PET/CT

Dr Sanjai N Moderator: Dr Aswini Kumar Mohapatra

 INTRODUCTION – PET SCAN

 PET scan is an established mode of imaging for the diagnosis, staging

and follow up in oncologic practice

 It is a 3D diagnostic imaging technology in nuclear medicine

measuring physiological function of cellular metabolism
 ADVANCES TO PET/CT

 Most important limitation of PET is that anatomic structures are poorly

depicted

 Later a single intergrated device was invented by Townsend and his

colleagues in 1998

 To overcome this CT images were superimposed with PET images using

software algorithms
 PRINCIPLE OF PET SCAN

 FDG - affinity towards glucose receptors on cell surface

 Overexpression of glucose transporter 1 receptors on cancer tissue

surfaces enhances glycolysis and attracts more FDG uptake,
where conversion into FDG-6-phosphate by glucose-6-phosphatase
takes place

 This process can be translated using a PET system as an intense

uptake of FDG, called metabolic imaging
FDG METABOLISM

Griffeth LK. Use of PET/CT scanning in cancer patients: technical and practical considerations. InBaylor University Medical
Center Proceedings 2005 Oct 1 (Vol. 18, No. 4, pp. 321-330). Taylor & Francis.
ANNIHILATION OF ATOMS – CONVERSION OF
PARTICLE TO EM ENERGY
Decay of the radiotracers

Produce small particles called positrons

React with electrons in the body

Two particles combine and they annihilate each other

Kapoor V et al . An introduction to PET-CT imaging. Radiographics. 2004 Mar;24(2):523-43.

ANNIHILATION OF ATOMS

Annihilation produces a small amount of energy in

the form of two photons

Each photon has an energy of 511kev

Photons are detected by crystal

detectors in PET scanner
 STANDARD UPTAKE VALUE (SUV)
 A measurement of relative tissue uptake of F18 FDG compared to
dose injected

 SUV = Tracer activity in the tissue

Injected dose/patient weight

Kapoor V et al . An introduction to PET-CT imaging. Radiographics. 2004 Mar;24(2):523-43.

 STANDARD UPTAKE VALUE (SUV)

 If SUV is >2.0 is suggestive of malignancy, whereas lesions with SUVs <2

are considered to be benign.

Pitfall: False positivity

 Active infectious or inflammation may result in SUVs comparable to
SUVs in malignancy.
 Clinical history ,anatomic correlation and HPE are required for
confirmation of any finding on FDG PET

Andrew Newberg MD, in Radiology Secrets Plus (Third Edition), 2011

PROTOCOL
A TYPICAL PET/CT IMAGE SET OBTAINED FROM A 53-YEAR-OLD MAN WITH
LYMPHOMA WITH INCREASED FDG UPTAKE IN THE SPLEEN AND MULTIPLE INTRA
THORACIC AND EXTRA THORACIC NODES.
CORONAL IMAGES ARE SHOWN (A) CT, (B) PET, AND (C) FUSION IMAGE.
INDICATIONS- ONCOLOGICAL AND NON
ONCOLOGICAL

 Oncology-
 Primary areas of interest are Diagnosis, staging, treatment-effectiveness
monitoring, and radio therapeutic planning (96%)

 Non oncological -
 Infection (2%) – TB, NTM

 Non infection inflammatory process-pneumoconiosis, sarcoidosis, cystic

fibrosis
 INDICATIONS- ONCOLOGICAL
AND NON ONCOLOGICAL CONDT

Non oncological -

 Cardiology (1%)- to assess myocardial perfusion

 Neurology (1%)- Alzheimer’s, Parkinson’s, Tumor recurrence and

viability vs. post-surgical, post-chemo, post-radiotherapy changes of
tissue necrosis
ROLE OF FDG PET/CT NON–SMALL CELL LUNG
CANCER

 NCCN recommend PET/CT with fluorine 18 FDG for evaluation of patients

with stage I to stage IV NSCLC
 Combining FDG PET with a conventional workup led to a 51% relative
reduction in futile thoracotomy, with an overall one in five reduction in
unnecessary surgery
 As per NCCN guidelines, PET/CT positive for distant disease and
mediastinal nodes needs histopathologic confirmation
 PET/CT recommended for evaluation of an incidentally detected lung
nodule measuring more than 8 mm

van Tinteren H, Hoekstra OS, Smit EF, et al. Effectiveness of positron emission tomography in the preoperative
assessment of patients with suspected non-small-cell lung cancer: the PLUS multicentre randomised trial. Lancet 2002
IMAGING
ROLE OF PET/CT IN NSCLC PRIMARY
TUMOR
 FDG PET/CT is superior to CT in differentiating between tumor and
postobstructive atelectasis, a distinction that is important for local
disease staging, percutaneous biopsy, radiation therapy planning, and
assessment of treatment response
IMAGING
ROLE OF PET/CT IN NSCLC PRIMARY
TUMOR
 FDG PET/CT may add specificity to CT findings of lymphangitic
carcinomatosis by showing increased metabolism in nodular interlobular
septal thickening

 False-negative can be seen in nodules less than 8–10 mm in diameter

(T1a), mucinous adenocarcinomas with a relatively small amount of cells,
and low-grade malignancies such as carcinoma in situ (Tis) and minimally
invasive adenocarcinoma
IMAGING
 ROLE OF PET/CT IN DISTANT
METASTASIS IN NSCLC

 High accuracy of FDG PET/CT in the diagnosis of malignant pleural

effusion

 FDG PET/CT has greater sensitivity and specificity than bone

scintigraphy for imaging metastases to the bone marrow
ROLE OF PET/CT IN DISTANT
METASTASIS
 In locally advanced NSCLC that is suitable for curative intent, FDG
PET/CT may be used to identify unsuspected metastases, reducing
the frequency of futile thoracotomies

 The rates of progression-free survival and overall survival are

significantly worse (P < .001) in upstaged disease with PET/CT
ROLE OF PET/CT IN DISTANT
METASTASIS
  Contrast-enhanced MRI has a higher sensitivity than FDG PET/CT
for assessing brain metastases in patients with lung cancer (21% vs
77%)

 Nodal uptake of FDG that is higher than the blood pool is suspicious
for nodal metastases; if higher than the liver uptake, highly
concerning for nodal metastases
ROLE OF PET/CT IN DISTANT
METASTASIS
 Mean CT attenuation greater than 10 HU and a maximum SUV greater
than 3.1 had a sensitivity and specificity of 97% and 86% for identifying
adrenal mets

 Adrenal hyperplasia, adrenal adenoma, and infections such as

tuberculosis can result in false-positive results

 Histologic diagnosis is recommended if the adrenal gland is the only

site of metastatic disease
 LIMITATIONS OF PET/CT

 Inflammatory disease is a known confounder

 Difficulty in depicting invasion of the chest wall or diaphragm
 Non detection of some well-differentiated pulmonary
adenocarcinomas
 Misclassification of benign inflammatory nodules
 High costs
 Exposure to radiation
IMAGING
 LIMITATIONS OF PET/CT

 False positivity: Inflammatory pseudotumor (43%), tuberculoma

(37%), organizing pneumonia (6%)
 Interstitial pneumonitis, previous tuberculosis, silicosis, and
emphysema
 False negativity: small nodule, low cellular density in lesions such as
carcinoma in situ,  mucinous adenocarcinoma
 LIMITATIONS OF PET/CT

 False positive uptake of FDG by normal tissues, such as the brain,

muscles, salivary glands, thyroid gland, myocardium, gastrointestinal
tract, and the urinary tract.

 Patient motion artifacts with the PET/CT

TUBERCULOSIS AND NONTUBERCULOUS
MYCOBACTERIA

1) Pulmonary type - more localised type of infection

2) Lymphatic pattern - more intense, systemic infection
Potential role in the functional assessment of inflammatory and
infectious pulmonary diseases
“Different uptake patterns according to the grade of inflammatory
activity”
NON-ONCOLOGICAL CONDITIONS

 It has been used to monitor the course of disease after treatment in

aspergillosis and to evaluate the efficacy of chemotherapy in
echinococcosis infection
 Role in organising pneumonia (OP), consequences of solid-organ
transplantation, drugs and radiotherapy, or aspiration diseases
 Increased uptake has been studied in pneumoconiosis
 It may be recommended for use as in symptomatic patients in
sarcoidosis
NON-ONCOLOGICAL CONDITIONS

 FDG uptake correlate significantly with functional markers of disease

severity, such as diffusing capacity for carbon monoxide and forced vital
capacity 
 In cystic fibrosis - higher rates of decline in pulmonary function have
higher numbers of neutrophils in BAL and higher PET-measured rates of
FDG uptake
 Due to the inflammatory base reactivity involved in LCH development,
FDG-PET/CT can be helpful in its clinical assessment, including
monitoring response to therapy 
NON-ONCOLOGICAL CONDITIONS

 FDG-PET is useful in differentiating pulmonary infection from acute

rejection as the latter does not elicit as high a neutrophilic response to
infection
CONTRAINDICATIONS

 Specific clinical contraindications- Pregnancy, contagious active

disease, allergic reaction

 Relative contraindication – recent chemo/radiotherapy, medicines

that change metabolism- Insulin; caffeine, alcohol, tobacco within
24 hrs
THANK YOU