CPI PET-CT Special Edition 2014

Expert Panel on PET/CT
Special Edition 2014

All questions and images that appear in this module were authored and
critically reviewed by a panel of experts in the eld of PET/CT to ensure that
they were functional and valid. The experts reviewed each question and
image in terms of its applicability to a general radiologist’s practice today. In
addition, they assessed the timeliness of the content and the quality of the
images to determine whether they met today’s quality standards. The expert
panel also provided the discussions for each answer published in this report
as well as the references of educational sources for further learning. We wish
to thank the panel members for their expert input and review.
Marc A. Seltzer, MD
Esma A. Akin, MD
Sundeep M. Nayak, MD
Stephanie Pei-Fang Yen, MD
Ruth Lim, MD, BS
Alan H. Siegel, MD
Rathan M. Subramaniam, MD, PhD
Gary A. Ulaner, MD
Don C. Yoo, MD
Marc A. Seltzer, MD
CPI PET/CT Panel Chair/Editor
Associate Professor of Radiology, Geisel School of Medicine at Dartmouth,
Director, PET/CT Program, Dartmouth-Hitchcock Medical Center
Harris L. Cohen, MD, FACR
CPI Program Chair/Editor in Chief
Chairman of Radiology, University of Tennessee Health Science Center;
Radiologist-in-Chief, Le Bonheur Children’s Hospital; Professor of
Radiology, Pediatrics and Obstetrics & Gynecology
John K. Phillips, MD
Assistant Editor in Review
Assistant Professor of Radiology (Af liated), University of Tennessee Health
Science Center; Chief, Radiology and Nuclear Medicine VA Medical Center
Memphis
Objectives
This self-assessment module is a component of the American College of
Radiology’s Continuous Professional Improvement (CPI) program. The
intent of the CPI program is to assess your overall imaging knowledge
including areas evaluated by the American Board of Radiology’s
examination and to provide you with information on the items tested.
The objectives for CPI PET/CT Special Edition 2014 are as follows:
• Assess and manage a variety of hypothetical clinical
situations related to PET/CT;
• Assess image findings and exercise independent
medical judgment based on the images and/or facts
provided concerning PET/CT;
• Identify clinical and imaging principles relevant to the
cases encountered and topics discussed in the practice
of PET/CT; and
• Enhance clinical practice strategies based on the
practitioner’s self-assessment in the area of PET/CT.
Instructions
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Marc A. Seltzer, MD, Chair
Esma A. Akin, MD
Harris L. Cohen, MD, FACR
Ruth Lim, MD, BS
Sundeep M. Nayak, MD
John K. Phillips, MD
Alan H. Siegel, MD
Rathan M. Subramaniam, MD, PhD
Gary A. Ulaner, MD
Stephanie Pei-Fang Yen, MD
Don C. Yoo, MD
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Release Date: 04/2014 Expiration Date: 04/2017

Self-Assessment Examination
CPI PET/CT Special Edition 2014
IMAGE-RELATED QUESTIONS

1. You are shown positron emission tomography/computed
tomography (PET/CT) images (Figures 1-1, 1-2, 1-3, 1-4,
and 1-5) of a 29-year-old man with a history of testicular
cancer who underwent right-sided orchiectomy 10
months previously, followed by chemotherapy. He now
presents with a right-sided groin mass. Which one of the
following is the MOST likely diagnosis?
A. Non-Hodgkin lymphoma
B. Metastatic testicular carcinoma
C. Postoperative urinoma
D. Groin abscesses
Review Answer 1
Fig 1-1. Chest/abdomen/pelvis. Fluorodeoxyglucose positron
emission tomography/computed tomography (PET/CT).
Maximum intensity projection. Frontal view.
Fig 1-2. Pelvis. CT. Contrast enhancement. Axial plane.
Fig 1-3. Pelvis. Fused PET/CT. Axial plane.
Fig 1-4. Groin. CT. Contrast enhancement. Axial plane.
Fig 1-5. Groin. Fused PET/CT. Axial plane.

2. You are shown maximum intensity projection (Figures 2-1
and 2-2) and axial fused images from an 18F-
fluorodeoxyglucose PET/CT (Figures 2-3 and 2-4) and
corresponding contrast-enhanced CT images (Figures 2-
5 and 2-6) of a 36-year-old woman who presents with
chronic lower abdominal pain. Which one of the
following is the BEST interpretation of the etiology for
the FDG-avid lesions seen in the pelvis?
A. Bladder diverticulum
B. Bladder carcinoma
C. Cervical carcinoma
D. Cystic ovarian neoplasm
Review Answer 2
Fig 2-1. Chest/abdomen/pelvis. PET/CT. Maximum intensity
projection. Frontal view.
projection. Sagittal view.
Fig 2-3. Pelvis. Fused 18F-fluorodeoxyglucose (FDG) PET/CT.
Axial plane. Level of femoral heads.
Fig 2-4. Pelvis. CT. Contrast enhancement. Axial plane. Level
of femoral heads.
Fig 2-5. Pelvis. Fused 18F-FDG PET/CT. Axial plane. Somewhat
higher level than Figure 2-3, through iliac bones.
Fig 2-6. Pelvis. CT. Contrast enhancement. Axial plane.
Somewhat higher level than Figure 2-4, through iliac bones.

3. An 18F-FDG PET/CT scan was performed in a 2-year-old
girl with a history of neuroblastoma. Based on the
findings in Figure 3-1, which one of the following is the
MOST likely diagnosis?
A. Diaphragmatic metastases
B. Peritoneal metastases
C. Physiologic uptake
D. Adrenal metastases
Review Answer 3
Fig 3-1. Chest/abdomen. FDG PET/CT. a) MIP. Coronal plane.
b) MIP. Magnified image of abdomen. c) CT. Coronal plane. d)
Fused PET/CT. Frontal view.

4. A 13-year-old girl with osteosarcoma of the left distal
femur had an F-FDG PET/CT scan performed at
diagnosis (Figure 4-1) and again after 2 cycles of
chemotherapy (Figure 4-2). Based on the findings in
Figures 4-1 and 4-2, which one of the following is
CORRECT ?
A. The primary tumor has progressed.
B. The primary tumor shows interval response to
treatment.
C. There is new metastatic disease in the left tibia.
D. There is new metastatic disease in the lungs.
Review Answer 4
Fig 4-1. Whole body. FDG PET/CT. Maximum intensity
projection. Baseline scan at diagnosis.
Fig 4-2. Whole body. FDG PET/CT. Maximum intensity
projection. Scan after 2 cycles of chemotherapy.

5. A 1-year-old female infant had a sodium 18F-fluoride (18F-
fluoride) PET bone scan performed for left thigh pain
and swelling. Based on the findings in Figure 5-1, which
one of the following is the LEAST likely diagnosis?
A. Left femur Ewing sarcoma
B. Isolated left femur fracture
C. Multiple fractures including bilateral ribs
D. Osteomyelitis
Review Answer 5
Fig 5-1. Whole body. Sodium 18F-fluoride PET bone scan.
Maximum intensity projection.

6. A 3-year-old girl presents with seizures and light-colored
skin patches, without any focal neurological deficits.
Based on the images from a T2-weighted brain magnetic
resonance imaging scan (Figure 6-1a) and an interictal
18F-FDG PET (Figure 6-1b) scan, which one of the
following is TRUE ?
A. The left frontal lesion is the most likely epileptogenic
focus.
B. The most likely differential diagnoses are metastatic
disease or abscesses.
C. An ictal brain perfusion single-photon emission
computed tomography scan would not contribute
additional useful information.
D. Findings are consistent with tuberous sclerosis
complex.
Review Answer 6
Fig 6-1. Brain. a) Magnetic resonance. T2 weighted. Axial
plane. Level of lateral ventricles. b) Interictal FDG PET. Axial
plane. Level of lateral ventricles.

7. A 67-year-old heavy smoker presented with a productive
cough. This led to the discovery of a new right upper
lobe lung nodule on chest radiography (Figure 7-1). FDG
PET/CT evaluation was requested for further
management. Assuming biopsy of the nodule yielded
adenocarcinoma, which one of the following is TRUE ?
A. This is stage I lung cancer as contralateral nodules
are not FDG-avid.
B. This is stage I lung cancer in 3 different locations (1
right and 2 left).
C. This is stage I lung cancer only if contralateral
nodules are proven benign.
D. This is stage IV lung cancer as contralateral nodules
are metastatic (M1b).
Review Answer 7
Fig 7-1. Chest. a) CT. Axial plane. Level of superior
mediastinum/upper lobes. b) FDG PET. Axial plane. Red
arrow points to the dominant right upper lobe biopsy-proven
adenocarcinoma. Green arrows point to small CT-visualized
pulmonary nodules in the left upper lobe.

8. Which one of the following is the BEST explanation for
the findings displayed in Figure 8-1?
A. Diabetic patient with blood sugar greater than 200
mg/dL just prior to FDG injection
B. Infiltration of the injected dose
C. Recent meal eaten 2 hours prior to the FDG injection
D. Vigorous exercise the morning of the PET/CT scan
Review Answer 8
Fig 8-1. Chest/abdomen/pelvis. FDG PET. Maximum intensity

9. Which one of the following is the BEST explanation for
the findings displayed in Figure 9-1 of a 23-year-old
man?
A. Lymphoma
B. Nonfasting state
C. Recent exercise
D. Brown fat
Review Answer 9
Fig 9-1. Chest/abdomen/pelvis. FDG PET. Maximum intensity

10. You are shown select axial images from an FDG PET/CT
performed on a 64-year-old woman with newly
diagnosed sarcoma (Figures 10-1, 10-2, 10-3, and 10-4).
Figure 10-1 shows an FDG avid lytic lesion in the right
sacrum. Which one of the following is the MOST likely
explanation for the high FDG uptake seen in Figure 10-2,
which is at a level just superior to the sacral lesion?
A. Soft tissue extension of tumor
B. Paraspinal abscess
C. Biopsy tract inflammation
D. Physiologic FDG avidity in muscle
Review Answer 10
Fig 10-1. Pelvis. CT. Axial plane.
Fig 10-2. Pelvis. Fused PET/CT. Axial plane.
Fig 10-3. Pelvis. CT. Axial plane. Slightly superior level to
Figure 10-1.
Fig 10-4. Pelvis. Fused PET/CT. Axial plane. Slightly superior
level to Figure 10-1 and co-registering with Figure 10-3.

11. FDG PET images (Figures 11-1, 11-2, and 11-3) are
presented from a 40-year-old woman 1 month following
bilateral mastectomies for breast cancer and flap
reconstructions. Which one of the following is the MOST
likely explanation for the FDG avidity in the chest wall,
bilaterally?
A. Postmastectomy inflammation
B. Residual breast cancer
C. Mastitis
D. Postsurgical infection
Review Answer 11
Fig 11-1. Thorax. CT. Axial plane. Level of heart.
Fig 11-2. Thorax. Fused PET/CT. Axial plane. Level of heart.
Fig 11-3. Thorax. FDG PET. Axial plane.

12. Figure 12-1 is the baseline MIP image from a PET/CT
obtained in 51-year-old man with newly diagnosed non-
Hodgkin lymphoma. After 4 cycles of chemotherapy, a
repeat PET/CT (Figure 12-2), a chest CT (Figure 12-3),
and fused PET/CT image of the chest (Figure 12-4), were
performed to assess response to therapy. Which one of
the following is the MOST likely cause of FDG avidity in
the lungs seen on the posttreatment PET/CT?
A. Pulmonary lymphoma
B. Postchemotherapy pneumonitis
C. Primary pulmonary malignancy
D. Focal pneumonia
Review Answer 12
projection just prior to starting chemotherapy.
projection following completion of 4 cycles of chemotherapy.
Fig 12-3. Chest. CT. Axial plane. Level of hila. Image taken
after 4 cycles of chemotherapy.
Fig 12-4. Chest. Fused PET/CT. Axial plane. Same level as
Figure 12-3. Image taken after 4 cycles of chemotherapy.

13. Figures 13-1, 13-2, 13-3, and 13-4 are CT and PET/CT
images from a 15-year-old boy with Ewing sarcoma of
the spine, following treatment with radiation therapy,
chemotherapy, and steroids. Which one of the following
is the MOST likely cause of FDG avidity in the femurs
and tibias?
A. Metastatic Ewing sarcoma
B. Osteomyelitis
C. Physiologic growth plates
D. Bone infarcts
Review Answer 13
Fig 13-1. Distal femurs. CT. Axial plane.
Fig 13-2. Distal femurs. Fused PET/CT. Axial plane.
Fig 13-3. Distal femurs and proximal tibias. CT. Coronal
plane.
Fig 13-4. Distal femurs and proximal tibias. Fused PET/CT.
Coronal plane.

14. Figures 14-1 and 14-2 are from a PET/CT of a man with
thoracic lymphoma, treated with thoracic radiation and
chemotherapy. Which one of the following is the MOST
likely cause of the FDG-avid finding in the left hip?
A. Lymphoma
B. Extraosseous osteogenic sarcoma
C. Heterotopic ossification
D. Fracture
Review Answer 14
Fig 14-1. Pelvis. CT. Axial plane. Level of acetabuli.
Fig 14-2. Pelvis. Fused PET/CT. Axial plane. Same level as
Figure 14-1.

15. A 60-year-old man with a history of prostate cancer
presents with back and hip pain. Which one of the
following is the BEST interpretation of the 18F-fluoride
PET/CT scan (Figure 15-1)?
A. Lumbar and right hip metastases
B. Lumbar metastases and osteoarthritis of the right hip
C. Lumbar degenerative disc disease and osteoarthritis
of the right hip
D. Lumbar degenerative disc disease and right hip
metastasis
Review Answer 15
Fig 15-1. Pelvis. 18F-fluoride PET/CT. a) PET. Axial plane. b)
PET. Coronal plane. c) PET. Sagittal plane. d) CT. Axial plane.
e) CT. Coronal plane. f) CT. Sagittal plane.

16. A 64-year-old man with a history of chronic lymphocytic
leukemia (CLL) involving multiple nodal regions
including both axillae presents with an enlarging right
neck mass, pain under his right jaw, and sore throat.
Based on findings from the 18F-FDG PET (Figure 16-1),
CT (Figure 16-2), fused PET/CT (Figure 16-3), and
PET/MIP (Figure 16-4), which one of the following is the
BEST interpretation of the abnormality in the right
neck?
A. Recurrent CLL
B. Abscess
C. Primary head/neck malignancy
D. Richter transformation
Review Answer 16
Fig 16-1. Neck. 18F-FDG PET. Axial plane.
Fig 16-2. Neck. CT. Axial plane.
Fig 16-3. Neck. Fused PET/CT. Axial plane.
Fig 16-4. Neck/chest/abdomen/pelvis. PET. Maximum
intensity projection. Frontal view.

17. You are shown the prechemotherapy (Figures 17-1 a, b,
and c) and post 4 cycles of chemotherapy (Figures 17-1
d, e, and f) PET/CTs of a 28-year-old woman with
primary mediastinal diffuse large B-cell lymphoma.
Based on those images, which one of the following is the
BEST interpretation of the findings?
A. Residual active mediastinal lymphoma
B. Residual active mediastinal lymphoma with new site
of lymphoma in bone
C. No active mediastinal lymphoma
D. No active mediastinal lymphoma but new site of
lymphoma in bone
Review Answer 17
Fig 17-1. Chest. 18F-FDG PET/CT. a) Maximum intensity
projection. Frontal view. Prechemotherapy. b) PET. Axial
plane. Prechemotherapy. c) CT. Axial plane.
Prechemotherapy. d) Maximum intensity projection. Frontal
view. Post 4 cycles of chemotherapy. e) PET. Axial plane. Post
4 cycles of chemotherapy. f) CT. Axial plane. Post 4 cycles of
chemotherapy.

18. In Figure 18-1 you are shown anterior maximum
intensity projection, axial PET, CT, and fused PET/CT
images of a 57-year-old man referred for restaging of
treated colon cancer. What is the approximate likelihood
of malignancy associated with the incidental FDG-avid
lesion seen in the neck?
A. <10%
B. 10%–20%
C. 30%–50%
D. >60%
Review Answer 18
Fig 18-1. A) Neck/chest/abdomen/pelvis. Maximum intensity
projection. Frontal view. B) Neck. PET. Axial plane. C) Neck.
CT. Axial plane. D) Neck. Fused PET/CT. Axial plane.

19. You are shown axial FDG PET (Figure 19-1A), fused FDG
PET/CT (Figure 19-1B), and CT (Figure 19-1C) images of
a 62-year-old man with squamous cell carcinoma of the
base of the tongue and metastatic cervical nodes. Of the
cervical neck node levels listed, to which ONE does this
node belong?
A. III
B. IV
C. V
D. VI
Review Answer 19
Fig 19-1. Neck. A) FDG PET. Axial plane. B) Fused FDG
PET/CT. Axial plane. C) CT. Axial plane.

20. You are shown an axial fused FDG PET/CT image (Figure
20-1) from an 18F-FDG PET/CT scan obtained in an 85-
year-old man being restaged for papillary carcinoma of
the thyroid. Which one of the following is the MOST
likely explanation for the high FDG uptake seen in the
larynx?
A. Left vocal cord paralysis
B. Right vocal cord paralysis
C. Vocal cord malignancy
D. No abnormality
Review Answer 20
Fig 20-1. Neck. Fused PET/CT. Axial plane.

21. A 77-year-old woman with progressive cognitive decline
over a 2-year-period has an FDG PET scan (Figure 21-1).
All of the following are possible diagnoses based on the
scan findings EXCEPT: A. Alzheimer dementia
B. Dementia with Lewy bodies
C. Frontotemporal dementia
D. Parkinson disease dementia
Review Answer 21
Fig 21-1. Brain. FDG PET. Axial plane.

22. Figure 22-1 shows coronal, axial, and sagittal planes
obtained from a PET scan performed after 4 cycles of
chemotherapy for treatment of mediastinal diffuse large
B-cell lymphoma. What is the MOST likely cause of the
diffuse marrow and splenic activity shown?
A. Granulocyte colony-stimulating factor administration
B. Erythropoietin administration
C. Postchemotherapy rebound
D. Anemia
Review Answer 22
Fig 22-1. PET/CT. a) Neck/chest/abdomen/pelvis. Coronal
plane. b) Upper abdomen. Axial plane. c)
Neck/chest/abdomen/pelvis. Sagittal plane. Images were
obtained after 4 cycles of chemotherapy for treatment of
lymphoma.

23. A PET/CT was performed in a 65-year-old man with a T3
squamous cell carcinoma of the right lung invading the
chest wall. Regarding the FDG-avid lesions seen in the
left axilla (Figures 23-1 and 23-2), which one of the
following is the MOST likely cause?
A. Second primary neoplastic process
B. Unrelated inflammatory adenopathy
C. Contralateral nodal metastases
D. Dose infiltration in the left arm
Review Answer 23
Fig 23-1. Left axilla. PET. Maximum intensity projection.
Frontal view.
Fig 23-2. Chest. a) PET. Axial plane. b) PET. Coronal plane. c)
PET. Sagittal plane. d) CT. Axial plane. e) CT. Coronal plane. f)
CT. Sagittal plane.

24. The PET/CT images shown in Figure 24-1 were obtained
in a 27-year-old man with a history of mediastinal
involvement by large B-cell lymphoma following
completion of 6 cycles of chemotherapy. The differential
diagnosis would include all of the following EXCEPT: A.
Lymphoma transformation
B. Post chemotherapy inflammation
C. Residual active lymphoma
D. Functioning thymic tissue
Review Answer 24
Fig 24-1. Mediastinum. PET/CT. a) Maximum intensity
projection. Axial plane. b) Maximum intensity projection.
Coronal plane. c) CT. Axial plane. d) PET/CT. Axial plane.

25. The finding shown in Figure 25-1 was seen as an
incidental finding in a patient with a newly diagnosed
localized (early stage) nonsmall-cell lung cancer. Which
one of the following is the MOST likely etiology of this
incidental finding?
A. Reactive lymph node
B. Benign intraparotid neoplasm
C. Primary parotid carcinoma
D. Metastasis
Review Answer 25
Fig 25-1. PET/CT. a) Head. PET. Axial plane. b)
Head/neck/chest. PET. Coronal plane. c) Head. Fused PET/CT.
Axial plane. d) Head/neck/chest. Fused PET/CT. Coronal
plane.

26. The finding shown in Figure 26-1 was seen as an
incidental finding in a patient with a newly diagnosed
colon cancer. Which one of the following is the MOST
likely etiology of this incidental finding?
A. Pituitary adenoma
B. Pituitary metastasis
C. Pituitary carcinoma
D. Normal pituitary
Review Answer 26
Fig 26-1. Head. PET/CT. a) PET. Axial plane. b) PET. Coronal
plane. c) CT. Axial plane. d) CT. Coronal plane.

27. When characterizing an indeterminate CT-visualized
adrenal nodule, such as the one shown in Figure 27-1,
all of the following PET criteria have been reported to
have a high accuracy for stating that the nodule is likely
malignant EXCEPT which one?
A. Maximum standardized uptake value (SUVmax) of the
adrenal nodule is greater than 3.1.
B. Ratio of the SUVmax of the nodule to the SUV
average of the liver is greater than 1.0.
C. Visual assessment that the adrenal nodule has FDG
uptake greater than the liver background.
D. Visual assessment that the adrenal nodule has FDG
uptake greater than the mediastinal background.
Review Answer 27
Fig 27-1. Adrenal gland. PET/CT. a) Upper abdomen. PET.
Axial plane. b) Chest/abdomen. PET. Coronal plane. c) Upper
abdomen. CT. Axial plane. d) Chest/abdomen. CT. Coronal
plane.
NONIMAGE-RELATED QUESTIONS

28. Regarding normal physiologic uptake of 18F-FDG in
children, which one of the following is LEAST likely to
demonstrate 18F-FDG uptake greater than liver
reference background?
A. Thymus
B. Waldeyer ring
C. Bone physes
D. Adrenal glands
Review Answer 28

29. Regarding hypermetabolic brown adipose tissues, which
one of the following is CORRECT?
A. Occurs less commonly in children than in adults
B. Can be reduced by warming the patient
C. Does not occur in the upper abdomen
D. Does not occur during warm weather
Review Answer 29

30. 18F-FDG PET does NOT have an established role in
which one of the following pediatric conditions?
A. Wilms tumor
B. Brain tumors
C. Mesenchymal hamartoma
D. Langerhans cell histiocytosis
E. Neuroblastoma
Review Answer 30

31. Which one of the following brain lesions has the
LOWEST avidity for FDG?
A. Juvenile pilocytic astrocytoma
B. Toxoplasmosis
C. Medulloblastoma
D. Metastases
E. Choroid plexus papilloma
Review Answer 31

32. Which one of the following is the APPROXIMATE
whole-body radiation dose from 555 MBq (15 mCi) of
FDG?
A. 0.5 mSv
B. 5.0 mSv
C. 50.0 mSv
D. 5.0 Sv
Review Answer 32

33. Which one of the following CT parameters will
INCREASE the radiation dose to a patient receiving a
PET/CT?
A. Increase the pitch
B. Decrease the tube current
C. Increase the tube voltage
D. Increase the gantry rotation speed
Review Answer 33

34. Which one of the following is the BEST approach to
performing an FDG PET scan in a diabetic patient?
A. Continue all diabetic medications and have the
patient fast for 4 hours.
B. Continue all diabetic medications and have the
patient eat a light meal just prior to FDG
administration to avoid hypoglycemia.
C. Discontinue regular insulin and have the patient fast
for 18 hours.
D. Discontinue regular insulin and have the patient fast
for 4 hours.
Review Answer 34

35. Approximately how long after administration of
granulocyte colony-stimulating factor is it COMMON to
have increased FDG avidity in the bone marrow?
A. 1 week
B. 1 month
C. 1 year
D. Indefinitely
Review Answer 35

36. In addition to the bone marrow, granulocyte colony-
stimulating factor COMMONLY increases the FDG
avidity of which other organ?
A. Spleen
B. Liver
C. Kidneys
D. Pancreas
Review Answer 36

37. Bisphosphonates are used to decrease bone pain and
fractures in patients with bone metastases, myeloma,
osteoporosis, and Paget disease. Which one of the
following is a COMMON FDG-avid complication of
bisphosphonate usage?
A. Pneumonia
B. Colitis
C. Osteonecrosis
D. Hepatitis
Review Answer 37

38. In comparing 18F-fluoride PET bone scans to
conventional 99mtechnetium methylene diphosphonate
(99mTc-MDP) bone scans, the 18F-fluoride PET bone
scans have which ONE of the following?
A. Higher sensitivity for detecting osteoblastic bone
metastases
B. Lower sensitivity in detecting osteolytic bone
metastases
C. Lower effective radiation dose
D. Longer delay time required between tracer injection
and imaging
Review Answer 38

39. Compared to conventional radiographs, 18F-fluoride PET
is LESS sensitive in the detection of which one of the
following fractures in children of suspected
nonaccidental trauma?
A. Rib
B. Vertebral body
C. Corner metaphyseal
D. Spinous process
Review Answer 39

40. Which one of the following types of lymphomas is the
LEAST likely to be 18F-FDG-avid?
A. Diffuse large B cell
B. Follicular
C. Marginal zone/mucosa-associated lymphoid tissue
D. Hodgkin
Review Answer 40

41. PET/CT is NOT an appropriate indication for which one
of the following lymphoma subtypes?
A. Hodgkin lymphoma, initial staging
B. Diffuse large B-cell lymphoma, initial staging
C. Indolent non-Hodgkin lymphoma, initial staging
D. Indolent non-Hodgkin lymphoma when transformation
is suspected
Review Answer 41

42. Which one of the following statements regarding cardiac
activity noted on an oncologic PET/CT scan using 18F-
FDG is CORRECT?
A. The interatrial septum, apex of the left ventricle, and
right atrial appendage are common sites of normal
variant focal cardiac FDG uptake.
B. An FDG-avid mass in the wall of the left ventricle is
most likely due to a benign or malignant primary
cardiac neoplasm rather than a metastasis.
C. Intense activity in the left ventricular wall is
commonly seen in patients who have undergone a
prolonged fasting of greater than 12 hours.
D. Of the major cancer types imaged with PET/CT, lung
cancer is the least common to metastasize to the
heart.
Review Answer 42

43. Which one of the following is TRUE regarding 18F-FDG
PET/CT after radiation treatment for lung cancer?
A. Post radiation inflammatory changes in the lungs
rarely last more than 6 months.
B. Focally increased activity in the radiation port 3
months after completion of radiation is always
indicative of residual or recurrent malignancy.
C. Inflammatory changes from radiation can mask
residual or recurrent malignancy and serial PET/CT
scans may be necessary before malignancy can be
excluded.
D. Radiation-induced esophagitis rarely occurs in
patients with radiation to the mediastinum or spine.
E. It is recommended to wait at least 1 year before
performing the first restaging PET/CT scan to avoid
false-positive results.
Review Answer 43

44. An 18F-FDG PET/CT scan performed in a patient for
evaluation of a solitary pulmonary nodule after
intravenous administration of 18F-FDG demonstrates an
intense focus of increased activity in the descending
colon without a CT correlate. No additional
abnormalities are seen on the PET/CT scan. Which one
of the following is TRUE?
A. As no correlate is seen on the CT portion of this study,
this is a benign finding and no further workup is
necessary.
B. This finding most likely represents metastatic disease.
C. Colonic activity is not normally seen, and this finding
most likely represents focal inflammation.
D. The patient is most likely on metformin which
typically results in focally increased colonic activity.
E. This is an indeterminate finding on PET/CT and
should be reported as suspicious for a premalignant
versus malignant colonic neoplasm.
Review Answer 44

45. Which one of the following statements regarding liver
activity on 18F-FDG PET/CT scans is TRUE?
A. Normal physiologic liver activity is greater than
mediastinal blood pool activity and splenic activity.
B. Normal physiologic liver activity is less than
mediastinal blood pool activity but greater than
splenic activity.
C. Granulocyte colony-stimulating factor can result in
diffuse homogeneous intense liver activity.
D. Normal physiologic liver activity typically has a
maximum standardized uptake value range of 5 to7.
E. The liver usually appears more heterogeneous when a
patient is scanned with the arms up as opposed to
when the scan is performed with the arms down.
Review Answer 45

46. Regarding FDG PET imaging for medullary thyroid
cancers (MTC), which one of the following choices is
TRUE?
A. Serum tumor markers are useful to predict FDG PET
positivity.
B. Medullary thyroid lesions are typically aggressive
lesions with intense FDG uptake.
C. An 111-Indium pentetreotide scan is more sensitive
than FDG PET for detecting recurrent MTC.
D. Sensitivity of FDG PET/CT for MTC is higher in
patients with MEN IIA than in patients with MEN IIB
or sporadic MTC.
Review Answer 46

47. In patients with squamous cell carcinoma involving the
head and neck region, what is the accepted OPTIMAL
time interval between completion of chemoradiation and
evaluation of response to therapy and restaging using
FDG PET/CT?
A. 1–2 weeks
B. 2–3 weeks
C. 4–6 weeks
D. 8–12 weeks
Review Answer 47

48. In Hodgkin lymphoma, when interpreting a PET/CT
performed after chemotherapy, the National
Comprehensive Cancer Network (NCCN) recommends
using which ONE of following PET imaging criteria to
assess treatment response and determine further
treatment options?
A. PET response evaluation in solid tumors
B. International Working Group response criteria
C. Standardized uptake value criteria
D. Deauville PET criteria
Review Answer 48

49. The HIGHEST normal tissue concentration of FDG, as
measured by standardized uptake value, is in which one
of the following?
A. Pancreas
B. Spleen
C. Liver
D. Brain
Review Answer 49

50. When entering the patient information in the PET/CT
scanner computer, the technologist incorrectly enters
the patient body weight as 100 lbs, instead of 100 kg (1
kg = 2.2 lbs). Unaware of this mistake, the interpreting
radiologist measures the standardized uptake value
(SUV) of a lung tumor as 10.0. Which one of the
following is the CORRECT SUV of the lung tumor?
A. 2.2
B. 4.55
C. 12.2
D. 22.0
Review Answer 50

END OF QUESTION SECTION
ANSWER KEY
CPI PET/CT Special Edition
2014

1. B
2. C
3. C
4. A
5. C
6. D
7. C
8. C
9. D
10. C
11. A
12. B
13. D
14. C
15. D
16. D
17. C
18. C
19. C
20. B
21. C
22. A
23. B
24. A
25. B
26. A
27. D
28. D
29. B
30. C
31. B
32. B
33. C
34. D
35. B
36. A
37. C
38. A
39. C
40. C
41. C
42. A
43. C
44. E
45. A
46. A
47. D
48. D
49. D
50. D
RATIONALES AND
REFERENCES
Answer 1 is B.
Metastatic testicular carcinoma is the correct answer. The hypermetabolic
lesions shown in Figures 1-1, 1-2, 1-3, 1-4, and 1-5 correspond to right
inguinal and right external iliac nodal metastases on the side of prior
orchiectomy, a typical pattern of spread for testicular carcinoma.
Option A is not correct.
Option A is incorrect since a second primary malignancy solely on the right
side is less probable than metastatic disease.
Option C is not correct.
Option C is incorrect since none of the foci of increased uptake correspond to
uid density lesions on the corresponding CT scan.
Option D is not correct.
Option D is incorrect since no secondary signs of abscess, such as loculated
uid, air, or fat stranding are seen around the groin mass.
Review Question 1
Reference:
Reinhardt MJ, Müller-Mattheis VG, Gerharz CD, Vosberg HR, Ackermann R, Müller-Gärtner HW.
FDG PET evaluation of retroperitoneal metastases of testicular cancer before and after
chemotherapy. J Nucl Med. 1997:38:99-101.
Answer 2 is C.
Of the given choices, the most likely explanation for the ndings of a
hypermetabolic heterogeneously enhancing mass posterior to the bladder
(Figure 2-3) and a hypermetabolic right external iliac node (Figure 2-4), is
cervical cancer with right external iliac nodal metastasis.
The mass is located posterior to the urinary bladder and does not
communicate with the bladder itself, excluding a bladder diverticulum as the
explanation for the image ndings.
Option B is not correct.
The mass is located posterior to the bladder and does not involve the bladder
itself, making bladder cancer an unlikely explanation.
The mass is located in the midline posterior to the bladder and does not have
cystic features on the contrast-enhanced CT scan, making a cystic ovarian
neoplasm an unlikely explanation.
Review Question 2
Reference:
Son H, Kositwattanarerk A, Hayes MP, et al. PET/CT evaluation of cervical cancer: spectrum of
disease. RadioGraphics. 2010;30:1251-1268.
Answer 3 is C.
Crying infants and children can demonstrate high 18F-FDG uptake in
muscles of respiration, including diaphragms, abdominal oblique muscles,
and intercostal muscles.
Fig 3-1. Annotated. Chest/abdomen. 18F-FDG PET/CT. a)
Maximum intensity projection (MIP). Coronal plane. b) MIP.
Magnified image of abdomen. c) CT. Coronal plane. d) Fused
PET/CT. Coronal plane. Single arrows on all images point to
diaphragmatic crura. Double arrows on (a) point to
intercostal muscles.
High uptake in the diaphragmatic crura (single arrows on Figure 3-1,
annotated) can be mistaken for retroperitoneal lymphadenopathy or adrenal
metastases. Correlation with fused PET/CT images can assist in localizing
the diffusely increased FDG uptake to the diaphragmatic musculature and
excluding metastatic lesions.
Peritoneal metastases typically have corresponding soft tissue density
abnormalities seen on CT and have 18F-FDG uptake that is more irregular,
asymmetric, and nodular than would be seen with diffuse physiologic
diaphragmatic FDG uptake as shown in the test case.
High uptake in the diaphragmatic crura can be mistaken for adrenal
metastases. Correlation with fused PET/CT images can assist in localizing
the high FDG uptake to the diaphragmatic musculature and exclude adrenal
pathology. Respiratory motion artifact can prevent accurate co-registration of
PET and CT images.
Review Question 3
Reference:
Shammas A, Lim R, Charron M. Pediatric FDG PET/CT: physiologic uptake, normal variants, and
benign conditions. RadioGraphics. 2009;29:1467-1486.
Answer 4 is A.
The tumor in the left distal femur shows interval increase in the intensity and
extent of 18F-FDG uptake on the follow-up PET scan (Figure 4-2), indicating
tumor progression and poor response to therapy. Enlargement of the tumor
was subsequently con rmed by MRI.
Response to treatment would demonstrate an interval decrease in intensity
and extent of 18F-FDG uptake in the primary tumor.
There is new low-level diffuse uptake in the metaphyses of the left tibia,
which is due to increasing hyperemia of the left lower extremity, and is
unlikely due to metastatic disease.
The PET images show no metabolic abnormality in the lungs. Even if all
PET images show normal activity throughout the lungs, the corresponding
CT scan should be carefully inspected as small pulmonary metastases due to
sarcoma may be below the metabolic resolution of PET.
Review Question 4
References:
Bajpai J, Kumar R, Sreenivas V, et al. Prediction of chemotherapy response by PET/CT in
osteosarcoma: correlation with histologic necrosis. J Pediatr Hematol Oncol. 2011;33:e271-e278.
Caldarella C, Salsano M, Isgrò MA, Treglia G. The role of uorine-18- uorodeoxyglucose positron
emission tomography in assessing the response to neoadjuvant treatment in patients with
osteosarcoma. Int J Mol Imaging. 2012;2012:870301.
Cistaro A, Lopci E, Gastaldo L, Fania P, Brach Del Prever A, Fagioli F. The role of 18F-FDG PET/CT
in the metabolic characterization of lung nodules in pediatric patients with bone sarcoma. Pediatr
Blood Cancer. 2012;15;59:1206-1210.
Answer 5 is C.
With the exception of the left femur, Figure 5-1 shows normal sodium 18F-
uoride (18F- uoride) tracer uptake in all other regions of the skeleton. The
symmetric intense tracer uptake seen in the costochondral junctions of all
ribs and in the growth plates of the upper and lower extremities represents
normal costochondral and normal growth plate activity in a young child.
Osteogenic sarcoma, such as Ewing sarcoma or osteosarcoma, typically has a
high degree of uptake on 18F- uoride PET scan.
Recent fractures typically have a high degree of focal tracer uptake on an
18F- uoride PET scan. The patient described in this question was being
evaluated for possible nonaccidental trauma and plain radiographs showed a

left femur fracture. The 18F- uoride PET scan was performed to exclude
other sites of possible fracture.
Osteomyelitis typically has a high degree of uptake on 18F- uoride PET.
Review Question 5
References:
Drubach LA, Johnston PR, Newton AW, Perez-Rossello JM, Grant FD, Kleinman PK. Skeletal trauma
in child abuse: detection with 18F-NaF PET. Radiology. 2010;255:173-181.
Drubach LA, Sapp MV, Laf n S, Kleinman PK. 18F-NaF PET imaging of child abuse. Pediatr Radiol.
2008;38:776-779.
Answer 6 is D.
The 18F-FDG PET scan shows multiple foci of hypometabolism
corresponding to numerous T2-bright subcortical tubers on MRI. Tuberous
sclerosis complex (TSC) tubers are typically triangular in con guration, with
the apex pointed towards the ventricles. Tubers are thought to represent foci
of abnormal neuronal migration. They are typically hypometabolic on an 18F-
FDG PET scan, thus making it dif cult to pinpoint which tuber is most likely
to be the epileptogenic focus.
TSC tubers are typically hypometabolic on an 18F-FDG PET scan, thus
making it dif cult to pinpoint which tuber is most likely to be the
epileptogenic focus.
Metastatic lesions or abscesses typically cause prominent T2 edema
surrounding them on T2-weighted images. The test images displayed show
no edema surrounding the brain masses/tubers. The patient has no known
primary malignancy and no infectious signs or symptoms.
The nding of a single hyperintense focus on an ictal brain perfusion single-
photon emission computed tomography (SPECT) scan may guide the
neurosurgeon to remove the suspected epileptogenic focus. The SPECT
ndings should be correlated with results from electroencephalography,
MRI, and/or magnetoencephalography.
Review Question 6
References:
Desai A, Bekelis K, Thadani VM, et al. Interictal PET and ictal subtraction SPECT: sensitivity in the
detection of seizure foci in patients with medically intractable epilepsy. Epilepsia. Epub 2012 Oct 2.
Evans LT, Morse R, Roberts DW. Epilepsy surgery in tuberous sclerosis: a review. Neurosurg Focus.
2012;32:E5.
Horky LL, Treves ST. PET and SPECT in brain tumors and epilepsy. Neurosurg Clin N Am.
2011;22:169-184, viii.
Kim S, Mountz JM. SPECT imaging of epilepsy: an overview and comparison with 18F-FDG FDG
PET. Int J Mol Imaging. 2011;2011:813028.
Answer 7 is C.
Chest CT (Figure 7-1a) shows a dominant right upper lobe nodule which is
FDG-avid (Figure 7-1b). The mass was successfully biopsied. Fine-needle
aspiration cytology yielded moderately to poorly differentiated bronchogenic
adenocarcinoma. Right upper lobectomy showed a 1.7 cm moderately
differentiated (G2) adenocarcinoma with negative margins and lymph nodes
negative for malignancy. Left upper lobe wedge biopsy via minithoracotomy
showed pulmonary hamartoma and a focus of osseous metaplasia without
identifying any malignancy. As there is no role for adjuvant chemotherapy
for stage I nonsmall-cell lung cancer, surveillance chest CT protocol was
followed. Option C is correct because the right upper lobe FDG-avid process
is proven malignant by tissue sampling; no local regional disease or distant
metastasis is identi ed by FDG avidity, and contralateral subthreshold micro-
nodules showed no identi able malignancy at the time of surgical resection.
Option A is not correct because the sub-cm left-sided lung nodules are too
small to characterize by PET and renders them indeterminate and not
necessarily benign.
Option B is not correct because it is not possible to assign a malignant
histology prospectively based on the absence of FDG avidity in lung micro-
nodules.
Option D is not correct because the sub-cm–sized nodules in the left lung are
likely below the resolution of PET and, therefore, too small to characterize as
benign or malignant.
Review Question 7
Reference:
Field JK, Smith RA, Aberle DR, et al; IASLC CT Screening Workshop 2011 Participants. International
Association for the Study of Lung Cancer Computed Tomography Screening Workshop 2011 report.
J Thorac Oncol. 2012;7:10-19.
Answer 8 is C.
The maximum intensity projection PET image shows diffusely increased
FDG uptake in the major skeletal muscle groups throughout the body as well
as throughout the left ventricular myocardium.
Eating within several hours of FDG administration will result in an increase
in endogenous circulating insulin which, in turn, causes glucose and FDG to
move into skeletal and cardiac muscles.
An elevated blood glucose level may result in decreased sensitivity of FDG
PET for tumor detection due to competition between the injected FDG and
the patient’s elevated circulating blood glucose. Hyperglycemia alone will
not cause diffuse muscular uptake of FDG.
An in ltrated FDG dose may lead to a noisier image (due to fewer counts
delivered to the rest of the body) and may result in diffusely increased blood
pool activity (due to ongoing resorption of the in ltrated dose into the
vascular system). It will not result in preferential FDG uptake in muscles.
While vigorous exercise within 24 hours of the FDG injection can result in
high FDG uptake within skeletal muscles, the pattern of muscle uptake
typically has a more regional distribution with FDG uptake more prominent
in the major muscle groups used for the exercise performed.
Review Question 8
Reference:
Cohade C. Altered biodistribution on FDG PET with emphasis on brown fat and insulin effect. Semin
Nucl Med. 2010;40:283-293.
Answer 9 is D.
There is increased FDG uptake in the bilateral periclavicular, axillary,
cervical and thoracic paraspinal, and subcostal regions. This is a distribution
typical of FDG uptake in brown fat.
Brown fat is mitochondria rich, adrenergically mediated tissue that exists in
children and adults. High FDG uptake in brown fat is believed to be due to
nonshivering thermoregulation caused by sympathetic stimulation. FDG
uptake in brown fat can be suppressed with varying degrees of success by
administering a benzodiazepine or beta blocker to the patient prior to the
FDG injection.
The distribution of FDG uptake seen is typical of uptake within brown fat. In
clinical practice, the CT portion of PET/CT would be examined and this
would con rm the location of the FDG-avid foci is within fat and not related
to any soft tissue abnormality.
A nonfasting state would shift FDG into skeletal muscle. In particular,
activity would be prominent in major muscle groups throughout the body.
Recent exercise would cause increased activity in the muscles groups that
were stressed.
Review Question 9
Reference:
Nucl Med. 2010;40:283-293.
Answer 10 is C.
In addition to the focal FDG uptake in the sacral lesion (Figure 10-2), there is
ill-de ned FDG uptake corresponding to a linear soft tissue density
extending from the posterior right pelvic skin surface towards the right
sacrum (Figure 10-4). The linear morphology of this lesion is consistent with
in ammation along the course of a biopsy tract, which was used to make the
histologic diagnosis of the right sacral metastasis.
The CT does not show extraosseous extension of the tumor. Extraosseous
extension would not have a linear morphology.
Abscesses usually do not have a linear morphology.
The lesion does not conform to the location of a muscle.
Review Question 10
Reference:
Bhargava P, Zhuang H, Kumar R, Charron M, Alavi A. Iatrogenic artifacts on whole-body 18F-FDG

PET imaging. Clin Nucl Med. 2004;29:429-439.
Answer 11 is A.
The images show diffusely increased FDG uptake symmetrically in the deep
and super cial soft tissue margins of the bilateral ap breast reconstructions.
In the early months following surgery, FDG-avid soft tissue in ammation in
and adjacent to the surgical bed is an expected nding. In this case there is
diffuse soft tissue in ammation in the chest wall bilaterally following
mastectomies and breast reconstruction surgery.
It would be unusual for residual malignancy to be seen following
mastectomy.
Following mastectomy, there is no residual breast tissue for mastitis to occur.
There are no CT ndings to suggest a postsurgical abscess. It would be
unusual for a postsurgical infection to be bilateral as well as at both the deep
and super cial margins of the aps.
Review Question 11
Reference:
Bakheet SM, Powe J, Kandil A, Ezzat A, Rostom A, Amartey J. 18F-FDG uptake in breast infection
and in ammation. Clin Nucl Med. 2000;25:100-103.
Answer 12 is B.
The images shown in Figures 12-2 and 12-3 show mild diffusely increased
FDG uptake in the lungs and ill-de ned ground-glass opacities on CT. The
ndings are most suggestive of posttreatment pneumonitis.
Several chemotherapeutics may induce posttreatment pneumonitis, including
bleomycin, paclitaxel, and pralatrexate.
There is no pulmonary opacity on CT to suggest lymphoma. Furthermore, it
would be very unusual for a new area of lymphoma to develop given the
excellent response of the original lymphoma to chemotherapy.
There is no pulmonary opacity on CT; therefore, there is no imaging
evidence of primary pulmonary malignancy.
There is no pulmonary opacity on CT; therefore, there is no evidence to
suggest a focal pneumonia.
Review Question 12
Reference:
Connerotte T, Lonneux M, de Meeûs Y, et al. Use of 2-[18F] uoro-2-deoxy-D-glucose positron

emission tomography in the early diagnosis of asymptomatic bleomycin-induced pneumonitis. Ann
Hematol.2008;87:943-945.
Answer 13 is D.
The serpentine morphology of the FDG-avid lesions, as well as their location
at the end of long bones, is consistent with bone infarcts. The bone infarcts
are probably secondary to steroid usage in the test patient. Bone infarcts may
be FDG-avid.
Metastases would not be serpentine in morphology.
Multifocal osteomyelitis would be unusual after chemotherapy. Furthermore,
their avidity would not appear serpentine.
Growth plates would be linear in morphology.
Review Question 13
Reference:
Grigolon MV, Delbeke D. 18F-FDG uptake in a bone infarct: a case report. Clin Nucl Med.
2001;26:613-614.
Answer 14 is C.
The peripheral calci cation with central lucency is consistent with
heterotopic ossi cation. Heterotopic ossi cation is often the result of prior
trauma. Heterotopic ossi cation may be FDG-avid.
It would be usual for a new area of lymphoma to present as a calci ed mass.
Extraosseous osteogenic sarcoma normally has greater ossi cation centrally.
Thoracic radiation therapy should not induce a pelvic sarcoma.
There is no evidence of a fracture on the corresponding CT.
Review Question 14
Reference:
Deryk S, Goethals L, Vanhove C, et al. Imaging characteristics of heterotopic mesenteric ossi cation
on FDG PET and Tc-99m bone SPECT. Clin Nucl Med. 2008;33:496-499.
Answer 15 is D.
The degree of 18F- uoride uptake does not help distinguish between
malignant and benign lesions. The location and pattern of 18F- uoride uptake
are important, and the addition of CT greatly increases the speci city of 18F-
uoride PET imaging. The test patient has an 18F- uoride–avid sclerotic
metastatic lesion of the right superior acetabulum and 18F- uoride–avid
degenerative disc disease in the lower lumbar spine as seen on the CT
images.
The increased 18F- uoride uptake in the lower lumbar spine corresponds on
the CT images to degenerative disc disease. The focal uptake present in the
right hip corresponds on the CT images to a sclerotic lesion, consistent with
a metastasis.
The increased 18F- uoride activity in the lower lumbar spine corresponds to
degenerative disc disease seen on the CT images. The focal increased 18F-
uoride activity in the right hip corresponds to a sclerotic lesion seen on CT
in the right superior acetabulum, consistent with a metastasis and not
osteoarthritis.
The 18F- uoride uptake in the lower lumbar spine is due to degenerative disc
disease. However, the focal 18F- uoride activity in the right hip corresponds
on CT to a sclerotic metastasis and not osteoarthritis.
Review Question 15
Reference:
Society of Nuclear Medicine and Molecular Imaging Website. SNM Practice Guideline for Sodium
18
F-Fluoride PET/CT Bone Scans 1.1.
http://interactive.snm.org/docs/Practice%20Guideline%20NaF%20PET%20V1.1.pdf
Answer 16 is D.
Richter transformation refers to indolent lymphomas, such as chronic
lymphocytic leukemia (CLL) transforming to a higher grade lymphoma,
most often diffuse large B-cell type. It can be suspected clinically when there
is rapid lymph node enlargement, clinical presentation of B symptoms (fever
>38C, night sweats, and weight loss), and elevated lactate dehydrogenase.
PET/CT is helpful in con rming the suspected clinical diagnosis by showing
marked hypermetabolic activity at the transformed nodal sites which is in
contrast to the low-grade metabolic activity noted at the sites of the indolent
lymphoma such as in the axillae of the test patient (Figure 16-4). PET/CT
can also help choose the best biopsy site for tissue con rmation.
Recurrent CLL is incorrect because of the much greater intensity of 18F-FDG
uptake of this nodal mass, in contrast to the low-grade metabolic activity of
the other nodal groups involved with CLL.
There is no evidence of an abscess collection on the correlative CT images.
The mass is solid.
Given the clinical context of a history of CLL with an enlarging markedly
hypermetabolic neck nodal mass, Richter transformation is the most likely
diagnosis.
Review Question 16
Reference:
Cronin CG, Swords R, Truong MT, et al. Clinical utility of PET/CT in lymphoma. AJR Am J
Roentgenol. 2010;194:W91-W103.
Answer 17 is C.
The anatomic size of the mediastinal mass has signi cantly decreased on the
posttherapy scan with the residual mass showing no signi cant increased
metabolic activity compared to background mediastinal blood pool activity,
indicating no residual active lymphoma. The diffuse increased marrow
activity represents reactive marrow change from granulocyte colony-
stimulating factor treatment.
The residual anterior mediastinal mass shows no signi cant metabolic
activity above background mediastinal blood pool activity and, therefore,
should be considered consistent with NO active lymphoma.
The anatomic size of the mediastinal mass has signi cantly decreased on the
posttherapy scan with the residual mass showing no signi cant increased
metabolic activity compared to background mediastinal blood pool activity,
indicating no residual active lymphoma.
There is no active mediastinal lymphoma. However, the diffuse increased
marrow activity represents reactive marrow change, not lymphomatous
involvement of bone.
Review Question 17
Reference:
Juweid ME, Stroobants S, Hoekstra OS, et al. Use of positron emission tomography for response
assessment of lymphoma: consensus of the Imaging Subcommittee of International Harmonization
Project in Lymphoma. J Clin Oncol. 2007;25:571-578.
Answer 18 is C.
Focal FDG uptake is noted incidentally within the thyroid. It should be
considered highly suspicious for a malignant primary thyroid neoplasm. The
likelihood of this nding being malignant is approximately 30%–40% with
some studies reporting even higher percentages. The most common
malignancy associated with focal FDG-avid thyroid uptake is papillary
thyroid carcinoma. Because of the relatively high risk of malignancy of the
nding, further investigation with ultrasound and biopsy of the lesion are
recommended.
Options A, B, and D are not correct.
The remaining answer options do not represent the correct percent likelihood
of malignancy for an incidentally noted FDG-avid thyroid nodule.
Review Question 18
Reference:
Treglia G, Bertagna F, Sadeghi R, Verburg FA, Ceriani L, Giovanella L. Focal thyroid incidental uptake
detected by 18F- uorodeoxyglucose positron emission tomography. Meta-analysis on prevalence
and malignancy risk. Nuklearmedizin. 2013;52:130-136.
Answer 19 is C.
There is a hypermetabolic left cervical lymph node which is a level V neck
node. In imaging-based nodal classi cation, level V nodes are the posterior
triangle nodes. They are located posterior to the back of the
sternocleidomastoid muscle from the skull base to the level of the clavicles.
FDG PET/CT has the potential to detect regional lymph node metastases in
normal-sized nodes. FDG PET/CT has high sensitivity (84%–92%) and
speci city (95%–99%) for detection of lymph node metastases in head and
neck cancer.
Level III nodes are the midjugular nodes, located from the inferior border of
the hyoid bone to the level the cricoid arch. These lie anterior to the back of
the sternocleidomastoid muscle.
Level IV nodes are the low jugular nodes, located from the inferior border of
the cricoid arch to the level of the clavicle. These lie anterior to the back of
the sternocleidomastoid muscle and the posterolateral margin of the anterior
scalene muscle.
Level VI nodes are the visceral nodes, located between the carotid arteries
from the level of the inferior border of the body of hyoid bone to the superior
border of the manubrium.
Review Question 19
Reference:
Saindane AM. Pitfalls in the staging of cervical lymph node metastasis. Neuroimaging Clin N Am.
2013;23:147-166.
Answer 20 is B.
The axial fused PET/CT image (Figure 20-1) demonstrates absent FDG
uptake in the right vocal cord, corresponding to right vocal cord paralysis
with increased FDG uptake corresponding to increased muscle activity
within the normal left vocal cord. These ndings are typical for a right vocal
cord paralysis due to injury of the recurrent laryngeal nerve. This nding
should not be mistaken for abnormal FDG uptake secondary to malignancy.
To avoid misdiagnosis in such cases, the nding should be correlated with
clinical features of vocal cord paralysis.
Absent activity in the right vocal cord indicates right-sided vocal cord
paralysis; therefore, left vocal cord paralysis is incorrect.
While vocal cord malignancy can have high FDG uptake, this would be
unlikely given the absent activity in the right vocal cord and diffuse normal-
appearing activity in the left vocal cord.
Markedly asymmetric vocal cord activity is not a normal nding on FDG
PET.
Review Question 20
Reference:
Vachha B, Cunnane MB, Mallur P, Moonis G. Losing your voice: etiologies and imaging features of
vocal fold paralysis. J Clin Imaging Sci. 2013;3:15.
Answer 21 is C.
Figure 21-1 shows markedly decreased FDG uptake throughout the bilateral
parietal, temporal and occipital cortex sparing the medial occipital cortex.
This pattern of abnormal glucose metabolism would be consistent with
dementia due to Alzheimer, Lewy body disease, or Parkinson, but would
NOT represent frontotemporal dementia given the normal FDG uptake seen
throughout the bilateral frontal cortex. In frontotemporal dementia, FDG
PET shows decreased FDG uptake in the frontal and/or temporal lobes.
In Alzheimer dementia, FDG PET typically shows decreased FDG uptake in
the cortices of both parietal and/or temporal lobes. In more advanced stages
of Alzheimer disease, decreased FDG uptake may spread to the occipital and
frontal regions as well, but with sparing of the sensorimotor and primary
visual cortex.
In dementia with Lewy bodies, FDG PET ndings are similar to those of
Alzheimer disease, ie, parietal and/or temporal hypometabolism, but also
with additional reduction of FDG uptake in the occipital cortices.
Dementia due to Parkinson disease is a type of Lewy body dementia with the
clinical signs of dementia not occurring until a year or more after the
diagnosis of Parkinson disease. FDG PET ndings in dementia due to
Parkinson disease are similar to those in Alzheimer disease (parietal and/or
temporal hypometabolism) but with additional reduction of FDG uptake in
the occipital cortices.
Review Question 21
Reference:
Silverman DH. Brain 18F-FDG PET in the diagnosis of neurodegenerative dementias: comparison with
perfusion SPECT and with clinical evaluations lacking nuclear imaging. J Nucl Med. 2004;45:594-
607.
Answer 22 is A.
Granulocyte colony-stimulating factor (G-CSF) stimulates the bone marrow
to produce more white blood cells and is commonly administered to patients
during chemotherapy for lymphoma and other types of cancer. G-CSF
decreases the incidence of chemotherapy-induced febrile neutropenia and
helps patients tolerate their chemotherapy. On PET scans performed during
G-CSF therapy, most patients will have a scan pattern of diffusely increased
FDG uptake in the bone marrow (greater than or equal to liver) and a large
portion of these patients will also have diffusely increased FDG uptake in the
spleen (greater than or equal to liver).
Erythropoietin (EPO) administration has been reported to cause diffuse FDG
uptake in the bone marrow. Diffuse splenic FDG uptake during EPO
administration has not been reported.
Following completion of chemotherapy, rebound marrow hyperplasia can
cause diffuse FDG uptake in the bone marrow. Diffuse splenic FDG uptake
as a postchemotherapy rebound effect is not commonly seen.
Anemia can cause reactive marrow hyperplasia resulting in diffuse FDG
uptake in the bone marrow. Diffuse splenic FDG uptake in patients with
anemia is not commonly seen.
Review Question 22
References:
Sugawara Y, Fisher SJ, Zasadny KR, Kison PV, Baker LH, Wahl RL. Preclinical and clinical studies of
bone marrow uptake of uorine-1- uorodeoxyglucose with or without granulocyte colony-
stimulating factor during chemotherapy.J Clin Oncol. 1998;16:173-180.
Sugawara Y, Zasadny KR, Kison PV, Baker LH, Wahl RL. Splenic uorodeoxyglucose uptake
increased by granulocyte colony-stimulating factor therapy: PET imaging results. J Nucl Med.
1999;40:1456-1462.
Answer 23 is B.
The most likely cause of the FDG-avid lesions seen in the left axilla is an
unrelated in ammatory adenopathy. In this case, the adenopathy was due to
an H1N1 vaccination administered intramuscularly in the left deltoid muscle
3 days prior to the PET/CT exam. The maximum intensity projection image
(Figure 23-1) shows not only the FDG-avid adenopathy in the left axilla, but
also shows a small focus of activity in the left upper arm, which was the site
of vaccine injection in the left deltoid muscle.
Recent vaccinations can result in FDG uptake at the injection site and within
regional lymph nodes. The regional lymph nodes are typically normal-sized
or borderline enlarged on CT.
A second primary neoplastic process originating in the left axilla in a patient
with a right lung neoplasm invading the chest wall would be a rare
occurrence and is not the most likely cause of the left axillary ndings.
An isolated distant site of metastasis in the left axilla would be an unusual
presentation in a patient with otherwise locally con ned right lung cancer
with no other sites of suspected metastatic disease.
Dose in ltration can result in FDG uptake within the draining sentinel lymph
nodes on the side of injection. The lymph nodes are typically not enlarged
and FDG uptake may be seen within lymphatic vessels draining away from
the injection.
Review Question 23
References:
Panagiotidis E, Exarhos D, Housianakou I, Bournazos A, Datseris I. FDG uptake in axillary lymph
nodes after vaccination against pandemic (H1N1). Eur Radiol. 2010;20:1251-1253.
Thomassen A, Lerberg Nielsen A, Gerke O, Johansen A, Petersen H. Duration of 18F-FDG avidity in

lymph nodes after pandemic H1N1v and seasonal in uenza vaccination. Eur J Nucl Med Mol
Imaging. 2011;38:894-898.
Answer 24 is A.
The differential diagnosis would NOT include lymphoma transformation.
Lymphoma transformation refers to the transformation from a slow-growing
indolent type lymphoma, such as chronic lymphocytic leukemia or follicular
lymphoma, into a more aggressive type lymphoma such as diffuse large B-
cell lymphoma. The type of lymphoma shown in this test case was diffuse
large B-cell lymphoma, an aggressive type of lymphoma that would be
unlikely to undergo transformation to another type of lymphoma.
In this case, the abnormality is focally FDG-avid and located at the site of the
test patient’s primary mediastinal lymphoma. As a result, the decision was
made to undergo sternotomy with limited surgical excision of the residual
anterior mediastinal mass. Pathology revealed normal thymic tissue and
adjacent areas of brosis, with no residual lymphoma. Follow-up PET/CT 3
months later with no further treatment (Figure 24-2) showed no active
disease in the mediastinum. FDG-avid postsurgical changes were
incidentally noted at the sternotomy site. The follow-up ndings con rm that
there was no residual active lymphoma in the mediastinum.
Fig 24-2. Mediastinum. PET/CT. Follow-up scan 3 months
after Figure 24-1. a) Maximum intensity projection.Axial
plane. b) Maximum intensity projection. Coronal plane. c) CT.
Axial plane. d) PET/CT. Axial plane. The poststernotomy
follow-up scan shows resolution of the hypermetabolic
activity in the mediastinum. Intense linear FDG uptake in the
sternum is due to recent sternotomy. No further treatment is
necessary.
FDG-avid hyperplastic thymic tissue is commonly seen in children and
young adults in the early months following completion of chemotherapy. As
the thymus normally involutes with aging, the morphologic appearance of
thymic hyperplasia can be quite variable ranging from homogeneous and
curvilinear, to heterogenous, patchy, asymmetric, and focal.
In one retrospective study, the most common pattern of physiologic thymic
FDG uptake seen on post-chemotherapy PET scans was an inverted V-shaped
FDG-avid anterior mediastinal mass seen in 60% of patients, with
asymmetric unilateral mediastinal extension in 24%, and focal midline
mediastinal uptake in 16% of patients. In this study, the average maximum
standardized uptake value of thymic FDG uptake was 3.73 +/- 1.22.
Options B, C, and D are all possible
explanations.
Review Question 24
Reference:
Jerushalmi J, Frenkel A, Bar-Shalom R, Khoury J, Israel O. Physiologic thymic uptake of 18F-FDG in

children and young adults: a PET/CT evaluation of incidence, patterns, and relationship to
treatment. J Nucl Med. 2009;50:849-853.
Answer 25 is B.
The images show an FDG-avid left intraparotid mass. As an incidental
nding on PET/CT, the most likely etiology of the FDG-avid intraparotid
mass as seen in Figure 25-1 is a benign intraparotid neoplasm, such as
Warthin tumor or pleomorphic adenoma.
A benign reactive intraparotid lymph node can have this appearance on
PET/CT but is not the most common cause of this incidental nding.
Primary parotid carcinoma can have this appearance on PET/CT but is a rare
malignancy and is not the most common cause of this incidental nding.
An intraparotid metastasis can have this appearance on PET/CT but would be
unlikely in this patient with early stage lung cancer.
Review Question 25
References:
Lee SK, Rho BH, Won KS. Parotid incidentaloma identi ed by combined 18F- uorodeoxyglucose
whole-body positron emission tomography and computed tomography: ndings at grayscale and
power Doppler ultrasonography and ultrasound-guided ne-needle aspiration biopsy or core-needle
biopsy. Eur Radiol. 2009;19:2268-2274.
Wang HC, Zuo CT, Hua FC, et al. Ef cacy of conventional whole-body FDG PET/CT in the incidental
ndings of parotid masses. Ann Nucl Med. 2010;24:571-577.
Answer 26 is A.
Figure 26-1 shows an FDG-avid pituitary lesion. As an incidental nding on
PET/CT, the most likely etiology of this FDG avid lesion is a benign
pituitary adenoma. Further evaluation with pituitary MRI should be
considered.
A pituitary metastasis can have this appearance on PET/CT but is a rare site
of metastasis and is not the most common cause of this incidental nding.
Primary pituitary carcinoma can have this appearance on PET/CT but is a
rare malignancy and is not the most common cause of this incidental nding.
The normal pituitary has no visible FDG uptake on PET/CT.
Review Question 26
Reference:
Hyun SH, Choi JY, Lee KH, Choe YS, Kim BT. Incidental focal 18F-FDG uptake in the pituitary
gland: clinical signi cance and differential diagnostic criteria. J Nucl Med. 2011;52:547-550.
Answer 27 is D.
An indeterminate adrenal nodule that has FDG uptake greater than the
mediastinal background but less than or equal to the liver background has a
high likelihood of representing a benign adrenal neoplasm. In a recent series
of 105 patients with adrenal nodules measuring at least 1 cm in size, the
correct diagnosis of malignancy was made with a sensitivity of 80% and
speci city of 97% using this visual assessment criteria.
Options A, B, and C are not correct.
The remaining answer choices are all established PET criteria for
characterizing an adrenal nodule as likely malignant.
Review Question 27
Reference:
Evans PD, Miller CM, Marin D, et al. FDG-PET/CT characterization of adrenal nodules: diagnostic
accuracy and interreader agreement using quantitative and qualitative methods. Acad Radiol.
2013;20:923-929.
Answer 28 is D.
18F-FDG uptake in the normal adrenal glands of children and adults is low,
ie, less than or equal to that of the liver. Adrenal hyperplasia can have high
FDG uptake (greater than liver), but is typically a bilateral process resulting
in symmetric diffuse FDG-avid adrenal enlargement seen on CT.
The thymus is a triangular-shaped organ in the anterior mediastinum that
typically has diffusely increased FDG uptake (liver or greater) in children.
Within 1 to 2 months following completion of chemotherapy, a high degree
of FDG uptake in the thymus is likely due to rebound thymic hyperplasia.
Waldeyer ring is the ring of lymphoid tissue in the nasopharynx and
oropharynx that includes the adenoid, palatine, pharyngeal, and lingual
tonsils. It peaks in size at 6 to 8 years of age and is normally seen on PET/CT
with moderate-to-intense physiologic levels of FDG uptake.
The physes are the site of active bone growth in skeletally immature patients
and normally have a high level of physiologic FDG uptake.
Option E is not correct.
High FDG uptake in brown adipose tissue is more frequently seen in children
than in adults.
Review Question 28
Reference:
Shammas A, Lim R, Charron M. Pediatric FDG PET/CT: physiologic uptake, normal variants, and
benign conditions. RadioGraphics. 2009;29:1467-1486.
Answer 29 is B.
One common technique to reduce hypermetabolic brown adipose tissue in
children is to warm the patient prior to injecting FDG by using extra
clothing, heating blankets, and/or raising the ambient temperature of the
patient injection/uptake room. Other commonly used techniques include
administration of oral and intravenous medications, such as diazepam,
alprazolam, fentanyl, and propranolol. These medications have
antiadrenergic properties and, when given prior to the FDG injection, can
help reduce the uptake of FDG in brown adipose tissue.
Hypermetabolic brown adipose tissue is more commonly seen in children
and adolescents than in adults. Prevalence of hypermetabolic brown adipose
tissue on PET scans has been reported as 1.3%–1.9% in adults and 15%–
50% in children.
Hypermetabolic brown adipose tissue can be seen in the upper abdomen,
most commonly in the perinephric, perihepatic, and midline anterior
abdominal wall regions.
In warm weather conditions, patients may commonly be exposed to cool
temperatures from air-conditioning, which can result in high FDG uptake in
brown adipose tissue.
Review Question 29
Reference:
Hong TS, Shammas A, Charron M, Zukotynski KA, Drubach LA, Lim R. Brown adipose tissue 18F-
FDG uptake in pediatric PET/CT imaging. Pediatr Radiol. 2011;41:759-768.
Answer 30 is C.
Mesenchymal hamartoma comprises approximately 8% of all pediatric
tumors, making it the second most common pediatric liver tumor after
hepatoblastoma. Eighty percent are found within the rst 2 years of life and
the remainder are detected by 5 years of age. Typically, it presents as a large
benign multicystic liver mass. However, its imaging characteristics are
variable, ranging from a few large cysts to a solid mass occupying one or
both lobes of the liver. The use of 18F-FDG PET in the evaluation of pediatric
mesenchymal hamartoma has not been described in published literature.
Preliminary data in Wilms tumor suggest FDG uptake may correlate with the
degree of histological differentiation (the higher the FDG uptake the more
dedifferentiated), may help differentiate benign nephrogenic rests and
nephroblastomatosis from Wilms tumor, may be useful to detect additional
sites of disease, and may help direct biopsy site or guide surgical planning.
18F-FDG PET can be used to con rm and measure avidity of primary brain
tumors, locate metastases, identify best site for biopsy, monitor response to
therapy, locate residual tumor, and monitor for tumor recurrence. It can also
be used to differentiate recurrent/residual tumor from radiation necrosis,
other posttreatment changes (eg, edema, gliosis), and infection (eg,
toxoplasmosis).
18F-FDG PET is more sensitive than the skeletal survey for identifying active
Langerhans cell histiocytosis lesions, and it can be used in patients receiving
chemotherapy to assess response to therapy.
In neuroblastoma patients, 18F-FDG PET has been found to be superior to
metaiodobenzylguanidine (MIBG) imaging for evaluating soft tissues and
extracranial skeletal lesions.
Review Question 30
References:
Binkovitz LA, Olshefski RS, Adler BH. Coincidence FDG PET in the evaluation of Langerhans’ cell
histiocytosis: preliminary ndings. Pediatr Radiol. 2003;33:598-602.
Kaste SC. Oncological imaging: tumor surveillance in children. Pediatr Radiol. 2011;41:505-508.
Kushner BH, Yeung HW, Larson SM, Kramer K, Cheung NK. Extending positron emission
tomography scan utility to high-risk neuroblastoma: uorine-18 uorodeoxyglucose positron
emission tomography as sole imaging modality in follow-up of patients. J Clin Oncol.
2001;19:3397-3405.
Sharp SE, Shulkin BL, Gelfand MJ, Salisbury S, Furman WL. 123I-MIBG scintigraphy and 18F-FDG
PET in neuroblastoma. J Nucl Med. 2009;50:1237-1243.
Siddiqui MA, McKenna BJ. Hepatic mesenchymal hamartoma: a short review. Arch Pathol Lab Med.
2006;130:1567-1569.
Stringer MD, Alizai NK. Mesenchymal hamartoma of the liver: a systematic review. J Pediatr Surg.
2005;40:1681-1690.
Weckesser M. Molecular imaging with positron emission tomography in paediatric oncology--FDG
and beyond. Pediatr Radiol. 2009;39:450-455.
Answer 31 is B.
Nonbacterial brain infections, such as toxoplasmosis and fungal infection,
typically demonstrate low-level FDG uptake.
Juvenile pilocytic astrocytoma typically has high FDG uptake.
Medulloblastoma typically has high FDG uptake.
Brain metastases typically has high FDG uptake.
Choroid plexus papilloma typically has high FDG uptake.
Review Question 31
Reference:
Kim S, Salamon N, Jackson HA, Blüml S, Panigrahy A. PET imaging in pediatric neuroradiology:
current and future applications. Pediatr Radiol. 2010;40:82-96.
Answer 32 is B.
Estimates of whole-body radiation dose from 555 MBq (15 mCi) of FDG fall
into the 5–10 mSv range, making answer Option B the best answer.
Options A, C, and D are not correct.
Review Question 32
Reference:
Hays MT, Watson EE, Thomas SR, Stabin M. MIRD dose estimate report no. 19: radiation absorbed
dose estimates from 18F-FDG. J Nucl Med. 2002;43:210-214.
Answer 33 is C.
The radiation dose to a patient is exponentially related to the tube voltage.
Increasing the tube voltage will increase the radiation dose to the patient if
other parameters are held the same.
Radiation dose and pitch are inversely proportional. Increasing the pitch will
decrease the radiation dose to the patient if other parameters are held the
same.
Radiation dose is linearly proportional to the tube current. Decreasing the
tube current by 50% will decrease the radiation dose by 50% if other
parameters are held the same.
Radiation dose and gantry rotation speed are inversely proportional.
Increasing the gantry rotation speed will decrease the radiation dose to the
patient if other parameters are held the same.
Review Question 33
Reference:
McNitt-Gray MF. AAPM/RSNA physics tutorial for residents: topics in CT. Radiation dose in CT.
RadioGraphics. 2002;22:1541-1553.
Answer 34 is D.
Insulin will move FDG into skeletal muscle and potentially decrease activity
within a suspected tumor. This will lower the sensitivity of the scan for
detecting the primary tumor. Diabetic patients should not, however, undergo
extensive fasting.
Patients should discontinue insulin prior to an FDG PET scan. Insulin will
drive glucose and FDG into skeletal muscle and potentially decrease the
sensitivity of the examination.
Patients should discontinue insulin prior to an FDG PET scan.
Extended periods of fasting or withdrawal of insulin should be avoided in
diabetic patients.
Review Question 34
Reference:
Nucl Med. 2010;40:283-293.
Answer 35 is B.
FDG avidity by bone marrow after granulocyte colony-stimulating factor (G-
CSF) treatment remains higher than the baseline level for up to 4 weeks post
completion of G-CSF. The elevated marrow FDG uptake is sustained longer
than the period of blood neutrophil count elevation.
Increased FDG avidity in bone marrow following G-CSF is common for up
to 4 weeks, not 1 week.
to 4 weeks, not 1 year.
to 4 weeks, not inde nitely.
Review Question 35
Reference:
Sugawara Y, Fisher SJ, Zasadny KR, Kison PV, Baker LH, Wahl RL. Preclinical and clinical studies of
bone marrow uptake of uorine-18- uorodeoxyglucose with or without granulocyte colony-
stimulating factor during chemotherapy. J Clin Oncol. 1998;16:173-180.
Answer 36 is A.
Increased FDG uptake is often observed in the spleen during and after
granulocyte colony-stimulating factor (G-CSF) treatment. This change is less
frequent and not as marked as the change observed in the bone marrow.
G-CSF usage has not been associated with increased FDG avidity in the liver.
G-CSF usage has not been associated with increased FDG avidity in the
kidneys.
G-CSF usage has not been associated with increased FDG avidity in the
pancreas.
Review Question 36
Reference:
Sugawara Y, Zasadny KR, Kison PV, Baker LH, Wahl RL. Splenic uorodeoxyglucose uptake
increased by granulocyte colony-stimulating factor therapy: PET imaging results. J Nucl Med.
1999;40:1456-1462.
Answer 37 is C.
Bisphosphonate usage is associated with osteonecrosis of the jaw. CT
appearance may be sclerotic, lytic, or mixed lytic and sclerotic. The jaw
osteonecrosis may be FDG-avid.
Bisphosphonate usage has not been associated with pneumonia.
Bisphosphonate usage has not been associated with colitis.
Bisphosphonate usage has not been associated with hepatitis.
Review Question 37
Reference:
Morag Y, Morag-Hezroni M, Jamadar DA, et al. Bisphosphonate-related osteonecrosis of the jaw: a
pictorial review. RadioGraphics. 2009;29:1971-1984.
Answer 38 is A.
The literature shows that 18F- uoride PET bone scan has a higher sensitivity
than 99mtechnetium methylene diphosphonate (99mTc-MDP) bone scan in
detecting both osteoblastic and osteolytic lesions. The addition of CT greatly
improves its speci city in differentiating benign lesions from metastases.
Studies have shown that 18F- uoride imaging has a higher sensitivity than
conventional 99mTc-MDP bone scan in the detection of osteolytic lesions.
The effective radiation dose for 18F- uoride is 0.024 mSv/MBq (0.089
rem/mCi). For a standard imaging dose of 370 MBq (10 mCi) 18F- uoride,
the effective dose is 8.9 mSv (0.0089 rem). In comparison, the effective dose
for 99mTc-MDP is 0.0057 mSv/MBq (0.021 rem/mCi). For a standard dose of
925 MBq (25 mCi) 99mTc-MDP, the effective dose is 5.3 mSv (0.53 rem), or
approximately 70% lower than that for 18F- uoride.
18F- uoride is cleared more rapidly from the blood and incorporated almost
2 times faster into the bony matrix than is 99mTc-MDP. This results in a high
bone-to-soft tissue ratio and allows for a shorter time to image following
injection. Imaging can be performed as early as 30–45 minutes post injection
of 18F- uoride.
Review Question 38
References:
Even-Sapir E, Metser U, Flusser G, et al. Assessment of malignant skeletal disease: initial experience
with 18F- uoride PET/CT and comparison between 18F- uoride PET and 18F- uoride PET/CT. J
Nucl Med. 2004;45:272-278.
Schirrmeister H, Guhlmann A, Elsner K, et al. Sensitivity in detecting osseous lesions depends on
anatomic localization: planar bone scintigraphy versus 18F PET. J Nucl Med. 1999;40:1623-1629.
Smith GT. Society of Nuclear Medicine Website. 18F-Sodium Fluoride PET Imaging. Webinar
presented on July 13, 2010. http://webinars.snm.org/?meeting=8022110
Society of Nuclear Medicine and Molecular Imaging Website. SNM Practice Guideline for Sodium
18
F-Fluoride PET/CT Bone Scans 1.1.
http://interactive.snm.org/docs/Practice%20Guideline%20NaF%20PET%20V1.1.pdf.
Answer 39 is C.
18F- uoride is more sensitive than the conventional skeletal survey in the
detection of rib and spinal fractures in children of suspected nonaccidental
trauma. However, 18F-NaF PET has a lower sensitivity in the detection of the
classic corner metaphyseal fractures compared to skeletal radiographs,
reported in 1 study to be only approximately 70%. The sensitivity of 18F-NaF
PET is said to be approximately 2 times greater however than that reported
for radionuclide bone scintigraphy of metaphyseal corner fractures.
18F- uoride PET is highly sensitive in the detection of rib fractures, greater
than that of the conventional skeletal survey.
18F- uoride PET has a higher sensitivity than skeletal radiographs in the
detection of vertebral fractures.
18F- uoride PET is more sensitive than skeletal radiographs in the diagnosis
of spinous process fractures.
Review Question 39
Reference:
Drubach LA, Johnston PR, Newton AW, Perez-Rossello JM, Grant FD, Kleinman PK. Skeletal trauma
in child abuse: detection with 18F-NaF PET. Radiology. 2010;255:173-181.
Answer 40 is C.
Most subtypes of newly diagnosed lymphomas have reliably high 18F-FDG
avidity, including Hodgkin disease, diffuse large B-cell lymphoma, and
follicular lymphoma. Studies have shown that marginal zone/ mucosa-
associated lymphoid tissue (MALT) lymphoma and small lymphocytic
lymphoma, however, have lower 18F-FDG avidity.
Diffuse large B-cell lymphoma has high 18F-FDG avidity.
Follicular lymphoma has high 18F-FDG avidity.
Hodgkin lymphoma has high 18F-FDG avidity.
Review Question 40
Reference:
Weiler-Sagie M, Bushelev O, Epelbaum R, et al. 18F-FDG avidity in lymphoma readdressed: a study of

766 patients. J Nucl Med. 2010;51:25-30.
Answer 41 is C.
Initial staging PET/CT is usually not indicated in the indolent lymphomas as
those are usually considered incurable, with the main goal aimed to treat the
clinical manifestations of the disease.
Initial staging PET/CT is an appropriate indication for all curable
lymphomas, such as Hodgkin and diffuse large B-cell lymphoma.
Baseline PET/CT is an appropriate indication for diffuse large B-cell
lymphoma.
PET/CT is an appropriate indication for evaluation of low-grade, indolent
lymphoma when Richter transformation is suspected. PET/CT is helpful to
con rm the suspected transformation to a higher grade lymphoma and also
helps guide a suitable biopsy site.
Review Question 41
References:
Cronin CG, Swords R, Truong MT, et al. Clinical utility of PET/CT in lymphoma. AJR Am J
Roentgenol. 2010;194:W91-W103.
Podoloff DA, Advani RH, Allred C, et al. NCNN Task Force Report: Positron Emission Tomography
(PET)/Computed Tomography (CT) Scanning in Cancer. J Natl Compr Canc Netw. 2007;5:S1-S22.
Answer 42 is A.
Normal variant physiologic cardiac activity can be seen in all chambers of
the heart, typically with a diffuse or heterogeneous uptake pattern. Figure 42-
1 shows 2 common patterns of normal variant physiologic cardiac activity.
There is variable myocardial FDG uptake in the left ventricle depending on
whether the heart is primarily utilizing glucose or free fatty acids for its
source of energy. With a prolonged fast of greater than 12 hours, one would
expect the heart will be primarily utilizing free fatty acids for metabolism
and, therefore, have a relatively low level of FDG uptake.
Fig 42-1. Heart. Left to right: CT, PET, and fused PET-CT. Axial
plane. Images centered on the heart show 2 common normal
variant patterns of physologic myocardial FDG uptake. A)
Images show diffusely increased FDG uptake throughout all
walls of the left ventricular myocardium. B) Images
demonstrate diffusely increased FDG uptake primarily
confined to the lateral wall of the left ventricular
myocardium.
Focal cardiac activity can be seen as a normal variant in the interatrial
septum, the apex of the left ventricle, and in the atrial appendages. If focal
activity is seen in the heart, and not in a location of a normal physiologic
variant, further evaluation with MRI may be necessary to exclude cardiac
malignancy.
An FDG-avid mass in the wall of the lateral ventricle is not usually due to a
primary cardiac neoplasm. Metastases to the heart are much more common
than primary cardiac neoplasms (both benign and malignant). Metastases to
the heart were found in 1.23% of 12,485 consecutive autopsies, compared
with a 0.056% prevalence of primary cardiac neoplasms.
Lung cancer and lymphoma are the 2 most common tumors to metastasize to
the heart.
Review Question 42
References:
Lopaschuk GD, Ussher JR, Folmes CD, Jaswal JS, Stanley WC. Myocardial fatty acid metabolism in
health and disease. Physiol Rev. 2010;90:207-258.
Maurer AH, Burshteyn M, Adler LP, Steiner RM. How to differentiate benign versus malignant cardiac
and paracardiac 18F-FDG uptake at oncologic PET/CT. RadioGraphics. 2011;31:1287-1305.
Answer 43 is C.
Post radiation in ammatory changes from radiation-induced thermal injury
can last 18 months or longer. Radiation brosis starts to develop within 6–12
months after completion of radiation therapy and can progress for up to 2
years before stability occurs. Post radiation in ammatory changes can result
in focally increased uptake on PET/CT which can be dif cult to differentiate
from residual and recurrent malignancy. Serial PET/CT or CT scans may be
necessary to differentiate in ammatory changes from malignancy.
Post radiation in ammatory changes in the lungs from radiation-induced
thermal injury can last 18 months or longer. Radiation brosis starts to
develop within 6–12 months after completion of radiation therapy and can
progress for up to 2 years before stability occurs.
Post radiation in ammatory changes from radiation-induced thermal injury
can last 18 months or longer. Post radiation in ammatory changes can result
in focally increased uptake on PET/CT which can be dif cult to differentiate
from residual and recurrent malignancy. Serial PET/CT or CT scans may be
necessary to differentiate in ammatory changes from malignancy.
Radiation-induced esophagitis is a relatively common side effect in patients
who receive radiation therapy to the mediastinum or spine for lymphoma or
lung, esophageal or other cancers. The severity of radiation-induced
esophagitis can vary from mild esophagitis lasting a few days to weeks to
severe esophagitis with severe pain and dysphagia lasting months. The longer
duration and the greater intensity of the radiation treatment, the greater the
risk of radiation-induced esophagitis.
It is generally recommended to wait at least 3–6 months before performing
the initial restaging PET/CT scan to avoid false-positive results from post
radiation in ammatory changes. Serial follow-up imaging with PET/CT or
CT may still be necessary before residual or recurrent tumor can be
excluded.
Review Question 43
References:
Bruzzi JF, Munden RF. PET/CT imaging of lung cancer. J Thorac Imaging. 2006;21:123-136.
van Loon J, Grutters J, Wanders R, et al. Follow-up with 18FDG- PET/CT after radical radiotherapy
with or without chemotherapy allows the detection of potentially curable progressive disease in
nonsmall-cell lung cancer patients: a prospective study. Eur J Cancer. 2009;45:588-595.
Answer 44 is E.
Even though there is no CT correlate, a focus of intense FDG uptake in the
colon has a high likelihood of representing a premalignant or malignant
colonic neoplasm. Colonoscopy should be considered for further evaluation.
In one of the largest series addressing this issue in a database of 6,000
patients, focal colonic uptake was reported in 64 patients; 48 of whom
underwent colonoscopy for further evaluation. At colonoscopy, a malignant
or premalignant lesion was proven in 65% of the patients – 25% had a
malignant and 45% a premalignant histology.
colon has a high likelihood of representing a premalignant or malignant
colonic neoplasm. Colonoscopy should be considered for further evaluation.
As no additional sites of abnormal activity are seen, isolated metastatic
disease as the etiology of the focus of activity is unlikely.
colon should be considered suspicious for a premalignant or malignant
colonic neoplasm. Focal colonic in ammation or focal physiologic colonic
activity are also possible explanations for this nding. Colonoscopy should
be considered for further evaluation.
Metformin administration has been reported to cause diffusely increased
FDG uptake in both the large and small bowel. The mechanism of action for
intestinal FDG uptake in humans is not well understood. Metformin use is
not associated with an isolated focal area of increased bowel activity.
Review Question 44
References:
Gontier E, Fourme E, Wartski M, et al. High and typical 18F-FDG bowel uptake in patients treated with
metformin. Eur J Nucl Med Mol Imaging. 2008;35:95-99.
Treglia G, Calcagni ML, Ru ni V, et al. Clinical signi cance of incidental focal colorectal 18F-
uorodeoxyglucose uptake: our experience and a review of the literature. Colorectal Dis.
2012;14:174-180.
Answer 45 is A.
Normal physiologic liver activity is greater than both mediastinal blood pool
activity and splenic activity. Diffuse splenic activity greater than liver activity
can be seen with diffuse involvement of lymphoma, granulomatous disease,
and in patients who receive granulocyte colony-stimulating factor (G-CSF).
G-CSF does not result in increased liver activity.
Normal physiologic liver activity is greater than both mediastinal blood pool
activity and splenic activity. Diffuse splenic activity greater than liver activity
can be seen with diffuse involvement of lymphoma, granulomatous disease,
and in patients who receive G-CSF.
G-CSF does not result in increased liver activity.
G-CSF does not result in increased liver activity. Diffuse splenic activity
greater than liver activity can be seen with diffuse involvement of lymphoma,
granulomatous disease, and in patients who receive G-CSF.
Normal physiologic liver activity typically has a maximum standardized
uptake value (SUVmax) range of 1.6 to 3.6.
Having the patient’s arms down while imaging the body can result in a more
heterogeneous appearance of the liver, as CT is used for attenuation
correction and the added scatter that results from having the patient’s arms at
the side of the body can cause an apparent heterogenous FDG uptake in the
liver.
Review Question 45
Reference:
Sureshbabu W, Mawlawi O. PET/CT imaging artifacts. J Nucl Med Technol. 2005;33:156-161.
Answer 46 is A.
Detection rates of FDG PET/CT in medullary thyroid cancer (MTC) are
higher when the calcitonin level is >1000 ng/ml and when the
carcinoembryonic antigen level is >5 ng/ml.
Medullary thyroid lesions are typically indolent lesions with relatively low
FDG uptake. In 1 study, lesions due to MTC had an SUVmax ranging from a
low of 2 to a high of 7.
In several small series comparing the sensitivity of FDG PET to 111-Indium
pentetreotide scans, FDG PET had a higher sensitivity for detecting recurrent
MTC.
Sensitivity of FDG PET/CT for MTC in patients with MEN IIA syndrome is
signi cantly lower than in patients with sporadic MTC or MEN IIB.
Review Question 46
References:
Ong SC, Schöder H, Patel SG, et al. Diagnostic accuracy of 18F-FDG PET in restaging patients with
medullary thyroid carcinoma and elevated calcitonin levels. J Nucl Med. 2007;48:501-507.
Skoura E, Datseris IE, Rondogianni P, et al. Correlation between calcitonin levels and 18F-FDG
PET/CT in the detection of recurrence in patients with sporadic and hereditary medullary thyroid
cancer. ISRN Endocrinol. 2012; 2012:375231.
Answer 47 is D.
In head and neck cancer, most studies evaluating the sensitivity and
speci city of FDG PET/CT for evaluation of treatment response and
restaging post chemoradiation therapy show relatively high sensitivity and
speci city between 8–12 weeks. Compared to CT and MRI, FDG PET/CT is
the modality of choice for therapy assessment in head and neck squamous
cell carcinoma.
Radiologic surveillance after therapy allows for early and accurate detection
of recurrent disease, offering a survival bene t if the patient is a potential
candidate for surgery or re-radiation. The sensitivity of FDG PET/CT may be
compromised early after therapy as residual tumor deposits may be too small
to resolve on PET. Increased FDG uptake is not speci c for malignant cells
and can also occur in tissues in amed secondary to irradiation or surgical
manipulation.
The optimal time period after chemoradiation completion for evaluating FDG
PET/CT response to therapy and restaging is 8–12 weeks. One to 2 weeks is
too early and may not pick up residual tumor deposits.
Two to 3 weeks is too early for optimal analysis. Eight to 12 weeks is best.
Four to 6 weeks is too early for optimal analysis. Eight to 12 weeks is best.
Review Question 47
References:
Andrade RS, Heron DE, Degirmenci B, et al. Posttreatment assessment of response using FDG
PET/CT for patients treated with de nitive radiation therapy for head and neck cancers. Int J Radiat
Oncol Biol Phys. 2006;65:1315-1322.
Mori M, Tsukuda M, Horiuchi C, et al. Ef cacy of uoro-2-deoxy-D-glucose positron emission
tomography to evaluate responses to concurrent chemoradiotherapy for head and neck squamous
cell carcinoma. Auris Nasus Larynx. 2011;38:724-729.
Answer 48 is D.
The Deauville PET criteria is now part of the National Comprehensive
Cancer Network (NCCN) guidelines for use in response assessments of
Hodgkin lymphoma after 2 or 4 cycles of chemotherapy. The Deauville
criteria is a visual interpretation of the PET/CT scan using a 5-point scoring
system. Post chemotherapy PET scans are scored according to the degree of
FDG uptake in sites initially involved by lymphoma as: (1) no uptake; (2)
uptake less than or equal to mediastinum background; (3) uptake greater than
mediastinum but less than or equal to liver; (4) uptake moderately increased
above liver at any site; or (5) uptake markedly increased above liver at any
site. A score of 1–3 is regarded as negative and 4 or 5 as positive for the
presence of residual active lymphoma. In a recent international validation
study in 260 patients with advanced-stage Hodgkin lymphoma treated with a
standard chemotherapy regimen, the Deauville PET criteria had a negative
predictive value of 0.94 and a positive predictive value of 0.73. The 3-y
failure-free–survival was 95% for PET-negative and 28% for PET-positive
patients (P < 0.0001).
This criteria is not recommended by the NCCN for response assessment.
This criteria is not recommended by the NCCN for response assessment.
SUV measurements are not recommended by the NCCN for response
assessment.
Review Question 48
Reference:
Biggi A, Gallamini A, Chauvie S, et al. International validation study for interim PET in ABVD-
treated, advanced-stage Hodgkin lymphoma: interpretation criteria and concordance rate among
reviewers. J Nucl Med. 2013;54:683-690.
Answer 49 is D.
The brain has the highest normal tissue concentration of FDG. On average,
the gray matter of the brain has a standardized uptake value (SUV) that is
approximately 3 to 4 times the SUV of the normal liver. In one representative
study, the average SUV was 8.2 in the cerebellum, compared to average
SUVs of 1.5, 1.8, and 2.1 in the pancreas, spleen, and liver, respectively.
Because of the normally high concentration of FDG uptake in the brain, the
sensitivity of FDG PET to detect brain metastases may be severely
compromised.
The pancreas does not have the highest normal tissue concentration of FDG.
The spleen does not have the highest normal tissue concentration of FDG.
The liver does not have the highest normal tissue concentration of FDG.
Review Question 49
Reference:
Wang Y, Chiu E, Rosenberg J, Gambhir SS. Standardized uptake value atlas: characterization of
physiological 2-deoxy-2-18F uoro-D-glucose uptake in normal tissues. Mol Imaging Biol.
2007;9:83-90.
Answer 50 is D.
SUV is directly proportional to the patient body weight. If the technologist
incorrectly enters the patient weight in pounds instead of kilograms, all SUV
measurements will be falsely low by a factor of 1 / 2.2. In other words, the
actual SUV will be 2.2 times higher than the SUV obtained with the
incorrect body weight entered.
SUV normalized to the patient’s body weight (SUVbw) is the most common
semiquantitative measurement made on PET/CT. The SUVbw is the
concentration of activity in the tumor divided by the concentration of activity
in the entire body. In formula terms:
The SUVbw is directly proportional to the body weight. One kilogram (kg) is
equivalent to 2.2 pounds (lbs). Hence, in the test question scenario, the true
SUV would be 2.2 times higher than that obtained with the incorrect input of
100 lbs in a patient of 100 kg or 220 lbs.
The actual SUV is 2.2 times higher than the SUV obtained with the incorrect
body weight input.
The actual SUV is 2.2 times higher than the SUV obtained with the incorrect
body weight input.
Review Question 50
Reference:
Keyes JW Jr. SUV: standard uptake or silly useless value? J Nucl Med. 1995;36:1836-1839.

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