Improvement of Hepatic Lesion Characterization by 18F-FDG PET/CT with the Use of the Lesion to Background Liver Activity Ratio

The tumor‐to‐liver ratio of the standardized uptake value is a useful FDG‐PET/CT parameter for predicting malignant intraductal papillary mucinous neoplasm of the pancreas

Background

The present study aimed to investigate the efficacy of positron emission tomography with 18Fluoro‐deoxyglucose (FDG‐PET/CT) for predicting malignant intraductal papillary mucinous neoplasm (IPMN).

Methods

The records of 88 patients pathologically diagnosed with IPMN after surgery at Ehime University Hospital and Ehime Prefectural Central Hospital from April 2009 to December 2020 were retrospectively reviewed. The patients’ characteristics, blood chemistry, and imaging examinations were evaluated as potential predictors of malignant IPMN. Of the PET/CT results, the maximum standardized uptake value (SUVmax) of the tumor, the tumor‐to‐blood pool ratio of the SUV (TBR), and the tumor‐to‐liver ratio of the SUV (TLR) were compared.

Results

On pathology, the diagnosis was adenoma (IPMA) in 40 patients, high‐grade dysplasia (HGD) in 26 patients, and carcinoma (IPMC) in 22 patients. HGD and IPMC were defined as malignant IPMN. On multivariate analyses, TLR ≥ 1.3 and high‐risk stigmata were independent predictors of malignant IPMN (P = .001 and P = .007, respectively). When both HRS and TLR ≥ 1.3 were present, the positive predictive value for malignancy was 88.2%. Furthermore, TLR was significantly higher for patients with IPMC than with HGD (P = .039).

Conclusion

TLR can be a useful predictor for differentiating benign from malignant IPMN and may be associated with postoperative outcomes.

ACR Appropriateness Criteria® Liver Lesion-Initial Characterization

Incidental liver masses are commonly identified on imaging performed for other indications. Since the prevalence of benign focal liver lesions in adults is high, even in patients with primary malignancy, accurate characterization of incidentally detected lesions is of paramount clinical importance. This document reviews utilization of various imaging modalities for characterization of incidentally detected liver lesions, discussed in the context of several clinical scenarios. For each clinical scenario, a summary of current evidence supporting the use of a given diagnostic modality is reported. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

[18F]Fluorocholine Uptake of Parathyroid Adenoma Is Correlated with Parathyroid Hormone Level

PURPOSE

The aim of the study was to investigate the relationship between [¹⁸F]fluoromethyl-dimethyl-2-hydroxyethylammonium ([¹⁸F]FCh) positron emission tomography (PET) parameters, laboratory parameters, and postoperative histopathological results in patients with primary hyperparathyroidism (pHPT) due to parathyroid adenomas.

PROCEDURES

This retrospective study was conducted in 52 patients with biochemically proven pHPT. [¹⁸F]FCh-PET parameters (maximum standardized uptake value: SUV_max) in early phase (after 2 min) and late phase (after 50 min), metabolic volume, and adenoma-to-background ratio (ABR), preoperative laboratory results (PTH and serum calcium concentration), and postoperative histopathology (location, size, volume, and weight of adenoma) were assessed. Relationship of PET parameters, laboratory parameters, and histopathological parameters was assessed using the Mann-Whitney U test and Spearman correlation coefficient. MRI characteristics of parathyroid adenomas were also analyzed.

RESULTS

The majority of patients underwent a PET/MR scan, 42 patients (80.7 %); 10 patients (19.3 %) underwent PET/CT. We found a strong positive correlation between late-phase SUV_max and preoperative PTH level (r = 0.768, p < 0.001) and between late-phase ABR and preoperative PTH level (r = 0.680, p < 0.001). The surgical specimen volume was positively correlated with the PET/MR lesion volume (r = 0.659, p < 0.001). No significant association was observed between other [¹⁸F]FCh-PET parameters, laboratory parameters, and histopathological findings. Cystic adenomas were larger than non-cystic adenomas (p = 0.048).

CONCLUSIONS

[¹⁸F]FCh uptake of parathyroid adenomas is strongly correlated with preoperative PTH serum concentration. Therefore, the preoperative PTH level might potentially be able to predict success of [¹⁸F]FCh-PET imaging in hyperparathyroidism, with higher lesion-to-background ratios being expected in patients with high PTH. PET/MR is accurate in estimating the volume of parathyroid adenomas.

Clinical efficacy of dual-phase scanning using (68)Ga-DOTATOC-PET/CT in the detection of neuroendocrine tumours

AIM

To investigate whether delayed scanning at approximately 90 minutes post-injection of (68)Ga-labelled 1,4,7,10-tetraazacyclododecane-N,N',N″,N‴-tetraacetic acid-d-Phe(1)-Tyr(3)-octreotide (DOTATOC) had any clinical benefits regarding the evaluation of neuroendocrine tumours (NETs), relative to conventional combined positron-emission tomography (PET) and computed tomography (CT) at 60 minutes post-injection.

MATERIALS AND METHODS

Fifty-four patients who underwent DOTATOC-PET/CT for suspected or known NETs were retrospectively reviewed. PET/CT was performed twice at approximately 60 and 90 minutes post-injection. For visual analysis, a five-point grading scale (0: definitely normal to 4: definitely abnormal) was used, and grade 3-4 lesions were regarded as positive. For quantitative analysis, the time course of the maximum standardised uptake value (SUVmax) in each lesion and the mean SUV of physiological uptake in the liver were evaluated.

RESULTS

Of the 54 patients, 43 had a total of 132 lesions. In interpreting the early images, there were four grade 3 lesions, and the remaining 128 lesions were grade 4. All 132 lesions were grade 4 in the delayed images. SUVs and tumour-to-liver ratios for hepatic lesions were slightly higher in delayed scanning than in early scanning (SUV, 26.8±21.2 versus 28.2±21.2 [p<0.01]; tumour-to-liver ratio, 5.9±4.5 versus 6.2±4.6 [p<0.01]), which did not affect the detection rate. Additionally, bone and peritoneal metastases had slightly higher SUVs at delayed imaging (p<0.05), but there was no difference in diagnostic performance. No significant difference in the SUVs for pancreatic lesions and primary sites in the bowel were observed between the early and delayed scans.

CONCLUSION

Delayed scanning may be helpful for improving diagnostic confidence in some cases, although it provided no specific merits for diagnostic accuracy in detecting primary or metastatic NETs.

Liver metabolic activity changes over time with neoadjuvant therapy in locally advanced rectal cancer

OBJECTIVE

The aim of this study was to evaluate, using PET/computed tomography (CT), changes in liver metabolic activity in patients with locally advanced rectal cancer (LARC) after neoadjuvant chemoradiotherapy (CRT).

PATIENTS AND METHODS

A total of 29 biopsy-proven LARC patients between 2009 and 2012 were studied. Liver standardized uptake values (SUVs) and SUVs adjusted for lean body mass (SULs) were obtained from PET/CT images obtained at 1 h (early) and 2 h (late) after (18)F-fluorodeoxyglucose ((18)F-FDG) administration both before and after neoadjuvant CRT. Age, sex, BMI, lean body mass, blood glucose level, and (18)F-FDG dose, which can influence liver SUVs and SULs, were also analyzed.

RESULTS

Fourteen (48%) men and 15 (52%) women with a mean age of 62±11 years (range 34-80 years) were included in the study. The mean SUVs and SULs were significantly decreased in the late scans. Sex was significantly correlated with the mean liver SUV in early and late scans. The mean SUV differed significantly between male and female patients in early and late images (P<0.05). In a multivariate stepwise regression analysis, only liver SUVs (maximum and mean) were significantly associated with BMI before and after therapy. SUVs were significantly higher in the high (≥25) BMI group after but not before therapy. Mean SUL was not influenced by BMI.

CONCLUSION

Liver (18)F-FDG uptake is consistent before and after neoadjuvant CRT therapy in patients with LARC. When assessing response to therapy and using liver metabolic activity to indicate background activity, BMI should be considered as it can influence liver metabolic activity.

Potential role of FDG PET/CT in evaluating patients with hepatic incidentalomas

This review article is focused on the role of FDG PET/CT in diagnosing and characterizing hepatic incidentalomas. A large variety of unsuspected lesions can be detected in the liver both with ultrasound and CT performed for other reasons; the prevalence of liver incidentalomas increases in patients with chronic liver disease or preexisting oncologic history. The major challenge is to discriminate benign from malignant lesions. There is a large body of literature indicating that FDG PET/CT is a useful tool to this purpose even if it is unspecific (ie, it cannot differentiate a primary tumor from a secondary lesion). Occasionally, FDG PET/CT can be useful for biopsy guidance.

Implications of Ambient Glucose Variation on the Target-to-Background Ratio of Hepatic Tumors By (18)FDG-PET Imaging

Objectives:

To investigate the effects of ambient glucose on quantitative analysis of hepatic tumors on 2-deoxy-2-(¹⁸F)-fluoro-D-glucose (¹⁸FDG) positron emission tomography (PET) and to establish a method for glucose correction.

Patients and Methods:

Eighty-six patients with hepatic lesions identified on ¹⁸FDG PET/computed tomography (CT) were analyzed. The serum glucose level (Glc) was recorded prior to imaging, and the maximum standardized uptake value (SUV) in the hepatic tumors and the average SUV in normal liver were determined. The inverse relationship of SUV to glucose can be defined as d (SUV)/d (Glc) = g*SUV/(Glc), where g is the glucose sensitivity. Simulations using glucose level from 70 to 250 mg/dl were performed to evaluate the effects of Glc on the maximum SUV of malignant hepatic lesions and normal liver.

Results:

By logarithmic transformation and linear regression, g for metastasis was significantly higher than that for normal liver (−0.636 ± 0.144 vs. −0.0536 ± 0.0583; P = 0.00092). Simulation studies showed that the SUV in malignant lesions will decrease rapidly when Glc level is >120 mg/dl, while background liver remains relatively constant up to 250 mg/dl.

Conclusion:

The tumor FDG uptake is much more sensitive to ambient glucose level variation than the background liver. Therefore, correction by the glucose sensitivity factor will result in more accurate SUV measurements and make semi-quantitative analysis of ¹⁸FDG PET scans more reliable.