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Imaging of Adrenal Incidentalomas with PET Using ¹¹C-Metomidate and ¹⁸F-FDG

¹ Turku PET Centre, University of Turku, Turku, Finland
² Department of Oncology and Radiotherapy, Turku University Central Hospital, Turku, Finland
³ Department of Internal Medicine, Tampere University Hospital, Tampere, Finland
⁴ Department of Internal Medicine, Helsinki University Hospital, Helsinki, Finland
⁵ Department of Internal Medicine, Turku University Central Hospital, Turku, Finland

Our aim was to evaluate the use of PET with ¹¹C-metomidate and ¹⁸F-FDG for the diagnosis of adrenal incidentalomas. Methods: Twenty-one patients underwent hormonal screening before dynamic imaging of the upper abdomen with ¹¹C-metomidate, and for 19 of these 21 patients, static ¹⁸F-FDG imaging followed. Uptake of ¹¹C-metomidate and ¹⁸F-FDG in incidentalomas was quantified and correlated with the hormonal work-up and the mass size on CT (median, 2.5 cm; range, 2–10 cm). Results: The final diagnoses were hormonally active adenoma (n = 7), nonsecretory adenoma (n = 5), adrenocortical carcinoma (n = 1), pheochromocytoma (n = 2), benign noncortical tumor (n = 2), normal adrenal (n = 1), and malignant noncortical tumor (n = 3). Diagnosis was established at surgery (n = 9), percutaneous biopsy (n = 4), or follow-up (n = 8). The highest uptake of ¹¹C-metomidate, expressed as standardized uptake value (SUV), was found in adrenocortical carcinoma (SUV = 28.0), followed by active adenomas (median SUV = 12.7), nonsecretory adenomas (median SUV = 12.2), and noncortical tumors (median SUV = 5.7). Patients with adenomas had significantly higher tumor–to–normal-adrenal ¹¹C-metomidate SUV ratios than did patients with noncortical tumors. ¹⁸F-FDG detected 2 of 3 noncortical malignancies but failed to detect adrenal metastases from renal cell carcinoma. All inactive and most active adenomas were difficult to detect with ¹⁸F-FDG against background activity, whereas both pheochromocytomas and adrenocortical carcinoma showed slightly increased uptake of ¹⁸F-FDG. There was no correlation between uptake of ¹¹C-metomidate or ¹⁸F-FDG and mass size. Conclusion: ¹¹C-Metomidate is a promising PET tracer to identify incidentalomas of adrenocortical origin. ¹⁸F-FDG should be reserved for patients with a moderate to high likelihood of neoplastic disease.

Key Words: adrenal gland • PET • radionuclide imaging • metomidate • ¹⁸F-FDG

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