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524Chapter 28 Current Research Efforts
Section 5
Imaging Atlas
29
PET–Computed Tomography Atlas
M. Beth McCarville
Fluorine-18-fluorodeoxyglucose (FDG) positron emission tomography
(PET) is a functional imaging modality that capitalizes on the fact that
pathologic processes are generally highly metab
olically active and
accumulate more glucose (and FDG) than normal tissue. However, sites
of normal metabolic activity can also demonstrate intense FDG uptake
and can sometimes be difficult to distinguish from disease activity.

Fusion imaging modalities that acquire both functional and correlative
anatomic imaging provide an important advantage over PET alone
because they allow the accurate anatomic localization of sites of
increased FDG activity (1–5). In this chapter, normal sites of FDG activ-
ity are correlated with computed tomography (CT) anatomy in images
obtained during PET-CT scanning. Examples of pathologic FDG activ-
ity are included to illustrate the unique value of this fusion imaging
modality in distinguishing normal from pathologic activity.
Head and Neck
Identifying normal FDG activity in the head and neck, as elsewhere in
the body, is aided by its bilaterally symmetric distribution. Because the
brain is exclusively dependent on glucose metabolism, it accumulates
intense FDG activity. Accumulation is greatest in the cerebral cortex,
basal ganglia, thalamus, and cerebellum (Figs. 29.1 and 29.2). Intense
activity is sometimes present, not only in the brain, but also in the ocular
muscles and optic nerves (Fig. 29.2). Because FDG is known to accu-
mulate in saliva (6,7), minimal to moderate activity may be present in
the salivary and parotid glands (Fig. 29.3). Fluorodeoxyglucose uptake
also occurs in the lymphatic tissues of the pharynx, specifically within
the Waldeyer ring, which consists of the nasopharyngeal, palatine, and
lingual tonsils (Fig. 29.3). In patients who are tense, FDG activity may
be very prominent in the neck muscles secondary to contraction-
induced metabolic activity. Fluorodeoxyglucose activity in the normal
thyroid gland is usually absent or minimal but can be prominent. Intrin-
sic laryngeal muscles of phonation can exhibit intense FDG activity
527
528Chapter 29 PET–Computed Tomography Atlas
Figure 29.2. A,B: Axial PET-CT images show FDG activity in normal optic nerves (arrowheads), tem-
poral lobes (straight arrows), and cerebellum (curved arrows).
A

A
Figure 29.1. A,B: Axial positron emission tomography–computed tomography (PET-CT) images show
fluorodeoxyglucose (FDG) activity in normal cerebral cortex (arrows), head of caudate (curved arrows),
and thalami (arrowheads).
B
B
A
M.B. McCarville 529
Figure 29.3. A,B: Axial PET-CT images show FDG uptake in a normal Waldeyer ring (arrowheads) and
normal parotid glands (arrows).
especially in patients who engage in speech activity immediately before
or after the injection of FDG (Fig. 29.4) (7–9). To reduce such activity,
patients should be encouraged to remain silent beginning 15 minutes
prior to radioisotope injection until the imaging session is complete.
Chest
Intense FDG activity is often present within brown adipose tissue in
the supraclavicular regions, axilla, and paraspinal regions of the pos-
terior mediastinum. The primary function of brown adipose tissue is
A
Figure 29.4. A,B: Axial PET-CT images show normal FDG activity in the perilaryngeal tissues (arrows)
often seen in patients who have engaged in speech after FDG injection.
B
B
the production of heat. Brown fat differs from other tissues by
the presence of an uncoupling protein within its mitochondria. This
protein leads to a markedly reduced production of adenosine triphos-
phate (ATP) while increasing the oxidation of fatty acids to a maximal
rate, resulting in the production of heat. During stimulated thermoge-
nesis, glucose prevents this highly metabolic brown fat from becoming
ATP-deprived by providing ATP through anaerobic glycolysis (10).

Thermogenesis, therefore, leads to an accumulation of glucose and
FDG within brown fat. Brown fat is known to be particularly metabol-
ically active in pediatric patients, females, and persons with a low body
mass index (10–12). Positron emission tomography–CT is especially
useful in localizing sites of intense FDG activity in the supraclavicular
regions because the CT will demonstrate either the absence (in the case
of brown fat) or the presence of a soft tissue mass in the area of
increased activity (Figs. 29.5 and 29.6).
The thymus is located in the anterior mediastinum and extends
from the thoracic inlet to the heart. Normal thymic FDG activity
is homogeneous and may be minimal, moderate, or more intense
than the mediastinal blood pool (Fig. 29.7). On CT the thymus has
a quadrilateral-shaped configuration with homogeneous density. In
530 Chapter 29 PET–Computed Tomography Atlas
A
B
C
Figure 29.5. A: Maximum intensity projection (MIP) image showing intense, symmetric activity in the
supraclavicular regions (arrow). B,C: Axial PET-CT images allow localization of this activity to supra-
clavicular brown fat (arrows). This finding is common in pediatric patients.
M.B. McCarville 531
Figure 29.6. A 26-year-old woman with non-Hodgkin’s lymphoma. A,B: Axial PET-CT images show
FDG activity in both supraclavicular brown fat (arrows) and pathologic supraclavicular nodes (arrow-
head
s). This example illustrates the value of PET-CT in identifying adenopathy that may be difficult to
distinguish from physiologic brown fat activity on PET alone.
A
A
B
C

Figure 29.7. A: MIP anterior PET image shows normal thymic contour and FDG activity (arrow) in a
3-year-old girl. B,C: Axial PET-CT images allow localization of activity to the thymus (arrows).
B
532 Chapter 29 PET–Computed Tomography Atlas
early childhood, the lateral margins are slightly convex outward until
adolescence when the thymus begins to involute and becomes
more triangular in appearance. The normal thymus should have
smooth margins and should never be nodular or lobulated (13).
At about 1 hour after injection of FDG, blood pool activity in the
mediastinum is moderate whereas lung activity is low. The heart
has variable FDG avidity, usually with intense activity seen in the left
ventricular myocardium (Fig. 29.8). Activity in the myocardium is
dependent on serum insulin levels. When insulin levels are high,
such as following a meal, the myocardium shifts from the metabolism
of free-fatty acids to the glycolytic pathway, resulting in intense
myocardial FDG activity (14,15). Fasting for 4 to 6 hours before
the administration of FDG reduces both serum glucose and insulin
availability, leading to decreased myocardial FDG activity. Minimal
to moderate FDG activity may be present within the distal esopha-
gus due to gastroesophageal reflux, muscle contraction, or inflam-
mation (8,15).
Abdomen and Pelvis
Fusion imaging is especially helpful in the abdomen and pelvis because
sites of FDG activity can be difficult to localize accurately on PET alone,
and sites that demonstrate abnormal FDG uptake may be overlooked
on CT alone when the abnormality is subtle or unexpected (Fig. 29.9).
In the upper abdomen, the cruces of the diaphragms and accessory
muscles of respiration may demonstrate intense FDG activity, particu-
larly in patients with increased work of breathing (Fig. 29.10) (8). There
may be intense activity in the region of the adrenal glands within

normal retroperitoneal brown fat. Liver activity is usually patchy but
uniform in distribution without focal areas of intense activity. Splenic
Figure 29.8. A,B: Axial PET-CT images show typical intense FDG activity in a normal left ventricular
myocardium (arrows).
A
B
M.B. McCarville 533
Figure 29.9. A,B: Axial PET-CT images show intense FDG activity within a metastatic deposit in the
pancreas (arrows) of a 10-year-old girl with widely metastatic rhabdomyosarcoma. This pancreatic
deposit was not clinically suspected and was overlooked on a CT scan performed 2 days earlier.
A
A
Figure 29.10. A,B: Axial PET-CT images show normal FDG activity in the crus of the left diaphragm
(straight arrows) and normal, homogeneous FDG uptake within the liver (curved arrows) and spleen
(arrowheads). The spleen usually shows activity that is equal to or less than that of the liver.
uptake is generally uniform and equal to or less than that of the liver
(Figs. 29.10, 29.11, and 29.12).
Fluorodeoxyglucose activity in the bowel is commonly seen but
poorly understood. Postulated causes of bowel activity include smooth
muscle contraction, metabolically active mucosa, uptake in lymphoid
tissue, swallowed secretions containing FDG, and colonic microbial
uptake (15–17). The stomach usually shows minimal to moderate activ-
ity within the fundus, although occasionally intense activity is seen
B
B
A
534 Chapter 29 PET–Computed Tomography Atlas
Figure 29.11. A,B: Axial PET-CT images show a focal area of abnormal activity that localizes to the
liver (arrows). This was proven by biopsy to be metastatic Hodgkin’s lymphoma in this 12-year-old
girl with ataxia-telangiectasia and Hodgkin’s lymphoma.

A
(Fig. 29.13). In these instances, correlating with CT imaging is useful in
excluding obvious abnormalities within the stomach wall or to local-
ize the activity to adjacent soft tissue abnormalities, such as adenopa-
thy or pancreatic neoplasms. The degree of FDG activity in the small
bowel and colon may be minimal, moderate, or intense and can be focal
or diffuse (Fig. 29.14). Fluorodeoxyglucose activity in the small bowel
and colon is often increased in patients who have fasted and is often
most pronounced in the region of the cecum and right colon (15). The
value of PET imaging in colorectal cancer is well established; however,
Figure 29.12. A 17-year-old boy with stage IV Hodgkin’s disease. A,B: Axial PET-CT images show
abnormal FDG activity in the spleen and nodes in the splenic hilum (straight arrows) and porta hepatis
(curved arrows), consistent with lymphomatous involvement. Note that splenic activity is greater than
the normal liver.
B
B
M.B. McCarville 535
Figure 29.13. A,B: Axial PET-CT images show moderate FDG activity in the wall of a normal stomach
(arrows). Normal gastric FDG activity can vary from minimal to intense.
A
without correlative CT imaging, the findings of bowel activity on PET
alone can be misleading. Computed tomography is useful in localizing
the activity to the bowel and may demonstrate underlying bowel
pathology such as a focal mass or an apple core lesion (Fig. 29.15). Even
so, evaluation of the bowel by CT performed as part of a standard PET-
CT scan may be limited by the lack of oral or intravenous contrast
material. If bowel pathology is a specific concern, the use of contrast
agents may enhance lesion conspicuity.
Fluorodeoxyglucose also accumulates in the glomerular filtrate
but, unlike glucose, it is not resorbed in the renal tubules. This results

in the intense accumulation of FDG in the renal collecting systems,
ureters, and bladder (Fig. 29.16). The value of PET in evaluating the
Figure 29.14. MIP anterior image show-
ing normal colonic activity (arrows).
B
536 Chapter 29 PET–Computed Tomography Atlas
A
B
C
Figure 29.15. This example illustrates the value of PET-CT in localizing abnormal bowel activity. A:
MIP anterior image shows a small focus of intense activity in the left abdomen (arrow) in this 19-year-
old man with previously treated neuroendocrine tumor. B,C: Axial PET-CT images localize the activ-
ity to a small colonic filling defect that was biopsied and found to be an adenomatous polyp.
Figure 29.16. MIP anterior image of the
abdomen shows the normal distribution
of FDG activity in the kidneys (arrow),
ureters (arrow), and urinary bladder
(arrow).
M.B. McCarville 537
A
B
Figure 29.17. A,B: Axial PET-CT images show the normally intense activity seen in the kidneys (arrows)
due to the accumulation of FDG in the glomerular filtrate.
kidneys is limited by the intense activity normally present within the
renal collecting systems, which may obscure underlying abnormalities
(Fig. 29.17). However, correlative PET-CT imaging may improve
lesion conspicuity and localization of renal tumors. Intense FDG
activity within the ureters is a common finding due to pooling of the
radiotracer in the recumbent patient (8). Correlation with CT imaging
allows distinction of the normal ureter from abnormal adjacent

structures.
Within the female pelvis, intense FDG activity may be present in
normal ovaries and uteri, depending on the phase of the patient’s men-
strual cycle (18). Positron emission tomography–CT is extremely useful
in localizing FDG activity to these structures (Fig. 29.18). Activity
within normal ovaries may not be bilaterally symmetric because the
Figure 29.18. A,B: Axial PET-CT images show FDG activity within normal ovaries (arrows) in this 17-
year-old girl who was in remission from stage IIA Hodgkin’s disease. The degree of FDG uptake in the
ovaries and uterus varies with menstrual phase. Normal ovarian activity may be asymmetric, as in this
case.
A
B
538 Chapter 29 PET–Computed Tomography Atlas
Figure 29.19. A,B: Axial PET-CT images show bilaterally symmetric and intense activity in normal
testes in this 19-year-old boy. The degree of FDG activity in normal testes can vary from minimal to
intense but should be symmetric.
ovary containing the dominant follicle may be more physiologically
active than the contralateral ovary. Correlation with the patients’ clin-
ical history is useful in ruling out malignancy as an underlying cause
of FDG uptake in the uterus and ovaries. In equivocal cases, follow-up
PET-CT should show resolution or a diminution of FDG activity when
the etiology is physiologic in nature (18). Within the male pelvis, activ-
ity in the normal testes can vary from minimal to intense, but should
be bilaterally symmetric (Fig. 29.19).
Musculoskeletal
Increased uptake of glucose into skeletal muscle is known to occur
during muscle exercise (19). Likewise, the uptake of glucose, and hence
FDG, into skeletal muscle is increased when muscle is electrically stim-
ulated to undergo isometric contraction (19,20). The mechanism of
glucose uptake into muscle is poorly understood, but it is distinct from

the regulation of glucose metabolism by insulin. Increased blood flow
and the translocation of glucose from the intracellular pool to the sar-
colemmal membrane and activation of the protein carriers GLUT-1 and
GLUT-4, in response to calcium released from the sarcoplasmic reticu-
lum during muscle stimulation, may be responsible (19). When PET
imaging reveals muscle FDG activity that is bilaterally symmetric (Fig.
29.20), it is likely due to increased glucose metabolism secondary to vol-
untary muscle contraction. Symmetric uptake of FDG in the neck and
paravertebral muscles can be caused merely by patient anxiety. Admin-
istration of the muscle relaxant and anxiolytic agent diazepam has been
effective in abolishing the high muscle FDG uptake seen in some
patients (19). Asymmetric muscle activity can be due to the sequelae of
local treatments such as surgery or radiation therapy or can be seen in
a recently exercised muscle, even if the activity occurred prior to the
A
B
M.B. McCarville 539
A
B
C
Figure 29.20. Three-year-old boy with previously treated rhabdomyosarcoma of the left lower leg. A:
MIP anterior image of the body shows symmetric activity in the forearm muscles (arrows). Note also
the appearance of the normal bone marrow with increased activity in the growing physes of the prox-
imal humeri (arrowhead), knees (curved arrow), and distal tibiae. The distribution of bone marrow
activity depends on patient age. Younger children have relatively more metabolically active marrow
than older children. Normal marrow activity is generally equal to or less than the liver. B ,C: Axial PET-
CT images localize the forearm activity to the forearm muscles (arrows). Such activity can be seen in
tense patients or may be related to physical activity.
injection of FDG (Fig. 29.21) (15). When FDG muscle activity is not bilat-
erally symmetric, the correlative anatomic information provided by CT

is extremely useful in elucidating the underlying cause of the abnor-
mality particularly when an intra- or perimuscular mass is present.
Interpretation of the PET appearance of normal bone marrow in chil-
dren requires knowledge of the age-dependent conversion patterns
from hematopoietic to fatty marrow (21–24). Younger children have rel-
atively more metabolically active and FDG-avid hematopoietic marrow
within long bones than older children whose marrow has undergone
fatty conversion. Intense FDG activity may be present in the physes of
growing children (Fig. 29.20). Fluorodeoxyglucose uptake in normal
bone marrow is generally less than or equal to that of the liver (Fig.
29.20). Diffuse and symmetric increased FDG bone marrow activity is
often seen in patients receiving granulocyte colony-stimulating factor
(G-CSF) (Fig. 29.22) (25). Occasionally, focal areas of increased FDG
activity are present within the vertebral bodies that can be difficult to
540 Chapter 29 PET–Computed Tomography Atlas
A
RL
B
RL
Figure 29.21. A 14-year-old boy with metastatic osteosarcoma. A,B: Axial PET-
CT images show increased activity in the thenar muscles of the left hand
(arrows) relative to the right (arrowheads). This was felt to be related to the
physical activity of this patient, who had exercised the left hand while playing
a video game prior to FDG injection.
Figure 29.22. An 18-year-old woman under treat-
ment for rhabdomyosarcoma who had recently
received granulocyte colony-stimulating factor (G-
CSF). MIP anterior image shows marrow activity
that is diffusely increased relative to the liver. This
pattern of marrow activity is commonly seen in

patients receiving G-CSF.
distinguish from a pathologic process. Generally, a repeating pattern of
patchy increased activity throughout the spine can be seen on the sagit-
tal or coronal images that is characteristic of physiologic uptake. When
increased bone marrow activity is solitary or nonuniformly distributed,
other causes, such as infection, metastatic disease, or primary bone
malignancies, should be considered. Correlative CT imaging, utilizing
a bone window, may reveal an underlying destructive process, frac-
ture, or other pathology (Fig. 29.23).
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