Atlas and Anatomy of PET/MRI

Murad, Vanessa; Kim, E. Edmund; Paeng, Jin-Chul; Im, Hyung-Jun; Cheon, Gi-Jeong

doi:10.1007/978-3-030-92349-5_1

Vanessa Murad^5,6,
E. Edmund Kim^7,8,
Jin-Chul Paeng⁵,
Hyung-Jun Im⁹ &
…
Gi-Jeong Cheon⁵

1380 Accesses

Abstract

Hybrid positron emission tomography/magnetic resonance image (PET/MRI) has undergone rapid evolution during the last years, moving from a predominantly research field to clinical practice. With the advances in faster silicon photomultiplier detectors, MRI-based attenuation correction, and image reconstruction, significant improvements in equipment and image quality have been achieved. Currently, there are fully integrated PET/MRI systems that allow simultaneous and more rapid acquisition, improving not only the technical quality but also the experience for patients who need a low radiation dose [1–3]. With this technology comes the possibility of performing multiparametric MRI studies, where detailed anatomical evaluation and functional evaluation are possible, not only considering the qualitative and quantitative data of PET but also integrating multiple parameters such as perfusion (contrast-enhanced sequences), cellularity (diffusion-weighted sequence), metabolites (spectroscopic analysis), and texture analysis. Additionally, recent developments are very promising in giving the possibility of incorporating advanced data and biomarkers to integrate with bioinformatics and allow a better understanding of the disease, as well as an efficient evaluation, prediction of response to treatment, and follow-up [4–7].

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PET/CT and PET/MRI, Normal Variations, and Artifacts

PET/MRI: Technical Challenges and Recent Advances

Article 26 January 2016

Hybrid Imaging: From Anatomy to Function

Keywords

Hybrid positron emission tomography/magnetic resonance image (PET/MRI) has undergone rapid evolution during the last years, moving from a predominantly research field to clinical practice. With the advances in faster silicon photomultiplier detectors, MRI-based attenuation correction, and image reconstruction, significant improvements in equipment and image quality have been achieved. Currently, there are fully integrated PET/MRI systems that allow simultaneous and more rapid acquisition, improving not only the technical quality but also the experience for patients who need a low radiation dose [1,2,3]. With this technology comes the possibility of performing multiparametric MRI studies, where detailed anatomical evaluation and functional evaluation are possible, not only considering the qualitative and quantitative data of PET but also integrating multiple parameters such as perfusion (contrast-enhanced sequences), cellularity (diffusion-weighted sequence), metabolites (spectroscopic analysis), and texture analysis. Additionally, recent developments are very promising in giving the possibility of incorporating advanced data and biomarkers to integrate with bioinformatics and allow a better understanding of the disease, as well as an efficient evaluation, prediction of response to treatment, and follow-up [4,5,6,7].

With the growing availability of PET/MRI, its main and differential applications have also been clarified. Nonspecific ¹⁸F-fludeoxyglucose (FDG) PET/MRI continues to be the most widely used, and thus new radiotracers are expanding the field to be explored. Among the most frequent applications of ¹⁸F-FDG PET/MRI, where its superiority over PET/CT has been demonstrated, are the evaluation of head and neck, colorectal, gynecological, bone and soft tissue tumors, as well as the evaluation and characterization of primary or secondary liver lesions [8,9,10,11,12]. It has also shown good results in non-tumor pathology such as epilepsy, inflammatory bowel disease, and cardiac sarcoidosis [4, 13].

The creation of new radiotracers that can be imaged both with PET/MRI and PET/CT, depending on the case and availability, has allowed great advances in the evaluation of other oncological and non-oncological pathologies. In the case of neuroendocrine tumors and prostate cancer, targeting somatostatin receptors with ⁶⁸Ga-DOTATOC, targeting PSMA with ⁶⁸Ga-PSMA-11 among others available tracers, and the inclusion of ¹⁷⁷Lu agents have revolutionized the diagnosis and treatment of these pathologies respectively [14, 15]. In the field of neuroimaging, the wide availability of radiotracers has made it possible to improve the evaluation of multiple targets different from glucose metabolism (FDG), such as DNA synthesis (¹⁸F-fluorothymidine), protein synthesis (¹¹C-methionine, ¹⁸F-fluoroethyl-L-tyrosine [FET], ¹⁸F-fluoro-L-3,4-dihydroxyphenylalanine [DOPA]), and hypoxia (¹⁸F-fluoromisonidazole) [16, 17]. In the field of degenerative diseases, where much remains to be explored and research is very promising, examples of emerging invaluable applications are amyloid PET and Tau PET for Alzheimer’s disease, as well as ¹⁸FP-CIT PET for Parkinson’s disease [18, 19].

In this chapter, we present multiple demonstrative examples of the different uses of PET/MR, with the most relevant anatomical references for each case.

1 Head and Neck

1.1 Case 1

A 75-year-old male patient, with worsening dizziness and weakness in both legs. Brain malignancy was suspected on brain CT, so ¹⁸F- FDG PET/MR was performed. Images revealed marked increased activity in a well-defined enhancing mass involving the corpus callosum, crossing the midline and with subependymal extension. Primary central nervous system (CNS) lymphoma was suspected, and stereotaxic biopsy confirmed a diffuse large B-cell lymphoma (Fig. 1) [20].

1.2 Case 2

A 72-year-old man with diagnosis of lymphoplasmacytic lymphoma (LPL)/Waldenström macroglobulinemia (WM) from marginal zone lymphoma, with central nervous system involvement. After surgery and chemotherapy, complete response was achieved, but the patient attended an early checkup with headache, so ¹⁸F-FDG PET/MR was performed. Images showed focal increased activity in a lobulated mass at the periventricular white matter, adjacent to the posterior horn of the left lateral ventricle with perilesional edema, which showed predominantly low signal on T2WI and heterogeneous contrast enhancement, which are frequent findings of lymphoma involvement. With these findings, a relapse was confirmed, and treatment was initiated again (Fig. 2) [21].

1.3 Case 3

A 5-year-old patient with gradual loss of vision in the right eye. Clinical examination and contrast-enhanced MRI were performed and confirmed the diagnosis of retinoblastoma. ¹⁸F-FDG PET/MR was performed during initial workup and staging. Minimal uptake was found in the primary tumor and the presence of metabolically active metastases was ruled out (Fig. 3) [22].

1.4 Case 4

A 49-year-old woman with a headache and decreased mobility of the right eye. ¹⁸F-FDG PET/MR was performed, and images showed a metabolically active mass with heterogeneous enhancement in the olfactory recess involving the cribriform plate and ethmoid air cells. The lesion produced lateral displacement of the right medial rectus muscle, compression of the optic chiasm, and obstruction of the sphenoid sinuses. Subsequent biopsy confirmed the diagnosis of an olfactory neuroblastoma, also known as esthesioneuroblastoma (Fig. 4) [23].

1.5 Case 5

A 48-year-old male patient with progressive proptosis, impaired visual acuity, and headaches. ¹⁸F-FDG PET/MR was performed, finding diffuse metabolically active infiltration of the soft tissues in both orbits and eyelids, with encasement and displacement of the optic nerves and muscles, without infiltration. Biopsy revealed the diagnosis of an extra nodal marginal zone B-cell lymphoma (EMZBC) (Fig. 5) [22].

1.6 Case 6

A 55-year-old male patient with sore throat and a soft tissue mass in the right nasopharyngeal wall on physical examination. Biopsy revealed nasopharyngeal squamous cell carcinoma, so ¹⁸F-FDG PET/MR was performed for staging. Images showed increased metabolic activity in the right nasopharyngeal area at a soft tissue mass, consistent with the primary tumor. Hypermetabolic, enlarged, metastatic lymph node (LN) was also found in the right neck, level II (Figs. 6 and 7) [24].

1.7 Case 7

A 55-year-old female patient with a growing ulcerated mass in the right sublingual area. Biopsy was performed confirming an adenoid cystic carcinoma with cribriform pattern, so ¹⁸F-FDG PET/MR was performed for staging. Images showed a focal hypermetabolic lesion in the right sublingual space, displacing the tongue’s intrinsic muscles, without infiltrating them. Ipsilateral, level II, hypermetabolic lymph node metastasis was also found (Fig. 8) [10].

1.8 Case 8

A 55-year-old male patient with a history of persistent dysphagia and cough. Direct endoscopic examination was performed finding a laryngeal mass, consistent with an epiglottic squamous cell carcinoma. ¹⁸F-FDG PET/MR was performed for staging, finding a prominent hypermetabolic mass in the superior aspect of the epiglottis, projecting towards the upper airway and decreasing its caliber. No hypermetabolic lymph nodes or distant metastases were observed (Fig. 9) [10].

1.9 Case 9

A 21-year-old man with a non-painful, progressively growing right parotid mass. Ultrasound-guided biopsy revealed a secretory carcinoma, so ¹⁸F-FDG PET/MR was performed for staging. Images showed a hypermetabolic irregular mass involving both the superficial and deep lobes of the right parotid gland, without associated metastatic lymph nodes (Fig. 10) [25].

1.10 Case 10

A 57-year-old man with a painful, rapidly growing left cervical mass. Ultrasound was performed finding an enlarged, necrotic lymph node, which biopsy revealed a metastatic carcinoma. ¹⁸F-FDG PET/MR was performed suspecting primary head and neck malignancy, and images showed a hypermetabolic mass in the hypopharynx, predominantly left side, with multiple metastatic lymph nodes in the left neck. The diagnosis of primary squamous cell carcinoma in this location was confirmed (Fig. 11) [10].

1.11 Case 11

A 22-year-old man with headache, occasional fever, and weakness in both arms. Laboratory tests did not show definite abnormalities, so ¹⁸F-FDG PET/MR and MRI were performed to rule out unknown origin infection vs occult malignancy. Images showed diffusely increased activity along the spinal cord with corresponding ill-defined high signal intensity lesions in T2WI. With these findings and other neurological tests, the diagnosis of acute disseminated encephalomyelitis (ADEM) was confirmed (Fig. 12) [26].

1.12 Case 12

A 67-year-old male patient with a history of left maxillary sinus squamous cell carcinoma, treated 9 years ago with radiotherapy and surgery (resection with flap reconstruction). He attended his annual checkup completely asymptomatic and among other studies ¹⁸F-FDG PET/MR was performed. Images showed focal increased activity in the lateral wall of the left nostril on the medial aspect of the surgical flap, which also presented heterogeneous contrast enhancement, which was not evident in the previous study. This finding was confirmed as a local recurrence (Fig. 13) [10].

2 Chest

2.1 Case 1

A 62-year-old male patient with a solitary pulmonary nodule and history of heavy smoking. ¹⁸F-FDG PET/MR was performed during staging. Images showed moderately increased activity in a small solid nodule at the left lower lobe, which was later resected and confirmed as an adenocarcinoma. No metabolically active metastases were detected (Figs. 14, 15, 16, 17, 18, and 19) [27, 28].

2.2 Case 2

Chest X-ray was performed on a 43-year-old woman due to a history of tuberculosis. A mediastinal mass was found, so evaluation with ¹⁸F-FDG PET/MR was indicated. Images showed mild focal increased activity at an oval, well-defined mass in the anterior and superior mediastinum as the only finding. Posterior biopsy confirmed a low-grade thymoma, type A (Fig. 20) [29].

2.3 Case 3

A 39-year-old woman with family history of breast cancer (two sisters), who attended with a palpable mass in the right breast. Initial studies confirmed an invasive ductal carcinoma, so ¹⁸F-FDG PET/MR was performed for staging. Images showed a metabolically active mass in the right breast with metastatic axillary lymph nodes in levels I and II. Intense FDG uptake was found in the left ventricular wall, probably related to poor fasting (Figs. 21 and 22).

3 Abdomen and Pelvis

3.1 Case 1

A 60-year-old male patient with weight loss of 10 kg over 7 months. Endoscopy and biopsy confirmed the diagnosis of a gastric adenocarcinoma, so ¹⁸F-FDG PET/MR was done for initial staging. Images showed a hypermetabolic lesion along the lesser curvature of the stomach, corresponding to the primary tumor. Another focal lesion with increased activity was found in the liver S5, which was confirmed as a liver metastasis [30]. As an incidental finding, a cystic lesion was observed in the left perineal soft tissues, which corresponded to a dermoid cyst (Figs. 23, 24, and 25).

3.2 Case 2

A 69-year-old female patient with a history of right nephrectomy 10 years ago due to a renal liposarcoma, who presented with abdominal discomfort. Endoscopy was done and revealed a signet-ring cell gastric cancer, so ¹⁸F-FDG PET/MR was done for initial staging. Focal increased activity was observed in the gastric antrum corresponding to the primary tumor, as well as in several enlarged lymph nodes (LNs) in the lesser curvature area, metastatic. Additionally, mild, diffuse, increased activity was found in fat-attenuating lesions at the retrocrural area and peritoneum, which were consistent with recurred liposarcoma (Figs. 26 and 27) [30, 31].

3.3 Case 3

A 74-year-old male patient with persistent abdominal pain during the last 3 months. Ultrasound was performed finding a suspicious mass in the gallbladder, so he was referred for ¹⁸F-FDG PET/MR evaluation. Images showed a marked hypermetabolic mass in the gallbladder fundus with intermediate, heterogeneous signal intensity in T2WI, consistent with a primary adenocarcinoma. Hypermetabolic liver invasion was excluded, as well as distant metastases (Fig. 28) [32].

3.4 Case 4

A 42-year-old patient, hepatitis B virus carrier, underwent abdominal ultrasonography for a routine health check. A liver mass was found, so ¹⁸F-FDG PET/MR was indicated for further evaluation. Images showed moderate focal increased activity in the liver S7 at a lobulated mass with arterial enhancement and delayed washout, consistent with a hepatocarcinoma. The patient underwent right liver posterior sectionectomy and the final diagnosis was combined hepatocellular carcinoma (HCC) and cholangiocarcinoma (CCA), which explains the high FDG uptake of the lesion (Fig. 29) [33].

3.5 Case 5

A 58-year old patient with a history of a rare liver schwannoma, who presented with abdominal mass. ¹⁸F-FDG PET/MR was done to search for malignant transformation. Images showed mild focal increased activity at the solid component of a complex irregular mass in the liver dome, which also showed heterogeneous signal intensity and delayed enhancement. Excisional biopsy was done, and a schwannoma with malignant transformation was confirmed (Figs. 30 and 31) [34].

3.6 Case 6

A 72-year-old woman with recurrent abdominal pain, weight loss, and fever. Initial studies confirmed the diagnosis of a pancreatic tail adenocarcinoma and due to the suspicion of liver metastases, ¹⁸F-FDG PET/MR was indicated. Images showed focal increased activity in a hypovascular pancreatic tail mass consistent with the primary tumor; due to the location of the lesion, no dilation of the main pancreatic duct was observed. Additionally, multiple focal hypermetabolic liver lesions were identified in the right hepatic lobe, corresponding to metastasis (Fig. 32) [32].

3.7 Case 7

A 69-year-old woman with persistent abdominal pain and distention. Abdominal ultrasound showed biliary dilatation and a suspicious pancreatic mass. ¹⁸F-FDG PET/MR was done finding a hypermetabolic mass in the pancreatic head with dilatation of the main pancreatic duct and atrophy of the distal pancreatic parenchyma, typical findings of an adenocarcinoma at this location. No metabolically active metastases were detected (Fig. 33) [32].

3.8 Case 8

An 80-year-old woman with bloating, heaviness, and abdominal distention. Endoscopy was done finding a prominent mass in the stomach, so ¹⁸F-FDG PET/MR was performed. Images showed slight and diffuse increased activity in a prominent rounded and very well-defined mass at the stomach, with heterogeneous contrast enhancement due to the presence of necrosis. Surgical resection of the lesion was done, and the final diagnosis was a low-grade gastrointestinal stromal tumor (GIST) , as suspected (Fig. 34) [35].

3.9 Case 9

A 59-year-old man with a 3-month history of gradually increasing rectal bleeding. Colonoscopy was performed finding a circumferential mass in the sigmoid colon, consistent with an adenocarcinoma. During initial staging, liver metastases were suspected, so ¹⁸F-FDG PET/MR was performed. Images show intense FDG uptake in the sigmoid colon at the primary tumor, without hypermetabolic pelvic or retroperitoneal lymph nodes. However, multiple metabolically active liver metastases were identified in both lobes (Fig. 35) [36].

3.10 Case 10

A 74-year-old man with prostate cancer, Gleason 8 (4 + 4), diagnosed with multiparametric MRI and transrectal biopsy. ¹⁸F-Choline PET/CT was performed for staging and images showed focal increased activity in the primary tumor at the left peripheral zone of the prostate gland with exophytic extension to the recto-prostatic angle and probable involvement of the neurovascular bundle (see MRI correlation). Also, two different metastatic bone lesions were observed, one slightly hypermetabolic, ill-defined intramedullary lesion in the right ischial tuberosity, and other cortical sclerotic lesion in the left ischial tuberosity without FDG uptake (Fig. 36) [15].

3.11 Case 11

A 41-year-old woman referred for ¹⁸F-FDG PET/MR due to abnormal findings on her annual general checkup. At colonoscopy, a lobulated subepithelial mass was found on the anterior aspect of the rectum; there was no definite abnormal increased activity in the lesion, which was later confirmed as a leiomyoma. Also, a complex right adnexal cystic mass without abnormal increased FDG uptake was observed; the final diagnosis was a hemorrhagic cyst (Figs. 37 and 38) [36].

3.12 Case 12

A 59-year-old female patient with an abnormal Pap smear test. Cervical punch biopsy revealed a squamous cell carcinoma, so ¹⁸F-FDG PET/MR was done for initial staging. Images showed a hypermetabolic mass in the uterine cervix involving the posterior upper vaginal wall, but not the parametrium. No abnormal hypermetabolic lesions suggesting metastasis were found (Figs. 39 and 40) [37, 38].

3.13 Case 13

A 41-year-old female patient with vaginal bleeding. Cervical biopsy revealed a squamous cell carcinoma, so ¹⁸F-FDG PET/MR was done for staging. Images showed a hypermetabolic uterine cervical mass involving the parametrium and the lower third of the vagina. Hypermetabolic and enlarged metastatic LNs were also found in both the external iliac and left internal and perirectal areas (Figs. 41, 42, 43, and 44) [37, 38].

4 Musculoskeletal System

4.1 Case 1

A 42-year-old female patient with a palpable mass in the right lower leg. ¹⁸F-FDG PET/MR was performed for further evaluation, finding a multilobulated soft tissue mass with moderately increased activity at the posterior compartment of the right lower leg. Enlarged LNs with mildly increased metabolism were also observed in the right external iliac, inguinal, and popliteal regions. Posterior biopsy confirmed synovial sarcoma in the primary mass, and reactive inflammatory LNs in other locations, which is an expected finding since sarcomas very rarely metastasize to LNs (Figs. 45, 46, 47, 48, and 49) [39, 40].

4.2 Case 2

A 39-year-old male patient with a palpable mass in the right thigh. ¹⁸F-FDG PET/MR was done for initial evaluation and staging. Images showed mild increased activity at a well-marginated enhancing mass in the right inner thigh. Myxoid liposarcoma was revealed by needle biopsy (Fig. 50) [39].

4.3 Case 3

A 16-year-old female patient with chronic pelvic pain. X-ray and CT scan revealed an aggressive bone lesion in the left pelvic bone, and needle biopsy confirmed the diagnosis of osteosarcoma, so ¹⁸F-FDG PET/MR was performed for staging. Images showed increased activity at a destructive bony lesion in the left pelvic bone involving the ilium, sacrum, and acetabulum, and encasing the left internal iliac vessels and sacral plexus. Inside the mass, an area with signal void on T2WI and marked contrast enhancement was identified, suggestive of intratumoral aneurysm. Multiple mild hypermetabolic metastatic lung nodules were also found (Figs. 51 and 52) [41, 42].

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Acknowledgments

The authors gratefully acknowledge Dr. Dong Soo Lee and Dr. Keon Wook Kang for their contributions to this chapter as it appeared in the previous edition.

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Authors and Affiliations

Department of Nuclear Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
Vanessa Murad, Jin-Chul Paeng & Gi-Jeong Cheon
Department of Diagnostic Imaging, Fundacion Santa Fe de Bogotá University Hospital, Bogota, Colombia
Vanessa Murad
Department of Radiological Sciences, University of California, Irvine, School of Medicine, Orange, CA, USA
E. Edmund Kim
Department of Nuclear Medicine and Department of Molecular Medicine, Graduate School of Convergence Science and Technology, Seoul National University College of Medicine, Seoul, Republic of Korea
E. Edmund Kim
Departments of Applied Bioengineering, Molecular Medicine, and Biopharmaceutical Sciences, Graduate School of Convergence Science and Technology, Seoul National University, Seoul, Republic of Korea
Hyung-Jun Im

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Department of Radiological Sciences, University of California, Irvine, School of Medicine, Orange, CA, USA
E. Edmund Kim
Department of Nuclear Medicine, Seoul National University College of Medicine, Seoul, Korea (Republic of)
Vanessa Murad
Department of Nuclear Medicine, Seoul National University College of Medicine, Seoul, Korea (Republic of)
Jin-Chul Paeng
Department of Nuclear Medicine, Seoul National University College of Medicine, Seoul, Korea (Republic of)
Gi-Jeong Cheon

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Murad, V., Kim, E.E., Paeng, JC., Im, HJ., Cheon, GJ. (2022). Atlas and Anatomy of PET/MRI. In: Kim, E.E., Murad, V., Paeng, JC., Cheon, GJ. (eds) Atlas and Anatomy of PET/MRI, PET/CT and SPECT/CT. Springer, Cham. https://doi.org/10.1007/978-3-030-92349-5_1

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DOI: https://doi.org/10.1007/978-3-030-92349-5_1
Published: 04 February 2022
Publisher Name: Springer, Cham
Print ISBN: 978-3-030-92348-8
Online ISBN: 978-3-030-92349-5
eBook Packages: MedicineMedicine (R0)

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