Prostatic Utricle Cysts as a Potential Pitfall in PSMA PET/CT Interpretation.

ABSTRACT: A 60-year-old man with T2aN0M0 prostate cancer underwent intensity-modulated radiotherapy targeting the prostate and seminal vesicles. Experiencing biochemical recurrence after 6 years, 68Ga-PSMA-11 PET/CT revealed focal radioactivity in the posterior midline of the prostate, identified as a prostatic utricle cyst on subsequent MRI. Similar findings appeared in a previous 18F-piflufolastat PET/CT, with negative biopsy results. The patient then received intensity-modulated radiotherapy directed to 2 PSMA-avid pelvic nodes and leuprolide acetate, achieving an undetectable PSA in 4 months. This case highlights a potential pitfall in PSMA PET interpretation associated with prostatic utricle cysts.

Radioactive Iodine Therapy in Differentiated Thyroid Cancer: An Update on Dose Recommendations and Risk of Secondary Primary Malignancies.

Radioactive iodine (RAI) therapy with iodine-131 is performed in select cases of differentiated thyroid cancer (DTC), typically for remnant ablation, adjuvant therapy, or treatment of known persistent disease. Herein, we review updated RAI dose recommendations and associated risks of secondary primary malignancy (SPM). RAI dose is usually chosen empirically based on the risk assessment of tumor recurrence and other factors. Dose recommendations differ slightly among relevant medical societies. As of April 2024, most medical societies, including the American Thyroid Association (ATA), European Thyroid Association (ETA), Society of Nuclear Medicine and Molecular Imaging/European Association of Nuclear Medicine (SNMMI/ EANM), and National Comprehensive Cancer Network (NCCN), recommend a dose of 1.11 GBq (30 mCi) I-131 for remnant ablation. For adjuvant therapy, the recommended RAI dose ranges from 1.11 to 3.7 GBq (30-100) mCi I-131, although doses up to 5.6 GBq (150 mCi) may also be considered. In patients with known or suspected metastatic disease, at least 3.7 GBq (100 mCi) I-131 should be administered, and RAI doses as high as 7.4 GBq (200 mCi) may be justified depending on the suspected tumor burden and extent. Dosimetry has the advantage of tailoring the RAI dose to each patient's pharmacokinetics, resulting in ≥ 7.4 GBq (200 mCi) of I-131 in most cases. There is an ongoing debate about the risk of developing SPM due to RAI therapy, with several multicenter studies and meta-analyses concerning SPM being published in the last 2 years. The incidence of RAI-associated SPM varies according to the study design and detection method. Several studies showed no increased incidence, and there was no specific secondary cancer or cancer group linked to RAI exposures. Some reports indicated that cumulative RAI doses exceeding 5.6-7.4 GBq (150-200 mCi) were found to represent an increased risk for developing SPM. However, a clearly defined dose threshold cannot be provided based on the current literature. Nonetheless, caution should be exercised when considering repeated RAI therapies for persistent metastatic PTC, with a cumulative dose exceeding 37.0 GBq (1,000 mCi), due to the potential risk of developing SPM and other long-term toxicity. Further research is warranted to understand better the relationship between RAI dose and the risk of SPM.

Incidental Finding of Spindle Cell Sarcoma on 68 Ga-PSMA-11 PET/CT.

ABSTRACT: A 78-year-old man underwent 68 Ga-prostate-specific membrane antigen-11 (PSMA-11) PET/CT for biochemical recurrence of prostate adenocarcinoma following a simple prostatectomy. The scan showed PSMA-avid local recurrence within the prostatectomy bed and a suspicious right internal iliac nodal metastasis. In addition, there was a mildly avid subcutaneous lesion in the right flank, which revealed high-grade spindle cell sarcoma at histopathology. This case represents a potential pitfall for PSMA-11 PET imaging. The presentation of mildly avid, atypical soft tissue lesions should warrant a biopsy to allow for proper diagnosis and treatment management.

Potential Pitfall of Fluciclovine PET/CT in Castrate-Resistant Prostate Cancer With Adrenal Metastasis.

ABSTRACT: An 83-year-old man with castrate-resistant prostate cancer underwent an 18 F-fluciclovine PET/CT scan, which was negative for local disease recurrence or locoregional lymphadenopathy, but there were multiple fluciclovine-avid bone metastases. In addition, mildly avid bilateral adrenal nodules were thought to be benign. However, on follow-up PET/CT 10 months later, while on additional therapy with enzalutamide, the bilateral nodules became mass lesions with interval decreased fluciclovine avidity. Adrenal metastases were suspected given their rapid growth, with subsequent CT-guided biopsy revealing metastatic prostate cancer without tumor necrosis. This false-negative case highlights the diagnostic challenge of fluciclovine PET in characterizing adrenal lesions.

Sincalide-Stimulated Cholescintigraphy: A Retrospective Study and Proposal of a Modified Workflow.

PURPOSE: Current guidelines for sincalide-stimulated cholescintigraphy (SSC) call for a 60-minute sincalide infusion, and a gallbladder ejection fraction (GBEF) ≥38% is considered normal. In this retrospective study, we hypothesize that most patients reach a normal GBEF by 30 minutes. METHODS: Eligible patients had undergone a 60-minute SSC from January to December 2019. The clinical SSC data were previously processed on a Xeleris workstation (GE Healthcare). In subjects with GBEF ≥38% based on standard SSC, the GBEF at 20 minutes and 30 minutes were retrospectively calculated using manual pixel height measurements. Receiving operating characteristic was analyzed to determine the best GBEF cutoff at 30 minutes. RESULTS: Of 302 subjects, mean age of 46 ± 17 years, 33 (10.9%) showed an abnormal GBEF <38% suggestive of functional gallbladder disorder. In the remaining 269 patients (89.1%) with a normal GBEF, 60.6% and 86.6% reached a normal GBEF at 20 minutes and 30 minutes, respectively. Moreover, a GBEF threshold >29.1% at 30 minutes was associated with a negative predictive value of 99.6%, indicating that a 60-minute SSC was not necessary. The GBEF values were not associated with sex, age, patient symptoms, or type of referral. Manually calculated GBEFs on the time-activity curve showed excellent correlation with the primary values. We propose a modified workflow that splits the 60-minute SSC into two 30-minute image sets to allow for a screening GBEF at 30 minutes. If GBEF is >29.1% at 30 minutes, the second image set may be stopped, and the examination is complete. CONCLUSIONS: The majority of patients (77.2%) undergoing the standard 60-minute SSC reach a normal GBEF already by 30 minutes. The proposed workflow shortens the SCC procedure by 30 minutes, while maintaining high diagnostic accuracy and contributing to improved procedure efficiency and reduced patient discomfort as well as symptoms.

PET/CT Limitations and Pitfalls in Urogenital Cancers.

Hybrid FDG PET/CT plays a vital role in oncologic imaging and has been widely adopted for the staging and restaging of a variety of malignancies. Its diagnostic value in urogenital malignancies is less well-known, not at least because of the variable FDG avidity of these tumor entities, the sites of these tumors, and technical challenges associated with sequential imaging of CT and PET. PET/CT interpretation thus can be especially challenging and is associated with many pitfalls, which can lead to both false-positive and false-negative diagnoses as well as incorrect assessment of metabolic change following therapy. Currently, FDG PET/CT is not the standard of care for the initial diagnosis or staging of early-stage or low-risk urogenital cancers; however, it can help evaluate distant metastatic disease, response to therapy, and disease recurrence in high-risk patients. Knowledge of imaging features of tumor metabolic avidity and pitfalls is essential for accurate interpretation.

18F-FDG PET/MRI Primary Staging of Cervical Cancer: A Pilot Study with PET/CT Comparison.

We report our PET/MRI experience from a pilot study that compared the diagnostic performance of 18F-FDG PET/MRI versus PET/CT in staging of cervical cancer. Methods: Six adults with newly diagnosed cervical cancer underwent a single 18F-FDG injection with a dual-imaging protocol: standard-of-care PET/CT followed by research PET/MRI. The diagnostic interpretation and SUVmax for the 2 modalities were compared. Results: Both modalities detected all primary tumors (median size, 3.9 cm) and all 4 metastases present in 2 of the 6 patients (median size, 0.9 cm). PET/MRI provided greater diagnostic confidence than PET/CT and upstaged the disease in 4 patients. On the basis of the imaging findings alone, the additional information from PET/MRI would have led to a change in clinical management in 3 of 6 patients. The primary lesion showed a median SUV of 12.8 on PET/CT and 18.2 on PET/MRI (P = 0.03). SUVs, however, correlated strongly between the 2 modalities (ρ = 0.96, P < 0.001). Conclusion: Our pilot study supports the notion that PET/MRI has the potential to impact clinical decisions and treatment strategies in women with cervical cancer. Further studies are, however, warranted to define the value that PET/MRI adds to PET/CT.

68Ga-DOTATATE PET/MRI for Neuroendocrine Tumors: A Pictorial Review.

Neuroendocrine tumors (NETs) constitute a variety of neoplastic entities and exhibit variable degrees of neuroendocrine differentiation and phenotypes, as well as genetic profiles. Ga-DOTATATE PET is a novel imaging technique for NET. Although PET/CT is commonly utilized for oncologic imaging, PET/MRI is particularly suited for NETs, as MRI provides greater soft tissue contrast than CT, allowing for improved detection and characterization of NETs, particularly when liver metastasis is suspected or needs to be ruled out. The current pictorial review aims to illustrate the complementary advantages, as well as pitfalls of Ga-DOTATATE PET/MRI in the evaluation of NETs.

18F-Fluciclovine PET/MRI in a Patient With Squamous Cell Carcinoma of the Uterine Cervix Correlated With 18F-FDG PET/CT.

A 32-year-old woman with a FIGO (International Federation of Gynecology and Obstetrics) stage IIA invasive squamous cell carcinoma of the uterine cervix underwent a clinical FDG PET/CT scan, which revealed intense uptake in the primary. On research F-fluciclovine PET/MRI, the primary showed elevated fluciclovine uptake at 5 and 40 minutes after radiotracer injection, with no evidence of regional or distant metastasis. Fluciclovine PET may have diagnostic value for cervical cancer imaging with a potential advantage over FDG of minimal urinary activity from renal excretion; however, in this patient, the metabolic activity was inferior to that of FDG PET.

Dentate Nucleus Signal Intensity Increases Following Repeated Gadobenate Dimeglumine Administrations: A Retrospective Analysis.

Background Increased cerebral signal intensity (SI) has been reported in patients undergoing MRI with gadolinium-based contrast agents (GBCAs). Published data on gadobenate dimeglumine have been somewhat contradictory. Purpose To evaluate the relationship between dosage of gadobenate dimeglumine and SI change at MRI following multiple gadobenate dimeglumine administrations. Materials and Methods In this retrospective study, patients referred for clinically indicated brain MRI from January 2006 through May 2016 were evaluated for inclusion. Eligible patients were between 18 and 90 years old at their baseline brain MRI and had never received a GBCA, had undergone three or more MRI examinations with gadobenate dimeglumine, and had the baseline scan and another brain MRI scan available for comparison. The primary group consisted of patients with four or fewer supratentorial lesions smaller than 3 cm who underwent axial T1-weighted MRI at 1.5 T. One patient had also undergone prior radiation therapy. The secondary group consisted of patients with a history of brain radiation therapy or craniotomy who underwent 1.5-T and 3-T same-plane T1-weighted MRI (in any order). The SI for up to eight brain MRI examinations per patient was measured, and relative SI changes from baseline to interval scans were calculated. A subgroup analysis was performed to assess the gadobenate dimeglumine washout since the last gadolinium exposure. All patients had normal renal and liver functions. Linear mixed regression analyses were performed for variables with P < .05. Results In 43 patients (14 men, 29 women; median age, 49 years; age range, 25-73 years), the dentate nucleus (DN)-to-middle cerebral peduncle (MCP) SI ratio showed a mean increase of 6.7% ± 3.9 in the primary group and 4.0% ± 2.7 in the secondary group (both P < .001) following the administration of 134 mL ± 141 gadobenate dimeglumine over 55 months ± 35.2. The DN/MCP SI ratio increased linearly with the amount of gadobenate dimeglumine, with a mean increase of 0.015% ± 0.004 per 1 mL of gadobenate dimeglumine (R2 = 0.3, P < .001). Conclusion In patients receiving multiple doses of gadobenate dimeglumine, a linear relationship existed between gadobenate dimeglumine administrations and an increase in the dentate nucleus-to-middle cerebral peduncle signal intensity ratio at MRI. © RSNA, 2020 See also the editorial by McDonald and Kallmes in this issue.

Differential 18F-FDG and 18F-Fluciclovine Uptake Pattern in a Patient With Poorly Differentiated Adenocarcinoma of the Lung and Prostate Cancer Biochemical Recurrence.

A 72-year-old man with a history of T1cN0M0 prostate adenocarcinoma and rising prostate-specific antigen underwent a fluciclovine PET/CT scan that showed high uptake in several para-aortic nodes, suspicious for prostate cancer. A right upper lobe single pulmonary nodule (SPN), demonstrated only mild uptake, which raised the suspicion for a lung primary. Subsequent FDG PET/CT showed high uptake in the SPN, revealing poorly differentiated adenocarcinoma at biopsy, but with no abnormal uptake in the para-aortic nodes. This case highlights the complementary potential of fluciclovine and FDG PET in patients with a history of prostate cancer biochemical recurrence and SPN.

Tumor volume delineation: A pilot study comparing a digital positron-emission tomography prototype with an analog positron-emission tomography system.

We evaluated the potential differences of a digital positron-emission tomography (PET) prototype equipped with photon-counting detectors (D-PET, Philips Healthcare, Cleveland, Ohio, USA) in tumor volume delineation compared with the analog Gemini TF PET system (A-PET, Philips). Eleven oncologic patients first underwent clinical fluorodeoxyglucose (FDG) PET/computed tomography (CT) on A-PET. The D-PET ring was then inserted between the PET and CT scanner of A-PET and the patient was scanned for the second time. Two interpreters reviewed the two sets of PET/CT images for image quality and diagnostic confidence. FDG avid lesions were evaluated for volume measured at 35% and 50% of maximum standard uptake value (SUV) thresholds (35% SUV, 50% SUV), and for SUV gradient as a measure of lesion sharpness. Bland-Altman plots were used to assess the agreement between the two PET scans. Qualitative lesion conspicuity, sharpness, and diagnostic confidence were greater at D-PET than that of A-PET with favorable inter-rater agreements. Median lesion size of the 24 measured lesions was 1.6 cm. The lesion volume at D-PET was smaller at both 35% SUV and 50% SUV thresholds compared with that of A-PET, with a mean difference of - 3680.0 mm3 at 35% SUV and - 835.3 mm3 at 50% SUV. SUV gradient was greater at D-PET than at A-PET by 49.2% (95% confidence interval: 34.1%-60.8%). Given the smaller volume definition, coupled with improved conspicuity and sharpness, digital PET may be more robust and accurate in tumor rendering compared with analog PET not only for radiotherapy planning but also in prognostication and systemic treatment monitoring.

Multipurpose computed tomography window for fusion display with functional imaging.

Current positron emission tomography/computed tomography (PET/CT) and single photon emission CT (SPECT)/CT displays have major drawbacks, in that the CT only shows one tissue type at a time, which leads to a suboptimal fusion display. We developed a multipurpose CT level/window aiming at enhancing fusion display. A total of thirty CT examinations as part of fluorodeoxyglucose PET/CT examinations (15 were open source from the OsiriX website and 15 from our PET facility) and the open-source software MIPAV were used. During the development phase, a nuclear medicine physician manually modified the lookup table in a way that preserved the soft tissue contrast as well as enhanced the lung and bone tissue as much as possible. The developed multipurpose CT window was used in the subsequent validation phase and scored by two nuclear medicine physicians, who scored the image quality based on a 3-point score. Descriptive statistics was used to summarize the visual scores. The multipurpose CT window is a composite of several segments of linear CT levels/windows and contains an inverted linear level/window in the low range of Hounsfield unit designed to enhance lung/soft tissue contrast. In doing so, the multipurpose CT window preserves the high soft tissue contrast; the visualization of the lung parenchyma is satisfactory; the contrast for the bone tissue is improved but remains suboptimal when compared with conventional bone window. The multipurpose CT window was found to be "very useful" (median score 3; 95% confidence interval [CI] 2.0-3.0) for the purpose of fusion with functional imaging, with a prevalence asymmetry index 0.97 (95% CI 0.83-1.0). The multipurpose CT window was developed for image fusion and is not intended for diagnostic purposes. It shows favorable similarities to conventional CT windows with only minor artifacts and allows for enhanced visualization of fused PET/CT and SPECT/CT images. The multipurpose CT window is particularly valuable for case review/demonstrations on standard personal computers and handheld devices (smartphones, tablets).

Normalized Subtraction of Serial Brain Magnetic Resonance Images and Fludeoxyglucose-Positron Emission Tomography Images for Tumor Treatment Monitoring: Case Report and Method Description.

A 60-year-old Caucasian male with a long history of cigarette smoking was diagnosed with epidermal growth factor receptor-mutation negative lung adenocarcinoma. The single cerebral metastasis in the right frontal lobe was treated with stereotactic radiosurgery and systemic chemotherapies. Normalized subtraction (NS) method was used to evaluate the serial brain magnetic resonance (MR) and fludeoxyglucose-positron emission tomography (FDG-PET) findings retrospectively, and the potential benefit of concurrent NS of serial MR images (MRIs) and PET images was demonstrated. MIM 4.1 (MIM Software Inc., Cleveland, OH) was used to co-register MRI with PET data and to perform NS on the serial MRI and PET data. MIM 4.1 provides fully automated alignment of imaging data by maximization of mutual information. Cortical regions distant from the brain lesion were used to adjust for the intensity differences between scans, so the voxel differences in normal brain regions were near zero in the NS images. A difference of 15% or greater in voxel densities was used for both MRI and PET, above or below which a change in MR signal intensity and FDG avidity was considered significant. The use of NS, in this case, allowed for an enhanced correlation of morphologic and functional information, which may have added value in the early treatment monitoring of brain tumors and help distinguish recurrent tumor from postradiation changes.

Targeted Therapy and Immunotherapy Response Assessment with F-18 Fluorothymidine Positron-Emission Tomography/Magnetic Resonance Imaging in Melanoma Brain Metastasis: A Pilot Study.

INTRODUCTION: This pilot study aimed at exploring the utility of the proliferation tracer F-18 fluorothymidine (FLT) and positron-emission tomography (PET)/magnetic resonance imaging (MRI) (FLT-PET/MRI) for early treatment monitoring in patients with melanoma brain metastasis (MBM) who undergo targeted therapy or immunotherapy. MATERIAL AND METHODS: Patients with newly diagnosed MBM underwent baseline and follow-up FLT-PET/MRI scans at 3-4 weeks of targeted therapy or immunotherapy. Up to six measurable brain lesions ≥1.0 cm per subject, as identified on T1-weighted post-gadolinium images, were included for quantitative analyses. The maximum SUV of each lesion was divided by the mean SUV of the pons to obtain the SUV ratio (SUVR). RESULTS: Five enrolled subjects underwent the baseline FLT-PET/MRI study in which the MBM showed a median size of 1.7 cm (range 1.0-2.9) and increased metabolic activity with SUVR of 9.9 (range 3.2-18.4). However, only two subjects (cases #1 and #2) returned for a follow-up scan. At baseline, a total of 22 lesions were analyzed in all five subjects, which showed a median size of 1.7 cm (range 1.0-2.9) and median SUVR of 9.9 (range 3.2-18.4). At follow-up, case #1 was a 55-year-old man who received targeted BRAF inhibitor and MEK inhibitor therapy with dabrafenib and trametinib. Fused PET/MRI data of six measured lesions demonstrated a significant reduction in MBM proliferative activity (median -68%; range -38 to -77%) and size (median -23%; range -4 to -55%) at three weeks of therapy. Nevertheless, the subject eventually progressed and died 13 months after therapy initiation. Case #2 was a 36-year-old man who received immunotherapy with nivolumab and ipilimumab. The five measured MBM lesions showed a mixed response at both proliferative and morphologic imaging at 1-month follow-up. Some lesions demonstrated interval decrease while others interval increase in proliferative activity with a median -44% (range -77 to +68%). On MRI, the size change was +7% (range -64 to +50%). The therapy was switched to dabrafenib and trametinib, which led to a partial response. The patient is still alive 16 months following therapy initiation. CONCLUSION: The five cases presented show the potential benefit of hybrid FLT-PET/MRI for the diagnosis of MBM and treatment monitoring of targeted therapy and immunotherapy. However, further studies are required to assess their complementary role in distinguishing true progression from pseudoprogression.

Radium-223 Therapy for Patients with Metastatic Castrate-Resistant Prostate Cancer: An Update on Literature with Case Presentation.

Background and Purpose. Radium-223 dichloride (Xofigo®, Bayer HealthCare Pharmaceuticals Inc.) is the first α-particle emitter therapeutic agent approved by the FDA, with benefits in overall survival and delay in symptomatic skeletal event for patients with metastatic castrate-resistant prostate cancer (CRPC). Recent post hoc analyses of the phase III ALSYMPCA trial support the previously established safety profile as well as therapeutic effect and clinical outcome of Radium-223. Currently, Radium-223 is approved as a single agent therapy for metastatic CRPC. Clinical trials are currently investigating Radium-223 in additional clinical settings such as earlier asymptomatic disease and in combination with other agents including hormonal therapeutic agents and immunotherapeutic as well as chemotherapeutic agents. Trials are also ongoing in patients with other primary cancers such as breast cancer, thyroid cancer, and renal cancer metastatic to bone. In this article, the physics and radiobiology, as well as a literature update on the use of Radium-223, are provided along with case presentations, aiming at a better appreciation of research data as well as the assimilation of research data into clinical practice.

Are there radiographic, metabolic, and prognostic differences between cavitary and noncavitary nonsmall cell lung carcinoma? A retrospective fluorodeoxyglucose positron emission tomography/computed tomography study.

AIMS: The prognosis of nonsmall cell lung cancer with cavitation (NSCLC-c) is not well-known. We compared the positron emission tomography/computed tomography (PET/CT) findings and survival data of patients with NSCLC-c patients with those without cavitation (NSCLC-nc). METHODS: Between 7/2004 and 6/2007, cavitary lung lesions were identified in 46/248 patients undergoing fluorodeoxyglucose (FDG) PET/CT for lung nodule characterization or lung cancer staging. Within the same period, 40 of 202 patients with NSCLC-nc were randomly selected for comparison. The primary was assessed by location, size, cell type, and standardized uptake value (SUV). Disease stage was determined according to American Joint Committee on Cancer guidelines for lung cancer. Kaplan-Meier method was used for survival analysis and Cox regression to assess the effect of clinical and imaging variables on survival. RESULTS: NSCLC-c was found in 87% of patients that had a cavitary lung lesion at PET/CT. Squamous cell carcinoma, primary size and primary-to-liver SUV ratio differed significantly between NSCLC-c and NSCLC-nc, whereas age, gender, primary location, primary SUV, type of treatment, and disease stage did not. Median survival and overall 5-year survival were 19 months and 24% for NSCLC-c, and 31 months and 31% for NSCLC-nc, P = 0.23. Disease stage was the only predictor of survival. CONCLUSION: Cavitary lung lesions in patients undergoing FDG PET/CT harbor a significant risk for cancer. NSCLC-c is associated with squamous cell carcinoma, larger size, and greater FDG metabolism compared with NSCLC-nc, although these variables may not be predictive of survival. Nonetheless, PET/CT contributes to accurate staging and has an indirect impact on prognosis.

Image Quality and Diagnostic Performance of a Digital PET Prototype in Patients with Oncologic Diseases: Initial Experience and Comparison with Analog PET.

UNLABELLED: We report our initial clinical experience for image quality and diagnostic performance of a digital PET prototype scanner with time-of-flight (DigitalTF), compared with an analog PET scanner with time-of-flight (GeminiTF PET/CT). METHODS: Twenty-one oncologic patients, mean age 58 y, first underwent clinical (18)F-FDG PET/CT on the GeminiTF. The scanner table was then withdrawn while the patient remained on the table, and the DigitalTF was inserted between the GeminiTF PET and CT scanner. The patients were scanned for a second time using the same PET field of view with CT from the GeminiTF for attenuation correction. Two interpreters reviewed the 2 sets of PET/CT images for overall image quality, lesion conspicuity, and sharpness. They counted the number of suggestive (18)F-FDG-avid lesions and provided the TNM staging for the 5 patients referred for initial staging. Standardized uptake values (SUVs) and SUV gradients as a measure of lesion sharpness were obtained. RESULTS: The DigitalTF showed better image quality than the GeminiTF. In a side-by-side comparison using a 5-point scale, lesion conspicuity (4.3 ± 0.6), lesion sharpness (4.3 ± 0.6), and diagnostic confidence (3.4 ± 0.7) were better with DigitalTF than with GeminiTF (P < 0.01). In 52 representative lesions, the lesion maximum SUV was 36% higher with DigitalTF than with GeminiTF, lesion-to-blood-pool SUV ratio was 59% higher, and SUV gradient was 51% higher, with good correlation between the 2 scanners. Lesions less than 1.5 cm showed a greater increase in SUV from GeminiTF to DigitalTF than those lesions 1.5 cm or greater. In 5 of 21 patients, DigitalTF showed an additional 8 suggestive lesions that were not seen using GeminiTF. In the 15 restaging patients, the true-negative rate was 100% and true-positive rate was 78% for both scanners. In the 5 patients for initial staging, DigitalTF led to upstaging in 2 patients and showed the same staging in the other 3 patients, compared with GeminiTF. CONCLUSION: DigitalTF provides better image quality, diagnostic confidence, and accuracy than GeminiTF. DigitalTF may be the most beneficial in detecting small tumor lesions and disease staging.