Clinical Radiology (1996) 51, 603-613
Review
The Current Status of Clinical PET Imaging
G. J. R. COOK and M. N. MAISEY
The Clinical PET Centre, RadioIogical Sciences, United Medical and Dental School/Guys and
St Thomas' Hospitals Trust, London, UK
Positron emission tomography (PET), previously
regarded as a research tool, now has a significant role
to play in clinical diagnosis and management. The
advantages derived from functional imaging using
single photon nuclear medicine techniques compared to
anatomical imaging, including an increase in sensitivity
due to the ability to map function/metabolism rather
than structural change, are shared by PET. At the same
time, some of the disadvantages of conventional single
photon imaging are overcome. The high sensitivity of
single photon scintigraphy is associated with relatively
poor spatial resolution when compared to anatomical
imaging techniques such as computed tomography (CT)
or magnetic resonance imaging (MRI). PET relies on the
detection of two 511 KeV annihilation photons emitted
at nearly 180° to each other. By only accepting coincident
photons is it possible to locate more accurately the point
of emission, resulting in less scatter, increased spatial
resolution and more accurate quantitation.
A major strength of PET is that the short lived posi-
tron emitters include biologically important, naturally
occurring radionuclides of carbon, oxygen and nitrogen.
This means that many organic compounds can be
labelled by substituting a radioactive element, without
disturbance of normal biochemical pathways. Because of
the improved quantitation, it is possible to measure up-
take of a radiopharmaceutical or physiological function
in absolute units.
The perceived disadvantages of PET are related to
cost. An on site cyclotron unit is required for the shorter
lived radionuclides and this has inherent high capital and
running costs. The majority of clinical PET imaging is
now performed with the glucose analogue 2- 18f l u o r o - 2 -
deoxy-D-glucose ( 18 F D G ) which has a half-life of
110min and, therefore, allows peripheral imaging sites
to share a central cyclotron unit. Other alternatives to an
on site cyclotron exist. A 82Rb generator is available for
studying blood flow, particularly in cardiac studies, but
as yet it is still expensive. As the number of scanners
increases in the UK and as scanning time decreases, the
costs of PET will fall. Even now PET studies have a
similar cost to some single photon tracer studies and
complex MR studies.
More recently, conventional gamma cameras have
been adapted with thicker lead collimators or coinci-
dence detection electronics to image the higher energy
gamma rays of positron emitters. Spatial resolution is
relatively poor compared to PET, and although this
method has been reported as being sufficiently sensitive
Correspondence to: Dr G. J. R. Cook, Department of Nuclear
Medicine, Guys Hospital, St Thomas Street, London SE1 9RT, UK.
© 1996 The Royal Collegeof Radiologists.
for detecting myocardial viability, only tumours greater
than 2-3 cm are detected [1,2]. This method would have
greater availability and would be technically simpler
than PET and with further improvements in design is
likely to play a part in clinical nuclear medicine.
Although PET has advantages over conventional
nuclear medicine, the clinical role is very specific and
does not replace single photon or anatomical imaging
techniques, but it offers a complimentary procedure for
supplying functional and metabolic information in the
light of structural change. This structural/functional
relationship can be further enhanced by co-registration
techniques when the spatial resolution of PET allows
anatomical landmarks to be identified, so that functional
information can be accurately superimposed on high
resolution morphological data from MRI and CT [3].
This review describes the areas where PET now con-
tributes to clinical diagnosis and management, and
illustrates how it may complement morphological
imaging. Research studies which may lead to future
clinical applications are also identified.
ONCOLOGY
The ability of PET to identify and differentiate
tumour from normal cells relies on altered tumour
metabolism of various substrates. Most tumours demon-
strate enhanced glycolysis sufficient to locate malignant
tissue and differentiate it from normal or scar tissues
using the radiolabelled glucose analogue 18FDG.
Similarly, increased amino acid incorporation into
tumour tissue may be shown with labelled methionine
or leucine (lie methionine, l l c leucine). The labelling of
purine bases such as thymidine (llc thymidine) allows
tumour proliferative activity to be investigated but this
has as yet no clinical role.
The use of PET in oncology has increased dramatically
since the recent development of whole body scanners [4].
This allows the complete staging of tumours by detecting
disease in soft tissues, bone and central nervous system in
a single investigation. Complementary morphological
imaging may then allow exact anatomical localization
of tumour deposits, particularly if image registration
techniques are used. The strength of PET in oncology
lies in its ability to map functional or metabolic abnor-
malities rather than displaying structural change, and in
the high tumour to background ratios obtained. Conse-
quently, it is possible to differentiate tumour from scar or
non-viable tumour tissue in masses detected on CT or
MRI following therapy. PET may also be used to guide