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Hypermetabolic Images of Digestive Tract in Pet-‐Ct

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Hypermetabolic Images of Digestive Tract in Pet-‐Ct HYPERMETABOLIC IMAGES OF DIGESTIVE TRACT IN PET-CT, DIFFERENTIAL DIAGNOSIS Verónica Gigirey MD (1), Liliana Servente MD(2), Margarita García Fontes MD(3) (1) Ex assistant (2) Assistant Professor (3) Associate Professor, Hospital de Clinicas, Montevideo, Uruguay. Radiologist physicians, Uruguayan Center of Molecular Imaging (CUDIM) Abstract Positron emission tomograpHy (PET), using 18 F-fluorodeoxyglucose (18 F-FDG) Has been successfully implemented for evaluation of malignant tumors, sHowing HigH sensitivity in detecting tumors in the digestive tract, but with low specificity due to several pHysiological and pathological patterns of FDG uptake in the digestive tract. By combining PET and CT (PET-CT) we can localize and cHaracterize the FDG uptake focus. It is necessary to be familiar with uptake patterns in the digestive tract to differentiate between pHysiological and pathological patterns and within these in order to distinguisH between inflammatory and tumoral alterations. To acHieve this we set the following goals: 1) To describe and cHaracterize pHysiological versus pathological uptake of 18F-FDG in the digestive tract in PET-CT studies. 2) To revise findings of PET-CT studies with 18F-FDG carried out in CUDIM(Uruguayan Center of Molecular Imaging) with oncologic patients wHo present Hyper-metabolic lesions in the digestive tract and its pathological correlation. Correlation with CT and combination of PET-CT can sometimes Help identify the cause in uptake increase and it is recommended that focuses of HigHer uptake in the bowel should be evaluated with endoscopy. Keywords Gastrointestinal tract, focal lesions, 18 F-FDG, PET-CT, Oncology , Pitfalls Revista Imagenología. Vol. XVI. N 1. Oct. 2012 2 HYPERMETABOLIC IMAGES OF DIGESTIVE TRACT IN PET-CT, DIFFERENTIAL DIAGNOSIS 1- Introduction these pHysiological variants and the metabolic uptake patterns since they Combining positron emission migHt lead us to false positive diagnosis tomograpHy (PET) and computed of malignancy. Any segment of the tomograpHy (CT) in a single unit (PET- digestive tract (DT) can uptake FDG in a CT) represents an important milestone focal, segmental or diffused way and in Oncology, Nuclear Medicine and also with a variable intensity (mild, Radiology fields, allowing a HigHly moderate or intense), which we will precise fusion and correlation of define later (section 2.d). THe exact morpHological images (obtained with etiology of this pHysiological uptake of CT) and metabolic images (obtained by the gastrointestinal tract is unknown PET). but it is probably due to multiple Fluor-18-fluorodeoxyglucose (18 F-FDG) factors. Among described causes for PET Has been successfully implemented sucH uptake are: metabolic activity of for evaluation of malignant tumors smooth muscle, metabolic activity of especially in the last decade. Increase in mucosa and/or lympHoid tissue accumulation of radiotracer 18 F-FDG associated with mucosa and active (FDG) in neoplassic tissues is a excretion of FDG. (4,5). Diffuse uptake consequence of an increase in the of FDG in the DT can be defined as expression and activity of glucose pHysiological and not related to transport proteins wHicH are the result malignant pathology with HigH of a greater anaerobic metabolism of certainty. However a focal and tumoral cells. (1,2). However, uptake of circumscribed area of FDG increase can FDG is not specific to neoplassic suggest malignancy. (4,5). processes. It accumulates Hybrid PET-CT units provide an pHysiologically in several normal anatomical localization of these sites of organs, including the brain, muscles, FDG accumulation (6,7). Several salivary glands, myocardium, authors Have sHown that precise gastrointestinal apparatus and urinary localization of Hyper-metabolic lesions tract. Furthermore, FDG also using PET-CT improve diagnosis accumulates in benign lesions: efficacy. (7,8). inflammatory or granulomatous processes. (3,4). It is important to also know that there are certain non-Hypermetabolic 18F-FDG PET-CT is sensitive in the neoplasms sucH as slow-growth lesions, detection of malignant tumors of the which Have a great mucous component intestine, but its specificity is reduced and tumors with signet-ring cells, which due to several pHysiological and may not be very avid for FDG; therefore pathological patterns of FDG uptake in their analysis sHould be cautious. the bowel. It is important to know 2 ORIGINAL ARTICLE Other tumors sucH as low-grade Focal nodular uptake and multi-focal neuroendocrine, lympHomas and nodular uptake are predictive of carcinoids may not sHow significant pathological findings that can include metabolic activity. Extensive superficial malignancy. It is necessary to perform a lesions, sucH as those with central colonoscopy for a correct evaluation of necrosis can Have a low FDG uptake. these cases. (13). A pattern of diffuse (9,10). uptake, regardless of its grade is predictive of normal results in FDG PET-CT Has sHown to be very colonoscopy, wHereas a segmental and sensitive in detecting primary intense pattern can indicate an neoplasia, However its specificity is inflammatory condition. It Has been lower due to pHysiological uptake and observed that dysplastic adenomas and the abovementioned inflammatory hyper-plastic polyps may present a causes. THe main use of PET-CT using pattern of focal or multi-focal uptake; FDG is in the staging and re-staging of therefore FDG may be useful in the patients with colon cancer, due to detection of pre-malignant entities in detection of regional lympHatic ganglia the colon (14). and distant metastasis. B D A E C Figure1. 73 years old male. PET-CT for evaluation of solitary pulmonary nodule (SPN). A) PET coronal image: focal uptake in the inferior mediastinum middle line B-C) CT axial plane and sagittal reconstruction: with out obvious lesions D-E) Axial and sagittal fusion: Increase in physiological focal uptake in esophagus gastric union. Revista Imagenología. Vol. XVI. N 1. Oct. 2012 4 HYPERMETABOLIC IMAGES OF DIGESTIVE TRACT IN PET-CT, DIFFERENTIAL DIAGNOSIS In this work we revised studies in wHicH 2- Material and methods. we found focal uptake of FDG at the 2.a. Patients: Reports of 18-F-FDG PET- level of the digestive tract in patients CT total body studies of those patients with known tumoral pathology of the wHo attended CUDIM for a period of 4 digestive spHere and in those in wHicH months (MarcH to June 2011) with it was a finding. In this last case, different oncologic indications were monitoring was carried out to revised retrospectively. Out of this determine if they were malignant or population (450 patients) metabolically premalignant lesions or another active images of the DT of 32 patients etiology. who were referred for staging of Objectives of this work are: tumors of gastrointestinal tract, were analyzed. Patients bearing carcinoid tumors (on wHom a study with 68Ga 1- Describe and cHaracterize was performed) and those indicated for pHysiological versus re-staging were excluded. Furthermore, pathological uptake of 18-F- findings from Hypermetabolic lesions FDG in the digestive tract in informed in 8 patients with other PET-CT studies. primary tumors were revised and 2- Revise findings in 18-F-FDG cHaracteristics of these images were PET-CT studies performed in analyzed. THis selection was not CUDIM on oncologic performed randomly. Patients wHo patients wHo presented could be monitored in order to sHow Hypermetabolic lesions in endoscopic, anatomical-pathological the digestive tract and its and or developmental correlation were pathological correlation. selected. A B C Figure 2- Increased physiological diffused Up take in the colon. 58 years old male. SPN high surgical risk. A) Coronal PET image: increased diffuse uptake in the colon (arrow), B) CT coronal reconstruction: without solid focal or diffuse lesions , C) Coronal fusion. 4 ORIGINAL ARTICLE 2.b. PET-CT Protocol: A Hybrid General administered before the study in cases Electric PET-CT Unit, wHicH acquires PET of known digestive pathology.Once and multiple detector CT images (64 discarded contraindications for its use, detectors) of the patients in one water-soluble iodinated contrast session was used. The axes of both medium was injected (1-2 cc/kg body systems are mecHanically aligned for weigHt) as long as the patient does not correct correlation. Images were Have recent studies or diagnostic obtained from the vertex to the doubts. WHen the study is over patient superior third of the thigH. To acHieve must be re-Hydrated. coincidence between CT and PET 2d. Evaluation of PET-CT images: The images, the study was performed with grade of FDG uptake in the digestive the patient breathing easily. CT data tract was evaluated via a visual analysis was first acquired within the following of the images comparing with normal parameters: 140 kV and 80 mA; with a uptake of liver (background) 4,75 mm thick sections. Next, PET considering it mild wHen it is less that emission data was acquired in 3D mode liver uptake and moderate to intense during 3 minutes for eacH field (eacH 20 wHen it is more pronounced. cm long). A repetitive reconstruction Quantitative analysis was also used by and an attenuation CT map was used measuring SUV (¨standardized uptake for PET images. THe images were value¨) wHicH measures radiation analyzed in Advantage work station, activity detected by PET, normalized analyzing CT, PET image and the fusion according to the patient´s weigHt and of both in axial, coronal and sagittal the injected dose. It is considered mild planes. PET data were also examined in uptake if SUV is lower than 2,5, maximum intensity projection (MIP) in moderate if it is between 2.5 and 4 and the coronal plane. intense if SUV is HigHer than 4. (12). 2.c. Preparation of the patient: These studies were revised by a Preparation of the patient includes: 6 radiologist and a nuclear medicine Hours of fasting, resting the previous pHysician who identified the pattern of day, adequate Hydration, decrease in FDG uptake: focal, segmental or diffuse consumption of carboHydrates 24 and also identified the grade of uptake: Hours before and to avoid smoking.
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