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Clinical Value of Manual Fusion of PET and CT Images in Patients with Suspected Recurrent Colorectal Cancer

¹ Department of Diagnostic Imaging and Nuclear Medicine, Kyoto University Graduate School of Medicine, 54 Shogoinkawahara-cho, Sakyo-Ku, Kyoto 606-8507, Japan.
² Department of Image-Based Medicine, Institute of Biomedical Research and Innovation, Kobe, Japan.

View larger version (128K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1 —After PET scanning, patients underwent CT with same fixation device. They were repositioned by staff who referred to median and bilateral flank lines on surface of skin, which were marked before PET scanning.

View larger version (90K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2A —65-year-old asymptomatic woman (patient 13 in Table 1) with history of colon cancer. During follow-up period, recurrence was not suspected. CT (A), PET (B), and fusion (C) images. Fusion images of PET and CT reveal focal intense uptake corresponding to part of uterus and peritoneum. Peritoneal dissemination was confirmed at surgery. These lesions (arrows, A) were missed on review of CT alone.

View larger version (68K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2B —65-year-old asymptomatic woman (patient 13 in Table 1) with history of colon cancer. During follow-up period, recurrence was not suspected. CT (A), PET (B), and fusion (C) images. Fusion images of PET and CT reveal focal intense uptake corresponding to part of uterus and peritoneum. Peritoneal dissemination was confirmed at surgery. These lesions (arrows, A) were missed on review of CT alone.

View larger version (78K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2C —65-year-old asymptomatic woman (patient 13 in Table 1) with history of colon cancer. During follow-up period, recurrence was not suspected. CT (A), PET (B), and fusion (C) images. Fusion images of PET and CT reveal focal intense uptake corresponding to part of uterus and peritoneum. Peritoneal dissemination was confirmed at surgery. These lesions (arrows, A) were missed on review of CT alone.

View larger version (86K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3A —42-year-old woman (patient 22 in Table 1) who had undergone surgical resection for colon cancer 2 years earlier. During follow-up period after surgery, carcinoembryonic antigen levels slightly increased to 8.1 mg/dL. CT (A), PET (B), and fusion (C) images. Moderate uptake corresponding to left paraaortic node (arrows, A and B) is observed, suggesting lymph node metastasis; this finding was interpreted as equivocal on CT alone and on PET alone. Metastasis was confirmed at surgery.

View larger version (47K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3B —42-year-old woman (patient 22 in Table 1) who had undergone surgical resection for colon cancer 2 years earlier. During follow-up period after surgery, carcinoembryonic antigen levels slightly increased to 8.1 mg/dL. CT (A), PET (B), and fusion (C) images. Moderate uptake corresponding to left paraaortic node (arrows, A and B) is observed, suggesting lymph node metastasis; this finding was interpreted as equivocal on CT alone and on PET alone. Metastasis was confirmed at surgery.

View larger version (83K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3C —42-year-old woman (patient 22 in Table 1) who had undergone surgical resection for colon cancer 2 years earlier. During follow-up period after surgery, carcinoembryonic antigen levels slightly increased to 8.1 mg/dL. CT (A), PET (B), and fusion (C) images. Moderate uptake corresponding to left paraaortic node (arrows, A and B) is observed, suggesting lymph node metastasis; this finding was interpreted as equivocal on CT alone and on PET alone. Metastasis was confirmed at surgery.

View larger version (93K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4A —80-year-old man (patient 4 in Table 1) with colon cancer. CT (A), PET (B), and fusion (C) images. Multiple pulmonary nodules (arrows, A) are apparent, indicating metastases to lung, but were missed due to lack of 18F-FDG uptake. Patient died of progressive lung metastases and pleural carcinomatosis 2 months after PET and CT scans were obtained. Several foci of intense uptake (arrowheads, B) are noted on PET, indicating metastases to mediastinal lymph nodes and pleura.

View larger version (70K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4B —80-year-old man (patient 4 in Table 1) with colon cancer. CT (A), PET (B), and fusion (C) images. Multiple pulmonary nodules (arrows, A) are apparent, indicating metastases to lung, but were missed due to lack of 18F-FDG uptake. Patient died of progressive lung metastases and pleural carcinomatosis 2 months after PET and CT scans were obtained. Several foci of intense uptake (arrowheads, B) are noted on PET, indicating metastases to mediastinal lymph nodes and pleura.

View larger version (78K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4C —80-year-old man (patient 4 in Table 1) with colon cancer. CT (A), PET (B), and fusion (C) images. Multiple pulmonary nodules (arrows, A) are apparent, indicating metastases to lung, but were missed due to lack of 18F-FDG uptake. Patient died of progressive lung metastases and pleural carcinomatosis 2 months after PET and CT scans were obtained. Several foci of intense uptake (arrowheads, B) are noted on PET, indicating metastases to mediastinal lymph nodes and pleura.

View larger version (100K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5A —72-year-old woman (patient 40 in Table 1) with rectal cancer recurrence. CT (A), PET (B), and fusion (C) images. Presacral lesion (arrow, A) was missed using CT alone and was interpreted as physiologic uptake by bowel (arrow, B) on PET alone and on side-by-side review of PET and CT images. Accurate diagnosis of local recurrence was obtained after interpretation of fused images.

View larger version (61K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5B —72-year-old woman (patient 40 in Table 1) with rectal cancer recurrence. CT (A), PET (B), and fusion (C) images. Presacral lesion (arrow, A) was missed using CT alone and was interpreted as physiologic uptake by bowel (arrow, B) on PET alone and on side-by-side review of PET and CT images. Accurate diagnosis of local recurrence was obtained after interpretation of fused images.

View larger version (76K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5C —72-year-old woman (patient 40 in Table 1) with rectal cancer recurrence. CT (A), PET (B), and fusion (C) images. Presacral lesion (arrow, A) was missed using CT alone and was interpreted as physiologic uptake by bowel (arrow, B) on PET alone and on side-by-side review of PET and CT images. Accurate diagnosis of local recurrence was obtained after interpretation of fused images.

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