of rupture. However, the contemporary imaging-based risk prediction of aneurysm enlargement or life-threatening aneurysm-rupture remains limited as these are restricted to visual parameters which fail to provide a personalized risk assessment. Therefore, new insights into early diagnostic approaches to detect AA and therefore to prevent aneurysm-rupture are crucial. Multiple new techniques are developed to obtain a more accurate understanding of the biological processes and pathological alterations at a (micro)structural and molecular level of aortic degeneration. Advanced anatomical imaging combined with molecular imaging, such as molecular MRI, or positron emission tomography (PET)/CT provides novel diagnostic approaches for in vivo visualization of targeted biomarkers. This will aid in the understanding of aortic aneurysm disease pathogenesis and insight into the pathways involved, and will thus facilitate early diagnostic analysis of aneurysmal disease. In this study, we reviewed these molecular imaging modalities and their association with aneurysm growth and/or rupture risk and their limitations. Furthermore, we outline recent pre-clinical and clinical developments in molecular imaging of AA and provide future perspectives based on the advancements made within the field. Within the vastness of pre-clinical markers that have been studied in mice, molecular imaging targets such as elastin/collagen, albumin, matrix metalloproteinases and immune cells demonstrate promising results regarding rupture risk assessment within the pre-clinical setting. Subsequently, these markers hold potential as a future diagnosticum of clinical AA assessment. However currently, clinical translation of molecular imaging is still at the onset. Future human trials are required to assess the effectivity of potentially viable molecular markers with various imaging modalities for clinical rupture risk assessment.

Polymer Nanoparticles and Nanomotors Modified by DNA/RNA Aptamers and Antibodies in Targeted Therapy of Cancer

Polymer nanoparticles and nano/micromotors are novel nanostructures that are of increased interest especially in the diagnosis and therapy of cancer. These structures are modified by antibodies or nucleic acid aptamers and can recognize the cancer markers at the membrane of the cancer cells or in the intracellular side. They can serve as a cargo for targeted transport of drugs or nucleic acids in chemo- immuno- or gene therapy. The various mechanisms, such as enzyme, ultrasound, magnetic, electrical, or light, served as a driving force for nano/micromotors, allowing their transport into the cells. This review is focused on the recent achievements in the development of polymer nanoparticles and nano/micromotors modified by antibodies and nucleic acid aptamers. The methods of preparation of polymer nanoparticles, their structure and properties are provided together with those for synthesis and the application of nano/micromotors. The various mechanisms of the driving of nano/micromotors such as chemical, light, ultrasound, electric and magnetic fields are explained. The targeting drug delivery is based on the modification of nanostructures by receptors such as nucleic acid aptamers and antibodies. Special focus is therefore on the method of selection aptamers for recognition cancer markers as well as on the comparison of the properties of nucleic acid aptamers and antibodies. The methods of immobilization of aptamers at the nanoparticles and nano/micromotors are provided. Examples of applications of polymer nanoparticles and nano/micromotors in targeted delivery and in controlled drug release are presented. The future perspectives of biomimetic nanostructures in personalized nanomedicine are also discussed.