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.     

Positron emission tomography/computed tomography with 18F-fluorocholine improve tumor staging and treatment allocation in patients with hepatocellular carcinoma

1. Download high-res image (150KB)
2. Download full-size image

     

A pilot study of the use of 2‐[18F]‐fluoro‐2‐deoxy‐D‐glucose–positron emission tomography to assess the distribution of activated lymphocytes in patients with systemic lupus erythematosus

Objective

The 2‐[¹⁸F]‐fluoro‐2‐deoxy‐D ‐glucose–positron emission tomography (FDG‐PET) technique provides information on uptake and metabolism of glucose in various tissues. Compared with resting cells, activated lymphocytes take up radioactively labeled glucose analog at a higher rate, which makes it possible to identify lymphoid organs with higher concentrations of activated lymphocytes. This study was undertaken to compare the pattern of PET images and quantitative FDG uptake in lymphoid organs of patients with active systemic lupus erythematosus (SLE) versus patients with inactive SLE and to correlate these findings with peripheral blood lymphocyte phenotypes.

Methods

Ten patients with active SLE and 9 patients with inactive SLE were studied. FDG‐PET images were obtained from the inguinal region to above the ear, starting at 60 minutes after injection of FDG. Standardized uptake values using lean body mass were determined over areas of interest.

Results

Both patients with active lupus and those with inactive lupus had increased FDG uptake in lymph nodes when compared with healthy volunteers, and there was no statistically significant difference between the 2 groups of lupus patients. Thymic uptake was demonstrated in 5 of 10 patients with active lupus compared with 0 of 9 patients with inactive disease. Three of the 5 patients with active SLE who were over 29 years of age had thymic uptake. Of the activation markers tested, only the CD3/CD71 population of cells was significantly different between the patient groups, with an increased percentage in the active disease group (P = 0.0247).

Conclusion

Increased FDG uptake in lymph nodes of both patients with active SLE and patients with inactive SLE suggests that metabolic, and probably immunologic, activity is enhanced not only in active, but also in clinically quiescent, disease. The increased thymic uptake observed only in patients with active disease suggests that the thymus plays an important role during periods of disease activity.

     

Efficacy of 3D‐positron emission tomography/computed tomography for upper abdomen

Recent advancement in computed tomography (CT) enables us to obtain high spatial resolution image and made it possible to construct extensive high‐definition three‐dimensional (3D) images. But a lack of contrast resolution in CT alone is still remained problem. Meanwhile, as fluorodeoxyglucose‐positron emission tomography (PET) can visualize tumors in high contrast, we can create 3D images fusing the accumulation in tumors on PET/CT images. Such images can play the role of a “map of body” which makes it easy to understand the anatomical information before surgery. We also try to evaluate segmental liver function by using PET/CT fusion images. By using ¹¹C‐methionine PET/contrast‐enhanced CT, superior image quality compared to single photon emission computed tomography/CT can be obtained. CT, especially with contrast enhancement for obtaining anatomical imaging information plus PET for obtaining functional imaging information is a highly compatible combination, and adding these two types information will further increase clinical usefulness.     

Role of [18F] fludeoxyglucose positron emission tomography in the selection of liver transplan-tation candidates in patients with hepatocellular carcinoma

BACKGROUND: The Milan criteria are widely accepted among many centers. However, patients with hepatocellular carcinoma beyond the Milan criteria might still benefit from liver transplantation(LT) when tumor itself is not aggressive. [~(18)F] fluorodeoxyglucose positron emission tomography/computed tomography imaging could provide useful information of tumor behaviors, which is helpful to predict the prognosis for many tumors. METHOD: In order to determine its role in candidate selection for LT, we therefore retrospectively analyzed 103 recipients with preoperative positron emission tomography(PET) findings. RESULTS: Positive PET findings(PET+) were significantly associated with tumor nodule numbers(P=0.013), tumor grade(P=0.025), macro-(P=0.002) and micro-vascular invasion(P=0.002), as well as the Milan criteria(P=0.018). PET+ patients had significantly increased risk of tumor recurrence post-LT compared to PET negative(PETˉ) patients(P=0.007). The 1-, 3-, and 5-year overall survival rate of PETˉ patients were 96.0%, 87.2% and 76.2%, compared to 74.7%, 55.4% and 49.9% in PET+ patients, respectively(P0.05). The 1-, 3-, and 5-year recurrence-free survival rate of PETˉ patients were 91.8%,81.9% and 76.0%, compared to 70.1%, 39.3% and 21.9% in PET+ patients, respectively(P0.05). Recipients within the Milan criteria showed comparable 1-, 3-, and 5-year survival rates in comparison with those beyond the Milan criteria with a PETˉ findings(1-, 3-, and 5-year overall survival rates, 97.5%, 83.3%, and 83.3% vs 90.0%, 80.0%, and 66.7%, P= 0.123; 1-, 3-, and 5-year recurrence-free survival rates, 95.1%, 73.1%, and 73.1% vs 90.0%, 78.8%, and 65.6%, P=0.148).CONCLUSIONS: Certain patients with hepatocellular carcinoma and negative PET findings, who have exceeded the Milan criteria, are also eligible candidates for LT. Preoperative PET/CT imaging is an important marker, which should be incorporated in extended candidate selection criteria for LT.     

[18F]-fluorodeoxyglucose positron emission tomography in patients with suspected recurrence of breast cancer

AIM: To evaluate the role of [18F]-fluorodeoxyglucose positron emission tomography (FDG-PET) in patients presenting with a suspicion of breast cancer relapse after primary treatment. MATERIALS AND METHODS: Sixty consecutive female patients with clinical (n=35) or radiological (n=25) suspicion of breast cancer recurrence were evaluated by FDG-PET. Positive PET findings were further evaluated by histological examination or clinical and radiological follow-up. In 25 patients, the serum tumor marker (CA 15-3) status was compared to the PET results. RESULTS: Disease relapse was proven in 40 patients. Additionally, in three patients a second cancer was diagnosed with (n=1), and without (n=2) concomitant disease relapse. PET missed local recurrence in three patients, and was false positive in another four. In patient-based analysis, the overall sensitivity, specificity, and accuracy were 89%, 84%, and 87%, and 100%, 97%, and 98% for locoregional recurrence and distant metastases, respectively. FDG-PET was more sensitive than the serum tumor marker CA 15-3 in detecting relapsed breast cancer. CONCLUSION: FDG-PET is a valuable tool in the follow-up of patients with breast cancer.     

Bone marrow 18F‐fluoro‐2‐deoxy‐d‐glucose positron emission tomography/computed tomography cannot replace bone marrow biopsy in diffuse large B‐cell lymphoma

This study aimed to investigate whether visual and quantitative ¹⁸F‐fluoro‐2‐deoxy‐d ‐glucose positron emission tomography/computed tomography (FDG‐PET/CT)‐based bone marrow assessment can replace blind bone marrow biopsy (BMB) in newly diagnosed diffuse large B‐cell lymphoma (DLBCL). This retrospective study included 78 patients with newly diagnosed DLBCL who had undergone both FDG‐PET/CT and BMB. FDG‐PET/CT images were visually evaluated for bone marrow involvement. Patient‐based sensitivity of visual FDG‐PET/CT assessment was calculated using BMB as the reference standard. Metabolically active volume, maximum standardized uptake value, 3D partial volume corrected mean standardized uptake value, and 3D partial volume corrected mean metabolic volume product (cMVP_mean) of FDG‐avid bone marrow lesions were measured. Cox regression analysis was used to determine the influence of (potential) prognostic factors (BMB status, visual [dichotomous] FDG‐PET/CT bone marrow status, metabolically active volume, maximum standardized uptake value, 3D partial volume corrected mean standardized uptake value, 3D partial volume corrected mean metabolic volume product, and International Prognostic Index score) on progression‐free survival and overall survival. FDG‐PET/CT detected bone marrow involvement in 34 (43.6%) cases and BMB in 16 (20.5%) of 78 cases, of whom 11 were also detected by FDG‐PET/CT, resulting in a patient‐based sensitivity of 68.8% (95% confidence interval = 44.2%–86.1%) for FDG‐PET/CT. In the multivariate Cox proportional hazards model, only BMB status was an independent predictive factor of progression‐free survival (P = 0.016) and overall survival (P = 0.004). In conclusion, FDG‐PET/CT misses bone marrow involvement that has been detected by BMB in a non‐negligible proportion of patients. Furthermore, both visual and quantitative FDG‐PET/CT‐based bone marrow assessments are prognostically inferior to BMB. Therefore, FDG‐PET/CT cannot replace BMB in newly diagnosed DLBCL. Am. J. Hematol. 89:726–731, 2014. © 2014 Wiley Periodicals, Inc.     

Appropriate use of positron emission tomography with [18F]fluorodeoxyglucose for staging of oncology patients

Positron emission tomography (PET) was developed in the mid-1970, and its initial applications were for heart and brain imaging research. Nowadays, this technology is aimed mainly at staging or restaging tumours as it allows the assessment of biochemical processes that are either specific or associated with tumour biology.The full appreciation of PET potentials and limitations among general practitioners and internists cannot be considered achieved and the appropriate use of PET especially when coupled to X-ray computed tomography (CT) is still suboptimal.The majority of PET studies rely on the use of fluorodeoxyglucose labelled with fluorine-18 (FDG), which is a radiopharmaceutical specific for glucose transport and metabolism.PET with FDG is amenable for studying most type of tumours, including those of the head and neck, lung, oesophagus, colo-rectal, gastrointestinal stromal tumours, pancreas, some types of lymphomas and melanoma, whereas in some tumours, including those of the reproductive system, brain, breast and bones, there is a limited role for PET and there is no substantial role for FDG-PET for the bronchoalveolar, hepatocellular, urinary system, testicular, neuroendocrine, carcinoids and adrenal tumours, differentiated thyroid cancers, and several subtypes of malignant lymphoma. Thus, the limits of FDG have stimulated the use and development of other radiopharmaceuticals. These tracers represent the opportunity for expanding the use of PET to other areas in oncology in the near future.     

Use of positron emission tomography with methyl‐11C‐choline and 2‐18F‐fluoro‐2‐deoxy‐D‐glucose in comparison with magnetic resonance imaging for the assessment of inflammatory proliferation of synovium

Objective

To compare positron emission tomography (PET) and magnetic resonance imaging (MRI) in the evaluation of inflammatory proliferation of synovium.

Methods

Ten patients (mean ± SD age 36 ± 13 years) with inflammatory joint disease and with clinical signs of inflammation of the joint were studied. A new tracer for cellular proliferation, methyl‐¹¹C‐choline (¹¹C‐choline), and a widely used tracer for the detection of inflammation and cancer, 2‐¹⁸F‐fluoro‐2‐deoxy‐D ‐glucose (¹⁸F‐FDG), were applied for PET imaging, and the results were compared with the findings from gadolinium diethylenetriaminepentaacetic acid–enhanced MR images. The uptake of ¹¹C‐choline and ¹⁸F‐FDG in the inflamed synovium was measured and expressed as the standardized uptake value (SUV) and the kinetic influx constant (K_i) obtained from graphic analysis, and these values were compared with quantitative values on MRI. Synovial volumes were measured on the coronal contrast‐enhanced T1‐weighted MR images using the standard software of the MR imager.

Results

All patients showed high accumulation of both ¹¹C‐choline and ¹⁸F‐FDG at the site of arthritic changes, where quantification of the tracer uptake was performed. The SUV of ¹¹C‐choline was 1.5 ± 0.9 gm/ml (mean ± SD; n = 10) and the SUV of ¹⁸F‐FDG was 1.9 ± 0.9 gm/ml (n = 10) (P = 0.017). The K_i of ¹¹C‐choline (mean ± SD 0.048 ± 0.042 minute⁻¹) was 8‐fold higher than the K_i of ¹⁸F‐FDG (0.006 ± 0.003 minute⁻¹) (P = 0.009). Both the uptake of ¹¹C‐choline and the uptake of ¹⁸F‐FDG correlated highly with the volume of synovium; the highest correlation was observed with the K_i of ¹¹C‐choline (r = 0.954, P < 0.0001).

Conclusion

In the use of PET scans,¹¹C‐choline can be regarded as a promising tracer for quantitative imaging of proliferative arthritis changes. Nevertheless, subsequent prospective studies with larger numbers of patients are necessary to further characterize the relationship between the findings on PET imaging and the clinical and functional measures of inflammation.

     

Advantages of positron emission tomography‐computed tomography imaging in esophageal squamous cell carcinoma

To explore the value of positron emission tomography‐computed tomography (PET‐CT) scan in esophageal squamous cell carcinoma (ESCC), we retrospectively summarize the results of PET‐CT scan from 118 patients, with ESCC who underwent PET‐CT scan in the different courses during treatment. Then, the results of PET‐CT scan plus other conventional methods were analyzed to identify the value of PET‐CT scan in diagnosis, staging, response evaluation, monitoring recurrence, and metastasis following treatment. It is suggested that PET‐CT scan possess high value in diagnosis and gives more favorable indication in N and M staging. PET‐CT scan should be translated into routine surveillance for postoperation follow up and is one of more helpful evaluators of response to chemoradiotherapy or chemotherapy.     

18F]fluoro-2-deoxy-D-glucose ([18F]FDG) positron emission tomography imaging of thymic carcinoid tumor presenting with recurrent Cushing's syndrome

We report a case of a young woman with Cushing's syndrome (CS), in whom although endocrine investigations and negative pituitary imaging were suggestive of ectopic ACTH secretion, the results of inferior petrosal sinus (IPS) sampling after coricotropin-releasing hormone (CRH) stimulation were suggestive of pituitary ACTH hypersecretion. (111)In-labelled octreotide and high-resolution computer tomography (CT) revealed a lesion possibly responsible for the ACTH source in the thymus. Thymectomy confirmed concomitant ectopic CRH and probable ACTH production by a thymic neuroendocrine carcinoma. After an 8-year remission period the patient developed a clinical and biochemical relapse. A high-resolution computed tomography (CT) scan of the thorax showed a 2-cm nodule in the thymic bed, which was positive on a [(18)F]fluoro-2-deoxy-D-glucose ([(18)F]FDG) positron emission tomography (PET) scan. However, a repeated thymectomy did not result in remission. A repeat [(18)F]FDG PET study showed persistent disease in the thymic bed and also uptake in the adrenals. The patient underwent bilateral adrenalectomy, which resulted in clinical remission. A further [(18)F]FDG PET scan 8 months later showed no progression of the thymic tumor and confirmed complete excision of the adrenals. This is a rare case of concomitant CRH and ACTH secretion from a thymic carcinoid tumor; the case illustrates the usefulness of functional imaging with [(18)F]FDG PET in the diagnosis, management and follow-up of neuroendocrine tumors.     

Positron emission tomography imaging of drug-induced tumor apoptosis with a caspase-3/7 specific [18F]-labeled isatin sulfonamide

Of the molecular biochemical alterations that occur during apoptosis, activation of caspases, notably caspase-3, is probably the most attractive for developing specific in vivo molecular imaging probes. We recently designed a library of isatin-5 sulfonamides and selected [¹⁸F]ICMT-11 for further evaluation on the basis of subnanomolar affinity for activated capsase-3, high metabolic stability, and facile radiolabeling. In this present study, we have demonstrated that [¹⁸F]ICMT-11 binds to a range of drug-induced apoptotic cancer cells in vitro and to 38C13 murine lymphoma xenografts in vivo by up to 2-fold at 24 h posttreatment compared to vehicle treatment. We further demonstrated that the increased signal intensity in tumors after drug treatment, detected by whole body in vivo microPET imaging, was associated with increased apoptosis. In summary, we have characterized [¹⁸F]ICMT-11 as a caspase-3/7 specific PET imaging radiotracer for the assessment of tumor apoptosis that could find utility in anticancer drug development and the monitoring of early responses to therapy.