Lung Scintigraphy in various Lung Pathologies

NMT631

The Lung

Alveolar Septa Ultrastructure

• Capillary endothelium and basement membrane• Pulmonary interstitium (fine elastic fibers, small

collagen bundles, few fibroblast-like & smooth muscle cells, mast cells, and rare mononuclear cells)

• Alveolar epithelium – type I pneumocytes (continuous layer of flattened,

platelike covering 95% of the alveolar surface, and– type II pneumocytes (rounded, synthesize pulmonary

surfactant, repair of alveolar epithelium) • Pores of Kohn –passage of air, bacteria, and exudates• Alveolar macrophages (phagocytoses carbon, dust

particles)

• exposure? costophrenic angles? Infiltrates? bronchi? hilar vasculature?

NORMAL

CXR

Lung Pathologies• Degenerative• Inflammatory + Pleura• Neoplastic

ATELECTASIS ACUTE LUNG INJURY Acute Respiratory Distress Syndrome OBSTRUCTIVE LUNG DISEASES Emphysema Chronic Bronchitis Asthma Bronchiectasis CHRONIC INTERSTITIAL LUNG DISEASES Fibrosing Diseases

o Idiopathic Pulmonary Fibrosiso Nonspecific Interstitial Pneumoniao Cryptogenic Organizing Pneumoniao Pneumoconiosis

Coal Worker’s Pneumoconiosis Silicosis Asbestosis and Asbestos-Related Diseases

o Drug- and Radiation-Induced Pulmonary Diseases GRANULOMATOUS DISEASE Sarcoidosis PULMONARY EOSINOPHILIA SMOKING-RELATED INTERSTITIAL DISEASES VASCULAR ORIGIN DISEASES Pulmonary Embolism, Hemorrhage, and Infarction Pulmonary Hypertension Diffuse Alveolar Hemorrhage Syndromes

o Goodpasture Syndromeo Idiopathic Pulmonary Hemosiderosiso Wegener Granulomatosis

PULMONARY INFECTIONSo Community-Acquired Acute Pneumoniaso Community-Acquired Atypical Pneumonias

Influenza Virus Type A/H1N1 Infectiono Aspiration Pneumoniao Lung Abscesso Chronic Pneumonias

Tuberculosiso Histoplasmosis, Coccidioidomycosis, and Blastomycosiso Pneumonia in the Immunocompromised Host

Cytomegalovirus Infections/ Cytomegalovirus Mononucleosis

Pneumocystis Pneumoniao Opportunistic Fungal Infections

Candidiasis Cryptococcosis Mucormycosis and invasive aspergillosis

o Pulmonary Disease in Human Immunodeficiency Virus Infection LUNG TUMORSo Carcinomao SCLC & NSCLCo Carcinoid PLEURAL LESIONSo Pleural effusion & Pleuritiso Pneumothorax, Hemothorax, and Cyclothoraxo Malignant Mesothelioma LESIONS OF THE UPPER RESPIRATORY TRACTo Nasopharyngeal Carcinomao Laryngeal Tumors

ATELECTASIS (COLLAPSE)• Incomplete expansion• PA PV shunting (V/Q

imbalance & hypoxia)• Resorption (tumor, mucous

plug) • Compression (fluid, blood,

air)• Contraction (fibrosis)

http://gamma.wustl.edu/vq052te164.html

Ventilation scintigraphy demonstrates minimal ventilation of the left lower lobe and delayed ventilation images show air trapping at the right lung base. Perfusion images are mildly patchy showing nonsegmental perfusion defects. No pleural-based, large subsegmental or segmental perfusion defects are seen. Blunting of the bilateral costophrenic angles is present, consistent with the patient's known pleural effusions. Perfusion of the left lower lobe is maintained in the area of near absent ventilation, indicating the presence of a functional right to left shunt. Chest radiograph performed the same day demonstrates bilateral pleural effusions and a retrocardiac density suggesting left lower lobe atelectasis or infiltrate.

ACUTE LUNG INJURYAcute Respiratory Distress Syndrome (ARDS)

• NON-specific pattern of lung injury• Diffuse alveolar capillary and epithelial

damage (DAD) (aka, “SHOCK” lung)• respiratory insufficiency, cyanosis, and

severe arterial hypoxemia, may progress to multisystem organ failure

• INFECTION, PHYSICAL INJURY, TOXIC CHEMICAL, DIC

• As opposed to neonatal ARDSAcute care setting applications of nuclear medicine may also include diagnosing ARDS. A 29-year-old patient after multi-organ trauma suffered a year before was referred to the nuclear medicine department for lung V/Q scintigraphy before right-sided pneumonectomy. A car accident in which the patient had participated resulted in multiple spinal fractures, tetraplegia and blunt chest trauma with bilateral pulmonary contusion and right lung atelectasis. Despite treatment the collapsed lung did not re-expand and subsequent CT scans showed multiloculated effusion in the right pleural cavity, suggestive of pleural empyema. The fluid persisted despite long-term chest tube drainage. The patient started having recurrent fevers and his condition deteriorated. Right lung resection was suggested as a possible treatment and the patient was referred for preoperative lung perfusion scintigraphy.

Perfusion (99mTc-MAA) and ventilation (Technegas) SPECT-CT transaxial scans. Perfusion (A) and ventilation (B) SPECT-CT transaxial scans show a collapsed right lung with severely reduced perfusion (A, red arrow) and lack of ventilation (B, red arrow). Matching defect of perfusion and ventilation is present in the lower left lobe (A, B, yellow arrows). The upper left lobe shows a normal perfusion and ventilation pattern

Perfusion (99mTc-MAA) and ventilation (Technegas) sagittal SPECT-CT scans. Matching perfusion-ventilation defect in the lower left lobe is visible (A, B, red arrows). Perfusion in the lower left lobe is preserved only in the parenchymal consolidation area in the posterior lateral segment (A, yellow arrow)

As V/Q scintigraphy suggested the patient’s gaseous exchange was maintained by a single lobe, which notably increased operative risk, the right-sided pneumonectomy was excluded from possible treatment options.

Nuclear Med Rev 2016; 19, 1: 51–53

OBSTRUCTIVE LUNG (AIRWAY) DISEASESEmphysema

• COPD, or “END-STAGE” lung disease

• Centri-acinar, Pan-acinar, Paraseptal, Irregular

• (Progressive) Expiratory air trapping, i.e., Wheezing

• Like cirrhosis, thought of as END-STAGE of multiple chronic small airway obstructive etiologies

• NON-specific• Increased crepitance, Bullae• Clinically likely to produce

recurrent pneumonias, and progressive failure

A 56-year-old man with smoking history of 38 pack-years and pulmonary emphysema. Chest CT at the middle lung (left) shows central lung dominant LAA (arrows). The transaxial (at the same lung level as X-ray CT) and coronal Technegas SPECT (right; top) show a stripe sign (arrows), as well as perfusion SPECT (arrows) (right; bottom) indicative of lower susceptibility of the peripheral lung for alveolar destruction.

Nuclear Medicine Communications 2008, 29:553–561

OBSTRUCTIVE LUNG (AIRWAY) DISEASESChronic Bronchitis

• Inhalants, pollution, cigarettes• Chronic cough• Can often progress to emphysema• Mucus hypersecretion, early, i.e. goblet cell increase• CHRONIC bronchial inflammatory infiltrate• Chronic bronchiolitis (small airway disease/bronchiolitis

obliterans)

The imaging and clinical findings were thought to be most consistent with bronchiolitis obliterans (chronic rejection).

Woman with cystic fibrosis, status post bilateral lung transplantation approximately three years ago.

http://gamma.wustl.edu/newtfh/general/combined/submitted_174166.html

OBSTRUCTIVE LUNG (AIRWAY) DISEASESAsthma

• Similar to chronic bronchitis but:• Wheezing is hallmark (bronchospasm, i.e.

“wheezing”)• Strong allergic role, i.e., eosinophils, IgE, allergens• Often starting in Childhood• Atopic (allergic) or Non-atopic (infection)• Chronic small airway obstruction and infection• 1) Mucus hypersecretion with plugging, 2)

lymphocytes/eosinophils, 3) lumen narrowing, 4) smooth muscle hypertrophy

Male, 33 yo, sudden shortness of breath. No risk factors. Asthma as a child but no treatment since teens. Received aerosol therapy twice before VQ SPECT. Clinical low prob but positive D Dimer. Images show widespread irregular perfusion and ventilation, multiple discrete areas of partial mismatch, but no defect is truly vascular in configuration. Was read as negative for PE, consideration was for asthma. Patient responded well to aerosol therapy. Final diagnosis: asthma attack.

SPECTLUNG teaching and information resource

Bronchiectasis

• Dilation of the bronchus, associated with, often, necrotizing inflammation

• Congnital• TB, other bacteria, many viruses• Bronchial obstruction (i.e., Large airway,

Not small airway)• Rheumatoid arthritis, SLE, IBD

(Inflammatory Bowel Disease)

Nuclear Imaging of the Chest By Y. W. Bahk. Et. al. Page 574

Sino-bronchiectasis (CT and Technegas SPECT images). CT revealed thickening of bronchial walls and bronchiectasis in upper and lower right lung fields and also in the left lung. Technegas and perfusion SPECT transverse images (lower to upper slices) showed multiple defects in both lungs. Perfusion defects were more widespread than Technegas deposition, so perfusion was impaired more severely than ventilation in the areas of bronchiectasis.

CHRONIC INTERSTITIAL (RESTRICTIVE, INFILTRATIVE) LUNG DISEASESFibrosing Diseases

Idiopathic Pulmonary Fibrosis (UIP)

• Idiopathic• Repeated cycles of

epithelial activation/injury• Honeycomb fibrosis (Usual

Interstitial Pneumonia)

53 year old with long standing history of pulmonary fibrosis is evaluated for lung transplantation. VQ scan shows absent perfusion with preserved ventilation (V-P mismatches)

http://gamma.wustl.edu/vq038te167.html

CHRONIC INTERSTITIAL (RESTRICTIVE, INFILTRATIVE) LUNG DISEASESFibrosing Diseases

Nonspecific Interstitial Pneumonia

• “Trashcan diagnosis”, of any pneumonia (pneumonitis) of any known or unknown etiology – better prognosis than UIP

• Fibrosis – diffuse (ground glass)

• Cellular infiltrate (lymphs & plasma cells)

Parenchymal honeycombing (UIP) on CT (A) with associated intense 18F-FDG uptake (B) typical of usual interstitial pneumonitis.

J Nucl Med 2009; 50:538–545

NSIP vs. UIP

CHRONIC INTERSTITIAL (RESTRICTIVE, INFILTRATIVE) LUNG DISEASES

Fibrosing DiseasesCryptogenic Organizing Pneumonia

• Idiopathic• “Bronchiolitis Obliterans O.P.”

(BOOP)• Patchy airspace consolidation

(Masson bodies - polypoid plugs of alveolar ducts/alveoli/bronchioles)

• Spontaneous recovery/ long term steroids

Brochiolitis obliterans with organizing pneumonia (BOOP)

http://gamma.wustl.edu/pt115te162.html

CHRONIC INTERSTITIAL (RESTRICTIVE, INFILTRATIVE) LUNG DISEASES

Pneumoconiosis

• Occupational • Dust/ Chemicals/ Organic

materials– Coal (anthracosis)– Silica– Asbestos– Be, FeO, BaSO4, CHEMO– Hay, flax, Bagasse, insecticides,

etc.• Alveolar macrophage mediated

injury/fibrosis

Computed tomography (CT) images of small multiple pneumoconiotic nodules (a-1) and large pneumoconiotic nodules (b-1). The degree of the accumulation of 11C methionine (MET: a-2, b-2; right) was size dependent as well as that of fl uoro-deoxy-Dglucose (FDG: a-2, b-2; left)

Ann Nucl Med (2007) 21:331–337

• 3 essential factors:– Specific

substance (based on “coal rank”)

– Appropriate size (1-5m)

– Sufficient exposure (yrs)

• Coal macules (dust-laden macrophages) & coal nodule (macule + collagen fibers)

• Progressive centrilobular emphysema

CHRONIC INTERSTITIAL (RESTRICTIVE, INFILTRATIVE) LUNG DISEASES

Coal Worker’s Pneumoconiosis(Anthracosis)

Ann Nucl Med (2007) 21:331–337

Silicosis• Most common• Macrophage mediated fibrogenic

cytokines• “Whorled” silicotic nodules• Hylar “eggshell” calcifications

FDG PET findings in a case with acute pulmonary silicosis. FDG PET scan demonstrates a peripherally diffuse uptake in both the lungs, especially in both apical and posterior regions indicating active inflammation. Besides, faint FDG uptake is also noted in mediastinal lymph nodes.

Ann Nucl Med. 2009 Dec;23(10):883-6

Asbestosis and Asbestos-Related Diseases

• Amphiboles > pathogenicity than serpentine chrysotile

• Asbestosis, lung cancer, and mesothelioma

• Diffuse interstitial fibrosis• Visceral pleura fibrosis • Dense collagenous calcified

“parietal pleural plaques”

Drug- and Radiation-Induced Pulmonary Diseases

• Pneumonitis• Interstitial

fibrosis

Ann Nucl Med (2008) 22:335–338

FDG positron emission tomography imaging of drug-induced pneumonitis

Ann Nucl Med. 2008 Oct;22(8):719-22

Granulomatous Disease- Sarcoidosis

• Mainly lung, but eye, skin or anywhere

• Non-caseating granulomas (idiopathic)

• Immune, genetic factors

• F>>M• B>>W• Young adult African

American women

99mTc-Infliximab scintigraphy of a sarcoidosis patient acquired at 6 h (anterior and posterior views showing a moderate and diffuse uptake in the lung parenchyma.

Biomed Res Int. 2015; 40 1341

Granulomatous Disease- Pulmonary Eosinophilia

• infiltration • alveolar IL-5 activation of

eosinophils• Unclear etiology• Drugs/toxins/helminths/fungi/

idiopathic• Simple pulmonary eosinophilia

(Loeffler syndrome), characterized by transient pulmonary lesions and thickened alveolar septa with eosinophil infiltrate

Simple pulmonary eosinophilia in a 52-year-old healthy man who underwent voluntary cancer screening. A. Transverse CT scan obtained with the lung window setting shows a semisolid nodule in the left lower lobe (arrow). B. The coronal FDG PET scan shows the increased uptake in the nodule with an SUV of 4.5 (arrow). Kor J Radiol. 2005 Oct-Dec;6(4):208-213

Granulomatous DiseaseSmoking-Related Interstitial Diseases

• DIP (Desquamative Interstitial Pneumonia)

• “Smokers macrophages” accumulation within airspaces

• Inflammation, septal thickening, possible fibrosis

• Resolution with steroids/smoking cessation

• M>>F• Cigarettes• 100% Survival

PET findings in smoker’s nodular Pulmonary Langerhans Cell Histiocytosis (PLCH). Chest CT images on the left upper and lower panels show multiple lung nodules in a smoker with surgical lung biopsy-proven PLCH. The corresponding PET images on the right upper and lower panels show PET characteristics of the multiple pulmonary nodules. The larger pulmonary nodules (arrowhead) demonstrated intense PET uptake, while other nodules (arrow) are PET-negative (Standardized Uptake Value < 2.5)

Vascular Origin Diseases

Pulmonary Embolism, Hemorrhage, and Infarction

• Usually secondary to debilitated states with immobilization, or following surgery

• Usually deep leg and deep pelvic veins (DVT), NOT superficial veins

• Follows Virchow’s triad, i.e., 1) flow problems, 2) endothelial disruption, 3) hypercoagulabilty

• Usually do NOT infarct, usually ventilate

• When they DO infarct, the infarct is hemorrhagic

• Decreased PO2, acute chest pain, V/Q MIS-match

• DX: Chest CT, V/Q scan, angiogram• RX: short term heparin, then long

term coumadin

Vascular Origin DiseasesPulmonary Hypertension

• COPD, C”I”PD (vicious cycle)• CHD (Congenital HD, increased left

atrial pressure)• Recurrent PEs• Autoimmune, e.g., PSS

(Scleroderma), i.e., fibrotic pulmonary vasculature

Perfusion scan from a patient with severe chronic thromboembolic pulmonary hypertension (CTEPH). The right lung has nearly no blood flow. The left lung has multiple wedge shaped blood flow defects

The ventilation scan is from the same patient. The left lung has preserved ventilation. These findings are classic for CTEPH.

Normal pulmonary arteriole

Very thickened arteriole in pulmonary HTN

Diffuse Alveolar Hemorrhage Syndromes

Goodpasture Syndrome• Destruction of

glomerular and alveolar basement membrane

• Ab’s (anti-GBM) to the alpha-3 chains of collagen IV

• Hemorrhage, hemoptysis, glomerulonephritis

99mTc DTPA RENAL STUDY OF A PATIENT WITH Goodpasture’s syndrom. In addition to poor renal perfusion and function, increased uptake of DTPA in the lungs is noticed. Left: 5s images for 45s after injection; Right: 2min x 16 frames

Clin Nucl Med. 1985 Oct;10(10):724-6

Diffuse Alveolar Hemorrhage Syndromes

Idiopathic Pulmonary Hemosiderosis• Rare, Children & young adults• Hemosidering laden

macrophages• CxR:

– diffuse B/L alveolar infiltrates– Hilar & mediastinal adenopathy

• Tx: systemic corticosteroids A, Relatively normal lungs after episode of alveolar consolidation. B, 3 hr after administration of 99mTc RBC. Patient in remission. Activity centered in heart, liver, and spleen. C, Exacerbation of disease; alveolar consolidation. D, Same time as C; activity shifted to lungs. Boundary of lungs with heart and liver obscured by intrapulmonary hemorrhage.Nuclear Scan of Pulmonary Hemorrhage in Idiopathic Pulmonary Hemosiderosis; AJR 132:120-121

Diffuse Alveolar Hemorrhage Syndromes

Wegener Granulomatosis• Anti-Neutrophil Cytoplasmic

Antibodies (ANCA)• Granulomas and patchy necrotizing

vasculitis in arteries and veins (lungs, kidneys and other organs)

• End-organ damage• Long-term immunosuppression

A 65-year-old woman with WG with elevated ANCA titers. Abnormal FDG uptake in the nasopharynx and lung (A), bilateral auditory tubes (CT alone is negative) (B), and nodular shadows in both lungs (C). At 5 mo follow-up after treatment, both ANCA titers were WNL, with no FDG uptake in the nasal mucosa, auditory tubes and lungs (D, E, F)

Ann Nucl Med. 2013 Apr; 27(3): 209–216

Pneumonia• Aka, Lower respiratory infections (as

opposed to upper)• Predisposing factors:

– Loss of cough reflex– Loss of mucin/Cilia function– Alveolar macrophage interference– Vascualr flow issues – Bonchial airflow issues

• Most common cause of death• Usually does NOT occur in healthy

people spontaneously• Bronchopneumonia

– Patchy infection/inflammation of bronchi/bronchioles/alveoli in > 1 lobe

• Lobar pneumonia– Exudate in contiguous air spaces of a lobe

 COMMUNITY-ACQUIRED BACTERIAL ACUTE PNEUMONIAS (BACTERIAL)• Streptococcus Pneumoniae• Haemophilus Influenzae• Moraxella Catarrhalis• Staphylococcus Aureus• Klebsiella Pneumoniae• Pseudomonas Aeruginosa• Legionella Pneumophila

COMMUNITY-ACQUIRED ATYPICAL (VIRAL AND MYCOPLASMAL) PNEUMONIAS (NON-BACTERIAL)• Influenza Infections• Severe Acute Respiratory Syndrome (SARS)

NOSOCOMIAL PNEUMONIA

ASPIRATION PNEUMONIA

LUNG ABSCESS• Etiology and Pathogenesis.

CHRONIC PNEUMONIA• Histoplasmosis, Morphology• Blastomycosis, Morphology• Coccidioidomycosis, Morphology

PNEUMONIA IN THE IMMUNOCOMPROMISED HOST

PULMONARY DISEASE IN HUMAN IMMUNODEFICIENCY VIRUS INFECTION

Types of Pneumonia

PULMONARY INFECTIONSCommunity-Acquired Acute Pneumonias

• Mostly bacterial• Viral from upper RT infection• Sudden onset of high fever, shaking chills, pleuritic

chest pain, mucopurulent cough, possible hemoptysis

• S. pneumoniae (i.e., the pneumococcus) is most common cause

Patient with pneumonia in the right lung and PE. Sagittal slices show reduced–absent ventilation posteriorly with reduced perfusion in the same area. Preserved perfusion adjacent to the pleura (stripe sign; blue arrow). Moreover, absent perfusion with preserved ventilation in the medial lobe (red arrow)

Breathe 2012;9:48-60

DOI:10.13179/canchemtrans.2013.01.02.0021

Community-Acquired Atypical Pneumonias

Influenza Virus Type A/H1N1 Infection• Viral (Influenza)• Mycoplasmal (M. pneumoniae (obligate intracellular))• Inflammation confined to alveolar walls• Free of cellular exudate (unlike consolidation in

bacterial)

• Not bacterial • Cultures not helpful

44-year-old woman: 4-day post-vaccination. Accumulation (arrow) was clearly demonstrated in the axillary lymph node. SUVmax was 6.1 and the diameter was 4 mm. The accumulation had disappeared 1 year later

Ann Nucl Med (2012) 26:248–252

• Frequently “interstitial”, NOT alveolar

PULMONARY INFECTIONS

Aspiration Pneumonia• Unconsicous Pts• Patients in prolonged bed rest• Aspiration of gastric contents • Lack of ability to swallow or gag• Posterior lobes (gravity dependent) most commonly involved (esp. sup segments

of LL)• Often leads to abscess

Am J Radiol 2013; 200:437–441

PULMONARY INFECTIONS

Lung Abscess• Aspiration• Septic embolization• Neoplasm• From neighbouring

structures:– esophagus– spine– pleura– diaphragm

• Any pneumonia which is severe and destructive, and untreated enough

Practical Nuclear Medicine, edited by Peter F. Sharp, et.al.

A 54-year-old patient developed cough with foul-smelling sputum production. A chest radiograph shows lung abscess in the left lower lobe, superior segment.

PULMONARY INFECTIONS

Tuberculosis• 20 tuberculosis important

consideration in HIV-positives w/ pulmonary disease

• Caeseous granuloma• Pleural effusions, tuberculous

empyema, or obliterative fibrous pleuritis

Tuberculosis, edited by M. Monir

Transaxial 18F FDG-PET/CT lesion in the upper lobe of the right lung corresponding to tuberculoma.

Rev Esp Med Nucl Imagen Mol 2009; 28:22

PULMONARY FUNGAL INFECTIONS

Histoplasmosis, Coccidioidomycosis, and Blastomycosis

• Histoplasma capsulatum (Histoplasmosis), Blastomyces dermatidis (Blastomycosis), Coccidioides immitis (Coccidiomycosis)

• Spores in bird or bat droppings, soil• Mimics TB • Pulmonary granulomas, often large and calcified• Tiny organisms live in macrophages• Ohio, Mississippi valley (Histo, Blasto), American Southwest (Coccidio)• MANY other organs can be affected

Coronal (left) and transaxial (right) 18F-FDG PET demonstrating the primary laryngeal tumor and the focus of blastomycosis .

This patient had "persistent pneumonia“. The Xe-133 images were normal with perfusion images showing absence of perfusion to the right lung consistent with Fibrosing mediastinitis post histoplasmosis occluding central vessels.

Pneumonia in the Immunocompromised Host

• Immunosuppression post disease, for organ transplantation and antitumor therapy, or by irradiation

• Pulmonary infiltrate and signs of infection (e.g., fever)

A 42 year old homosexual male presented with a 3 week history of fevers and sweats. He denied respiratory symptoms such as cough or sputum. He was diagnosed as HIV positive 5 years earlier but had not manifest with lymphadenopathy or opportunistic infections.Findings: CXR was normal. Gallium-67 scintigraphy revealed diffuse lung uptake. Washings from fibreoptic bronchoscopy confirmed Pneumocystis carinii (PCP) infection.

Bronchiolitis obliterans following M. pneumoniae infection. (A) Chest X-ray showing normal. (B) 99mTc-MAA perfusion scan revealing slight defect. (C) 81mKr-aerosol ventilation demonstrating prominent multiple defects throughout the lung field.

Front. Microbiol., May 2016

med.harvard.edu/JPNM/TF93_94

Pneumonia in the Immunocompromised Host

Cytomegalovirus Infections/ Cytomegalovirus Mononucleosis

• Herpesvirus family• Infected cells display gigantism of entire cell and

nucleus• Nucleus with enlarged inclusion surrounded clear

halo (“owl’s eye”)• 50-100% persons sero+ve• CM with infectious mononucleosis–like illness,

with fever, atypical lymphocytosis, lymphadenopathy, and hepatomegaly, abnormal LFT

• Leukocytes - major reservoirs

Complete body image of maximum intensity. Lateral cervical (A) and celiac (Ac) hypermetabolic adenopathies. Diffuse augmentation of metabolic activity in the spleen (B).

Rev Esp Med Nucl. 2010;29(6):304-307

18F-FDG-PET-CT in cytomegalovirus-induced mononucleosis

Pneumonia in the Immunocompromised Host

Pneumocystis Pneumonia • P. jiroveci – fungus (formerly P. carinii - protozoan)• 100% of population seropositive (latent, reactivation in

immunocomprimised)• Confined to lung, interstitial pneumonitis• Fever, dry cough, and dyspnea• Bilateral perihilar and basilar infiltrates

Clin Nucl Med 2015;40: 679–681

Several cases of pulmonary infection diagnosed using nuclear imaging have been reported, even when the anatomical imaging appeared normal.

C

FDG PET (A) was performed 7 days after chest CT, and a second CT (B) was obtained after FDG PET (A). FDG PET demonstrated pathologic uptake through the bilateral lung fields as opposed to the pleura. Pneumocystis jirovecii was amplified by PCR from her sputum and was diagnosed with PCP. Trimethoprim-sulfamethoxazole was administered for 3 weeks. Posttreatment FDG-PET revealed complete disappearance of the abnormal uptake (C).

Opportunistic Fungal InfectionsCandidiasis

• Candida albicans• Normal microbiota• In immunecompromised:

– systemic candidiasis– associated pneumonia– bilateral nodular

infiltrates

(a) Increased uptake of 18F-FDG in multiple foci in both lungs in patient positive for C. albicans (b) Normal 18F-FDG PET after three months.

Clin Microbiol Infect. , Vol 11; 6, 2005, 493–495

Opportunistic Fungal InfectionsCryptococcosis

• C. neoformans• Opportunistic• inhalation from the

soil or from bird droppings

• Lung localization/ dissemenation (mainly CNS)

Cryptococcosis associated mediastinal lymphadenitis was found. PET/CT showed one pulmonary nodule at the left upper lobe, with hilar lymph node involvement

Acta Radiol. 2009 May;50(4):374-8.

Opportunistic Fungal InfectionsMucormycosis and Invasive aspergillosis

• Uncommon• Invasive pulmonary

disease may be:– localized (e.g., cavitary

lesions)– diffuse “miliary”

involvement• Non-invasive

Aspergilloma (“fungus ball”) formation (colonization of preexisting pulmonary cavities (e.g., lung cysts, posttuberculosis cavitary lesions)

A 34-year-old woman who presented with long-standing fever and dry cough. FDG PET/CT was done to localize cause. A, Whole-body maximum-intensity-projection PET did not reveal any definite hypermetabolic focus. B, Axial PET/CT shows soft-tissue-density solitary pulmonary nodule (thick arrow) in right lung with perinodular opacity (thin arrow), so called “halo sign,” without significant FDG uptake in nodule (maximum standardized uptake value, 1.1). Diagnosis of infective cause was made on PET/CT. Biopsy from nodule revealed diagnosis of noninvasive aspergillosis.

Am J Radiol :203, July 2014

Pulmonary Disease in Human Immunodeficiency Virus Infection

• Leading contributor of morbidity and mortality• Dx & Tx challenging • Pulmonary infiltrates from infectious/non-infectious causes• “opportunistic” infections• Bacterial pneumonias

FDG-PET/CT performed on a HIV positive patient before (A) and after therapy (B). The pathologic uptake in the left lung and mediastinum before therapy almost completely disappeared after therapy. This case highlights metabolic response may indicate clinical response and guide duration of antimicrobial therapy.

Semin Nucl Med. 2013 Sep;43(5):349-66

LUNG TUMORSCarcinoma

• Benign, malignant, epithelial, mesenchymal, but 90% are Carcinomas

• Biggest USA killer (prevalence not as high as prostate or breast but mortality higher; only 15% 5 year survival)

• Tobacco (polycyclic aromatic hydrocarbons, such as benzopyrene, anthracenes, radioactive isotopes)

• Radiation, asbestos, radon• C-MYC, K-RAS, EGFR, HER-2/neu

Tc-99m DTPA aeraol ventilation scan

Perfusion scan

PE protocol chest CT

AP portable CXR

Matching ventilation and perfusion defects in the superior segment of the right lower lobe. The perfusion defect appears larger than the ventilatory abnormality. CxR: Cardiomegaly, pulmonary edema, and Rt. infrahilar mass MIR teaching file _105232

Lung Tumors - Carcinoma

SCLC & NSCLC

SCLC: Pre-Tx (upper); post-Tx (lower)

NSCLC

Cancer Imaging. 2013; 13(1): 73–80 MIR teaching file_125330

Lung TumorsCarcinoid

• Neuroendocrine tumor arising from Kulchitsky cells in bronchial mucosa

• Early age group (mean 40y)• M=F• 1-5% of all lung neoplasms• Often resectable & curable• No relation with smoking or

environmental factors• Carcinoid syndrome (attacks of

diarrhea, flushing, cyanosis)

Lung carcinoid. Indium-111 octreotide scan of the thorax and subdiaphragmatic areas shows a primary lung carcinoid (arrow) and metastases in the liver

PLEURAL LESIONSPleural effusion &

PleuritisNuclear Medicine: The Requisites, 4th edition

Atlas of Clinical Nuclear Medicine, 3rd Edn.

PLEURAL LESIONSPneumothorax, Hemothorax, and Chylothorax

Atlas of Clinical Nuclear Medicine, 3rd Edn.

• Air – Pneumothorax• Blood – Hemothorax• Infection – Empyema• Chyle – Chylothorax• Tumor – “tumor-

thorax” or tumor tamponade

• Fluid - Pleurothorax

PLEURAL LESIONSMalignant Mesothelioma

• “Benign” vs. “Malignant” differentiation does not matter, but a self limited localized nodule can be regarded as benign, and a spreading tumor can be regarded as malignant

• Visceral or parietal pleura, pericardium, or peritoneum

• Most are regarded as asbestos caused or asbestos “related”

Fig. 2A —Categories T3 and T4 malignant pleural mesothelioma.

A, Fused PET/CT (A) and CT (B) images in 62-year-old man show category T3 malignant pleural mesothelioma and single focus of chest wall invasion (arrow). Categories T3 and T4 malignant pleural mesothelioma

Fig. 2C —Categories T3 and T4 malignant pleural mesothelioma.

C, Coronal fused PET/CT (C) and CT (D) images in 67-year-old man show category T4 malignant pleural mesothelioma with multifocal chest wall invasion (arrows). Images also show metastatic disease (arrowheads, C).

LESIONS OF THE UPPER RESPIRATORY TRACT

Nasopharyngeal Carcinoma

• strong epidemiologic links to EBV

• incidence among Chinese (?viral + genetic)

30-year-old man for evaluation of recently diagnosed nasopharyngeal mass. Hypermetabolic left parapharyngeal mass with metastatic foci in cervical and mediastinal lymph nodes and within numerous lung nodules consistent with primary nasopharyngeal malignancy with local and distant metastases. AJR, August 2014, Volume 203, Number 2

LESIONS OF THE UPPER RESPIRATORY TRACT

Laryngeal Tumors• Main feature – hoarseness• Non-malignant – voval chord nodules (polyps)(contact trauma/ “singers nodes”)• Benign - Laryngeal papilloma• Malignant – Laryngeal carcinoma (> 40y, M>>F, smokers)

Coronal 18F-FDG PET (A) and 18F-FLT PET (B) images of patient diagnosed with primary laryngeal cancer. With both imaging modalities, uptake of the tracer in the laryngeal region can be observed. Maximum 18F-FDG SUV was 3.2, and maximum 18F-FLT SUV was 1.2. Physiologic 18F-FDG uptake can be seen in the muscles of the neck, and physiologic 18F-FLT uptake can be seen in the bone marrow of the ribs and sternum.

J Nucl Med. 2004 Feb;45(2):226-31