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© CTI PET Systems, Inc. 1998CA 5.98Positron Emission Tomography

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Clinical Case StudiesClinical Case Studies


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Osteosarcoma19-year-old male with history of osteosarcoma of right lower leg.

Follow-up CT scan showed growing lesion in lung. Leg biopsy negative for residual tumor.

Whole-body PET scan showed high FDG uptake in femur. Lung lesion seen on CT had low lung accumulation rate with SUV of 2.

Original treatment plan based on CT, and biopsy would have been thoracotomy to resect lung lesion. After PET scan found high FDG uptake in leg, another femur biopsy was attempted but unsuccessful. Two weeks later, patient’s thigh exhibited swelling, and another biopsy was done which revealed a malignant fibrous histiocytoma. The leg was amputated.

AP PROJECTION IMAGE

Courtesy of Amjad Ali, M.D. • Rush-Presbyterian-St. Luke's Medical Center


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Lung Cancer63-year-old male with lung cancer. Tumor removed from right upper lobe several months ago.

CT scan showed new lesion in left lung.

Whole-body FDG PET scan found focal FDG accumulation in left lung lesion. In addition, several other lesions unsuspected by CT were seen in right lung and mediastinal lymph nodes.

Conventional treatment based on CT would have been thoracotomy to resect left lung lesion. After PET found others areas of focal FDG uptake, treatment was switched to chemotherapy. The lesions could still be seen on follow-up CT scan after chemotherapy, but a second FDG study (not shown) indicated the FDG uptake had returned to normal, avoiding possible resection.

CORONAL TRANSVERSE



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Myocardial Viability50-year-old female with history of heart disease waiting for possible cardiac transplant.

Thallium scintigraphy found large non-reversible defect; myocardium judged non-viable.

FDG PET scan found good viability throughout the myocardium except for a small part of the apex.

Conventional treatment plan based on single photon nuclear medicine study would have been placing the patient on transplant waiting list. After PET, coronary artery bypass graft was performed resulting in improved cardiac function. Patient had significant improvement in quality of life.



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Abdominal Cancer49-year-old male with abdominal pain. Laparoscopy was negative, but a mass was found in the lung. Bronchoscopy confirmed the lung lesion was a tumor.

CT of the abdomen read as negative.

Whole-body PET scan found increased FDG uptake in the lung lesion, but also found a focus of increased FDG accumulation in the abdomen.

Conventional treatment plan based on CT would have been a thoracotomy to remove the lung mass. After PET found the area of FDG uptake in the abdomen, it was also seen on a new CT scan and confirmed by biopsy to be cancer. The treatment was changed to chemotherapy.


AP PROJECTION IMAGE


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Breast Cancer40-year-old female with breast cancer had lumpectomy along with chemo/radiation therapy one year prior. The patient experienced pain in the right shoulder 10 months later.

Bone scan negative. CT scan initially read as negative.

Whole-body, FDG PET scan found numerous lymph node metastases in the upper chest.

Treatment plan based on conventional diagnostic techniques would have been watchful waiting. PET scan found a number of lymph node metastases, and patient was put back on chemo/radiation therapy. Re-read of CT after PET still could not accurately gauge extent of disease.


AP PROJECTION

TRANSVERSE


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Metastatic Melanoma71-year-old male with metastatic melanoma on left shoulder discovered 12/94.

CT performed on 7/10/95 demonstrated tumor of the distal femur with negative findings in the abdomen. Bone scan on 7/13/95 showed an abnormal femur and four spine lesions.

Whole-body FDG PET scan demonstrates numerous lesions throughout the body.

Patient was scheduled for an amputation and total knee replacement based on CT and bone scan results. After PET found multiple lesions, surgery was cancelled, avoiding both the cost and the trauma of an operation that would not be effective.


AP PROJECTION


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Breast Cancer71-year-old female with suspected breast abnormality.

Histology from breast biopsy indicated fibroadenoma. Patient referred to PET to examine possible brain lesion seen on MR, but not clearly identified as an area of ischemia.

FDG brain scan found low glucose uptake in brain lesion. However, whole-body PET scan (same FDG injection) found a focus of uptake in left breast along with numerous lung lesions.

Second breast biopsy after PET found infiltrating columnar cell carcinoma. Final diagnosis was breast cancer with lung metastases, along with brain ischemia.

TRANSVERSE

CORONAL

CORONAL

Courtesy of Franca Chierichetti, M.D. and Giorgio Ferlin, M.D. • Ospedale di Castelfranco Veneto - TV - Italy


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Brain Cancer65-year-old male referred to evaluate brain lesion with clinical suspicion of ischemia.

CT and MR showed lesion in left frontal parietal region, surrounded by edema, with characteristics that indicated it could be a metastatic lesion. PET ordered to confirm brain lesion and look for primary.

FDG brain scan found high glucose uptake in the left frontal parietal lesion with an adjacent hypometabolic region. A small hypermetabolic focus was seen in the upper temporal. Whole-body scan (same injection) was negative for metastases.

Surgery revealed grade 4 anaplastic astrocytoma surrounded by edema. The tumor was found infiltrating the upper temporal region.

Courtesy of Franca Chierichetti, M.D. and Giorgio Ferlin, M.D. • Ospedale di Castelfranco Veneto - TV - Italy


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Myocardial Viability2-month-old baby having had surgery at birth to correct switched pulmonary artery and aorta. After surgery the baby still had an akinetic anterior myocardial wall.

Cardiac stress was not possible. Thallium nuclear scan would not have had adequate resolution, so PET was ordered to assess the akinesis.

PET NH3 and FDG scans showed myocardium to be just stunned and still viable. Revascularization recommended.

Bend in coronary vasculature was successfully corrected with second surgery.

NH3

FDG

Courtesy of Pierluigi Zanco, M.D. and Giorgio Ferlin, M.D. • Ospedale di Castelfranco Veneto - TV - Italy


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Myocardial Viability20-year-old male pro soccer player with abnormal electrocardiogram on routine physical.

No chest pain or angina, PET ordered to assess myocardial perfusion.

PET rest and dypridimole stress NH3 scans showed a similar uptake pattern, indicating there was not a flow imbalance in the coronary arteries. However, Patlak analysis showed the flow reserve to be 2.2, compared to an age-matched control value of >3.

STRESS

REST

Flow Values (ml/min/g)

Apex Ant Lat Inf Sept MeanREST 0.41 0.49 0.70 0.65 0.69 0.63STRESS 1.06 1.45 1.29 1.43 1.49 1.41

Courtesy of Pierluigi Zanco, M.D. and Giorgio Ferlin, M.D. • Ospedale di Castelfranco Veneto - TV - Italy


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Hodgkins Lymphoma20-year-old female with Hodgkins disease.

MR found a metastatic lesion in the mediastinum. PET ordered to assess the lesion after the first round of chemotherapy.

Whole-body FDG scan found the mediastinal lesion to still be hypermetabolic after therapy. In addition, a focus of FDG uptake was found on the top of the liver.

The PET results led to a second stronger round of chemotherapy. Another PET after the second series found the hypermetabolic lesions were eliminated.

AFTER 1ST CHEMO

AFTER 2ND CHEMO

Courtesy of Giorgio Ferlin, M.D. • Ospedale di Castelfranco Veneto - TV - Italy


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Testicular Cancer50-year-old male with cancer of the testis.

Patient could not have surgery due to lymph node involvement in pelvis, so radiation and chemotherapy were performed. Patient referred to PET to assess progress of therapy.

Whole-body, FDG PET scan found a focal area of uptake in the right lung.

After PET found the lung lesion, a much stronger cycle of radiation and chemotherapy was initiated. After this round, CT and echo scans of the liver were both negative. However, a second PET scan found liver lesions, a lung lesion, and hypermetabolic areas in the abdominal lymph nodes. The patient died a few months later.

Courtesy of Giorgio Ferlin, M.D. • Ospedale di Castelfranco Veneto - TV - Italy

AFTER 1ST CHEMO AND RADIATION

AFTER 2ND CYCLE OF THERAPY


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EpilepsyPatient suffered from intractable drop seizures since the age of 18 months. MRI showed no abnormalities. Interictal scalp EEG demonstrated epileptiform activity emanating from the right parietal region.

FDG PET scan demonstrated one focal area of cortical hypometabolism in the right posterior parietal region. Ictal EEG demonstrated seizure onset from the right parietal lobe.

The PET abnormality guided the subdural grid placement with very good correlation. The patient was submitted to surgery and is seizure-free.

Courtesy of Harry Chugani, M.D. • Children’s Hospital of Michigan


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Osteosarcoma9-year-old female with a history of osteosarcoma in the right shoulder.

Initial PET scan showed a high metabolic rate of glucose in the right shoulder indicating aggressive tumor growth. The patient was treated with chemotherapy.

Ten weeks following chemotherapy a follow-up PET glucose study was performed to evaluate the metabolic tumor response to therapy. The study showed a marked reduction of glucose metabolism in the tumor region.

The patient underwent biopsy and no tumor tissue was found

Courtesy of Children’s Hospital of Michigan

ORIGINAL PET SCAN

FOLLOW-UP PET SCAN


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Metastatic Melanoma71-year-old male with metastatic melanoma on the right shoulder discovered 4/95.

CT performed 5/95 showed multiple pulmonary lesions and the patient underwent chemotherapy 6/95 and 9/95.

A whole-body FDG PET scan performed 10/95 showed numerous lesions throughout the body.

After the PET scan showed multiple lesions the chemotherapy scheduled for 11/95 was cancelled due to the unfavorable prognosis.

Courtesy of Dr. M. Lübeck, Prof. Dr. M. Clausen • University Hospital Eppendorf, Hamburg


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Follicular Thyroid Cancer41-year-old female with follicular thyroid carcinoma. Primary diagnosis and nearly total thyroidektomy 11/92, I-131 therapy 12/92. A local tumor relapse without iodine uptake was resected 2/94.

Elevated thyroglobulin levels were found again on 3/96 (9µg/l). An I-131 whole-body scan showed no focal increase of iodine accumulation. No pathological findings were reported from ultrasound of the neck.

A whole-body FDG PET scan showed a lesion with a high level of FDG uptake in the left paralaryngeal region.

The treatment plan based on conventional diagnostic techniques would have been watchful waiting. The PET scan clearly showed local tumor relapse and another resection was performed. Carcinoma was proven histologically. Serum thyroglobulin measurements were negative after surgery.



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Hodgkin’s Disease39-year-old female with Hodgkin’s disease discovered 6/94 (infiltration of lung and mediastinum). Patient was in complete remission after chemo- and radiotherapy.

Ultrasound 12/95 and CT 1/96 showed a tumor in the right lobe of the liver.

A whole-body FDG PET scan showed no lesion with phathologically increased FDG accumulation. The region seen on CT had a liver-like FDG accumulation rate.

The treatment plan based on CT/ultrasound results would have been another round of chemotherapy. After PET showed no increased focal uptake in the liver, chemotherapy was cancelled. Follow-up examinations will be performed.



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Non-Hodgkin Lymphoma48-year-old female with non-Hodgkin lymphoma IIIA discovered 12/90, underwent high dose chemotherapy and stem cell separation/bone marrow transplantation after paraaortic recurrence 2/93.

CT of the abdomen performed after chemotherapy was read as negative with respect to a second recurrence versus retroperitoneal fibrosis.

Whole-body FDG PET scan 9/94 revealed pathologically increased FDG uptake in the paraaortic, parailiacal and inguinal lymph node regions as well as in one large retroclavicular lymph node on the left side indicating tumor recurrence.

The retroclavicular lymphoma was removed surgically and the abdominal recurrence was treated by chemotherapy. A clinically impressive response to therapy was reported. A second PET scan confirmed remission in all known tumor sites, but showed suspicious FDG uptake in the left presacral region of the pelvis later identified as recurrence of NHL.

PRE TREATMENT

POST TREATMENTCourtesy of Dr. M. Lübeck, Prof. Dr. M. Clausen • University Hospital Eppendorf, Hamburg


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Focal Epilepsy Due to Cortical Dysplasia10-month-old male infant with early infantile epilepsy suffered from intractable partial as well as generalized seizures, a severe developmental delay and reduced growth of the head circumference.

EEG showed a right-sided temporo-parieto-occipital epileptic focus with frequent generalization. MRI did not conclusively prove a cortical dysplasia. A neurodegenerative disorder was suspected due to a global deficit of supratentorial myelinisation.

A FDG PET scan of the brain showed a right-side zone of severe hypometabolism extending backward from the postcentral cyrus, including a small area of hypermetabolism in the parietal lobe. There was reduced metabolism of the right frontal lobe.

PET findings strongly supported the diagnosis of cortical dysplasia. After non-invasive monitoring a resection restricted to right posterior temporal, parietal and occipital lobe was performed and confirmed a multilobular cortical dysplasia. Postoperatively the child was almost seizure-free under treatment with carbamazepin and phenobarbital. There was impressive progress in psychomotor milestones as well as of head growth.



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Paraganglioma44-year-old male with known malignant paraganglioma. Disease occurred first in 1965 with subsequent resection. In 1990, recurrence at the aortic bifurcation was noted. In 1992, left retroperitoneal periaortic lymph node recurrence was noted and resected.

MRI showed probable recurrence in the left bifurcation region of the aorta. Chest x-ray was normal. Whole-body FDG PET imaging was ordered to assess recurrence and rule out possibility of metastatic disease.

The whole-body PET scan showed increased FDG uptake in several areas, including most notably the lower neck on the left posteriorly to the clavicle. Several small abnormalities are noted throughout the paravertebral, cervical, thoracic and lumbar regions suggestive of lymph node involvement. In the region of known tumor at the aortic bifurcation, there is a large hypermetabolic abnormality consistent with the area of questionable recurrent disease.

Courtesy of Emory University


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Malignant Pheochromocytoma35-year-old male with known abdominal malignant pheochromocytoma.

Whole-body FDG PET imaging was performed to assess extent and possibility of metastatic disease. Prior to the FDG PET study, there was no suggestion of metastatic disease.

The PET scan shows a large multilobulated mass with increased FDG activity in the left mid-abdomen. This is the area of known tumor. However, another hypermetabolic lesion is noted at approximately the C7 vertebral body. Subsequent CT scan through this area reveals a lytic lesion consistent with metastatic disease.



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Brain Metastases with Unknown Primary54-year-old male with squamus cell brain metastases of unknown primary. The patient had a previous negative metastatic workup.

After conventional therapy for brain metastases including surgery and radiation, a recently obtained MRI scan showed two new enhancing lesions in the left temporal and parietal lobes. An FDG PET study was obtained to differentiate radiation necrosis from recurrent tumor. Due to the possibility that the lung was the source of the brain metastases, lung imaging with FDG PET was also performed.

On the FDG PET images, 2 hypermetabolic abnormalities are noted in the left temporal and parietal lobes consistent with recurrent tumor. On the lung emission images, a left hilar abnormality is noted which is suspicious for tumor. Subsequent follow-up with chest CT reveals a large apical left upper segment mass consistent with bronchogenic carcinoma.



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Adenocarcinoma48-year-old female who was discovered on routine physical exam to have left axillary adenopathy. Subsequent biopsy revealed adenocarcinoma, apparently metastatic from unknown primary.

Patient had subsequent mammography which did not define a definite area of abnormality. However, fine needle aspiration was performed in an area of suspicious abnormality. This revealed nonmalignant tissue.

FDG PET study showed three discrete abnormalities localized in the left axilla in area of known tumor. There is mild breast asymmetry. However, a focal abnormality suspicious for tumor in the breast is not noted.



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Chest Pain31-year-old male with IDDM has been on dialysis for one year. The patient has had one 10 minute episode of chest pain and shortness of breath. The patient is hypertensive.

An attenuation-corrected PET perfusion study using found normal distribution of 82Rb on both rest and stress imaging. No fixed or reversible defects are identified.



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Unstable Angina57-year-old female with a history of coronary artery disease who had a PTC in 1991 and CABG in 1993. The patient is being evaluated for increased angina.

On the rest portion of the study there is mildly diminished perfusion noted at the apex and slightly anteriorly. This appears unchanged from a previous study. During the stress portion of the study the patient developed significant EKG changes. The stress images reveal prominent reduction in the moderate range in perfusion inferiorly, inferolaterally and laterally. This particular constellation of findings is consistent with significant ischemia.



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Myocardial Viability

A 58-year-old male with posterolateral myocardial infarction in 1997.

Coronar angiography showed subtotal LCX-stenosis. Tc-99-tetrofosmin myocardial SPECT imaging showed an irreversible sterolateral defect.

FDG PET (with 250 mg Acipimox) found clear FDG uptake in the posterolateral region, demonstrating viability. Patient was subsequently scheduled for PTCA.

Courtesy of Prof. Dr. Peter Lind • Abteilung für Nuklearmedizin und spezielle Endokrinologie, Klagenfurt, Austria

Tc-99-tetrofosmin SPECT

FDG PET


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Alzheimer’s Disease

A 71-year-old woman with a two-year history of dementia.

CT was read as normal.

Bilateral diminished glucose utilization in the temporal and parietal cortex gave clear evidence of SDAT.



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Colorectal Cancer

A 47-year-old woman, one month after hemicolectomy due to sigmoid cancer (pT3G2NO).

Ultrasonography of the liver showed a suspicious lesion in segment 7. CT showed hypodense lesion in the dorsal region of the right lobe of the liver.

FDG PET scan showed very clear uptake in the dorsal region of the right lobe of the liver and an additional lesion in the ventral region of the right lobe. Both lesions were confirmed surgically.


Transverse

Coronal

Sagittal


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Follicular Thyroid CancerAn 83-year-old woman, five years after thyroidectomy and I-131 ablation (2960 MBq in 1992); second I-131 therapy (7400 MBq in 1997) due to Tg-elevation.

A Tc-99m-tetrofosmin whole-body scan showed positive lesions in the parahilar lung areas and in the liver. The post-therapeutic I-131 whole-body scan revealed positive Iodine 131 accumulation in the liver metastasis, but no uptake in the lung lesion.

The FDG PET scan found clear uptake in multiple lung lesions and in the two liver lesions.



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Lung Cancer

A 40-year-old woman with 25 pack/year smoking history complained of right scapular pain. Chest radiograph showed a mediastinal mass.

CT showed a 3.0 cm right mediastinal mass and paratracheal and right hilar adenopathy.

Whole-body FDG PET scan revealed a lift hilar lesion not predicted by CT. Multiple areas of abnormal uptake were also seen in the mediastinum and right hilum.

Mediastinoscopy and biopsy revealed adenocarcinoma.

Courtesy of Carolyn Cidis Meltzer M.D. • University of Pittsburgh Medical Center PET Facility

Transverse

Coronal

Sagittal


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Esophageal Cancer

A 51-year-old man with poorly differentiated adenocarcinoma of the mid-esophagus.

The CT scan found an infiltrative mass in the mid-esophagus.

The whole-body FDG PET scan found mid esophageal mass and an unsuspected extensive right paratracheal tumor.

Bronchoscopy: Tumor eroding right mainstem bronchus.

Pathology: Poorly differentiated squamous cell lung cancer.



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Epilepsy

A man with chronic left MCA stroke and waxing and wanig expressive aphasia, s/p heart transplant. Presents with very frequent (every 5 min.) simple partial seizures (right hemifield visual disturbance).

Ictal FDG PET brain study showed marked left temporal and occipital hypermetabolism bordering hypometabolic stroke territory.

A repeat interictal FDG PET brain study showed mild remaining temporal hypermetabolism.

Treatment of seizures between the 2 scans resulted in improved language function.



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Lymphoma

A 56-year-old female with B-cell lymphoma.

Initial FDG PET study showed high grade lymphoma and malignant ascites.

Follow-up PET scan after polychemotherapy documents residual lymphoma of the abdominal bulk and metastatic abdominal spread.

The patient is now scheduled for additional high-dose chemotherapy and autologous bone marrow transplantation.

Courtesy of Nuklearmedizin der RWTH Klinikum Aachen, Germany

Before Chemotherapy

After First Round

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