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Early Detection of Cancer Recurrence: ¹⁸F-FDG PET/CT Can Make a Difference in Diagnosis and Patient Care

¹ Department of Nuclear Medicine, Rambam Health Care Campus, Haifa, Israel; ² B. Rappaport School of Medicine, Technion–Israel Institute of Technology, Haifa, Israel; and ³ Department of Oncology, Rambam Health Care Campus, Haifa, Israel

View larger version (49K): [in this window] [in a new window]   FIGURE 1.  PET/CT precisely localizes suspected foci of abnormal 18F-FDG uptake for diagnosis and estimation of extent of recurrence. A 66-y-old man with colon cancer, stage C, after surgical removal of primary tumor, was assessed for recurrence suggested by elevated levels of CEA serum marker. Results of CT scan performed 2 wk before present examination were negative. (A) 18F-FDG PET study (coronal slices) demonstrates foci of abnormal 18F-FDG uptake in right and middle abdomen. (B) Transaxial slices at level of these findings show paramedian left and right abnormal 18F-FDG foci seen on PET (left), localized by PET/CT (center) to slightly enlarged para-aortic lymph nodes, as demonstrated on CT (right), consistent with metastatic lymphadenopathy. (Focus of increased 18F-FDG uptake in right abdomen is localized by PET/CT to physiologic bowel activity.) On basis of these findings, chemotherapy regimen was changed from adjuvant protocol to drug combination used for treatment of metastatic disease. At follow-up 5 mo later, tumor markers had returned to normal, and repeat PET/CT results were negative. Patient is being reevaluated for consideration of consolidation radiotherapy to area of involved lymph nodes.

View larger version (62K): [in this window] [in a new window]   FIGURE 2.  PET/CT detects and characterizes pattern of metastatic spread. An 80-y-old woman with ovarian cancer, after surgery and chemotherapy, was assessed for recurrence suggested by elevated levels of CA-125 tumor marker. CT scan performed 16 d before present examination showed inconclusive findings in liver and renal cysts. (A) 18F-FDG PET study (coronal slices) demonstrates focal area of increased tracer uptake (marker) in right upper abdomen, adjacent to right kidney. (B) Transaxial slices at level of this suspected lesion show focus of increased 18F-FDG uptake on PET (left), localized by PET/CT (center) to mass (4 cm in diameter) in close proximity to duodenum, as demonstrated on CT (right). On basis of detection of single site of recurrence, it was decided to embark on curative approach, and patient was referred for surgery. Peritoneal metastasis was completely removed, and no other sites of disease were found in abdominal cavity. At follow-up 6 mo later, tumor marker had returned to normal levels, repeat PET/CT results were normal, and there was no evidence of active malignancy.

View larger version (57K): [in this window] [in a new window]   FIGURE 3.  PET/CT defines whole extent of recurrence in areas with complicated anatomy showing changes after treatment. A 46-y-old woman with breast cancer, after right mastectomy 9 y ago, presented with local recurrence and was referred for PET/CT study for treatment planning. (A) 18F-FDG PET study (coronal slices) demonstrates area of intense 18F-FDG uptake in right breast, consistent with known local recurrence. Additional small focus of slightly increased tracer uptake is seen in anterior chest wall (marker). (B) Transaxial slices at level of this equivocal 18F-FDG focus on PET (left) show that focus is localized by PET/CT (center) to lymph node in right internal mammary chain (9 mm in diameter), retrospectively identified on CT (right). After these PET/CT findings were obtained, patient was started on hormone therapy with aromatase inhibitor letrozole (Femara; Novartis). On basis of PET/CT findings, radiotherapy was planned to include internal mammary chain, in addition to irradiation of axilla and supraclavicular fossa. After completion of external radiation, patient received 192Ir brachytherapy implant. At 30 mo after therapy, patient was without evidence of disease, and PET/CT results were negative.