Hybrid PET/CT and SPECT/CT Imaging

Dominique Delbeke l Ora IsraelEditors

Hybrid PET/CT and SPECT/CT Imaging

A Teaching File

1 3

Editors

Dominique DelbekeDepartment of Radiology

and Radiological SciencesVanderbilt University Medical Center1161 21st Ave. S. & GarlandNashville TN 37232-2675USAdominique.delbeke@vanderbilt.edu

Ora IsraelDepartment of Nuclear MedicineRambam Health Care CampusBat-Galim35 254 HaifaIsraelo_israel@rambam.health.gov.il

ISBN 978-0-387-92819-7 e-ISBN 978-0-387-92820-3DOI 10.1007/978-0-387-92820-3Springer New York Dordrecht Heidelberg London

Library of Congress Control Number: 2009930385

# Springer ScienceþBusiness Media, LLC 2010All rights reserved. This workmay not be translated or copied in whole or in part without the written permission ofthe publisher (Springer ScienceþBusinessMedia, LLC, 233 Spring Street, NewYork, NY 10013, USA), except forbrief excerpts in connection with reviews or scholarly analysis. Use in connection with any form of informationstorage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology nowknown or hereafter developed is forbidden.The use in this publication of trade names, trademarks, service marks, and similar terms, even if they are notidentified as such, is not to be taken as an expression of opinion as to whether or not they are subject to proprietaryrights.While the advice and information in this book are believed to be true and accurate at the date of going to press,neither the authors nor the editors nor the publisher can accept any legal responsibility for any errors or omissionsthat may be made. The publisher makes no warranty, express or implied, with respect to the material containedherein.

Printed on acid-free paper

Springer is part of Springer ScienceþBusiness Media (www.springer.com)

To my children: Cerine and Cedric Jeanty.Dominique Delbeke

In loving memory of my parents.

To my husband, Stefan,

To Dalit, Yair, Harel and Rani.Ora Israel

Preface

Our profession has progressed tremendously over the last decade. A few years ago one of us(DD) was the senior editor of FDG Imaging: A Teaching File, a book that proved to be areference source of FDG image cases obtained both on dedicated PET tomographs andhybrid scintillation gamma cameras. This was followed by Nuclear Cardiology andCorrelative Imaging: A Teaching File, a text already providing important insights into thecomplementarity of SPECT and PET cardiac imaging with cardiovascular CT and MRI.These two books were modeled after Nuclear Medicine Imaging: A Teaching File, recentlyupdated with the second edition and designed as a manual of nuclear medicine cases,including studies that were performed with both SPECT and PET tracers.

Today, following the continuing development of new imaging devices and of ourunderstanding of molecular processes, we found an unmet need for presenting anddiscussing cases that demonstrate the role of hybrid imaging with SPECT/CT and PET/CT with a variety of radiopharmaceuticals used in daily practice.

With clinical cases related to multiple clinical entities presented in depth, Hybrid PET/CT and SPECT/CT Imaging: A Teaching File is designed to be a teaching manual andeveryday companion for our colleagues working in private practice, for residents training innuclear medicine or radiology, for medical students, and for physicians whose specialtiescarry over into molecular imaging with radiopharmaceuticals.

The first two chapters cover the technical aspects of hybrid imaging and a historicalperspective of the development of this technology. Recommendations for patientpreparation and acquisition protocols, with special emphasis on physiologic variants,pitfalls, and artifacts follow. The next 15 chapters are devoted to clinical applications inoncology, according to specific malignant diseases and patient populations. The final threechapters present relatively new clinical applications of hybrid imaging in the field ofcardiology, skeletal, and infectious diseases.

Each chapter begins with a succinct summary of the recent literature for the specificclinical application. This is followed by a series of case presentations ranging from thesimple to the more complex in an attempt to simulate clinical practice. Images are presentedin PET/SPECT stand-alone, CT stand-alone, and fused-images format in order to highlightthe advantages and incremental value of the hybrid technology in the cases selected. At theend of each chapter, up-to-date references allow the reader to follow in greater depth therapidly expanding volume of knowledge.

We sincerely hope that this text will provide nuclear physicians, radiologists, trainees,and those with an interest in hybrid imaging with a reference text that will enhance theirpractice of nuclear medicine. We also believe that this book will be used by our colleagues,the referring clinicians, interested in learning more about how this new medical imagingtechnology can be applied to their patients.

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Over the past decade, the two editors of this book have had the opportunity to worktogether on multiple projects related to novel technological developments and theirimplementation in the clinical routine. The teams at Vanderbilt, in Nashville, Tennessee,and Rambam, in Haifa, Israel, were separated geographically by thousands of miles, buttogether they developed a vast clinical experience with both SPECT/CT and PET/CT,exploring new clinical indications for the hybrid technology in what has since becomestandard practice in cancer patients and beyond.

It was a natural sequence of events that led from common work and research to awonderful professional and personal friendship. We have worked together with greatmentors, Dr Martin Sandler and the late Dr Dov Front, who have taught us to think, asktough questions, search for answers, and never give up. We have been fortunate to workwith wonderful teams, including physicians, technical and administrative staff, andphysicists. Our research involving hybrid imaging has been successful because we have alljoined forces and have developed a good working relationship with our colleagues, theengineers and scientists in the industry.

We are grateful to our valued contributors whom we know and appreciate for theirexpertise, knowledge, dedication, and contributions to the field of hybrid imaging for manyyears. This book is a collaborative effort of numerous teams in multiple centers all over theworld.

Most of all, our families have always been there for us, not only with words, but with actsof encouragement and understanding, making our journey throughHybrid Imaging a greatexperience.

Nashville, Tennessee Dominique Delbeke, MD, PhDHaifa, Israel Ora Israel, MD

viii Preface

Acknowledgments

We wish to express our gratitude to the staff of the Departments of Nuclear Medicine –physicians, physicists, technologists, and administrative assistants – at Vanderbilt andRambam, for their support, encouragement, and specifically their outstanding technicalassistance during our work on this project. We would like to thank all contributors,authors, and publishers who granted permission to reproduce their illustrations. Weacknowledge the work of the staff at Springer for their highly professional expertise,tireless assistance, and commitment to this text, as well as the work of the staff at HermesMedical Solutions for their contribution to producing the DVD.

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Contents

Part I General

I.1 History and Principles of Hybrid Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3James A. Patton

I.2 Normal Distribution, Variants, Pitfalls, and Artifacts . . . . . . . . . . . . . . . . . . . . 35Ora Israel and Dominique Delbeke

Part II Clinical Applications in Oncology

II.1 Tumors of the Central Nervous System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99Aaron C. Jessop, Ronald C. Walker, and Dominique Delbeke

II.2 Hybrid Imaging of Head and Neck Malignancies. . . . . . . . . . . . . . . . . . . . . . . 137Arie Gordin, Marcelo Daitzchman, and Ora Israel

II.3 Lung Cancer. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171Ronald C. Walker, Laurie B. Jones-Jackson, Aaron C. Jessop,and Dominique Delbeke

II.4 Breast Cancer. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 217Simona Ben-Haim and Vineet Prakash

II.5 Colorectal Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 261Dominique Delbeke and Ronald C. Walker

II.6 18F-FDG PET/CT in Tumors of the Gastrointestinal Tract: Esophageal and

Gastric Cancer and Gastrointestinal Stromal Tumors (GIST) . . . . . . . . . . . . . 293Rachel Bar-Shalom and Ludmila Guralnik

II.7 Hepatobiliary and Pancreatic Malignancies . . . . . . . . . . . . . . . . . . . . . . . . . . . 331Dominique Delbeke and Ronald C. Walker

II.8 Gynecological Tumors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 383Farrokh Dehdashti and Barry A. Siegel

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II.9 Hybrid Imaging in Malignancies of the Urinary Tract, Prostate,

and Testicular Cancers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 409Martine Klein and Marina Orevi

II.10 Thyroid Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 445Heather A. Jacene, Sibyll Goetze, and Richard L. Wahl

II.11 Endocrine Tumors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 475Yodphat Krausz

II.12 Lymphoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 513Michal Weiler-Sagie and Ora Israel

II.13 Melanoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 555Ronald C. Walker, Laurie B. Jones-Jackson, Aaron C. Jessop,and Dominique Delbeke

II.14 Malignancy of the Bone: Primary Tumors, Lymphoma,

and Skeletal Metastases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 583Einat Even-Sapir, Gideon Flusser, and Arye Blachar

II.15 Pediatric Applications for PET/CT and SPECT/CT. . . . . . . . . . . . . . . . . . . . 621Helen R. Nadel and Angela T. Byrne

Part III Other Clinical Applications

III.1 Cardiac Hybrid Imaging (PET/CT and SPECT/CT):

Assessment of CAD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 659Gabriel Vorobiof, Zohar Keidar, Sharmila Dorbala,and Marcelo F. Di Carli

III.2 Hybrid Imaging of Benign Skeletal Diseases . . . . . . . . . . . . . . . . . . . . . . . . . 683Einat Even-Sapir, Hedva Lerman, Gideon Flusser, and Arye Blachar

III.3 Infectious and Inflammatory Diseases. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 711Christopher J. Palestro, Zohar Keidar, and Charito Love

Subject Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 747

xii Contents

Expanded Chapter Contents

I.1 History and Principles of Hybrid Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3Single Photon Emission Computed Tomography. . . . . . . . . . . . . . . . . . . . . . . 3Data Acquisition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4SPECT Image Formation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Positron Emission Tomography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13PET Detectors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 142D Versus 3D Imaging. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16Data Acquisition and Image Reconstruction . . . . . . . . . . . . . . . . . . . . . . . . 16Time-of-Flight PET . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18Quantitative Techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

X-Ray Computed Tomography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21SPECT/CT and PET/CT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24Clinical SPECT/CT Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26Clinical PET/CT Systems. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27Contrast Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27Beam-Hardening Artifacts. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28Physiological Motion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28Radiation Dosimetry Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28Quality Assurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

I.2 Normal Distribution, Variants, Pitfalls, and Artifacts . . . . . . . . . . . . . . . . . . . . . 35PET/CT Imaging with 18F-Fluorodeoxyglucose. . . . . . . . . . . . . . . . . . . . . . . . 35Normal 18F-FDG Distribution and Physiologic Variants. . . . . . . . . . . . . . . 35Pitfalls and Artifacts on 18F-FDG Imaging. . . . . . . . . . . . . . . . . . . . . . . . . . 37Benign Processes Accumulating 18F-FDG . . . . . . . . . . . . . . . . . . . . . . . . . . 38Treatment-Related Processes Accumulating 18F-FDG . . . . . . . . . . . . . . . . . 38Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

Physiologic Distribution of Other PET Tracers . . . . . . . . . . . . . . . . . . . . . . . . 4018F-Fluoride . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4018F-Fluorothymidine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4018F-Fluorocholine and 11C-Choline. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4111C-Acetate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4111C-Methionine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4218F-Fluorodopamine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4218F-Fluoromisonidazole. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4268Ga-Somatostatin Receptors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

xiii

Physiologic Distribution of SPECT/CT Imaging Tracers. . . . . . . . . . . . . . . . . 43131I- and 123I-Iodine (131I and 123I) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43131I- and 123I-MIBG. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44111In-DTPA-Octreotide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4499mTc-Sestamibi . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45111In- and 99mTc-HMPAO-Leucocytes (WBC) . . . . . . . . . . . . . . . . . . . . . . . 4567Ga-Citrate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46111In-Prostascint1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46

Case Presentations

I.2.1 Normal 18F-FDG Distribution (DICOM Imageson DVD) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48

I.2.2 Physiologic 18F-FDG Uptake in aSymmetric Vocal Cord . . . . . . . . . 56I.2.3 Rebound Thymic Hyperplasia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58I.2.4 Recurrent Hodgkin’s Disease and Abdominal Wall

Muscular Uptake in a Patient with Nausea and Vomiting . . . . . . . . 61I.2.5 Diffuse Muscular Uptake in a Non-fasting Patient . . . . . . . . . . . . . . 63I.2.6 Pericarditis and Crossed Ectopic Kidney . . . . . . . . . . . . . . . . . . . . . . 66I.2.7 18F-FDG Uptake in Menstruating Uterus and Right Ovary

at Mid-Menstrual Cycle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70I.2.8 Hodgkin’s Disease and Lactating Breast . . . . . . . . . . . . . . . . . . . . . . 73I.2.9 Brown Adipose Tissue Above and Below the Diaphragm . . . . . . . . . 75I.2.10 Normal Distribution of 18F-FLT in a Patient with

Menetrier’s Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80I.2.11 131I-iodine: Remnant Left Lobe Thyroid Tissue

on Post-Ablation Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82I.2.12 131I-iodine: Physiological Uterine Uptake During Menstruation

on Post-Ablation Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84I.2.13 123I MIBG: Right Adrenal Pheochromocytoma and Dilated

Right Renal Pelvis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87I.2.14 99mTc-sestamibi: Left Parathyroid Adenoma. Atrophy of Right

Submandibular Gland and Slightly Enlarged Right Lobe of theThyroid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91

II.1 Tumors of the Central Nervous System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99Physiologic Distribution of 18F-FDG in the CNS . . . . . . . . . . . . . . . . . . . . . . 100Initial Evaluation and Staging of Primary Cerebral Tumors . . . . . . . . . . . . . . 101Evaluation of Treated Primary Cerebral Tumors . . . . . . . . . . . . . . . . . . . . . . . 102Evaluation of Cerebral Metastases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102Evaluation of Meningiomas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104Guidelines and Recommendations for the use of 18F-FDG PETand PET/CT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104Case Presentations

II.1.1 Low-grade Glioma (Oligodendroglioma, WHOGrade II) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105

II.1.2 Recurrent Glioma with Transformation from Low-Gradeto High-Grade . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108

II.1.3 Primary Lymphoma of CNS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110

xiv Expanded Chapter Contents

II.1.4 Toxoplasmosis (DICOM Images on DVD) . . . . . . . . . . . . . . . . . . . 113II.1.5 Stage IV Non-small Cell Lung Cancer with Cerebral

Metastases and Poor FDG Uptake within the Brain dueto Hyperglycemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117

II.1.6 Right Frontal Cerebral Arteriovenous Malformation . . . . . . . . . . . 119II.1.7 Recurrent Glioblastoma Multiforme with Diminished Uptake

in the Right Temporal Region due to Post-therapy Changesand Crossed Cerebellar Diaschisis (DICOM Images on DVD) . . . . 122

II.1.8 Meningioma. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126II.1.9 Recurrent Low-grade Glioma Evaluated with

11C-methionine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131

II.2 Hybrid Imaging of Head and Neck Malignancies . . . . . . . . . . . . . . . . . . . . . . . 137Staging of Head and Neck Carcinoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138Cervical Lymph Node Metastases of Unknown Tumors . . . . . . . . . . . . . . . . . 140Monitoring Response to Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141Diagnosis and Restaging of Recurrence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 142Planning of Radiotherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 142Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143Guidelines and Recommendations for the Use of 18F-FDG PETand PET/CT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143Case Presentations

II.2.1 Neck Metastasis of Unknown Origin . . . . . . . . . . . . . . . . . . . . . . . . 144II.2.2 Cancer of the Larynx with Suspected Lung Metastases . . . . . . . . . . 146II.2.3 Recurrent Cancer of the Nasopharynx: PET/CT Guided

Biopsy and Diagnosis (DICOM Images on DVD) . . . . . . . . . . . . . . 149II.2.4 Second Primary Cancer of the Esophagus in Patient

with Suspected Recurrence of Laryngeal Tumor . . . . . . . . . . . . . . . 153II.2.5 Recurrent Cancer of the Larynx: PET/CT Guided Biopsy

and Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 156II.2.6 Assessment of the Post-Irradiated Edematous Larynx

with PET/CT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 158II.2.7 Cancer of the Base of the Tongue with Normal Size Cervical

Metastasis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 160II.2.8 Multiple Regional and Distant Metastases in Patient with

Advanced Laryngeal Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162II.2.9 Benign FDG-avid Lesion: Warthin’s Tumor of Parotid Gland . . . . 166

II.3 Lung Cancer. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171Indeterminate Pulmonary Nodules . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171Non-surgical Evaluation of Pulmonary Nodules . . . . . . . . . . . . . . . . . . . . . 17218F-FDG PET/CT for Evaluation of Pulmonary Nodules . . . . . . . . . . . . . . 173Guidelines for Evaluation of Indeterminate Nodules . . . . . . . . . . . . . . . . . . 174

Non-Small-Cell Lung Carcinoma (NSCLC). . . . . . . . . . . . . . . . . . . . . . . . . . . 175TNM Staging of NSCLC. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17518F-FDG Imaging for Staging of NSCLC at Presentation:Comparison to CT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 176Detection of Extra-Thoracic Metastases . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177

Expanded Chapter Contents xv

Impact of 18F-FDG Imaging on Management of NSCLC at Presentation . . . 17818F-FDG Imaging for Monitoring Therapy of NSCLC . . . . . . . . . . . . . . . . 178Detection of Recurrence and Restaging with 18F-FDG PET or PET/CT . . 179Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179

Small-Cell Lung Carcinoma (SCLC) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18018F-FDG PET and PET/CT for Staging, Restaging, and Assessmentof Treatment Response of SCLC. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 180Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181

Malignant Pleural Mesothelioma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18118F-FDG Imaging of MPM. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183Assessment of Metabolic Response to Treatment of MPM . . . . . . . . . . . . . 184Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 184

Guidelines and Recommendations for the Use of 18F-FDG PET and PET/CT 184Case Presentations

II.3.1 Solitary Pulmonary Nodule with Moderate 18F-FDG Uptake:Solitary Metastasis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 186

II.3.2 Solitary Pulmonary Mass with Moderate 18F-FDG Uptake:Granuloma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 188

II.3.3 Solitary Pulmonary Nodule with Intense 18F-FDG Uptake:Primary Lung Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 190

II.3.4 Multi-focal Primary Lung Cancer: Bronchoalveaolar CellCarcinoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 192

II.3.5 Restaging of Recurrent NSCLC: Recurrent TNM Stage IIA . . . . . 194II.3.6 Pre-operative Staging of NSCLC with 18F-FDG PET/CT:

Stage IIIA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 197II.3.7 Pre-operative Staging of NSCLC with 18F-FDG PET/CT:

Stage IIIB and Adenomatous Polyp of the Transverse Colon . . . . . 199II.3.8 Pre-operative Staging of NSCLC with 18F-FDG PET/CT:

Stage IV and Radiation Pneumonitis (DICOM Images on DVD) . . 201II.3.9 Pre-operative Staging of SCLC with 18F-FDG PET/CT:

Limited-Stage Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 205II.3.10 Pre-treatment Staging of Malignant Pleural Mesothelioma with

18F-FDG PET/CT (DICOM Images on DVD) . . . . . . . . . . . . . . . . 207II.3.11 Use of 18F-FDG PET/CT for Radiation Treatment Planning of

NSCLC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 211

II.4 Breast Cancer. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21718F-FDG PET and PET/CT for the Detection and Staging of BreastCancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21818F-FDG PET and PET/CT for the Detection of Metastatic BreastCancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21918F-FDG PET and PET/CT for the Detection and Staging of RecurrentBreast Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21918F-FDG Imaging to Monitor Therapy of Breast Cancer . . . . . . . . . . . . . . . . 22018F-FDG PET/CT for Radiation Therapy Planning in Breast Cancer. . . . . . . 221Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 221Guidelines and Recommendations for the Use of 18F-FDG PET andPET/CT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 222

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Case Presentations

II.4.1 Unsuspected Breast Primary Cancer . . . . . . . . . . . . . . . . . . . . . . . . . 223II.4.2 Metastatic Breast Cancer to Omentum, Peritoneum, and

Ovaries with Partial Response to Treatment. . . . . . . . . . . . . . . . . . . 226II.4.3 Metastatic Breast Cancer to Liver, T8 Vertebral Body, Right

Femur, and Acetabulum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 232II.4.4 Recurrent Left Breast Cancer with Regional Metastases

to Left Chest Wall and Synchronous Right Thyroid PapillaryCancer (DICOM Images on DVD). . . . . . . . . . . . . . . . . . . . . . . . . . 236

II.4.5 Solitary Hepatic Metastasis, Right Chest Wall Breast CancerRecurrence, and Right Apical Lung Metastasis CausingBrachial Plexopathy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 242

II.4.6 Metastatic Breast Cancer to Bones, Left Lung, and Pleura:Good Response to Therapy in Left Lung and Pleura; PartialResponse to Therapy in Bones (DICOM Images on DVD) . . . . . . 246

II.5 Colorectal Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26118F-FDG PET and PET/CT for Screening and Diagnosis of ColorectalCarcinoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26118F-FDG PET and PET/CT in the Initial Staging of Colorectal Carcinoma . . 26218F-FDG PET and PET/CT for Assessment of Recurrent ColorectalCarcinoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 262Detection and Restaging of Recurrence . . . . . . . . . . . . . . . . . . . . . . . . . . . . 262Impact on Management and Cost Analysis in Patients with RecurrentDisease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 263

18F-FDG Imaging for Monitoring Therapy Response of ColorectalCarcinoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 265Systemic Chemotherapy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 265Radiation Therapy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 265Regional Therapy to the Liver. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 266

Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 266Guidelines and Recommendations for the Use of 18F-FDG PETand PET/CT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 266Case Presentations

II.5.1 Incidental Primary Transverse Colon Carcinoma in a Patientwith Lung Cancer and Malignant Fibrohistiocytoma (DICOMImages on DVD) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 268

II.5.2 Primary Metastatic Rectal Carcinoma . . . . . . . . . . . . . . . . . . . . . . . 274II.5.3 Colon Cancer with Hepatic Metastases . . . . . . . . . . . . . . . . . . . . . . 279II.5.4 Local Recurrence and Metastatic Retroperitoneal Lymph Nodes

(DICOM Images on DVD) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 281II.5.5 Colon Cancer with Pulmonary Metastases . . . . . . . . . . . . . . . . . . . . 286II.5.6 Mucinous Adenocarcinoma of the Colon . . . . . . . . . . . . . . . . . . . . . 288

II.6 18F-FDG PET/CT in Tumors of the Gastrointestinal Tract: Esophageal and

Gastric Cancer and Gastrointestinal Stromal Tumors (GIST) . . . . . . . . . . . . . . 29318F-FDG Imaging in Esophageal Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 293

18F-FDG Imaging for Staging of Esophageal Cancer . . . . . . . . . . . . . . . . . . 294

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18F-FDG Imaging for Monitoring Response to Treatmentof Esophageal Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29518F-FDG Imaging for Diagnosis of Recurrent Esophageal Cancer . . . . . . . 296

18F-FDG Imaging in Gastric Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29618F-FDG Imaging for Diagnosis and Staging of Gastric Cancer . . . . . . . . . 29718F-FDG Imaging for Monitoring Response to Treatment of GastricCancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29818F-FDG Imaging for Diagnosis of Recurrent Gastric Cancer. . . . . . . . . . . 298

18F-FDG Imaging in Gastrointestinal Stromal Tumors . . . . . . . . . . . . . . . . . . 29918F-FDG Imaging at Initial Diagnosis of GIST . . . . . . . . . . . . . . . . . . . . . . 30018F-FDG Imaging for Monitoring Response to Treatmentof GIST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 300

Guidelines and Recommendations for the Use of 18F-FDG PETand PET/CT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 301Case Presentations

II.6.1 Distal Esophageal Cancer at Staging: Loco-regionalMetastatic Adenopathy at the Level of the Gastro-hepaticLigament and Distant Non-regional Metastasis in LeftPre-tracheal Lymph Node (DICOM Images on DVD) . . . . . . . . . . 302

II.6.2 Increase Focal 18F-FDG Gastric Uptake at Site of UpperAnastomosis, Most Probably due to Physiologic Uptakeor a Mild Inflammatory Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . 307

II.6.3 Primary Gastric Cancer with no Evidence of Metastases;Degenerative Changes in Cervical Spine (DICOM Imageson DVD) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 309

II.6.4 Adenocarcinoma of Gastro-esophgeal Junction with NodalMetastasis in Porta-hepatic Region and Inflammatory LungInfiltrate. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 315

II.6.5 Para-rectal GIST with no Evidence for Metastases: CompleteMetabolic Response to treatment with Gleevec on 18F-FDG-PETand Partial Response with Residual Para-rectal Mass on CT . . . . . 319

II.6.6 Recurrent GIST within Multiple Omental and PeritonealMetastases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 322

II.7 Hepatobiliary and Pancreatic Malignancies. . . . . . . . . . . . . . . . . . . . . . . . . . . . 331Hepatobiliary Neoplasms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 331Pancreatic Neoplasms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 332Imaging of Hepatobiliary and Pancreatic Neoplasms . . . . . . . . . . . . . . . . . . . 332Hepatic Metastases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 334

18F-FDG PET/CT Imaging of Hepatic Metastases. . . . . . . . . . . . . . . . . . . . 334Hepatocellular Carcinoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 334

18F-FDG PET/CT for Diagnosis and Staging of HCC. . . . . . . . . . . . . . . . . 33511C-Acetate Imaging of HCC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 335

Cholangiocarcinoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33618F-FDG PET/CT for Diagnosis and Staging of Cholangiocarcinoma . . . . 336

Gallbladder Carcinoma. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33718F-FDG PET/CT for Diagnosis and Staging of GallbladderCarcinoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 337

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18F-FDG Imaging for Monitoring Therapy of Hepatic Tumors . . . . . . . . . 337Pancreatic Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 338

18F-FDG PET/CT for Preoperative Diagnosis of Pancreatic Carcinoma. . . 33918F-FDG PET/CT for Staging of Pancreatic Carcinoma . . . . . . . . . . . . . . . 34018F-FDG PET/CT in the Post-therapy Setting . . . . . . . . . . . . . . . . . . . . . . . 340Impact of 18F-FDG PET/CT on Management of Patients withPancreatic Carcinoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 340

Limitations of 18F-FDG Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 341Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 341Guidelines and Recommendations for the Use of 18F-FDG PETand PET/CT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 342Case Presentations

II.7.1 Hepatocellular Carcinoma (DICOM Images on DVD) . . . . . . . . . . 343II.7.2 Cholangiocarcinoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 350II.7.3 Gallbladder Carcinoma. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 355II.7.4 Pancreatic Carcinoma (DICOM Images on DVD). . . . . . . . . . . . . . 360II.7.5 Klatskin’s Tumor and Acute Pancreatitis . . . . . . . . . . . . . . . . . . . . . 366II.7.6 Cavernous Hemangioma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 371II.7.7 Focal Nodular Hyperplasia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 373II.7.8 Monitoring Therapy of Hepatic Metastases Treated with

90Y-microspheres . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 377

II.8 Gynecological Tumors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 383Cervical Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 383

18F-FDG PET/CT in Staging Cervical Cancer . . . . . . . . . . . . . . . . . . . . . . . 38318F-FDG PET/CT in Directing Therapy in Cervical Cancer . . . . . . . . . . . . 38418F-FDG PET/CT in Predicting Prognosis in Cervical Cancer. . . . . . . . . . . 38418F-FDG PET/CT in Post-therapy Monitoring of Cervical Cancer . . . . . . . 385

Ovarian Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38518F-FDG PET/CT in Diagnosis and Staging of Ovarian Cancer . . . . . . . . . 38518F-FDG PET/CT in Assessment of Response to Therapy in OvarianCancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38618F-FDG PET/CT in Detection of Recurrent Ovarian Cancer. . . . . . . . . . . 386

Endometrial Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 387Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 387Guidelines and Recommendations for the Use of 18F-FDG PETand PET/CT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 388Case Presentations

II.8.1 Cervical cancer, Staging: Regional and Distant Metastases(DICOM Images on DVD) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 389

II.8.2 Cervical cancer, Staging: Regional Metastases and BenignAxillary Node Uptake . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 394

II.8.3 Cervical Cancer, Staging: Regional Metastases; MetabolicResponse to Chemoradiation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 397

II.8.4 Ovarian Cancer, Recurrence: Diffuse AbdominalCarcinomatosis (DICOM Images on DVD) . . . . . . . . . . . . . . . . . . . 400

II.8.5 Endometrial Cancer, Recurrence in Abdominal Wall, and PelvicMetastases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 405

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II.9 Hybrid Imaging in Malignancies of the Urinary Tract, Prostate,

and Testicular Cancers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 409Renal Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 409PET/CT Imaging for Diagnosis and Staging of RCC . . . . . . . . . . . . . . . . . . 410PET/CT Imaging During Follow-Up and Recurrent RCC. . . . . . . . . . . . . . 410Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 411

Bladder Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41118F-FDG Imaging of Bladder Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41111C-Choline Imaging of Bladder Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41211C-Acetate and 11C-Methionine Imaging of Bladder Cancer . . . . . . . . . . . 412Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 413

Prostate Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 413PET/CT and SPECT/CT of Primary Prostate Cancer . . . . . . . . . . . . . . . . . 413PET/CT and SPECT/CT of Metastatic Prostate Cancer . . . . . . . . . . . . . . . 414PET/CT and SPECT/CT in Recurrent Prostate Cancer . . . . . . . . . . . . . . . . 415Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 416

Testicular Cancer. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41618F-FDG Imaging for Staging of Testicular Tumors . . . . . . . . . . . . . . . . . . 41718F-FDG Imaging of Residual and Recurrent Testicular Tumors . . . . . . . . 41718F-FDG Imaging in Follow-up of NSGCT . . . . . . . . . . . . . . . . . . . . . . . . . 418Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 418

Guidelines and Recommendations for the use of 18F-FDG PETand PET/CT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 418Case Presentations

II.9.1 Renal Cell Carcinoma with Left Pulmonary Metastasis. . . . . . . . . . 419II.9.2 RCC with Recurrent Skeletal Metastasis (DICOM Images

on DVD) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 422II.9.3 Muscle Invasive TCC of Bladder with Single Nodal Metastasis . . . 426II.9.4 Muscle Invasive TCC of Bladder with Bilateral Pelvic Lymph

Nodes Metastases (DICOM Images on DVD) . . . . . . . . . . . . . . . . . 429II.9.5 Primary Prostate Cancer with Right Obturator Nodal

Metastasis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 434II.9.6 Local Recurrence of Prostate Cancer and Paget’s Disease

of Right Iliac Bone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 436II.9.7 Metastatic Seminoma Achieving a Complete Remission . . . . . . . . . 438

II.10 Thyroid Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 445Differentiated Thyroid Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 446Radioiodine Whole-Body Scintigraphy with SPECT/CT . . . . . . . . . . . . . . . 44618F-FDG PET/CT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 446

Hurthle Cell Carcinoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 447Anaplastic Thyroid Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 448Medullary Thyroid Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 448Thyroid Incidentalomas on 18F-FDG PET/CT . . . . . . . . . . . . . . . . . . . . . . . . 449Guidelines and Recommendations for the Use of 18F-FDG PET and PET/CT . . 449Case Presentations

II.10.1 Recurrent Papillary Thyroid Carcinoma in Right UpperParatracheal Lymph Nodes (DICOM Images on DVD) . . . . . . . . 450

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II.10.2 Metastatic Papillary Thyroid Cancer, Bilateral Central andRight lateral Neck Lymph Nodes (DICOM Images on DVD). . . . 453

II.10.3 Persistent, Iodine-avid Hurthle Cell Carcinoma in LeftIliac/Sacral Metastasis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 458

II.10.4 Anaplastic Thyroid Carcinoma in the Thyroid Glandand Possible Metastasis in a Left Parotid Lymph Node . . . . . . . . . 460

II.10.5 Medullary Thyroid Cancer with Metastatic Left NeckLymphadenopathy, Active and Treated Skeletal Metastases,and Treated Hepatic Metastases . . . . . . . . . . . . . . . . . . . . . . . . . . . 463

II.10.6 Recurrent Medullary Thyroid Cancer with Right Paratrachealand Left Level II Lymph Nodes, Skeletal Metastases, andPhysiologic Scalene Muscle 18F-FDG Uptake . . . . . . . . . . . . . . . . 465

II.10.7 Recurrent Melanoma of the Right Nasal Cavity Mucosaand Papillary Thyroid Carcinoma. . . . . . . . . . . . . . . . . . . . . . . . . . 468

II.11 Endocrine Tumors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 475Imaging Protocols . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 476SPECT/CT and PET/CT Tracers for Imaging of NE Tumors . . . . . . . . . . . . . 476SPECT/CT and PET/CT Imaging of GEP Tumors . . . . . . . . . . . . . . . . . . . . . 478SPECT/CT and PET/CT Imaging of Neural Crest Tumors. . . . . . . . . . . . . . . 479SPECT/CT Imaging of Parathyroid Adenoma. . . . . . . . . . . . . . . . . . . . . . . . . 481Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 482Case Presentations

II.11.1 Well-differentiated Small Intestine NeuroendocrineTumor with Mesenteric Metastasis (DICOM Imageson DVD) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 483

II.11.2 VIPoma in Body of the Pancreas . . . . . . . . . . . . . . . . . . . . . . . . . . 488II.11.3 Pancreatic Neuroendocrine Carcinoma with Disseminated

Hepatic and Skeletal Metastases Expressing High Densityof Somatostatin Receptors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 491

II.11.4 Suspected Recurrence of Pheochromocytoma in LeftAdrenal Bed. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 494

II.11.5 123I-MIBG Avid Pheochromocytoma Metastatic to Lungsand Liver . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 498

II.11.6 Left Upper Parathyroid Adenoma in Posterior Locationbetween the Trachea and Esophagus. . . . . . . . . . . . . . . . . . . . . . . . 503

II.11.7 Ectopic Parathyroid Adenoma in Mid-anterior Lower Neck . . . . . 506II.11.8 68Ga-DOTATOC-avid Neuroendocrine Tumor in Tail

of Pancreas. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 508

II.12 Lymphoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 513Non-Hodgkin’s Lymphoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 513Hodgkin’s Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51518F-FDG Imaging for Diagnosis of NHL and HD. . . . . . . . . . . . . . . . . . . . . . 51618F-FDG Imaging at Initial Staging of Lymphoma . . . . . . . . . . . . . . . . . . . . . 516

18F-FDG Avidity of HD and NHL. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 516Comparative Performance of 18F-FDG Imaging and CT. . . . . . . . . . . . . . . 516Diagnosis of Bone Marrow Involvement. . . . . . . . . . . . . . . . . . . . . . . . . . . . 517

Expanded Chapter Contents xxi

18F-FDG Staging Criteria in HD and NHL . . . . . . . . . . . . . . . . . . . . . . . . . . . 51718F-FDG Imaging for Monitoring Therapy Response in Lymphoma . . . . . . . 517Definition of Response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 517Timing of 18F-FDG Imaging in Assessing Response to Treatmentin Lymphoma. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 518During and End-of-Treatment 18F-FDG Imaging in Lymphoma . . . . . . . . 51818F-FDG Imaging of a Residual Mass . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 519Pitfalls in Interpretation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 519

18F-FDG Imaging for Diagnosis and Restaging of Lymphoma Recurrence . . . 520Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 520Guidelines and Recommendations for the Use of 18F-FDG-PETand PET/CT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 521Case Presentations

II.12.1 NHL-DLCL of the Spleen (with local invasion to LN insplenic hilum and to tail of pancreas) (DICOM Imageson DVD) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 523

II.12.2 NHL-DLCL Stage IV: Good Response to Treatment. . . . . . . . . . 529II.12.3 HD, Nodular Sclerosis Type Stage III: Good Early Response

at Mid-treatment (DICOM Images on DVD). . . . . . . . . . . . . . . . . 532II.12.4 Recurrent Small Lymphocytic NHL and Infection in Right

Groin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 536II.12.5 HD, Refractory to First Line Chemotherapy: CR after

Salvage Therapy and AHCT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 540II.12.6 Recurrent Follicular Grade II NHL and Gastritis . . . . . . . . . . . . . 542II.12.7 Early Relapse of HD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 544II.12.8 Recurrent Follicular Grade II NHL . . . . . . . . . . . . . . . . . . . . . . . . 547II.12.9 HD in Complete Remission: Transient Foci of Increased

18F-FDG Activity due to Inflammation . . . . . . . . . . . . . . . . . . . . . 550

II.13 Melanoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 555Cutaneous Melanoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 555Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 555Staging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 556Detection of Recurrence and Restaging with 18F-FDG PETand PET/CT. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 559

Choroidal Melanoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 561Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 562Guidelines and Recommendations for the Use of 18F-FDG PETand PET/CT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 562Case Presentations

II.13.1 Metastatic Melanoma with Cerebral Metastases Seenon CT Only . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 563

II.13.2 Metastatic Melanoma s/p Regional Lymph NodeDissection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 565

II.13.3 Metastatic Melanoma to the Right Ventricle and PulmonaryEmboli (DICOM Images on DVD). . . . . . . . . . . . . . . . . . . . . . . . . 567

II.13.4 Choroidal Melanoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 570II.13.5 No Evidence of Recurrence in a Patient Treated with Vaccine. . . . 573

xxii Expanded Chapter Contents

II.13.6 Widely Metastatic Melanoma including the Mesentery(DICOM Images on DVD) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 575

II.13.7 SPECT/CT of a Cervical Sentinel Lymph Node. . . . . . . . . . . . . . . 579

II.14 Malignancy of the Bone: Primary Tumors, Lymphoma, and Skeletal

Metastases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 583Skeletal Metastases, Bone Lymphoma, and Multiple Myeloma. . . . . . . . . . . . 583

18F-FDG PET/CT for Diagnosis of Malignant Skeletal Lesions . . . . . . . . . 58318F-FDG PET/CT for Monitoring Response to Therapy. . . . . . . . . . . . . . . 584Advantages of 18F-FDG PET/CT in Malignant SkeletalInvolvement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 584Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 584

Primary Skeletal Malignancies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58518F-FDG PET/CT for Diagnosis of Primary Skeletal Tumors . . . . . . . . . . . 58518F-FDG PET/CT for Staging Primary Skeletal Tumors . . . . . . . . . . . . . . . 58518F-FDG PET/CT for Monitoring Response to Therapy. . . . . . . . . . . . . . . 586Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 586

Case Presentations

II.14.1 Lung Cancer with Direct Extension to Bone and DistantSkeletal Metastases (DICOM Images on DVD) . . . . . . . . . . . . . . . 587

II.14.2 Marrow-based and Cortical Skeletal Metastases before andwith Partial Response after Treatment, and Hepatic Metastases . . 592

II.14.3 Lung Cancer with Extensive Skeletal Metastatic Spreadand Invasion of the Epidural Space at T11 . . . . . . . . . . . . . . . . . . . 598

II.14.4 Lymphoma with Skeletal Involvement and SuspectedInvolvement of the Left S1 Neural Foramen, in additionto Nodal Pleural and Muscular Disease . . . . . . . . . . . . . . . . . . . . . 600

II.14.5 Primary Lymphoma of the Bone. . . . . . . . . . . . . . . . . . . . . . . . . . . 604II.14.6 Multiple Myeloma with Active Disease in Rib and

Post-radiotherapy Inactive Disease in Vertebra . . . . . . . . . . . . . . . 610II.14.7 Ewing Sarcoma of the Proximal Femur with Muscular

Involvement, Pulmonary Metastases, and Suspected AdditionalDistant Sites of Disease in Bone and Lymph Nodes (DICOMImages on DVD) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 612

II.15 Pediatric Applications for PET/CT and SPECT/CT. . . . . . . . . . . . . . . . . . . . 621Neuroblastoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 621Sarcoma. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 622Lymphoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 623Considerations on Radiation Exposure from PET/CT. . . . . . . . . . . . . . . . . . . 624PET/CT Procedure and Preparation of the Pediatric Patient . . . . . . . . . . . . . . 625SPECT/CT Procedure and Preparation of the Pediatric Patient . . . . . . . . . . . 625Case Presentations

II.15.1 B-Cell Lymphoblastic Lymphoma, Stage IV Disease with Left andRight Face/Neck Disease and Bilateral Skeletal Involvement of theLower Extremities (DICOM Images on DVD). . . . . . . . . . . . . . . . 627

II.15.2 Multiple GIST Tumors Metastatic to the Liver andUnconfirmed Pulmonary Chondromas. . . . . . . . . . . . . . . . . . . . . . 633

Expanded Chapter Contents xxiii

II.15.3 Ewing Sarcoma with Solitary Skeletal Metastasis. . . . . . . . . . . . . . 637II.15.4 ALL with Diffuse Skeletal Involvement, Renal and GIT

Involvement; Post-surgical Changes Related to PreviousRotationplasty for Osteogenic Sarcoma . . . . . . . . . . . . . . . . . . . . . 640

II.15.5 Stage IV Neuroblastoma with Residual Retrocrural Soft TissueDisease and Skeletal Metastasis in the Sacrum after Treatment andPost-surgical Changes Left Upper Quadrant (DICOM Images onDVD) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 645

II.15.6 Occult Calcaneal Stress Fracture. . . . . . . . . . . . . . . . . . . . . . . . . . . 651

III.1 Cardiac Hybrid Imaging (PET/CT and SPECT/CT): Assessment of CAD . . . 659Imaging Protocols for Hybrid Cardiac Imaging . . . . . . . . . . . . . . . . . . . . . . . . 659CT Imaging for Hybrid Cardiac SPECT/CT and PET/CT. . . . . . . . . . . . . . 659Cardiac SPECT/CT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 661Cardiac PET/CT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 661

Quality Control of Cardiac Hybrid Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . 662Clinical Applications of Cardiac Hybrid Imaging . . . . . . . . . . . . . . . . . . . . . . 662Diagnosis of CAD Using Cardiac Hybrid Imaging. . . . . . . . . . . . . . . . . . . . 662Risk Assessment Using Cardiac Hybrid Imaging . . . . . . . . . . . . . . . . . . . . . 663Guiding Management of CAD Using Cardiac Hybrid Imaging . . . . . . . . . . 664

Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 665Case Presentations

III.1.1 Cardiac SPECT/Low Dose CT for Attenuation Correction:Normal Patient with Misregistration. . . . . . . . . . . . . . . . . . . . . . . . 666

III.1.2 Cardiac PET/Low Dose CT for Attenuation Correction:Normal Patient with Misregistration. . . . . . . . . . . . . . . . . . . . . . . . 668

III.1.3 Cardiac SPECT/CCTA: Hemodynamically SignificantLesion in the Territory of the RCA Related to Stenosisin SVG to RCA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 670

III.I.4 Cardiac SPECT/CCTA: Ischemia in the Inferior Wall Indicatingthe Hemodynamically Significant Lesion in the RCA. . . . . . . . . . . . 673

III.1.5 Normal PET MPS with High Calcium Score (> 1,000) . . . . . . . . . 676III.1.6 Moderate Stenosis in the RCA with Normal PET MPS . . . . . . . . . 679

III.2 Hybrid Imaging of Benign Skeletal Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . 68399mTc-MDP SPECT/CT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68318F-Fluoride PET/CT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68518FDG PET/CT. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 686Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 687Case Presentations

III.2.1 Incidentally Found Fibrous Dysplasia in the Left Tibia . . . . . . . . . 688III.2.2 Parosteal Ossifying Lipoma in the Left Fibula . . . . . . . . . . . . . . . . 691III.2.3 Giant Cell Tumor of the Sacral Bone and Presacral Region

(DICOM Images on DVD) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 694III.2.4 Chronic Recurrent Multifocal Ostemyelitis in the Thoracic

Spine, Knees, Right Humerus, and Scapula (DICOM Imageson DVD) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 699

III.2.5 Osteonecrosis in Both Knees . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 705

xxiv Expanded Chapter Contents

III.3 Infectious and Inflammatory Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 711Radionuclide Procedures. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 711Bone Scintigraphy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71167Gallium Scintigraphy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 712Labeled Leukocyte Scintigraphy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 712

18F-FDG Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 713Case Presentations

III.3.1 Right Quadriceps Abscess: 67Ga SPECT/CT . . . . . . . . . . . . . . . . . 714III.3.2 Soft Tissue Abscess and Osteomyelitis of the Mandibular

Bone Graft: 67Ga SPECT/CT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 717III.3.3 Soft Tissue Infection of the Left Lateral Ankle: 99mTc-MDP

and 111In-WBC SPECT/CT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 720III.3.4 Hepatic Abscess: 67Ga SPECT/CT . . . . . . . . . . . . . . . . . . . . . . . . . 724III.3.5 Osteomyelitis of the Medial Cuneiform and Right First

Metatarsal: 18F-FDG PET/CT . . . . . . . . . . . . . . . . . . . . . . . . . . . . 726III.3.6 Infected Right Femoropopliteal Graft: 18F-FDG PET/CT . . . . . . 728III.3.7A Fever of Unknown Origin: 18F-FDG PET/CT (DICOM

Images on DVD). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 731III.3.7B Dental Abscess: 18F-FDG PET/CT . . . . . . . . . . . . . . . . . . . . . . . . 734III.3.7C Infected Rental Cyst: 18F-FDG PET/CT . . . . . . . . . . . . . . . . . . . . 736III.3.8 Healing Traumatic L3 Vertebral Fracture: 99mTc-MDP

SPECT/CT and 18F-FDG PET/CT (DICOM Imageson DVD) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 739

Expanded Chapter Contents xxv

Contributors

Rachel Bar-Shalom, MD Department of Nuclear Medicine, Rambam Health Care

Campus, B. and R. Rappaport School of Medicine, Technion—Israel Institute of

Technology, Haifa, Israel

Simona Ben-Haim, MD, DSc Institute of Nuclear Medicine, University College London

Hospital NHS Trust, London, UK

Arye Blachar, MD Department of Radiology, Sackler School of Medicine, Tel Aviv

Sourasky Medical Center, Tel Aviv University, Tel Aviv, Israel

Angela T. Byrne, MB, MRCPI, FFRRCSI Department of Radiology, British Columbia

Children’s Hospital, Vancouver, British Columbia, Canada

Marcelo Daitzchman, MD Department of Diagnostic Imaging, Rambam Health Care

Campus, Haifa, Israel

Farrokh Dehdashti, MD Mallinckrodt Institute of Radiology, Washington University

School of Medicine, St. Louis, MO, USA

Dominique Delbeke, MD, PhD Department of Radiology and Radiological Sciences,

Vanderbilt University Medical Center, Nashville, TN, USA

Marcelo F. Di Carli, MD, FACC Department of Medicine and Radiology, Division of

Nuclear Medicine-PET, Brigham and Women’s Hospital, Boston, MA, USA

Sharmila Dorbala, MBBS Department of Radiology and Medicine, Brigham and

Women’s Hospital, Harvard University, Boston, MA, USA

Einat Even-Sapir, MD, PhD Department of Nuclear Medicine, Tel-Aviv Sourasky

Medical Center, Tel Aviv University, Tel Aviv, Israel

Gideon Flusser, MD Department of Radiology, Tel Aviv Sourasky Medical Center, Tel

Aviv, Israel

Sibyll Goetze, MD Department of Radiology, Division of Nuclear Medicine/PET, The

University of Alabama at Birmingham, Birmingham, AL, USA

Arie Gordin, MD Department of Otolaryngology, Head and Neck Surgery, The Hospital

for Sick Children, Toronto, ON, Canada

Ludmila Guralnik, MD Departments of Diagnostic Imaging, Rambam Health Care

Campus, Haifa, Israel

xxvii

Ora Israel, MD RambamHealth Care Campus, B. and R. Rappaport School ofMedicine,

Technion, Israel Institute of Technology, Haifa, Israel

Heather A. Jacene, MD Division of Nuclear Medicine/PET, Russell H. Morgan

Department of Radiology and Radiological Science, Johns Hopkins University School of

Medicine, Baltimore, MD, USA

Aaron C. Jessop, MD Department of Radiology and Radiological Sciences, Vanderbilt

University Medical Center, Nashville, TN, USA

Laurie B. Jones-Jackson, MD Department of Radiology and Radiological Sciences,

Vanderbilt University Medical Center, Nashville, TN, USA

Zohar Keidar, MD, PhD Department of Nuclear Medicine, B. and R. Rappaport School

of Medicine, Rambam Health Care Campus, Haifa, Israel

Martine Klein, MD Department of Biophysics and Nuclear Medicine, Hadassah Hebrew

University Medical Center, Jerusalem, Israel

Yodphat Krausz, MD Department of Medical Biophysics and Nuclear Medicine,

Hadassah Hebrew University Medical Center, Jerusalem, Israel

Hedva Lerman,MD Department ofNuclearMedicine, Tel Aviv SouraskyMedical Center,

Tel Aviv, Israel

Charito Love, MD Division of Nuclear Medicine and Molecular Imaging, North Shore

Long Island Jewish Health System, Manhasset and New Hyde Park, NY, USA

Helen R. Nadel, MD, FRCPC Division of Nuclear Medicine, Department of Radiology,

British Columbia Children’s Hospital, University of British Columbia, Vancouver, BC,

Canada

Marina Orevi, MD Department of Biophysics and Nuclear Medicine, Hadassah Medical

Center, Jerusalem, Israel

Christopher J. Palestro, MD Albert Einstein College of Medicine of Yeshiva University,

Bronx, NY, USA; Division of Nuclear Medicine and Molecular Imaging, North Shore

Long Island Jewish Health System, Manhasset and New Hyde Park, NY, USA

James A. Patton, PhD Department of Radiology and Radiological Sciences, Vanderbilt

University Medical Center, Nashville, TN, USA

Vineet Prakash, MBChB, MRCP, FRCR Institute of Nuclear Medicine, University

College London Hospital NHS Trust, London, UK

Barry A. Siegel, MD Division of Nuclear Medicine, Edward Mallinckrodt Institute of

Radiology and the Alvin J. Siteman Cancer Center Washington University School of

Medicine, Saint Louis, MO, USA

Gabriel Vorobiof, MD Department of Cardiovascular Imaging, Yale University, New

Haven, CT, USA

Richard L. Wahl, MD Russell H. Morgan Department of Radiology and Radiological

Science, Division of Nuclear Medicine/PET, Johns Hopkins University School of

Medicine, Baltimore, MD, USA

xxviii Contributors

Ronald C. Walker, MD Department of Radiology and Radiological Sciences, VanderbiltUniversity Medical Center, Nashville, TN, USA

Michal Weiler-Sagie, MD, PhD Department of Nuclear Medicine, Rambam Health CareCampus, Haifa, Israel

Contributors xxix

Part I

General

Chapter I.1

History and Principles of Hybrid Imaging

James A. Patton

Introduction

Positron emission tomography (PET) and single photon emission computed tomography

(SPECT) systems are used to image distribution of radiopharmaceuticals in order toprovide physicians with physiological information for diagnostic and therapeutic purposes.

However, these images often lack sufficient anatomical detail, a fact that has triggered the

development of a new technology termed hybrid imaging. Hybrid imaging is a term that isnow being used to describe the combination of x-ray computed tomography (CT) systems

with nuclear medicine imaging devices (PET and SPECT systems) in order to provide the

technology for acquiring images of anatomy and function in a registered format during asingle imaging session with the patient positioned on a common imaging table. There are

two primary advantages to this technology. First, the x-ray transmission images acquired

with CT can be used to perform attenuation correction of the PET and SPECT emissiondata. In addition, the CT anatomical images can be fused with the PET and SPECT

functional images to provide precise anatomical localization of regions of questionable

uptake of radiopharmaceuticals. This chapter will provide a review of SPECT, PET, andCT instrumentation and then discuss the technology involved in combining these systems to

provide the capabilities for hybrid imaging.

Single Photon Emission Computed Tomography

For many years, nuclear medicine procedures have been performed using a scintillation

camera. Originally, multiple planar projections were acquired to provide diagnostic infor-mation, but, more recently, the techniques of SPECT have been utilized. During this time,

the scintillation camera has evolved to a high-quality imaging device, and much of this

evolution is due to the integration of digital technology into every aspect of the dataacquisition, processing, and display processes.

Conventional planar images generally suffered from poor contrast due to the presence of

overlying and underlying activity that interferes with imaging of the region of interest. This

is caused by the superposition of depth information into single data points collected from

J.A. Patton (*)Department of Radiology and Radiological Sciences, Vanderbilt University Medical Center,Nashville, TN, USAe-mail: jim.patton@vanderbilt.edu

D. Delbeke, O. Israel (eds.), Hybrid PET/CT and SPECT/CT Imaging,DOI 10.1007/978-0-387-92820-3_1, � Springer ScienceþBusiness Media, LLC 2010

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perpendicular or angled lines of travel of photons from the distribution being studied intothe holes of the parallel hole collimator fitted to the scintillation camera. The resultingplanar image is low in contrast due to the effect of the superposition of depth information.This effect can be reduced by collecting images from multiple positions around thedistribution and producing an image of a transverse slice through the distribution.The resulting tomographic image is of higher contrast than the planar image due tothe elimination of contributions of activity above and below the region of interest. This isthe goal of SPECT, i.e., to provide images of slices of radionuclide distributions with imagecontrast that is higher than that provided by conventional techniques.

Data Acquisition

Instrumentation

The introduction of the scintillation camera by Anger and Rosenthal in 19591 and itsultimate evolution into the imaging system of choice for routine nuclear medicine imagingapplications resulted in a great deal of effort being expended toward the extension of thescintillation camera as a tomographic imaging device. In the early 1960s, Kuhland Edwards established the fundamentals for SPECT using multi-detector scanningsystems to acquire cross-sectional images of radionuclide distributions.2–4 In the 1970s,Muehllehner,5 Keyes and colleagues6 and Jaszczak and colleagues7 adapted this technologyto a rotating scintillation camera. The result of these efforts along with the integration ofcomputer systems was the development of the modern day SPECT system as a scintillationcamera/computer system with one, two, or three heads and tomographic imaging capabil-ity. The scintillation camera collects tomographic data by rotating around the region ofinterest and acquiring multiple planar projection images during its rotation. It is imperativethat the region of interest is included in every projection image. If this is not the case, theresulting truncation of the images will produce artifacts in the final reconstructed images.The camera may move in a continuous motion during acquisition but typically remainsstationary during the acquisition of each projection image before advancing to the nextposition in a ‘‘step and shoot’’ mode of operation. A complete 3608 rotation of a scintillationcamera with a rectangular field of view will completely sample a cylindrical region ofinterest. Originally, camera systems were only capable of circular orbits; however, modernday systems have elliptical orbit capability. This is accomplished by equipping the collima-tors with sensors that detect the presence of the patient and maintain the camera head(s) inclose proximity to the patient as the orbit is completed. Since the spatial resolution ofcollimators used with the scintillation camera degrades with distance from the collimatorface, the optimum resolution is obtained in each projection image when the camera is asclose to the patient as possible.

Initial SPECT applications were performedwith a single-head scintillation camera acquir-ing data from a 3608 orbit as shown in Fig. I.1.1A.When interest in imaging the myocardiumbecame prominent, experimental work demonstrated that acceptable images could beobtained using a 1808 orbit (right anterior oblique to left posterior oblique).8,9 Althoughthis results in an incomplete sampling of the region of interest, this lies in the near field of viewof the camera throughout the partial orbit where the spatial resolution is optimum, andimages of acceptable quality are obtained. Early in the evolution of SPECT imaging, itbecame evident that optimum counting statistics formany applications could not be obtained

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in a reasonable time frame that could be tolerated by patients. This situationwas remedied bythe development of multi-head scintillation cameras. The first system to evolve was a dual-head camera in a fixed 1808 geometry permitting a 3608 acquisition with only a 1808 rotationof the gantry. This development provided a twofold increase in sensitivity for SPECTapplications. However, this increase in sensitivity was not available for cardiac applicationsusing 1808 acquisitions. To address this problem, special purpose, dual-head cameras weredeveloped with the camera heads fixed in a 908 geometry as shown in Fig. I.1.1B. This madethe twofold increase in sensitivity also available for cardiac imaging, and the acquisition ofprojections through 1808 could be acquiredwith a 908 rotation of the dual-head gantry. Sincemany scintillation cameras must serve multiple purposes in nuclear medicine departments,the next step was the development of dual-head, variable-angle scintillation cameras asshown in Fig. I.1.1C. These cameras can acquire images with the heads in a 1808 geometryfor routine 3608 applications, and one head can be moved into a 908 geometry with the otherhead for 1808 cardiac applications. The two latter configurations are presently considered thecameras of choice for cardiac imaging.

Acquisition Parameters

Collimation

SPECT applications typically make use of parallel hole collimators in order to establish anorthogonal detection geometry with the crystal detectors. Imaging of low-energy radio-nuclides is generally limited to the use of general purpose, parallel hole collimators.

The resulting images typically exhibited poor spatial resolution. The emergence of multi-head cameras and the resulting increase in sensitivity have made it possible to improvespatial resolution by the use of high-resolution collimators, and these collimators are nowthe choice for most imaging applications.

Matrix Size

For most SPECT applications, the acquisition matrix size for acquiring planar projectionimages is typically a 64 � 64 data point array. The decision is based on the size of the

Fig. I.1.1 Scintillation cameras for nuclear medicine applications have evolved from single-head (A) todual-head, fixed 908 geometry (B), and finally to dual-head, variable-angle multipurpose cameras(C) (Reprinted with permission of Springer Science+Business Media from Vitola J, Delbeke D, eds.Nuclear Cardiology and Correlative Imaging: A Teaching File. New York: Springer-Verlag, 2004.)

I.1 History and Principles of Hybrid Imaging 5

smallest object to be imaged in the distribution being studied. Sampling theory states that inorder to resolve frequencies (objects) up to a maximum frequency (smallest object) at leasttwo measurements must be made across one cycle (the object). This maximum frequency isreferred to as the Nyquist frequency. For example, using a camera with a 540-mm field ofview, a zoom factor of 1.4 and a 64� 64 acquisitionmatrix size would result in a pixel size of6 mm, making it possible to image structures of 1.2 cm or larger. This is generallyconsidered sufficient for most SPECT applications. The one exception is bone SPECTwhere a 128� 128 matrix may be used to take advantage of the higher counting statistics toimprove spatial resolution.

Arc of Rotation

As previously stated, a 1808 acquisition is acceptable (right anterior oblique position to leftposterior oblique position) for cardiac imaging since the myocardium is always in the nearfield of the detector(s). Photons traveling in a posterior direction from the myocardiummust travel significant distances through tissue and, therefore, spatial resolution andsensitivity (due to attenuation) are degraded in posterior and right posterior obliqueviews. Thus, the data from the omitted projections are considered to be of poor qualityand generally not acquired. For most applications, however, a 3608 acquisition is requiredin order to obtain a complete set of projections for acceptable image reconstructions.

Projections per Arc of Rotation

The same sampling theory previously described also applies to the determination of thenumber of projection views that should be acquired throughout an arc of rotation. Withcurrent instrumentation, 120 views are typically obtained with a 3608 acquisition, and,therefore, 60 views are generally acquired with a 1808 acquisition.

Time per Projection

In general, SPECT techniques require the acquisition of as many photon events as possiblein order to produce high-quality images. However, the limiting factor is typically the timethat a patient can remain motionless during the acquisition. This is typically a period of15–30 min and results in imaging times of 15–30 s for each projection when 120 projectionsare acquired in a 3608 rotation. For cardiac applications, the imaging time is typicallyreduced to 10–15 min.

SPECT Image Formation

SPECT data are acquired in the form of multiple projection images as the scintillationcamera heads rotate about the region of interest. Each acquired image is actually a set ofcount profiles measured from different views with the number of count profiles deter-mined by the number of rows of pixels in the acquisition matrix (e.g., 64 for a 64 � 64matrix size). Using parallel hole collimators, each pixel is the sum of measured photonevents traveling along a perpendicular ray and interacting at a point in the detectorcrystal represented by the pixel location. For a 3608 acquisition with 120 acquired

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