Bruzzi et al.

Nuclear Medicine • Original Research

PET/CT
Without
18F-FDG
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Accumulatio
n

A C E N T U
R Y O F Incidental Findings on
Integrated PET/CT That
MEDICAL IMAGING
Do Not Accumulate 18F-FDG
John F. Bruzzi1 OBJECTIVE. The purpose of this study was to report the prevalence of abnormalities that
Mylene T. Truong do not show increased 18F-FDG uptake on the CT component of integrated PET/CT in patients
Edith M. Marom with non–small cell lung cancer.
Osama Mawlawi MATERIALS AND METHODS. Images from all PET/CT studies performed consecu-
Donald A. Podoloff tively between April and October 2003 on patients with non–small cell lung cancer were retro-
spectively reviewed. All abnormalities present on the CT component of the PET/CT scans that
Homer A. Macapinlac
did not show abnormally increased 18F-FDG uptake were documented.
Reginald F. Munden
RESULTS. Three hundred twenty-one patients with non–small cell lung cancer (179 men,
Bruzzi JF, Truong MT, Marom EM, et al. 142 women; mean age, 67 years; age range, 38–91 years) underwent initial staging (198/321
[62%]) or restaging (123/321 [38%]) PET/CT imaging during the study period. In 263 (82%)
of the patients, CT showed 1,231 abnormalities that were not 18F-FDG avid. The abnormalities
were located in the thorax (n = 650), abdomen and pelvis (n = 444), head and neck (n = 69),
and bony skeleton (n = 68). In total, 298 (24%) of the abnormalities that were not 18F-FDG avid
were located outside the range of a standard thoracic CT scan. The clinical importance of these
abnormalities was classified as major (n = 48 [4%]), moderate (n = 465 [38%]), or minor
(n = 718 [58%]). Four (1%) of the patients had findings of major clinical importance that did
not show increased 18F-FDG uptake and were previously unsuspected.
CONCLUSION. Among patients with non–small cell lung cancer undergoing PET/CT,
there is a high prevalence of CT abnormalities that do not show correlative 18F-FDG avidity
but that may be clinically important.

he emergence of 18F-FDG PET as with routine lung cancer staging. Therefore

T an important functional imaging

technique has changed the man-
ner in which malignant diseases
are staged and followed. Routine PET com-
bines the information from emission scans
it is important that CT images be interpreted
in addition to PET images. The purpose of
our study was to report the prevalence of ab-
normalities that do not show increased
18F-FDG uptake on the CT component of in-

Keywords: CT, 18F- FDG PET, incidental abnormalities, lung
cancer, PET, PET/CT
DOI:10.2214/AJR.05.0712
Received April 26, 2005; accepted after revision
August 31, 2005.
1All authors: Department of Thoracic Imaging, M. D.
Anderson Cancer Center, 1515 Holcombe Blvd., Unit 0371,
Houston, TX 77030-4095. Address correspondence to
J. F. Bruzzi (john.bruzzi@di.mdacc.tmc.edu).
AJR 2006; 187:1116–1123
0361–803X/06/1874–1116
© American Roentgen Ray Society
obtained with 18F-FDG and from transmis-
sion scans obtained with germanium-68 or
cesium-137 for attenuation correction. CT
has been adapted as the transmission scan,
and the adaptation has enabled acquisition
of fused PET/CT images. Although they can
be used purely for attenuation correction,
CT images acquired in the course of
PET/CT studies can also be fused with PET
images to improve localization and interpre-
tation of sites of abnormal 18F-FDG uptake,
providing advantages over either CT or PET
alone and possibly affecting patient care [1].
In addition, the CT component of PET/CT is
also whole-body CT, and abnormalities that
can affect treatment decisions may be
present, particularly in areas not imaged
tegrated PET/CT in patients with non–small
cell lung cancer.
Materials and Methods
The study consisted of a retrospective analysis
of consecutive PET/CT scans obtained at our insti-
tution between April and October 2003. During this
6-month period, a total of 1,189 PET/CT scans
were obtained at our institution. Among the pa-
tients undergoing the scans, 321 patients (179 men,
142 women; mean age, 67 years; age range, 38–91
years) had a diagnosis of non–small cell lung can-
cer, and their PET/CT scans were included in the
study. For patients with more than one PET/CT
scan during the study period, only the first scan was
included in the analysis. The study was approved by
the institutional review board.

1116 AJR:187, October 2006


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Patients fasted for at least 6 hours before the
PET/CT study. Blood glucose was measured 1 hour
before injection of 18F-FDG; if the blood glucose
level exceeded 200 mg/dL, the examination was de-
ferred. Approximately 1 hour before scanning, pa-
tients received an injection of a mean of 15 mCi
(555 MBq; range, 12–20 mCi, 444–740 MBq) of
radioactive-labeled 18F-FDG. All scans were ob-
tained on an integrated PET/CT scanner (Discovery
ST-8, GE Healthcare). PET scans were acquired in
the 2D mode for 3 minutes per bed position. PET
images were reconstructed with standard vendor-
provided reconstruction algorithms, which incor-
porated ordered subset expectation maximization.
Attenuation correction of PET images was per-
formed with attenuation data from the CT compo-
nent of the examination. The manufacturer’s soft-
ware was used to correct emission data for scatter,
random events, and dead-time losses.
The CT component of the study comprised an un-
enhanced MDCT examination from the base of the
skull to the upper thighs (120 mA; 140 kVp; table
speed, 13.5 mm/rotation). Axial CT images were re-
constructed with a slice thickness of 3.75 mm.
For our study, axial CT images from all of the
PET/CT studies were retrospectively reviewed on
stand-alone PACS workstations (iSite, Stentor) and
were correlated with findings from the accompany-
ing PET and fused PET/CT images. Each case was
reviewed independently by two diagnostic radiolo-
gists experienced in diagnostic CT and PET/CT in-
terpretation. The radiologists documented the pres-
ence of CT abnormalities that did not show
abnormal 18F-FDG uptake (defined as 18F-FDG ac-
cumulation in the lesion that did not exceed that of
normal soft-tissue activity in the surrounding nor-
mal soft tissue, measured visually). In cases in
which the two radiologists recorded different find-
ings, the images were reviewed by a third radiolo-
gist, after which all three radiologists made a final
decision about which lesions should be recorded.
For each patient with an abnormality present on CT
scans that did not show increased 18F-FDG uptake,
details were recorded concerning the nature of the
abnormality, the anatomic location, and any infor-
mation from previous and subsequent imaging
studies and from the medical notes. Note was also
made of cases in which the abnormality was re-
garded as situated outside the range of a staging CT
scan of the thorax—that is, the abnormality was
considered extrathoracic when it was located either
above the level of the thoracic inlet or below the
level of the adrenal glands.
All recorded findings were classified as being
of major, moderate, or minor significance, corre-
sponding to definitions previously used in similar
studies [2, 3]. A finding was considered of major
importance when the CT appearance was highly
AJR:187, October 2006
PET/CT Without 18F-FDG Accumulation
suspicious for an abnormality relevant to the im- including 84 patients (26%) who underwent
mediate treatment of the patient. Such abnormali- follow-up PET/CT.
ties included additional cancers, metastatic le- Of these patients, 263 (82%) had at least
sions, and other abnormalities necessitating one finding present on the CT component of
prompt clinical assessment or intervention as well the studies that did not exhibit correlative
as important comorbid conditions expected to se- 18F-FDG activity. These abnormalities con-
riously compromise the patient’s prognosis. stituted a total of 1,231 findings, of which
Abnormalities were considered of moderate 650 were located in the thorax, 444 in the
importance when the imaging appearances sug- abdomen or pelvis, 69 in the head and neck,
gested clinically important disease but required and 68 in the bony skeleton (Tables 1–3 and
further correlation with other clinical or imaging Figs. 1–4). One hundred ninety (59%) of the
findings. Abnormalities of moderate importance patients had at least one abnormality located
included findings that may have required eventual outside the range of a standard chest CT ex-
medical or surgical treatment. Abnormalities were amination, accounting for a total of 298
considered of minor importance when the imaging such findings, a rate of 24%.
appearances did not suggest clinically important
disease and did not require additional workup. Findings of Major Importance
Forty-eight (4%) of the abnormalities in 43
Results (13%) of the patients were considered of major
A total of 321 patients with non–small cell importance, representing CT findings relevant to
lung cancer underwent integrated PET/CT the immediate treatment of the patient. These ab-
for staging or monitoring during the study normalities were located in the thorax (n = 29),
period. Analyzed PET/CT scans comprised abdomen or pelvis (n = 8), head and neck
198 initial staging scans (62%) and 123 re- (n = 5), and bony skeleton (n = 6). These find-
staging scans (38%). Nine (3%) of the pa- ings are detailed in Tables 1–3. Thirteen (1%) of
tients had undergone previous PET/CT. Fol- the findings of major importance that were ex-
low-up imaging and clinical information trathoracic in location would not have been de-
were available for 281 (88%) of the patients, tected with a routine chest CT examination.
TABLE 1: Incidental Thoracic PET/CT Findings That Did Not Accumulate
18F-FDG
No. of Findings
Finding Total Major Moderate Minor
Pulmonary nodules 184 11 173
Coronary artery calcification 105 105
Aortic or supraaortic calcification 89 89
Pleural effusion 58 58
Calcified pulmonary nodules 56 56
Parenchymal consolidation 39 30 9
Pericardial effusion 37 37
Valve calcification 19 19
Pleural plaques 11 11
Idiopathic pulmonary fibrosis 8 8
Pneumothorax 8 8
Thoracic aneurysm 8 8
Aberrant anatomy 7 7
Subcutaneous emphysema 7 7
Breast nodule 2 2
Sebaceous cyst 2 2
Pulmonary artery dilatation 2 2
Othera 8 2 3 3
aBronchiectasis, cardiomegaly, lymphangitis, mitral stenosis, pleural metastases, pulmonary hamartoma,
chest wall lipoma, aspirated material in bronchus.
1117
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Bruzzi et al.

TABLE 2: Incidental Abdominal and Pelvic PET/CT Findings That Were Not In total, four (1%) of the patients had addi-
18F-FDG Avid
tional abnormalities present on PET/CT scans
No. of Findings that did not show elevated 18F-FDG uptake
Finding Total Major Moderate Minor and were both clinically important and previ-
ously unsuspected. Three of the patients had
Renal cyst 66 66
metastases, and one patient had a large ab-
Calcified hepatic or splenic granulomas 55 55
dominal aortic aneurysm.
Colonic diverticulosis 48 48
Liver cyst 44 44 Findings of Moderate Importance
Prostate enlargement 39 39 The 465 (38% of the total 1,231)
Cholelithiasis 38 38
non–18F-FDG-avid abnormalities classified
as being of moderate importance were
Adrenal adenoma 31 31
found in 222 (69%) of the patients. These
Aortic aneurysm 19 2 17 abnormalities were located in the thorax
Hiatal hernia 11 11 (n = 313), abdomen or pelvis (n = 145), and
Indeterminate hepatic lesion 11 11 bony skeleton (n = 7). Seventy-six (6%) of
Uterine fibroids 8 8 the findings were outside the range of a rou-
tine chest CT scan.
Indeterminate adrenal nodule 7 7
Fifteen (1% of the total 1,231) of the
Renal calculi 6 6 findings initially considered of moderate
Renal atrophy 6 6 importance on the basis of their initial CT
Renal mass 5 3 2 appearance on PET/CT were found to be
Adnexal mass 5 5 malignant on subsequent tests. This number
Pancreatic mass 3 3
included 10 metastatic pulmonary nodules
that had enlarged by the time of follow-up
Aberrant anatomy 3 3
imaging; three cytology-proven malignant
Iliac artery aneurysm 3 3 pleural effusions, one biopsy-proven hepa-
Steatosis 3 3 tocellular carcinoma; and one biopsy-
Liver cirrhosis 3 3 proven prostatic carcinoma. All of these ab-
Hydronephrosis 2 2 normalities were already known from pre-
vious imaging studies. Overall, 89 (7%) of
Signs of portal venous hypertension 2 2
the findings of major or moderate impor-
Splenic cyst 2 2
tance that were outside the range of a stan-
Splenic metastasis 2 2 dard CT chest examination were found in
Bladder diverticulum 2 2 74 (23%) of the patients.
Previous nephrectomy 2 2
Umbilical hernia 2 2
Findings of Minor Importance
The 718 (58% of the total 1,231) findings
Othera 16 1 9 6
of minor importance were found in 262
aAppendicolith, colonic lipoma, inguinal hernia, pancreatic pseudocyst, paracolic mass, penile implant, (82%) of the patients. These abnormalities
gallbladder neurilemmoma, perihepatic hepatoma, calyceal diverticulum, adrenal myolipoma, adrenal
calcification, vulval cyst, sebaceous cyst, adnexal dermoid cyst, cervical cyst, splenomegaly. were located in the thorax (n = 308), abdo-
men and pelvis (n = 291), head and neck
(n = 64), and bony skeleton (n = 55). Of
these findings, 209 (17%) were outside the
In 40 of the 43 patients, the abnormalities sponding CT images were clearly abnormal. range of a routine chest CT scan. None of
were already known from previous studies. The presence of these metastatic lesions was these abnormalities was found to be of clin-
However, in three (1%) of the patients, the ad- subsequently confirmed with CT-guided bi- ical significance on follow-up.
ditional abnormalities detected on the CT im- opsy (the case of renal metastases) (Fig. 1) and
ages represented metastatic disease (one case with MRI (the cases of brain metastasis) Discussion
of left renal metastases and two cases of brain (Fig. 2). All three patients underwent manage- Recent guidelines from the American So-
metastases) that had not been suspected before ment of the metastatic lesions (radiofrequency ciety of Clinical Oncology call for initial
the PET/CT study. These abnormalities were ablation of renal metastasis and radiosurgery staging of lung cancer with chest radiogra-
found in one initial baseline study (one case of of cerebral metastases). In addition, PET/CT phy and contrast-enhanced CT of the thorax
brain metastasis) and in two restaging studies depicted a previously unsuspected 6.7-cm ab- with additional 18F-FDG PET in the absence
(one case of brain metastasis and one of renal dominal aortic aneurysm in one patient under- of distant metastatic disease on CT. Imaging
metastasis). None of these lesions showed going initial baseline staging of non–small cell of bones, brain, and abdomen is reserved for
18F-FDG uptake higher than that of normal lung cancer. The patient underwent surgical re- select cases [4]. Therefore, for most pa-
surrounding soft tissue. In all cases, the corre- pair of the aneurysm. tients, anatomic imaging of the abdomen,

1118 AJR:187, October 2006

 PET/CT Without 18F-FDG Accumulation
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TABLE 3: Incidental Head and Neck and in Bony Skeletal PET/CT Findings That
Were Not 18F-FDG Avid
Finding
Head and Neck
Facial sinus opacification
Facial sinus polyp
Indeterminate thyroid nodule
Thyroid goiter
Brain metastasis
Evidence of previous cerebrovascular accident
Craniotomy defect
Extradural abscess
Othera
Bones
Spondyloarthrosis
Healed fracture
Degenerative joint disease
Bone metastases
Osteitis condensans ilii
Otherb
aOrbital phthisis, subdural hematoma, severe cerebral atrophy,
bCostal synostosis, vertebral hemangioma, bone island.
pelvis, and head and neck is not routinely
performed. However, because of an increase
in the use of integrated 18F-FDG PET/CT in
examinations of lung cancer patients, it is
possible to evaluate many areas with CT that
are not routinely evaluated with conven-
tional methods. Although metabolically ac-
tive abnormalities are detected, abnormali-
ties of significance may be present that are
not metabolically active. Such abnormali-
ties may have an immediate impact on treat-
ment or may be of potential relevance for fu-
ture patient care.
The importance of potential findings on
the CT component of PET/CT is reflected
in a recent white paper from the American
College of Radiology [5] regarding inter-
pretation of PET/CT studies. In the white
paper it is recommended that the interpret-
ing radiologist or nuclear physician report
additional findings present on CT images,
even if the examination is performed purely
for anatomic localization only. There is
much debate about who should interpret the
studies, but it is clear that the CT compo-
nent of the study cannot be ignored. There-
fore, a comprehensive analysis of all CT
images in addition to PET images is neces-
AJR:187, October 2006
No. of Findings
Total Major Moderate Minor
22 22
21 21
7 7
6 6
3 3
3 3
2 2
1 1
4 1 3 quantify the significance of abnormalities
32 32
15 7 8
9 9
6 6
3 3
3 3
sebaceous cyst.
sary, although laborious and often unre-
warding because the study is routinely per-
formed without IV contrast medium at most
institutions. Furthermore, reimbursement
rates for interpreting both CT and PET im-
ages together do not reflect the extra time
required for interpretation of the CT images
and the PET images.
Evidence in our study shows that careful
evaluation of the CT component of inte-
grated PET/CT scans may provide clinically
important information. In our review of the
cases of 321 patients with non–small cell
lung cancer who underwent integrated
PET/CT at our institution, 263 (82%) of the
patients had additional findings on CT that
did not exhibit abnormal 18F-FDG uptake.
Most of these findings either were already
known from previous imaging studies or
were considered clinically unimportant.
Forty-three (13%) of the patients, however,
had findings considered of major clinical
importance. In the cases of four (1%) of
these patients, the additional findings were
not previously known and prompted further
investigation, yielding three additional
cases of malignancy (one case of renal me-
tastasis and two cases of cerebral me-
tastases) and a 6.7-cm infrarenal abdominal
aortic aneurysm. Although three of these
four patients already had known metastatic
disease elsewhere in the body, detection of
the additional abnormalities changed clini-
cal management by leading to lesion-spe-
cific treatment (radiofrequency ablation of
renal metastasis, stereotactic-guided radio-
surgery of cerebral metastasis, and surgical
repair of aortic aneurysm, respectively).
Our classification of abnormalities as be-
ing of major, moderate, or minor clinical
importance, although somewhat arbitrary,
was based on methods described in similar
studies [2, 3] and was used in an attempt to
present on initial PET/CT images. Most of
the additional findings detected in our study
were classified as being of minor impor-
tance and included abnormalities such as
gallstones, colonic diverticulosis, prostate
enlargement, and renal calculi, which are
extremely common in the general popula-
tion and do not warrant additional investi-
gation or follow-up. Early detection of such
findings in patients already found to have
malignant disease most likely has no imme-
diate clinical benefit. However, we believe
it is nevertheless important to document the
presence of these clinically minor findings
because, if symptoms due to these abnor-
malities develop, it is likely that the diagno-
sis will be reached more quickly if the
presence of the abnormalities is known.
Similarly, such documentation can become
clinically relevant in the event of subse-
quent detection of the abnormalities with
other imaging studies. In these cases, com-
parison with the previous PET/CT studies
may become invaluable. Reporting the
presence of such apparently minor abnor-
malities on PET/CT images is therefore in
accordance with good clinical care, partic-
ularly when the patient is being billed for
the CT component of the study in addition
to the PET component.
The lack of apparent 18F-FDG accumula-
tion by additional malignant lesions in our
study may have occurred for a variety of rea-
sons. In the cases of the two patients with
brain metastases, it is already known that
PET has relatively low sensitivity for cere-
bral metastatic lesions, mainly because of
the limited spatial resolution of PET scan-
ners and the intense metabolic activity al-
ready present throughout the rest of the cor-
tex [6]. In certain cases, brain metastases
appear as areas of reduced 18F-FDG uptake
1119
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Bruzzi et al.

compared with the surrounding cortex [7]. It
must also be remembered in interpretation of
PET/CT studies for restaging that many pa-
tients have already undergone a variety of
chemotherapy regimens and radiation ther-
apy, which may alter the biology of tumor
cells and affect their growth or their ability
to take up 18F-FDG. In addition, it should be
recognized that certain tumors with variable
18F-FDG uptake, such as prostate cancer,
hepatocellular carcinoma, renal cell carci-
noma, and osteoblastic bone metastases
[8–13], may be present in patients with lung
cancer and may be more readily detected
owing to their abnormal appearance on CT
images than owing to their PET appearance.
Therefore, for a variety of reasons, important
information may be present on the CT com-

A B

C D
Fig. 1—67-year-old man with non–small cell lung cancer and incidental left renal mass detected at staging PET/CT.
A, Axial unenhanced CT image (3.75-mm slice thickness) from staging PET/CT scan shows hypodense mass in interpolar region of left kidney (arrow) that was not clearly
simple cyst and was suspicious for renal malignancy. Area had not been included in initial diagnostic chest CT scan.
B, Correlative PET shows no increased 18F-FDG uptake within mass compared with adjacent renal cortex (arrow). Further evaluation of this lesion was recommended on basis
of CT appearance.
C, Fused PET/CT image corresponding to B shows no increased 18F-FDG uptake within mass compared with adjacent renal cortex (arrow). Focus of abnormally increased
uptake of 18F-FDG (arrowhead) in L3 vertebral body is consistent with bone metastasis.
D, Enhanced CT scan of abdomen obtained after A–C confirms presence of heterogeneously enhancing left renal mass (arrow) suspicious for malignancy. Subsequent biopsy
revealed renal metastasis.

1120 AJR:187, October 2006


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A B
C D
ponent of PET/CT studies that does not show
abnormally elevated 18F-FDG uptake and
that may be detected only through careful
analysis of all CT images.
Many incidental findings identified on
CT can be confidently characterized, in-
cluding benign adrenal adenomas, bladder
diverticulae, lipomas, and dermoid cysts.
However, more problematic is the detec-
tion of indeterminate lesions that may re-
quire further imaging or biopsy before
AJR:187, October 2006
PET/CT Without 18F-FDG Accumulation
their innocuous nature can be determined.
The presence and importance of these inde-
terminate abnormalities raise issues al-
ready being debated in reference to other
cross-sectional imaging tools such as CT
colonography [2, 3, 14, 15] and lung cancer
screening [16]. Swensen et al. [16] re-
ported a high incidence of additional CT
findings in their study of lung cancer
screening with CT. They identified 696
findings that were deemed clinically im-
Fig. 2—Brain of 65-year-old man with progressive
non–small cell lung cancer.
A, Unenhanced CT image from staging PET/CT study
shows area of vasogenic edema (arrow) in right
parietal lobe of brain with evidence of mild
compressive mass effect on right lateral ventricle.
There had been no clinical suspicion of metastasis to
brain.
B, Correlative PET image shows normal symmetric
cortical activity and area of vasogenic edema (arrow).
C, Fused PET/CT image corresponding to B shows
normal symmetric cortical activity and area of
vasogenic edema (arrow).
D, Gadolinium-enhanced T1-weighted image in axial
plane (TR/TE, 600/8) confirms presence of enhancing
cortical nodule (arrow) in parietal lobe consistent with
cerebral metastasis. Lesion was subsequently
managed with stereotactic radiosurgery.
portant, requiring further evaluation or in-
tervention. Most of these abnormalities
were found to be false-positive findings.
The detection of additional abnormalities
can be expected to be higher with PET/CT,
which includes a CT examination of almost
the entire body. The benefit of earlier de-
tection of unexpected abnormalities must
be carefully balanced against the increased
cost of the examination and anxiety expe-
rienced by patients.
1121
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C D
The foregoing factors pose challenges to
the way PET/CT studies are interpreted [17].
It is clearly desirable for the interpreting
physician to be able to discriminate clini-
cally important findings that may affect clin-
ical management from more innocuous inci-
dental findings that require no further
evaluation. Competence in both diagnostic
cross-sectional imaging and PET is ideally
required. However, at present these two spe-
cialties usually have independent training
programs, and few radiologists and nuclear
medicine physicians have dual board certifi-
1122
Bruzzi et al.
A B
cation. There is still much discussion about
the ideal way in which PET/CT studies
should be interpreted, reported, and reim-
bursed. Clear consensus on such issues is
lacking in the radiologic community [18].
Whether the CT images should be inter-
preted independently of the PET study or as
an integral part of the PET/CT examination
varies from institution to institution and de-
pends on local issues, such as the way in
which PET/CT studies are performed, de-
partmental organization, and billing meth-
ods. At our institution, we believe a single
Fig. 3—67-year-old woman with non–small cell lung
cancer treated for 4 months with chemotherapy who
complained of worsening lower back pain.
A, Unenhanced CT image from initial PET/CT study
shows mixed lytic and blastic lesion (arrow) of
vertebral body.
B, Fused PET/CT image shows no activity in T11
vertebral body (arrow). Accumulation of 18F-FDG
(arrowhead) in adjacent lung parenchyma represents
persistent metabolic activity in primary lung
carcinoma.
C, Sagittal T2-weighted MR image (TR/TE, 3,800/97) of
spine confirms presence of metastasis (arrow) to T11
without evidence of extension into spinal cord.
D, Sagittal T2-weighted image (3,800/97) from MRI scan
obtained 4 months after C shows progression of
metastasis resulting in compression fracture (arrow) of
T11 vertebral body and extension of tumor into
extradural space, impinging on spinal cord.
report that includes information from both
PET and CT images is ideal for communicat-
ing all relevant details to the clinician to help
direct patient care.
Many additional abnormalities present on
CT images from PET/CT studies do not
show increased 18F-FDG uptake. Although
only a relatively small percentage influence
immediate clinical management, we believe
these additional findings are of sufficient
clinical importance to justify systematic re-
view of the CT images from PET/CT studies
and should be included in the final report.
AJR:187, October 2006
 PET/CT Without 18F-FDG Accumulation
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Fig. 4—57-year-old woman with metastatic non–small cell lung cancer. Example of
abnormality detected at PET/CT of non–small cell lung cancer that did not show
increased 18F-FDG uptake and that was only evident on CT images.
A, Axial unenhanced CT scan depicts classic appearance of fat-containing dermoid
cyst (arrow) in pelvis.
B, Correlative PET image shows no 18F-FDG uptake within lesion (arrow). Although
dermoid cyst remained asymptomatic, early detection of cyst with PET/CT may have
provided important additional information in event of subsequent complications from
torsion or hemorrhage of cyst resulting in abdominal pain.
C, Fused PET/CT image corresponding to B shows no uptake in lesion (arrow).

B C

References 7. Rohren EM, Provenzale JM, Barboriak DP, Cole- 30:203–204

1. Bar-Shalom R, Yefremov N, Guralnik L, et al. Clin-
ical performance of PET/CT in evaluation of can-
cer: additional value for diagnostic imaging and pa-
tient management. J Nucl Med 2003; 44:1200–1209
2. Hara AK, Johnson CD, MacCarty RL, Welch TJ. In-
cidental extracolonic findings at CT colonography.
Radiology 2000; 215:353–357
3. Hellstrom M, Svensson MH, Lasson A. Extraco-
lonic and incidental findings on CT colonography
(virtual colonoscopy). AJR 2004; 182:631–638
4. Pfister DG, Johnson DH, Azzoli CG, et al. Ameri-
can Society of Clinical Oncology treatment of un-
resectable non-small cell lung cancer guideline: up-
date 2003. J Clin Oncol 2004; 22:330–353
5. Coleman RE, Delbeke D, Guiberteau MJ, et al.
Concurrent PET/CT with an integrated imaging
system: intersociety dialogue from the Joint Work-
ing Group of the American College of Radiology,
the Society of Nuclear Medicine, and the Society of
Computed Body Tomography and Magnetic Reso-
nance. J Nucl Med 2005; 46:1225–1239
6. Coleman RE. PET in lung cancer staging. Q J Nucl
Med 2001; 45:231–234
man RE. Screening for cerebral metastases with
FDG PET in patients undergoing whole-body stag-
ing of non-central nervous system malignancy. Ra-
diology 2003; 226:181–187
8. Effert PJ, Bares R, Handt S, Wolff JM, Bull U, Jakse G.
Metabolic imaging of untreated prostate cancer by
positron emission tomography with 18fluorine-la-
beled deoxyglucose. J Urol 1996; 155:994–998
9. Liu IJ, Zafar MB, Lai YH, Segall GM, Terris MK.
Fluorodeoxyglucose positron emission tomography
studies in diagnosis and staging of clinically organ-
confined prostate cancer. Urology 2001; 57:108–111
10. Trojan J, Schroeder O, Raedle J, et al. Fluorine-
18 FDG positron emission tomography for imag-
ing of hepatocellular carcinoma. Am J Gastroen-
terol 1999; 94:3314–3319
11. Kang DE, White RL Jr, Zuger JH, Sasser HC, Tei-
gland CM. Clinical use of fluorodeoxyglucose F 18
positron emission tomography for detection of renal
cell carcinoma. J Urol 2004; 171:1806–1809
12. An YS, Yoon JK, Lee MH, Joh CW, Yoon SN. False
negative F-18 FDG PET/CT in nonsmall cell lung
cancer bone metastases. Clin Nucl Med 2005;
13. Kao CH, Hsieh JF, Tsai SC, Ho YJ, Yen RF. Com-
parison and discrepancy of 18F–2-deoxyglucose
positron emission tomography and Tc-99m MDP
bone scan to detect bone metastases. Anticancer Res
2000; 20:2189–2192
14. Edwards JT, Wood CJ, Mendelson RM, Forbes GM.
Extracolonic findings at virtual colonoscopy: impli-
cations for screening programs. Am J Gastroenterol
2001; 96:3009–3012
15. Ginnerup Pedersen B, Rosenkilde M, Christiansen
TE, Laurberg S. Extracolonic findings at computed
tomography colonography are a challenge. Gut
2003; 52:1744–1747
16. Swensen SJ, Jett JR, Hartman TE, et al. Lung cancer
screening with CT: Mayo Clinic experience. Radi-
ology 2003; 226:756–761
17. von Schulthess GK. Maximising the benefit of in-
tegrated PET/CT: the road ahead. Eur J Nucl Med
Mol Imaging 2004; 31:1462–1463
18. Blodgett TM, Casagranda B, Townsend DW, Meltzer
CC. Issues, controversies, and clinical utility of com-
bined PET/CT imaging: what is the interpreting phy-
sician facing? AJR 2005; 184[suppl]:S138–S145

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