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 Rajesh Gupta · Robert Matthews
Lev Bangiyev · Dinko Franceschi
Mark Schweitzer

PET/MR Imaging

A Case-Based Approach

123
PET/MR Imaging
Rajesh Gupta • Robert Matthews
Lev Bangiyev • Dinko Franceschi
Mark Schweitzer

PET/MR Imaging
A Case-Based Approach
Rajesh Gupta Robert Matthews
Department of Radiology Department of Radiology
Stony Brook University Hospital Stony Brook University Hospital
Stony Brook, NY, USA Stony Brook, NY, USA

Lev Bangiyev Dinko Franceschi

Department of Radiology Department of Radiology
Stony Brook University Hospital Stony Brook University Hospital
Stony Brook, NY, USA Stony Brook, NY, USA

Mark Schweitzer
Department of Radiology
Stony Brook University Hospital
Stony Brook, NY, USA

ISBN 978-3-319-65105-7    ISBN 978-3-319-65106-4 (eBook)

https://doi.org/10.1007/978-3-319-65106-4

Library of Congress Control Number: 2017953439

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To my wonderful wife, Priya, for her sweet love and
encouragement that propels me. To my family, especially my
father, Vipin, and my brother, Apar, for their continual support.
In loving memory of my mother, Ankan, to whom I am forever
grateful. To my mentors and coauthors for their commitment to
lifelong learning.
Rajesh Gupta

Dedicated to all the Matthews and Stone family.

Robert Matthews

To my wife, Elina, and my children, Sharon and Alan, who are

the purpose of life. Also, my parents, Yakov and Natalya, to
whom I owe my life.
Lev Bangiyev

To my loving wife, Maja, and our wonderful children, Ana,

Dora, Nika, and Dinko Domagoj, for their love,
encouragement, and support. In memory of my parents, without
whose guidance I would not be here today.
Dinko Franceschi

For my beautiful wife, Sheryl, for her love and support.

For Shira and Daniel, for teaching me the importance
of furthering our understanding of disease.
Mark Schweitzer
Foreword

PET is fundamentally a functional imaging technique that achieves high sen-

sitivity for various physiological processes through injection of radiolabeled
ligands that are analogs of endogenous compounds, or that have high affinity
for specific molecular targets. Although many radiotracers have been devel-
oped and employed in research for a range of applications in normal and
disease conditions, only a handful are currently approved for the clinic, and
of these by far the most dominant is the glucose analog F18-fluorodeoxyglucose
(FDG). FDG is treated similarly to glucose by the body up to and including
the first step of glycolysis with phosphorylation by hexokinase, after which it
is trapped within the cell, unable to proceed down the glycolytic pathway due
to its substitution of fluorine for a hydroxyl group. Because FDG and glucose
compete for transport into cells based on their relative proportions in plasma,
it is beneficial to lower and stabilize blood glucose concentrations at baseline
by fasting before injecting FDG. In addition, insulin levels should be at base-
line to prevent FDG from being driven into skeletal and cardiac muscle.
Uptake into malignant tissue is enhanced not only by the increased metabolic
demands of proliferation but also by a general preference of cancerous cells
for anaerobic glycolysis, even in the presence of sufficient oxygen, which
provides less ATP than aerobic glycolysis for the same amount of glucose
consumed, known as the Warburg effect [1].
Although FDG PET is highly sensitive to a wide range of cancer types, it
generally provides limited structural information, has poorer spatial resolu-
tion, and involves a modest dose of ionizing radiation (~10 mSv). Moreover
abnormalities are sometimes difficult to distinguish from normal uptake pat-
terns and their variations, or other pathological conditions such as infection
and inflammation which can result in high FDG uptake [2]. Similarly, benign
lesions such as benign primary parotid tumors and thyroid adenomas can
present with high focal uptake.
The advent of PET/CT was intended to improve both sensitivity and speci-
ficity compared to PET alone while providing vastly improved anatomical
detail for localization purposes [3]. In this approach, the PET and CT systems
are adjacent to each other in a single gantry and share the same patient bed,
allowing a high degree of alignment between the detailed structural images
from CT and the functional data from PET without the need for software
coregistration. Moreover, the CT provides a fast and accurate method for cor-
rection of gamma-ray attenuation in PET. PET/CT is now the clinical stan-
dard and it is employed for initial staging, therapy response, surveillance of

vii
viii Foreword

recurrence, as well as for prognostic purposes. Because molecular imaging

such as PET can reflect metabolic changes, which occur on a faster time scale
than anatomical changes, PET has also become an invaluable tool in the
development and screening of cancer drug candidates [4].
A drawback of PET/CT is that the CT adds radiation dose to the PET pro-
cedure which already involves a modest radiation dose [5]. In fact, the dose
from the CT portion alone can be multiples of that from the PET tracer. Thus,
low-dose CT protocols have been developed which reduce the CT exposure
[6] compared to fully diagnostic CT which is not always necessary. Another
limitation of CT is poor soft tissue contrast, which can hinder adequate evalu-
ation of structures in the head and neck, musculoskeletal, and pelvic regions.
Contrary to CT, MRI provides superb contrast among different soft tissue
types and structural abnormalities by exploiting a multitude of pulse
sequences to enhance different tissue properties, with or without the use of an
exogenous contrast agent. The types of sequences are mainly divided between
those that reflect T1 and T2 relaxation properties, with a large number of
variations that, for example, suppress water and fat or reflect water diffusion.
MRI excels at structural imaging with high spatial resolution and sensitivity.
While functional modes such as fMRI have been developed and continue to
be refined, they have not yet found widespread clinical application.
Thus, it has long been realized that PET/MRI could be an even more pow-
erful combination of imaging modalities than PET/CT, with initial prototype
systems developed starting in the 1990s and continuing to the present [7].
MRI involves no ionizing radiation and therefore PET/MRI introduces less
potential long-term risk to the patient than PET/CT. MRI can provide multi-
ple image sets within a single imaging session, each with unique contrast
mechanisms. Also, MRI can be implemented in a simultaneous mode with
PET, further optimizing the spatial alignment of the images and generating
the possibility to assess multiple functional parameters at the same time
which has substantial implications for brain imaging research.
But the close integration of PET and MRI was a much more daunting
technical challenge than PET/CT. This is related to the vulnerability of tradi-
tional PET components to the strong static and rapidly fluctuating electro-
magnetic fields associated with MRI, and of MRI to susceptibility artifacts,
eddy currents, and radiofrequency emission from PET hardware located
within the field of view [7]. For example, the photosensors used in conven-
tional PET scanners (photomultiplier tubes) are highly sensitive to magnetic
fields and do not function at all in the strong static fields used in
MRI. Fortunately, the introduction of robust and compact solid-state photo-
detectors, including avalanche photodiodes (APDs) and then silicon photo-
multipliers (SiPMs), has provided a chance to move forward more quickly
with this imaging approach. Early clinical systems were sequential imagers,
much like PET/CT, except that the PET and MRI gantries were separate,
located at opposite ends of the patient bed to minimize cross-interference [8].
This allowed optimal performance of both modalities, and even time-of-flight
capability in the Philips Ingenuity TF [9], with a minimum investment in
technology development, but did not optimize the imaging efficiency as well
as the PET/CT. In order to minimize total imaging time and enable the
Foreword ix

exploration of multiple functional measures at the same time, simultaneous

PET/MRI approaches were developed. Siemens introduced the first simulta-
neous PET/MRI, the Biograph mMR [10], which is based on APD photosen-
sors, providing PET with typical whole-body spatial resolution and long axial
field of view (25 cm) inside a 3 T MRI. Subsequently GE introduced the
Signa PET/MR based on SiPM photosensors [11], which has a similar geom-
etry and performance, except that it is able to provide improved time resolu-
tion that allows time-of-flight (TOF) acquisition and processing to improve
SNR [12]. All the cases in this book are from the Siemens Biograph mMR
PET/MR scanner, although the clinical scenarios and challenges are similar
for all PET/MRI systems.

Technical Challenges

Attenuation

A particular challenge for PET/MRI is the robust determination of PET atten-

uation correction using MRI data only (MR attenuation correction or MRAC).
This correction has up to an order of magnitude effect on the PET data and is
critical for quantitative and semi-quantitative (standardized uptake value or
SUV) PET imaging. In PET/CT, the CT component provides accurate photon
attenuation coefficients (“mu” values) at CT energies (~100 keV) which can
be robustly scaled to PET energy (511 keV) with a bilinear approach (known
as CTAC) [13]. However, MRI operates on an entirely different principle and
cannot determine photon attenuation coefficients in a direct way.
The first and still most common MRAC approach is to use a Dixon MRI
sequence to segment tissue into the two classes of fat and water, and then to
assign their known attenuation coefficients (0.085 and 0.095 cm−1, respec-
tively) to produce the mu map of the patient. Unfortunately, the Dixon
sequence cannot define bone which is known to have the highest mu value of
~0.15 cm−1. Although this is somewhat mitigated by the fact that bone usually
occupies only a small fraction of the imaging volume, regions near bone will
be underestimated. Moreover the Dixon segmentation algorithm can reverse
the tissue classes about 10% of the time [14], necessitating additional, usually
manual measures to verify accuracy of the attenuation correction.
A newer approach uses an ultrashort echo time (UTE) approach to create
a third class for bone. While this has been an improvement, this sequence is
so far restricted to head and neck imaging and often underestimates bone and
overestimates air cavities. Recent approaches involve comparing an opti-
mized MRI sequence of the patient to an atlas or database of patients who
have received both the MRI sequence and CT. While this seems to be the best
approach so far for the brain, it is not clear how effective it will be for those
with anatomy that is not well represented in the database, and its extension to
body remains a challenge. Developing improved methods for MRAC remains
an active research area [15].
A general problem in MRAC is truncation of the arms in MR images
which can cause underestimation of attenuation if not accounted for.
x Foreword

Algorithmic methods like MLAA (maximum likelihood activity and attenuation)

[16] attempt to add arms to the mu map based on consistency between the
measured PET and mu map. However, this needs to be performed for each
bed position and the result is not always stable. It can result in discontinuous
artifacts in coronal whole-body PET images at the intersection of bed
positions with disparate MLAA estimates of the arms.

Spatial Resolution

Another issue in simultaneous PET/MRI systems is the reduction of spatial

resolution near the edges of the FOV due to the so-called parallax effect
which becomes prominent when the PET detectors are close to the FOV. A
typical PET/CT system has a patient opening of ~60 cm while the PET detec-
tors are located at a much larger diameter of ~80–90 cm, in part to reduce the
effects of parallax. But in simultaneous PET/MRI systems, the PET system
must fit inside the confined bore of an MRI which implies that the detectors
cannot be placed much farther away to reduce the parallax effect. Modern
iterative image reconstruction approaches can mitigate this effect by incorpo-
rating the point spread function into the algorithm—while this can restore the
resolution to some degree, there is a cost in image noise. One advantage
though is that the small diameter reduces the number of detectors and
increases the axial acceptance angle which improves detection sensitivity as
well as cost.

Conclusion

Simultaneous PET and MRI technology is still relatively new to the clinic and
has not yet reached full acceptance, in part due to its high cost but also due to
limited large-scale prospective validation studies. The initial phase of adoption
focused on clinical feasibility and the degree to which it was equivalent to
PET/CT for detecting lesions. In the following years, PET/MRI developed to
a stage where it is superior to PET/CT for some malignancies [17, 18] and has
evolved into non-oncologic clinical applications such as assessment of neuro-
degenerative diseases. However, cultural and historical obstacles remain in the
routine clinical adoption of PET/MR imaging. Cancer specialists have consid-
erable training and experience with PET/CT, but not necessarily in the com-
plex language of MRI, its benefits, variety of imaging sequences and contrast
mechanisms, and its limitations such as new types of artifacts to be inter-
preted. This book is an attempt to introduce the nuances of PET/MR imaging
to oncologists, radiologists, and other specialized physicians who are already
familiar with PET/CT. Our hope is that a deeper understanding of PET/MRI,
including its advantages and disadvantages, by practicing physicians will help
place this new technology in the most effective role in patient care.

Department of Radiology and Biomedical Engineering Paul Vaska, PhD

Stony Brook University Medical School,
Stony Brook, NY, USA
Foreword xi

References
1. Bensinger SJ, Christofk HR. New aspects of the Warburg effect in cancer cell biology.
Semin Cell Dev Biol. 2012;23:352–61.
2. Metser U, Even-Sapir E. Increased (18)F-fluorodeoxyglucose uptake in benign, nonphysi-
ologic lesions found on whole-body positron emission tomography/computed tomogra-
phy (PET/CT): accumulated data from four years of experience with PET/CT. Semin Nucl
Med. 2007;37:206–22.
3. Wechalekar K, Sharma B, Cook G. PET/CT in oncology—a major advance. Clin
Radiol. 2005;60:1143–55.
4. Kelloff GJ, Hoffman JM, Johnson B, Scher HI, Siegel BA, Cheng EY, et al. Progress
and promise of FDG-PET imaging for cancer patient management and oncologic drug
development. Clin Cancer Res. 2005;11:2785–808.
5. Fahey F, Stabin M. Dose optimization in nuclear medicine. Semin Nucl Med.
2014;44:193–201.
6. Xia T, Alessio AM, De Man B, Manjeshwar R, Asma E, Kinahan PE. Ultra-low dose
CT attenuation correction for PET/CT. Phys Med Biol. 2012;57:309–28.
7. Vaska P, Cao T. The state of instrumentation for combined positron emission tomogra-
phy and magnetic resonance imaging. Semin Nucl Med. 2013;43:11–8.
8. Cho ZH, Son YD, Kim HK, Kim KN, Oh SH, Han JY, et al. A fusion PET-MRI system
with a high-resolution research tomograph-PET and ultra-high field 7.0 T-MRI for the
molecular-genetic imaging of the brain. Proteomics. 2008;8:1302–23.
9. Zaidi H, Ojha N, Morich M, Griesmer J, Hu Z, Maniawski P, et al. Design and per-
formance evaluation of a whole-body ingenuity TF PET-MRI system. Phys Med Biol.
2011;56:3091–106.
10. Delso G, Fürst S, Jakoby B, Ladebeck R, Ganter C, Nekolla SG, et al. Performance
measurements of the Siemens mMR integrated whole-body PET/MR scanner. J Nucl
Med. 2011;52:1914–22.
11. Grant AM, Deller TW, Khalighi MM, Maramraju SH, Delso G, Levin CS. NEMA
NU 2–2012 performance studies for the SiPM-based ToF-PET component of the GE
SIGNA PET/MR system. Med Phys. 2016;43:10.
12. Surti S. Update on time-of-flight PET imaging. J Nucl Med. 2015;56:
98–105.
13. Kinahan PE, Hasegawa BH, Beyer T. X-ray-based attenuation correction for posi-
tron emission tomography/computed tomography scanners. Semin Nucl Med.
2003;33:166–79.
14. Ladefoged CN, Hansen AE, Keller SH, Holm S, Law I, Beyer T, et al. Impact of incor-
rect tissue classification in Dixon-based MR-AC: fat-water tissue inversion. EJNMMI
Phys. 2014;1:101.
15. Ladefoged CN, Law I, Anazodo U, St. Lawrence K, Izquierdo-Garcia D, Catana C,
et al. A multi-centre evaluation of eleven clinically feasible brain PET/MRI attenuation
correction techniques using a large cohort of patients. Neuroimage. 2016;147:346–59.
16. Rezaei A, Defrise M, Bal G, Michel C, Conti M, Watson C, et al. Simultaneous recon-
struction of activity and attenuation in time-of-flight PET. IEEE Trans Med Imaging.
2012;31:2224–33.
17. Heusch P, Nensa F, Schaarschmidt B, Sivanesapillai R, Beiderwellen K, Gomez B,
et al. Diagnostic accuracy of whole-body PET/MRI and whole-body PET/CT for TNM
staging in oncology. Eur J Nucl Med Mol Imaging. 2015;42:42–8.
18. Sher AC, Seghers V, Paldino MJ, Dodge C, Krishnamurthy R, Krishnamurthy R, et al.
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Preface

Clinical applications of PET/MR imaging have been rapidly emerging over

the last several years, and the use of this modality is bound to gain momentum
in the diagnosis and treatment of various diseases. As this is a relatively new
endeavor in the clinical realm, there is a paucity of resources that compile a
collection of high-quality PET/MRI cases. Starting a new undertaking fre-
quently brings a level of uncertainty and anxiety. In such instances, we rely
on references that can help us gain confidence and expertise. We created this
book to provide a case-based overview of PET/MR imaging for the novice.
Interpretation of PET/MRI requires understanding of both PET and MRI
findings. In comparison to the CT component of PET imaging, MRI is more
complex to master and requires comprehension of various MR sequences that
can be acquired.
This collection of PET/MRI cases includes both benign and malignant
pathologies organized by organ systems. Each case starts with a brief clinical
history that is followed by images. The diagnosis is then revealed with detailed
imaging findings along with a discussion describing disease pathology, as well
as PET and MRI imaging characteristics. Suggested further reading resources
are provided to give readers an opportunity to delve deeper into the individual
cases. The cases in this book have been gathered over several years and repre-
sent a spectrum of cases encountered in the everyday clinical setting.
This book is intended as an introduction to PET/MR imaging, especially
for radiology and nuclear medicine residents, fellows, and practicing physi-
cians, as well as clinicians across a variety of specialties. We hope that you
will find this book informative and useful as the medical community contin-
ues to incorporate PET/MR imaging into clinical practice.

Stony Brook, NY, USA Rajesh Gupta, MD

 Robert Matthews, MD
 Lev Bangiyev, DO
 Dinko Franceschi, MD
 Mark Schweitzer, MD

xiii
Acknowledgements

We express our gratitude to the physicians, technicians, nurses, and support

staff within the Department of Radiology and Clinical Services at Stony
Brook University Hospital for their dedication to their patients. We would
also like to thank the editorial and development staff at Springer who made
this book possible.

xv
Contents

Part I Musculoskeletal
Case 1 Recurrent High-Grade Sarcoma . . . . . . . . . . . . . . . . . . . . .    3
Rajesh Gupta
Case 2 Bone Metastases from Lung Cancer . . . . . . . . . . . . . . . . . .    5
Rajesh Gupta
Case 3 Benign Notochordal Remnant . . . . . . . . . . . . . . . . . . . . . . .    7
Rajesh Gupta
Case 4 Ewing Sarcoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .    9
Apar Gupta
Case 5 Multiple Myeloma. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   13
Rajesh Gupta
Case 6 Osteomyelitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   15
Rajesh Gupta
Case 7 Malignant Soft Tissue Myxofibrosarcoma . . . . . . . . . . . . .   17
Rajesh Gupta
Case 8 Vertebral Body Hemangioma. . . . . . . . . . . . . . . . . . . . . . . .   19
Rajesh Gupta
Case 9 Therapy-Induced Marrow Changes. . . . . . . . . . . . . . . . . . .   21
Rajesh Gupta
Case 10 Benign Spinal Cord Compression . . . . . . . . . . . . . . . . . . . .   25
David Pouldar and Robert Matthews
Case 11 Prostate Cancer with F-18 Sodium Fluoride. . . . . . . . . . . .   27
Ana M. Franceschi and Robert Matthews
Case 12 Tarlov Cyst. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   31
Rajesh Gupta
Case 13 Cellulitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   33
Rajesh Gupta
Case 14 Degenerative Spine: Modic Type I Changes. . . . . . . . . . . .   35
Rajesh Gupta and Robert Matthews

xvii
xviii Contents

Case 15 Extramedullary Multiple Myeloma. . . . . . . . . . . . . . . . . . .   37

Rajesh Gupta
Case 16 Aortitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   39
Rajesh Gupta
Case 17 Primary Bone Lymphoma. . . . . . . . . . . . . . . . . . . . . . . . . . .   41
Rajesh Gupta
Case 18 Radiation Effect on Bone Marrow. . . . . . . . . . . . . . . . . . . .   43
David Pouldar and Robert Matthews
Case 19 Recurrent Myxoid Liposarcoma . . . . . . . . . . . . . . . . . . . . .   45
Rajesh Gupta
Case 20 Osseous Sarcoidosis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   47
Eric van Staalduinen
Case 21 Osteoblastic Metastasis from Breast Cancer. . . . . . . . . . . .   49
Rajesh Gupta
Case 22 Muscle Strain. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   51
Jingyu Zhou and Amit Gupta
Case 23 Acute Benign Vertebral Compression Fracture. . . . . . . . .   53
Rajesh Gupta
Case 24 Spinal Neuropathic Arthropathy. . . . . . . . . . . . . . . . . . . . .   55
Anastasia Plaunova and Kelly Tisovic
Case 25 Well-Differentiated Liposarcoma. . . . . . . . . . . . . . . . . . . . .   59
Rajesh Gupta

Part II Chest
Case 26 Pulmonary Sarcoidosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   63
Kavitha Yaddanapudi
Case 27 Cardiac Metastasis from Renal Cell Carcinoma . . . . . . . .   65
Kavitha Yaddanapudi and Robert Matthews
Case 28 Breast Cancer (Invasive Ductal Carcinoma). . . . . . . . . . . .   67
Elham Safaie
Case 29 Benign Thymic Rebound Hyperplasia. . . . . . . . . . . . . . . . .   69
Rajesh Gupta
Case 30 Pulmonary Infarct. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   71
Kavitha Yaddanapudi
Case 31 Mediastinal Lymphoma. . . . . . . . . . . . . . . . . . . . . . . . . . . .   73
Rajesh Gupta
Case 32 Inflammatory Breast Cancer. . . . . . . . . . . . . . . . . . . . . . . .   75
Elham Safaie
Case 33 Benign Loculated Pleural Effusion . . . . . . . . . . . . . . . . . . .   77
Kavitha Yaddanapudi
Contents xix

Case 34 Chest Wall Metastasis from Renal Cell Carcinoma. . . . . .   79

Rajesh Gupta
Case 35 Non-small Cell Lung Cancer . . . . . . . . . . . . . . . . . . . . . . . .   81
Kavitha Yaddanapudi
Case 36 Cardiac Sarcoidosis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   83
Robert Matthews
Case 37 Internal Mammary Lymph Node Metastasis
from Breast Cancer. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   85
Robert Matthews and Elham Safaie
Case 38 Lung Metastases. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   87
Kavitha Yaddanapudi
Case 39 Pleural Metastases from Invasive Thymoma . . . . . . . . . . .   89
Kavitha Yaddanapudi
Case 40 Thoracic Aortic Aneurysm. . . . . . . . . . . . . . . . . . . . . . . . . .   91
Kavitha Yaddanapudi and Rajesh Gupta
Case 41 Mediastinal Sarcoidosis. . . . . . . . . . . . . . . . . . . . . . . . . . . . .   93
Kavitha Yaddanapudi
Case 42 Metastatic Breast Cancer to the Liver. . . . . . . . . . . . . . . . .   95
Elham Safaie and Robert Matthews
Case 43 Multifocal Pneumonia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   97
Rajesh Gupta
Case 44 Invasive Lobular Breast Cancer. . . . . . . . . . . . . . . . . . . . . .   99
David Capaldi
Case 45 Hodgkin’s Lymphoma of the Lung . . . . . . . . . . . . . . . . . . . 101
Rajesh Gupta

Part III Gastrointestinal

Case 46 Liver Metastases from Colon Cancer . . . . . . . . . . . . . . . . . 105
Robert Matthews
Case 47 Esophageal Adenocarcinoma . . . . . . . . . . . . . . . . . . . . . . . . 107
Robert Matthews
Case 48 Focal Colonic Activity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109
Robert Matthews
Case 49 Diffuse Fatty Liver. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111
Robert Matthews
Case 50 Pancreatic Ductal Adenocarcinoma. . . . . . . . . . . . . . . . . . . 113
Robert Matthews
Case 51 Diffuse Splenic Uptake . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115
Robert Matthews
Case 52 Simple Hepatic Cyst and Hemorrhagic Hepatic Cyst . . . . 117
Robert Matthews
xx Contents

Case 53 Carcinoid Tumor with Gallium DOTATATE . . . . . . . . . . . 121

Joseph R. Stein
Case 54 Large Gallstone and Sludge. . . . . . . . . . . . . . . . . . . . . . . . . 125
Christopher Shackles and Amit Gupta
Case 55 Cecal Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127
Robert Matthews
Case 56 Non-FDG Avid Hepatocellular Carcinoma. . . . . . . . . . . . . 129
Robert Matthews
Case 57 Metformin Induced Bowel Uptake. . . . . . . . . . . . . . . . . . . . 131
Amit Gupta and Robert Matthews
Case 58 Splenic Hemangioma. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133
Robert Matthews
Case 59 Invasive Anal Cancer. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135
Robert Matthews
Case 60 Liver Iron Deposition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137
Robert Matthews
Case 61 Peritoneal Metastases from Colon Cancer . . . . . . . . . . . . . 139
Robert Matthews
Case 62 Malignant Gallbladder Polyp. . . . . . . . . . . . . . . . . . . . . . . . 141
Robert Matthews
Case 63 Diverticulitis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143
Robert Matthews
Case 64 Splenic Lymphoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145
Robert Matthews
Case 65 Gastric Adenocarcinoma. . . . . . . . . . . . . . . . . . . . . . . . . . . . 147
Robert Matthews
Case 66 Rectal Cancer. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151
Robert Matthews
Case 67 FDG Avid Hepatocellular Carcinoma. . . . . . . . . . . . . . . . . 153
Mark K. Youssef
Case 68 Metastatic Pancreatic Insulinoma
with Gallium DOTATATE . . . . . . . . . . . . . . . . . . . . . . . . . . 155
Rajesh Gupta and Robert Matthews
Case 69 Focal Nodular Hyperplasia. . . . . . . . . . . . . . . . . . . . . . . . . . 159
Robert Matthews
Case 70 Acute Enteritis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161
Robert Matthews
Case 71 Pancreatic Head Cancer. . . . . . . . . . . . . . . . . . . . . . . . . . . . 163
Robert Matthews
Contents xxi

Case 72 GIST Hemorrhagic Metastases . . . . . . . . . . . . . . . . . . . . . . 165

Robert Matthews
Case 73 Recurrent Colon Cancer. . . . . . . . . . . . . . . . . . . . . . . . . . . . 167
Robert Matthews
Case 74 Neuroendocrine Tumor Gallbladder. . . . . . . . . . . . . . . . . . 169
Robert Matthews
Case 75 Hepatic Chemoembolization Resulting in Chemical
Cholecystitis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171
Christopher Shackles and Amit Gupta

Part IV Genitourinary
Case 76 Cervical Cancer. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177
Rajesh Gupta
Case 77 Simple Renal Cysts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179
Rajesh Gupta
Case 78 Mature Cystic Ovarian Teratoma . . . . . . . . . . . . . . . . . . . . 181
Rajesh Gupta
Case 79 Papillary Urothelial Neoplasm of the Bladder,
Low Malignant Potential . . . . . . . . . . . . . . . . . . . . . . . . . . . 183
Rajesh Gupta
Case 80 Adrenal Adenoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185
Rajesh Gupta
Case 81 Invasive Cancer of the Vulva . . . . . . . . . . . . . . . . . . . . . . . . 187
Rajesh Gupta
Case 82 Physiological FDG Uptake in the Uterus and Ovary. . . . . 189
Jerrin Varghese and Amit Gupta
Case 83 Renal Cell Carcinoma. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 191
Robert Matthews
Case 84 Urinoma: Urinary Fistula. . . . . . . . . . . . . . . . . . . . . . . . . . . 195
Rajesh Gupta
Case 85 Endometrial Polyps and Tamoxifen-Associated
Changes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 197
Rajesh Gupta
Case 86 Prostate Cancer. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 199
Rajesh Gupta
Case 87 Colovaginal Fistula . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 201
Rajesh Gupta
Case 88 Seroma: Post-Operative . . . . . . . . . . . . . . . . . . . . . . . . . . . . 203
Rajesh Gupta
xxii Contents

Case 89 Uterine Leiomyomas. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 205

Rajesh Gupta
Case 90 Invasive Small Cell Bladder Cancer . . . . . . . . . . . . . . . . . 207
Robert Matthews and Rajesh Gupta
Case 91 Bladder Cancer Causing Hydronephrosis in Patient
with Duplicated Collecting System. . . . . . . . . . . . . . . . . . . 211
Rajesh Gupta
Case 92 Recurrent Prostate Cancer with Fluciclovine. . . . . . . . . . 213
Ana M. Franceschi and Robert Matthews
Case 93 Endometrial Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 217
Rajesh Gupta and Apar Gupta

Part V Head and Neck

Case 94 Orbital Rhabdomyosarcoma . . . . . . . . . . . . . . . . . . . . . . . 221
James Bai and Lev Bangiyev
Case 95 Chronic Thyroiditis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 223
Frank Papik and Robert Matthews
Case 96 Base of the Tongue Squamous Cell Carcinoma . . . . . . . . 225
James Bai and Lev Bangiyev
Case 97 Brown Adipose Tissue. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 227
Amit Gupta
Case 98 Squamous Cell Carcinoma of the Maxilla. . . . . . . . . . . . . 229
James Bai and Lev Bangiyev
Case 99 Physiological FDG Uptake in Tonsils. . . . . . . . . . . . . . . . . 231
Jerrin Varghese and Amit Gupta
Case 100 Recurrent Laryngeal Cancer. . . . . . . . . . . . . . . . . . . . . . . 233
Rajesh Gupta
Case 101 Benign Sinus Disease. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 235
Frank Papik and Robert Matthews
Case 102 Recurrent Soft Palate Cancer. . . . . . . . . . . . . . . . . . . . . . . 237
Dharmesh Tank
Case 103 Recurrent Salivary Gland Cancer. . . . . . . . . . . . . . . . . . . 241
Ana M. Franceschi and Lev Bangiyev
Case 104 Tonsillar Squamous Cell Carcinoma. . . . . . . . . . . . . . . . . 243
James Bai and Lev Bangiyev
Case 105 Benign Thyroid Adenoma. . . . . . . . . . . . . . . . . . . . . . . . . . 247
Laura L. Rosenkrantz and Robert Matthews
Case 106 Retropharyngeal Cancer. . . . . . . . . . . . . . . . . . . . . . . . . . . 249
Matthew Comito and James Bai
Contents xxiii

Case 107 Supraglottic Laryngeal Cancer . . . . . . . . . . . . . . . . . . . . . 253

Apar Gupta
Case 108 Recurrent Rhabdomyosarcoma
of the Infratemporal Fossa . . . . . . . . . . . . . . . . . . . . . . . . . 257
Matthew Comito
Case 109 Warthin Tumor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 261
Ana M. Franceschi
Case 110 Squamous Cell Carcinoma of the Scalp. . . . . . . . . . . . . . . 263
Laura L. Rosenkrantz and Robert Matthews
Case 111 Orbital Sarcoidosis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 265
Dharmesh Tank and Anuj Rajput

Part VI Neuroradiology
Case 112 High-Grade Glioma. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 271
Anuj Rajput, Michael Goodman, and Lev Bangiyev
Case 113 Alzheimer’s Disease. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 275
Ana M. Franceschi, Michael J. Hoch, and Timothy M.
Shepherd
Case 114 Pituitary Adenoma. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 277
Jingyu Zhou
Case 115 Oligodendroglioma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 281
Michael J. Hoch, Ana M. Franceschi, and Timothy M.
Shepherd
Case 116 Vascular Dementia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 285
Priya Sharma and Rajesh Gupta
Case 117 Tumor Progression. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 289
Anuj Rajput, Michael Goodman, and Lev Bangiyev
Case 118 Meningioma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 293
Priya Sharma and Rajesh Gupta
Case 119 Mesial Temporal Lobe Sclerosis. . . . . . . . . . . . . . . . . . . . . 295
Ana M. Franceschi, Michael J. Hoch, and Timothy M.
Shepherd
Case 120 Brain Abscess. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 299
James Bai and Lev Bangiyev
Case 121 Glioblastoma Recurrence with Negative FDG PET. . . . . 301
Anuj Rajput, Michael Goodman, and Lev Bangiyev
Case 122 Logopenic Primary Progressive Aphasia. . . . . . . . . . . . . . 305
Michael J. Hoch, Lev Bangiyev, and Timothy M.
Shepherd
xxiv Contents

Case 123 Crossed Cerebellar Diaschisis. . . . . . . . . . . . . . . . . . . . . . . 307

Michael J. Hoch, Ana M. Franceschi, and Timothy M.
Shepherd
Case 124 Amyloid Plaques in Alzheimer’s Disease. . . . . . . . . . . . . . 309
Ana M. Franceschi and Robert Matthews
Case 125 Posterior Cortical Atrophy. . . . . . . . . . . . . . . . . . . . . . . . . 311
Michael J. Hoch, Ana M. Franceschi, and Timothy M.
Shepherd
Case 126 Primary CNS Lymphoma. . . . . . . . . . . . . . . . . . . . . . . . . . 313
Anuj Rajput, Michael Goodman, and Lev Bangiyev
Case 127 Creutzfeldt-Jakob Disease . . . . . . . . . . . . . . . . . . . . . . . . . 315
Ana M. Franceschi, Michael J. Hoch, and Timothy M.
Shepherd
Case 128 Calvarial Hemangioma. . . . . . . . . . . . . . . . . . . . . . . . . . . . 317
Rajesh Gupta and Priya Sharma
Case 129 Dementia with Lewy Body . . . . . . . . . . . . . . . . . . . . . . . . . 319
Ana M. Franceschi, Michael J. Hoch, and Timothy M.
Shepherd
Case 130 Cerebral Amyloid Angiopathy
with Alzheimer’s Disease. . . . . . . . . . . . . . . . . . . . . . . . . . . 321
Robert Matthews
Case 131 Dural Metastases. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 325
Ana M. Franceschi and Robert Matthews
Case 132 Frontotemporal Dementia. . . . . . . . . . . . . . . . . . . . . . . . . . 327
Ana M. Franceschi
Case 133 Neurosarcoidosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 329
Eric van Staalduinen
Case 134 Tumor Pseudoprogression. . . . . . . . . . . . . . . . . . . . . . . . . . 331
Anuj Rajput, Michael Goodman, and Lev Bangiyev
Case 135 Semantic Dementia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 333
Lev Bangiyev, Michael J. Hoch, and Timothy M.
Shepherd
Case 136 Normal Pressure Hydrocephalus. . . . . . . . . . . . . . . . . . . . 335
Ana M. Franceschi and Lev Bangiyev
Case 137 Brain Metastases. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 337
Anuj Rajput, Michael Goodman, and Lev Bangiyev
Index. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 339
Contributors

James Bai, MD Department of Radiology, Stony Brook University Hospital,

Stony Brook, NY, USA
Lev Bangiyev, DO Department of Radiology, Stony Brook University
Hospital, Stony Brook, NY, USA
David Capaldi, MD, MBA Department of Radiology, Stony Brook
University Hospital, Stony Brook, NY, USA
Matthew Comito, MD Department of Radiology, Stony Brook University
Hospital, Stony Brook, NY, USA
Ana M. Franceschi, MD Department of Radiology, NYU Langone Medical
Center, New York, NY, USA
Michael Goodman, BA Stony Brook University School of Medicine, Stony
Brook University Hospital, Stony Brook, NY, USA
Amit Gupta, MD Department of Radiology, Stony Brook University
Hospital, Stony Brook, NY, USA
Apar Gupta, MD, MBA Department of Radiation Oncology, Rutgers
Cancer Institute of New Jersey, New Brunswick, NJ, USA
Rajesh Gupta, MD Department of Radiology, Stony Brook University
Hospital, Stony Brook, NY, USA
Michael J. Hoch, MD Department of Radiology and Imaging Sciences,
Emory University Hospital, Atlanta, GA, USA
Robert Matthews, MD Department of Radiology, Stony Brook University
Hospital, Stony Brook, NY, USA
Frank Papik, BA Stony Brook University School of Medicine, Stony Brook
University Hospital, Stony Brook, NY, USA
Anastasia Plaunova, MD Department of Radiology, Stony Brook University
Hospital, Stony Brook, NY, USA
David Pouldar, MD Albany Medical Center, College of Medicine, Albany,
NY, USA
Anuj Rajput, MD Department of Radiology, Stony Brook University
Hospital, Stony Brook, NY, USA

xxv
xxvi Contributors

Laura L. Rosenkrantz, BS, MS Stony Brook University School of

Medicine, Stony Brook University Hospital, Stony Brook, NY, USA
Elham Safaie, MD Department of Radiology, Stony Brook University
Hospital, Stony Brook, NY, USA
Christopher Shackles, DO Department of Radiology, Stony Brook
University Hospital, Stony Brook, NY, USA
Priya Sharma, MD Department of Psychiatry, Parkwood Institute, Western
University, London, ON, Canada
Timothy M. Shepherd, MD, PhD Department of Radiology, NYU Langone
Medical Center, New York, NY, USA
Eric van Staalduinen, DO Department of Radiology, Stony Brook
University Hospital, Stony Brook, NY, USA
Joseph R. Stein, DO Department of Radiology, Stony Brook University
Hospital, Stony Brook, NY, USA
Dharmesh Tank, MD Department of Radiology, Stony Brook University
Hospital, Stony Brook, NY, USA
Kelly Tisovic, MD Department of Neurology, Stony Brook University
Hospital, Stony Brook, NY, USA
Jerrin Varghese, MD Department of Radiology, Stony Brook University
Hospital, Stony Brook, NY, USA
Kavitha Yaddanapudi, MD Department of Radiology, Stony Brook
University Hospital, Stony Brook, NY, USA
Mark K. Youssef, MD Department of Radiology, Stony Brook University
Hospital, Stony Brook, NY, USA
Jingyu Zhou, MD Department of Radiology, Stony Brook University
Hospital, Stony Brook, NY, USA
Abbreviations

ADC Apparent diffusion coefficient

BLADE Motion-insensitive multi-shot turbo spin echo sequence
CT Computed tomography
DOTATATE DOTA-octreotate (radiopharmaceutical)
DWI Diffusion-weighted imaging
FDG F-18-fluorodeoxyglucose (radiopharmaceutical)
FLAIR Fluid-attenuated inversion recovery
FLASH Fast low angle shot, spoiled gradient echo sequence
GRE Gradient echo sequence
HASTE Half-Fourier acquisition single-shot turbo spin-echo
MIP Maximum intensity projection
MPRAGE 3D magnetization-prepared rapid acquisition GRE
MRI Magnetic resonance imaging
PET Positron emission tomography
SUV Standardized uptake value
SWI Susceptibility-weighted imaging
STIR Short tau inversion recovery
True FISP Fast imaging with steay-state free precession, gradient echo
sequence
TSE Turbo spin echo sequence
VIBE Volumetric interpolated breath-hold examination

xxvii
 Part I
Musculoskeletal
 Case 1
Recurrent High-Grade
Sarcoma
Rajesh Gupta
History
A 74-year-old female with left lower leg sar-
coma, treated by below-knee amputation, has a
new palpable lump at the stump, concerning for
recurrence (Fig. 1.1).
Diagnosis
Recurrent high-grade sarcoma
Findings
• Moderately well-circumscribed lesion at the
medial aspect of the left stump which has low
signal on T1-weighted images and intermedi-
ate signal on T2-weighted images (arrows).
• Post-contrast image demonstrates heteroge-
neously avid contrast enhancement, mostly
peripheral (arrowheads).
• PET/MR fusion images show heterogeneous
abnormal FDG uptake within this soft tissue
lesion along the distal portion of the tibial
stump consistent with recurrence.
© Springer International Publishing AG 2018
R. Gupta et al., PET/MR Imaging, https://doi.org/10.1007/978-3-319-65106-4_1
Discussion
Sarcomas are malignant cancers that arise from
mesenchymal origins. They can arise in the mus-
cle, bone, fat, or connective tissue. Sarcomas
most often present as a mass. There are various
histopathological subtypes which manifest as
different clinical presentations and diagnoses. It
is important to assess the grade of the tumor as it
impacts staging, prognostic, and treatment
implications.
MR imaging is the primary modality of
choice to evaluate sarcomas, especially those
arising in the soft tissues. MR can reliably iden-
tify tumor depth beneath fascial planes, tumor
size, growth, and internal signal characteristics.
Generally, high-grade tumors show isointense
signal on T1-weighted images, heterogeneously
high signal on T2-weighted images, and hetero-
geneous enhancement on post gadolinium
images. Poorly defined tumor margin and peri-
tumoral contrast enhancement on MRI indicate a
more invasive and aggressive tumor implying a
higher-grade pathology.
FDG PET imaging can reliably distinguish
between low-grade and high-grade sarcomas by
3
4 R. Gupta
Fig. 1.1 T1 TSE axial of stump (a), T2 TSE with fat sup-
pression axial of stump (b), T1 GRE with fat suppression
post-gadolinium contrast axial of stump (c), PET/MR T1
the intensity of FDG uptake. FDG can detect
small areas of high-grade differentiation in a
large mass helping to direct biopsy targets. FDG
PET is effectively used for sarcoma tumor stag-
ing and monitoring treatment response.
Combined PET/MR provides excellent evalua-
tion of the sarcoma tumor and surrounding soft
tissues, as well as provides functional metabolic
activity to aid in accurate tumor grading and stag-
ing. It can detect satellite lesions away from the
VIBE axial fusion (d), and PET/MR T1 VIBE sagittal
fusion of left knee (e)
main mass and distant metastases allowing for
complete evaluation in one study.
Suggested Reading
Eary JF, Conrad EU. Imaging in sarcoma. J Nucl Med.
2011;52:1903–13.
Zhao F, Ahlawat S, Farahani SJ, Weber KL, Montgomery
EA, Carrino JA, et al. Can MR imaging be used to pre-
dict tumor grade in soft-tissue sarcoma? Radiology.
2014;272:192–201.
 Case 2
Bone Metastases from
Lung Cancer
Rajesh Gupta
History
A 78-year-old female with lung cancer presents
with bone pain (Fig. 2.1).
Diagnosis
Bone metastases from lung cancer (adenocar
cinoma)
Findings
• STIR hyperintense signal at T11 vertebral body
with increased signal on T1-weighted Dixon
out-­of-­phase indicating lack of fat content.
• PET/MR image shows intense FDG uptake at
T11 vertebral body (wide arrow).
• Similar hyperintense STIR signal at C7 verte-
bral body with increased FDG activity (curved
arrow).
Discussion
Skeletal metastases arise from a variety of pri-
mary cancers, with the most prevalent being lung
cancer, breast cancer, renal cell carcinoma, and
prostate cancer. Metastases account for the
majority of malignant bone tumors. They may be
asymptomatic or cause localized bone pain.
© Springer International Publishing AG 2018
R. Gupta et al., PET/MR Imaging, https://doi.org/10.1007/978-3-319-65106-4_2
Complications include pathologic fractures, cord
compression, and hyper- or hypocalcemia.
The goal of imaging in skeletal metastases is
to detect metastases early, assess treatment
response, and identify vertebrae with risk of frac-
ture. It can also be useful in determining if frac-
tures are causing spinal cord compression, which
may need surgical intervention. MR imaging can
detect metastatic bone marrow involvement very
early on due to its high soft-tissue contrast and
high spatial resolution. The T1-weighted and
STIR sequences are excellent for marrow evalua-
tion and eliminate the need for intravenous con-
trast in patients with poor renal function.
T1-weighted images have the highest sensitivity
at detecting vertebral metastases but low specific-
ity. The addition of STIR somewhat increases the
specificity. Generally, involved marrow will
show low T1-weighted signal due to fatty mar-
row replacement by malignant cells with
increased signal on STIR and T2 images. If con-
trast is given, these malignant lesions will dem-
onstrate enhancement. Purely osteoblastic lesions
demonstrate low signal on both T1 and
T2-weighted images, as well as STIR sequences.
Whole-body techniques to evaluate the skeleton
in one session are gaining popularity.
The Dixon technique provides uniform fat and
water separation that is resistant to inhomogene-
ity compared to chemical-shift fat-suppression
techniques. It also has the advantage of faster
scan times and maintaining image signal-to-
noise ratio. Dixon MRI sequences provide an
5
6 R. Gupta
Fig. 2.1 STIR sagittal (a), Dixon T1-weighted out-of-phase sagittal (b), PET/MR Dixon T1-weighted out-of-phase
sagittal fusion (c), and PET sagittal (d)
out-of-­
phase, in-phase image, fat-only, and
water-only images. Metastatic bone lesions
replace the bone marrow and do not drop on
opposed-phase imaging. Dixon-based whole-
body MRI has been shown to be specific and
more sensitive than bone scan in detecting bone
metastases, especially in breast cancer.
Overall MRI and PET imaging are roughly
equal in sensitivity in detecting metastases.
However, MRI has better resolution and can
detect smaller lesions, while PET has the capabil-
ity to effectively detect lesions on whole-body
images. It can provide metabolic information
related to the aggressiveness of the lesion and can
determine whether the lesion is active following
treatment. The use of FDG in PET/MR imaging
allows for superior anatomic localization and
functional assessment of malignant skeletal
lesions and their response to therapy.
Suggested Reading
Costelloe CM, Kundra V, Ma J, Chasen BA, Rohren
EM, Bassett RL Jr, et al. Fast Dixon whole-body
MRI for detecting distant cancer metastasis: a pre-
liminary clinical study. J Magn Reson Imaging.
2012;35(2):399–408.
Heindel W, Gübitz R, Vieth V, Weckesser M, Schober O,
Schäfers M. The diagnostic imaging of bone metasta-
ses. Dtsch Arztebl Int. 2014;111(44):741–7.
O’Sullivan GJ, Carty FL, Cronin CG. Imaging of
bone metastasis: an update. World J Radiol.
2015;7(8):202–11.
 Case 3
Benign Notochordal
Remnant
Rajesh Gupta
History
A 24-year old male with Hodgkin’s lymphoma
presents for restaging after treatment completion
(Fig. 3.1).
Diagnosis
Benign notochordal remnant
Findings
• Well-circumscribed lesion within L3 vertebral
body that is T1 hypointense and STIR hyper-
intense (thin arrow).
• No abnormal FDG activity associated with
lesion.
• No evidence for bone expansion, destruction,
or extraosseous extension.
Discussion
The notochord, in humans, is an embryonic struc-
ture that induces vertebral column formation and
then disappears, leaving cellular remnants in the
nucleus pulposus of the intervertebral discs. It is
believed that notochord regression can arrest at
any point, leaving notochordal cells along its
© Springer International Publishing AG 2018
R. Gupta et al., PET/MR Imaging, https://doi.org/10.1007/978-3-319-65106-4_3
course which can undergo hyperplasia.
Notochordal remnants are occasionally found in
the fetal and adult vertebrae on autopsy. Giant
vertebral notochordal rest and notochordal ham-
artoma are terms that have been used to describe
what is now collectively referred to as benign
notochordal cell tumors. These tumors are
intraosseous lesions of notochordal cell origin. It
is important to distinguish this benign entity from
chordoma, its malignant counterpart that also
arises from notochordal cells.
There are several MR imaging features that
can help distinguish a benign notochordal rem-
nant from chordoma. Both arise in the midline
and exhibit low to intermediate signal on T1 and
high signal on T2-weighted images. However,
chordomas usually enhance, are destructive and
expansile, and can be associated with a soft tissue
component. On the other hand, benign noto-
chordal cell remnants are usually confined to
bone without expansion and do not enhance fol-
lowing contrast administration.
Benign notochordal remnants will not show
hypermetabolic activity on FDG-PET imaging.
Chordomas most commonly arise in the sacro-
coccygeal region and have been described to
demonstrate heterogeneously increased FDG
uptake. Although benign notochordal remnants
are likely to be an incidental finding, PET/MR
imaging allows for thorough evaluation of these
benign lesions to ensure that there is no malig-
nant potential.
7
Another random document with
no related content on Scribd:
"Sure," she sneered, "sure it can be done. The 'dozer must have
almost half the power of this hulk. We'll get there all right. We'll get
there about the time the people upstairs pile up on the landing strip
that isn't there. Then we can use the 'dozer to give them a good,
Christian burial.
"Hell, Marsh, there's no sense trying to do it that way. That hole can't
be very big. If we take the mercury out of the 'dozer and add what we
can find lying around on the sand, and then pour it back in and weld
the hole shut, we'll be all right. We'll get there a day or two later, but
that won't be nearly as bad as if we try to tow with the 'dozer. Then
we can swap mercury again and use the 'dozer. Couldn't be any
simpler than that."
Like a fool, I tried to be logical: "How long do you think that weld
would hold, kid? And then where would we be?"
"Right where we are now, only maybe a few miles closer. We haven't
got anything to lose, and we've got everything to gain."
That was the start. In the course of an hour and a half, we covered
every possibility and impossibility of the situation. Whatever one of us
brought up, the other argued against. We talked like crazy.
We were.
When it finally penetrated that we'd both known everything we'd
covered, before we started, I said bluntly: "Shut up."
"Go to hell."
"I suppose I will, eventually. Should I expect to see you there?"
"No."
"I'm sure it can be arranged," I said as I got up.
"You're not going to—?" she asked, suddenly really alarmed.
"No." By that time, she was on her feet, too. I spun her around and
forced her to the floor. Then I tied her hands behind her back with
some wire that had been lying on the floor behind me. I didn't try to tie
her too tightly; just tight enough to be sure she couldn't get at the
knots.
She didn't resist nearly as much as I had expected.
I repeated the process on her ankles, then gagged her to stop the
insane conversation, and put her in her bunk.
Then I turned out the lights and crawled into my own.
It never occurred to me that there were dozens of things she could
cut herself loose with, just lying around the compartment.

I awoke and threw my arm up from sheer instinct. I grabbed

something soft, and half-heard a metallic clatter behind my head.
There was a weight on top of me, and then the weight and I were on
the floor, locked together with the blanket between us.
Full consciousness was slow in coming, in spite of the shock of the
activity. It seemed better, somehow, to just stay in that halfway state
and enjoy it without knowing why. Finally, gradually, it penetrated that
these were "the motions" that we were going through, but that we
were not just "going through the motions."
This was for real.
A nasty question followed the thought: if this was for real, why did she
keep wriggling and twisting all the time? The answer was close
behind. She never had been able to hold still when her husband held
her.
It seemed ages before we both realized how unsatisfactory it was to
be separated by that blanket, and released each other and lay apart,
with the blanket half on me and half on her. After more ages, I got up
and turned on the lights. There were certain formalities that really
should be observed.
While I pulled on the outer skin of my spacesuit—I wouldn't be
outside long enough to need any more—Helene quietly picked out
the large wrench she'd dropped at the head of my bunk, and put it
back in the case it had come from.
Love and hate are separated only by the thin edge of a coin ... flip it
and it can come up either way....
I picked up a sterile specimen tube and a thin, small sheet of metal,
locked my helmet in place, and went out.
It took me a little longer than I'd expected to find a reasonably large
blob of mercury, but I made up for it by getting it into the tube on the
second attempt.
I was just beginning to feel the cold when I got back to the tractor.
Helene had the specimen preservation kit out and open. I sealed the
mercury in transparent plastic, made a ring from a piece of wire,
bonded the mercury to it, and coated the whole works with more of
the transparent plastic.
It wasn't much, but—
Then we got out the Bible.
Later, we set up a double bunk.
We didn't set the alarm. That was our honeymoon.

Neither of us said a word in the morning; actually it was past noon.

We didn't have to. There was only one thing we could do that made
the slightest sense.
I got out the welder and burned off the tractor's cab, then went
underneath and cut through the mountings on the useless engine and
everything else that wasn't an absolute essential.
Helene dumped everything movable and non-essential from inside.
Shortly before dusk I tossed the now-useless welder on top of the
other junk and climbed onto the 'dozer and pulled out. There weren't
any brakes on what was left of the tractor, but that would have to not
matter. We were going to have to drive 'round the clock or not get
there in time. A bulldozer is not a fast vehicle under any
circumstances.
Logically, I couldn't see that we had much chance of covering eleven
hundred miles in that rig, without having to make at least one stop
quick enough to collapse the towbar and land the tractor on top of the
'dozer.
Emotionally, I couldn't believe a word of it. I knew we were going to
get there.
We did.
Forty-eight days after the crash, I drove through the blackened edge
of the northernmost "marker area," and parked just inside its southern
tip.
When I came up through the airlock, Helene was looking out what
had been the forward port of the tractor, which now faced the area we
would have to make into a landing strip.
When I had the inner layer of my suit half off, she spoke for the first
time since we'd been married: "We made it, Marsh."
I joined her and looked out into the dusk. It was going to be rough,
but we could do it. "Not quite," I said, "we've still got that strip to chew
out."
She was silent a moment, then said, tightening her arm around me: "I
know. I said we made it, Marsh."
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