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¹⁸F-FDG PET/CT delineation of predominantly pericardial involvement in recurrent pleural mesothelioma

PET/CT VRT shows the extent and orientation of the pericardial hyper metabolic lesions with clear delineation of the lesions in the right and left lateral, anterior, inferior, and posterobasal aspect of the heart. The mild hyperme tabolism in the pleura of the upper lobe of the left lung is also visualized and reflects previously diagnosed pleural mesothelioma.

5-minute, low-dose, single-bed, whole-body ¹⁸F-FDG PET/CT delineation of predominantly pericardial involvement in recurrent pleural mesothelioma

08/13/2024

By Partha Ghosh, MD, Siemens Healthineers Molecular Imaging, Hoffman Estates, Illinois, USA
Data and images courtesy of Rigshospitalet, Copenhagen, Denmark

History

An elderly woman with history of asbestos exposure and pleural mesothelioma that was treated with left-sided pleurodesis presented with chest pain and respiratory distress. Clinical examination and X-ray revealed gross left-sided pleural effusion along with enlargement of the cardiac silhouette.

One hour following a 3.8 mCi (144 MBq) intravenous (IV) injection of Fludeoxyglucose F 18 (¹⁸F-FDG) Injection, the patient underwent a 5-minute, whole-body, single-bed PET/CT performed on Biograph Vision Quadra™.

Findings

Figures 1 to 6 show multiple nodular peritoneal recurrences around the heart with extension into the left hilar region in a case of previously diagnosed pleural mesothelioma in the left upper lobar pleura treated with pleurodesis. PET/CT helped define the extent and degree of hypermetabolism within the lesions along with delineation of associated peritoneal thickening and pleural effusion.

PET MIP and MPR images show multiple hypermetabolic nodular masses in the thorax around the heart, especially in the right lateral, left lateral, posterobasal, and inferior aspect. A small focal nodular hypermetabolism is also seen in the left hilar region. The left upper lobe of the lung shows low intensity linear uptake, reflecting mild hypermetabolism in the pleura of the left upper lobe, which may reflect previously diagnosed pleural mesothelioma treated with left pleurodesis.

Figure 1: PET MIP and MPR images show multiple hypermetabolic nodular masses in the thorax around the heart, especially in the right lateral, left lateral, posterobasal, and inferior aspect. A small focal nodular hypermetabolism is also seen in the left hilar region. The left upper lobe of the lung shows low intensity linear uptake, reflecting mild hypermetabolism in the pleura of the left upper lobe, which may reflect previously diagnosed pleural mesothelioma treated with left pleurodesis.

Axial CT, PET/CT, and PET slices at various levels in the thorax from the aortic root to the level of the diaphragm show the locations of nodular hypermetabolic masses in the pericardium. Focal uptake with corresponding pericardial thickening visualized just posterior to the aortic root (left top row), anterior and right of the aorta in the plane of the superior vena cava (left middle row) as well as in the left lateral aspect of the left ventricle (left bottom row) is visualized. Large pleural effusion and gross pericardial thickening is visualized, especially in the pericardium around aortic root and left ventricle. A nodular lesion is also visualized in the posterobasal aspect just to the right of the descending aorta (right middle row). The large nodular mass with intense hypermetabolism and variegated contrast enhancement on CT (right lower row) reflects the mass in the inferior pericardium.

Figure 2: Axial CT, PET/CT, and PET slices at various levels in the thorax from the aortic root to the level of the diaphragm show the locations of nodular hypermetabolic masses in the pericardium. Focal uptake with corresponding pericardial thickening visualized just posterior to the aortic root (left top row), anterior and right of the aorta in the plane of the superior vena cava (left middle row) as well as in the left lateral aspect of the left ventricle (left bottom row) is visualized. Large pleural effusion and gross pericardial thickening is visualized, especially in the pericardium around aortic root and left ventricle. A nodular lesion is also visualized in the posterobasal aspect just to the right of the descending aorta (right middle row). The large nodular mass with intense hypermetabolism and variegated contrast enhancement on CT (right lower row) reflects the mass in the inferior pericardium.

Coronal slices of contrast CT, PET/CT, and PET images of the thorax from anterior to posterior show nodular hypermetabolic masses in the pericardium in the right lateral aspect of the heart adjacent to the right atrium and superior vena cava (left top and middle rows) and also in the inferior aspect as well as left lateral aspect of the left ventricle (left top, middle, and bottom rows). A small focal hypermetabolic lesion in the left hilar region is also visualized (right top row). Focal lesions in the posterobasal aspect of the left ventricle are also visualized (right middle and bottom rows) along with mild irregular linear hypermetabolism in the left upper lobar pleura, reflecting previous disease treated with pleurodesis. Severe pleural effusion involving entire posterior aspect of left lung is also visualized on CT.

Figure 4: Coronal slices of contrast CT, PET/CT, and PET images of the thorax from anterior to posterior show nodular hypermetabolic masses in the pericardium in the right lateral aspect of the heart adjacent to the right atrium and superior vena cava (left top and middle rows) and also in the inferior aspect as well as left lateral aspect of the left ventricle (left top, middle, and bottom rows). A small focal hypermetabolic lesion in the left hilar region is also visualized (right top row). Focal lesions in the posterobasal aspect of the left ventricle are also visualized (right middle and bottom rows) along with mild irregular linear hypermetabolism in the left upper lobar pleura, reflecting previous disease treated with pleurodesis. Severe pleural effusion involving entire posterior aspect of left lung is also visualized on CT.

Sagittal reconstructions of CT, PET/CT, and PET images show hypermetabolic foci in the anterior, inferior, posterobasal pericardium as well as along the superior vena caval margin, reflecting focal pericardial lesions which appear to be recurrence of previously diagnosed pleural mesothelioma. The severe pleural effusion in the posterior aspect of the left lung seen on CT reflects the free pleural fluid collecting in the posterior aspect in the supine position. PET MIP image with a slight rotation shows the pericardial lesions in different aspects around the ventricles and the vena cava and aortic roots. Significant hypermetabolism in the intestines, especially in the left colic flexure, reflects physiological activity in the gut.

Figure 5: Sagittal reconstructions of CT, PET/CT, and PET images show hypermetabolic foci in the anterior, inferior, posterobasal pericardium as well as along the superior vena caval margin, reflecting focal pericardial lesions which appear to be recurrence of previously diagnosed pleural mesothelioma. The severe pleural effusion in the posterior aspect of the left lung seen on CT reflects the free pleural fluid collecting in the posterior aspect in the supine position. PET MIP image with a slight rotation shows the pericardial lesions in different aspects around the ventricles and the vena cava and aortic roots. Significant hypermetabolism in the intestines, especially in the left colic flexure, reflects physiological activity in the gut.

Discussion

Peritoneal recurrence is a rare manifestation of pleural mesothelioma. ¹⁸F-FDG PET/CT has been widely used for imaging of pleural mesothelioma both for staging and chemotherapy response assessment. PET-guided radiation therapy also has been evaluated.¹ In this patient with an established diagnosis of pleural mesothelioma involving the left upper lobar pleura treated with pleurodesis, ¹⁸F-FDG PET/CT revealed mild hypermetabolism in the primary pleural involvement in the left upper lobar pleura with associated severe pleural effusion as well as regions of fibrosis. Multiple nodular hypermetabolic pericardial lesions were visualized around the ventricles, the right lateral margin of the right atria extending along the vena caval margins, as well as in the anterior and inferior aspect of the right and left ventricles and in the posterobasal aspect just lateral to the descending aorta. The left hilar region also shows focal malignant lesions. Substantial pericardial thickening was seen apart from the focal pericardial lesions without severe pericardial effusion or calcification. The study clearly suggested pericardial recurrence with left hilar extension from primary pleural mesothelioma with the disease burden indicating need for chemotherapy.

PET/CT imaging of pleural and pericardial malignancies requires high resolution and high lesion contrast for PET as well as high-quality thin-slice CT for delineation of the true extent of pleural and pericardial involvement along with associated findings such as pleural and pericardial thickening and effusion. Long axial field of view (FOV) PET/CT systems like Biograph Vision Quadra provide high sensitivity enabling high-quality PET acquisition at short scan times in order to improve patient convenience and reduce motion, which in such patients with chest pain and respiratory distress, may be often problematic.

Conclusion

This case demonstrates how Biograph Vision Quadra achieves 5-minute, low-dose, single-bed, whole-body ¹⁸F-FDG PET/CT to help delineate predominantly pericardial involvement in recurrent pleural mesothelioma. The 106-cm axial FOV along with the ultra-fast time of flight (TOF) performance of the system was instrumental in delivering a fast, high image quality PET acquisition in 5 minutes. Furthermore, the 128-slice CT provided high-quality contrast CT for visualization of pleural and pericardial malignant deposits, thickening, and effusions.

Examination protocol

Scanner: Biograph Vision Quadra PET/CT

PET
Injected dose	3.8 mCi (144 MBq) ¹⁸F-FDG
Post-injection delay	60 minutes
Acquisition	1 bed position/5 minutes per bed
	Total scan time: 5 minutes
Image reconstruction	440 x 440 matrix, PSF+TOF, 4i5s
	Gaussian filter 2

CT (with contrast)
Tube voltage	80 kV
Tube current	148 ref mAs
Slice collimation	128 x 0.6 mm
Slice thickness	2 mm

The outcomes achieved by the Siemens Healthineers customers described herein were achieved in the customer’s unique setting. Since there is no “typical” hospital and many variables exist (eg, hospital size, case mix, level of IT adoption) there can be no guarantee that others will achieve the same results.

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Fuccio C, et al. ¹⁸F-FDG-PET/CT in malignant mesothelioma. Biomed Pharmacother. 2013;67(6):539-42. doi:10.1016/j.biopha.2013.01.008.

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