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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3723_Библиотеки_им_академика_М_И_Перельмана
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24 Cardiovascular FDG-PET Atlas ofCases
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a b
c
Fig. 24.14 PET 1 Interpretation. Whole-body FDGPET/CT (a) was performed in order to exclude an underlying neoplastic process given the important extent of
PE. The RUL opacity seen on CTPA (b, yellow arrow)
was associated with slightly increased uptake (c, orange
arrow, SUV
most probable diagnosis. Diffuse increased uptake is seen
within the right atrium (d, red arrow, SUV
=3.4). Alveolar hemorrhage remained the
max
= 6.2) and
max
d
e
right ventricle (d, gray arrow, SUV
with right heart strain (RHS). Isolated uptake in the posterolateral papillary muscle of the left ventricle is seen (d,
green arrow, SUV
increased uptake is visualized at the level of the stomach
(e, white arrow), suggestive of gastritis. No clear underlying neoplastic process was evidenced
=4.7), a nonspecic nding. Diffuse
max
=7.5), compatible
max
Follow-Up
Oral anticoagulation was initiated, with indeterminate duration of therapy. A follow-up TTE
performed 4 months later showed improvement
of the right ventricle dilation and pressure overload (Fig.24.15).
Teaching Point
As FDG-PET/CT scans are often performed
without contrast, a diagnosis of PE is mostly
suggested by the presence of indirect signs [51].
The “rim sign” (slight FDG uptake around the
area of subpleural consolidation) is strongly
suggestive of pulmonary infarction which can
be secondary to PE or tumoral arterial obstruction [51]. An additional secondary sign is the
presence of increased FDG uptake within the
right heart chambers, suggestive of RHS [52–
54]. However, RHS is not specic to PE as there
exists multiple causes of increased pulmonary
arterial pressure [52]. In this case, intense
uptake was seen within both the right atrium and
right ventricle, while the left heart chambers
were spared. Multiple patterns of RHS secondary to PE have been reported, including fourchamber increase in cardiac uptake, isolated
right ventricular uptake, and moderate right
atrial uptake with very subtle right ventricular
uptake [52–54].
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a b
Y. A. Lucinian et al.
c
Fig. 24.15 PET 2 Interpretation. Follow-up whole-body
FDG-PET/CT (a) performed 6months following the initiation of anticoagulant therapy showed resolution of the
Case 11
Initial Evaluation
A 59-year-old, known for hypertension, presented with frequent palpitations and a feeling of
chest “heaviness.” Physical examination revealed
a systolic ejection murmur best heard in the left
upper sternal border, which increased with inspiration. Holter monitoring showed frequent premature ventricular contractions. CTPA performed
to exclude PE showed a multilobulated anterior
mediastinal mass measuring 3.9×6.2cm invading the main pulmonary artery (MPA). Proximal
MPA thrombosis could not be excluded. On TTE,
hypermetabolic RUL opacity (b). Increased uptake was
not seen within the right atrium and right ventricle (c),
suggesting resolution of the RHS
the mass was shown to cause severe supravalvular pulmonary stenosis (Fig.24.16).
Follow-Up
As thrombosis within the MPA was strongly suspected, low molecular weight heparin was initiated in order to prevent embolism. The patient
subsequently underwent surgery for mass resection with pulmonary homograft implantation.
Histopathologic analysis conrmed the diagnosis
of undifferentiated sarcoma with central necrosis.
The surgeon described a mass originating from
within the anterolateral wall of the MPA.The nal
diagnosis was pulmonary artery sarcoma (PAS).
24 Cardiovascular FDG-PET Atlas ofCases
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a b
c
Fig. 24.16 PET Interpretation. Whole-body FDG- PET/
CT (a) was performed to further characterize the mediastinal mass and assess the extent of disease involvement.
Intense FDG uptake (SUV
interest was visualized (b, transaxial view, red arrow) (c,
sagittal view, red arrow). Hypometabolism within the center of the mass was seen (b, blue arrow) consistent with
central necrosis. A focus of hypometabolism was also
= 8.0) within the mass of
max
d
e
noted posterolaterally to the mass (b, c, yellow arrows),
corresponding to a lling defect on CTPA (d, e, yellow
arrows) and most likely representing an associated thrombus in the MPA.No hypermetabolic pulmonary nodules or
lymphadenopathy were seen. In the absence of other associated lesions and given the lesion uptake intensity, the
diagnosis of a primary malignant tumor such as a sarcoma
was strongly favored
Teaching Point
In this case, FDG-PET complemented CTPA
ndings by identifying thrombosis within the
MPA. Indeed, hypometabolic lling defects in
the pulmonary arteries can be suggestive of PE
[51, 55]. Intense FDG uptake conrmed the
malignant nature of the mass. PET also played
an integral role in the preoperative workup by
excluding metastases and another primary neoplastic lesion. The value of FDG-PET in the
detection of soft tissue and bone sarcomas is
well documented, with a reported pooled sensitivity of 91% and specicity of 85% [56].
However, as PAS are excessively rare, only a
few cases have been reported in the literature
[57–59]. Tueller et al. described a series of
patients with PAS in which FDG-PET played an
integral role in the preoperative workup, including tumor staging [59].
Case 12
Initial Evaluation
A 45-year-old man, known for COPD, hypertension, repaired ventricular septal defect (VSD)
and thoracic aortic aneurysmal dilatation with
dissection, underwent vascular graft replacement
of both ascending and descending aorta, as well
as endovascular stent placement within the transverse and descending aorta. At the time of presentation, he had not undergone any invasive
procedure in the preceding 2years. A week after
being treated for pneumonia, the patient presented with fatigue, fever, chills and diaphoresis.
Blood cultures were positive for Haemophilus
inuenzae. TTE showed a mobile structure within
the left ventricle that was suggestive of either
vegetation or surgical material from his VSD
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a b
Y. A. Lucinian et al.
c
Fig. 24.17 PET 1 Interpretation. Whole-body FDGPET/CT (a) was performed following a myocardial suppression protocol. Myocardial suppression was adequate.
Intense and heterogeneous FDG uptake (SUV
was seen within the endovascular stent (b, c, red arrows).
The areas involved extended from the mid-portion of the
= 10.7)
max
repair. CTPA showed a very small perigraft air
bubble at the level of the aortic arch (Fig.24.17).
Follow-Up
As the patient had already undergone multiple
cardiovascular interventions, conservative medical treatment with antibiotics was chosen
(Fig.24.18).
aortic arch to the beginning of the descending thoracic
aorta. Adjacent hypermetabolic lymph nodes were noted
(b, gray arrows, SUV
of abnormal FDG uptake. These ndings were compatible
with vascular graft infection (VGI)
= 5.3). Valvular areas were free
max
Teaching Point
In this case, FDG-PET was helpful in conrming
the diagnosis of VGI in light of nondenitive TTE
and CTPA ndings, as well as assessing treatment
efcacy. VGI is associated with signicant morbidity and mortality, with early and accurate diagnosis
critical for optimal management. However, diagnosis remains challenging despite the introduction of
standardized diagnostic criteria [60, 61]. FDG-
24 Cardiovascular FDG-PET Atlas ofCases
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a
b
c
Fig. 24.18 PET 2 Interpretation. Follow-up whole-body
FDG-PET/CT (a) was performed following 5weeks of
antibiotic treatment. A signicant decrease in FDG uptake
within the aortic endovascular stent was noted (b, c, red
arrows), and SUV
lymphadenopathy persisted on CT, but their associated
reduced from 10.7 to 6.5. Adjacent
max
PET/CT is increasingly used for both imaging and
treatment monitoring of VGI [7, 62–64]. Reported
diagnostic accuracy is excellent, with pooled sensitivity of 93–96% and specicity of 74–80% [62,
65, 66]. Specicity of FDG-PET/CT in this setting
is mainly hampered by postoperative inammation, which can be observed several months following intervention. In the meta-analysis by Folmer
etal., FDG- PET/CT was shown to outperform CT
angiography (CTA) which had a reported pooled
sensitivity of 67% and specicity of 63% [66].
uptake was signicantly decreased (b, gray arrows,
SUV
=3.7) from the prior study. Myocardial suppres-
max
sion was inadequate, with relatively intense uptake seen
within both the left and right ventricular walls (c, orange
arrow)
Case 13
Initial Evaluation
A 40-year-old man noticed discharge at the level
of his sternotomy wound. He underwent heart
transplantation 2years ago for restrictive cardiomyopathy. Discharge culture was positive for
Staphylococcus epidermidis, but there was doubt
about skin contamination. Blood cultures were
negative (Fig.24.19).
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a b
Y. A. Lucinian et al.
c
Fig. 24.19 PET 1 Interpretation. Whole-body FDGPET/CT (a) was performed following a myocardial suppression protocol in order to evaluate for the presence of a
sternal wound infection (SWI). Myocardial suppression
was sub-optimal. A small retrosternal collection associated with intense FDG uptake (SUV
= 11.7) affecting
max
Follow-Up (1)
A diagnosis of DSWI with sternocutaneous stula
was made. A 3week course of antibiotic treatment
was initiated. Despite initial improvement, suprasternal discharge relapsed 3months later (Fig.24.20).
Follow-Up (2)
In light of the FDG-PET/CT results compatible with progression of the infectious process,
the anterior portion of the superior mediastinum was seen
(b), extending superiorly above the manubrium and reaching the skin. On the low-dose CT scan (LDCT), no bone
abnormalities at the level of the sternum were noted (c).
These ndings were compatible with deep SWI (DSWI)
a second course of antibiotic treatment was initiated alongside surgical debridement. Clinical
improvement occurred rapidly and was sustained
(Fig.24.21).
Follow-Up (3)
Residual FDG uptake was deemed secondary to a
chronic quiescent infection. As the patient was
clinically stable and no discharge was apparent,
further treatment was not pursued.
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a
b
c
Fig. 24.20 PET 2 Interpretation. A second whole-body
FDG-PET/CT (a) was performed. Myocardial suppression failed despite adherence to the preparation protocol.
Marked progression of the retrosternal collection was
noted, now extending from the manubrium to the xiphoid
Teaching Point
In this case, FDG-PET was helpful in conrming
diagnosis of DSWI, assessing its extent, and
monitoring treatment efcacy. SWIs represent a
rare but dangerous complication following cardiac surgery [67, 68]. Management depends on
the depth of the infection [67]. CT is usually the
initial imaging modality employed to evaluate
SWI [68]. Its reported sensitivity is very high, but
its specicity is hampered by postsurgical
process. The FDG uptake intensity slightly increased
from an SUV
lymph nodes were noted in the anterior mediastinum.
Again, no obvious bone abnormalities were seen on
LDCT (c)
value of 11.7 to 13.6 (b). Hypermetabolic
max
changes which can be indistinguishable from
infection. Although literature on FDG-PET
assessment of SWI is limited, published case
reports and retrospective studies suggest its utility in this setting [69–71]. Hariri etal. reported an
excellent diagnostic accuracy of 94%, with a sensitivity of 91% and a specicity of 97%, with
qualitative analysis employing uptake patterns
(diffuse low-grade, diffuse high-grade, focal,
sternal wire, soft-tissue extension) outperforming
quantitative analysis [69].
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a b
Y. A. Lucinian et al.
c
Fig. 24.21 PET 3 Interpretation. Follow-up whole-body
FDG-PET/CT (a) was performed a year later. Overall, the
extent of the retrosternal hypermetabolic activity regressed
signicantly (b); however, two residual foci of FDG
uptake persisted, one involving the mediastinum anterior
to the aortic arch with extension to the skin above the
Case 14
Initial Evaluation
A 61-year-old woman, known for liver hemangioma and colorectal polyps, presented with palpitations and fatigue. Blood cultures were negative.
CTPA showed a nodular lesion with lobulated
contours attached to the leaets of the pulmonary
valve. TEE showed a lobulated mass of
18 × 10 mm alongside the anterior wall of the
MPA superior to the pulmonary valve accompanied by a lament-like structure of 3 × 12 mm
attached to the pulmonary valve. Suspected diagnoses included marantic endocarditis, thrombosis
at the level of the pulmonary valve, and a neoplastic process (Fig.24.22).
manubrium (b, yellow arrow) and the other involving the
lower portion of the retrosternal region (b, red arrow).
FDG uptake intensity did not vary signicantly
(SUV
=14.5). No musculoskeletal abnormalities were
max
noted on LDCT (c)
Follow-Up
The patient underwent surgical resection of the
mass. Histopathologic analysis conrmed the diagnosis of broelastoma. Follow-up TTE showed no
residual mass.
Teaching Point
Multiple studies have suggested FDG-PET’s utility in distinguishing malignant from benign cardiac lesions, primarily using semiquantitative
analysis [16]. In this case, the absence of signicant FDG uptake within the lesion was compatible
with a benign process. Although papillary broelastomas represent the second most common pri-
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a b
c
Fig. 24.22 PET Interpretation. Whole-body FDG- PET/
CT (a) was performed following a myocardial suppression protocol. Myocardial suppression was excellent. No
abnormal uptake was seen at the level of the myocardium,
valvular areas (including the pulmonary valve) and the
mary cardiac tumor in adults, reports of associated
FDG-PET ndings are very scarce [72, 73]. Nensa
et al. reported the case of a patient with aortic
valve broelastoma associated with low FDG
uptake (SUV
= 2.1) [72]. Similarly, Ibrahim
max
etal. reported the case of a pulmonary valve broelastoma without associated focal uptake [74].
Case 15
Initial Evaluation
A 57-year-old man, with no relevant medical history,
presented with shortness of breath and generalized
weakness. Physical exam only revealed bradycardia.
High-sensitivity cardiac troponin T (hs-cTnT) levels
were normal. ECG showed third degree (complete)
atrioventricular (AV) block. A chest radiograph was
normal. TTE was normal, with a reported LVEF of
65%. As the patient was relatively young with a
seemingly unexplained AV block, cardiac sarcoidosis (CS) was suspected (Fig.24.23).
d
e
MPA (b, transaxial view) (c, sagittal view), suggestive of
a benign etiology. There were no hypermetabolic lesions
on whole-body FDG-PET/CT images. The lesion seen on
CTPA is shown in images (d) (transaxial view, red arrow)
and (e) (sagittal view, red arrow)
Follow-Up (1)
The patient underwent dual chamber permanent
pacemaker implantation as well as endobronchial ultrasound guided biopsy of the hilar
lymph nodes. Histopathologic analysis showed
the presence of noncaseating granulomas, compatible with a diagnosis of sarcoidosis. As such,
the patient was diagnosed with CS according to
both the Heart and Rhythm Society (HRS) and
Japan Circulation Society (JCS) proposed diagnostic criteria [82, 83]. Oral prednisone treatment was initiated at a dose of 60mg per day
(Fig.24.24).
Follow-Up (2)
Tapering of prednisone was pursued. Pacemaker
interrogation revealed that ventricular pacing
dropped from 100% to <1%, suggesting improvement of complete heart block.
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a b
f
d
c
e
Fig. 24.23 PET 1 Interpretation. Whole-body FDGPET/CT was performed following a myocardial suppression protocol consisting of low-carbohydrate diet, 12 h
fasting, and intravenous heparin in order to exclude cardiac sarcoidosis (a). Myocardial suppression was excellent. Focal myocardial uptake was visualized at the level
of the right ventricle free wall (b, red arrow, SUV
and the basal inferoseptal wall (c, gray arrow,
SUV
=5.2). Hypermetabolic bilateral hilar lymphade-
max
nopathy was seen (d, white arrows, SUV
max
= 4.8). No
max
=5.3)
Teaching Point
In this case, FDG-PET/CT was crucial for the initial diagnosis of CS, identifying extra-cardiac
involvement, guiding biopsy, and monitoring
treatment efcacy. As focal FDG uptake was
present in the absence of perfusion defects, earlystage CS was most likely [75]. FDG-PET also
showed good anatomic correlation between the
suspected cause of the ECG abnormality (i.e.,
involvement of the bundle of His in the basal
other abnormal uptake was noted at the thoracic level.
Multiple hypermetabolic foci were visualized within the
liver (e, yellow arrows, SUV
arrows, SUV
concomitantly showed homogeneous perfusion throughout the left ventricle (f). In light of PET ndings, sarcoidosis with hilar, myocardial, splenic and hepatic
involvement was strongly suspected, although a lymphoproliferative disorder was not completely excluded
= 5.4). Rest 82Rb PET-MPI performed
max
=5.5) and spleen (e, blue
max
interventricular septum) and the location of FDG
uptake. As reported by Manabe etal., interventricular septum FDG uptake is associated with
AV block [76]. Multiple studies have shown
FDG-PET to be an accurate and useful imaging
modality in the evaluation of CS [77]. As such,
the two main consensus guidelines to propose
diagnostic criteria for CS, the 2014 HRS expert
consensus statement and the 2016 JCS guidelines
for the diagnosis and treatment of cardiac sarcoidosis, include PET imaging [78–79].
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