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PET/CT in the Evaluation of Childhood Sarcomas

¹ Department of Radiological Sciences, St. Jude Children's Research Hospital, 332 N Lauderdale St., Memphis, TN 38105.
² Department of Radiology, College of Medicine, University of Tennessee, Memphis, TN.
³ Department of Hematology-Oncology, St. Jude Children's Research Hospital, Memphis, TN.

View larger version (34K): [in a new window]   Fig. 1A. —12-year-old girl who presented with abdominal lymphadenopathy, anemia, and pleural effusion. Differential diagnosis included Burkitt's lymphoma versus solid tumor. Bone marrow biopsy revealed alveolar rhabdomyosarcoma. Primary site was not identified at physical examination. Maximum-intensity-projection PET image revealed primary site in left calf (arrow). Note also diffuse bone marrow metastatic disease evidenced by increased activity throughout skeleton relative to liver.

View larger version (70K): [in a new window]   Fig. 1B. —12-year-old girl who presented with abdominal lymphadenopathy, anemia, and pleural effusion. Differential diagnosis included Burkitt's lymphoma versus solid tumor. Bone marrow biopsy revealed alveolar rhabdomyosarcoma. Primary site was not identified at physical examination. Contrast-enhanced axial MRI of left calf primary tumor was obtained after PET/CT. This deeply seated tumor (T) was missed at initial physical examination.

View larger version (65K): [in a new window]   Fig. 2A. —19-year-old woman who presented with left thigh mass proven by biopsy to be high-grade malignant peripheral nerve sheath tumor. Anterior maximum-intensity-projection PET image shows primary left thigh tumor (straight arrow), abnormal left pelvic activity (arrowhead), and abnormal focus in thoracic vertebra (curved arrow).

View larger version (67K): [in a new window]   Fig. 2B. —19-year-old woman who presented with left thigh mass proven by biopsy to be high-grade malignant peripheral nerve sheath tumor. STIR sagittal MR image of spine shows only subtle lesion (arrow) corresponding to abnormal focus seen on PET.

View larger version (62K): [in a new window]   Fig. 2C. —19-year-old woman who presented with left thigh mass proven by biopsy to be high-grade malignant peripheral nerve sheath tumor. Axial CT (C), PET (D), and fused PET/CT (E) images show intense activity in ninth thoracic vertebral body (arrows), which was proven by biopsy to be metastatic disease. Bone metastases are very rare in malignant peripheral nerve sheath tumor, and this metastatic deposit was not clinically suspected. Technetium-99m-labeled methyldiphosphonate bone scan obtained the day before PET showed no evidence of disease in thoracic spine.

View larger version (58K): [in a new window]   Fig. 2D. —19-year-old woman who presented with left thigh mass proven by biopsy to be high-grade malignant peripheral nerve sheath tumor. Axial CT (C), PET (D), and fused PET/CT (E) images show intense activity in ninth thoracic vertebral body (arrows), which was proven by biopsy to be metastatic disease. Bone metastases are very rare in malignant peripheral nerve sheath tumor, and this metastatic deposit was not clinically suspected. Technetium-99m-labeled methyldiphosphonate bone scan obtained the day before PET showed no evidence of disease in thoracic spine.

View larger version (58K): [in a new window]   Fig. 2E. —19-year-old woman who presented with left thigh mass proven by biopsy to be high-grade malignant peripheral nerve sheath tumor. Axial CT (C), PET (D), and fused PET/CT (E) images show intense activity in ninth thoracic vertebral body (arrows), which was proven by biopsy to be metastatic disease. Bone metastases are very rare in malignant peripheral nerve sheath tumor, and this metastatic deposit was not clinically suspected. Technetium-99m-labeled methyldiphosphonate bone scan obtained the day before PET showed no evidence of disease in thoracic spine.

View larger version (97K): [in a new window]   Fig. 3A. —Two opposing examples of benign nodal disease appearance on PET/CT. In 19-year-old woman who presented with large right popliteal fossa mass, mass was proven by biopsy to be embryonal rhabdomyosarcoma. Axial CT (A), PET (B), and fused PET/CT (C) images show absence of FDG activity within enlarged retroperitoneal node (arrows). This node underwent biopsy and was found to be negative for tumor.

View larger version (62K): [in a new window]   Fig. 3B. —Two opposing examples of benign nodal disease appearance on PET/CT. In 19-year-old woman who presented with large right popliteal fossa mass, mass was proven by biopsy to be embryonal rhabdomyosarcoma. Axial CT (A), PET (B), and fused PET/CT (C) images show absence of FDG activity within enlarged retroperitoneal node (arrows). This node underwent biopsy and was found to be negative for tumor.

View larger version (68K): [in a new window]   Fig. 3C. —Two opposing examples of benign nodal disease appearance on PET/CT. In 19-year-old woman who presented with large right popliteal fossa mass, mass was proven by biopsy to be embryonal rhabdomyosarcoma. Axial CT (A), PET (B), and fused PET/CT (C) images show absence of FDG activity within enlarged retroperitoneal node (arrows). This node underwent biopsy and was found to be negative for tumor.

View larger version (104K): [in a new window]   Fig. 3D. —Two opposing examples of benign nodal disease appearance on PET/CT. Same patient as described in Figures 2A, 2B, 2C, 2D, and 2E has malignant peripheral nerve sheath tumor. Axial CT (D), PET (E), and fused PET/CT (F) images show enlarged FDG-avid left external iliac node (arrows) that was not metastatic but contained follicular hyperplasia and sinus histiocytosis seen on pathologic review.

View larger version (55K): [in a new window]   Fig. 3E. —Two opposing examples of benign nodal disease appearance on PET/CT. Same patient as described in Figures 2A, 2B, 2C, 2D, and 2E has malignant peripheral nerve sheath tumor. Axial CT (D), PET (E), and fused PET/CT (F) images show enlarged FDG-avid left external iliac node (arrows) that was not metastatic but contained follicular hyperplasia and sinus histiocytosis seen on pathologic review.

View larger version (78K): [in a new window]   Fig. 3F. —Two opposing examples of benign nodal disease appearance on PET/CT. Same patient as described in Figures 2A, 2B, 2C, 2D, and 2E has malignant peripheral nerve sheath tumor. Axial CT (D), PET (E), and fused PET/CT (F) images show enlarged FDG-avid left external iliac node (arrows) that was not metastatic but contained follicular hyperplasia and sinus histiocytosis seen on pathologic review.

View larger version (87K): [in a new window]   Fig. 4A. —Same patient as in Figures 1A, and 1B. Bone marrow biopsy revealed alveolar rhabdomyosarcoma. Axial CT (A), PET (B), and fused PET/CT (C) images show numerous intensely FDG-avid metastatic deposits (arrows) in both breasts, not appreciated at initial physical examination.

View larger version (88K): [in a new window]   Fig. 4B. —Same patient as in Figures 1A, and 1B. Bone marrow biopsy revealed alveolar rhabdomyosarcoma. Axial CT (A), PET (B), and fused PET/CT (C) images show numerous intensely FDG-avid metastatic deposits (arrows) in both breasts, not appreciated at initial physical examination.

View larger version (64K): [in a new window]   Fig. 4C. —Same patient as in Figures 1A, and 1B. Bone marrow biopsy revealed alveolar rhabdomyosarcoma. Axial CT (A), PET (B), and fused PET/CT (C) images show numerous intensely FDG-avid metastatic deposits (arrows) in both breasts, not appreciated at initial physical examination.

View larger version (84K): [in a new window]   Fig. 4D. —Same patient as in Figures 1A, and 1B. Bone marrow biopsy revealed alveolar rhabdomyosarcoma. Axial CT (D), PET (E), and fused PET/CT (F) images show presumed metastatic nodal disease in external iliac chain on opposite side of primary tumor (arrows).

View larger version (72K): [in a new window]   Fig. 4E. —Same patient as in Figures 1A, and 1B. Bone marrow biopsy revealed alveolar rhabdomyosarcoma. Axial CT (D), PET (E), and fused PET/CT (F) images show presumed metastatic nodal disease in external iliac chain on opposite side of primary tumor (arrows).

View larger version (69K): [in a new window]   Fig. 4F. —Same patient as in Figures 1A, and 1B. Bone marrow biopsy revealed alveolar rhabdomyosarcoma. Axial CT (D), PET (E), and fused PET/CT (F) images show presumed metastatic nodal disease in external iliac chain on opposite side of primary tumor (arrows).

View larger version (54K): [in a new window]   Fig. 4G. —Same patient as in Figures 1A, and 1B. Bone marrow biopsy revealed alveolar rhabdomyosarcoma. Axial CT (G), PET (H), and fused PET/CT (I) images show abnormal focus of activity in small soft-tissue nodule in left thigh (arrows). All these sites of abnormal activity responded to chemotherapy and are presumed to have been metastatic.

View larger version (35K): [in a new window]   Fig. 4H. —Same patient as in Figures 1A, and 1B. Bone marrow biopsy revealed alveolar rhabdomyosarcoma. Axial CT (G), PET (H), and fused PET/CT (I) images show abnormal focus of activity in small soft-tissue nodule in left thigh (arrows). All these sites of abnormal activity responded to chemotherapy and are presumed to have been metastatic.

View larger version (33K): [in a new window]   Fig. 4I. —Same patient as in Figures 1A, and 1B. Bone marrow biopsy revealed alveolar rhabdomyosarcoma. Axial CT (G), PET (H), and fused PET/CT (I) images show abnormal focus of activity in small soft-tissue nodule in left thigh (arrows). All these sites of abnormal activity responded to chemotherapy and are presumed to have been metastatic.

View larger version (78K): [in a new window]   Fig. 5A. —19-year-old man who underwent reexcision of leiomyosarcoma from proximal left thigh in 1999. Follow-up MRI revealed enlarged left external iliac nodes, so PET/CT was performed for further evaluation. Maximum-intensity-projection PET image shows abnormal activity in left pelvis (arrow). Activity in chest muscles was believed to be physiologic in nature.

View larger version (94K): [in a new window]   Fig. 5B. —19-year-old man who underwent reexcision of leiomyosarcoma from proximal left thigh in 1999. Follow-up MRI revealed enlarged left external iliac nodes, so PET/CT was performed for further evaluation. Axial CT (B), PET (C), and fused PET/CT (D) images localize this activity to enlarged left external iliac nodes (arrow). These were proven by biopsy to be recurrent leiomyosarcoma.

View larger version (72K): [in a new window]   Fig. 5C. —19-year-old man who underwent reexcision of leiomyosarcoma from proximal left thigh in 1999. Follow-up MRI revealed enlarged left external iliac nodes, so PET/CT was performed for further evaluation. Axial CT (B), PET (C), and fused PET/CT (D) images localize this activity to enlarged left external iliac nodes (arrow). These were proven by biopsy to be recurrent leiomyosarcoma.

View larger version (85K): [in a new window]   Fig. 5D. —19-year-old man who underwent reexcision of leiomyosarcoma from proximal left thigh in 1999. Follow-up MRI revealed enlarged left external iliac nodes, so PET/CT was performed for further evaluation. Axial CT (B), PET (C), and fused PET/CT (D) images localize this activity to enlarged left external iliac nodes (arrow). These were proven by biopsy to be recurrent leiomyosarcoma.

View larger version (46K): [in a new window]   Fig. 6A. —16-year-old boy with large right pelvic Ewing's sarcoma, treated preoperatively with chemotherapy and radiation therapy. Maximum-intensity-projection PET image, obtained before neoadjuvant therapy, shows intense FDG activity in primary tumor (arrow) without evidence of metastatic disease.

View larger version (81K): [in a new window]   Fig. 6B. —16-year-old boy with large right pelvic Ewing's sarcoma, treated preoperatively with chemotherapy and radiation therapy. Maximum-intensity-projection PET image, obtained after neoadjuvant therapy, shows minimal activity within tumor (arrow), suggestive of good response. Pathologic inspection of resected tumor showed less than 5% residual viable tumor.

View larger version (78K): [in a new window]   Fig. 7A. —18-year-old woman with widely metastatic alveolar rhabdomyosarcoma who developed palpable metastatic soft-tissue nodules on anterior abdominal wall. PET/CT was performed as part of metastatic evaluation. Maximum-intensity-projection PET image shows multiple sites of abnormal FDG activity in chest, abdomen, pelvis, femurs, and right humerus, which were better localized on PET/CT than on PET alone.

View larger version (64K): [in a new window]   Fig. 7B. —18-year-old woman with widely metastatic alveolar rhabdomyosarcoma who developed palpable metastatic soft-tissue nodules on anterior abdominal wall. PET/CT was performed as part of metastatic evaluation. Maximum-intensity-projection PET image, obtained after bone marrow transplantation and treatment with chemotherapy, shows dramatic response of all metastatic sites.

View larger version (82K): [in a new window]   Fig. 8A. —This 10-year-old boy had previously undergone left pneumonectomy for metastatic osteosarcoma when he presented with new right pulmonary metastases that were treated with radiofrequency ablation. Axial CT (A), PET (B), and fused PET/CT (C) images obtained before radiofrequency ablation show abnormal activity within right upper lobe pulmonary nodule (arrows). Biopsy of this nodule at time of radiofrequency ablation confirmed presence of osteosarcoma.

View larger version (61K): [in a new window]   Fig. 8B. —This 10-year-old boy had previously undergone left pneumonectomy for metastatic osteosarcoma when he presented with new right pulmonary metastases that were treated with radiofrequency ablation. Axial CT (A), PET (B), and fused PET/CT (C) images obtained before radiofrequency ablation show abnormal activity within right upper lobe pulmonary nodule (arrows). Biopsy of this nodule at time of radiofrequency ablation confirmed presence of osteosarcoma.

View larger version (60K): [in a new window]   Fig. 8C. —This 10-year-old boy had previously undergone left pneumonectomy for metastatic osteosarcoma when he presented with new right pulmonary metastases that were treated with radiofrequency ablation. Axial CT (A), PET (B), and fused PET/CT (C) images obtained before radiofrequency ablation show abnormal activity within right upper lobe pulmonary nodule (arrows). Biopsy of this nodule at time of radiofrequency ablation confirmed presence of osteosarcoma.

View larger version (73K): [in a new window]   Fig. 8D. —This 10-year-old boy had previously undergone left pneumonectomy for metastatic osteosarcoma when he presented with new right pulmonary metastases that were treated with radiofrequency ablation. Axial CT (D), PET (E), and fused PET/CT (F) images obtained after radiofrequency ablation show minimal activity only at periphery of the tumor (arrows), which may be due to inflammation or flare phenomenon.

View larger version (53K): [in a new window]   Fig. 8E. —This 10-year-old boy had previously undergone left pneumonectomy for metastatic osteosarcoma when he presented with new right pulmonary metastases that were treated with radiofrequency ablation. Axial CT (D), PET (E), and fused PET/CT (F) images obtained after radiofrequency ablation show minimal activity only at periphery of the tumor (arrows), which may be due to inflammation or flare phenomenon.

View larger version (60K): [in a new window]   Fig. 8F. —This 10-year-old boy had previously undergone left pneumonectomy for metastatic osteosarcoma when he presented with new right pulmonary metastases that were treated with radiofrequency ablation. Axial CT (D), PET (E), and fused PET/CT (F) images obtained after radiofrequency ablation show minimal activity only at periphery of the tumor (arrows), which may be due to inflammation or flare phenomenon.

View larger version (68K): [in a new window]   Fig. 9A. —6-year-old boy who presented with right forearm mass that was proven by biopsy to be alveolar rhabdomyosarcoma. Axial CT (A), PET (B), and fused PET/CT (C) images at baseline show intense FDG activity within primary tumor.

View larger version (70K): [in a new window]   Fig. 9B. —6-year-old boy who presented with right forearm mass that was proven by biopsy to be alveolar rhabdomyosarcoma. Axial CT (A), PET (B), and fused PET/CT (C) images at baseline show intense FDG activity within primary tumor.

View larger version (45K): [in a new window]   Fig. 9C. —6-year-old boy who presented with right forearm mass that was proven by biopsy to be alveolar rhabdomyosarcoma. Axial CT (A), PET (B), and fused PET/CT (C) images at baseline show intense FDG activity within primary tumor.

View larger version (66K): [in a new window]   Fig. 9D. —6-year-old boy who presented with right forearm mass that was proven by biopsy to be alveolar rhabdomyosarcoma. Axial CT (D), PET (E), and PET/CT (F) images obtained after surgical resection show no evidence of residual disease in operative bed. Surgical resection margins were negative for tumor on pathologic review.

View larger version (58K): [in a new window]   Fig. 9E. —6-year-old boy who presented with right forearm mass that was proven by biopsy to be alveolar rhabdomyosarcoma. Axial CT (D), PET (E), and PET/CT (F) images obtained after surgical resection show no evidence of residual disease in operative bed. Surgical resection margins were negative for tumor on pathologic review.

View larger version (53K): [in a new window]   Fig. 9F. —6-year-old boy who presented with right forearm mass that was proven by biopsy to be alveolar rhabdomyosarcoma. Axial CT (D), PET (E), and PET/CT (F) images obtained after surgical resection show no evidence of residual disease in operative bed. Surgical resection margins were negative for tumor on pathologic review.

View larger version (113K): [in a new window]   Fig. 10A. —Same 18-year-old woman with recurrent metastatic alveolar rhabdomyosarcoma as seen in Figures 6A, and 6B. PET/CT, performed as part of metastatic evaluation, revealed many unsuspected sites of soft-tissue metastatic disease. Axial CT (A), PET (B), and fused PET/CT (C) images show left breast metastasis (arrows).

View larger version (71K): [in a new window]   Fig. 10B. —Same 18-year-old woman with recurrent metastatic alveolar rhabdomyosarcoma as seen in Figures 6A, and 6B. PET/CT, performed as part of metastatic evaluation, revealed many unsuspected sites of soft-tissue metastatic disease. Axial CT (A), PET (B), and fused PET/CT (C) images show left breast metastasis (arrows).

View larger version (73K): [in a new window]   Fig. 10C. —Same 18-year-old woman with recurrent metastatic alveolar rhabdomyosarcoma as seen in Figures 6A, and 6B. PET/CT, performed as part of metastatic evaluation, revealed many unsuspected sites of soft-tissue metastatic disease. Axial CT (A), PET (B), and fused PET/CT (C) images show left breast metastasis (arrows).

View larger version (114K): [in a new window]   Fig. 10D. —Same 18-year-old woman with recurrent metastatic alveolar rhabdomyosarcoma as seen in Figures 6A, and 6B. PET/CT, performed as part of metastatic evaluation, revealed many unsuspected sites of soft-tissue metastatic disease. Axial CT (D), PET (E), and fused PET/CT (F) images show abnormal FDG activity in pancreas (straight arrows), mesenteric nodule (curved arrows), and subcutaneous nodule (arrowheads), all unusual sites of metastatic rhabdomyosarcoma. Pancreatic and mesenteric sites, shown here, were present but overlooked on conventional CT performed 1 week before PET/CT.

View larger version (73K): [in a new window]   Fig. 10E. —Same 18-year-old woman with recurrent metastatic alveolar rhabdomyosarcoma as seen in Figures 6A, and 6B. PET/CT, performed as part of metastatic evaluation, revealed many unsuspected sites of soft-tissue metastatic disease. Axial CT (D), PET (E), and fused PET/CT (F) images show abnormal FDG activity in pancreas (straight arrows), mesenteric nodule (curved arrows), and subcutaneous nodule (arrowheads), all unusual sites of metastatic rhabdomyosarcoma. Pancreatic and mesenteric sites, shown here, were present but overlooked on conventional CT performed 1 week before PET/CT.

View larger version (67K): [in a new window]   Fig. 10F. —Same 18-year-old woman with recurrent metastatic alveolar rhabdomyosarcoma as seen in Figures 6A, and 6B. PET/CT, performed as part of metastatic evaluation, revealed many unsuspected sites of soft-tissue metastatic disease. Axial CT (D), PET (E), and fused PET/CT (F) images show abnormal FDG activity in pancreas (straight arrows), mesenteric nodule (curved arrows), and subcutaneous nodule (arrowheads), all unusual sites of metastatic rhabdomyosarcoma. Pancreatic and mesenteric sites, shown here, were present but overlooked on conventional CT performed 1 week before PET/CT.

View larger version (118K): [in a new window]   Fig. 10G. —Same 18-year-old woman with recurrent metastatic alveolar rhabdomyosarcoma as seen in Figures 6A, and 6B. PET/CT, performed as part of metastatic evaluation, revealed many unsuspected sites of soft-tissue metastatic disease. Axial CT (G), PET (H), and fused PET/CT (I) images show additional mesenteric metastasis missed by conventional CT (arrows).

View larger version (75K): [in a new window]   Fig. 10H. —Same 18-year-old woman with recurrent metastatic alveolar rhabdomyosarcoma as seen in Figures 6A, and 6B. PET/CT, performed as part of metastatic evaluation, revealed many unsuspected sites of soft-tissue metastatic disease. Axial CT (G), PET (H), and fused PET/CT (I) images show additional mesenteric metastasis missed by conventional CT (arrows).

View larger version (64K): [in a new window]   Fig. 10I. —Same 18-year-old woman with recurrent metastatic alveolar rhabdomyosarcoma as seen in Figures 6A, and 6B. PET/CT, performed as part of metastatic evaluation, revealed many unsuspected sites of soft-tissue metastatic disease. Axial CT (G), PET (H), and fused PET/CT (I) images show additional mesenteric metastasis missed by conventional CT (arrows).

View larger version (87K): [in a new window]   Fig. 11A. —16-year-old girl with previously treated alveolar rhabdomyosarcoma who was being evaluated for bone marrow transplantation. Axial CT (A), PET (B), and fused PET/CT (C) images show clinically unsuspected left breast metastasis (arrows).

View larger version (61K): [in a new window]   Fig. 11B. —16-year-old girl with previously treated alveolar rhabdomyosarcoma who was being evaluated for bone marrow transplantation. Axial CT (A), PET (B), and fused PET/CT (C) images show clinically unsuspected left breast metastasis (arrows).

View larger version (56K): [in a new window]   Fig. 11C. —16-year-old girl with previously treated alveolar rhabdomyosarcoma who was being evaluated for bone marrow transplantation. Axial CT (A), PET (B), and fused PET/CT (C) images show clinically unsuspected left breast metastasis (arrows).

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