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Atlas of Clinical Positron Emission Tomography Second edition Sally F Barrington MSc MD FRCP Consultant Physician in Nuclear Medicine at the PET Imaging Centre at St Thomas', Guy's, King's and St Thomas' School of Medicine, London, UK Michael N Maisey BSc MD FRCP FRCR Emeritus Professor of Radiological Sciences, Guy’s, King’s and St Thomas’ School of Medicine, London, UK Richard L Wahl MD FANCP Professor of Radiology and Oncology, Director, Division of Nuclear Medicine/PET, Henry N. Wagner Professor of Nuclear Medicine, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA Hodder Arnold AMEMBER OF THE HODDER HEADLINE GROUP First published in Great Britain in 2006 by Hodder Arnold, an imprint of Hodder Education and a member of the Hodder Headline Group 338 Euston Road, London NW1 3BH http://www.hoddereducation.com Distributed in the United States of America by Oxford University Press Inc., 198 Madison Avenue, New York, NY10016 Oxford is a registered trademark of Oxford University Press © 2006 Barrington, Maisey, and Wahl All rights reserved. Apart from any use permitted under UK copyright law, thispublication may only be reproduced, stored or transmitted, in any form, orby any means with prior permission in writing of the publishers or in the case of reprographic production in accordance with the terms of licences issuedby the Copyright Licensing Agency. In the United Kingdom such licences are issued by the Copyright Licensing Agency: 90 Tottenham Court Road, London W1T 4LP. Whilst the advice and information in this book are believed to be true and accurate at the date of going to press, neither the author[s] nor the publisher can accept any legal responsibility or liability for any errors or omissions thatmay be made. In particular, (but without limiting the generality of the preceding disclaimer) every effort has been made to check drug dosages; however it is still possible that errors have been missed. Furthermore, dosageschedules are constantly being revised and new side-effects recognized.For these reasons the reader is strongly urged to consult the drugcompanies’ printed instructions before administering any of the drugs recommended in this book. Disclaimer: The discussion in the text is not a comprehensiveinterpretation of all aspects of the PET/CT images but emphasizes the keyteaching points for educational purposes only. British Library Cataloguing in Publication Data A catalogue record for this book is available from the British Library Library of Congress Cataloging-in-Publication Data A catalog record for this book is available from the Library of Congress ISBN-10: 0-340-81693 7 ISBN-13: 978-0-340-816936 1 2 3 4 5 6 7 8 9 10 Commissioning Editor: Joanna Koster Development Editor: Sarah Burrows Project Manager: Gavin Smith Production Controller: Joanna Walker Cover Design: Georgina Hewitt Typeset in 11 on 13 pt Minion by Phoenix Photosetting Printed and bound in Italy by Printer Trento What do you think about this book? Or any other Hodder Arnold title? Please visit our website at www.hoddereducation.com This eBook does not include the ancillary media that was packaged with the printed version of the book. For Lewis, Irene, and Sandy This page intentionally left blank CONTENTS Contributors vi Foreword vii Preface viii Acknowledgments ix List of abbreviations x PART I: INTRODUCTION 1 Principles and methods 3 Paul K Marsden 2 Normal variants and potential problems/pitfalls 31 PART II: APPLICATIONS OF PET IN ONCOLOGY 3 Overview of oncologic applications of PET and PET/CT 71 4 Lung cancer 81 5 Lymphoid neoplasms 119 6 Colorectal and hepatobiliary tumors 149 7 Esophageal cancer 179 8 Head and neck cancer 195 9 Breast cancer 213 10 Gynecological cancers 231 11 Melanoma 247 12 Endocrine tumors 267 13 Urologic cancers 291 14 Musculoskeletal cancer 315 15 Brain tumors 325 16 Pediatric oncology 347 Eva A Wegner PART III: OTHER APPLICATIONS OF PET 17 Neurology and psychiatry 361 18 Cardiology 383 19 Infection and inflammation 401 Index 421 CONTRIBUTORS Nicholas R Maisey MBBS MRCP MD Consultant Physician in Medical Oncology at Guy’s and St Thomas’ NHS Foundation Trust, London, UK Paul K Marsden PhD Senior Lecturer, The PET Imaging Centre at St Thomas’ Hospital, Guy’s, King’s and St Thomas’ School of Medicine, London, UK Eva A Wegner BMed, FRACP Consultant Physician, Department of Nuclear Medicine, The Prince of Wales and Sydney Children’s Hospitals, Randwick, New South Wales, Australia; Formerly The PET Imaging Centre at St Thomas’, Guy’s, King’s and St Thomas’ School of Medicine, London, UK FOREWORD Making the diagnosis In the diagnostic process, the nuclear physician or radiologist converts the evidence in the images before him or her into the name of a particular disease. This is a matter of judgment, which, in turn, depends on the care, dedication, education, and experience of the interpreting physician. The process is not an arcane 'natural art' or 'process based on pure intuition' that would make it no more than hand waving. 'Making the diagnosis' is a rational process involving both inductive and deductive reasoning that (when successful) culminates in the interpreting physician's commitment to a particular diagnosis or diagnoses, presented to the referring physician together with a probability statement of his or her degree of certainty. The diagnostic process is a matter of expert judgment, honed by a wealth of observation and experience. It is the product of the process of reasoning, informed by a history of relevant experience. This is not to deny that, at times, upon confronting all the available data, including 'molecular images', a good radiologist or nuclear medicine physician, rather like a good car mechanic, may make a correct diagnostic judgment almost instantly; but then the initial 'impression' must be subject to analysis of all the available data. The authors have great personal experience, and illustrate how expert diagnostic thinking is applied in the interpretation of the images, with emphasis on PET and PET/CT. They present what could become the basis for designing successful expert PET and PET/CT systems of the future. Students and practitioners of nuclear imaging would do well to start their journey by studying this book. Henry N. Wagner Jr. MD Professor Emeritus of Medicine and Radiology and Radiological Science; Professor of Environmental Health Sciences; and Director, Division of Radiation Health Sciences Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA PREFACE The first edition of this book was written in the early days of clinical PET. Its purpose was to share experience from the first 5 years of our institutions and hopefully to shorten the learning curve of others entering the field. Since the first edition, the number of PET centers in the world has increased markedly and PET has become an integral part of the diagnostic work-up and management of patients in oncology while continuing to be applied in neurology and cardiology. PET is no longer regarded as a ‘niche’ imaging tool but has become part of mainstream diagnostics alongside CT, MR, and ultrasound. Improvements in camera technology have contributed to better PET image quality and the emergence of PET/CT has been the most significant recent advance. PET/CT has provided us with new challenges and this second edition is timely as it attempts once more to share our combined experience in this rapidly changing field. The development of PET/CT requires new skills to be learnt and the sharing of established skills with greater cooperation and integration between nuclear medicine and radiology. The same format has been used as the first edition. Each chapter gives clinical background information, including the relevant epidemiology, pathology, and staging (for the oncology chapters) and lists the key management issues followed by clinical cases. Each case represents a real patient seen in one of our departments with PET, CT, and fused images shown and the key points highlighted. Each chapter concludes with a summary of the clinicalindications for PET/CT imaging and a set of references for further reading about thetopic. This second edition has been expanded because the use of PET for imaging certain cancers, which were featured in the first edition as ‘emerging applications’ have now become established applications. We have also extended the book to cover pediatric PET applications, and infection and inflammation imaging to reflect the increasing breadth of PET and PET/CT imaging. The main emphasis, however, remains on oncology, mostly with FDG, which continues to represent 90% of the workload in our two centers. PET and PET/CT continues to be a fascinating and fast-moving imaging specialty. We hope we have conveyed our enthusiasm for PET and PET/CT in these pages and that you the reader will come to share in that enthusiasm. We further hope that our state-of-the-art images and clinical case material illustrating key teaching points will prove useful in educating both the novice and experienced practitioners regarding PET and PET/CT. SFB, MNM, RLW London and Baltimore, 2005 ACKNOWLEDGMENTS PET/CT is a multidisciplinary modality. It requires a dedicated team of scientists, doctors, radiographers, and administration staff to offer a high-quality clinical service. It is crucial to have a good relationship with referring clinicians to make the best use of the knowledge provided by PET and to incorporate that knowledge into improved patient management. We wish to acknowledge the support, hard work, and dedication of our colleagues, which is so important in maintaining the service we offer to our patients. This book would not have been possible without them. St Thomas’ PET Imaging Centre Clinical Manager: M Dakin Cyclotron: P Halsted, M Kelly, A Page Radiochemistry: G D’Costa, K Kahlon, N Ossoulyan Physicists and Computer Scientists: Dr PK Marsden, E Somer, J MacKewn, P Schleyer, P Liepins Clinicians: Dr MJ O’Doherty, Professor I Fogelman, Dr TO Nunan, Dr SF Barrington, Dr SC Rankin, Dr S Vijayanathan Radiographers/Nuclear Medicine Technologists : N Benatar (superintendent) R Dobbin, S Bray, M Cunneen, K Hau Imaging Assistant: Dr K Curran Secretary: M Maureso Johns Hopkins PET Centre Clinical Manager: J Nieve Cyclotron: Professor R Dannals Radiochemistry: H Ravert, W Mathews, R Smoot, A Horti Physicists and Computer Scientists: Mr JP Leal and Professor J Links Clinicians: Dr K Friedman, Professor Z Szabo, Professor RL Wahl, Professor H Ziessman, Dr H Jacene, Dr C Cohade, Dr R Rosen, Dr P Patel, Dr J Frost Radiographers/Nuclear Medicine Technologists: L King, L Kerin, D Franz Secretary/Service Coordinators: M Willett, A Herbert, N Cooper Specifically we would like to acknowledge the contributions of Paul Marsden who has again provided an excellent introductory chapter covering the basic science and outlining the elements involved in PET. We would like to thank Eva Wegner for sharing with us with the expertise in pediatric PET that she developed during the 3 years she spent at St Thomas’. We are especially grateful to Nick Maisey for his oncological expertise and for advising us on the epidemiology, pathology, and staging in the chapters that focus on cancer. It was because of the pivotal role of our colleagues in our working lives that the first edition of this book was dedicated to those who helped us to establish and run our joint Centres. We continue to be extremely grateful to them. We also wish to acknowledge the unwavering support and love of our families, which is the foundation for our working and home lives. It is for this reason that the second edition of this book is dedicated to our spouses, Lewis, Irene, and Sandy.