Lung Scintigraphy in various

Lung Pathologies
NMT631
The Lung
• Capillary endothelium and basement membrane Alveolar Septa
• Pulmonary interstitium (fine elastic fibers, small Ultrastructure
collagen bundles, few fibroblast-like & smooth
muscle cells, mast cells, and rare mononuclear
cells)
• Alveolar epithelium
– type I pneumocytes (continuous layer of flattened,
platelike covering 95% of the alveolar surface, and
– type II pneumocytes (rounded, synthesize pulmonary
surfactant, repair of alveolar epithelium)
• Pores of Kohn –passage of air, bacteria, and
exudates
• Alveolar macrophages (phagocytoses carbon, dust
particles)
N
O C
R
M X
A
L
R
• exposure? costophrenic angles?
Infiltrates? bronchi? hilar vasculature?
 • Degenerative
Lung Pathologies •
•
Inflammatory
Neoplastic
+ Pleura

ATELECTASIS PULMONARY INFECTIONS

o Community-Acquired Acute Pneumonias
ACUTE LUNG INJURY
o Community-Acquired Atypical Pneumonias
 Acute Respiratory Distress Syndrome
 Influenza Virus Type A/H1N1 Infection
OBSTRUCTIVE LUNG DISEASES o Aspiration Pneumonia
 Emphysema o Lung Abscess
 Chronic Bronchitis o Chronic Pneumonias
 Asthma  Tuberculosis
 Bronchiectasis
o Histoplasmosis, Coccidioidomycosis, and Blastomycosis
o Pneumonia in the Immunocompromised Host
CHRONIC INTERSTITIAL LUNG DISEASES
 Fibrosing Diseases  Cytomegalovirus Infections/ Cytomegalovirus
o Idiopathic Pulmonary Fibrosis Mononucleosis
o Nonspecific Interstitial Pneumonia  Pneumocystis Pneumonia
o Cryptogenic Organizing Pneumonia o Opportunistic Fungal Infections
o Pneumoconiosis
 Candidiasis
 Coal Worker’s Pneumoconiosis
 Cryptococcosis
 Silicosis
 Asbestosis and Asbestos-Related Diseases  Mucormycosis and invasive aspergillosis
o Drug- and Radiation-Induced Pulmonary Diseases o Pulmonary Disease in Human Immunodeficiency Virus Infection

GRANULOMATOUS DISEASE LUNG TUMORS

 Sarcoidosis
o Carcinoma
o SCLC & NSCLC
PULMONARY EOSINOPHILIA
o Carcinoid
SMOKING-RELATED INTERSTITIAL DISEASES
PLEURAL LESIONS
VASCULAR ORIGIN DISEASES o Pleural effusion & Pleuritis
 Pulmonary Embolism, Hemorrhage, and Infarction
o Pneumothorax, Hemothorax, and Cyclothorax
 Pulmonary Hypertension
o Malignant Mesothelioma
 Diffuse Alveolar Hemorrhage Syndromes
o Goodpasture Syndrome
o Idiopathic Pulmonary Hemosiderosis LESIONS OF THE UPPER RESPIRATORY TRACT
o Wegener Granulomatosis o Nasopharyngeal Carcinoma
o Laryngeal Tumors
 • Incomplete expansion
ATELECTASIS (COLLAPSE)
• PA  PV shunting (V/Q
imbalance & hypoxia)
• Resorption (tumor,
mucous plug)
• Compression (fluid,
blood, air)
• Contraction (fibrosis)

Ventilation scintigraphy demonstrates minimal ventilation of the left

lower lobe and delayed ventilation images show air trapping at the
right lung base. Perfusion images are mildly patchy showing
nonsegmental perfusion defects. No pleural-based, large subsegmental
or segmental perfusion defects are seen. Blunting of the bilateral
costophrenic angles is present, consistent with the patient's known
pleural effusions. Perfusion of the left lower lobe is maintained in the
area of near absent ventilation, indicating the presence of a functional
right to left shunt. Chest radiograph performed the same day
demonstrates bilateral pleural effusions and a retrocardiac density
suggesting left lower lobe atelectasis or infiltrate. http://gamma.wustl.edu/vq052te164.html
 ACUTE LUNG INJURY • NON-specific pattern of lung injury
Acute Respiratory Distress Syndrome (ARDS) • Diffuse alveolar capillary and epithelial
damage (DAD) (aka, “SHOCK” lung)
• respiratory insufficiency, cyanosis, and
severe arterial hypoxemia, may progress
to multisystem organ failure
• INFECTION, PHYSICAL INJURY, TOXIC
CHEMICAL, DIC
• As opposed to neonatal ARDS
Acute care setting applications of nuclear medicine may also include diagnosing ARDS. A 29-year-old
patient after multi-organ trauma suffered a year before was referred to the nuclear medicine
department for lung V/Q scintigraphy before right-sided pneumonectomy. A car accident in which the
patient had participated resulted in multiple spinal fractures, tetraplegia and blunt chest trauma with
bilateral pulmonary contusion and right lung atelectasis. Despite treatment the collapsed lung did not re-
expand and subsequent CT scans showed multiloculated effusion in the right pleural cavity, suggestive of
pleural empyema. The fluid persisted despite long-term chest tube drainage. The patient started having
recurrent fevers and his condition deteriorated. Right lung resection was suggested as a possible
treatment and the patient was referred for preoperative lung perfusion scintigraphy.

Perfusion (99mTc-MAA) and ventilation (Technegas) SPECT-CT transaxial

scans. Perfusion (A) and ventilation (B) SPECT-CT transaxial scans show a
collapsed right lung with severely reduced perfusion (A, red arrow) and
lack of ventilation (B, red arrow). Matching defect of perfusion and
ventilation is present in the lower left lobe (A, B, yellow arrows). The Perfusion (99mTc-MAA) and ventilation
upper left lobe shows a normal perfusion and ventilation pattern (Technegas) sagittal SPECT-CT scans.
Matching perfusion-ventilation defect in
the lower left lobe is visible (A, B, red
arrows). Perfusion in the lower left lobe
is preserved only in the parenchymal
consolidation area in the posterior lateral
segment (A, yellow arrow)

As V/Q scintigraphy suggested the patient’s gaseous exchange was maintained by a single lobe, which notably
increased operative risk, the right-sided pneumonectomy was excluded from possible treatment options.

Nuclear Med Rev 2016; 19, 1: 51–53

 OBSTRUCTIVE LUNG (AIRWAY) DISEASES
Emphysema

• COPD, or “END-STAGE” lung

disease
• Centri-acinar, Pan-acinar,
Paraseptal, Irregular
• (Progressive) Expiratory air
trapping, i.e., Wheezing
• Like cirrhosis, thought of as
END-STAGE of multiple
chronic small airway
obstructive etiologies
• NON-specific
• Increased crepitance, Nuclear Medicine Communications

Bullae 2008, 29:553–561

• Clinically likely to produce

recurrent pneumonias, and
progressive failure
A 56-year-old man with smoking history of 38 pack-years and pulmonary
emphysema. Chest CT at the middle lung (left) shows central lung dominant
LAA (arrows). The transaxial (at the same lung level as X-ray CT) and coronal
Technegas SPECT (right; top) show a stripe sign (arrows), as well as perfusion
SPECT (arrows) (right; bottom) indicative of lower susceptibility of the
peripheral lung for alveolar destruction.
 OBSTRUCTIVE LUNG (AIRWAY) DISEASES
Chronic Bronchitis

Woman with cystic fibrosis, status post bilateral lung

transplantation approximately three years ago.

• Inhalants, pollution, cigarettes

• Chronic cough
• Can often progress to emphysema
• Mucus hypersecretion, early, i.e. goblet cell increase
• CHRONIC bronchial inflammatory infiltrate
• Chronic bronchiolitis (small airway disease/bronchiolitis The imaging and clinical findings were thought to be most
obliterans) consistent with bronchiolitis obliterans (chronic rejection).
http://gamma.wustl.edu/newtfh/general/combined/submitted_174166.html

• Similar to chronic bronchitis but:
• Wheezing is hallmark (bronchospasm, i.e.
“wheezing”)
• Strong allergic role, i.e., eosinophils, IgE, allergens
• Often starting in Childhood
• Atopic (allergic) or Non-atopic (infection)
• Chronic small airway obstruction and infection
• 1) Mucus hypersecretion with plugging, 2)
lymphocytes/eosinophils, 3) lumen narrowing, 4)
smooth muscle hypertrophy
OBSTRUCTIVE LUNG (AIRWAY) DISEASES
Asthma
Male, 33 yo, sudden shortness of breath. No risk factors.
Asthma as a child but no treatment since teens. Received
aerosol therapy twice before VQ SPECT. Clinical low prob but
positive D Dimer. Images show widespread irregular perfusion
and ventilation, multiple discrete areas of partial mismatch,
but no defect is truly vascular in configuration. Was read as
negative for PE, consideration was for asthma. Patient
responded well to aerosol therapy. Final diagnosis: asthma
attack.
SPECTLUNG teaching and information resource

Bronchiectasis
• Dilation of the bronchus, associated
with, often, necrotizing inflammation
• Congnital
• TB, other bacteria, many viruses
• Bronchial obstruction (i.e., Large
airway, Not small airway)
• Rheumatoid arthritis, SLE, IBD
(Inflammatory Bowel Disease)
Nuclear Imaging of the Chest By Y. W. Bahk. Et. al. Page 574
Sino-bronchiectasis (CT and Technegas SPECT images). CT
revealed thickening of bronchial walls and bronchiectasis in
upper and lower right lung fields and also in the left lung.
Technegas and perfusion SPECT transverse images (lower to
upper slices) showed multiple defects in both lungs. Perfusion
defects were more widespread than Technegas deposition, so
perfusion was impaired more severely than ventilation in the
areas of bronchiectasis.
CHRONIC INTERSTITIAL (RESTRICTIVE, INFILTRATIVE) LUNG DISEASES
Fibrosing Diseases
Idiopathic Pulmonary Fibrosis (UIP)

• Idiopathic
• Repeated cycles of
epithelial activation/injury
• Honeycomb fibrosis (Usual 53 year old with long standing history of pulmonary fibrosis
Interstitial Pneumonia) is evaluated for lung transplantation. VQ scan shows absent
perfusion with preserved ventilation (V-P mismatches)
http://gamma.wustl.edu/vq038te167.html
 CHRONIC INTERSTITIAL (RESTRICTIVE, INFILTRATIVE) LUNG DISEASES
Fibrosing Diseases
Nonspecific Interstitial Pneumonia
NSIP vs. UIP
• “Trashcan diagnosis”, of any
pneumonia (pneumonitis) of
any known or unknown
etiology – better prognosis
than UIP
• Fibrosis – diffuse (ground
glass)
• Cellular infiltrate (lymphs &
plasma cells)

Parenchymal honeycombing
(UIP) on CT (A) with associated
intense 18F-FDG uptake (B)
typical of usual interstitial
pneumonitis.

J Nucl Med 2009; 50:538–545

 Brochiolitis obliterans with organizing pneumonia (BOOP)
CHRONIC INTERSTITIAL (RESTRICTIVE, INFILTRATIVE) LUNG DISEASES
Fibrosing Diseases
Cryptogenic Organizing Pneumonia

• Idiopathic
• “Bronchiolitis Obliterans O.P.”
(BOOP)
• Patchy airspace consolidation
(Masson bodies - polypoid
plugs of alveolar
ducts/alveoli/bronchioles)
• Spontaneous recovery/ long
term steroids http://gamma.wustl.edu/pt115te162.html
 CHRONIC INTERSTITIAL (RESTRICTIVE, INFILTRATIVE) LUNG DISEASES

Pneumoconiosis

• Occupational
• Dust/ Chemicals/ Organic
materials
– Coal (anthracosis)
– Silica
– Asbestos
– Be, FeO, BaSO4, CHEMO
– Hay, flax, Bagasse,
insecticides, etc. Computed tomography (CT) images of small multiple pneumoconiotic
• Alveolar macrophage nodules (a-1) and large pneumoconiotic nodules (b-1). The degree of
the accumulation of 11C methionine (MET: a-2, b-2; right) was size
mediated injury/fibrosis dependent as well as that of fl uoro-deoxy-Dglucose (FDG: a-2, b-2;
left)
Ann Nucl Med (2007) 21:331–337
CHRONIC INTERSTITIAL (RESTRICTIVE, INFILTRATIVE) LUNG DISEASES

Coal Worker’s Pneumoconiosis

(Anthracosis)
• 3 essential factors:
– Specific
substance
(based on “coal
rank”)
– Appropriate size
(1-5m)
– Sufficient
exposure (yrs)
• Coal macules
(dust-laden
macrophages) &
coal nodule
(macule + collagen Ann Nucl Med (2007) 21:331–337
fibers)
• Progressive
centrilobular
emphysema
 • Most common Silicosis
• Macrophage mediated fibrogenic
cytokines
• “Whorled” silicotic nodules
• Hylar “eggshell” calcifications
Ann Nucl Med. 2009 Dec;23(10):883-6

FDG PET findings in a case with acute pulmonary silicosis. FDG PET scan
demonstrates a peripherally diffuse uptake in both the lungs, especially in both
apical and posterior regions indicating active inflammation. Besides, faint FDG
uptake is also noted in mediastinal lymph nodes.
 Asbestosis and
Asbestos-Related Diseases

• Amphiboles > pathogenicity

than serpentine chrysotile
• Asbestosis, lung cancer, and
mesothelioma
• Diffuse interstitial fibrosis
• Visceral pleura fibrosis
• Dense collagenous calcified
“parietal pleural plaques”
 Drug- and Radiation-Induced
Pulmonary Diseases
• Pneumonitis
• Interstitial
fibrosis

FDG positron emission

tomography imaging of
drug-induced pneumonitis

Ann Nucl Med (2008) 22:335–338

Ann Nucl Med. 2008 Oct;22(8):719-22

• Mainly lung, but Granulomatous Disease
eye, skin or
anywhere - Sarcoidosis
• Non-caseating Biomed Res Int. 2015; 40 1341

granulomas
(idiopathic)
• Immune, genetic
factors
• F>>M 99mTc-Infliximab scintigraphy of a sarcoidosis patient
• B>>W acquired at 6 h (anterior and posterior views showing a
moderate and diffuse uptake in the lung parenchyma.
• Young adult
African American
women

• infiltration
• alveolar IL-5  activation of
eosinophils
• Unclear etiology
• Drugs/toxins/helminths/fungi/id
iopathic
• Simple pulmonary eosinophilia
(Loeffler syndrome),
characterized by transient
pulmonary lesions and
thickened alveolar septa with
eosinophil infiltrate
Granulomatous Disease
- Pulmonary Eosinophilia
Simple pulmonary eosinophilia in a 52-year-old
healthy man who underwent voluntary cancer
screening. A. Transverse CT scan obtained with
the lung window setting shows a semisolid
nodule in the left lower lobe (arrow). B. The
coronal FDG PET scan shows the increased
uptake in the nodule with an SUV of 4.5
(arrow).
Kor J Radiol. 2005 Oct-Dec;6(4):208-213
 Granulomatous Disease
Smoking-Related Interstitial Diseases

• DIP (Desquamative
Interstitial Pneumonia)
• “Smokers macrophages”
accumulation within
airspaces
• Inflammation, septal
thickening, possible fibrosis
• Resolution with
steroids/smoking cessation

• M>>F
PET findings in smoker’s nodular Pulmonary Langerhans Cell Histiocytosis (PLCH).
• Cigarettes Chest CT images on the left upper and lower panels show multiple lung nodules in a
smoker with surgical lung biopsy-proven PLCH. The corresponding PET images on the
right upper and lower panels show PET characteristics of the multiple pulmonary

• 100% Survival nodules. The larger pulmonary nodules (arrowhead) demonstrated intense PET uptake,
while other nodules (arrow) are PET-negative (Standardized Uptake Value < 2.5)
 Vascular Origin Diseases
Pulmonary Embolism,
Hemorrhage, and Infarction
• Usually secondary to debilitated
states with immobilization, or
following surgery
• Usually deep leg and deep pelvic
veins (DVT), NOT superficial
veins
• Follows Virchow’s triad, i.e., 1)
flow problems, 2) endothelial
disruption, 3) hypercoagulabilty
• Usually do NOT infarct, usually
ventilate
• When they DO infarct, the infarct
is hemorrhagic
• Decreased PO2, acute chest
pain, V/Q MIS-match
• DX: Chest CT, V/Q scan,
angiogram
• RX: short term heparin, then
long term coumadin
 Vascular Origin Diseases
Pulmonary Hypertension

Normal pulmonary arteriole

Perfusion scan from a patient with severe chronic

thromboembolic pulmonary hypertension (CTEPH).
The right lung has nearly no blood flow. The left lung
Very thickened arteriole has multiple wedge shaped blood flow defects
in pulmonary HTN

• COPD, C”I”PD (vicious cycle)

• CHD (Congenital HD, increased
left atrial pressure)
• Recurrent PEs
• Autoimmune, e.g., PSS
(Scleroderma), i.e., fibrotic
pulmonary vasculature The ventilation scan is from the same patient. The left lung has
preserved ventilation. These findings are classic for CTEPH.
 Diffuse Alveolar Hemorrhage Syndromes
Goodpasture Syndrome
• Destruction of
glomerular and
alveolar basement
membrane
• Ab’s (anti-GBM) to the
alpha-3 chains of
collagen IV
• Hemorrhage, 99mTc DTPA RENAL STUDY OF A PATIENT WITH Goodpasture’s syndrom. In
addition to poor renal perfusion and function, increased uptake of DTPA in the
lungs is noticed. Left: 5s images for 45s after injection; Right: 2min x 16 frames
hemoptysis,
Clin Nucl Med. 1985 Oct;10(10):724-6
glomerulonephritis
 Diffuse Alveolar Hemorrhage Syndromes
Idiopathic Pulmonary Hemosiderosis
• Rare, Children & young adults
• Hemosidering laden
macrophages
• CxR:
– diffuse B/L alveolar infiltrates
– Hilar & mediastinal adenopathy
• Tx: systemic corticosteroids
A, Relatively normal lungs after episode of
alveolar consolidation. B, 3 hr after
administration of 99mTc RBC. Patient in
remission. Activity centered in heart, liver, and
spleen. C, Exacerbation of disease; alveolar
consolidation. D, Same time as C; activity
shifted to lungs. Boundary of lungs with heart
and liver obscured by intrapulmonary
hemorrhage.
Nuclear Scan of Pulmonary Hemorrhage in Idiopathic Pulmonary Hemosiderosis;
AJR 132:120-121
 Ann Nucl Med. 2013 Apr; 27(3): 209–216

Diffuse Alveolar Hemorrhage Syndromes

Wegener Granulomatosis
• Anti-Neutrophil Cytoplasmic
Antibodies (ANCA)
• Granulomas and patchy
necrotizing vasculitis in arteries
and veins (lungs, kidneys and
other organs)
• End-organ damage
• Long-term immunosuppression

A 65-year-old woman with WG with elevated ANCA

titers. Abnormal FDG uptake in the nasopharynx
and lung (A), bilateral auditory tubes (CT alone is
negative) (B), and nodular shadows in both lungs
(C). At 5 mo follow-up after treatment, both ANCA
titers were WNL, with no FDG uptake in the nasal
mucosa, auditory tubes and lungs (D, E, F)
 Pneumonia
• Aka, Lower respiratory infections (as
opposed to upper)
• Predisposing factors:
– Loss of cough reflex
– Loss of mucin/Cilia function
– Alveolar macrophage interference
– Vascualr flow issues
– Bonchial airflow issues
• Most common cause of death
• Usually does NOT occur in healthy
people spontaneously
• Bronchopneumonia
– Patchy infection/inflammation of
bronchi/bronchioles/alveoli in > 1
lobe
• Lobar pneumonia
– Exudate in contiguous air spaces of
a lobe
 Types of Pneumonia
COMMUNITY-ACQUIRED BACTERIAL ACUTE PNEUMONIAS (BACTERIAL)
• Streptococcus Pneumoniae
• Haemophilus Influenzae
• Moraxella Catarrhalis
• Staphylococcus Aureus
• Klebsiella Pneumoniae
• Pseudomonas Aeruginosa
• Legionella Pneumophila

COMMUNITY-ACQUIRED ATYPICAL (VIRAL AND MYCOPLASMAL) PNEUMONIAS (NON-BACTERIAL)

• Influenza Infections
• Severe Acute Respiratory Syndrome (SARS)

NOSOCOMIAL PNEUMONIA

ASPIRATION PNEUMONIA

LUNG ABSCESS
• Etiology and Pathogenesis.

CHRONIC PNEUMONIA
• Histoplasmosis, Morphology
• Blastomycosis, Morphology
• Coccidioidomycosis, Morphology

PNEUMONIA IN THE IMMUNOCOMPROMISED HOST

PULMONARY DISEASE IN HUMAN IMMUNODEFICIENCY VIRUS INFECTION

 PULMONARY INFECTIONS
Community-Acquired Acute Pneumonias
• Mostly bacterial
• Viral from upper RT infection
• Sudden onset of high fever, shaking chills,
pleuritic chest pain, mucopurulent cough,
possible hemoptysis
• S. pneumoniae (i.e., the pneumococcus) is
most common cause
DOI:10.13179/canchemtrans.2013.01.02.0021

Patient with pneumonia in the right lung and PE.

Sagittal slices show reduced–absent ventilation
posteriorly with reduced perfusion in the same
area. Preserved perfusion adjacent to the pleura
(stripe sign; blue arrow). Moreover, absent
perfusion with preserved ventilation in the medial
lobe (red arrow)
Breathe 2012;9:48-60
 Community-Acquired Atypical Pneumonias
Influenza Virus Type A/H1N1 Infection
• Viral (Influenza) • Frequently “interstitial”, NOT alveolar
• Mycoplasmal (M. pneumoniae (obligate
intracellular))
• Inflammation confined to alveolar walls
• Free of cellular exudate (unlike consolidation in
bacterial)

• Not bacterial Ann Nucl Med (2012) 26:248–252

• Cultures not helpful

44-year-old woman: 4-day post-vaccination.

Accumulation (arrow) was clearly demonstrated in
the axillary lymph node. SUVmax was 6.1 and the
diameter was 4 mm. The accumulation had
disappeared 1 year later
 PULMONARY INFECTIONS

Aspiration Pneumonia
• Unconsicous Pts
• Patients in prolonged bed rest
• Aspiration of gastric contents
• Lack of ability to swallow or gag
• Posterior lobes (gravity dependent) most commonly involved (esp. sup
segments of LL) Am J Radiol 2013; 200:437–441

• Often leads to abscess

 A 54-year-old patient
PULMONARY INFECTIONS developed cough with foul-
smelling sputum production.
A chest radiograph shows

Lung Abscess lung abscess in the left lower

lobe, superior segment.

• Aspiration
• Septic embolization
• Neoplasm
• From neighbouring
structures:
– esophagus
– spine
– pleura
– diaphragm
• Any pneumonia which is
severe and destructive,
and untreated enough
Practical Nuclear Medicine, edited by Peter F. Sharp, et.al.
 PULMONARY INFECTIONS

Tuberculosis
• 20 tuberculosis important
consideration in HIV-positives
w/ pulmonary disease
• Caeseous granuloma
• Pleural effusions, tuberculous
empyema, or obliterative
fibrous pleuritis

Tuberculosis, edited by M. Monir

Rev Esp Med Nucl Imagen Mol 2009; 28:22

Transaxial 18F FDG-PET/CT lesion

in the upper lobe of the right lung
corresponding to tuberculoma.
 PULMONARY FUNGAL INFECTIONS
Histoplasmosis, Coccidioidomycosis, and Blastomycosis
• Histoplasma capsulatum (Histoplasmosis), Blastomyces dermatidis (Blastomycosis),
Coccidioides immitis (Coccidiomycosis)
• Spores in bird or bat droppings, soil
• Mimics TB
• Pulmonary granulomas, often large and calcified
• Tiny organisms live in macrophages
• Ohio, Mississippi valley (Histo, Blasto), American Southwest (Coccidio)
• MANY other organs can be affected

This patient had "persistent pneumonia“. The Xe-133 images were Coronal (left) and transaxial (right) 18F-FDG
normal with perfusion images showing absence of perfusion to the
right lung consistent with Fibrosing mediastinitis post histoplasmosis PET demonstrating the primary laryngeal
occluding central vessels. tumor and the focus of blastomycosis .
 Pneumonia in the Immunocompromised Host
med.harvard.edu/JPNM/TF93_94
• Immunosuppression post
disease, for organ
transplantation and antitumor
therapy, or by irradiation
• Pulmonary infiltrate and signs
of infection (e.g., fever)
Front. Microbiol., May 2016

A 42 year old homosexual male presented with a 3

Bronchiolitis obliterans following M.
pneumoniae infection. (A) Chest X-ray showing
normal. (B) 99mTc-MAA perfusion scan
revealing slight defect. (C) 81mKr-aerosol
ventilation demonstrating prominent multiple
defects throughout the lung field.
week history of fevers and sweats. He denied
respiratory symptoms such as cough or sputum.
He was diagnosed as HIV positive 5 years earlier
but had not manifest with lymphadenopathy or
opportunistic infections.
Findings: CXR was normal. Gallium-67 scintigraphy
revealed diffuse lung uptake. Washings from
fibreoptic bronchoscopy confirmed Pneumocystis
carinii (PCP) infection.
 Pneumonia in the Immunocompromised Host
Cytomegalovirus Infections/
Cytomegalovirus Mononucleosis
• Herpesvirus family
• Infected cells display gigantism of entire cell
and nucleus 18F-FDG-PET-CT in
• Nucleus with enlarged inclusion cytomegalovirus-induced
mononucleosis
surrounded clear halo (“owl’s eye”)
• 50-100% persons sero+ve
• CM with infectious mononucleosis–like
illness, with fever, atypical lymphocytosis,
lymphadenopathy, and hepatomegaly,
abnormal LFT
• Leukocytes - major reservoirs

Complete body image of maximum intensity.

Lateral cervical (A) and celiac (Ac) hypermetabolic
adenopathies. Diffuse augmentation of metabolic
activity in the spleen (B).

Rev Esp Med Nucl. 2010;29(6):304-307

 Pneumonia in the Immunocompromised Host

Pneumocystis Pneumonia
• P. jiroveci – fungus (formerly P. carinii - protozoan)
Several cases of pulmonary
• 100% of population seropositive (latent, reactivation in infection diagnosed using
immunocomprimised) nuclear imaging have been
reported, even when the
• Confined to lung, interstitial pneumonitis anatomical imaging appeared
normal.
• Fever, dry cough, and dyspnea
• Bilateral perihilar and basilar infiltrates
Clin Nucl Med 2015;40: 679–681
C

FDG PET (A) was performed 7 days after chest CT, and a second CT (B) was obtained after
FDG PET (A). FDG PET demonstrated pathologic uptake through the bilateral lung fields as
opposed to the pleura. Pneumocystis jirovecii was amplified by PCR from her sputum and
was diagnosed with PCP. Trimethoprim-sulfamethoxazole was administered for 3 weeks.
Posttreatment FDG-PET revealed complete disappearance of the abnormal uptake (C).
 Opportunistic Fungal Infections
Candidiasis

• Candida albicans
• Normal microbiota
• In immunecompromised:
– systemic candidiasis
– associated pneumonia (a) Increased uptake of 18F-FDG in
multiple foci in both lungs in patient
– bilateral nodular positive for C. albicans (b) Normal 18F-
FDG PET after three months.
infiltrates Clin Microbiol Infect. , Vol 11; 6, 2005, 493–495
 Opportunistic Fungal Infections
Cryptococcosis
• C. neoformans
• Opportunistic
• inhalation from the
soil or from bird
droppings
• Lung localization/
dissemenation Cryptococcosis associated mediastinal
lymphadenitis was found. PET/CT showed one
(mainly CNS) pulmonary nodule at the left upper lobe, with
hilar lymph node involvement
Acta Radiol. 2009 May;50(4):374-8.
 Opportunistic Fungal Infections
Mucormycosis and Invasive aspergillosis
Am J Radiol :203, July 2014
• Uncommon
• Invasive pulmonary
disease may be:
– localized (e.g.,
cavitary lesions)
– diffuse “miliary”
involvement
• Non-invasive
Aspergilloma (“fungus
ball”) formation A 34-year-old woman who presented with long-standing fever and dry
cough. FDG PET/CT was done to localize cause. A, Whole-body
(colonization of maximum-intensity-projection PET did not reveal any definite
preexisting pulmonary hypermetabolic focus. B, Axial PET/CT shows soft-tissue-density solitary
cavities (e.g., lung pulmonary nodule (thick arrow) in right lung with perinodular opacity
cysts, posttuberculosis (thin arrow), so called “halo sign,” without significant FDG uptake in
nodule (maximum standardized uptake value, 1.1). Diagnosis of
cavitary lesions) infective cause was made on PET/CT. Biopsy from nodule revealed
diagnosis of noninvasive aspergillosis.
 Pulmonary Disease in Human Immunodeficiency Virus Infection
• Leading contributor of morbidity and mortality
• Dx & Tx challenging
• Pulmonary infiltrates from infectious/non-infectious causes
• “opportunistic” infections
• Bacterial pneumonias
Semin Nucl Med. 2013 Sep;43(5):349-66

FDG-PET/CT performed on a HIV positive patient before (A) and after therapy (B). The pathologic uptake in the left lung and
mediastinum before therapy almost completely disappeared after therapy. This case highlights metabolic response may indicate clinical
response and guide duration of antimicrobial therapy.
 LUNG TUMORS
Carcinoma
AP portable CXR
• Benign, malignant, epithelial,
mesenchymal, but 90% are
Carcinomas
• Biggest USA killer (prevalence not
as high as prostate or breast but Tc-99m DTPA aeraol ventilation scan
mortality higher; only 15% 5 year
survival)
• Tobacco (polycyclic aromatic
hydrocarbons, such as
benzopyrene, anthracenes,
radioactive isotopes)
• Radiation, asbestos, radon Perfusion scan

• C-MYC, K-RAS, EGFR, HER-2/neu

Matching ventilation and perfusion defects in the superior segment
of the right lower lobe. The perfusion defect appears larger than the
ventilatory abnormality. CxR: Cardiomegaly, pulmonary edema, and
Rt. infrahilar mass MIR teaching file _105232 PE protocol chest CT
Lung Tumors -
Carcinoma
SCLC & NSCLC

Cancer Imaging. 2013; 13(1): 73–80 MIR teaching file_125330

SCLC: Pre-Tx (upper); NSCLC

post-Tx (lower)
 Lung Tumors
Carcinoid
• Neuroendocrine tumor arising
from Kulchitsky cells in bronchial
mucosa
• Early age group (mean 40y)
• M=F
• 1-5% of all lung neoplasms
• Often resectable & curable
• No relation with smoking or
environmental factors
Lung carcinoid. Indium-111
• Carcinoid syndrome (attacks of octreotide scan of the thorax and
diarrhea, flushing, cyanosis) subdiaphragmatic areas shows a
primary lung carcinoid (arrow) and
metastases in the liver
PLEURAL LESIONS
Pleural effusion &
Pleuritis
Nuclear Medicine: The Requisites, 4th edition

Atlas of Clinical Nuclear Medicine, 3rd Edn.

 PLEURAL LESIONS
Pneumothorax, Hemothorax, and Chylothorax
Atlas of Clinical Nuclear Medicine, 3rd Edn.

• Air – Pneumothorax
• Blood – Hemothorax
• Infection – Empyema
• Chyle – Chylothorax
• Tumor – “tumor-
thorax” or tumor
tamponade
• Fluid - Pleurothorax
 PLEURAL LESIONS
Malignant Mesothelioma
• “Benign” vs.
“Malignant”
differentiation does
not matter, but a self
limited localized
nodule can be
regarded as benign,
and a spreading tumor
can be regarded as
malignant Fig. 2A —Categories T3 and T4 Fig. 2C —Categories T3
and T4 malignant pleural
• Visceral or parietal malignant pleural mesothelioma. mesothelioma.

pleura, pericardium, or A, Fused PET/CT (A) and CT (B)
peritoneum images in 62-year-old man show
category T3 malignant pleural
• Most are regarded as mesothelioma and single focus of
chest wall invasion (arrow).
asbestos caused or Categories T3 and T4 malignant
asbestos “related” pleural mesothelioma
C, Coronal fused PET/CT
(C) and CT (D) images in
67-year-old man show
category T4 malignant
pleural mesothelioma
with multifocal chest
wall invasion (arrows).
Images also show
metastatic disease
(arrowheads, C).
 LESIONS OF THE UPPER RESPIRATORY TRACT
Nasopharyngeal Carcinoma

• strong
epidemiologic
links to EBV
•  incidence
among Chinese
(?viral + genetic)
30-year-old man for evaluation of recently
diagnosed nasopharyngeal mass. Hypermetabolic
left parapharyngeal mass with metastatic foci in
cervical and mediastinal lymph nodes and within
numerous lung nodules consistent with primary
nasopharyngeal malignancy with local and distant
metastases. AJR, August 2014, Volume 203, Number 2
 LESIONS OF THE UPPER RESPIRATORY TRACT
Laryngeal Tumors
• Main feature – hoarseness
• Non-malignant – voval chord nodules (polyps)(contact trauma/ “singers
nodes”)
• Benign - Laryngeal papilloma
• Malignant – Laryngeal carcinoma (> 40y, M>>F, smokers)
J Nucl Med. 2004 Feb;45(2):226-31

Coronal 18F-FDG PET (A) and 18F-FLT PET (B) images of patient diagnosed with primary
laryngeal cancer. With both imaging modalities, uptake of the tracer in the laryngeal region
can be observed. Maximum 18F-FDG SUV was 3.2, and maximum 18F-FLT SUV was 1.2.
Physiologic 18F-FDG uptake can be seen in the muscles of the neck, and physiologic 18F-FLT
uptake can be seen in the bone marrow of the ribs and sternum.