Clinical PET-CT in Radiology (eBook)

Preface 6
Contents 8
Contributors 12
Chapter 1: Principles, Design, and Operation of Multi-slice CT 16
Basic CT Principles 16
CT Design 19
Advanced CT Principles 20
Topogram 21
Conventional CT 21
Spiral CT 21
Cone-Beam CT 22
Cardiac CT 23
Dynamic CT 26
Dose and Image Quality 26
Penumbra Effects 30
Manufacturers’ Efforts 31
Summary 32
References 33
Chapter 2: PET Imaging Basics 35
PET Radiotracers 35
Coincidence Detection Physics 35
Positron Annihilation 35
Coincidence Detection 35
Image Reconstruction 36
Background Events 37
Scattered Events 37
Random Events 38
Background Events and Count Statistics 38
Extended Axial Field of View and 3D PET 38
Spatial Resolution and Block Detectors 39
Attenuation 39
Attenuation Correction 40
PET Quantitation 42
References 42
Chapter 3: Design and Operation of Combined PET-CT Scanners 43
Introduction 43
Design Objectives 44
Current Technology for PET-CT 45
CT-Based Attenuation Correction 48
PET-CT Protocols 49
Conclusions 51
References 51
Chapter 4: CT-Based Attenuation Correction for PET 53
Transforming the CT Images 54
Benefits of CT-Based Attenuation Correction 57
Metal Artifacts and Contrast Agents 57
Cardiac Applications 59
References 59
Chapter 5: Technical Artifacts in PET-CT Imaging 61
Introduction 61
PET-CT and CT-Based Attenuation Correction 61
Artifacts: Origins, Presence, and Corrections 62
Motion Artifacts 63
Respiration-Induced Mismatch 63
Cardiac Motion 63
Muscle Relaxation 64
Global Patient Motion 65
High-Density Artifacts 66
Metal Implants 66
CT Contrast Agents 68
Patient Setup Considerations 70
Arm Position and Beam Hardening 70
Truncation Effects 70
Positioning Aids 71
Conclusion 71
References 72
Chapter 6: Quantitation of PET Data in Clinical Practice 74
Time Dependence 74
SUVmax 75
Glucose and Insulin Levels 75
Body Weight 75
Partial Volume 75
Nonmalignant FDG Uptake 76
Threshold Concept 76
Target to Background Ratio 77
Assessment of Response to Therapy 78
Reproducibility of SUV Measurements 78
Conclusion 78
References 78
Chapter 7: Patient Preparation and Management 80
Scheduling 80
Support Services 82
Patient Preparation 82
Preappointment Communication and Consultation 82
Managing Patients with Diabetes 84
Managing Patients with Pain, Claustrophobia, or Anxiety 85
Hydration 87
Physical Activity 87
Diet and Fasting 87
Bowel Preparations 87
Managing Patients Who Are Pregnant or Nursing 87
PET-CT Examination Duration 88
Prior Imaging Examinations and Clinical Information 88
Appointment Check-in and Day of Service Clinical Consultation 88
FDG Administration and Uptake Phase 89
IV Setup and FDG Administration 90
CT Contrast Media 91
The FDG Uptake Phase 92
PET-CT Imaging Acquisition 92
Postimaging Considerations 95
Conclusion 95
References 95
Chapter 8: Radiation Protection of Technologists and Ancillary Personnel 96
Introduction 96
The Challenges of PET-CT 96
The Principle of ALARA 96
PET-CT Regulations 97
Regulatory Authority 97
Occupational and Public Dose Limits 97
Receipt and Disposal of Radioactive Material 98
Quality Control 98
Warning Signs and Shielding Personal Protective Equipment 98
Medical Events 98
Record Retention 98
Minimizing Radiation Exposure to Technologists and Physicians 99
Minimizing Radiation Exposure to Patients 100
Minimizing Radiation Exposure to Ancillary Personnel 101
PET-CT Shielding Considerations 101
Summary 102
References 102
Chapter 9: Application of CT Contrast Agents in PET-CT Imaging 104
Introduction 104
Contrast Agents in CT 104
Intravenous Contrast Agents 104
Oral Contrast Agents 105
Contrast Agents in PET-CT 105
Contrast Agents and PET Attenuation Correction 105
Contrast Protocols 107
Benefits of CT Contrast Agents in PET-CT 109
Lesion Detection and Characterization 109
Lesion Localization 109
Contrast Indications in PET-CT 112
Summary 113
References 113
Chapter 10: Performance, Interpretation, and Reporting of PET-CT Scans for Body Oncology Imaging 115
PET-CT Protocols for Body Oncology Imaging 115
Torso Imaging and Whole Body Imaging 121
Head and Neck Imaging 122
Oral Contrast 122
Intravenous Contrast 124
Image Reconstruction and Postprocessing 124
PET-CT Performed for Radiation Therapy Planning 125
Interpretation and Reporting of Body Oncology PET-CT Scans 126
References 127
Chapter 11: Pediatric Management and Preparation in PET-CT 129
Preinjection Preparation 129
Protocol 129
Glucose Status 129
Bowel Contrast 129
Activity Restriction 129
Injection and Uptake 130
Vascular Access 130
Hydration 130
Activity Restriction 130
Scanning 130
Sedation 130
Iodinated Contrast 130
CT Scanning 131
CT Radiation Dose Modulation 131
PET Scanning 131
Suggested Readings 131
Chapter 12: PET-CT in Radiation Treatment Planning 132
Target Volumes 132
Clinical Applications 132
Non-small Cell Lung Cancer 132
Head and Neck Cancer 136
Other Malignancies 136
Technical Issues in PET-CT Treatment Planning 136
Defining the Target 137
Future Directions for Radiation Therapy Planning 138
Biologic Target Volume 138
Tumor Motion 138
Conclusions 138
References 139
Chapter 13: Probability and the Principles of Diagnostic Certainty in Medical Imaging 141
Validity of Clinical Information Provided 141
Spectrum (Selection) Bias 142
Diagnostic and Test Review Bias 143
Verification Bias 144
Other Sources of Bias in Diagnostic Studies 145
Clinical Information and the Presence of Disease 145
Sensitivity and Specificity 145
The Receiver Operating Characteristic (ROC) Curve 145
Clinical Information, Patient Characteristics, and the Probability of Disease 147
A Few Notes of Caution Regarding Uncertainty 149
Meta-analysis and Evidence in Diagnostic Trials 150
Given This Information, What Should Be Done? 151
Economic Evaluation: Diagnostic Efficacy at Levels 5 and 6 151
Use of the ROC Curve to Compare Cost-Effectiveness of Tests 153
Summary 153
References 154
Chapter 14: Principles of Medical Imaging in the Diagnosisand Staging of the Cancer Patient 156
TNM Staging 156
Clinical and Pathologic Staging 162
Limitations of TNM Staging 162
Staging Issues with New Technology 162
PET-CT Imaging and Staging 163
References 164
Chapter 15: Principles of PET in Cancer Treatment for the Assessment of Chemotherapy and Radiotherapy Response and for Radiotherapy Treatment Planning 165
PET and Response Assessment 165
PET and Radiotherapy Planning 166
Technicalities of Planning 166
Challenges of Clinical Applications 167
Significance of Clinical Evidence 167
Planning Inaccuracies 167
The Future of PET in Treatment Planning: Imaging Biologic Phenotype In Vivo 168
Dose Painting and Biologic Target Volume 168
Conclusions 169
References 169
Chapter 16: PET-CT Imaging of Lung Cancer 171
Primary Diagnosis of Lung Cancer 171
Staging Lung Cancer with PET-CT 174
T Staging 175
Lymph Node Staging 176
Detection of Metastases 178
Bronchioloalveolar Carcinoma 179
Small Cell Lung Cancer 180
Restaging Lung Cancer with PET-CT 181
Regional Recurrence of Lung Cancer Following Surgical Treatment 182
Recurrence of Lung Cancer Following Radiation Therapy 183
Therapy Monitoring with PET-CT 184
PET-CT in Radiation Therapy Planning 184
Pitfalls of Combined PET-CT Imaging of Pulmonary Malignancies 184
References 187
Chapter 17: PET-CT of Esophageal Cancer 189
Diagnosis 189
Staging 189
Restaging 193
Therapy Monitoring 193
RT Planning 195
References 199
Chapter 18: PET-CT of Head and Neck Cancers 200
Imaging the Patient with Head and Neck Cancer 200
Staging and Restaging 200
Conventional Imaging 200
Advanced Cross-sectional Techniques 201
Role of PET-CT in Staging 203
Role of PET-CT in Posttreatment Monitoring 203
PET-CT in Unknown Primary Tumors 204
Salivary Gland Malignancies 206
Treatment Planning 207
Treatment Complications 207
Pitfalls and Artifacts of PET-CT in the Head and Neck 208
Thyroid Gland 209
Salivary Glands 209
Muscles of the Neck and Face 210
Muscles of the Oropharynx and Nasopharynx 211
Laryngeal Muscles 211
Fat 211
Lymphoid Tissue 212
Mucosa 212
PET-CT Artifacts 212
Conclusion 212
References 213
Chapter 19: PET-CT of Thyroid Cancer 215
Anatomy Relevant for PET-CT 217
The Thyroid Gland 217
Lymphatic Drainage 218
Classification and Staging of Thyroid Carcinoma 218
18F-FDG PET in Thyroid Cancer 219
Normal Distribution of FDG in the Neck, Variants, and Pitfalls 219
Focal and Diffuse High Uptake in the Thyroid Gland as an Incidental Finding on FDG PET 221
Influence of TSH Level on 18F-FDG Uptake 222
131I Negative/Thyroglobulin Positive Patient 223
Hürthle Cell Carcinoma 225
Medullary Thyroid Cancer 225
Anaplastic Thyroid Carcinoma 226
References 228
Chapter 20: PET-CT in Breast Cancer 232
Role of PET-CT in Initial Diagnosis of Breast Cancer 232
Staging 233
T Staging 237
N Staging 237
M Staging 240
Restaging 243
Therapy Monitoring 246
Radiation Therapy Planning 246
References 248
Chapter 21: PET-CT in Colorectal Carcinoma 249
Current Management of Colorectal Cancer 249
Surgical Treatment of Rectal Cancer 249
Surgical Treatment of Colon Cancer 249
Role of PET/CT in the Initial Diagnosis of Colorectal Carcinoma 252
Staging of Colorectal Carcinoma with PET/CT 252
Patterns of Regional Colorectal Cancer Spread and Metastases 252
T Staging 254
Regional Lymph Node Staging (N Staging) 255
Metastatic Disease 255
Hepatic Metastases 255
Lymph Node Metastases 256
Pulmonary Metastases 258
Osseous Metastases 258
Other Soft Tissue Metastases 259
Restaging of Colorectal Cancer 259
Pitfalls and Issues in Reporting PET-CT of Colorectal Cancer 261
False-Negative FDG-PET Findings 262
Therapy Monitoring with PET-CT 263
Radiation Therapy Planning for Colorectal Cancer with PET-CT 266
Chapter 22: PET-CT Imaging of Lymphoma 270
Pathologic and Clinical Classification of Lymphomas 270
Staging of Lymphomas 271
Staging Workup of Lymphomas 271
Role of Imaging in Management of Lymphoma 271
Aggressive NHL and HD 271
Mantle Cell Lymphoma 272
Indolent (Low-Grade) NHL 272
PET-CT for Diagnosis and Staging of Lymphoma 272
Nodal Lymphoma 273
CT in Nodal Lymphoma 273
FDG PET in Nodal Lymphoma 276
Extranodal Lymphoma 280
CT and MRI in Extranodal Lymphoma 280
FDG PET in Extranodal Lymphoma 281
FDG PET Versus Ga-67 Imaging 284
Influence of PET-CT on Patient Management at Initial Staging 284
PET-CT for Restaging and Evaluationof Therapy Response 285
CT in the Posttherapy Evaluationof Lymphoma 286
FDG PET in the Posttherapy Evaluationof Lymphoma 286
Prediction of Therapy Outcome After Completion of Therapy 286
Combined Modality Therapy Including Radiation Therapy 289
High-dose Chemotherapy and Autologous Stem Cell Transplantation 289
Early Prediction of Response During Therapy 289
Comparison of FDG PET and Ga-67 Imagingin Posttherapy Evaluation 290
Special Considerations with Lymphoma Imaging 291
Benign Lymphoproliferative Disorders 291
AIDS-Related Lymphoma 292
Thymic Uptake 292
BM Uptake After Administration of Colony Stimulators 292
Posttransplantation Period 292
Conclusion 293
References 293
Chapter 23: PET-CT Imaging in Multiple Myeloma, Solitary Plasmacytoma, and Related Plasma Cell Dyscrasias 297
Tumor Biology 297
Diagnosis and Conventional Staging 298
Current Treatment 299
Role of PET-CT Imaging in Multiple Myeloma 299
Clinical PET and PET-CT Imaging Protocols 302
Role of FDG PET and PET-CT in MM and Related Plasma Cell Dyscrasias 304
Focal Lesions 305
Extramedullary Disease 306
Diffuse Uptake 306
Detection of Infection 308
Pitfalls, Pearls, and Caveats 311
Vertebroplasty 311
Biopsies 311
False-Negative (Chemotherapy Effect) 311
Other Plasma Cell Dyscrasias 313
Monoclonal Gammopathy of Undetermined Significance (MGUS) 313
Solitary Plasmacytoma 313
Castleman’s Disease 313
Waldenström’s Macroglobulinemia 314
Summary 315
References 316
Chapter 24: PET-CT of Melanoma 317
Overview of Contemporary Management 317
Staging of Melanoma 318
Staging System 318
Clinical Staging and Restaging of Melanoma 318
PET-CT and Melanoma 320
Role of PET-CT in the Initial Diagnosis of Melanoma 321
Role of PET-CT in the Staging of Melanoma 321
Role of PET-CT in Surveillance and Restaging of Melanoma 323
Pitfalls and Selected Issues in Performing and Reporting PET-CT of Melanoma 325
Therapy Monitoring with PET-CT During Treatment 328
Radiation Therapy Planning for Melanoma with PET-CT 328
Conclusion 328
References 330
Chapter 25: PET-CT of Ovarian Cancer 332
Role of PET-CT on Initial Diagnosisof Ovarian Cancer 332
Staging of Ovarian Cancer with PET-CT 333
Restaging of the Ovarian Cancer with PET-CT 335
Therapy Monitoring with PET-CT During Treatment 339
References 339
Chapter 26: PET-CT of Cervical and Uterine Cancer 340
Cervical Carcinoma 340
Role of PET-CT in Initial Diagnosis of Cervical Cancer 341
Staging of Cervical Cancer with PET-CT 341
Staging Method 341
Stage of Cervical Cancer and Prognosis 342
PET-CT Findings in Staging of Cervical Cancer 342
Pitfalls and Selected Issues in Performing and Reporting PET-CT In Patients with Cervical Carcinoma 346
Restaging Cervical Cancer with PET-CT 347
Pitfalls and Selected Issues in Performing and Reporting PET-CT in Restaging Patients with Uterine Cancer 348
Cervical Cancer Therapy Monitoring with PET-CT 349
Role of PET-CT in Radiotherpy Planning 349
Cancer of the Uterine Corpus 349
Role of PET-CT in the Diagnosis of Uterine Cancer 351
Staging Uterine Cancer with PET-CT 351
Staging Method 351
PET-CT Findings in Staging Uterine Cancer 352
Stage I and II 352
Stage III and IV 352
Pitfalls and Selected Issues in Performing and Reporting PET-CT in Patients with Uterine Cancer 353
Restaging of Uterine Cancer with PET-CT 355
Pitfalls and Selected Issues in Performing and Reporting PET-CT in Restaging Patients with Uterine Cancer 355
Uterine Cancer Therapy Monitoring with PET-CT 355
Role of PET-CT in Radiotherapy Planning 356
The Role of PET-CT for Uterine and Cervical Cancers: Highlights and Recommendation 356
References 357
Chapter 27: PET-CT of Testicular Malignancies 359
Management of Nonmetastatic Testicular Cancer (Stage I) 359
Management of Metastatic Testicular Cancer (Stages II and III) 361
Role of PET-CT in Initial Diagnosis of Testicular Cancer 362
Staging of Testicular Cancer with PET-CT 362
Restaging of Testicular Cancer with PET-CT 364
Therapy Monitoring of Testicular Cancer with PET-CT 367
Radiation Therapy Planning for Testicular Cancer with PET-CT 370
References 370
Chapter 28: PET-CT in Pediatric Malignancies 371
Lymphoma 371
Hodgkin’s Disease 371
Non-Hodgkin’s Lymphoma 373
Rhabdomyosarcoma 374
Neuroblastoma 376
Osteosarcoma and Ewing Sarcoma 378
Osteosarcoma 378
Ewing Sarcoma 379
Other Tumors and Tumor-like Conditions 380
Hepatic Malignancies 380
Hepatoblastoma 380
Hepatocellular Carcinoma 381
Langerhans’ Cell Histiocytosis 381
Inflammatory Pseudotumor 381
Renal Tumors 382
Wilms Tumor 382
Clear Cell Sarcoma 382
Rhabdoid Tumor of Kidney 383
Imaging Pitfalls in PET-CT of Pediatric Malignancies 383
CT Dose and Image Contrast 383
Patient Movement During Scan Acquisition 383
Brown Fat FDG Uptake in Children 384
Thymus Gland Enlargement and FDG Uptake 384
Other Variants 385
Conclusion 386
References 386
Chapter 29: PET-CT of Renal Cell Carcinoma 388
Role of PET-CT for Initial Diagnosis of Renal Cell Carcinoma 388
Staging of Renal Cell Carcinoma with PET-CT 389
T Stage 391
N Staging 392
M Staging 393
Restaging Renal Cell Carcinoma with PET-CT 393
Renal Cell Carcinoma Therapy Monitoring and Planning with PET-CT 395
Conclusion 395
References 395
Chapter 30: PET-CT in Soft Tissue Malignancies 397
Role of PET-CT in the Initial Diagnosis of Soft Tissue Tumors 398
Soft Tissue Sarcoma Staging 401
Role of PET-CT in Tumor Staging 402
Restaging with PET-CT 403
Therapy Monitoring with PET-CT 404
Pitfalls and Pearls 404
References 405
Chapter 31: PET-CT of Pancreatic Cancer 406
Diagnosis of Pancreatic Carcinoma with PET-CT 407
Staging of Pancreatic Carcinoma with PET-CT 408
T Stage 409
N Stage 411
M Stage 411
R Stage 412
Restaging Pancreatic Carcinoma with PET-CT 412
Pitfalls and Issues of Reporting in PET-CT Imaging of Pancreatic Carcinoma 413
Role of PET-CT in Post Treatment Monitoring 414
Conclusion 415
References 415
Chapter 32: PET-CT of Bone Metastases 417
Radiographic Evaluation 418
Traditional 418
PET 419
18F Fluoride and 18F FDG – Mechanisms 419
18F Fluoride and 18F FDG – Applications 420
Location of the Metastasis Within Bone 420
Differentiation of Benign and Malignant Bone Processes on PET-CT Imaging 423
Monitoring Therapy and Quantification 426
Formal Kinetic Analysis 428
Integration of CT Findings 428
PET-CT Compared with Other Imaging Methods 428
Conclusions 428
References 429
Index 430