Incremental diagnostic utility of gastric distension FDG PET/CT

  • Pierre-Yves Le Roux
  • Cuong P. Duong
  • Carlos S. Cabalag
  • Bimal K. Parameswaran
  • Jason Callahan
  • Rodney J. Hicks
Original Article



To assess the diagnostic utility of gastric distension (GD) FDG PET/CT in both patients with known gastric malignancy and those not known to have gastric malignancy but with incidental focal FDG uptake in the stomach.


This retrospective analysis included 88 patients who underwent FDG PET/CT following GD with hyoscine N-butylbromide (Buscopan®) and water ingestion as part of routine clinical evaluation between 2004 and 2014. FDG PET/CT scans before and after GD were reported blinded to the patient clinical details in 49 patients undergoing pretreatment staging of gastric malignancy and 39 patients who underwent GD following incidental suspicious gastric uptake. The PET findings were validated by a composite clinical standard.


In the 49 patients undergoing pretreatment staging of gastric malignancy, GD improved PET detection of the primary tumour (from 80 % to 90 %). PET evaluation of tumour extent was concordant with endoscopic/surgical reports in 31 % (interpreter 1) and 45 % (interpreter 2) using pre-GD images and 73 % and 76 % using GD images. Interobserver agreement also improved with GD (κ = 0.29 to 0.69). Metabolic and morphological quantitative analysis demonstrated a major impact of GD in normal gastric wall but no significant effect in tumour, except a minor increase in SUV related to a delayed acquisition time. The tumour to normal stomach SUVmax ratio increased from 3.8 ± 2.9 to 9.2 ± 8.6 (mean ± SD) with GD (p < 0.0001), facilitating detection and improved assessment of the primary tumour. In 25 (64 %) of the 39 patients with incidental suspicious gastric uptake, acquisition after GD correctly excluded a malignant process. In 10 (71 %) of the remaining 14 patients with persistent suspicious FDG uptake despite GD, malignancy was confirmed and in 3 (21 %) an active but benign pathology was diagnosed.


GD is a simple way to improve local staging with FDG PET in patients with gastric malignancy. In the setting of incidental suspicious gastric uptake, GD is also an effective tool for ruling out malignancy and leads to the avoidance of unnecessary endoscopy.


FDG PET/CT Gastric cancer Staging Gastric distension Incidental finding 



We thank Elizabeth Drummond and Annette Hogg for developing and maintaining the PET database.

Compliance with ethical standards


Pierre-Yves Le Roux has received funding from the France-Australia Science Innovation Collaboration (FASIC) programme.

Conflicts of interest


Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional research committee and with the principles of the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards.

Informed consent

The requirement to obtain informed consent for this retrospective study was waived by the PMCC Ethics Committee (trial 14_151R).


  1. 1.
    Kamangar F, Dores GM, Anderson WF. Patterns of cancer incidence, mortality, and prevalence across five continents: defining priorities to reduce cancer disparities in different geographic regions of the world. J Clin Oncol. 2006;24(14):2137–50.CrossRefPubMedGoogle Scholar
  2. 2.
    Woo SK, Kim S, Kim TU, Lee JW, Kim GH, Choi KU, et al. Investigation of the association between CT detection of early gastric cancer and ultimate histology. Clin Radiol. 2008;63(11):1236–44.CrossRefPubMedGoogle Scholar
  3. 3.
    Kiff RS, Taylor BA. Comparison of computed tomography, endosonography, and intraoperative assessment in TN staging of gastric carcinoma. Gut. 1994;35(2):287–8.PubMedCentralCrossRefPubMedGoogle Scholar
  4. 4.
    Chen J, Cheong JH, Yun MJ, Kim J, Lim JS, Hyung WJ, et al. Improvement in preoperative staging of gastric adenocarcinoma with positron emission tomography. Cancer. 2005;103(11):2383–90.CrossRefPubMedGoogle Scholar
  5. 5.
    Li B, Zheng P, Zhu Q, Lin J. Accurate preoperative staging of gastric cancer with combined endoscopic ultrasonography and PET-CT. Tohoku J Exp Med. 2012;228(1):9–16.CrossRefPubMedGoogle Scholar
  6. 6.
    Youn SH, Seo KW, Lee SH, Shin YM, Yoon KY. 18F-2-deoxy-2-fluoro-D-glucose positron emission tomography: computed tomography for preoperative staging in gastric cancer patients. J Gastric Cancer. 2012;12(3):179–86.PubMedCentralCrossRefPubMedGoogle Scholar
  7. 7.
    Ha TK, Choi YY, Song SY, Kwon SJ. F18-fluorodeoxyglucose-positron emission tomography and computed tomography is not accurate in preoperative staging of gastric cancer. J Korean Surg Soc. 2011;81(2):104–10.PubMedCentralCrossRefPubMedGoogle Scholar
  8. 8.
    Kamimura K, Nagamachi S, Wakamatsu H, Fujita S, Nishii R, Umemura Y, et al. Role of gastric distention with additional water in differentiating locally advanced gastric carcinomas from physiological uptake in the stomach on 18F-fluoro-2-deoxy-D-glucose PET. Nucl Med Commun. 2009;30(6):431–9.CrossRefPubMedGoogle Scholar
  9. 9.
    Wu CX, Zhu ZH. Diagnosis and evaluation of gastric cancer by positron emission tomography. World J Gastroenterol. 2014;20(16):4574–85.PubMedCentralCrossRefPubMedGoogle Scholar
  10. 10.
    Shimada H, Okazumi S, Koyama M, Murakami K. Japanese Gastric Cancer Association Task Force for Research Promotion: clinical utility of 18F-fluoro-2-deoxyglucose positron emission tomography in gastric cancer. A systematic review of the literature. Gastric Cancer. 2011;14(1):13–21.CrossRefPubMedGoogle Scholar
  11. 11.
    Koga H, Sasaki M, Kuwabara Y, Hiraka K, Nakagawa M, Abe K, et al. An analysis of the physiological FDG uptake pattern in the stomach. Ann Nucl Med. 2003;17(8):733–8.CrossRefPubMedGoogle Scholar
  12. 12.
    Salaun PY, Grewal RK, Dodamane I, Yeung HW, Larson SM, Strauss HW. An analysis of the 18F-FDG uptake pattern in the stomach. J Nucl Med. 2005;46(1):48–51.PubMedGoogle Scholar
  13. 13.
    Zhu Z, Li F, Mao Y, Cheng W, Cheng X, Dang Y. Improving evaluation of primary gastric malignancies by distending the stomach with milk immediately before 18F-FDG PET scanning. J Nucl Med Technol. 2008;36(1):25–9.CrossRefPubMedGoogle Scholar
  14. 14.
    Cristescu R, Lee J, Nebozhyn M, Kim KM, Ting JC, Wong SS, et al. Molecular analysis of gastric cancer identifies subtypes associated with distinct clinical outcomes. Nat Med. 2015;21(5):449–56.CrossRefPubMedGoogle Scholar
  15. 15.
    Kaneko Y, Murray WK, Link E, Hicks RJ, Duong C. Improving patient selection for 18F-FDG PET scanning in the staging of gastric cancer. J Nucl Med. 2015;56(4):523–9.CrossRefPubMedGoogle Scholar
  16. 16.
    Kamimura K, Fujita S, Nishii R, Wakamatsu H, Nagamachi S, Yano T, et al. An analysis of the physiological FDG uptake in the stomach with the water gastric distention method. Eur J Nucl Med Mol Imaging. 2007;34(11):1815–8.CrossRefPubMedGoogle Scholar
  17. 17.
    Oda I, Saito D, Tada M, Iishi H, Tanabe S, Oyama T, et al. A multicenter retrospective study of endoscopic resection for early gastric cancer. Gastric Cancer. 2006;9(4):262–70.CrossRefPubMedGoogle Scholar
  18. 18.
    Okines A, Verheij M, Allum W, Cunningham D, Cervantes A; ESMO Guidelines Working Group. Gastric cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol. 2010;21 Suppl 5:v50–4.Google Scholar
  19. 19.
    Mukai K, Ishida Y, Okajima K, Isozaki H, Morimoto T, Nishiyama S. Usefulness of preoperative FDG-PET for detection of gastric cancer. Gastric Cancer. 2006;9(3):192–6.CrossRefPubMedGoogle Scholar
  20. 20.
    Lee SJ, Lee WW, Yoon HJ, Lee HY, Lee KH, Kim YH, et al. Regional PET/CT after water gastric inflation for evaluating loco-regional disease of gastric cancer. Eur J Radiol. 2013;82(6):935–42.CrossRefPubMedGoogle Scholar
  21. 21.
    Yun M, Choi HS, Yoo E, Bong JK, Ryu YH, Lee JD. The role of gastric distention in differentiating recurrent tumor from physiologic uptake in the remnant stomach on 18F-FDG PET. J Nucl Med. 2005;46(6):953–7.PubMedGoogle Scholar
  22. 22.
    Mocellin S, Marchet A, Nitti D. EUS for the staging of gastric cancer: a meta-analysis. Gastrointest Endosc. 2011;73(6):1122–34.CrossRefPubMedGoogle Scholar
  23. 23.
    Ott K, Fink U, Becker K, Stahl A, Dittler HJ, Busch R, et al. Prediction of response to preoperative chemotherapy in gastric carcinoma by metabolic imaging: results of a prospective trial. J Clin Oncol. 2003;21(24):4604–10.CrossRefPubMedGoogle Scholar
  24. 24.
    Abgral R, Le Roux PY, Rousset J, Querellou S, Valette G, Nowak E, et al. Prognostic value of dual-time-point 18F-FDG PET-CT imaging in patients with head and neck squamous cell carcinoma. Nucl Med Commun. 2013;34(6):551–6.CrossRefPubMedGoogle Scholar
  25. 25.
    Zhuang H, Pourdehnad M, Lambright ES, Yamamoto AJ, Lanuti M, Li P, et al. Dual time point 18F-FDG PET imaging for differentiating malignant from inflammatory processes. J Nucl Med. 2001;42(9):1412–7.PubMedGoogle Scholar
  26. 26.
    Wagner J, Aron DC. Incidentalomas: a “disease” of modern imaging technology. Best Pract Res Clin Endocrinol Metab. 2012;26(1):3–8.CrossRefPubMedGoogle Scholar
  27. 27.
    Hicks RJ. The customer is always right, even when you are justifiably wrong. J Nucl Med. 2014;55(12):1923–4.CrossRefPubMedGoogle Scholar
  28. 28.
    Wang G, Lau EW, Shakher R, Rischin D, Ware RE, Hong E, et al. How do oncologists deal with incidental abnormalities on whole-body fluorine-18 fluorodeoxyglucose PET/CT? Cancer. 2007;109(1):117–24.CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2015

Authors and Affiliations

  • Pierre-Yves Le Roux
    • 1
    • 2
  • Cuong P. Duong
    • 3
  • Carlos S. Cabalag
    • 3
  • Bimal K. Parameswaran
    • 1
  • Jason Callahan
    • 1
  • Rodney J. Hicks
    • 1
    • 4
  1. 1.Peter MacCallum Cancer CentreDivision of Radiation Oncology and Cancer ImagingEast MelbourneAustralia
  2. 2.Department of Nuclear MedicineBrest University HospitalBrestFrance
  3. 3.Department of Surgical OncologyPeter MacCallum Cancer CentreEast MelbourneAustralia
  4. 4.The University of MelbourneParkvilleAustralia

Personalised recommendations