[FDG-PET/CT in oncology. German Guideline]. / FDG-PET/CT in der Onkologie. Leitlinie.

FDG-PET/CT examinations combine metabolic and morphologic imaging within an integrated procedure. Over the past decade PET/CT imaging has gained wide clinical acceptance in the field of oncology. This FDG-PET/CT guideline focuses on indications, data acquisition and processing as well as documentation of FDG-PET/CT examinations in oncologic patients within a clinical and social context specific to Germany. Background information and definitions are followed by examples of clinical and research applications of FDG-PET/CT. Furthermore, protocols for CT scanning (low dose and contrast-enhanced CT) and PET emission imaging are discussed. Documentation and reporting of examinations are specified. Image interpretation criteria and sources of errors are discussed. Quality control for FDG and PET/CT-systems, qualification requirements of personnel as well as legal aspects are presented.

Effect of thyrotropin-releasing hormone on dog thyroid in vitro.

The in vitro action of thyrotropin-releasing hormone (TRH) on the cyclic AMP level and iodine metabolism in dog thyroid, has been studied. TRH inhibited cyclic AMP accumulation and subsequent secretion in slices stimulated by thyrotropic hormone (TSH), prostaglandin E1, cholera toxin and to a lesser extent forskolin. The effect of TRH was suppressed in a medium deprived of calcium or in the presence of isobutylmethylxanthine. TRH also stimulated iodide binding to proteins, but not cyclic GMP accumulation. Although all these characteristics of TRH action on dog thyroid fit those of prostaglandin F1 alpha in this tissue, TRH effects were not relieved by indomethacine. The possibility of a TRH action through other known inhibitors of the cyclic AMP system in dog thyroid such as: acetylcholine, alpha-adrenergic agents, adenosine, iodide were checked and ruled out. The possible involvement of other neurotransmitters, such as ATP or vasoactive intestinal peptide were studied but could not be substantiated. Our data suggest the existence of a direct negative action of TRH on the thyroid itself besides its stimulatory role at the pituitary level. The great variability of the TRH effect was overcome by pretreatment of the dog by pyridostigmine, an acetylcholinesterase inhibitor.

Prospective investigation of positron emission tomography in lung nodules.

PURPOSE: Solitary pulmonary nodules (SPNs) are commonly identified by chest radiographs and computed tomography (CT). Biopsies are often performed to evaluate the nodules further. An accurate, noninvasive diagnostic test could avoid the morbidity and costs of invasive tissue sampling. We evaluated the ability of fluorine-18 deoxyglucose positron emission tomography (FDG-PET) to discriminate between benign and malignant pulmonary nodules in a prospective, multicenter trial. METHODS: Eighty-nine patients who had newly identified indeterminate SPNs on chest radiographs and CT were evaluated with FDG-PET. PET data were analyzed semiquantitatively by calculating standardized uptake values (SUVs) as an index of FDG accumulation and also by a visual scoring method. PET results were compared with pathology results. RESULTS: Sixty SPNs were malignant and 29 were benign. Using SUV data, PET had an overall sensitivity and specificity for detection of malignant nodules of 92% and 90%. Visual analysis provided a slightly higher, but not statistically significant, sensitivity of 98% and lower specificity of 69%. For SPNs < or = 1.5 cm (34 of 89), the sensitivity and specificity of SUV and visual analysis were 80% and 95% and 100% and 74%, respectively. CONCLUSION: FDG-PET can accurately characterize indeterminate SPNs. PET imaging provides a noninvasive method to evaluate indeterminate SPNs, which can reduce the need for invasive tissue biopsy.

Evaluation of myocardial ischemia using a rest metabolism/stress perfusion protocol with fluorine-18 deoxyglucose/technetium-99m MIBI and dual-isotope simultaneous-acquisition single-photon emission computed tomography.

OBJECTIVES: This study sought to develop a dual-isotope single-acquisition single-photon emission computed tomographic (SPECT) protocol using a multihead SPECT camera equipped with an ultra-high energy collimator to evaluate rest metabolism/stress perfusion simultaneously with fluorine-18 (F-18) deoxyglucose/technetium-99m (Tc-99m) 2-hexakis-2-methoxy-2-methylpropyl isonitrile (MIBI). BACKGROUND: The most accurate and logistic method of identifying injured but viable myocardium remains a diagnostic challenge. METHODS: Sixty-five patients were given 25 to 50 g of glucose and, after approximately 60 min, an injection of 370 MBq (10 mCi) of F-18 fluorodeoxyglucose. After a 35-min distribution phase, patients underwent exercise or pharmacologic stress followed by administration of 925 MBq (25 mCi) of Tc-99m MIBI. Five patients underwent F-18 fluorodeoxyglucose position emission tomography before dual-isotope SPECT: RESULTS: With a window of 20% for both photopeaks and a technetium-99m/fluorine-18 concentration of 3.2:1, the "spillover" from fluorine-18 into the technetium-99m window is < 6% of the total counts in the window in patients with a normal distribution of both radiopharmaceuticals. Phantom images clearly demonstrated cardiac defects measuring 2 x 1 and 2 x 0.5 cm. There was no significant difference in the images of the five patients who underwent both positron emission tomography and SPECT: Fifty-seven patients (mean [+/- SD] age 55 +/- 15 years, range 25 to 83; 38 men, 19 women) had satisfactory images and were included in the study. Twenty-one patients had normal study results; 15 had mismatched defects; 14 had matched defects; and 7 had both matched and mismatched defects. Twenty-three patients (mean age 54 +/- 6 years, range 30 to 83; 14 men, 9 women) underwent coronary angiography within 3 months of dual-isotope SPECT: There were seven normal studies, eight with mismatched defects, one with a matched defect and seven with matched and mismatched defects. When stenosis > 70% was used as the criterion for a diagnosis of coronary artery disease, dual-isotope SPECT had a sensitivity of 100%, specificity of 88%, positive predictive value of 93%, negative predictive value of 100% and an accuracy of 96%. CONCLUSIONS: Dual-isotope SPECT may provide an alternative, accurate, cost-effective method to nitrogen-13 ammonia/F-18 fluorodeoxyglucose positron emission tomography or thallium-201 reinjection for identifying injured or dysfunctional but viable myocardium.

Stimulation of the adenosine 3',5'-monophosphate and the Ca2+ messenger systems together reverse dopaminergic inhibition of prolactin release.

Dopaminergic inhibition of PRL release stimulated by agents that affect cytosolic Ca2+ concentrations, C-kinase activity, and cAMP levels was studied in perifused rat anterior pituitary cells cultured on cytodex beads. We used A23187 (20 microM) to increase intracellular Ca2+, the phorbol ester 12-O-tetradecanoyl-phorbol-13-acetate (TPA; 50 nM) to stimulate C-kinase, forskolin (10 microM) to increase intracellular cAMP, and 8-bromo-cAMP to mimic cAMP. Dopamine (10 microM) inhibited PRL release to 20-60% of the basal release within 10 min. After 30 min of preincubation with dopamine, the absolute amount of release stimulated by 100 nM TRH was strongly inhibited, although the pattern of release, a quick burst followed by sustained release at a lower rate, was the same in the presence or absence of dopamine. A23187 (20 microM) caused a rapid burst of PRL release that subsided within 10 min, and TPA (50 nM) caused a sustained release that began within 4 min and continued for at least 30 min. TPA and A23187 combined caused a rapid burst of release followed by a sustained phase of release similar to that caused by TRH. Preincubation with dopamine inhibited the absolute amount of PRL release caused by A23187 alone, TPA alone, or the two combined, although, as with TRH, the pattern of release remained the same. Forskolin (1 or 10 microM) or 8-bromo-cAMP (3 mM) induced a 1.5- to 2-fold increase in PRL release, and this was completely prevented by dopamine. Preincubation with both dopamine and 8-bromo-cAMP or forskolin restored the amount of release stimulated by TPA alone or TPA and A23187 in the presence of dopamine to the level of release stimulated by these agents in the absence of dopamine. Therefore, activating either the cAMP messenger system or the Ca2+ system alone will not abolish dopaminergic inhibition, but activating the two together will. These results suggest that dopamine blocks release by inhibiting both adenylate cyclase and a step in the Ca2+ messenger system.

Difference in calcium requirements for forskolin-induced release of prolactin from normal pituitary cells and GH4C1 cells in culture.

We investigated the role of Ca++ in cAMP-stimulated PRL release from 1) primary cultures of male rat pituitary glands, 2) primary cultures of estrogen-induced pituitary tumors from Fischer rats, and 3) the pituitary tumor cell line GH4C1. Forskolin, an activator of adenylate cyclase, increased intracellular cAMP concentrations in GH4C1 cells at least 20-fold within 15 min. This increase occurred in the presence or absence of added extracellular Ca++ or in the presence of D600 or Co++. Forskolin increased PRL release from the three types of cells. The three systems differed in the Ca++ sensitivity of forskolin-induced release, but showed little difference in the Ca++ sensitivity of K+-induced release. This was shown in two ways. The cells were incubated either 1) in a medium without added Ca++ or 2) in the presence of a Ca++ channel inhibitor, D600. In normal cells, K+- and forskolin-induced release were equally inhibited when extracellular Ca++ was removed or D600 was added. In GH4C1 cells, Ca++ removal or D600 addition (100 microM) completely blocked K+-induced release, but had little effect on forskolin-induced release. The response of Fischer tumor cells was intermediate between those of normal and GH4C1 cells. 45Ca++ uptake by GH4C1 cells was not affected by forskolin, whereas the release of 45Ca++ from preloaded cells was increased slightly only 30 min after the addition of forskolin in three of four experiments. The difference in Ca++ requirements between normal and GH4C1 cells for forskolin stimulation may be due to the release of cellular Ca++ stores by cAMP. These stores may not be as large in normal cells as they are in GH4C1 cells, and therefore the requirement for extracellular Ca++ occurs. Alternatively, GH4C1 cells may release PRL by a mechanism different from that which normal cells use.

Dopamine inhibits prolactin release when cyclic adenosine 3',5'-monophosphate levels are elevated.

We purified lactotrophs from pituitary tumors induced by estrogen in ovariectomized female Fischer 344 rats from 80% of the population before to more than 90% after purification through a continuous Percoll density gradient. The percentage of lactotrophs was evaluated by immunofluorescence. The patterns of PRL release stimulated by 100 nM TRH, 20 microM A23187 (a Ca++ ionophore), 50 nM 12-O-tetradecanoyl-phorbol-13-acetate (a C-kinase activator), or combinations of these agents, or inhibited by 10 microM dopamine were similar in perifused primary cultures of tumor lactotrophs to patterns in cultures of anterior pituitary cells from female retired breeders used previously. In particular, dopamine completely inhibited the release stimulated by forskolin. Intracellular cAMP concentrations and PRL accumulation in the medium were measured in monolayer cultures of purified tumor lactotrophs. In 9 separate experiments, forskolin (10 microM) increased intracellular cAMP concentrations more than 60-fold above control after 30 min of incubation. Preincubation (30 min) with dopamine (10 microM) reduced the cAMP accumulation caused by forskolin, but levels were still at least 20-fold above basal levels in most experiments. PRL release was stimulated 2-fold with forskolin alone, but there was no stimulation of PRL release by forskolin in the presence of dopamine even though cAMP levels were elevated above basal. Therefore, a decrease in cAMP levels is not necessary to inhibit PRL release, and dopamine must have a mechanism for inhibiting PRL release in addition to inhibiting adenylate cyclase.

Oncological applications of FDG PET imaging: brain tumors, colorectal cancer, lymphoma and melanoma.

This article will focus primarily on body oncology diagnosis, staging and therapy monitoring using fluorodeoxyglucose (FDG) PET imaging. Common pitfalls and artifacts in body FDG imaging will be covered. Examples of diagnosis, staging and therapy monitoring of brain tumor, colorectal cancer, lymphoma and melanoma will be given. Importance of correlation with anatomic imaging and practical use of FDG imaging in patient management will be stressed.

Correlative pediatric imaging.

Nuclear medicine, ultrasound, and magnetic resonance imaging (MRI) are considered ideal imaging modalities for pediatric patients. The future is even more promising for pediatric imaging with the development of newer and improved radiopharmaceuticals, instrumentation and diagnostic modalities such as positron emission tomography, labeled monoclonal antibodies, and faster dynamic and contrast enhanced MRI methods. However, correlation of more conventional imaging modalities with nuclear medicine, ultrasound and MRI remain essential for optimal patient care.

Image fusion using an integrated, dual-head coincidence camera with X-ray tube-based attenuation maps.

UNLABELLED: The purpose of this study was to characterize a dual-head gamma camera capable of FDG imaging using coincidence detection and equipped with an integrated x-ray transmission system for attenuation correction, anatomic mapping, and image fusion. METHODS: Radiation dose (425 mrads skin dose) and tissue contrast (0.7% deviation from expected values) were assessed for the x-ray system. Registration of transmission and emission scans was validated using a hot sphere phantom and was verified in selected patient studies. RESULTS: Fusion of anatomic maps and FDG images allowed precise anatomic localization of lesions identified using dual-head coincidence imaging. CONCLUSION: The combined approach of x-ray attenuation, anatomic mapping, and image fusion with scintigraphic studies provides a new diagnostic tool for nuclear medicine and fertile ground for future research.

Cat-scratch disease: report of a case with liver lesions and no lymphadenopathy.

The usual presentation of cat-scratch disease (CSD) is a subacute regional lymphadenitis following cutaneous inoculation. We present the case of a 10-yr-old white female with a 4-wk history of abdominal pain and fever, without associated lymphadenopathy. A 67Ga scintigram showed inhomogenous uptake by the liver. An abdominal computed tomographic (CT) scan revealed multiple low density lesions in the liver and the spleen, that were confirmed at laparotomy. Stellate microabscesses were seen on a wedge biopsy of the liver and a CSD antigen skin test was positive. CSD should be considered in the differential diagnosis of liver lesions, even in the absence of lymphadenopathy. This case emphasizes the importance of inhomogeneous 67Ga uptake by the liver.

FDG PET and dual-head gamma camera positron coincidence detection imaging of suspected malignancies and brain disorders.

UNLABELLED: The purpose of the study was to compare the diagnostic accuracy of fluorodeoxyglucose (FDG) images obtained with a dual-head coincidence gamma camera (DHC) with those obtained with a dedicated PET in a series of 26 patients. METHODS: Nineteen patients with known or suspected malignancies and 7 patients with neurological disorders underwent PET imaging after injection of approximately 10 mCi of FDG. Whole-body imaging was performed on 19 patients and brain imaging on 7 patients. DHC images were then acquired for 30 min over the region of interest using a dual-head gamma camera equipped with 3/8-in.-thick NaI(TI) crystals and parallel slit-hole collimators. The images were reconstructed in the normal mode, using photopeak/photopeak, photopeak/Compton and Compton/photopeak coincidence events. RESULTS: Although the spatial resolutions of PET with a dedicated PET scanner and of DHC are in the same range, the lesion detectability remains superior with PET (4 mm for PET versus 13.5 mm for DHC in phantom experiments) with a contrast ratio of 5:1. This is most probably attributable to the higher sensitivity of PET (2238 coincidences/min/microCi for PET versus 89 coincidences/min/microCi for DHC). The pattern of uptake and interpretation for brain imaging was similar on both PET and DHC images in all patients. In the 19 oncology patients, 38 lesions ranging from 0.7 to 5 cm were detected by PET. DHC imaging detected 28 (73%) of these lesions. Among the 10 lesions not seen with DHC, 5 were less than 1.2 cm, 2 were located centrally within the liver and suffered from marked attenuation effects and 3 were adjacent to regions with high physiological activity. The nondetectability of some lesions with DHC compared with PET can be explained by several factors: (a) start of imaging time (mean+/-SD: 73+/-16 min for PET versus 115+/-68 min for DHC, leading to FDG decay to 6.75 mCi for PET and 5.2 mCi for DHC); (b) limited efficiency of a 3/8-inch-thick Nal(TI) crystal to detect 18F photons; (c) suboptimal two-dimensional reconstruction algorithm; and (d) absence of soft-tissue attenuation correction for centrally located lesions. CONCLUSION: FDG DHC imaging is a promising technique for oncological and brain imaging.

Carcinoma in a transplanted kidney detected with MAG3 scintigraphy.

We report on two cases of infiltrative renal tumor developing in two kidney transplant recipients from a single cadaveric donor source. Interestingly, while this is only the second case of a de novo renal allograft tumor, both were morphologically infiltrative. The fact that both tumors were infiltrative may be secondary to immunosuppression therapy. While computed tomography (CT) evaluation of suspected renal pathology provides excellent anatomical detail, renal transplant recipients are initially evaluated using ultrasound and renal scintigraphy to avoid contrast reagents which could further impair renal function, as well as to reduce the image procedure cost and the patient radiation dose. Unfortunately, infiltrative tumors may be isoechoic on ultrasound, providing a confusing or conflicting report when compared to scintigraphic findings. This case report is significant radiographically because the original neoplasm was initially detected using technetium-99m-labeled mercaptoacetyltriglycine (99mTc-MAG3) scintigraphy and was not appreciated by sonographic studies, even retrospectively. This case demonstrates the usefulness of 99mTc-MAG3 scintigraphy to follow-up evaluations of renal transplants by providing detailed anatomical information as well as functional analysis of the kidney.

Rest myocardial perfusion/metabolism imaging using simultaneous dual-isotope acquisition SPECT with technetium-99m-MIBI/fluorine-18-FDG.

UNLABELLED: The purpose of this study was to develop a dual-isotope simultaneous acquisition (DISA) protocol using a multihead SPECT camera equipped with an ultrahigh-energy (UHE) collimator to evaluate simultaneously rest cardiac perfusion and metabolism with 99mTc-MIBI/18FDG. METHODS: Physical measurements were first performed with phantoms to develop the acquisition protocol. Fifteen patients underwent DISA-SPECT with 99mTc-MIBI/18FDG to validate the protocol. To evaluate the quality of the 99mTc-MIBI images acquired with the UHE collimator, four patients underwent a resting 99mTc-MIBI scan acquired with a high-resolution, low-energy collimator prior to DISA-SPECT. RESULTS: With a window of 20% for both photopeaks and a 99mTc/18F concentration ratio of 3.2:1, the spillover from 18F into the 99mTc window is 6% of the counts in the window for normal subjects. Phantom images clearly demonstrated defects measuring 2 x 1 and 2 x 0.5 cm. Technetium-99m-MIBI images obtained with the UHE and high-resolution collimators provided similar diagnostic information. Using a stenosis of > 70% as criteria to diagnose coronary artery disease, DISA-SPECT had a sensitivity of 100% and a positive predictive value of 93%. CONCLUSION: Simultaneous evaluation of rest myocardial perfusion/metabolism with a multihead SPECT camera equipped with an UHE collimator is possible using 99mTc-MIBI/18FDG with a dual-isotope simultaneous acquisition protocol.

Staging recurrent metastatic colorectal carcinoma with PET.

UNLABELLED: Accurate detection of recurrent colorectal carcinoma remains a diagnostic challenge. The purposes of this study were to assess the accuracy of 18FDG-PET in patients with recurrent colorectal carcinoma in detecting liver metastases compared with computed tomography (CT) and CT portography, detecting extrahepatic metastases compared with CT and evaluating the impact on patient management. METHODS: Fifty-two patients previously treated for colorectal carcinoma presented on 61 occasions with suspected recurrence and underwent 18FDG-PET of the entire body. PET, CT and CT portography images were analyzed visually. The final diagnosis was obtained by pathology (n = 44) or clinical and radiological follow-up (n = 17). The impact on management was reviewed retrospectively. RESULTS: A total of 166 suspicious lesions were identified. Of the 127 intrahepatic lesions, 104 were malignant, and of the 39 extrahepatic lesions, 34 were malignant. Fluorine-18-fluorodeoxyglucose imaging was more accurate (92%) than CT and CT portography (78% and 80%, respectively) in detecting liver metastases and more accurate than CT for extrahepatic metastases (92% and 71%, respectively). Fluorine-18-fluorodeoxyglucose detected unsuspected metastases in 17 patients and altered surgical management in 28% of patients. CONCLUSION: These data identify that 18FDG-PET is the most accurate noninvasive method for staging patients with recurrent metastatic colorectal carcinoma and plays an important role in management decisions in this setting.

Nitrogen-13-ammonia and PET to detect allograft coronary artery disease after heart transplantation: comparison with coronary angiography.

UNLABELLED: The diffuse nature of allograft coronary artery disease (CAD) suggests that global myocardial blood flow (MBF) may decrease with time after transplantation; therefore the diagnosis of this disease remains problematic. METHODS: To investigate whether PET detects a fall in allograft MBF over time, PET scans (108) were obtained from 43 heart transplant recipients. Thirty-five patients underwent two serial PET scans 1 yr apart. MBF was measured by PET using 13N-ammonia as a tracer. Coronary angiography was performed parallel with PET imaging and compared with perfusion rates measured by PET scans. RESULTS: MBF measured by PET decreased sequentially with time. The mean MBF was 73 +/- 21, 56 +/- 13, 51 +/- 11 and 51 +/- 27 ml/min/100 g of tissue in patients surviving 3 mo, 1, 2 and 3 yr after transplantation, respectively. Significant MBF decrease occurred within 1 yr after transplantation. Sequential PET studies showed a decrease in MBF in 22 of 35 patients (63%). Mean MBF for the first and second scans was 65 +/- 18 and 54 +/- 16, respectively. MBF decrease was more profound in patients (n = 11) angiographic evidence of CAD. There was a trend towards increased rejection and CMV infection rates in patients with decreased MBF. CONCLUSION: With time, PET detects a decrease in MBF in cardiac allografts. The frequency of MBF decrease detected by PET is concordant with the true incidence of allograft CAD, suggesting that sequential PET is a more sensitive modality for monitoring allograft CAD than angiography.

FDG-SPECT: correlation with FDG-PET.

UNLABELLED: The clinical utility of FDG-PET imaging in the evaluation of patients with cardiac, oncologic and neurologic diseases is well documented. The major disadvantages of PET continue to be its high cost and limited availability. METHODS: With the goal of providing equivalent diagnostic information using a widely available, less expensive modality, we evaluated the clinical utility of FDG-SPECT imaging with a conventional dual-headed camera as compared to PET in 21 patients. RESULTS: To compare the image quality of the two modalities, major physical parameters and phantom determinations were obtained. By using the 511-keV collimators, we achieved resolution and system volume sensitivity that were less than those for PET by factors of 2.6 and 8, respectively. The SPECT system, on the other hand, could easily resolve 2 x 0.5-cm cold defects in the heart phantom and 2-cm hot lesions in a 22-cm cylindrical phantom with a target-to-background ratio of 5:1. FDG-SPECT imaging of nine patients with heart disease yielded similar diagnostic information of the amount of viable myocardium present when compared to PET. In seven of eight patients, malignant tissue visualized with FDG-PET was seen equally well with SPECT. The lesions not visualized with FDG-SPECT were either small (< or = 1.5 cm) or benign. SPECT imaging of four patients with cerebral lesions was inconclusive due to the small sample size but seemed promising. CONCLUSION: FDG-SPECT with 511-keV collimation is less expensive, more available and technically simpler than PET. We believe that FDG-SPECT has achieved sufficient sensitivity and resolution to detect myocardial viability and diagnose malignant tumors > or = 2 cm in diameter.

Estimation of left ventricular mass and infarct size from nitrogen-13-ammonia PET images based on pathological examination of explanted human hearts.

The purpose of this study was to develop a technique to quantify left ventricular mass and infarct size in chronic ischemic heart disease from PET images based on correlation with pathological examination of explanted human hearts. Fourteen hearts from patients with cardiomyopathy who had 13N-ammonia scans prior to orthoptic heart transplantation were studied. Accurate estimation of the relative infarct size was possible in patients with a well-delineated, nearly transmural infarct (r = 0.93, y = 1.1x - 0.7, n = 11). Both absolute and relative infarct mass measurements on PET images correlated well with pathological measurements. We identified a population of patients with patchy interstitial or subendocardial scarring with globally reduced perfusion, for which the infarct size could not be estimated using the criteria derived for the patients with well-delineated infarcts.

Optimal interpretation of FDG PET in the diagnosis, staging and management of pancreatic carcinoma.

UNLABELLED: This study had two purposes: to optimize the semiquantitative interpretation of 18F-fluorodeoxyglucose (FDG) PET scans in the diagnosis of pancreatic carcinoma by analyzing different cutoff levels for the standardized uptake value (SUV), with and without correction for serum glucose level (SUV(gluc)); and to evaluate the usefulness of FDG PET when used in addition to CT for the staging and management of patients with pancreatic cancer. METHODS: Sixty-five patients who presented with suspected pancreatic carcinoma underwent whole-body FDG PET in addition to CT imaging. The PET images were analyzed visually and semiquantitatively using the SUV and SUV(gluc). The final diagnosis was obtained by pathologic (n = 56) or clinical and radiologic follow-up (n = 9). The performance of CT and PET at different cutoff levels of SUV was determined, and the impact of FDG PET in addition to CT on patient management was reviewed retrospectively. RESULTS: Fifty-two patients had proven pancreatic carcinoma, whereas 13 had benign lesions, including chronic pancreatitis (n = 10), benign biliary stricture (n = 1), pancreatic complex cyst (n = 1) and no pancreatic pathology (n = 1). Areas under receiver operating characteristic curves were not significantly different for SUV and SUV(gluc). Using a cutoff level of 3.0 for the SUV, FDG PET had higher sensitivity and specificity than CT in correctly diagnosing pancreatic carcinoma (92% and 85% versus 65% and 61%). There were 2 false-positive PET (chronic pancreatitis, also false-positive with CT) and 4 false-negative PET (all with true-positive CT, abnormal but nondiagnostic) examinations. There were 5 false-positive CT (4 chronic pancreatitis and 1 pancreatic cyst) and 18 false-negative CT (all with true-positive FDG PET scans) examinations. FDG PET clarified indeterminate hepatic lesions or identified additional distant metastases (or both) in 7 patients compared with CT. Overall, FDG PET altered the management of 28 of 65 patients (43%). CONCLUSION: FDG PET is more accurate than CT in the detection of primary tumors and in the clarification and identification of hepatic and distant metastases. The optimal cutoff value of FDG uptake to differentiate benign from malignant pancreatic lesions was 2.0. Correction for serum glucose did not significantly improve the accuracy of FDG PET. Although FDG PET cannot replace CT in defining local tumor extension, the application of FDG PET in addition to CT alters the management in up to 43% of patients with suspected pancreatic cancer.

The role of hybrid cameras in oncology.

The rapid advances in imaging technologies are a challenge for nuclear medicine physicians, radiologists, and clinicians who must integrate these technologies for optimal patient care and outcome at minimal cost. Multiple indications for functional imaging using F-18-fluorodeoxyglucose (FDG) are now well accepted in the field of oncology, including differentiation of benign from malignant lesions, staging malignant lesions, detection of malignant recurrence, and monitoring therapy. The use of FDG imaging was first shown using dedicated positron emission tomography (PET) with multiple full rings of bismuth germanate detectors. Most manufacturers now have available hybrid gamma cameras capable of imaging conventional single-photon emitters, as well as positron emitters such as FDG. This new technology was developed to make FDG imaging more widely accessible, first using single photon emission computed tomography (SPECT) with high-energy collimators, and then using dualhead coincidence (DHC) detection with multihead gamma cameras that improved spatial resolution. Most hybrid gamma cameras are now equipped with thicker NaI(TI) crystals to improve sensitivity. Technical developments are still evolving with correction for attenuation and new iterative reconstruction algorithms to improve the quality of the images. Users need to be familiar with the rapid developments of the technology as well as its limitations. Currently, one model of hybrid gamma camera is equipped with an integrated x-ray transmission system for attenuation correction, anatomic mapping, and image fusion. This powerful tool has promising clinical applications including intensity-modulated radiation therapy.