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The Role of Gastric Distention in Differentiating Recurrent Tumor from Physiologic Uptake in the Remnant Stomach on ¹⁸F-FDG PET

Division of Nuclear Medicine, Department of Diagnostic Radiology, Yonsei University College of Medicine, Seoul, South Korea

Physiologic ¹⁸F-FDG uptake in the stomach can often cause false-positive results and lowers the usefulness of ¹⁸F-FDG PET in evaluating the remnant stomach. We assessed the role of gastric distension to see whether it is beneficial for the differentiation of recurrent tumors from physiologic ¹⁸F-FDG uptake in the remnant stomach. Methods: Thirty patients (22 men and 8 women; age range, 27–80 y; mean age, 58.3 y) with a history of subtotal gastrectomy for gastric cancer underwent ¹⁸F-FDG PET for various clinical indications. After whole-body imaging, the patients were asked to drink water, and then spot imaging of the stomach was performed. ¹⁸F-FDG uptake in the remnant stomach was considered positive for malignancy if it was persistently increased, whether focal or diffuse, after water ingestion. We used 2 standardized uptake value (SUV) criteria to differentiate benign from malignant uptake. First, a lesion was considered benign if its SUV was less than 2 on whole-body imaging. Second, for a lesion with an SUV of 2 or above, it was classified as benign if SUV decreased by more than 10% after water ingestion. Results: Visual analysis of whole-body images produced 9 true-negative, 4 false-positive, 16 true-positive, and 1 false-negative results. Use of additional spot images produced 12 true-negative, 1 false-positive, 15 true-positive, and 2 false-negative results. When an SUV cutoff of 2 was applied for malignancy before water ingestion, all 17 patients with local recurrence were correctly identified, but 11 of the 13 patients without local recurrence were falsely considered to have a recurrent tumor in the remnant stomach. To reduce the false-positive results, we used the second SUV criterion after water ingestion. Use of that criterion produced 4 false-negative results although it correctly identified the 11 false-positive results as true negative. Conclusion: Gastric distension by having patients drink a glass of water seems to be a simple, cost-effective way of improving the diagnostic accuracy of ¹⁸F-FDG PET in patients with suspected recurrence in the remnant stomach. Visual analysis with special attention to the configuration of ¹⁸F-FDG activity after water ingestion seems to be more useful than the change in SUV in evaluating the remnant stomach.

Key Words: gastroenterology • oncology • PET

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