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PET CT Beginners Guide
MiadAlsulami.MD.FRCPC
PART : II
PET CT Beginners Guide 1
6/5/2024
Outlines :
• Primary Pleural Tumors and Pleural Metastases.
• Urological tumors ( RCC and Bladder Carcinomas).
• FDG PET CT in neuroendocrine tumors .
• Cases .
Malignant pleuralmesothelioma
• Malignant pleural mesothelioma (MPM) is the most common primary
neoplasm of the pleura, arising from pleural mesothelial cells.
• MPM usually related to occupational or environmental asbestos
exposure. Latency from exposure to tumor development ?
• MPM is a highly aggressive tumor with a very poor prognosis.
Histological Type of MPM
1-Epithelioid mesothelioma.
2- Non –epithelioid (Sarcomatoid, Biphasic etc).
Imaging in mesothelioma
• Contrast enhanced CT of the chest has been regarded as the primary
imaging modality for malignant pleural mesothelioma but is limited in
its ability to evaluate the degree of local invasion and to differentiate
benign from malignant soft-tissue abnormalities.
• FDG PET used for staging and the management of MPM.
• PET CT has a prognostic value in MPM ( Higher tumor uptake
predictive of worse prognosis) .
• Limitations : Talc pleurodesis. Why?
Role of PET CT in Mesothelioma
• PET/CT has been shown to detect response to therapy before there is
measurable morphologic change on CT.
• Reduction in FDG uptake in comparison with pretreatment values
suggested response to chemotherapy in contrast with CT evaluation,
which showed stable disease.
The Prognostic Valueof 18F-FDG PET Imaging at Stagingin Patientswith MalignantPleural Mesothelioma: A LiteratureReview
How to Differentiate betweenMPM and Talc
collection ?
• Difficult!
• Any history of Pleurodesis?
• Examine the CT for underlaying dens materials correlating to talc
particles.
• Can be challenging in patients with MPM who had previous
pleurodesis as the inflammatory reaction to talc particles will lead to
intense FDG uptake . Always contextualizedyour case .
Diffuse bi-phasic MPM.
The PrognosticValueof 18F-FDGPETImagingatStagingin PatientswithMalignantPleural Mesothelioma:ALiteratureReview
MPM with talc pleurodesis
Solitary Fibrous Tumor of the Pleura
• Solitary fibrous tumors account for less than 5% of all pleural tumors.
These tumors most often originate from the visceral pleura
• Usually smooth rounded tumors that may be pedunculated.
• Has a benign course.
• They may undergo malignant or sarcomatous degeneration.
• Solitary fibrous tumor has no associationwith asbestosexposure .
Imagingin Solitary Fibrous
• Thoracic CT is the test of choice.
• CT findings of solitary fibrous tumors vary with the size of the tumor,
with smaller masses often round, and homogeneously enhancing
after IV contrast .
• PET can differentiate benign from malignant solitary fibrous tumors
with excellent accuracy .
• Benign solitary fibrous tumors typically show a low level of FDG
uptake (SUV < 2.5).
Imagingof Pleural Lipoma and
Liposarcoma
• Limited role of FDG PET CT.
• Please review the dedicated sarcoma series on LinkedIn .
Pleural Metastases
• Metastatic pleural involvement is the most common pleural
malignancy.
• The predominant underlying primary diseases are bronchogenic
carcinoma (40%), breast carcinoma (20%), and lymphoma (10%)
followed by gastrointestinal and genitourinary malignancies.
• The most frequent manifestationof metastaticpleural involvement
is pleural effusion.
• PET has been shown to identify malignant pleural effusion or other
metastasis in patients with non–small cell lung cancer with sensitivity
of 88–100% and specificity of 67–94% .
• In a recent study involving patients with non–small cell lung cancer,
PET/CT showed 70.8% diagnostic accuracy in the differentiation of
pleural metastasis when the contrast-enhanced CT finding was
indeterminate.
Urological tumors.
• CT is the gold stander modality for the diagnosis and staging of RCC
and bladder carcinoma.
• PET is not useful in the diagnosis of primary tumors.
• PET has a role in diagnosing distant metastases and detecting
recurrence.
• PET shows a high sensitivity for distant metastases in RCC .However,
Cell type may affect sensitivity!.
• PET CT has a role in differentiating benign emboli from tumor
thrombosis ( Usually FDG avid ).
• PET CT has a role in detecting lytic metastasis ( Higher sensitivity and
better accuracy compared to bone scan ).
• PET CT is indicated to asses recurrence.
• PET CT has a role for monitoring response to Tyrosine Kinase .
FDG PET CT in neuroendocrine tumors
• FDG has a low sensitivity in well differentiated NET (58% sensitivity).
• Good sensitivity for poorly differentiated NET (92% vs. octreotide
69%)
• Increased FDG uptake suggests increased chance of invasion,
metastasis and overall poorer prognosis.
• In PGL , Ga 68 DOTATATE should be considered first . FDG is indicated
in selected cases and before radiolabeled therapy.
68Ga-DOTATATEand18F-FDGPET/CTin Paragangliomaand Pheochromocytoma:utility,patternsand heterogeneity
Teaching cases from MNGHA
67 years old male with transitional cell
carcinoma for staging .
PET CT  beginners Guide  covers some of the underrepresented topics  in PET CT
PET CT  beginners Guide  covers some of the underrepresented topics  in PET CT
PET CT  beginners Guide  covers some of the underrepresented topics  in PET CT
Teaching points
• The presence of radioactive urine limits the assessment of renal and
bladder lesions.
• Diuresis might be helpful.
• False negative results can result from the presence of urine activity
adjacent to the lesion.
• False positive results can occur from focal collection of radioactive
urine.
• Benign renal lesions such as oncocytoma can be avid in PET CT .
Teaching Case fromMcGilluniversity health
center
36 years old male with retroperitonealEwing
sarcoma for staging
PET CT  beginners Guide  covers some of the underrepresented topics  in PET CT
PET CT  beginners Guide  covers some of the underrepresented topics  in PET CT
Teaching points :
• Parotid Incidentalomas ( PGIs):
1. Warthin’s tumor is the second most common parotid gland tumor
after pleomorphic adenoma.
2. Unifocal Warthin’s tumor is common, multifocality and bilaterality
are rare.
3. Parotid Incidentaloma usually Identified by PET as they
moderately/intensely avid.
4. PGIs has a strong relationship with smoking.
5. Further evolution should be consideredin nonsmoker patients .
To be Continued ..

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PET CT beginners Guide covers some of the underrepresented topics in PET CT

  • 1. PET CT Beginners Guide MiadAlsulami.MD.FRCPC PART : II PET CT Beginners Guide 1 6/5/2024
  • 2. Outlines : • Primary Pleural Tumors and Pleural Metastases. • Urological tumors ( RCC and Bladder Carcinomas). • FDG PET CT in neuroendocrine tumors . • Cases .
  • 3. Malignant pleuralmesothelioma • Malignant pleural mesothelioma (MPM) is the most common primary neoplasm of the pleura, arising from pleural mesothelial cells. • MPM usually related to occupational or environmental asbestos exposure. Latency from exposure to tumor development ? • MPM is a highly aggressive tumor with a very poor prognosis.
  • 4. Histological Type of MPM 1-Epithelioid mesothelioma. 2- Non –epithelioid (Sarcomatoid, Biphasic etc).
  • 5. Imaging in mesothelioma • Contrast enhanced CT of the chest has been regarded as the primary imaging modality for malignant pleural mesothelioma but is limited in its ability to evaluate the degree of local invasion and to differentiate benign from malignant soft-tissue abnormalities. • FDG PET used for staging and the management of MPM. • PET CT has a prognostic value in MPM ( Higher tumor uptake predictive of worse prognosis) . • Limitations : Talc pleurodesis. Why?
  • 6. Role of PET CT in Mesothelioma • PET/CT has been shown to detect response to therapy before there is measurable morphologic change on CT. • Reduction in FDG uptake in comparison with pretreatment values suggested response to chemotherapy in contrast with CT evaluation, which showed stable disease. The Prognostic Valueof 18F-FDG PET Imaging at Stagingin Patientswith MalignantPleural Mesothelioma: A LiteratureReview
  • 7. How to Differentiate betweenMPM and Talc collection ? • Difficult! • Any history of Pleurodesis? • Examine the CT for underlaying dens materials correlating to talc particles. • Can be challenging in patients with MPM who had previous pleurodesis as the inflammatory reaction to talc particles will lead to intense FDG uptake . Always contextualizedyour case .
  • 8. Diffuse bi-phasic MPM. The PrognosticValueof 18F-FDGPETImagingatStagingin PatientswithMalignantPleural Mesothelioma:ALiteratureReview
  • 9. MPM with talc pleurodesis
  • 10. Solitary Fibrous Tumor of the Pleura • Solitary fibrous tumors account for less than 5% of all pleural tumors. These tumors most often originate from the visceral pleura • Usually smooth rounded tumors that may be pedunculated. • Has a benign course. • They may undergo malignant or sarcomatous degeneration. • Solitary fibrous tumor has no associationwith asbestosexposure .
  • 11. Imagingin Solitary Fibrous • Thoracic CT is the test of choice. • CT findings of solitary fibrous tumors vary with the size of the tumor, with smaller masses often round, and homogeneously enhancing after IV contrast . • PET can differentiate benign from malignant solitary fibrous tumors with excellent accuracy . • Benign solitary fibrous tumors typically show a low level of FDG uptake (SUV < 2.5).
  • 12. Imagingof Pleural Lipoma and Liposarcoma • Limited role of FDG PET CT. • Please review the dedicated sarcoma series on LinkedIn .
  • 13. Pleural Metastases • Metastatic pleural involvement is the most common pleural malignancy. • The predominant underlying primary diseases are bronchogenic carcinoma (40%), breast carcinoma (20%), and lymphoma (10%) followed by gastrointestinal and genitourinary malignancies. • The most frequent manifestationof metastaticpleural involvement is pleural effusion.
  • 14. • PET has been shown to identify malignant pleural effusion or other metastasis in patients with non–small cell lung cancer with sensitivity of 88–100% and specificity of 67–94% . • In a recent study involving patients with non–small cell lung cancer, PET/CT showed 70.8% diagnostic accuracy in the differentiation of pleural metastasis when the contrast-enhanced CT finding was indeterminate.
  • 15. Urological tumors. • CT is the gold stander modality for the diagnosis and staging of RCC and bladder carcinoma. • PET is not useful in the diagnosis of primary tumors. • PET has a role in diagnosing distant metastases and detecting recurrence. • PET shows a high sensitivity for distant metastases in RCC .However, Cell type may affect sensitivity!. • PET CT has a role in differentiating benign emboli from tumor thrombosis ( Usually FDG avid ).
  • 16. • PET CT has a role in detecting lytic metastasis ( Higher sensitivity and better accuracy compared to bone scan ). • PET CT is indicated to asses recurrence. • PET CT has a role for monitoring response to Tyrosine Kinase .
  • 17. FDG PET CT in neuroendocrine tumors • FDG has a low sensitivity in well differentiated NET (58% sensitivity). • Good sensitivity for poorly differentiated NET (92% vs. octreotide 69%) • Increased FDG uptake suggests increased chance of invasion, metastasis and overall poorer prognosis. • In PGL , Ga 68 DOTATATE should be considered first . FDG is indicated in selected cases and before radiolabeled therapy.
  • 20. 67 years old male with transitional cell carcinoma for staging .
  • 24. Teaching points • The presence of radioactive urine limits the assessment of renal and bladder lesions. • Diuresis might be helpful. • False negative results can result from the presence of urine activity adjacent to the lesion. • False positive results can occur from focal collection of radioactive urine. • Benign renal lesions such as oncocytoma can be avid in PET CT .
  • 26. 36 years old male with retroperitonealEwing sarcoma for staging
  • 29. Teaching points : • Parotid Incidentalomas ( PGIs): 1. Warthin’s tumor is the second most common parotid gland tumor after pleomorphic adenoma. 2. Unifocal Warthin’s tumor is common, multifocality and bilaterality are rare. 3. Parotid Incidentaloma usually Identified by PET as they moderately/intensely avid. 4. PGIs has a strong relationship with smoking. 5. Further evolution should be consideredin nonsmoker patients .