MR PET Imaging of Inflammation
in Paediatric Oncology Patients
Dr Timothy Cain
Paediatric Radiologist and Nuclear Medicine Specialist
The Royal Children’s Hospital Melbourne, Victoria, Australia
RCH Medical Imaging has a research collaboration
with Siemens Healthineers through the Murdoch
Children’s Research Institute
RCH MR PET is a global reference site for Siemens
Healthineers
Declarations
Objectives
• Be aware of MR PET for paediatric Imaging
• Demonstrate how MR PET can be used like PET CT for
investigation of inflammation
• Be aware of high frequency of incidental findings
• Be aware of benefits of MR for correlation with PET
Indications for FDG MR PET Imaging
Infection/inflammation
• Oncology
• Febrile neutropaenia – diagnosis of infective and non-infective causes
• Prior to bone marrow transplantation - screening
• Assessment of infection treatment success or recurrence
• Non-oncologic
• PUO – especially immune deficiency syndromes
• Arthralgia/Autoimmune/Vasculitis
RCH MR PET Imaging statistics
• 982 MR PET imaging studies were performed at the
RCH between April 2016 and December 2018
• 612 of these studies performed on oncology patients
• 28 oncology patients had imaging specifically to assess
inflammation
• febrile neutropenia
• assess response to treatment for infection.
Febrile Neutropaenia
• 15 yo male with
relapsed AML
• Febrile neutropenia
• Previous lung infection
with worsening fevers
despite appropriate
therapy – infection
elsewhere?
Febrile Neutropaenia
• LZ 5 yo female
• ALL - delayed consolidation
chemotherapy because of
candida sepsis
• FDG PET to determine
extent of disease
Persistent Fevers post BMT
• 9 yo male
• Persistent
unexplained high-
grade fever for over
1 week following
bone marrow
transplant
• Pancreatitis post
BMT
MR PET Inflammation
• 17 yo male T-cell ALL
• Febrile 6 days, hypotension
• Findings consistent with diffuse
inflammatory process involving
joints and muscles
• No focal source of infection or
inflammation demonstrated
RCH MR PET Findings
Incidental inflammation common
• Lung – pneumonia and anaesthesia related atelectasis
• Gastrointestinal tract – oesophagus, stomach, bowel
• Lymphoid tissue – cervical, axillary, inguinal
• Other
• Injection sites, muscle inflammation, skin inflammation
• Central line, surgical scar
MR PET Unexpected Lung uptake
Oct 2016 Nov 2017 Feb 2018
• 6 yo female
• Spitz naevus of left upper
arm; unknown potential
(Malignant melanoma?)
• Asymptomatic at time of
all studies
• MR imaging showed
unexpected RUL
collapse and RML
consolidation
MR PET Unexpected lung Inflammation
9 yo male with
Hodgkins Lymphoma
Unexpected Right
basal lung lesion on
late assessment PET
scan
Nov 2017 Jan 2018 May 2018
Initial staging early & late response assessment
MR PET ‘Incidental’ Inflammation
9 yo male with
Hodgkins
Lymphoma
Unexpected
Right basal
lung lesion
MR PET Reactive lymph nodes
• 12 yo Female with
incomplete excision of
fibrohistiocytic tumour
from left hand
• Enlarged and isotope
avid lymph nodes
• Biopsy proven reactive
nodes – post
immunisation left deltoid
muscle
MR PET – CVC related Inflammation
• 16 yo male Hodgkins
Lymphoma
• Good response post
treatment
• Focal uptake right
atrium – line tip related
inflammation
Baseline scan End of treatment
Sep 2107 Mar 2018
CT Mar 2018 (inspiration)
MR PET Mar 2018 (expiration)
MR PET - MSK Inflammation
• 7-year-old with Burkitt's lymphoma - primary in mandible
• Bilateral greater trochanter uptake
• Right infraspinatus (rotator cuff) tendinitis – high T2
signal in muscle
MR PET Bowel activity
• 7 yo male
• f/up PTLD post cardiac transplantation
• Recent diarrhoea suspicious of small bowel
PTLD recurrence
• RLL uptake unexpected pulmonary infection
• Lt deltoid recent immunisation (no uptake
on right side bilateral injections
• Colonic uptake suspicious of PTLD
recurrence
• Colonic biopsy –ve
MR PET in paediatric Infection and Inflammation
• Useful to identify source of infection in febrile patients
• Can be used to assess treatment response
• Detects a wide range of infective and inflammatory conditions
• Incidental or unexpected signs of inflammation are common,
but not all are significant
• Simultaneous MR often provides anatomical correlation that CT
would not be expected to provide
Acknowledgements…..
• RCH Foundation and Good Friday
Appeal
• Michael Kean and MR Technologists
• Duncan Veysey and Nuc Med
Technologists
• Peter Francis and MID imaging
specialists
• MID Nurses and Clerical staff
• Anaesthetists & Anaesthetic
technologists
• RCH Clinicians
• Simon Harvey and epilepsy team
• Michael Sullivan and oncology colleagues
• Child Life Therapists
Interested in Paediatric Imaging? Come to AOSPR 2019
Thank you for your attention
Dr Timothy Cain
Paediatric Radiologist and Nuclear Medicine Specialist
The Royal Children’s Hospital Melbourne, Australia