ARTICLE IN PRESS

Benign Cutaneous and Subcutaneous Lesions

on FDG-PET/CT
Ur Metser, MD, FRCPC,*,† and Noam Tau, MD*,†

18
F-FDG, the most commonly used PET radiopharmaceutical in clinical practice, can also accu-
mulate in inflammatory and infectious conditions. This may account for false-positive PET findings
when staging or restaging a patient with malignancy. As clinical use of FDG-PET-CT is increas-
ing, nuclear medicine physicians are encountering a myriad of cutaneous and subcutaneous lesions,
many of which are incidental and benign. The most common cause for the FDG avidity of these
lesions is inflammation. Although a specific diagnosis may not always be possible, background
clinical history and morphologic features of the lesion on CT may help narrow the differential di-
agnosis. This article aims to familiarize nuclear medicine physicians and radiologists with various
benign cutaneous and subcutaneous conditions encountered in routine clinical practice.
Semin Nucl Med ■■:■■–■■ © 2017 Elsevier Inc. All rights reserved.

Pathophysiology of 18F-FDG Inflammation is triggered by innate immune receptors that

identify pathogens and abnormal or damaged cells, and may
Uptake in Inflammation be induced by infection, injury, or exposure to toxins. In-

T he most common etiologies for increased FDG uptake

in the skin or subcutaneous tissues are inflammatory or
infectious (Table 1). FDG is a glucose analog with a meta-
bolic pathway similar to that of glucose, including uptake by
cell surface transporter proteins (mainly GLUT-1) and phos-
phorylation by hexokinase.1 In 1923, Otto Heinrich Warburg
suggested that most malignant cells produce energy by a high
rate of glycolysis followed by lactic acid fermentation in the
cytosol. This nonoxidative metabolism of glucose generates
more energy than the low rate of glycolysis followed by oxi-
dation of pyruvate in mitochondria of most normal cells. This
energy production process was termed the “Warburg effect.”2
In 1992, Kubota et al reported that FDG uptake in tumors
is due to uptake not only in tumor cells but also in tumor-
associated inflammatory cells.3 In fact, accumulation of FDG
is often higher in the inflammatory cells than in tumor cells,
enabling use of FDG-PET in imaging of inflammation and
infection.
*Joint Department of Medical Imaging, University Health Network, Mount
Sinai Hospital and Women’s College Hospital, University of Toronto,
Toronto, Ontario, Canada.
†Department of Medical Imaging, University of Toronto, Toronto, Ontario,
Canada.
Address reprint requests to Ur Metser, MD, FRCPC, Joint Department of
Medical Imaging, Princess Margaret Hospital, University Health Network,
610 University Ave, Suite 3-960, Toronto, ON, Canada M5G 2M9. E-mail:
ur.metser@uhn.ca
flammation is a complex cascade of cytokine-mediated
immunologic events that result in increased glucose metabo-
lism and FDG uptake.4 The earliest stages of inflammation
involve vasodilation, increased vascular permeability, and in-
creased blood flow, which then result in increased flux of FDG
into cells. This facilitates the recruitment of leukocytes, plasma
proteins, and fluids. Activated inflammatory cells show in-
creased expression of glucose transporters, and the affinity
of these transporter proteins to glucose is increased via
cytokines.5 Hexokinase is also upregulated during this process,
increasing the retention of FDG within these cells. Both pro-
cesses together cause FDG accumulation in recruited
inflammatory cells. FDG uptake appears to correlate well with
the density of inflammatory cells in both acute and chronic
inflammations.6 The neutrophil is a key effector cell of the
immune system and is an important component of host
defense. Neutrophil responds to external insults such as bac-
terial infection via chemotaxis, phagocytosis, degranulation,
and generation of toxic reactive oxygen intermediates. Acti-
vated neutrophils, either responding to an infection or as part
of inflammatory response, have increased glucose uptake and
metabolism.
In the past decade and a half, there has been an increase
in clinical use of FDG-PET, most commonly for staging or
restaging of various malignancies, or for therapy response as-
sessment. PET may also be utilized for non–malignancy-
related reasons, such as identifying a source of infection in

http://dx.doi.org/10.1053/j.semnuclmed.2017.02.007 1
0001-2998/© 2017 Elsevier Inc. All rights reserved.
 ARTICLE IN PRESS
2 U. Metser and N. Tau

Table 1 Infectious and Inflammatory Cutaneous and Subcutaneous Disorders That May Be FDG-avid
Systemic conditions involving skin
and subcutaneous tissues
Cutaneous disorders
Lesions primarily involving
subcutaneous tissues
Iatrogenic cutaneous and
subcutaneous lesions
MAC, Mycobacterium avium complex.
Sarcoidosis
Gout
Medium- and small-vessel vasculitides
Autoimmune Psoriasis
Pemphigus (various types)
Inflammatory Insect bite
Acne vulgaris
Hidradenitis suppurativa
Granulomatous vasculitis
Febrile neutrophilic dermatosis (Sweet syndrome)—paraneoplastic
Acquired perforating dermatosis
Steatocystoma multiplex (rare)
Necrobiotic xanthogranuloma (rare)
Infectious Erysipelas
Abscess
Herpes zoster
Furuncle/carbuncle
Rhinophyma
Mycobacteria—tuberculosis, MAC, and other nontuberculous mycobacteria
Toxoplasma
Fat necrosis—breast, post surgery
Lipodystrophy or lipoatrophy in HIV patients
Panniculitis—including erythema nodosum
Eosinophilic fasciitis, nodular fasciitis
Epidermoid cysts—uncomplicated or ruptured
Pilonidal sinus
Hematoma
Wound healing
Scars and keloids
Injections site granulomas
Drug reactions, including extravasation (ie, erlotinib, BCG, anakinra, silicone)
Foreign body reaction—mesh, gossypiboma, calcium hydroxylapatite dermal
filler, breast implant, and other implants
Infected foreign body

patients with fever of unknown origin or febrile neutropenia.7
Whatever the indication, benign skin or subcutaneous lesions
may be incidentally encountered. A familiarity with the various
etiologies and their imaging appearance may be helpful in
deriving a concise differential diagnosis.
Systemic Conditions Involving
Cutaneous and Subcutaneous
Tissues
Systemic inflammatory disorders may involve cutaneous and
subcutaneous tissues at different disease stages. The skin and
subcutaneous tissues can manifest as the sole site of disease,
as may be seen in cutaneous sarcoidosis, or may appear as a
further site of disease during the course of illness.
Sarcoidosis is the hallmark of a systemic disorder that may
involve the cutaneous and subcutaneous tissues and mani-
fest as FDG-avid lesions on PET. PET may be used in systemic
sarcoidosis to determine disease activity, to assess response
to therapy, or to evaluate for cardiac involvement.8,9 This sys-
temic autoimmune, inflammatory disease shows cutaneous
involvement more commonly than usually clinically appre-
ciated, with skin being the second most common site of disease
after the lungs. Reports show that 30%-35% of systemic sar-
coidosis patients have various skin findings, and in 10% of
patients, skin is the first or only site of disease.10 Acute forms
of sarcoidosis usually present with a discreet nodular appear-
ance (macules, papules, or other types), whereas plaque-
like disease usually accompanies the chronic form of disease.11
As expected, the PET appearance follows the clinical presen-
tation, with cutaneous FDG-avid lesions apparent in locations
of involved skin, whether as discreet nodules or plaque-like12
(Fig. 1).
Subcutaneous involvement is less common, with 2%-6%
of patients developing subcutaneous lesions during the course
of disease. In the chronic form, these subcutaneous, hard, in-
durated nodules are often asymptomatic but may present as
mildly tender.13 These nodules may also be the first or only
sign of disease.14,15 Subcutaneous sarcoid nodules are more
common in Caucasian women in the fifth and sixth decades.
 ARTICLE IN PRESS
Benign lesions on FDG-PET/CT 3

Figure 1 Cutaneous sarcoidosis involvement of the right breast. On PET, there is a metabolically active cutaneous lesion in the right inframammary fold,
with corresponding focal skin thickening on CT. Note the multiple foci of abnormal FDG uptake in the spleen in keeping with splenic involvement.

On PET, these appear as discreet FDG-avid nodules in the
subcutaneous fat.
The most common form of acute subcutaneous involvement
is erythema nodosum, which may be seen in approximately 10%-
35% of patients with subcutaneous sarcoidosis. Erythema nodosum
usually presents with painful erythematous rounded nodules, most
often located on the anterior surface of lower extremities, and may
also be accompanied by systemic symptoms such as malaise, fever,
and arthralgia. On pathology, erythema nodosum shows septal pan-
niculitis without granulomas. Although not specific to sarcoidosis,
when a young patient presents with erythema nodosum, sarcoid-
osis should be suspected.16 Löfgren syndrome, a subtype of
sarcoidosis, manifests as an acute triad of erythema nodosum, hilar
lymphadenopathy, and arthritis and is considered self-limiting, with
a better prognosis than systemic sarcoidosis.17
Autoimmune and Inflammatory
Cutaneous Conditions
There is a myriad of FDG-avid inflammatory skin condi-
tions. However, as PET is not routinely used to diagnose or
manage them, most FDG-avid cutaneous lesions are encoun-
tered incidentally. Location of lesions and demographic and
clinical data such as patient’s age may help in making the di-
agnosis. For example, FDG-avid lesions in skin folds may
suggest hidradenitis suppurativa (Fig. 2). Nonetheless, a defi-
nite diagnosis would require clinical examination.
A clinically important entity that should be kept in mind
is the cutaneous manifestations of paraneoplastic syn-
dromes. Sweet syndrome (acute febrile neutrophilic dermatosis)
may be seen secondary to systemic factors, such as infec-
tion, inflammation, vaccination, or drug exposure. In up to
21%-25% of patients, there may be an underlying malig-
nancy, mostly hematologic, and the dermatosis may be its
presenting symptom.18,19 The syndrome manifests acutely with
fever and rapidly appearing tender erythematous nodules,
mostly on the face, neck, and upper limbs, which may co-
alesce to form plaques. On pathology, these nodules have dense
neutrophil infiltrates, which may account for their FDG avidity.
As with Sweet syndrome but much less common, pem-
phigus can be the cutaneous expression of a paraneoplastic
syndrome, and is then termed paraneoplastic pemphigus.20
This specific pemphigus subset also has a strong relation-
ship with hematologic malignancies. Unlike the predictable
appearance of skin lesions in Sweet syndrome, paraneoplastic
pemphigus has a variable appearance, including pemphigus
vulgaris, bullous pemphigoid, or mimicking various other
nodular or plaque-like skin conditions. Therefore, a skin biopsy
is often necessary for a definitive diagnosis.
Skin Infections
Skin infections have variable clinical and imaging appear-
ances. Localized infections such as furuncles and abscesses
usually have a focal appearance both clinically and radio-
logically, and are easily differentiated from more widespread
infections such as cellulitis (Fig. 3A, B).
Acne vulgaris is a common skin disorder in teenagers and
presents a frequent indication for dermatology consulta-
tions. Nonetheless, there is still an open debate on the role

Figure 2 Hidradenitis suppurativa of the left groin. PET performed for restaging of squamous cell carcinoma of tongue showed incidental FDG
uptake in left groin, corresponding to irregular thickening on CT. This corresponded to tiny non–tender erythematous skin nodules shown
to represent hidradenitis suppurativa.
 ARTICLE IN PRESS
4 U. Metser and N. Tau
Figure 3 Focal and diffuse infections. (A) Cutaneous nodule with high metabolic activity in the left groin in keeping with a furuncle. (B) In
contrast, diffuse involvement pattern on PET, with subcutaneous fat stranding on CT, corresponding to right flank cellulitis.
infection has in the course of disease, and especially Propi-
onibacterium acnes bacterium. One view supports a purely
inflammatory response to overexcretion of sebum from se-
baceous glands, whereas other views claim the disease is purely
infectious. Treatment trends have shifted accordingly between
antibiotic and anti-inflammatory drugs, with current treat-
ment regimens being aimed at both.21 Regardless of the precise
etiology, both processes may be FDG-avid.
Although acne is a benign condition with mostly cos-
metic implications, there are systemic infections that may also
involve the skin, and often prove detrimental to patients’ well-
being as they are difficult to treat. Although more commonly
present in immunocompromised patients, either due to HIV
infection of secondary to immunosuppressive drugs, these sys-
temic infections can also affect patients following trauma and
surgery, and even immunocompetent patients. Toxoplasmo-
sis, tuberculosis, and other nontuberculous mycobacteria may
all involve the skin in the course of the disease.22-24 The clini-
cal and radiological appearances of all these conditions overlap
and may include multiple discreet nodules, ulcers, and skin
abscesses. Biopsies and cultures should be directed to the most
metabolically active lesion, whether cutaneous or other.
Although herpes zoster is common in elderly patients, there has
been an increased incidence in young immunocompromised pa-
tients in recent decades. Herpes zoster is a reactivation of varicella-
zoster virus dormant in the dorsal nerve root and cranial sensory
ganglia of patients previously infected with chickenpox. The re-
activation process causes the virus to multiply and spread within
the ganglion, through sensory nerves and later to the skin, causing
an intense inflammatory process and neuronal necrosis. This process
then results in the characteristic dermatomal rash characteristic
of the disease.25,26 On PET, this appearance can be best appreci-
ated using maximum intensity projection reconstruction or coronal
views, where the cutaneous FDG avid lesions appear along a single,
or rarely multiple dermatome.27
Lesions Primarily Involving
Subcutaneous Tissues
Subcutaneous tissues include adipose cells, blood vessels, nerves,
hair follicles, and collagen fibers. FDG-avid lesions may arise from
these structures or may extend from a cutaneous process. It should
be kept in mind that although uncommon, subcutaneous metas-
tases exist and should always be considered in the appropriate
clinical context, especially in melanoma patients.28,29
Fat necrosis is a benign inflammatory condition of fat, usually
appearing secondary to local tissue insult, including trauma,
surgery, biopsy, and radiation injury. Fat necrosis is common
in the breast, where it has been well documented, but can
appear in any subcutaneous tissue. Fat necrosis is usually FDG-
avid. A diagnosis can often be made based on PET and
morphological findings on CT, in the appropriate clinical context
(Fig. 4). However, it is important to keep in mind that other
conditions such as lipodystrophy, panniculitis, and even T-cell
lymphoma may have a similar appearance.30,31
Panniculitis is a general term for a group of pathologic pro-
cesses consisting of adipocyte necrosis with surrounding
inflammatory cells. The latter may be secondary to the ne-
crosis or the precipitating factor. As panniculitis may be a
marker of a systemic disorder such as lupus or scleroderma,
biopsy of the involved fat is necessary for specific diagnosis.32
Panniculitis-like T-cell lymphoma is an important differen-
tial diagnosis, and as it is not a benign process, it requires
prompt diagnosis and treatment.33,34
Patients receiving antiretroviral therapy for HIV may undergo
changes in their body fat distribution, termed HIV
lipodystrophy.35,36 The most stigmatizing of these changes is
loss of subcutaneous fat (lipoatrophy), especially in the face.
This is more common in patients receiving nucleoside analog
reverse-transcriptase inhibitors, but other culprit antiretroviral
drugs have also been implicated. Regardless of the exact cause,
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Benign lesions on FDG-PET/CT 5

Figure 4 Fat necrosis. PET performed for assessing sarcoidosis 3 months post abdominoplasty showing abnormal metabolic activity in diffuse
fat stranding of subcutaneous abdominal fat in keeping with fat necrosis.

the common end pathway is adipose cell apoptosis with in-
flammatory changes surrounding it, causing loss of fat tissue.
This process is FDG-avid and should be always considered
when imaging treated HIV patients37,38 (Fig. 5A, B).
Iatrogenic Cutaneous and
Subcutaneous Lesions
Postoperative wound infection and infected subcutaneously
placed devices such as ports or pacemakers are usually
FDG-avid (Fig. 6). However, the most common cause of
FDG uptake along a surgical wound is inflammation during
wound healing (Fig. 7). Persistent FDG update may be due
to keloid formation.39 Foreign body response such stitch
granuloma, mesh response, and others is also FDG-avid
(Fig. 8A, B). In fact, the inflammatory response to foreign
bodies can last for years after surgery.40,41 Another common
finding on PET is injection site granuloma. Variable acute
or chronic inflammatory responses with high-level FDG
uptake were reported in patients receiving immunotherapy

Figure 5 Cheek augmentation due to HIV lipoatrophy. (A) Moderate FDG uptake in
the left premaxillary area corresponding to high signal intensity on fat saturated in-
version recovery MRI (B). Both PET and MRI findings can be secondary to HIV
lipoatrophy and cheek augmentation performed 10 years earlier in this patient.
 ARTICLE IN PRESS
6 U. Metser and N. Tau
Figure 6 Infected right chest wall port site, confirmed clinically.
Figure 7 Abnormal FDG uptake in left abdominal surgical wound 5 weeks post surgery. This may be inflammatory, although clinical corre-
lation is needed to exclude wound infection.
in the form of subcutaneous bacillus Calmette–Guérin
injections, but have also been described in other types of
injected drugs42,43 (Fig. 9).
Benign Tumors
Benign cutaneous and subcutaneous tumors are uncom-
mon in general and even rarer on FDG-PET due to their low
metabolic cellular activity. However, there are a few excep-
tions that should be noted (Table 2).
Dermatofibroma (superficial benign fibrous histiocytoma) is the
most common mesenchymal tumor of the skin, with an uncer-
tain etiology. Dermatofibroma is composed of fibroblasts and
histiocytes and appears mostly on limbs of young to middle-
aged adults, especially women.44,45 Almost all subtypes of this tumor
are benign and do not require treatment. Most are limited to the
skin, although cases of deep penetrating or purely subcutaneous
dermatofibromas have been described.46,47 On PET, dermatofi-
bromas appear as small cutaneous (and less commonly
subcutaneous) focal soft tissue nodules with high FDG uptake.
Dermatofibromas can easily be confused with furuncles on imaging,
and clinical correlate is needed.
In contrast to the cutaneous nature of dermatofibroma,
hibernomas are subcutaneous brown fat tumors. Brown fat is a
Table 2 Benign FDG-avid Tumors
Dermatofibroma—superficial benign fibrous histiocytoma
Hibernoma
Neurofibroma and schwannoma in neurofibromatosis
Cholesterol granuloma
Pilomatricoma
Purely cutaneous Rosai-Dorfman disease
metabolically active tissue capable of generating heat and is com-
monly encountered on PET, mostly in young, thin women, more
often in cold conditions. Therefore, it is not surprising that
hibernomas are highly metabolically active as well48,49 (Fig. 10).
The FDG avidity of hibernomas helps to differentiate them from
their yellow fat counterparts—lipomas. Hibernomas commonly
arise in areas where brown adipose tissue would normally be ex-
pected and usually do not recur after resection. Although
hibernomas have a typical imaging appearance of a well-
demarcated, heterogeneous low-attenuation lesion on CT with high
FDG uptake, biopsy may be obtained to exclude a more sinister
process such as liposarcoma.50,51
Neurofibromatosis type 1 (NF1) is a common genetic disease
affecting 1 in 2500 live births and is caused by mutation of
the tumor-suppressor gene “neurofibromin”, resulting in a pre-
disposition to developing tumors, both benign and malignant,
termed neurofibromas.52 Cutaneous neurofibromas have no
malignant potential. The subcutaneous form may be nodular
or diffuse, with the latter termed plexiform neurofibroma.
These deeper and more complex benign tumors may undergo
transformation to malignant peripheral nerve sheath tumors.
Up to 10% of NF1 patients will develop malignant periph-
eral nerve sheath tumor during their lifetime, and these tumors
are one of the leading causes of death in this patient
population.53-55 Studies show that both benign and malig-
nant tumors in NF1 patients are FDG-avid (Fig. 11A, B), with
various FDG uptake thresholds suggested for detecting ma-
lignant transformation.56-58
Pilomatricoma, also known as pilomatrixoma or calcify-
ing epithelioma of Malherbe, is a benign tumor of hair follicles,
commonly appearing in the head and neck regions of pedi-
atric patients.59,60 Although this tumor has a typical appearance
on ultrasound, CT, and MRI (Fig. 12), a definite diagnosis
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Benign lesions on FDG-PET/CT 7

Figure 8 Postsurgical foreign body granuloma. (A) Patient’s 10 years’ postexploratory laparotomy showing high metabolic activity in a soft
tissue nodule located deep in the surgical scar, in keeping with a stitch granuloma. (B) Sagittal image in another patient post orchiectomy
shows FDG-avid nodule at resected tip of the spermatic cord in keeping with postorchiectomy suture granuloma.

Figure 9 Patient with malignant melanoma treated with subcutaneous injections of BCG to the abdominal wall. Note the intense abnormal
metabolic activity in the subcutaneous tissues in the right lower abdomen, corresponding to injection site.

Figure 10 Hibernoma. Metabolically active mass in posterior left thigh in keeping with histologically proven hibernoma.
 ARTICLE IN PRESS
8 U. Metser and N. Tau

Figure 11 Neurofibroma. Patient with neurofibromatosis type 1. (A) Left parasternal chest wall skin thickening on CT, with low-level meta-
bolic activity on PET, corresponding to a high T2-weighted signal on MRI in a known neurofibroma (B).

Figure 12 FDG-avid cutaneous lesion in the left neck of a 14-year-old adolescent boy who was previously treated for Hodgkin lymphoma. CT
shows fine calcifications in the lesion. Ultrasound shows a 2-cm large well-defined ovoid lesion with a hypoechogenic rim and central echogenic
foci, consistent with pilomatricoma. Despite its characteristic CT and ultrasonographic appearance, excisional biopsy was performed due to
the patient’s history. Histopathology confirmed pilomatricoma.(Case courtesy of Dr. H.J.A. Adams and Dr. T.C. Kwee.)
 ARTICLE IN PRESS
Benign lesions on FDG-PET/CT
can only be reached on postexcisional pathology.61,62 The level
of FDG uptake in these tumors is highly variable, and there-
fore PET is usually not helpful in reaching a specific diagnosis.
Tumor recurrence after complete excision is rare.
In summary, focal FDG uptake in the skin or subcutane-
ous tissues is a common incidental finding on PET. FDG
uptake is not specific for malignancy and may be due to in-
flammation, infection, or a benign tumor. Although a specific
diagnosis may not always be possible, background clinical
history and morphologic features of the lesion on CT may
help in narrowing the differential diagnosis.
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