Case 7 Nuclear

Radiological Category: Thoracic/Nuclear
Principal Modality (1): CT with FDG PET overlay
Principal Modality (2): CT with and without IV contrast
Case Report
Submitted by:
Matthew Bean MSIV
Faculty reviewer:
Sandra Oldham M.D
Date accepted:
August 28, 2014
Case History
64 year old male smoker from Mexico who presents with weight loss and
hemoptysis. He had a CT done at a hospital in Mexico which showed a lung
mass. Decided to come here instead of being worked up and treated in Mexico.
Radiological Presentations
CT with IV contrast from hospital in mexico.
CT w/FDG PET overlay
coronal views taken
Radiological Presentations
Findings and Differentials
OSH CT: Right sided, central lung mass with irregular borders.
Subsegmental, linear atelectasis right upper lobe.
MHH CT with FDG PET overlay: Right sided, central, FDG avid mass with lobulated
Multiple, confluent, enlarged, FDG avid para-aortic lymph nodes.
Moderate sized, right sided pleural effusion.
•Lung cancer: Primary vs. Metastatic
•Infectious: Fungal granuloma, active infection, granuloma secondary to
Discussion: PET/CT
Advantages of FDG-PET in Lymph Node Staging
FDG-PET has the ability to identify positive nodes that are smaller than the standard CT
pathologic enlargement criteria of one centimeter as well as identify larger size nodes
that are negative.
PET imaging with anatomically fused images is advantageous in being able to identify
the exact location of mediastinal nodes near the midline.
Staging - Distant metastases
One of the most important roles for FDG-PET
Commons sites
adrenal glands, liver, bones
Stage IV - palliative chemotherapy is indicated.
Direct biopsy site to confirm the highest stage of disease expediting the work up
FDG-PET scan can reveal a distant site of disease that can be biopsied. This often can
obviate the need to biopsy the primary lesion.
Biopsy based on an FDG-PET scan can make the diagnostic workup more effective.
Discussion: PET/CT
Sensitivity and Specificity
FDG-PET is very sensitive though not very specific
Sensitivity of 96.8 and specificity of 77.8 in accuracy to differentiate malignant and
benign lesions3. Negative FDG-PET significantly reduces the chance that a lesion is
This decreases with smaller lesions in the 5-7 mm range, continue follow up
May be adequate to obviate further clinical work up or continue non-invasive follow up
FDG avidity of bronchiolo-aveolar cell cancer is reduced
Sources of false positive FDG avid foci
Granulomatous disease is a common cause of false positive single pulmonary nodule.
Fungal granulomas due to coccidiomycosis, histoplasmosis, and aspergillosis.
Granulomas due to tuberculosis.
Sarcoidosis often has a characteristic pattern, but it can cause false positives.
Active infections
Post infectious nodules
Radiological Presentations
49 year old man with weight loss, chronic cough, recurrent low grade fever.
Radiological Presentations
52 year old man with 3 months of cough.
Discussion: Infectious
(L)Nocardia infection- Nodules/masses with irregular borders, FDG avid on PET,
mimicking malignancy on imaging. Abscess formation and cavitation is common.
Can also have associated pleural effusion and thickening. (R)Biopsy proven,
cryptogenic organizing pneumonia.
Both were suspected to be cancer until biopsy showed otherwise.
Authors: P. Diana, S. L. Betancourt; Houston, TX/US
Radiological Presentations
50 year old female with cough and cutaneous lesions of the shins.
Radiological Presentations
Same condition, different patient radiographic presentations.
Discussion: Sarcoidosis
Can have a variety of imaging presentation patterns in the chest/lungs like bilateral
hilar lymphadenopathy, diffuse lymphadenopathy, reticulonodular infiltrative
pattern, alveolar ground glass or dense nodular opacities, and bullae and cyst
formation. Tissue diagnosis is imperative.
Shetty A, Carter JD. Sarcoidosis mimicking lymphoma on FDGPET imaging. Radiology Case Reports. (Online) 2011;6:409.
Radiological Presentations
CT w/FDG PET overlay
coronal views
Biopsy showed squamous cell carcinoma.
Discussion: Neoplasms
Bronchogenic squamous carcinoma- Centrally located lung cancer secondary to
smoking, typically not calcified, can have area of central necrosis. At presentation,
25% of patients have spread to regional lymph nodes, 55% have distant
metastasis. PET/CT used widely for staging purposes.
Radiological Presentations
Another complication of smoking, same patient.
Johnson DH, Blot WJ, Carbone DP, et al. Cancer of the lung: non-small cell lung cancer and small cell lung cancer. In: Abeloff
MD, Armitage JO, Niederhuber JE, et al., eds. Abeloff’s Clinical Oncology. 4th ed. Philadelphia, Pa: Elsevier Churchill
Livingstone; 2008:chap 76.
National Cancer Institute: PDQ Non-Small Cell Lung Cancer Treatment. Bethesda, MD: National Cancer Institute. Date last
modified 08/08/2013. Available at:
National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology: Non-small cell lung cancer. Version
2.2013. Available at
Herring, William, Learning Radiology: Recognizing the Basics
Shetty A, Carter JD. Sarcoidosis mimicking lymphoma on FDG-PET imaging. Radiology Case Reports. (Online) 2011;6:409.
Radiological Presentations
Radiological Presentations
Discussion: Neoplasms
Metastatic disease- many peripheral, rounded nodules of varying sizes scatter
through both lungs. Most common sources of lung metastatic disease are breast,
colorectal, renal cell, and head/neck squamous carcinomas, and uterine

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