Positron emission tomography scanning in the evaluation of hepatocellular carcinoma

BACKGROUND/AIMS: 18F-fluorodeoxyglucose uptake allows estimation of glucose metabolism by tumor cells using positron emission tomography (PET). We evaluated the role of PET imaging in the diagnosis of hepatocellular carcinoma. METHODS: PET images were collected after intravenous injection of 8-12 mCi of 18F-FDG in 20 patients with hepatocellular carcinoma (HCC). PET tumor activity level was assessed on a scale of 1 to 4 compared to normal liver tissue. The PET score was compared with abdominal computerized tomography (CT) scan results and between tumors of different grades and differentiation. RESULTS: Of the 20 patients studied, 11 (55%) had positive PET scans (PET score: 3 or 4) while nine (45%) were negative (PET score: 1 or 2). CT scan was positive in 18 patients (90%) and negative in two (10%). PET, however, revealed metastases in three patients that were not seen on CT. On pathological review, well-differentiated and low-grade tumors had lower PET scores. Comparison of the well-differentiated with the moderately- and poorly-differentiated tumors revealed a statistically significant difference. No statistical significance was observed between the moderately- and poorly-differentiated tumors or between different tumor grades and PET scores. CONCLUSIONS: The sensitivity of PET in diagnosis of HCC was 55% compared to 90% for CT scanning, although only PET detected some tumors (including distant metastases). Well-differentiated and low tumor grades had lower activity on PET and correspondingly lower PET scores. PET imaging may help assess tumor differentiation and may be useful in the diagnosis and staging and prognostication of HCC as an adjunct to CT.     

Fluorine‐18 FDG imaging in hepatocellular carcinoma using positron coincidence detection and single photon emission computed tomography

Abstract: Background/aims: We prospectively evaluated whether fluorine‐18 deoxyglucose (FDG) positron coincidence detection (PCD) or FDG single‐photon emission computed tomography (SPECT) provides additional benefits to our conventional preoperative evaluation of lesion detection in patients suspected to have hepatocellular carcinoma (HCC). Methods: Thirteen consecutive patients with a suspected HCC underwent conventional preoperative evaluation with ultrasonography (US), triple‐phase helical computed tomography (CT), superparamagnetic iron oxides (SPIO) enhanced magnetic resonance imaging (MRI) and serum α‐fetoprotein (AFP) level. All 13 patients had an FDG‐PCD and SPECT. These results were evaluated to assess the value of FDG‐PCD and SPECT in addition to US, SPIO‐enhanced MRI and triple‐phase helical CT. Results: Ten of the 13 (77%) patients had at least one histologically confirmed HCC without extrahepatic abdominal spread. The tumors ranged in size from 1 to 8 cm and the serum AFP ranged from 3 to 30 000 µg/l. Of these 10 patients, two patients had an increased tumor F‐FDG uptake (sensitivity of 20%); one patient with an AFP of 5 µg/l and a tumor size of maximum 4.5 cm and one patient with an AFP of 249 µg/l and a tumor size of maximum 2 cm. In three patients with a benign liver mass, FDG imaging with either PCD or SPECT was negative. There was no false positive finding. Conclusions: We found poor sensitivity of FDG‐PCD and FDG‐SPECT for the detection of HCC. There were no clear relations between AFP or tumor size and FDG uptake. Therefore, we conclude that FDG imaging with PCD or SPECT has no value in the preoperative work‐up for HCC in patients with cirrhosis.     

Current and potential applications of positron emission tomography for multiple myeloma and plasma cell disorders

Fluorine-18 (18F)-fluorodeoxyglucose (FDG) positron emission tomography (PET) allows evaluation of elevated glucose metabolism in malignancies. There has been increasing interest in FDG PET/CT for plasma cell disorders since the International Myeloma Working Group outlined multiple applications of this imaging modality, including distinguishing smoldering myeloma from active multiple myeloma, confirmation of solitary plasmacytoma, and multiple indications in patients with known multiple myeloma, including determining extent of initial disease, monitoring therapy response, and detection of residual disease following therapy. The field of molecular imaging is now shifting focus from evaluation of metabolism to targeted evaluation of specific tumor markers. Targeted PET imaging targeted of CXCR4 and CD38 has advanced into translational clinical trials, bringing us closer to powerful imaging options for myeloma. In this review we discuss the current applications of FDG PET/CT in plasma cell disorders, as well as advances in targeted PET imaging.     

Positron emission tomography with computed tomography imaging of neuroinflammation in experimental autoimmune encephalomyelitis

2-[(18)F]Fluoro-2-deoxy-d-glucose positron emission tomography ([(18)F]FDG PET) detection of the up-regulated glycolysis associated with malignant transformation is a noninvasive imaging technique used extensively in cancer diagnosis. Although striking similarities exist in glucose transport and metabolism between tumor cells and activated immune cells, the potential use of [(18)F]FDG PET for the diagnosis and evaluation of autoimmune disorders has not been systematically investigated. Here we ask whether [(18)F]FDG PET in conjunction with computed tomography (CT) could be used to monitor a complex autoimmune disorder such as murine experimental autoimmune encephalomyelitis (EAE) and whether this approach is sensitive enough to evaluate therapeutic interventions. We found that (i) coregistration of metabolic (i.e., microPET) and high-resolution anatomical (i.e., CT) images allows serial quantification of glycolysis with [(18)F]FDG in various spinal column segments; (ii) [(18)F]FDG PET/CT can detect the increased glycolysis associated with paralysis-causing inflammatory infiltrates in the spinal cord; and (iii) the [(18)F]FDG measure of glycolysis in the spinal cord is sensitive to systemic immunosuppressive therapy. These results highlight the potential use of serial [(18)F]FDG PET/CT imaging to monitor neuroinflammation in EAE and suggest that similar approaches could be applied to the diagnosis and evaluation of other autoimmune and inflammatory disorders in animal models and in humans.     

The Role of 18F Fluorodeoxyglucose Positron Emission Tomography Scanning in the Diagnosis and Management of Systemic Vasculitis

Primary systemic vasculitis is a group of heterogeneous disorders, characterized by inflammation of blood vessels causing end organ damage from ischemia, aneurysm formation or dissection. Delay in the early diagnosis owing to non‐specific symptoms, lack of definitive serological tests, limited availability of biopsy and standard imaging tests pose significant challenge in the management of these diseases. 18F‐fluorodeoxyglucose (FDG) positron emission tomography (PET) scanning is being increasingly used in the management of systemic vasculitis, especially the large vessel vasculitides: giant cell arteritis (GCA) and Takayasu arteritis (TAK). FDG‐PET involves detection of positron rays emitted by FDG, a fluorinated glucose analogue which is avidly taken up by metabolically active inflammatory cells in the walls of involved blood vessels. 18F‐FDG‐PET scan, especially when combined with computed tomography or magnetic resonance imaging (MRI) can give information about active inflammation as well as structural damage associated with vasculitis. In patients with GCA, FDG‐PET has acceptable sensitivity and specificity for the early diagnosis in non‐cranial GCA, cranial GCA with negative biopsy, assessment of immediate response to treatment, predicting prognosis, but has limited value in serial follow‐up and prediction of relapses. In TAK, FDG‐PET can be useful for early diagnosis and probably for serial assessment of disease activity. FDG‐PET has a limited role in medium and small vessel vasculitis.     

18F‐Fluorodeoxyglucose (FDG)‐PET features of focal nodular hyperplasia (FNH) of the liver

Abstract: Aim: The aim of this paper is to describe the imaging pattern of focal nodular hyperplasia (FNH) by ¹⁸F‐fluorodeoxyglucose (18F‐FDG) positron emission tomography (PET). Methods: Eight consecutive asymptomatic patients with histologic proof of FNH underwent 18F‐FDG PET imaging. The lesions were found incidentally. The 18F‐FDG PET imaging was performed with a dedicated PET tomograph after intravenous injection of 300–370 MBq 18F‐FDG. The 18F‐FDG accumulation in the lesions was (semi)quantified by calculating the standardized uptake value (SUV) and SUV has been corrected for the lean body mass (LBM). Eight patients with liver metastases spread from melanoma (n=2) and colorectal carcinoma (n=6) served as controls. The size of the FNH lesions and of the control group ranged from 2.0 to 8.5 cm (mean 4.83 cm±2.37) and from 1.5 to 6 cm (mean 3.28±1.52), respectively. Results: While in malignant liver lesions the accumulation of 18F‐FDG was significantly increased, all FNH lesions showed normal or even decreased accumulation of 18F‐FDG. In FNH lesions, SUV ranged between 1.5 and 2.6 (mean 2.12±0.38), whereas all liver metastases showed an increased SUV ranging between 6.20 and 16.00 (mean 10.07±3.79). The SUV corrected for LMB (SUV_LBM) was similar to the SUV and ranged between 0.9 and 2.2 (mean 1.81±0.41) for FNH and between 5.9 and 16.3 (mean 9.15±4.03), respectively. Conclusion: In contrast to liver metastases, there is no increased glucose metabolism in FNH in vivo. The imaging feature of FNH by 18F‐FDG‐PET imaging is not specific for FNH; however, it may be helpful to differentiate FNH from liver metastases in cancer patients if radiological methods are not diagnostic.     

Unusual adrenal metastasis and abdominal carcinomatosis secondary to Hurthle cell carcinoma of the thyroid.

Hurthle cell carcinoma (HCC) of the thyroid is an uncommon and relatively rare differentiated thyroid neoplasm. To our knowledge, no reported case of adrenal metastases with abdominal carcinomatosis secondary to HCC of the thyroid has been demonstrated by F-18 FDG PET/CT imaging. One report of adrenal uptake on I-131 whole-body scan with HCC exists. In this case report, we describe a patient with HCC who had a left adrenal metastasis with abdominal carcinomatosis that was discovered using F-18 FDG PET/CT imaging.     

Fluorine-18 FDG positron emission tomography for imaging of hepatocellular carcinoma

OBJECTIVE: The detection of increased fluorine-18 fluorodeoxyglucose (18F-FDG) uptake by positron emission tomography (PET) is based on the enhanced glucose metabolism of tumor cells. Because the detection and staging of hepatocellular carcinoma (HCC) in patients with liver cirrhosis can be difficult, we prospectively evaluated the sensitivity of 18F-FDG PET in 14 consecutive patients with HCC. METHODS: Whole body and regional 18F-FDG PET of the liver were obtained. The results were compared with ultrasonography, contrast-enhanced, helical CT, histological grading, p53 protein expression of HCC, and serum alpha-fetoprotein (AFP) level. RESULTS: In 7 patients PET demonstrated increased tumor 18F-FDG uptake, whereas HCC was not distinguishable from nonmalignant liver tissue in 7 other patients. Hepatic lesions were detected by ultrasonography in all patients, whereas only 11 of 14 HCCs could be identified by CT. In 3 patients extrahepatic spread was demonstrated by 18F-FDG PET. Patients with increased tumor 18F-FDG uptake had significantly larger hepatic lesions and higher serum AFP levels than those with normal 18F-FDG uptake. Lesions could be visualized by 18F-FDG PET in 7 of 8 patients with moderately or poorly differentiated HCC, whereas none of the six well-differentiated tumors was detected. Two patients with strong p53 expression demonstrated increased tumor 18F-FDG uptake and extrahepatic metastases. CONCLUSIONS: The sensitivity of 18F-FDG PET for the imaging of HCC is low. Nevertheless, in patients with moderately or poorly differentiated HCC, tumors >5 cm, or with markedly elevated AFP levels 18F-FDG PET may contribute to an effective noninvasive staging.     

Diagnostic value for extrahepatic metastases of hepatocellular carcinoma in positron emission tomography/computed tomography scan

AIM: To evaluated the value of ¹⁸F-fluorodeoxyglucose (FDG) positron emission tomography (PET)/computed tomography (CT) scan in diagnosis of hepatocellular carcinoma (HCC) and extrahepatic metastases.METHODS: A total of 138 patients with HCC who had both conventional imaging modalities and ¹⁸F-FDG PET/CT scan done between November 2006 and March 2011 were enrolled. Diagnostic value of each imaging modality for detection of extrahepatic metastases was evaluated. Clinical factors and tumor characteristics including PET imaging were analyzed as indicative factors for metastases by univariate and multivariate methods.RESULTS: The accuracy of chest CT was significantly superior compared with the accuracy of PET imaging for detecting lung metastases. The detection rate of metastatic pulmonary nodule ≥ 1 cm was 12/13 (92.3%), when < 1 cm was 2/10 (20%) in PET imaging. The accuracy of PET imaging was significantly superior compared with the accuracy of bone scan for detecting bone metastases. In multivariate analysis, increased tumor size (≥ 5 cm) (P = 0.042) and increased average standardized uptake value (SUV) uptake (P = 0.028) were predictive factors for extrahepatic metastases. Isometabolic HCC in PET imaging was inversely correlated in multivariate analysis (P = 0.035). According to the receiver operating characteristic curve, the optimal cutoff of average SUV to predict extrahepatic metastases was 3.4.CONCLUSION: ¹⁸F-FDG PET/CT scan is invaluable for detection of lung metastases larger than 1 cm and bone metastases. Primary HCC having larger than 5 cm and increased average SUV uptake more than 3.4 should be considered for extrahepatic metastases.     

Emerging role of ~(18)F-fluorodeoxyglucose positron emission tomography for guiding management of hepatocellular carcinoma

Hepatocellular carcinoma(HCC) is one of major causes of cancer mortality worldwide. For decades, ~(18)F-fluorodeoxyglucose(FDG) positron emission tomography(PET) has been widely used for staging, predicting prognosis, and detecting cancer recurrence in various types of malignant diseases. Due to low sensitivity of FDG PET for detecting intrahepatic HCC lesions, the clinical value of FDG PET in HCC patients has been limited. However, recent studies with diverse analytic methods have shown that FDG PET has promising role in aiding management of HCC patients. In this review, we will discuss the clinical role of FDG PET for staging, predicting prognosis, and evaluating treatment response in HCC. Further, we will focus on recent clinical studies regarding implication of volumetric FDG PET parameters, the significance of FDG uptake in HCC for selecting treatment and predicting treatment response, and the use of radiomics of FDG PET in HCC.     

Diagnostic role of radiolabelled choline PET or PET/CT in hepatocellular carcinoma: a systematic review and meta-analysis

The role of fluorine-18-fluorodeoxygluose positron emission tomography/computed tomography (¹⁸F-FDG PET/CT) in hepatocellular carcinoma (HCC) has not been firmly established yet and its sensitivity has been reported to be in the range of 40–60 %. Because of this relatively low sensitivity alternative tracers have been proposed. The aim of our review is to analyse the literature data on the diagnostic role of ¹⁸F/¹¹C-choline PET/CT in the evaluation of HCC. A comprehensive computer literature search of PubMed/MEDLINE, Embase and Scopus databases was conducted to find relevant published articles about the role of whole-body ¹⁸F-choline or ¹¹C-choline PET or PET/CT in patients with HCC. Furthermore, a meta-analysis about the detection rate of this method in HCC was performed. Six articles were included in this systematic review and discussed. The meta-analysis of five out of six articles showed a DR of 84 % (95 % CI 79–89 %). The DR increased when poorly differentiated HCC was excluded from the analysis. Radiolabelled choline PET or PET/CT could be a valuable tool in detecting HCC and it is better than ¹⁸F-FDG PET/CT, especially in well to moderately differentiated lesions; on the other hand, poorly differentiated and higher-stage HCC could be better evaluated with ¹⁸F-FDG and dual tracer imaging should be considered and could be potentially useful to increase accuracy.     

Usefulness of 18F-fluorodeoxyglucose positron emission tomography in differential diagnosis and staging of cholangiocarcinomas

Background and Aim: ¹⁸F‐Fluoro‐2‐deoxy‐d ‐glucose positron emission tomography (¹⁸FDG‐PET) is promising for diagnosis and treatment of various malignancies. The aim of this study was to evaluate the clinical usefulness of ¹⁸FDG‐PET in differential diagnosis and staging of cholangiocarcinomas according to the intrahepatic, perihilar and common bile duct lesions and to compare with computerized tomography (CT) scan. Methods: From January 2000 to September 2003, 54 patients with suspected cholangiocarcinoma underwent abdominal CT scan and ¹⁸FDG‐PET within a 2‐week period. The PET images were analyzed visually and semiquantitatively. Results: The overall accuracy of ¹⁸FDG‐PET for discriminating malignant diseases of bile duct from benign conditions was slightly higher than that of CT scan (88.9% vs 81.5%). The sensitivity of ¹⁸FDG‐PET in perihilar cholangiocarcinoma was lower than the value of intrahepatic and common bile duct cancers (83.3% vs 91.3%, 90.9%); moreover, in cases of perihilar cancer, the sensitivity of ¹⁸FDG‐PET was lower than that of CT scans (83.3% vs 91.7%). ¹⁸FDG‐PET detected nine distant metastatic lesions not found by other imaging studies and excluded two patients who potentially had resectable condition in other imaging studies from unnecessary laparotomy. Conclusion: The clinical usefulness of ¹⁸FDG‐PET in differential diagnosis of bile duct cancers is related to the site of primary disease. Although it is a helpful method for differential diagnosis especially in cases of intrahepatic and common bile duct cancers, ¹⁸FDG‐PET can not provide confirmative clues in perihilar cholangiocarcinoma. ¹⁸FDG‐PET may hold promise in the detection of hidden distant metastasis and can play an additional role in the evaluation of resectability. ¹⁸FDG‐PET can be complementary to CT scan in diagnosing and staging of cholangiocarcinoma.     

Cardiac and pericardial tumors: A potential application of positron emission tomography-magnetic resonance imaging

Cardiac and pericardial masses may be neoplastic, benign and malignant, non-neoplastic such as thrombus or simple pericardial cysts, or normal variants cardiac structure can also be a diagnostic challenge. Currently, there are several imaging modalities for diagnosis of cardiac masses; each technique has its inherent advantages and disadvantages. Echocardiography, is typically the initial test utilizes in such cases, Echocardiography is considered the test of choice for evaluation and detection of cardiac mass, it is widely available, portable, with no ionizing radiation and provides comprehensive evaluation of cardiac function and valves, however, echocardiography is not very helpful in many cases such as evaluation of extracardiac extension of mass, poor tissue characterization, and it is non diagnostic in some cases. Cross sectional imaging with cardiac computed tomography provides a three dimensional data set with excellent spatial resolution but utilizes ionizing radiation, intravenous iodinated contrast and relatively limited functional evaluation of the heart. Cardiac magnetic resonance imaging(CMR) has excellent contrast resolution that allows superior soft tissue characterization. CMR offers comprehensive evaluation of morphology, function, tissue characterization. The great benefits of CMR make CMR a highly useful tool in the assessment of cardiac masses.(Fluorine 18) fluorodeoxygluocse(FDG) positron emission tomography(PET) has become a corner stone in several oncological application such as tumor staging, restaging, treatment efficiency, FDG is a very useful imaging modality in evaluation of cardiac masses. A recent advance in the imaging technology has been the development of integrated PET-MRI system that utilizes the advantages of PET and MRI in a single examination. FDG PET-MRI provides complementary information on evaluation of cardiac masses. The purpose of this review is to provide several clinical scenarios on the incremental value of PET and MRI in the evaluation of cardiac masses.     

Primary Cardiac Lymphoma: Echocardiography and F‐18‐Fluorodeoxyglucose Positron Emission Tomography in Selection of a Biopsy Site

A 63‐year‐old man was referred to our hospital because of a cardiac tumor. Transthoracic echocardiography revealed a rough, mobile tumor in the dilated right atrium, and transesophageal echocardiography showed that the tumor consisted of small, botryoidal masses. Catheter‐based biopsy carried a high risk of embolism. Therefore, we used F‐18‐fluorodeoxyglucose positron emission tomography (FDG‐PET), which revealed an abnormal accumulation in the right cervical lymph nodes, as well as in the heart. We safely performed biopsy of the lymph nodes and diagnosed the patient with primary cardiac lymphoma. We concluded that echocardiography and FDG‐PET are useful for selecting an appropriate biopsy site in primary cardiac lymphoma.     

Positron emission tomography/computed tomography with (18)F-fluorodeoxyglucose identifies tumor growth or thrombosis in the portal vein with hepatocellular carcinoma

Patients suffering from hepatocellular carcinoma (HCC) with tumor thrombus in the portal vein generally have a poor prognosis. Portal vein tumor thrombus must be distinguished from portal vein blood thrombus, and this identification plays a very important role in management of HCC. Conventional imaging modalities have limitations in discrimination of portal vein tumor thrombus. The application of positron emission tomography (PET) with 18F-fluorodeoxyglucose (18F-FDG) for discrimination between tumor extension and blood thrombus has been reported in few cases of HCC, while portal tumor thrombosis and portal vein clot identified by 18F-FDG PET/CT in HCC patients has not been reported so far. We present two HCC cases, one with portal vein tumor thrombus and one thrombosis who were identified with 18F-FDG PET/CT. This report illustrates the complimentary value of combining the morphological and functional imaging in achieving a correct diagnosis in such clinical situations.     

Pancreatic tuberculosis

A 63‐year‐old Japanese man visited our institute with fever of unknown origin. Findings on preoperative imaging modalities were consistent with pancreatic carcinoma, but a positive tuberculin skin test indicated tuberculosis infection. Negative results for Mycobacterium DNA polymerase chain reaction from sputum and bone‐marrow aspiration biopsy specimens ruled out pulmonary and miliary tuberculosis, respectively. Positron emission tomography (PET) with 2‐[fluorine‐18]‐fluoro‐2‐deoxy‐d ‐glucose (FDG) showed multiple labeled spots within the pancreas body and chest. Distal pancreatectomy was performed with a diagnosis of suspected pancreatic carcinoma, but the histological and microbiological diagnosis was Mycobacterium infection. A rare case of pancreatic tuberculosis evaluated by FDG PET is reported and discussed herein.     

Imaging in large-vessel vasculitis

Imaging has recently been acknowledged as at least equivalent to histology for confirming large-vessel vasculitis in the recommendations of scientific societies. Many studies have been recently published on the use of ultrasound, magnetic resonance imaging (MRI), computed tomography (CT) and fluorodeoxyglucose (FDG) positron emission tomography (PET) in giant cell arteritis and Takayasu arteritis. Ultrasound, MRI and CT show concentric, arterial wall thickening in vasculitis. PET demonstrates enhanced FDG uptake of inflamed artery walls due to increased glucose metabolism. Ultrasound is particularly useful for smaller arteries like the temporal arteries due to its high resolution. MRI and PET/CT provide an excellent overview particularly on extracranial arteries. However, ultrasound can also detect extracranial vasculitis while PET/CT may delineate vasculitis in temporal arteries. The diagnosis needs to be confirmed without delay as the sensitivity of imaging decreases with treatment. Ongoing studies are evaluating the role of imaging for follow-up.     

The use of FDG-PET scanning in lung cancer

Positron emission tomography (PET) imaging with fluorodeoxyglucose (FDG) is a very useful imaging modality that significantly contributes to the diagnosis and staging in patients with lung cancer. Additionally, FDG-PET has been shown to play an effective role to predict therapy response and to assess tumor aggressiveness as well as to define radiotherapy treatment fields. Further technologic improvements in PET scanners and new more tumor specific radiopharmaceuticals are likely to bring further benefits to the management of patients with lung cancer in the future.     

Advances in positron emission tomographic imaging of lung cancer

Positron emission tomography (PET) with [18F]fluorodeoxyglucose (FDG) has been established as a useful tool in the management of patients with non-small cell lung cancer and promises to be as valuable in the clinical management of other cancers. PET imaging with FDG allows the assessment of tumor glucose metabolism in vivo; however, a number of other PET tracers are being used in oncologic research to assess changes in other cellular processes associated with malignant transformation of the cell. [11C]-Labeled methionine and choline are being used to assess changes in cell membrane synthesis; however, small studies have not shown the added information from these tracers to be clinically useful. DNA synthesis can be assessed by measuring the uptake of the thymidine analog 3'-deoxy-3'-[18F]fluorothymidine, which may be more specific for evaluating malignancy without the problem of false-positive results from inflammatory lesions, as seen with FDG. Tumor hypoxia imaging with copper-labeled diacetyl-bis(N(4)-methylthiosemicarbazone) or [18F]fluoromisonidazole may provide a better method of predicting which tumors will respond best to conventional therapy. The role of PET will continue to evolve with further clinical studies using these and other new tracers.     

Fluorine-18 FDG imaging in hepatocellular carcinoma using positron coincidence detection and single photon emission computed tomography

BACKGROUND/AIMS: We prospectively evaluated whether fluorine-18 deoxyglucose (FDG) positron coincidence detection (PCD) or FDG single-photon emission computed tomography (SPECT) provides additional benefits to our conventional preoperative evaluation of lesion detection in patients suspected to have hepatocellular carcinoma (HCC). METHODS: Thirteen consecutive patients with a suspected HCC underwent conventional preoperative evaluation with ultrasonography (US), triple-phase helical computed tomography (CT), superparamagnetic iron oxides (SPIO) enhanced magnetic resonance imaging (MRI) and serum alpha-fetoprotein (AFP) level. All 13 patients had an FDG-PCD and SPECT. These results were evaluated to assess the value of FDG-PCD and SPECT in addition to US, SPIO-enhanced MRI and triple-phase helical CT. RESULTS: Ten of the 13 (77%) patients had at least one histologically confirmed HCC without extrahepatic abdominal spread. The tumors ranged in size from 1 to 8 cm and the serum AFP ranged from 3 to 30 000 microg/l. Of these 10 patients, two patients had an increased tumor F-FDG uptake (sensitivity of 20%); one patient with an AFP of 5 microg/l and a tumor size of maximum 4.5 cm and one patient with an AFP of 249 microg/l and a tumor size of maximum 2 cm. In three patients with a benign liver mass, FDG imaging with either PCD or SPECT was negative. There was no false positive finding. CONCLUSIONS: We found poor sensitivity of FDG-PCD and FDG-SPECT for the detection of HCC. There were no clear relations between AFP or tumor size and FDG uptake. Therefore, we conclude that FDG imaging with PCD or SPECT has no value in the preoperative work-up for HCC in patients with cirrhosis.