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Value of FDG Positron Emission Tomography in Conjunction with MR Imaging for Evaluating Therapy Response in Patients with Musculoskeletal Sarcomas

Miriam A. Bredella1, Gary R. Caputo and Lynne S. Steinbach

1 All authors: Department of Radiology, University of California, San Francisco, 505 Parnassus Ave., San Francisco, CA 94143-0628.



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  		Fig. 1A. —10-year-old boy with history of clear cell sarcoma of right foot, shown after amputation of fourth and fifth rays and radiation therapy. Sagittal fat-suppressed T1-weighted MR image obtained with gadopentetate dimeglumine shows patchy increased signal intensity and enhancement in tarsal and metatarsal bones (black arrows). In addition, diffuse increased signal intensity and enhancement in muscles and tendons along plantar surface (white arrow) are present. Findings are suggestive of tumor involvement versus changes caused by radiation therapy.

 


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  		Fig. 1B. —10-year-old boy with history of clear cell sarcoma of right foot, shown after amputation of fourth and fifth rays and radiation therapy. Axial FDG positron emission tomography image shows mildly increased diffuse FDG uptake in soft tissues (arrow) along plantar surface of right foot with standardized uptake value of 1.4. These changes were thought to be caused by inflammation. No hypermetabolic focus was detected. Clinical follow-up after 1.5 years did not show recurrent tumor.

 


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  		Fig. 2A. —16-year-old girl with metastatic Ewing's sarcoma of pelvis, shown after chemotherapy. Coronal T1-weighted fat-suppressed MR image obtained with gadopentetate dimeglumine shows large enhancing mass (curved arrow) with heterogeneous signal intensity in region of left iliac wing. In addition, enhancement of surrounding gluteus and iliopsoas muscles (straight arrow) can be seen. Findings are suggestive of either residual or new tumor. Areas in muscles that showed no enhancement are suggestive of tumor necrosis.

 


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  		Fig. 2B. —16-year-old girl with metastatic Ewing's sarcoma of pelvis, shown after chemotherapy. Coronal FDG positron emission tomography image does not show increased FDG uptake in area of left iliac bone. Subsequent biopsy of mass showed necrotic nonviable neoplasm, which is consistent with treated Ewing's sarcoma.

 


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  		Fig. 3A. —15-year-old girl with rhabdomyosarcoma of right thenar eminence, shown after chemotherapy and radiation therapy. Coronal fat-suppressed T1-weighted MR image with gadopentetate dimeglumine shows small foci of increased signal intensity and enhancement in heads and bases of third and fifth metacarpals and carpal bones (arrows). No mass lesions are visible. Findings are consistent with aggressive osteoporosis versus metastatic disease.

 


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  		Fig. 3B. —15-year-old girl with rhabdomyosarcoma of right thenar eminence, shown after chemotherapy and radiation therapy. Coronal FDG positron emission tomography image shows increased uptake in right hand (standardized uptake value, 1.6) (arrow) that is thought to represent changes caused by inflammation. Clinical follow-up over 3 years did not show recurrent tumor in this region.

 


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  		Fig. 3C. —15-year-old girl with rhabdomyosarcoma of right thenar eminence, shown after chemotherapy and radiation therapy. Coronal (C), axial (D), and sagittal (E) positron emission tomography images show focus of increased uptake (standardized uptake value, 6.5) in upper outer quadrant of left breast (arrow, C and D) and area of increased uptake (standardized uptake value, 4.3) in soft tissue overlying medial distal right humerus (arrow, E) that were suspicious for metastases. Subsequent biopsy of these two lesions revealed metastatic disease.

 


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  		Fig. 3D. —15-year-old girl with rhabdomyosarcoma of right thenar eminence, shown after chemotherapy and radiation therapy. Coronal (C), axial (D), and sagittal (E) positron emission tomography images show focus of increased uptake (standardized uptake value, 6.5) in upper outer quadrant of left breast (arrow, C and D) and area of increased uptake (standardized uptake value, 4.3) in soft tissue overlying medial distal right humerus (arrow, E) that were suspicious for metastases. Subsequent biopsy of these two lesions revealed metastatic disease.

 


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  		Fig. 3E. —15-year-old girl with rhabdomyosarcoma of right thenar eminence, shown after chemotherapy and radiation therapy. Coronal (C), axial (D), and sagittal (E) positron emission tomography images show focus of increased uptake (standardized uptake value, 6.5) in upper outer quadrant of left breast (arrow, C and D) and area of increased uptake (standardized uptake value, 4.3) in soft tissue overlying medial distal right humerus (arrow, E) that were suspicious for metastases. Subsequent biopsy of these two lesions revealed metastatic disease.

 


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  		Fig. 4A. —17-year-old boy with history of extraosseous myxoid chondrosarcoma of left shoulder, shown after multiple cycles of chemotherapy. Coronal fast spin-echo T2-weighted MR image obtained with fat saturation shows large heterogeneous soft-tissue mass (arrow) in left shoulder in region of suprascapular notch. These findings are indicative of residual or recurrent tumor.

 


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  		Fig. 4B. —17-year-old boy with history of extraosseous myxoid chondrosarcoma of left shoulder, shown after multiple cycles of chemotherapy. Axial FDG positron emission tomography image shows increased FDG uptake (standardized uptake value, 4.6) in left shoulder (arrows). This finding is consistent with residual or recurrent neoplasm. Results from subsequent biopsy showed residual or recurrent myxoid chondrosarcoma.

 


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  		Fig. 5. —13-year-old boy with history of osteogenic sarcoma of right femur, shown after chemotherapy and radiation therapy and resection of right femoral osteosarcoma with placement of total-knee arthroplasty. MR images and CT scans (not shown) were deemed inadequate for tumor evaluation because of extensive metallic artifacts. Sagittal FDG positron emission tomography image shows no increased FDG uptake in area of right femur and knee. Cold defect (arrow) in region of right knee arthroplasty is visible.

 

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