18-fluorodeoxyglucose positron emission tomography in nonendocrine neoplastic disorders of the gastrointestinal tract

Utility of computed tomography and 18 F-fluorodeoxyglucose with positron emission tomography/computed tomography for distinguishing appendiceal mucocele caused by mucinous adenocarcinoma from other pathologies

AIM

Differentiating appendiceal mucocele with mucinous adenocarcinoma from other pathologies before surgery is difficult. The objective of this study was to evaluate the utility of CT and ¹⁸ F-fluorodeoxyglucose (FDG) with positron emission tomography (PET)/CT for differentiating mucinous adenocarcinoma of appendiceal mucocele from other pathologies.

METHOD

The study included 25 patients who underwent surgery for clinically diagnosed appendiceal mucoceles detected on CT at the University of Tokyo Hospital. Among these patients, 19 underwent FDG-PET/CT preoperatively. We compared features of the CT imaging findings and maximum standard uptake values (SUV_max ) detected by FDG-PET/CT between mucocele with mucinous adenocarcinoma and other pathologies.

RESULTS

A total of 13 men (52%) and 12 women (48%) were included in this study, with a median age of 65 years (range 34-83). There were six patients (24%) with pathologically confirmed mucinous adenocarcinoma, 15 patients (60%) with appendiceal mucinous neoplasm and four patients (16%) with simple mucocele caused by chronic inflammation. On the CT findings, wall irregularity was the only significant feature for the two groups in this study (83.3% vs 0.0%, P < 0.01). There was a significant difference in the SUV_max levels on PET/CT between the two groups (100.0% vs 20.0%, P < 0.01).

CONCLUSION

Distinguishing between mucocele with mucinous adenocarcinoma and other pathologies using imaging modalities is challenging. Our results suggest that wall irregularity on CT and elevated SUV_max on PET/CT are useful factors that can be employed for such discrimination.

Diffusion-weighted MRI versus FDG-PET/CT for diagnosing pancreatic cancer: an indirect comparison meta-analysis

BACKGROUND

Fluorodeoxyglucose positron emission tomography (FDG-PET)/computed tomography (CT) and diffusion-weighted magnetic resonance imaging (DWI or DW-MRI) are tools for the diagnosis of pancreatic cancer. However, comparison of their diagnostic performance remains unknown.

PURPOSE

To indirectly compare the diagnostic value of DWI and FDG-PET/CT in the detection of pancreatic cancer.

MATERIAL AND METHODS

A literature search of PubMed, Embase, and Cochrane Library electronic databases for articles published through May 2018 yielded 875 articles. For the meta-analysis, we included 26 studies evaluating the efficacy of DWI and FDG-PET/CT for determining pancreatic cancer with a total of 1377 patients. QUADAS (Quality Assessment of Diagnostic Accuracy Studies) was used to assess the study quality. Sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR), diagnostic odds ratio (DOR), and the area under the receiver operating characteristic curves (AUC) with their 95% confidence intervals were calculated for each individual study.

RESULTS

There were no significant differences between DWI and FDG-PET/CT for sensitivity, specificity, PLR, NLR, or DOR, while DWI AUC was higher than that of FDG-PET/CT for the detection of pancreatic cancer.

CONCLUSION

The diagnostic value of both DWI and FDG-PET/CT were comparable and, hence, both techniques seem to be equally useful tools for the diagnosis of pancreatic cancer.

Clinical relevance of incidental finding of focal uptakes in the colon during 18F-FDG PET/CT studies in oncology patients without known colorectal carcinoma and evaluation of the impact on management

AIMS

To assess the significance and the impact of focal FDG uptake in the colon in oncology patients without known colorectal carcinoma.

MATERIALS AND METHODS

A retrospective study was undertaken on 2,220 (18)F-FDG PET/CT studies carried out consecutively in the Nuclear Medicine Department in our hospital from 2 December 2008 to 31 May 2010. Inclusion criteria were patients with abnormal (18)F-FDG uptake in colorectal area that could not be explained (or not previously known) by their clinical histories. Patients previously diagnosed with colorectal carcinoma were excluded. A total of 86 patients (57 male, average age 63.4, range 46-85) were finally included. Colonoscopy with biopsy was established as a reference test. The impact of these findings on the diagnostic-therapeutic management in these patients was evaluated.

RESULTS

A colonoscopy was performed in 54 of the 86 patients, this examination not having been done up-to-date in the remaining 32 patients. Biopsy was obtained in 43 lesions of the 54 patient in whom a colonoscopy was performed. Colon disease was detected in 49 of these 54 patients, obtaining 54 FDG incidental foci which corresponded to 10 previously unsuspected primary colorectal carcinoma, 3 metastases, 27 adenomatous polyps with different degrees of dysplasia and 14 inflammatory processes. In the remaining 5 patients, the colonoscopy was normal. PET/CT modified the diagnostic and treatment management in most of the patients (49/54, that is 91%).

CONCLUSIONS

These results confirm the need to determine the cause of abnormal (18)F-FDG colorectal uptakes in the PET/CT studies by using colonoscopy and biopsy. This approach allows for the detection and early treatment of malignant and premalignant lesions.

Value of contrast-enhanced 18F-fluorodeoxyglucose positron emission tomography/computed tomography in detection and presurgical assessment of pancreatic cancer: a prospective study

BACKGROUND AND AIM

Positron Emission Tomography (PET) using (18)F-fluorodeoxyglucose (FDG) associated with computed tomography (CT) is increasingly used for the detection and the staging of pancreatic cancer, but data regarding its clinical added value in pre-surgical planning is still lacking. The aim of this study is to investigate the performance of FDG PET associated with contrast-enhanced CT in detection of pancreatic cancer.

METHODS

We prospectively evaluated FDG PET/CT studies obtained in patients with suspicion of operable pancreatic cancer between May 2006 and January 2008. Staging was conducted according to a standardized protocol, and findings were confirmed in all patients by surgical resection or biopsy examination.

RESULTS

Forty-five patients with a median age of 69 (range 22-82) were included in this study. Thirty-six had malignant tumors and nine had benign lesions (20%). The sensitivity of enhanced versus unenhanced PET/CT in the detection of pancreatic cancer was 96% versus 72% (P=0.076), the specificity 66.6% versus 33.3% (P=0.52), the positive predictive value 92.3% versus 80% (P=0.3), the negative predictive value 80% versus 25% (P=0.2), and the accuracy 90.3% versus 64% (P=0.085).

CONCLUSIONS

Our preliminary data obtained in a limited number of patients shows that contrast-enhanced FDG PET/CT offers good sensitivity in the detection and assessment of pancreatic cancer, but at the price of a relatively low specificity. Enhanced PET/CT seems to be superior to unenhanced PET/CT. Further larger prospective studies are needed to establish its value for pre-surgical diagnosis and staging in pancreatic cancer.

Impact of 18-fluorodeoxyglucose positron emission tomography on the management of pancreatic cancer

BACKGROUND

We compared the usefulness of positron emission tomography with the glucose analogue 2-deoxy-2-[18F]-fluoro-D-glucose (FDG-PET) and multidetector-row computed tomography (MD-CT) in diagnosing pancreatic cancer and in determining the patients' suitability for surgery.

METHODS

We reviewed the clinical FDG-PET data of 103 consecutive pancreatic cancer patients between July 2004 and March 2009.

RESULTS

The detection rates of pancreatic cancer by MD-CT (89%) and FDG-PET (91%) were similar. From the MD-CT findings, 38 patients were judged as operable, and 65, inoperable. Among the inoperable patients, noncurative factors (metastasis to the liver, peritoneum, remote lymph nodes, bones, and other organs and major arterial invasion) were detected by MD-CT and/or FDG-PET. Detection rates of liver metastasis and arterial invasion by FDG-PET were significantly inferior to those of MD-CT (neither was detected by FDG-PET alone). Remote lymph nodes and bone metastasis were detected in 20 lesions by FDG-PET alone; however, MD-CT indicated other noncurative factors in these patients. All 65 patients could be diagnosed as inoperable without FDG-PET.

CONCLUSIONS

FDG-PET is not a suitable imaging modality for either diagnosis or preoperative treatment in pancreatic cancer patients. Since it is expensive, FDG-PET as a routine diagnostic tool in pancreatic cancer patients must be used with caution.

Vascular invasion in pancreatic cancer: Imaging modalities, preoperative diagnosis and surgical management

Pancreatic cancer is associated with a poor prognosis, and surgical resection remains the only chance for curative therapy. In the absence of metastatic disease, which would preclude resection, assessment of vascular invasion is an important parameter for determining resectability of pancreatic cancer. A frequent error is to misdiagnose an involved major vessel. Obviously, surgical exploration with pathological examination remains the “gold standard” in terms of evaluation of resectability, especially from the point of view of vascular involvement. However, current imaging modalities have improved and allow detection of vascular invasion with more accuracy. A venous resection in pancreatic cancer is a feasible technique and relatively reliable. Nevertheless, a survival benefit is not achieved by curative resection in patients with pancreatic cancer and vascular invasion. Although the discovery of an arterial invasion during the operation might require an aggressive management, discovery before the operation should be considered as a contraindication. Detection of vascular invasion remains one of the most important challenges in pancreatic surgery. The aim of this article is to provide a complete review of the different imaging modalities in the detection of vascular invasion in pancreatic cancer.

Subcutaneous metastasis from an occult esophageal cancer detected by PET-CT

We describe a unique case of an occult esophageal cancer patient without any significant symptomatology, which initially presented with a subcutaneous metastasis in the thigh. Eventually, FDG PET-CT unmasked the primary tumor of unknown origin.

PET and macro- and microautoradiographic studies combined with immunohistochemistry for monitoring rat intestinal ulceration and healing processes

18F-FDG PET is used mainly in clinical settings for imaging focal cancer sites, but the usefulness of the modality in imaging gastrointestinal ulcers has not been established. We investigated whether PET can be used for noninvasive monitoring of indomethacin-induced small-intestine ulceration.

METHODS

Intestinal ulcers were induced in rats by subcutaneous administration of indomethacin. An 18F-FDG PET scan was obtained at 1, 2, and 7 d after indomethacin administration. 18F-FDG uptake in the small intestine was quantified by gamma-counting, and macro- and microautoradiographic studies were performed to determine the site of 18F-FDG uptake in tissue and at the cellular level.

RESULTS

Ulcers observed in the intestine (mainly in the ileum) 1-4 d after indomethacin administration were most severe at 1 d after administration and were almost healed at day 7. The PET study showed increased 18F-FDG uptake in the intestine correlating to the severity of ulceration, returning to the basal level on day 7. Ex vivo imaging and gamma-counting showed that these regions of high uptake corresponded to regions of ulceration. A microautoradiographic study combined with immunohistochemistry revealed heavy accumulation of 18F-FDG in inflammatory cells containing peroxidase on day 1 and in cells forming granulation tissue (alpha-smooth muscle actin-positive myofibroblasts and ED2-positive macrophages) on days 2-4 in and around ulcers. Proliferating (Ki67-immunopositive) intestinal crypt cells were also densely labeled with 18F-FDG in intact intestinal tissue taken from the indomethacin-treated and the control animals.

CONCLUSION

Our experimental data suggest that 18F-FDG PET may be useful for evaluating the occurrence of small-intestine ulcers. Ulceration could be visualized early by the prominent uptake of 18F-FDG by inflammatory cells and by the formation of granulation tissue by cells in and around ulcers.

Pilot study using PET/CT as a novel, noninvasive assessment of disease activity in inflammatory bowel disease

BACKGROUND

A pilot study was performed investigating the possibility that positron emission tomography (PET) activity using 18-fluorodeoxyglucose (FDG) with nearly simultaneous computerized tomography (CT) for anatomic accuracy would identify regions of active inflammation in both ulcerative colitis (UC) and Crohn's disease (CD).

METHODS

Prospective clinical data was collected in 12 patients experiencing an exacerbation of their inflammatory bowel disease; 7 with CD and 5 with UC. A PET/CT scan (GE Discovery LS PET/CT scanner) was performed in all patients. Twenty patients undergoing PET/CT because of solitary pulmonary nodules served as controls. We graded the small bowel and 4 colon regions (ascending, transverse, descending, and rectosigmoid) with PET activity scores assigned to each region based on the amount of FDG uptake using the liver as the reference organ.

RESULTS

In UC patients, PET activity was seen in 13 of 24 (52%) regions. There was high (23 of 24; 95.8%) correlation between PET activity and disease activity as determined by colonoscopy, disease activity indices, and radiology. In patients with CD, PET activity was seen in 19 of 32 (59.4%) regions. Again, there was a high (26 of 32; 81.3%) correlation between PET activity and clinical disease activity. Of the 20 controls, significant PET activity (Grades 2 and 3) was seen in only 2 of 100 regions (2%).

CONCLUSIONS

We found that PET activity correlated well with active inflammation in both UC and CD, suggesting that this may be a noninvasive method of identifying disease activity in patients with inflammatory bowel disease.

Gastric GIST malignancy evaluated by 18FDG-PET as compared with EUS-FNA and endoscopic biopsy

OBJECTIVE

The usefulness of 18F-fluoro-2-deoxyglucose positron emission tomography (18FDG-PET), whose high rate of FDG accumulation indicates high metabolism and malignant potential, has already been reported. The aims of this study were to evaluate the malignancy of primary gastrointestinal stromal tumour (GIST) in the stomach by 18FDG-PET and to correlate the FDG uptake values with known risk factors as determined by histology after EUS-guided fine needle aspiration (EUS-FNA) or endoscopic biopsy.

MATERIAL AND METHODS

Of 29 patients with histologically proven GI-mesenchymal tumours, 21 with gastric GISTs underwent 18FDG-PET. Tumour size, mitotic index, Ki-67 labelling index (LI) and cellularity of the tumour tissue were compared with the standardized uptake value (SUV) of FDG.

RESULTS

Strong correlations were found between the SUV of FDG and EUS size, and mitotic index of EUS-FNA specimens (tumour size versus SUV, p=0.004, r=0.542; number of mitotic cells versus SUV, p=0.0078; n=21). Moreover, we examined the association between SUV and risk categories based on EUS-FNA findings using ROC curves. The cut-off values of FDG SUV were 2.2, 4.2 and 6.5 for the very low-, low-, intermediate- and high-risk groups, respectively.

CONCLUSIONS

18FDG-PET may be used to assess malignancy of GISTs. This image modality helps us determine the management strategy for these patients and complements the information on the biological behaviour and cellular proliferation of the tumours.

Evaluation of 2-deoxy-2-[18F]fluoro-D-glucose positron emission tomography in gastric carcinoma: relation to histological subtypes, depth of tumor invasion, and glucose transporter-1 expression

OBJECTIVE

Variable uptake of 2-deoxy-2-[18F]fluoro-D-glucose (FDG) has been noticed in positron emission tomography (PET) studies of gastric carcinoma patients, with low uptake occurring especially in some particular histological subtypes and early carcinomas. But this phenomenon has not been adequately explained. The aim of the present study is to clarify FDG uptake in gastric carcinomas especially focusing on histological subtypes, the depth of tumor invasion, and glucose transporter-1 (GLUT-1) expression which is considered to be one of the major factors for higher FDG uptake in human malignant tumors.

METHODS

FDG-PET was performed on 35 preoperative patients with gastric carcinoma. Forty macroscopically distinguishable lesions on a surgical specimen were histologically classified into two subtypes: Cohesive type (papillary adenocarcinoma, tubular adenocarcinoma, and solid type poorly differentiated adenocarcinoma) or Noncohesive type (signet-ring cell carcinoma and non-solid type poorly differentiated carcinoma). GLUT-1 expression was immunohistochemically determined. Histological parameters (GLUT-1 expression, histological subtypes, the depth of invasion, lymphatic permeation, venous invasion and tumor size) were evaluated, and factors for FDG uptake (detectability and the degree) and GLUT-1 overexpression were determined by multiple regression analysis.

RESULTS

Nineteen of 40 gastric carcinomas showed detectable FDG uptake (48%), multiple regression analysis revealed that both the depth of invasion and histological subtypes are independent factors that influence the detectable FDG uptake in gastric carcinoma (R2 = 0.66). GLUT-1 expression was seen from an early cancer stage and the cohesive type was an independent factor influencing the overexpression of GLUT-1 (R2 = 0.66). GLUT-1 expression was the most influential factor for the degree of FDG uptake in gastric carcinoma (R2 = 0.68).

CONCLUSIONS

This study provided important information on the clinical application of FDG-PET in gastric carcinoma that early or non-cohesive gastric carcinoma may show lower FDG uptake. Therefore, the usefulness of FDG-PET for the detection of gastric carcinoma is limited. But there is a possibility that FDG uptake associated with GLUT-1 expression may serve as a prognostic factor of gastric carcinoma representing tumor metabolism.

Evidence-based diagnosis and staging of pancreatic cancer

Only 20% of patients who present with pancreatic cancer will be amenable to potentially curative resection. Therefore, it is necessary to reliably identify patients who might benefit from major surgical intervention by employing the appropriate staging methods. In this review, the pros and cons of each imaging technique are discussed and an algorithm for single and combined use of the different imaging modalities is proposed. To date, contrast-enhanced multi-detector row helical CT (MDR-CT) together with endoscopic ultrasound (EUS) remain the first staging methods of choice. MDR-CT has a high sensitivity for identifying vascular invasion and EUS is able to detect lesions as small as 2-3 mm. ERCP is performed mainly in patients with biliary obstruction with the option for therapeutic intervention during the same session. MRI with MR-angiography, MRCP, PET/CT and staging laparoscopy are additional modalities which might give further information in cases of equivocal findings by MDR-CT and EUS. The role of tumour markers such as CA 19-9 and CEA is reserved for monitoring and diagnosing post-surgery recurrence. Cytological or histological confirmation should usually be performed in patients that are not eligible for surgery prior to the commencement of palliative radio- or chemotherapy. In the routine clinical setting, MDR-CT and EUS play the predominant roles by providing the most cost-effective and accurate means for diagnosing and staging most cases of pancreatic cancer.

Etiology of solitary extrapulmonary positron emission tomography and computed tomography findings in patients with lung cancer

PURPOSE

The aim of this prospective study was to assess the incidence and the nature of solitary extrapulmonary [18F] fluorodeoxyglucose (FDG) accumulations in patients with non-small-cell lung cancer (NSCLC) staged with integrated positron emission tomography and computed tomography (PET/CT) and to evaluate the impact on management.

PATIENTS AND METHODS

A total of 350 patients with NSCLC underwent whole-body PET/CT imaging. All solitary extrapulmonary FDG accumulations were evaluated by histopathology, further imaging, or clinical follow-up.

RESULTS

PET/CT imaging revealed extrapulmonary lesions in 110 patients. In 72 patients (21%), solitary lesions were present. A diagnosis was obtained in 69 of these patients, including 37 (54%) with solitary metastases and 32 (46%) with lesions unrelated to the lung primary. Histopathologic examinations of these 32 lesions revealed a second clinically unsuspected malignancy or a recurrence of a previous diagnosed carcinoma in six patients (19%) and a benign tumor or inflammatory lesion in 26 patients (81%). The six malignancies consisted of carcinoma of the breast in two patients, and carcinoma of the orbit, esophagus, prostate, and non-Hodgkin's lymphoma in one patient each. Benign tumors and inflammatory lesions included eight colon adenomas, four Warthin's tumors, one granuloma of the lower jaw, one adenoma of the thyroid gland, one compensatory muscle activity due to vocal chord palsy, two occurrences of arthritis, three occurrences of reflux esophagitis, two occurrences of pancreatitis, two occurrences of diverticulitis, one hemorrhoidal inflammation, and one rib fracture.

CONCLUSION

Solitary extrapulmonary FDG accumulations in patients with newly diagnosed lung cancer should be analyzed critically for correct staging and optimal therapy, given that up to half of the lesions may represent unrelated malignancies or benign disease.

[1,2-13C2]-D-glucose profiles of the serum, liver, pancreas, and DMBA-induced pancreatic tumors of rats

OBJECTIVES

In vitro stable isotope glucose tracer studies indicate that undifferentiated cells of the pancreas use glucose primarily through the nonoxidative reactions of the pentose cycle for nucleic acid ribose synthesis, whereas normal or less transformed cells primarily use the oxidative branch of the cycle.

METHODS

The pancreatic heads of 4 groups (5/group) of male rats were implanted with time-release pellets designed to deliver placebo or 7,12-dimethylbenzanthracene (DMBA) at 11, 33, or 56 mg/d. Four weeks after pancreatic exposure to DMBA, [1,2-C2]-D-glucose tracer (1 g/kg) was injected intraperitoneally followed by sera collection at 1 and 2 hours and harvest of tumors, adjacent pancreatic tissue, and sera at 3 hours.

RESULTS

Tumors (2-9 mm) were found across DMBA groups, with the largest in the high-dose group (> or =5 mm). Selective monitoring by gas chromatography-mass spectrometry of the doubly-labeled [1,2-C2]-D-ribose of RNA, which requires nonoxidative synthesis in the pentose cycle, showed a 2.8-, 2.9-, and 5.7-fold increase in pancreatic tumors. Liver and adjacent pancreas preferentially produced [1-C1]-D-ribose through the oxidative reactions of the cycle. Tumor-bearing animals also cleared and recycled tracer glucose at a faster rate.

CONCLUSIONS

Simultaneous selective positional ion monitoring of C-labeled metabolites and their mass isotopomers in tissues and blood opens new avenues for the early detection and response to therapy testing of pancreatic cancer using GC-MS and/or magnetic resonance imaging-based methods. This study emphasizes the benefits of stable isotope-based dynamic metabolic profiling, when applied in vivo, and the several advantages it offers to positron emission tomography.

Positron emission tomography/computed tomography influences on the management of resectable pancreatic cancer and its cost-effectiveness

OBJECTIVE

We sought to determine the impact of positron emission tomography/computed tomography (PET/CT) on the management of presumed resectable pancreatic cancer and to assess the cost of this new staging procedure.

SUMMARY BACKGROUND DATA

PET using 18F-fluorodeoxyglucose (FDG) is increasingly used for the staging of pancreatic cancer, but anatomic information is limited. Integrated PET/CT enables optimal anatomic delineation of PET findings and identification of FDG-negative lesions on computed tomography (CT) images and might improve preoperative staging.

MATERIAL AND METHODS

Patients with suspected pancreatic cancer who had a PET/CT between June 2001 to April 2004 were entered into a prospective database. Routine staging included abdominal CT, chest x-ray, and CA 19-9 measurement. FDG-PET/CT was conducted according to a standardized protocol, and findings were confirmed by histology. Cost benefit analysis was performed based on charged cost of PET/CT and pancreatic resection and included the time frame of staging and surgery.

RESULTS

Fifty-nine patients with a median age of 61 years (range, 40-80 years) were included in this analysis. Fifty-one patients had lesions in the head and 8 in the tail of the pancreas. The positive and negative predictive values for pancreatic cancer were 91% and 64%, respectively. PET/CT detected additional distant metastases in 5 and synchronous rectal cancer in 2 patients. PET/CT findings changed the management in 16% of patients with pancreatic cancer deemed resectable after routine staging (P = 0.031) and was cost saving.

CONCLUSIONS

PET/CT represents an important staging procedure prior to pancreatic resection for cancer, since it significantly improves patient selection and is cost-effective.