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given the signicant overlap in SUV values
between the subtypes [76].
Role ofFDG-PET/CT inResponse
Assessment ofPTLD
Treatment response assessment using end-oftreatment PET (EOT) or interim PET (iPET) has
been proven highly predictive for disease remission in both Hodgkin lymphoma (EOT-PET and
iPET) and non-Hodgkin lymphoma (EOT-PET)
[77, 78]. Despite the fact that evidence for FDGPET/CT to assess treatment response in PTLD is
less well established with only few studies
reported so far, the clinical importance is high.
Indeed, early identication of patients who are at
high or low risk for recurrence would allow to
adapt treatment early or to avoid unnecessary
toxic treatment, respectively. Zimmermann etal.
performed a retrospective study including 37
patients diagnosed with CD20-positive SOTrelated PTLD treated with uniform rituximabbased protocols. Most importantly, negative
predictive value of EOT-PET for disease relapse
was 92%, identifying a group with low risk of
recurrence and with excellent prognosis. On the
other hand, the low positive predictive value of
only 38% emphasizes the importance of additional diagnostic investigations before proceeding to new treatment [79]. Similar ndings were
observed in a retrospective study by Van
Keerberghen et al., including 41 patients with
CD20-positive PTLD following SOT, treated
also with a uniform risk-stratied sequential
treatment protocol (according to the Phase II
PTLD-1 trial) [80, 81]. Positive and negative predictive values for EOT-PET were 33% and 87%
respectively, conrming the identication of a
subgroup of patients with low risk of disease
recurrence. In addition, negative iPET scan
yielded a negative predictive value of 85%, but a
poor positive predictive value was observed
(13%) [80]. In a small retrospective study in
pediatric patients with SOT-related PTLD, the
role of PET in response assessment seemed less
clear due to the higher incidence of false positive
cases both at interim and EOT PET; however,
these results should be interpreted with caution
given the small sample size (n= 15) [82]. The
value of FDG-PET/CT for treatment response
assessment in pediatric PTLD warrants further
investigation.
Prognostic Role ofBaseline FDG
PET/CT inPTLD
Although several PTLD-specic prognostic
scores have been proposed, none of these have
been conrmed or validated. In contrast, the
International Prognostic Index (IPI)—consisting of 5 clinical/biochemical parameters: age,
lactate dehydrogenase (LDH) level, Eastern
Cooperative Oncology Group (ECOG) performance state, Ann Arbor stage and number of
extranodal sites involved—which has been
developed for aggressive lymphomas, seems to
have prognostic relevance in PTLD patients
[83–85]. In addition, the type of organ transplantation and the response to rituximab were
additional prognostic markers in the prospective
PTLD-1 trial [83]. In a recently published twocenter trial including 88 patients, Montes de
Jesus etal. explored the prognostic role of volumetric FDG-PET derived parameters, in particular metabolic tumor volume (MTV) and total
lesion glycolysis (TLG) in patients diagnosed
with PTLD [86]. In contrast to prognostic value
of MTV/TLG in other lymphomas and compared to the IPI score, these volumetric quantitative parameters were not predictive of overall
survival in their PTLD cohort [87, 88].
Several retrospective studies have shown that
FDG-PET/CT is a valuable technique with high
sensitivity and specicity to diagnose, stage and
assess treatment response in PTLD patients.
However, since large prospective studies are
lacking, the level of evidence remains rather low.
This is illustrated by several guidelines and recommendations, in which classical CT scans are
recommended with FDG-PET/CT being considered a useful addition [70]. Prospective and multicenter trials including larger patient populations
and well-designed methodologies are urgently
needed to establish the exact role of FDG-PET/
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J. Van Cleemput et al.
CT in PTLD at baseline as well as during and
after treatment. New hybrid imaging techniques
such as FDG-PET/MRI may help reduce radiation exposure, which is extremely important in
the pediatric transplant population.
Conclusion
All heart transplant recipients will suffer some form
of complication and FDG-PET/CT has been proven
a valuable tool to detect infectious complications as
well as to stage and assess treatment response in
PTLD patients. Even though the role of FDG-PET/
CT to detect rejection of cardiac allografts has not
been well investigated, preclinical data suggest its
potential usefulness in this setting.
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volume predicts outcome in high–tumor-burden follicular lymphoma: a pooled analysis of three multicenter studies. J Clin Oncol. 2016;34(30):3618–26.
Part VI
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Variants and Cases
Normal Variants, Not-So-Normal
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Variants, andPitfalls ofFDG-PET
inCardiovascular Imaging
IngridBloise, MatthieuPelletier-Galarneau,
andPatrickMartineau
23
Introduction
Positron emission tomography (PET) is emerging as an increasingly valuable tool for assessing
cardiovascular pathology. Increases in camera
and radiotracer availability, as well as its technical superiority over single photon emission computed tomography (SPECT), have resulted in an
increased use of PET for cardiac imaging [1].
Over the last few decades, cardiac PET imaging
has evolved from a specialized research tool contributing to the understanding of cardiac pathophysiology, to being rmly established in clinical
practice for the diagnosis and prognostication of
various cardiac pathologies [2].
Even though the last few years have seen a
push in the development and use of novel radiotracers, 18F-uorodeoxyglucose (FDG) remains
the workhorse of PET imaging, including for cardiovascular PET imaging. This can be accounted
for by several factors. First, FDG benets from
being well established due to widespread use in
I. Bloise
Department of Radiology, University of British
Columbia, Vancouver, BC, Canada
M. Pelletier-Galarneau
Montreal Heart Institute, Montréal, QC, Canada
e-mail: Matthieu.pelletier-galarneau@icm-mhi.org
P. Martineau (*)
BC Cancer, Vancouver, BC, Canada
e-mail: patrick.martineau@bccancer.bc.ca
oncological imaging. Second, a growing body of
literature supports the use of FDG PET in several
cardiovascular indications, such as for the evaluation of cardiovascular infection and inammation. Third, the physical properties of 18F,
including its relatively long half life of 110min
and short positron range makes it ideal for the
purposes of cardiovascular imaging.
As previously discussed in Chap. 3, the myocardium is a metabolic omnivore which can use
multiple different sources of energy, but preferentially uses free fatty acids and carbohydrates;
however, subject to availability and hormonal
conditions, cardiomyocytes can alter their preferred substrate. For example, in the fasted state,
fatty acids constitute the preferred source of
energy. Following a meal, blood insulin levels
increase and carbohydrates again become the
dominant source of adenosine triphosphate (ATP)
[3, 4]. The variability in the use of glucose (and
by extension, FDG) results in the variable patterns of normal FDG uptake in the heart encountered in clinical practice. Despite the variability,
the patterns of uptake seen in normal myocardium are nite and can easily be recognized by
the trained physician.
In this chapter, we review the normal patterns
of myocardial FDG uptake. We also discuss commonly seen variants which can occasionally be
associated with pathology, as well as review potential pitfalls which are occasionally encountered.
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022
M. Pelletier-Galarneau, P. Martineau (eds.), FDG-PET/CT and PET/MR in Cardiovascular
Diseases, https://doi.org/10.1007/978-3-031-09807-9_23
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I. Bloise et al.
Patterns ofMyocardial Uptake
Left Ventricular Uptake
It is well established that, even after careful
patient preparation with fasting for at least 4–6h
prior to imaging, physiological cardiac FDG
uptake may occur inhomogeneously in the left
ventricle. Furthermore, cardiac segments in the
same subjects may have signicant variations
when compared in serial studies [5], with either
an increase or decrease in tracer accumulation in
specic segments, or demonstrating an altogether
different pattern of uptake (Fig.23.1). In cases in
which the patient has not been prepared using a
specic myocardial suppression protocol, myocardial uptake is usually considered nonspecic
regardless of the uptake distribution.
The most commonly described patterns of
physiologic myocardial FDG uptake are (a) none
when the activity in the myocardium is the same
or less than in the blood pool in the ventricular
cavity, (b) diffuse with intense uptake seeing diffusely throughout all walls of the left ventricle,
and (c) lateral free wall when there is diffusely
increased FDG uptake in the lateral free wall of
the left ventricle. Also described is regional FDG
uptake in the basal segments of all four walls
assuming a ring gure, known as a basal-ring pattern (Fig.23.2).
In 1990, Gropler et al. evaluated healthy
patients with no history of cardiovascular disease
and no signicant risk factors for coronary artery
disease, and were able to show that the mean
activity in the septum and anterior walls was 20%
less than the mean activity in the inferior and lateral walls [6]. This was later conrmed by other
authors [5, 7, 8]. Reduced septal uptake has been
reported in patients with complete left bundle
branch block with this nding unrelated to
changes in perfusion [9, 10]. The mechanism
responsible for this is unclear but may be related
to mechanical dysynchrony. Finally, Gropler
etal. also demonstrated that there was no signicant difference in activity between the inferior
and lateral walls [6].
A focal area of increased metabolic activity
has been reported as the least common pattern of
uptake following myocardial suppression preparation [11]. When this pattern is present, uptake is
considered pathological unless it is related to
FDG accumulation in the papillary muscles, nor-
ab c
Fig. 23.1 Sequential MIP images of a 63-year-old man
following 6-h fasting shows variations in both the pattern
and intensity of myocardial uptake: on the earliest scan (a)
there is mild FDG uptake in a basal-ring pattern, which
increases in intensity on the following study (b), but
which shows no myocardial activity on the subsequent
study (c)
23 Normal Variants, Not-So-Normal Variants, andPitfalls ofFDG-PET inCardiovascular Imaging
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a
b
345
c
Fig. 23.2 Examples of the various patterns of normal
myocardial distribution encountered in clinical practice.
The column on the left demonstrates maximum intensity
projection images viewed anteriorly while the column on
the right shows transaxial fused PET-CT images through
the left ventricle. The various patterns are (a) absent
uptake, (b) diffuse left ventricular uptake, (c) basal ring,
and (d) lateral free wall uptake
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d
Fig. 23.2 (continued)
acb
I. Bloise et al.
Fig. 23.3 Focal uptake within the papillary muscles. In
this patient with diffuse left ventricular activity, focal
activity is clearly seen to localize within the left anterolat-
Fig. 23.4 Less commonly seen is intense papillary muscle activity in the absence of signicant left ventricular
uptake such as in this case
eral papillary muscle (arrow) on (a) contrast-enhanced
CT, (b) axial PET, and (c) Fused PET/CT images
mally located in the anterolateral and inferoposterior regions, either within the left ventricular
cavity or in the endocardial region (Figs. 23.3
and 23.4).
Various drugs have been reported to impact
the degree of LV uptake including bezabrate
and levothyroxine, both of which are reported to
decrease uptake, while benzodiazepines and cardiotoxic chemotherapeutic agents are reported to
increase the degree of uptake [12]. It is unclear if
the use of these drugs alters the pattern or just the
degree of uptake.
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