How to differentiate benign versus malignant cardiac and paracardiac 18F FDG uptake at oncologic PET/CT

Patients undergoing 2-[fluorine 18]fluoro-2-deoxy-d-glucose (FDG) whole-body oncologic positron emission tomography (PET)/computed tomography (CT) are studied while fasting. Cardiac FDG uptake in fasted patients has been widely reported as variable. It is important to understand the normal patterns of cardiac FDG activity that can be seen in oncologic FDG PET/CT studies. These include focal and regional patterns of increased FDG myocardial activity. Focal activity can be observed in papillary muscles, the atria, the base, and the distal anteroapical region of the left ventricle. Regional increased cardiac FDG activity may be diffuse or localized in the posterolateral wall or the base of the left ventricle. Abnormal patterns of cardiac FDG activity not related to malignancy include those associated with lipomatous hypertrophy of the interatrial septum, epicardial and pericardial fat, increased atrial activity associated with atrial fibrillation or a prominent crista terminalis, cardiac sarcoidosis, endocarditis, myocarditis, and pericarditis. Knowledge of these patterns of cardiac FDG activity is important to be able to recognize malignant disease involving the paracardiac spaces, myocardium, and pericardium. With a better understanding of the range of normal and abnormal patterns of cardiac FDG activity, important benign and malignant diseases involving the heart and pericardium can be recognized and diagnosed.