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(Radiology. 1999;210:823-828.)
© RSNA, 1999

Experimental Studies

FDG Imaging of Lung Nodules: A Phantom Study Comparing SPECT, Camera-based PET, and Dedicated PET

R. Edward Coleman, MD1, Charles M. Laymon, PhD1 and Timothy G. Turkington, PhD1

1 Department of Radiology, Duke University Medical Center, Box 3949, Rm 1420, Duke Hospital North, Erwin Rd, Durham, NC 27710.


   Abstract
TOP
 Abstract
Introduction
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 References
 
PURPOSE: To evaluate 2-[fluorine-18]fluoro-2-deoxy-D-glucose (FDG) imaging of simulated lung nodules in a realistic chest phantom by using attenuation-corrected and non–attenuation-corrected 511-keV single photon emission computed tomography (SPECT), camera-based positron emission tomography (PET), and dedicated PET imaging.

MATERIALS AND METHODS: Spheres with diameters of 6, 10, 13, and 22 mm were placed in the lungs of an anthropomorphic chest phantom to simulate nodules. The lungs, nodules, chest wall, and mediastinum were filled with fluorine-18 activities based on the average radionuclide concentrations in those structures from analysis of attenuation-corrected dedicated FDG PET scans. The image sets were evaluated visually and quantitatively by using contrast and signal-to-noise ratios.

RESULTS: Attenuation correction reduced the artificially high apparent uptake in the lungs, restored the spherical shape to the nodules, and provided an accurate outer body contour with appropriate intensity. Dedicated PET depicted all four nodules, camera-based PET depicted the three largest nodules, and SPECT depicted the two largest nodules. Lesion contrast was better on the attenuation-corrected images than on the non–attenuation-corrected images. The signal-to-noise ratio generally was improved with attenuation correction.

CONCLUSION: Attenuation correction results in many changes in the images and improves lesion detection.

Index terms: Emission CT (ECT), technology, 60.12162, 60.12163 • Fluorine • Glucose • Lung neoplasms, radionuclide studies, 60.3115 • Lung, nodule, 60.3115


   Introduction
TOP
 Abstract
 Introduction
MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 References
 
Positron emission tomography (PET) has developed as a technique that can help accurately determine the distribution of positron-emitting radionuclides. Scanners that are sensitive for the detection of the annihilation radiation and cover at least 15-cm longitudinal regions of the body are now routinely available for PET imaging (1). Because these scanners are unable to depict single-photon-emitting radionuclides, they are referred to as dedicated PET scanners.

At about the same time that dedicated PET scanners were being developed (2), attempts were being made to use opposed gamma cameras for annihilation coincidence detection (3). Gamma camera performance was much more limited at that time and often resulted in inadequate coincidence count rates. In addition, reconstruction of the resultant three-dimensional data has only recently become feasible. Gamma cameras with high-energy collimation have been used in the single-photon mode to image the 511-keV photons of 2-[fluorine-18]fluoro-2-deoxy-D-glucose (FDG). This technique has been demonstrated to be inadequate for tumor imaging with FDG but has been used successfully to detect viable myocardium (4,5). Recently, because of the improvements in electronics, gamma cameras are now being used for both single-photon and annihilation coincidence detection (6). The intrinsic resolution of these camera-based PET systems is comparable to that of dedicated PET scanners, but the systems are less sensitive for the detection of the annihilation radiation and are count-rate limited due to the thin sodium iodide detector and the limitations of imaging with two cameras instead of with the thousands of independent detectors typical of dedicated PET scanners (6).

Focal pulmonary opacities can be accurately characterized as benign or malignant with FDG and dedicated PET imaging (7). The accuracy for nodules with diameters of 7–15 mm is the same as that for nodules with diameters of 15–35 mm (8). Third-party payers are now reimbursing the cost of FDG PET performed to diagnose and stage lung cancer (9). Camera-based PET scanners are being used to evaluate focal pulmonary lesions, and the results of the initial clinical studies are beginning to appear in the literature (10,11). Images obtained with camera-based PET scanners have improved compared to images obtained with gamma cameras with thinner crystals, filter backpropagation algorithms, and not using attenuation correction (6). These improvements are not available with all systems at this time, but they will be incorporated into the new systems.

The purpose of this study was to compare dedicated PET, camera-based PET, and 511-keV collimated single photon emission computed tomography (SPECT) in the detection of pulmonary nodules of various sizes in a realistic chest phantom. Scans were reconstructed with and without the use of attenuation correction. This study permits the realistic evaluation of these imaging methods in the detection and characterization of lung nodules of various sizes.


   MATERIALS AND METHODS
TOP
 Abstract
 Introduction
 MATERIALS AND METHODS
RESULTS
 DISCUSSION
 References
 
Phantom
An anthropomorphic chest phantom (Data Spectrum, Hillsborough, NC) was used. This phantom is composed of various materials to mimic tissue attenuation; styrofoam mixed with water is used for the lungs, and Teflon is used for the spine. A separate compartment below the lungs enables simulation of liver uptake. The phantom is about the same size as the chest of a relatively large patient (~38 cm wide, ~25 cm deep). Nodules with diameters of 6, 10, 13, and 22 mm were placed in the lungs. The lungs, nodules, chest wall, and mediastinum were filled with 18F activities on the basis of the average radionuclide concentrations in those structures, as shown in Table 1. Region of interest (ROI) analysis was performed with attenuation-corrected dedicated PET scans obtained in 11 patients who had focal pulmonary lesions that were abnormal at imaging and standardized uptake value analysis. To minimize effects of scanner resolution and lesion size, maximal pixel values in the ROI were used (12).


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  		TABLE 1. 18F Activity Concentrations (µCi/mL) in Patients with Lung Cancer
 
The lungs, tumor spheres, liver, and remaining soft-tissue regions of the phantom were then filled in this ratio (but in a higher concentration) to allow for radioactive decay. Scan durations were chosen to match those used in typical clinical examinations: 30 minutes for camera-based PET and 511-keV SPECT and 10 minutes (per table position) for dedicated PET. In addition to being based on typical scanning times, the scan duration ratio is justified because it would take three table positions on the 15-cm axial field of view PET scanner to match the 40-cm axial field of view of the gamma camera system. Actual scanning times were adjusted to compensate for the decay of 18F: 511-keV SPECT was performed first; camera-based PET was performed second; and dedicated PET was performed last. After these examinations were performed, a 10-minute PET transmission scan was obtained with the phantom in place and emission activity present (11). Because both the 511-keV SPECT and dedicated PET scans were acquired at rates well below the count rate limits of the scanners (~5 kcps and ~40 kcps, respectively), it was deemed appropriate to change the scan duration to adjust for reduced or increased radioactivity. With camera-based PET, however, the scans are obtained much closer to rate-limiting situations, so the phantom was scanned with as realistic a count rate and duration as possible.

Scanning
The scanners used for the study were the Advance (GE Medical Systems, Milwaukee, Wis), in a standard configuration, and the Varicam (Elscint, Haifa, Israel), equipped with 1/2-inch-thick sodium iodide crystals. Varicam coincidence scanning was done with manufacturer-provided transaxial septa in front of the cameras. These septa were 3 mm thick, were spaced 13 mm center-to-center, and extended approximately 6 cm from the camera face. The septa reduce the amount of radiation that is detected from outside the field of view, limit the axial angles of photon pairs that are detected, allow for two-dimensional reconstruction of the data, and allow patients with 10 mCi (370 MBq) FDG to be imaged at a reasonable time after injection. In addition, the septa cut down on detected scattered events, as in two-dimensional dedicated PET. Between the septa and the sodium iodide detector is a graded absorber that preferentially transmits the unscattered 511-keV photons relative to the lower-energy scattered photons (13).

Dedicated PET scans were reconstructed with and without attenuation correction by using a Hann filter with a cutoff of 0.71 per centimeter. Reconstructed images were 128 x 128 x 35 and had 3.5 x 3.5 x 4.25-mm voxels. Images were transferred to off-line computers for display and analysis.

For camera-based PET, two types of events were used: events with both photons in the photopeak and events with one photon in the photopeak and one in a lower-energy window. Camera-based PET data were binned into 90 projections (two-degree sampling), a 128 x 128 matrix, and 4 x 4-mm pixels by using single-section rebinning (13). These projections were transferred to off-line computers and reconstructed by means of filtered back-projection. When these images were aligned with uncorrected PET images, an appropriate transformation was determined to scale, rotate, and translate the PET attenuation maps (reconstructed from transmission data) to spatially match the gamma camera coincidence images. Attenuation factors were then created by projecting through these reoriented attenuation maps, and the emission data were corrected with these factors. Finally, the corrected emission data were back-projected, which resulted in attenuation-corrected images. A three-dimensional Hann filter with a cutoff of 0.37 per centimeter was used to smooth the images.

For the 511-keV SPECT data, the same procedure was used to align the attenuation map with the uncorrected images. The nonuniform attenuation map was then used with the iterative Chang method (one iteration) (14) to reconstruct corrected SPECT images. A three-dimensional Hann filter (cutoff, 0.37 per centimeter) was used to smooth the images.

Three sections containing the centers of the four spheres were extracted from each of the six image sets and inspected visually and quantitatively. Quantitative analysis was done by placing an ROI on each sphere in a position and section that yielded the maximum pixel mean value. The diameters of the circular ROIs matched those of the spheres. For each sphere, 10 circular ROIs of the same diameter were placed throughout the lungs as a background region. The mean and SD were determined for each set of 10. Contrast (C) and signal-to-noise ratio (SNR) were determined for each identified lesion as follows: C = (L - µ)/µ and SNR = (L - µ)/{sigma}, where L is the lesion ROI value, µ the mean of the background ROIs, and {sigma} the SD of the background ROIs.


   RESULTS
TOP
 Abstract
 Introduction
 MATERIALS AND METHODS
 RESULTS
DISCUSSION
 References
 
Attenuation-corrected and non–attenuation-corrected images of the lung nodule phantom obtained with all three modalities are shown in the Figure. Three sections are shown for each image set. The sections closest to the centers of the three smallest spheres were selected, although the largest sphere was also visible in the section containing the smallest sphere.



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  		Figure 1. Transaxial images of simulated lung nodules. The three images that include all four nodule locations are shown for all modalities. 1 = non–attenuation-corrected dedicated PET scans, 2 = attenuation-corrected dedicated PET scans, 3 = non–attenuation-corrected camera-based PET scans, 4 = attenuation-corrected camera-based PET scans, 5 = non–attenuation-corrected SPECT scans, 6 = attenuation-corrected SPECT scans. All four nodules can be seen on the dedicated PET scans obtained with attenuation correction (row 2). The 22-mm-diameter nodule (curved arrow) is in the posterior part of the right lung on the middle image, the 13-mm-diameter nodule (open arrow) is in the anterior part of the left lung on the right image, the 10-mm-diameter nodule (straight solid arrow) is in the anterior part of the right lung on the left image, and the 6-mm-diameter nodule (arrowhead) is in the posterior part of the left lung on the middle images in rows 1–6. Attenuation correction reduces the apparent lung uptake, makes the lesions spherical instead of elongated, and corrects the artificially bright and inaccurate outer body contours. The improved lesion contrast with attenuation correction is most apparent for the small lesion.

 
Several imaging features are noteworthy. In all cases, use of attenuation correction reduced the artificially high apparent uptake in the lungs, although the effect is much more severe on the coincidence images than on the SPECT images. In addition, the elongation of the spherical lesions (without attenuation correction) is corrected along with the artificially bright outer body edge and inaccurate outer contour.

In these particular image sets, all four lesions are detectable on the attenuation-corrected dedicated PET images, and the 6-mm-diameter lesion is better discerned on the attenuation-corrected image than on the non–attenuation-corrected image. The smallest lesion is not seen on the camera-based PET images, and the 10-mm lesion is better discerned on the attenuation-corrected image than on the non–attenuation-corrected image. The two largest lesions are seen on the SPECT images.

Emission counts from the phantom were added axially over 10 cm. The results are as follows: dedicated PET, 9.9 million counts per 10 minutes; camera-based PET, 0.68 million counts per 30 minutes; and SPECT, 2.7 million counts per 30 minutes. Approximately 50% of the SPECT counts are from septal penetration.

Results of the ROI analysis are shown in Table 2. Regions were drawn only for spheres that could be clearly identified on either the corrected or uncorrected image set. Because of the nonuniformity of the lung region generated by the attenuation artifact, the variation in background regions was reduced considerably with attenuation correction, thereby increasing SNR. Contrast values increase (with this definition) with attenuation correction owing to the lowering of the artificially high background values.


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  		TABLE 2. Contrast and SNR of Simulated Nodules
 

   DISCUSSION
TOP
 Abstract
 Introduction
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
References
 
FDG PET imaging with dedicated PET scanners is very sensitive and accurate for evaluating focal pulmonary lesions that are indeterminate at computed tomography (7). The specificity is lower than the sensitivity because some inflammatory processes (eg, granulomatous inflammation) may accumulate FDG to the same degree as malignant lesions (8). Low-grade malignant lesions such as carcinoid tumors (15) and bronchoalveolar cell carcinoma (16) may not appear abnormal on dedicated PET scans. The use of standardized uptake values and lesion-to-background ratios has permitted semiquantitative analysis of the attenuation-corrected images, but semiquantitative analysis has not been demonstrated to be better than qualitative (visual) analysis (17). Because attenuation-corrected scans have been routinely obtained with dedicated PET scanners, very little data are available about the accuracy of non–attenuation-corrected scans in indeterminate focal pulmonary lesions.

Until recently, only dedicated PET scanners were being used for FDG imaging. At this time, there are approximately twice as many camera-based PET scanners than dedicated PET scanners (9). Camera-based PET scanners initially used 3/8-inch-thick crystals, but the low sensitivity of this crystal thickness limited its utility (6). Crystals with thicknesses of 5/8 and 3/4 inch are now being used. The single photon sensitivity for a 5/8-inch-thick crystal is approximately twice that for a 5/8-inch-thick crystal. Even with the thicker crystal, the system sensitivity of the camera-based system is much less than that of the dedicated PET scanner. In our phantom study, the sensitivity of camera-based PET was 10,000 counts per image, whereas that for dedicated PET was 200,000 counts per image. Iterative reconstruction of the camera-based PET images has been demonstrated to improve the image quality and will be available on the clinical systems (6).

Our results demonstrate that attenuation-corrected dedicated PET can depict nodules as small as 6 mm in diameter in a realistic chest phantom with radionuclide concentrations that were determined from normal tissues and nodules on attenuation-corrected dedicated PET scans. Non–attenuation-corrected dedicated PET images, camera-based PET images, and SPECT images did not provide adequate contrast for demonstrating the smallest nodule. Lesion contrast was improved with attenuation correction for all nodule sizes and all three modalities. Our results demonstrate the importance of attenuation correction for detecting small nodules. With use of the average radionuclide concentrations from the attenuation-corrected dedicated PET scans obtained in 11 patients with malignant nodules, these results suggest that nodules approximately 10 mm in diameter could be detected with clinical FDG studies by using attenuation-corrected camera-based PET. Preliminary clinical studies have demonstrated similar results (10,11).

With dedicated PET scanners, Bengel et al (18) evaluated the effects of attenuation correction on lesion-to-background count rates in a body phantom containing a cylinder with spheres of various sizes and in patients. The lesion-to-background count rates were used as contrast values. The authors reported higher contrast values for the spheres in the phantom and for areas of focal FDG uptake in patients on the non–attenuation-corrected images than on the attenuation-corrected images. The clinical results included 30 focal abnormalities in the lungs.

There are several methodologic differences between our study and the study of Bengel et al (18). First, the phantoms were different. Our phantom contained material to mimic lung attenuation, and the spheres were placed in this low-attenuation region. Bengel et al placed the spheres into a water-filled cylinder, which was placed in a body phantom. Their phantom study used a lesion-to-background activity ratio of 4.0 (15/3.7), whereas a ratio of 30.5 (1.037/0.034) was used in our study. They used a "ringlike" ROI around the focal abnormality to determine the background count rates, whereas we used 10 circular ROIs throughout the lung. With our method, there are more regions throughout the lungs that might have greater variability in counts. When we calculated contrast values with their formula for lesion-to-background count rates, contrast values were higher for the attenuation-corrected images than for the non–attenuation-corrected images. Our results do not confirm their conclusion that uncorrected images provide higher lesion contrast. We would expect the results of our phantom study to differ from their results because their phantom study did not simulate the lungs and would not have the artificially high lung uptake without attenuation correction.

Although the attenuation characteristics of our phantom are similar to those of the human chest and the radionuclide concentrations used in normal tissues and nodules were based on clinical data, the image quality and lesion detection rate in clinical studies may differ from those obtained in our phantom study. The radioactivity concentrations used in our study were meant to match typical FDG distribution. Previous studies have reported various values for tumor-lung uptake ratios. Knight et al (19) reported a mean ratio of 16.6 (range, 5.3–51.0) in 29 malignant lung nodules, and Lowe et al (20) reported a similarly wide range in 10 malignant nodules. Although the 30.5:1 ratio used for this phantom study is somewhat high compared to that used by Bengel et al (18) and to these other measurements, higher lesion values should be expected for our study because of the differences in methods. Scanner spatial resolution effects tend to yield low estimates for radioactivity concentrations of small lesions (12). Use of a high-resolution scanner and a maximum-pixel ROI method (compared with the use of ROI means) (21), however, minimized this error for the 11 patients analyzed. Factors such as FDG accumulation time (20) and blood glucose levels (22) lead to variation in actual tumor-lung ratios. Because lesion detectability is related to image contrast, which, in turn, is dependent on the uptake ratios, actual detectability of various nodule sizes will differ from patient to patient.

Other factors are different between the phantom and clinical studies. Motion is present in clinical studies but not in phantom studies. In clinical studies, the lungs, chest wall, and nodules move, which results in degradation of the image and in the detectability of small nodules—particularly at the lung bases where motion is greatest. The patient may move between the emission and transmission scan, and this motion may result in degradation of lesion contrast on the image. In the phantom study, the lesion and background radionuclide concentrations are uniform, whereas in patients, the radionuclide accumulation is frequently nonuniform in the lesion and background. Even with these limitations of the phantom study, the results do provide information comparing the relative merits of dedicated PET, camera-based PET, and 511-keV SPECT of suspected lung tumors.

The results were obtained by using acquisition geometries and image reconstructions that can be improved. For these systems, camera-based PET stands to improve the most with reconstruction algorithms that better account for the three-dimensional nature of the data. All three modalities may show substantial improvement with appropriate iterative reconstruction algorithms. Our results suggest the following: FDG SPECT can depict nodules as small as 13 mm in diameter, camera-based PET can depict nodules as small as 10 mm in diameter, and dedicated PET can depict nodules as small as 6 mm in diameter. The importance of attenuation correction in the detection of small lesions is demonstrated in this phantom study. The results may differ from those of clinical studies because of patient motion and lack of perfect registration between the transmission and emission images.

Practical Applications: These data demonstrate that dedicated PET can depict lung nodules at least 6 mm in diameter. A multicenter study of indeterminate focal pulmonary lesions demonstrated no difference in the accuracy of dedicated PET images in the characterization of lesions 0.7–1.5 cm in diameter compared to those 1.6–4.0 cm in diameter (8). In this experimental study, attenuation-corrected camera-based PET depicted nodules at least 10 mm in diameter, whereas non–attenuation-corrected camera-based PET depicted nodules at least 13 mm in diameter. In a study comparing non–attenuation-corrected camera-based PET scans to attenuation-corrected dedicated PET scans, 84% of lesions at least 1 cm in diameter and 90% of lesions at least 1.5 cm in diameter were detected with camera-based PET (10). These preliminary clinical data and experimental results suggest that, at this time, camera-based PET systems be used only to characterize nodules with diameters of 1.5 cm or more. When attenuation correction becomes routinely available on camera-based PET systems, clinical studies will be needed to document the smallest lesion size detectable. FDG SPECT of lung nodules requires nodules to be at least 1.3 cm in diameter. Martin et al (4) concluded that lesions larger than 1.5 cm in diameter could be routinely detected with FDG SPECT.


   Footnotes
 
R.E.C., C.M.L., and T.G.T. receive research support from Elscint.

Address reprint requests to R.E.C.

R.E.C. is a stockholder in PETNet Pharmaceutical, a supplier of FDG.

Abbreviations: FDG = 2-[fluorine-18]fluoro-2-deoxy-D-glucose ROI = region of interest SNR = signal-to-noise ratio

Author contributions: Guarantor of integrity of entire study, R.E.C.; study concepts, T.G.T., R.E.C.; study design, all authors; definition of intellectual content, T.G.T., R.E.C.; literature research, T.G.T., R.E.C.; clinical studies, all authors; experimental studies, C.M.L., T.G.T.; data acquisition, C.M.L., T.G.T.; data analysis, all authors; manuscript preparation, editing, and review, T.G.T., R.E.C.

Received May 20, 1998; revision requested July 14, 1998; revision received August 26, 1998; accepted October 7, 1998.
   References
TOP
 Abstract
 Introduction
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 References
 

  1. DeGrado TR, Turkington TG, Williams JJ, Stearns CW, Hoffman JM, Coleman RE. Performance characteristics of a whole-body PET scanner. J Nucl Med 1994; 35:1398-1406.[Abstract/Free Full Text]
  2. Phelps ME, Hoffman EJ, Mullani NA, Ter-Pogossian MM. Application of annihilation coincidence detection to transaxial reconstruction tomography. J Nucl Med 1975; 16:210-224.[Abstract/Free Full Text]
  3. Muehllehner G, Buchen MP, Dudek JH. Performance parameters of a positron imaging camera. IEEE Trans Nucl Sci 1976; 23:528-537.
  4. Martin WH, Delbeke D, Patton JA, et al. FDG-SPECT: correlation with FDG-PET. J Nucl Med 1995; 36:985-995.
  5. Delbeke D, Videlfsky S, Patton JA, et al. Rest myocardial perfusion/metabolism imaging using simultaneous dual-isotope acquisition SPECT with technetium 99m-MIBI/fluorine-18 FDG. J Nucl Med 1995; 36:2110-2119.[Abstract/Free Full Text]
  6. Coleman RE. Camera-based PET: the best is yet to come (editorial). J Nucl Med 1997; 38:1796-1797.[Free Full Text]
  7. Patz EF, Lowe VJ, Hoffman JM, Paine SS, Harris LK, Goodman PC. Persistent or recurrent bronchogenic carcinoma: detection with PET and 2-[18F]-2-deoxy-D-glucose. Radiology 1994; 191:379-382.[Abstract/Free Full Text]
  8. Lowe VJ, Fletcher JW, Gobar L, et al. Prospective investigation of positron emission tomography in lung nodules. J Clin Oncol 1998; 16:1075-1084.[Abstract]
  9. Coleman RE, Tesar RD. Clinical PET: are we ready?. J Nucl Med 1997; 38:5N-9N.
  10. Delbeke D, Sandler MP, Al-Sugair A, et al. Comparison of dedicated and camera-based PET imaging of FDG in patients with focal pulmonary lesions (abstr). J Nucl Med 1998; 39:108P-109P.
  11. Shreve PD, Steventon RS, Deters EC, et al. Oncologic diagnosis with 2-[fluorine-18] fluoro-2-deoxy-D-glucose imaging: dual-head coincidence gamma camera versus positron emission tomographic scanner. Radiology 1998; 207:431-437.[Abstract/Free Full Text]
  12. Hoffman EJ, Huang SC, Phelps ME. Quantitation in positron emission computed tomography. I. Effect of object size. J Cereb Blood Flow Metab 1987; 7:S4-S7.
  13. Daube-Witherspoon ME, Muehllehner G. Treatment of axial data in three-dimensional PET. J Nucl Med 1987; 28:1717-1724.[Abstract/Free Full Text]
  14. Chang LT. A method for attenuation correction in radionuclide computed tomography. IEEE Trans Nucl Sci 1978; NS-25:638-643.
  15. Erasmus JJ, McAdams HP, Patz EF, Coleman RE, Ahuja V, Goodman PD. Evaluation of primary pulmonary carcinoid tumors using positron emission tomography with 18F-fluorodeoxyglucose. AJR 1998; 170:1369-1373.[Abstract/Free Full Text]
  16. Kim BT, Kim Y, Lee KS, et al. Localized form of bronchoalveolar carcinoma: FDG PET findings. AJR 1997; 170:935-939.[Abstract/Free Full Text]
  17. Lowe VJ, Hoffman JM, DeLong DM, Patz EF, Coleman RE. Semiquantitative and visual analysis of FDG-PET images in pulmonary abnormalities. J Nucl Med 1994; 35:1771-1776.[Abstract/Free Full Text]
  18. Bengel FM, Ziegler SI, Avril N, Weber W, Laubenacher C, Schwaiger M. Whole-body positron emission tomography in clinical oncology: comparison between attenuation-corrected and uncorrected images. Eur J Nucl Med 1997; 24:1091-1098.[Medline]
  19. Knight SB, Delbeke D, Stewart JR, Sandler MP. Evaluation of pulmonary lesios with FDG-PET. Chest 1996; 109:982-988.[Abstract/Free Full Text]
  20. Lowe VJ, DeLong DM, Hoffman FM, Coleman RE. Optimum scanning protocol for FDG-PET evaluation of pulmonary malignancy. J Nucl Med 1995; 36:883-887.[Abstract/Free Full Text]
  21. Lowe VJ, Duhaylongsod FG, Patz EF, et al. Pulmonary abnormalities and PET data analysis: a retrospective study. Radiology 1997; 202:435-439.[Abstract/Free Full Text]
  22. Langen KJ, Braun U, Rota KC, et al. The influence of plasma glucose levels on fluorine-18-fluorodeoxyglucose uptake in bronchial carcinomas. J Nucl Med 1993; 321:355-359.




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