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FDG PET/CT Pitfalls in Gynecologic and Genitourinary Oncologic

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FDG PET/CT Pitfalls in Gynecologic and Genitourinary Oncologic This copy is for personal use only. To order printed copies, contact [email protected] 577 NUCLEAR MEDICI FDG PET/CT Pitfalls in Gynecologic and Genitourinary Oncologic Imaging1 N E Amish Lakhani, MBBS, MA (Cantab), FRCR The role of whole-body positron emission tomography (PET)/ Sairah R. Khan, MBBS, BSc, MRCP, computed tomography (CT) with fluorodeoxyglucose (FDG) is FRCR now established in the assessment of many gynecologic and genito- Nishat Bharwani, BSc, MBBS, MRCP, urinary malignant tumors. FDG PET/CT has been widely adopted FRCR for staging assessments in patients with suspected advanced dis- Victoria Stewart, BMedSci, BM BS, ease, in cases of suspected disease recurrence, and for determining MRCP, FRCR prognosis in a number of malignancies. A number of pitfalls are Andrea G. Rockall, BSc, MBBS, commonly encountered when reviewing FDG PET/CT scans in MRCP, FRCR gynecologic and genitourinary cases; these pitfalls can be classified Sameer Khan, MBBS, BSc, MRCP, into those that yield potential false-positive or false-negative results. FRCR Potential false positives include physiologic uptake of FDG by the Tara D. Barwick, MBChB, MSc, MRCP, FRCR endometrium and ovaries in premenopausal patients, physiologic renal excretion of FDG into the ureters and the urinary bladder, Abbreviations: CA-125 = ovarian carcinoma and increased FDG activity in benign conditions such as uterine antigen 125, EANM = European Association of fibroids, pelvic inflammatory disease, and benign endometriotic Nuclear Medicine, FDG = fluorodeoxyglucose, cysts. Potential false negatives include low-level FDG uptake by MIP = maximum intensity projection, RCC = renal cell carcinoma, SUV = standardized uptake necrotic, mucinous, cystic, or low-grade tumors and the masking value, SUVmax = maximum standardized uptake of serosal and peritoneal disease by adjacent physiologic bowel or value bladder activity. In addition, there are inherent technical limita- RadioGraphics 2017; 37:577–594 tions—such as motion artifact (from respiratory motion and bowel Published online 10.1148/rg.2017160059 peristalsis) and the limited spatial resolution of PET—that may Content Codes: limit the assessment of small-volume malignant disease. Knowledge of the key imaging features of physiologic and nonphysiologic FDG 1From the Department of Radiology, Charing Cross Hospital, Imperial College Healthcare uptake, in addition to understanding the principles of adequate NHS Trust, Fulham Palace Road, London W6 patient preparation and PET scanning protocols, is important for 8RF, England (A.L., S.R.K., N.B., V.S., S.K., T.D.B.); Faculty of Medicine, Department of accurate interpretation of gynecologic and genitourinary oncologic Surgery and Cancer (A.L., N.B., T.D.B.), and FDG PET/CT studies. Department of Surgery and Cancer (A.G.R.), Imperial College London, London, England; ©RSNA, 2017 • radiographics.rsna.org and Department of Radiology, the Royal Mars- den NHS Foundation Trust, London, England (A.G.R.). Recipient of a Certificate of Merit award for an education exhibit at the 2015 RSNA Annual Meeting. Received March 13, 2016; revision requested May 27 and received SA-CME LeaRNiNg OBJectiVes June 29; accepted July 19. For this journal-based SA-CME activity, the authors, editor, and re- After completing this journal-based SA-CME activity, participants will be able to: viewers have disclosed no relevant relationships. ■■Understand the role of FDG PET/CT in the multimodality investigation of gyneco- Address correspondence to A.L. (e-mail: logic and genitourinary cancers. [email protected]). ■■List the common causes of physiologic and nonphysiologic FDG uptake that com- © RSNA, 2017 plicate FDG PET/CT of gynecologic and genitourinary malignancies. ■■Describe the pathophysiologic mechanisms leading to potential false-positive and false-negative assessments in patients with gynecologic and genitourinary malignan- cies, explaining methods to minimize reporting pitfalls. See www.rsna.org/education/search/RG. 578 March-April 2017 radiographics.rsna.org ing involved in FDG PET/CT interpretation as TeacHiNg PoiNts primary reporters, or by reviewing FDG PET/ ■■ Endometrial or ovarian FDG activity in postmenopausal wom- CT studies to aid interpretation when report- en should be regarded as suspicious; further correlation with ing oncologic CT and MR imaging cases. It is clinical history and transvaginal US and/or MR imaging should be performed to exclude malignancy. therefore important to have a working knowledge ■■ It is always important to correlate cystic and mucinous lesions of FDG PET/CT and potential interpretation at US and/or MR imaging, as they are potentially false nega- pitfalls to ensure the safe and accurate evaluation tive at FDG PET/CT. of these studies. ■■ In patients with ovarian cancer, it is important to review the CT In this article, we review imaging protocols, component of the study for peritoneal nodularity and to also patient preparation, and common pitfalls in the be aware that FDG uptake in peritoneal carcinomatosis can be use of FDG PET/CT for assessment of gyneco- masked by tracer activity within the bowel. logic and genitourinary tumors (summarized in ■ ■ As primary RCCs generally have low-level tracer uptake at Table 2). In addition, we provide teaching points FDG PET/CT, the kidneys should be a review area and correla- tion with contrast-enhanced CT is important. to minimize false interpretation. ■■ When there is vesicovaginal fistulation to the urinary tract, contamination from urinary FDG excretion can lead to an FDG PET/CT Imaging Protocol overestimation of activity within malignant disease, or, con- Satisfactory scanning technique and patient prepa- versely, may mask disease. ration is necessary to allow accurate assessment of PET/CT while keeping patient radiation exposure levels as low as reasonably possible. Detailed patient preparation guidelines Introduction and institutional FDG PET/CT protocols are Positron emission tomography (PET)/computed beyond the scope of this article; the reader is tomography (CT) is a molecular imaging tech- referred to the Society of Nuclear Medicine nique that involves the intravenous administra- (SNM) 2006 (7) and the European Association tion of short-lived radiolabeled positron-emitting of Nuclear Medicine (EANM) 2014 (8) guide- molecules to image biologic processes in vivo. lines. The following points highlight aspects of The most frequently used tracer is 2-deoxy-2-flu- particular relevance to gynecologic and genito- orodeoxyglucose (FDG). Whole-body PET/CT urinary imaging: using FDG is an established tool in the multi- Sufficient prehydration is required to ensure a modality imaging assessment of gynecologic and low concentration of FDG in the urine. Patients genitourinary malignancies. It has been shown to are asked to void just before image acquisition be effective in disease staging, detection of early and are scanned in a caudal-to-cranial direction disease recurrence, and determining prognosis in to reduce the radiation dose to the bladder and a number of malignancies. help reduce artifact within the pelvis that may FDG is a glucose analog that is taken up by mask disease. The use of small doses of diuretic cells and phosphorylated by hexokinase to FDG- at the time of tracer injection may also be helpful 6-phosphate. As FDG-6-phosphate is not a sub- (9,10). On occasion, a catheter may be useful to strate for glycolysis and does not undergo further drain the bladder and limit tracer accumulation metabolism, it remains within the cell (1). Most within the pelvis (11). This may be particularly tumor cells take up FDG intensely by virtue of useful in cases of suspected bladder fistulas, increased glucose metabolism due to upregulated which may mask disease. expression of the glucose transporter proteins When using FDG PET/CT for radiation (the SLC2A [or GLUT] family) and increased therapy planning in patients with gynecologic and hexokinase activity (2,3). genitourinary malignancies, it is essential that Current evidence-based guidelines outline sev- patient positioning mimics that used at radiation eral indications for FDG PET/CT in gynecologic therapy; close liaison with the radiation therapy and urologic cancers, including malignancy detec- department is therefore imperative. Patients are tion, staging, and assessment for recurrence. Table imaged in the radiation therapy treatment posi- 1 outlines the current indications from the Royal tion, lying supine on a flatbed palette, with their College of Radiologists, Royal College Physicians, arms positioned down, and using immobilization and U.S. National Comprehensive Cancer Net- aids as needed (12). work (NCCN) (4,5). In 2008, the U.S. National The timing of posttherapeutic FDG PET/ Oncologic PET Registry (6) reported that 10.2% CT for response assessment in gynecologic and of PET studies were performed for patients with genitourinary malignancies is often crucial. The gynecologic malignancies. EANM guidelines recommend waiting 3 months As the use of FDG PET/CT rapidly grows, following radiation therapy to avoid mistaking increasing numbers of radiologists are becom- posttherapeutic changes for residual or recurrent RG • Volume 37 Number 2 Lakhani et al 579 Table 1: Indications for FDG PET/CT in Gynecologic and Genitourinary Malignancies Indications in gynecologic malignancy Staging of locally advanced cervical cancer being considered for radical chemoradiotherapy Response assessment of locally advanced cervical cancer after radical chemoradiotherapy Suspected
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