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Cross Sectional Anatomy of the

Chest, Abdomen, and Pelvis


Eric M. Rohren, M.D. Ph.D.
Chief, Positron Emission
Tomography
MD Anderson Cancer Center
Houston, TX
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Why CT Anatomy
Improved accuracy
Communication

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Why CT Anatomy
Improved accuracy
Differential diagnosis
Primary tumors
Pattern of metastatic disease

Communication

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Example

Hypermetabolic mass in the mediastinum


Clinical History: NSCLC
Irregular, hypermetabolic 2.8 cm nodal mass in
the AP window (station 5), consistent with
ipsilateral metastatic disease from NSCLC

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Example

Hypermetabolic mass in the mediastinum


Clinical History: Indeterminate thoracic mass
Smoothly-marginated 4.5 x 3.1 cm lobular mass in the
anterior mediastinum, centered in the retrosternal fat.
Although metabolically active, the intensity of uptake
(SUV=3.2) is less than typically seen with lymphoma
orto be reproduced
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lung carcinoma, and would be most consistent with

Example
Thyroidectomy and
radioiodine ablation

Completed
RoRx

Hypermetabolic mass in the mediastinum


Clinical History: Thyroid cancer with rising Tg
9 mm intensely hypermetabolic (SUV=8.8) lymph node in
the high retrosternal space below the sternal notch,
consistent with recurrent thyroid carcinoma. This Slides
node
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would likely be amenable to biopsy via ultrasound

Example

Hypermetabolic mass in the mediastinum


Clinical History: History of squamous cell carcinoma
4.4 x 3.7 cm
of the scalp
hypermetabolic mass with central necrosis in the anterior
heart, arising from the apical left ventricular myocardium,
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consistent with metastatic disease. There is an associated
l
i di l ff i

Why CT Anatomy
Improved accuracy
Communication
Results
Biopsy planning
Therapy planning

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Sample Report
67 year old man
Nasal carcinoma
surgical resection
radiation therapy

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Head and neck: Again seen are postsurgical changes of prior rhinectomy
and septectomy, stable in the interim. There is no hypermetabolism in or
adjacent to the surgical bed. Intense tracer activity is seen in the anterior
oral cavity. This region is partially obscured on the CT portion of the
examination by dense metallic streak artifact from non removable dental
hardware, but the activity appears to localize to the geniohyoid
musculature. There are no hypermetabolic lymph nodes along the cervical
chains. Slight asymmetry in radiotracer activity in the prevertebral
musculature is likely physiologic.

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Chest: Air-space consolidation in the right upper lobe posteriorly has

increased in size and density since the prior examination. There is now a
coalescent region of peripheral consolidation measuring approximately 11
x 5 cm (previously 5 x 2 cm) which is diffusely hypermetabolic on PET
(SUV=15.4). Subpleural consolidation at the left lung base posteriorly has
also increased in density, measuring 3.3 x 1.5 cm. This region is also
intensely hypermetabolic on PET scanning, with an SUV of 10.0. Regions
of subpleural septal thickening in the posterobasal segments of the lower
lobes bilaterally demonstrate low-grade radiotracer uptake. There are
changes of centrilobular emphysema in the mid and upper lungs. Intense
myocardial activity is physiologic. There is no nodal hypermetabolism in
the chest. There is low-grade (SUV=3.2) radiotracer activity in the right
and left pulmonary hila. There is no nodal hypermetabolism in mediastinal,
axillary, or supraclavicular chains. There are no pleural or pericardial
effusions.

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Abdomen and pelvis: Although morphologically stable in the interim, the

left adrenal gland now demonstrates nodular hypermetabolism at the


junction of the body and medial limb (image 107, SUV=4.5). There may be
a tiny focus of radiotracer activity in the body of the right adrenal gland
(image 102, SUV=3.4) although this is located in close proximity to
probable physiologic uptake in the right diaphragmatic crus. There is no
nodal hypermetabolism in retroperitoneal or pelvic chains. Tracer uptake in
the hepatic parenchyma is homogeneous. Peripheral activity outlining the
upper peritoneal surfaces likely represents uptake in the lateral
diaphragmatic musculature bilaterally. The spleen is normal in size and
FDG avidity. The pancreas is diffusely fatty replaced, with scattered
punctate calcifications particularly in the pancreatic head, possibly the
sequela of chronic pancreatitis.

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Musculoskeletal: There are scattered degenerative changes


in the spine, including asymmetric activity in the left C5/6 facet
joint. Marrow uptake is otherwise normal.

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Chest

Selected Topics

Lungs and Airways


Vascular anatomy
Nodal stations
GI

Abdomen and Pelvis


GI
Hepatic segmental anatomy
Vascular anatomy
Nodal groups

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CT Anatomy of the Chest

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Netter images used with permission from Netter Presentor

Lungs

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Lungs

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Lungs

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Pulmonary Lobes

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Right Major Fissure

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Left (Major) Fissure

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Right Minor Fissure

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Pulmonary Fissures

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Upper Lobes

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Lower Lobes

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Middle Lobe

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Lingula

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Pulmonary Lobes

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Right Major Fissure

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Left Fissure

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Right Minor Fissure

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Right Minor Fissure

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Right Minor Fissure

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Pulmonary Lobes on CT

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U
L

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M
U

U
L

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Pulmonary Segments

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Right Lung:
10 Segments
Right Upper Lobe
Apical
Anterior
Posterior

Right Middle Lobe


Lateral
Medial

Right Lower Lobe

Superior
Medial basal
Lateral basal
Anterior basal
Posterior basal

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Left Lung:
9 Segments
Left Upper Lobe

Apicoposterior
Anterior
Superior lingular
Inferior lingular

Left Lower Lobe

Superior
Medial basal
Lateral basal
Anterior basal
Posterior basal
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FDG Uptake in the Lungs


Normal Uptake

Metastatic Tumors

- No

- Lung
- Breast
- Colon
- Melanoma
- Bladder
- Renal cell cancer
- Osteosarcoma
- Etc.

Primary Tumors
- Non-small cell cancer
- Small cell cancer
- Carcinoid tumor
- Lymphoma

Infection/Inflammation
- Histoplasmosis
- Tuberculosis
- Sarcoidosis

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Left upper lobe

Left upper lobe

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Right upper lobe

Right lower lobe

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Left lower lobe

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Right lower lobe

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Trachea

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Carina
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Heart

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4 Chambers
Pulmonary circuit
Right atrium venous blood from body
Right ventricle pumps blood to lungs

Systemic circuit
Left atrium oxygenated blood from lungs
Left ventricle pumps blood to body
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Left Ventricle

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Right Ventricle

Left Ventricle

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Left Ventricle

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Right Ventricle

Left Ventricle

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Right Ventricle
Aortic Root

Left Ventricle

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Right Ventricle
Aortic Root

Left Ventricle

LeftSlidesAtrium
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Right Ventricle
Aortic Root

Left Ventricle

Right Atrium
LeftSlidesAtrium
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Pulmonary Outflow
Aorta

Right Atrium
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Left Atrium

Aortic Arch and Great Vessels

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Pulmonary Arteries

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FDG Uptake in Vessels


Normal Uptake

Infection/Inflammation

- No

- Atherosclerosis
- Vasculitis

Primary Tumors
- Rare

Metastatic Tumors
- Rare

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Takayasus arteritis

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Lymphatics

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Lymphatics
Hilar groups
Right hilar

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Lymphatics
Hilar groups
Right hilar
Left hilar

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Lymphatics
Thoracic groups above the hila
Precarinal

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Lymphatics
Thoracic groups above the hila
Precarinal
Azygous

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Lymphatics
Thoracic groups above the hila
Precarinal
Azygous
Right paratracheal

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Lymphatics
Thoracic groups above the hila
Precarinal
Azygous
Right paratracheal
Left paratracheal

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Lymphatics
Thoracic groups above the hila
Precarinal
Azygous
Right paratracheal
Left paratracheal
Aortopulmonary

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Lymphatics
Thoracic groups above the hila
Precarinal
Azygous
Right paratracheal
Left paratracheal
Aortopulmonary
Prevascular

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Lymphatics
Thoracic groups above the hila
Precarinal
Azygous
Right paratracheal
Left paratracheal
Aortopulmonary
Prevascular
Retrosternal

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Lymphatics
Thoracic groups above the hila
Precarinal
Azygous
Right paratracheal
Left paratracheal
Aortopulmonary
Prevascular
Retrosternal
Superior Mediastinal
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Lymphatics
Thoracic groups below the hila
Subcarinal

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Lymphatics
Thoracic groups below the hila
Subcarinal
Azygoesophageal

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Lymphatics
Thoracic groups below the hila
Subcarinal
Azygoesophageal
Retrocrural

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Lymphatics
Extrathoracic groups
Scalene

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Lymphatics
Extrathoracic groups
Scalene
Supraclavicular

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Lymphatics
Extrathoracic groups
Scalene
Supraclavicular
Axillary

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Digestive System

Esophagus
Stomach
Small intestine
Large intestine

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Esophagus

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FDG Uptake in the Esophagus


Normal Uptake

Infection/Inflammation

- Yes (+/-)

- Reflux esophagitis
- Candida
- Mucositis (RoRx)

Primary Tumors
- Squamous cell cancer
- Adenocarcinoma
- Lymphoma

Metastatic Tumors
- Rare

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Esophageal Cancer

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CT Anatomy of the Abdomen

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Stomach

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Stomach
Fundus
Body
Antrum

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FDG Uptake in the Stomach


Normal Uptake

Infection/Inflammation

- Yes

- Peptic ulcer disease

Primary Tumors
- Adenocarcinoma
- Leiomyosarcoma
- Lymphoma

Benign Conditions
- Leiomyoma

Metastatic Tumors
- Uncommon
- Breast
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Gastric carcinoma
Gastric carcinoma

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Gastric sarcoma
Gastric lymphoma

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Small Intestine

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Duodenum

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Jejunum
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Ileum
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FDG Uptake in the Small Bowel


Normal Uptake

Infection/Inflammation

- Yes

- Crohns disease
- Other entertitis

Primary Tumors
- Lymphoma
- Adenocarcinoma (rare)

Metastatic Tumors
- Melanoma

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Metastatic melanoma

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Ileocecal Valve

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Appendix

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Appendix

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CT Imaging: Colon

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Cecum

Appendix

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Ascending Colon

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Hepatic Flexure

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Transverse Colon

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Splenic Flexure

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Descending Colon

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Sigmoid Colon

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Rectum

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Anal canal

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FDG Uptake in the Colon


Normal Uptake

Infection/Inflammation

- Yes

- Crohns disease
- Ulcerative colitis
- Other colitis

Primary Tumors
- Adenocarcinoma
- Mucinous carcinoma

Benign Conditions
- Adenomatous polyps

Metastatic Tumors
- Rare

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Colon cancer

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Colon cancer

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Adenomatous
polyp

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CT Imaging: Liver

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Lobar Anatomy

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Lobar Anatomy
Lateral left
Medial left
Anterior right
Posterior right
Caudate

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Segmental Anatomy

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Segmental Anatomy

Bifurcation of right
and left portal venous
branches

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Segmental Anatomy
Segment II
Segment IVA
Segment VIII
Segment VII

LHV
MHV

RHV

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Segmental Anatomy

Falciform ligament
Gallbladder fossa
Right hepatic vein

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Segmental Anatomy
Segment III
Segment IVB
Segment V
Segment VI

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Segmental Anatomy
Segment I

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Hepatic Segments I-VIII


II
VII

VIII

IVa

III

IVb
V
VI
Caudate: I
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FDG Uptake in the Liver


Normal Uptake

Infection/Inflammation

- Yes

- Hepatic abscess
- Cholangitis

Primary Tumors
- Hepatocellular carcinoma
- Cholangiocarcinoma

Metastatic Tumors
- Colon
- Breast
- Pancreas
- Gastric
- Renal

Benign Conditions
- Hemangioma
- Cyst
- Hepatic adenoma
- Focal nodular hyperplasia

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Segment V

Segment VII

Segments V, VI, VII, VIII

Segment VI

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Segments VII & IVa

All Segments

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Metastasis
Gallstones

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Abdominal Vasculature

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Abdominal Aorta
5 Major Branches

Celiac Trunk
Superior Mesenteric Artery
Renal Arteries
Inferior Mesenteric Artery
Iliac Arteries

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Celiac
CeliacTrunk
Trunk

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Superior Mesenteric Artery

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Renal Arteries

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Mid Aorta

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Inferior Mesenteric Artery

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Aortic Bifurcation

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Common Iliac Arteries

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Internal and External Iliac Arteries

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External Iliac Arteries

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Femoral Arteries

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Femoral Veins

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Iliac Veins

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Inferior Vena Cava

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Inferior Vena Cava

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Renal Veins

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Inferior Vena Cava

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Superior Mesenteric Vein

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Portosplenic Confluence

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Portal and Splenic Veins

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Portal Vein

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Lymph Node Groups

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Abdominal groups

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Abdominal groups
Gastrohepatic

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Abdominal groups
Gastrohepatic
Portocaval

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Abdominal groups
Gastrohepatic
Portocaval
Aortocaval

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Abdominal groups
Gastrohepatic
Portocaval
Aortocaval
Left paraaortic

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Abdominal groups
Gastrohepatic
Portocaval
Aortocaval
Left paraaortic
Mesenteric

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Abdominal groups
Gastrohepatic
Portocaval
Aortocaval
Left paraaortic
Mesenteric
Aortic bifurcation

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Pelvic groups

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Pelvic groups
Common iliac

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Pelvic groups
Common iliac
Internal iliac

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Pelvic groups
Common iliac
Internal iliac
External iliac

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Pelvic groups
Common iliac
Internal iliac
External iliac

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Pelvic groups
Common iliac
Internal iliac
External iliac
Inguinal

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Pelvic groups
Common iliac
Internal iliac
External iliac
Inguinal

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Gallbladder and Bile Ducts

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Spleen

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Accessory Spleen

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Accessory Spleen

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FDG Uptake in the Spleen


Normal Uptake

Infection/Inflammation

- No

- G-CSF
- Sarcoidosis

Primary Tumors
- Lymphoma

Metastatic Tumors
- Uncommon
- Melanoma
- Colon cancer
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G-CSF effect

Metastatic
colon cancer

Lymphoma

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Adrenal Glands

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Body

Medial Limb

Lateral Limb

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FDG Uptake in the Adrenal Gland


Normal Uptake

Infection/Inflammation

- No

- Adrenal adenoma

Primary Tumors
- Pheochromocytoma
- Adrenocortical carcinoma

Metastatic Tumors
- Lung cancer
- Melanoma
- Renal cell cancer
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Metastatic lung
carcinoma

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Bilateral adrenal
metastases

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Follow up CT
1 year later

Metastatic lung
carcinoma

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Pancreas

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Pancreatic
body and tail

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Pancreatic
head

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Uncinate process

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FDG Uptake in the Pancreas


Normal Uptake

Infection/Inflammation

- No

- Pancreatitis

Primary Tumors
- Pancreatic cancer
- Islet cell tumors

Metastatic Tumors
- Unusual
- Renal cell cancer
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Conclusion
Basic anatomic knowledge can improve
the diagnostic value of PET
Correct use of anatomic terms facilitates
communication with referring clinicians
Anatomy is destiny.
- Sigmund Freud

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