Abstract
Over the past six years, PET/CT has spread rapidly and replaced conventional PET. Although PET/ CT is a combination of PET for functional information and CT for morphological information, their combination is synergistic. PET/CT fusion images result in higher diagnostic accuracy with fewer equivocal findings. This results in a greater impact on cancer diagnosis. With attenuation correction performed by the CT component, PET/CT can provide higher quality images over shorter examination times than conventional PET. As with all modalities, PET/CT has several characteristic artifacts such as misregistration due to respiration, overattenuation correction due to metals, etc. Awareness of these pitfalls will help the imaging physician use PET/CT effectively in daily practice.
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Frazee D. Positron emission tomography: a technology assessment of PET imaging-past, present, and future.Radiol Manage 2004; 26: 38–43.
Fukuda H, Matsuzawa T, Abe Y, Endo S, Yamada K, Kubota K, et al. Experimental study for cancer diagnosis with positron-labeled fluorinated glucose analogs: [18F]-2-fiuoro-2-deoxy-D-mannose: a new tracer for cancer detection.Eur J Nucl Med 1982; 7: 294–297.
Irie T, Ido T, Fukushi K, Iwata R, Uoji M, Tamate K, et al. Aspects of the preparation of18F-2-deoxy-2-fluoro-D-glu-cose (18FDG) for medical use.Radioisotopes 1982; 31: 11–15.
Hubner KF, Buonocore E, Gould HR, Thie J, Smith GT, Stephens S, et al. Differentiating benign from malignant lung lesions using “quantitative” parameters of FDG PET images.Clin Nucl Med 1996; 21: 941–949.
Hagberg RC, Segall GM, Stark P, Burdon TA, Pompili MF. Characterization of pulmonary nodules and mediastinal staging of bronchogenic carcinoma with F-18 fluorodeoxy-glucose positron emission tomography.Eur J Cardiothorac Surg 1997; 12: 92–97.
Bury T, Dowlati A, Paulus P, Corhay JL, Benoit T, Kayembe JM, et al. Evaluation of the solitary pulmonary nodule by positron emission tomography imaging.Eur Respir J 1996; 9: 410–414.
Kostakoglu L, Goldsmith SJ. Fluorine-18 fluorodeoxy-glucose positron emission tomography in the staging and follow-up of lymphoma: is it time to shift gears?Eur J Nucl Med 2000; 27: 1564–1578.
Sasaki M, Kuwabara Y, Koga H, Nakagawa M, Chen T, Kaneko K, et al. Clinical impact of whole body FDG-PET on the staging and therapeutic decision making for malignant lymphoma.Ann Nucl Med 2002; 16: 337–345.
Yamamoto F, Tsukamoto E, Nakada K, Takei T, Zhao S, Asaka M, et al.18F-FDG PET is superior to67Ga SPECT in the staging of non-Hodgkin’s lymphoma.Ann Nucl Med 2004; 18: 519–526.
Strauss LG, Clorius JH, Schlag P, Lehner B, Kimmig B, Engenhart R, et al. Recurrence of colorectal tumors: PET evaluation.Radiology 1989; 170: 329–332.
Keogan MT, Lowe VJ, Baker ME, McDermott VG, Lyerly HK, Coleman RE. Local recurrence of rectal cancer: evaluation with F-18 fluorodeoxyglucose PET imaging.Abdom Imaging 1997; 22: 332–337.
Ogunbiyi OA, Flanagan FL, Dehdashti F, Siegel BA, Trask DD, Birnbaum EH, et al. Detection of recurrent and metastatic colorectal cancer: comparison of positron emission tomography and computed tomography.Ann Surg Oncol 1997; 4: 613–620.
Beyer T, Tellmann L, Nickel I, Pietrzyk U. On the use of positioning aids to reduce misregistration in the head and neck in whole-body PET/CT studies.J Nucl Med 2005; 46: 596–602.
von Schulthess GK. Positron emission tomography versus positron emission tomography/computed tomography: from “unclear” to “new-clear” medicine.Mol Imaging Biol 2004; 6: 183–187.
Alpert NM, Berdichevsky D, Levin Z, Morris ED, Fischman AJ. Improved methods for image registration.Neuroimage 1996; 3: 10–18.
Alyafei S, Inoue T, Zhang H, Ahmed K, Oriuchi N, Sato N, et al. Image Fusion System Using PACS for MRI, CT, and PET Images.Clin Positron Imaging 1999; 2: 137–143.
Barra V, Boire JV. A general framework for the fusion of anatomical and functional medical images.Neuroimage 2001; 13: 410–424.
Kinahan PE, Townsend DW, Beyer T, Sashin D. Attenuation correction for a combined 3D PET/CT scanner.Med Phys 1998; 25: 2046–2053.
Townsend DW, Carney JP, Yap JT, Hall NC. PET/CT today and tomorrow.J Nucl Med 2004; 45 Suppl 1: 4S-14S.
Beyer T, Townsend DW, Brun T, Kinahan PE, Charron M, Roddy R, et al. A combined PET/CT scanner for clinical oncology.J Nucl Med 2000; 41: 1369–1379.
Kluetz P, Villemagne VV, Meltzer C, Chander S, Martinelli M, Townsend D. 20. The Case for PET/CT. Experience at the University of Pittsburgh.Clin Positron Imaging 2000; 3: 174.
Kluetz PG, Meltzer CC, Villemagne VL, Kinahan PE, Chander S, Martinelli MA, et al. Combined PET/CT Imaging in Oncology. Impact on Patient Management.Clin Positron Imaging 2000; 3: 223–230.
Martinelli M, Townsend D, Meltzer C, Villemagne VV. 7. Survey of Results of Whole Body Imaging Using the PET/CT at the University of Pittsburgh Medical Center PET Facility.Clin Positron Imaging 2000; 3: 161.
Brambilla M, Secco C, Dominietto M, Matheoud R, Sacchetti G, Inglese E. Performance characteristics obtained for a new 3-dimensional lutetium oxyorthosilicate-based whole-body PET/CT scanner with the National Electrical Manufacturers Association NU 2-2001 standard.J Nucl Med 2005; 46: 2083–2091.
Townsend DW, Beyer T, Blodgett TM. PET/CT scanners: a hardware approach to image fusion.Semin Nucl Med 2003; 33: 193–204.
Townsend DW, Beyer T. A combined PET/CT scanner: the path to true image fusion.Br J Radiol 2002; 75 Spec No: S24–30.
Kim JH, Czernin J, Allen-Auerbach MS, Halpern BS, Fueger BJ, Hecht JR, et al. Comparison between18F-FDG PET, in-line PET/CT, and software fusion for restaging of recurrent colorectal cancer.J Nucl Med 2005; 46: 587–595.
Beyer T, Antoch G, Blodgett T, Freudenberg LF, Akhurst T, Mueller S. Dual-modality PET/CT imaging: the effect of respiratory motion on combined image quality in clinical oncology.Eur J Nucl Med Mol Imaging 2003; 30: 588–596.
Sarikaya I, Yeung HW, Erdi Y, Larson SM. Respiratory artefact causing malpositioning of liver dome lesion in right lower lung.Clin Nucl Med 2003; 28: 943–944.
Goerres GW, Burger C, Schwitter MR, Heidelberg TN, Seifert B, von Schulthess GK. PET/CT of the abdomen: optimizing the patient breathing pattern.Eur Radiol 2003; 13: 734–739.
deJuan R, Seifert B, Berthold T, von Schulthess GK, Goerres GW. Clinical evaluation of a breathing protocol for PET/CT.Eur Radiol 2004; 14: 1118–1123.
Nehmeh SA, Erdi YE, Pan T, Pevsner A, Rosenzweig KE, Yorke E, et al. Four-dimensional (4D) PET/CT imaging of the thorax.Med Phys 2004; 31: 3179–3186.
Ay MR, Zaidi H. Development and validation of MCNP4C-based Monte Carlo simulator for fan-and cone-beam x-ray CT.Phys Med Biol 2005; 50: 4863–4885.
Larson SM, Nehmeh SA, Erdi YE, Humm JL. PET/CT in non-small-cell lung cancer: value of respiratory-gated PET.Chang Gung Med J 2005; 28: 306–314.
Boucher L, Rodrigue S, Lecomte R, Benard F. Respiratory gating for 3-dimensional PET of the thorax: feasibility and initial results.J Nucl Med 2004; 45: 214–219.
Cohade C, Wahl RL. Applications of positron emission tomography/computed tomography image fusion in clinical positron emission tomography-clinical use, interpretation methods, diagnostic improvements.Semin Nucl Med 2003; 33: 228–237.
Seemann MD. PET/CT: fundamental principles.Eur J Med Res 2004; 9: 241–246.
Kamel E, Hany TF, Burger C, Treyer V, Lonn AH, von Schulthess GK, et al. CT vs68Ge attenuation correction in a combined PET/CT system: evaluation of the effect of lowering the CT tube current.Eur J Nucl Med Mol Imaging 2002; 29: 346–350.
Burger C, Goerres G, Schoenes S, Buck A, Lonn AH, Von Schulthess GK. PET attenuation coefficients from CT images: experimental evaluation of the transformation of CT into PET 511 -keV attenuation coefficients.Eur J Nucl Med Mol Imaging 2002; 29: 922–927.
Goerres GW, Ziegler SI, Burger C, Berthold T, Von Schulthess GK, Buck A. Artifacts at PET and PET/CT caused by metallic hip prosthetic material.Radiology 2003; 226: 577–584.
Bujenovic S, Mannting F, Chakrabarti R, Ladnier D. Arti-factual 2-deoxy-2-[(l8)F]fluoro-D-glucose localization surrounding metallic objects in a PET/CT scanner using CT-based attenuation correction.Mol Imaging Biol 2003; 5: 20–22.
Antoch G, Jentzen W, Freudenberg LS, Stattaus J, Mueller SP, Debatin JF, et al. Effect of oral contrast agents on computed tomography-based positron emission tomography attenuation correction in dual-modality positron emission tomography/computed tomography imaging.Invest Radiol 2003; 38: 784–789.
Antoch G, Freudenberg LS, Egelhof T, Stattaus J, Jentzen W, Debatin JF, et al. Focal tracer uptake: a potential artifact in contrast-enhanced dual-modality PET/CT scans.J Nucl Med 2002; 43: 1339–1342.
DiFilippo FP, Brunken RC. Do implanted pacemaker leads and ICD leads cause metal-related artifact in cardiac PET/ CT?J Nucl Med 2005; 46: 436–443.
Bockisch A, Beyer T, Antoch G, Freudenberg LS, Kuhl H, Debatin JF, et al. Positron emission tomography/computed tomography-imaging protocols, artifacts, and pitfalls.Mol Imaging Biol 2004; 6: 188–199.
Robinson P, Parkin A. Respiratory motion artefacts on PET/CT.Eur J Nucl Med Mol Imaging 2003; 30: 1712.
Papathanassiou D, Becker S, Amir R, Meneroux B, Liehn JC. Respiratory motion artefact in the liver dome on FDG PET/CT: comparison of attenuation correction with CT and a caesium external source.Eur J Nucl Med Mol Imaging 2005; 32: 1422–1428.
Sourbelle K, Kachelriess M, Kalender WA. Reconstruction from truncated projections in CT using adaptive detruncation.Eur Radiol 2005; 15: 1008–1014.
Mawlawi O, Erasmus JJ, Pan T, Cody DD, Campbell R, Lonn AH, et al. Truncation Artifact on PET/CT: Impact on Measurements of Activity Concentration and Assessment of a Correction Algorithm.AJR Am J Roentgenol 2006; 186: 1458–1467.
Beyer T, Bockisch A, Kuhl H, Martinez MJ. Whole-Body18F-FDG PET/CT in the Presence of Truncation Artifacts.J Nucl Med 2006; 47: 91–99.
Torizuka T, Fisher SJ, Brown RS, Wahl RL. Effect of insulin on uptake of FDG by experimental mammary carcinoma in diabetic rats.Radiology 1998; 208: 499–504.
Beyer T, Antoch G, Muller S, Egelhof T, Freudenberg LS, Debatin J, et al. Acquisition protocol considerations for combined PET/CT imaging.J Nucl Med 2004; 45 Suppl 1: 25S-35S.
Watson CC, Casey ME, Bendriem B, Carney JP, Townsend DW, Eberl S, et al. Optimizing injected dose in clinical PET by accurately modeling the counting-rate response functions specific to individual patient scans.J Nucl Md 2005; 46: 1825–1834.
Halpern BS, Dahlbom M, Quon A, Schiepers C, Waldherr C, Silverman DH, et al. Impact of patient weight and emission scan duration on PET/CT image quality and lesion detectability.J Nucl Med 2004; 45: 797–801.
Halpern BS, Dahlbom M, Auerbach MA, Schiepers C, Fueger BJ, Weber WA, et al. Optimizing imaging protocols for overweight and obese patients: a lutetium orthosilicate PET/CT study.J Nucl Med 2005; 46: 603–607.
Jaskowiak CJ, Bianco JA, Perlman SB, Fine JP. Influence of reconstruction iterations on18F-FDG PET/CT standardized uptake values.J Nucl Med 2005; 46: 424–428.
Wu TH, Chu TC, Huang YH, Chen LK, Mok SP, Lee JK, et al. A positron emission tomography/computed tomography (PET/CT) acquisition protocol for CT radiation dose optimization.Nucl Med Commun 2005; 26: 323–330.
Li T, Schreibmann E, Thomdyke B, Tillman G, Boyer A, Koong A, et al. Radiation dose reduction in four-dimensional computed tomography.Med Phys 2005; 32: 3650–3660.
Wu TH, Huang YH, Lee JJ, Wang SY, Wang SC, Su CT, et al. Radiation exposure during transmission measurements: comparison between CT-and germanium-based techniques with a current PET scanner.Eur J Nucl Med Mol Imaging 2004; 31: 38–43.
Brix G, Lechel U, Glatting G, Ziegler SI, Munzing W, Muller SP, et al. Radiation exposure of patients undergoing whole-body dual-modality18F-FDG PET/CT examinations.J Nucl Med 2005; 46: 608–613.
Antoch G, Freudenberg LS, Beyer T, Bockisch A, Debatin JF. To enhance or not to enhance?18F-FDG and CT contrast agents in dual-modality18F-FDG PET/CT.J Nucl Med 2004; 45 Suppl 1: 56S-65S.
Brechtel K, Klein M, Vogel M, Mueller M, Aschoff P, Beyer T, et al. Optimized contrast-enhanced CT protocols for diagnostic whole-body18F-FDG PET/CT: technical aspects of single-phase versus multiphase CT imaging.J Nucl Med 2006; 47: 470–476.
Strobel K, Thuerl CM, Hany TF. How much intravenous contrast is needed in FDG-PET/CT?Nuklearmedizin 2005; 44 Suppl 1: S32–37.
Berthelsen AK, Holm S, Loft A, Klausen TL, Andersen F, Hojgaard L. PET/CT with intravenous contrast can be used for PET attenuation correction in cancer patients.Eur J Nucl Med Mol Imaging 2005; 32: 1167–1175.
Nakamoto Y, Chin BB, Kraitchman DL, Lawler LP, Marshall LT, Wahl RL. Effects of nonionic intravenous contrast agents at PET/CT imaging: phantom and canine studies.Radiology 2003; 227: 817–824.
Yau YY, Chan WS, Tarn YM, Vernon P, Wong S, Coel M, et al. Application of intravenous contrast in PET/CT: does it really introduce significant attenuation correction error?J Nucl Med 2005; 46: 283–291.
Rosenbaum SJ, Lind T, Antoch G, Bockisch A. False-Positive FDG PET Uptake-the Role of PET/CT.Eur Radiol 2006; 16: 1054–1065.
Kostakoglu L, Hardoff R, Mirtcheva R, Goldsmith SJ. PET-CT fusion imaging in differentiating physiologic from pathologic FDG uptake.Radiographics 2004; 24: 1411–1431.
Minotti AJ, Shah L, Keller K. Positron emission tomography/computed tomography fusion imaging in brown adipose tissue.Clin Nucl Med 2004; 29: 5–11.
Hany TF, Gharehpapagh E, Kamel EM, Buck A, Himms-Hagen J, von Schulthess GK. Brown adipose tissue: a factor to consider in symmetrical tracer uptake in the neck and upper chest region.Eur J Nucl Med Mol Imaging 2002; 29: 1393–1398.
Yeung HW, Grewal RK, Gonen M, Schoder H, Larson SM. Patterns of(18)F-FDG uptake in adipose tissue and muscle: a potential source of false-positives for PET.J Nucl Med 2003; 44: 1789–1796.
Cohade C, Mourtzikos KA, Wahl RL. “USA-Fat”: prevalence is related to ambient outdoor temperature-evaluation with18F-FDG PET/CT.J Nucl Med 2003; 44: 1267–1270.
Heiba SI, Bemik S, Raphael B, Sandella N, Cholewinski W, Klein P. The distinctive role of positron emission tomography/computed tomography in breast carcinoma with brown adipose tissue 2-fluoro-2-deoxy-D-glucose uptake.Breast J 2005; 11: 457–461.
Bar-Shalom R, Gaitini D, Keidar Z, Israel O. Non-malignant FDG uptake in infradiaphragmatic adipose tissue: a new site of physiological tracer biodistribution characterised by PET/CT.Eur J Nucl Med Mol Imaging 2004; 31: 1105–1113.
Truong MT, Erasmus JJ, Munden RF, Marom EM, Sabloff BS, Gladish GW, et al. Focal FDG uptake in mediastinal brown fat mimicking malignancy: a potential pitfall resolved on PET/CT.AJR Am J Roentgenol 2004; 183: 1127–1132.
Boland GW, Goldberg MA, Lee MJ, Mayo-Smith WW, Dixon J, McNicholas MM, et al. Indeterminate adrenal mass in patients with cancer: evaluation at PET with 2-[F-18]-fluoro-2-deoxy-D-glucose.Radiology 1995; 194: 131–134.
Erasmus JJ, Patz EF Jr, McAdams HP, Murray JG, Herndon J, Coleman RE, et al. Evaluation of adrenal masses in patients with bronchogenic carcinoma using18F-fluoro-deoxyglucose positron emission tomography.AJR Am J Roentgenol 1997; 168: 1357–1360.
Maurea S, Mainolfi C, Bazzicalupo L, Panico MR, Imparato C, Alfano B, et al. Imaging of adrenal tumors using FDG PET: comparison of benign and malignant lesions.AJR Am J Roentgenol 1999; 173: 25–29.
Bagheri B, Maurer AH, Cone L, Doss M, Adler L. Characterization of the normal adrenal gland with18F-FDG PET/ CT.J Nucl Med 2004; 45: 1340–1343.
Blake MA, Slattery JM, Kalra MK, Halpern EF, Fischman AJ, Mueller PR, et al. Adrenal lesions: characterization with fused PET/CT image in patients with proved or suspected malignancy-initial experience.Radiology 2006; 238: 970–977.
Reinartz P, Wieres FJ, Schneider W, Schur A, Buell U. Side-by-side reading of PET and CT scans in oncology: which patients might profit from integrated PET/CT?Eur J Nucl Med Mol Imaging 2004; 31: 1456–1461.
Buell U, Wieres FJ, Schneider W, Reinartz P.18FDG-PET in 733 consecutive patients with or without side-by-side CT evaluation: analysis of 921 lesions.Nuklearmedizin 2004; 43: 210–216.
Antoch G, Saoudi N, Kuehl H, Dahmen G, Mueller SP, Beyer T, et al. Accuracy of whole-body dual-modality fluorine-18-2-fluoro-2-deoxy-D-glucose positron emission tomography and computed tomography (FDG-PET/CT) for tumor staging in solid tumors: comparison with CT and PET.J Clin Oncol 2004; 22: 4357–4368.
Lardinois D, Weder W, Hany TF, Kamel EM, Korom S, Seifert B, et al. Staging of non-small-cell lung cancer with integrated positron-emission tomography and computed tomography.N Engl J Med 2003; 348: 2500–2507.
Israel O, Mor M, Guralnik L, Hermoni N, Gaitini D, Bar-Shalom R, et al. Is18F-FDG PET/CT useful for imaging and management of patients with suspected occult recurrence of cancer?J Nucl Med 2004; 45: 2045–2051.
Barranger E, Kerrou K, Petegnief Y, David-Montefiore E, Cortez A, Darai E Laparoscopic resection of occult metastasis using the combination of FDG-positron emission tomography/computed tomography image fusion with in-traoperative probe guidance in a woman with recurrent ovarian cancer.Gynecol Oncol 2005; 96: 241–244.
Gutzeit A, Antoch G, Kuhl H, Egelhof T, Fischer M, Hauth E, et al. Unknown primary tumors: detection with dual-modality PET/CT-initial experience.Radiology 2005; 234: 227–234.
Pelosi E, Pennone M, Deandreis D, Douroukas A, Mancini M, Bisi G. Role of whole body positron emission tomography/computed tomography scan with18F-fluorodeoxy-glucose in patients with biopsy proven tumor metastases from unknown primary site.Q J Nucl Med Mol Imaging 2006; 50: 15–22.
Metser U, Golan O, Levine CD, Even-Sapir E. Tumor lesion detection: when is integrated positron emission tomography/computed tomography more accurate than side-by-side interpretation of positron emission tomography and computed tomography?J Comput Assist Tomogr 2005; 29: 554–559.
Allen-Auerbach M, Quon A, Weber WA, Obrzut S, Crawford T, Silverman DH, et al. Comparison between 2-deoxy-2-[18F]fluoro-D-glucose positron emission tomography and positron emission tomography/computed tomography hardware fusion for staging of patients with lymphoma.Mol Imaging Biol 2004; 6: 411–416.
Tatsumi M, Cohade C, Nakamoto Y, Fishman EK, Wahl RL. Direct comparison of FDG PET and CT findings in patients with lymphoma: initial experience.Radiology 2005; 237: 1038–1045.
Bristow RE. Combined PET/CT for detecting recurrent ovarian cancer limited to retroperitoneal lymph nodes: Response to a letter from Dr. Maurie Markman.Gynecol Oncol 2006.
Sironi S, Messa C, Mangili G, Zangheri B, Aletti G, Garavaglia E, et al. Integrated FDG PET/CT in patients with persistent ovarian cancer: correlation with histologic findings.Radiology 2004; 233: 433–440.
Zissin R, Metser U, Hain D, Even-Sapir E. Mesenteric panniculitis in oncologic patients: PET-CT findings.Br J Radiol 2006; 79: 37–43.
Ciernik IF, Huser M, Burger C, Davis JB, Szekely G. Automated functional image-guided radiation treatment planning for rectal cancer.Int J Radiat Oncol Biol Phys 2005; 62: 893–900.
Ciernik IF, Dizendorf E, Baumert BG, Reiner B, Burger C, Davis JB, et al. Radiation treatment planning with an integrated positron emission and computer tomography (PET/CT): a feasibility study.Int J Radiat Oncol Biol Phys 2003; 57: 853–863.
Ashamalla H, Rafla S, Parikh K, Mokhtar B, Goswami G, Kambam S, et al. The contribution of integrated PET/CT to the evolving definition of treatment volumes in radiation treatment planning in lung cancer.Int J Radiat Oncol Biol Phys 2005; 63: 1016–1023.
Frank SJ, Chao KS, Schwartz DL, Weber RS, Apisarnthanarax S, Macapinlac HA. Technology insight: PET and PET/CT in head and neck tumor staging and radiation therapy planning.Nat Clin Pract Oncol 2005; 2: 526–533.
Leong T, Everitt C, Yuen K, Condron S, Hui A, Ngan SY, et al. A prospective study to evaluate the impact of FDG-PET on CT-based radiotherapy treatment planning for oesophageal cancer.Radiother Oncol 2006; 78: 254–261.
Messa C, Ceresoli GL, Rizzo G, Artioli D, Cattaneo M, Castellone P, et al. Feasibility of [18F]FDG-PET and coregistered CT on clinical target volume definition of advanced non-small cell lung cancer.Q J Nucl Med Mol Imaging 2005; 49: 259–266.
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Tsukamoto, E., Ochi, S. PET/CT today: System and its impact on cancer diagnosis. Ann Nucl Med 20, 255–267 (2006). https://doi.org/10.1007/BF02984642
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DOI: https://doi.org/10.1007/BF02984642