Classification of Physiological 18F-fluorodeoxyglucose Uptake in the Large Intestine: a Preliminary Study

Varying degrees of physiological uptake of 18F-fluorodeoxyglucose (FDG) are often noted in the large intestine and can be problematic when interpreting positron emission tomography (PET) images. In relation to colorectal tumor detection with FDG PET, we tentatively classified physiological FDG uptake in the large intestine according to its patterns and intensity. Subjects were 144 asymptomatic individuals (109 men, 35 women; mean age 57.5 ± 10.1 years) in our cancer screening program who underwent total colonoscopy within 24 days of FDG PET study and showed no evidence of colonic lesions on colonoscopy. Distinct FDG uptake on FDG PET images was classified into four types: focal, defined as distinctly nodular and visible on at least 4 axial; localized, 2 to 8 cm with SUVmean ≥ 4; diffuse, > 8 cm with SUVmean ≥ 4; and mixed, of more than one type. SUVmeans were examined by placing multiple circular regions of interest of 1 cm in diameter on the axial images. We found 21 distinct FDG uptakes matching our criteria in 20 of 144 subjects (13.9%): focal (n = 4), localized (n = 1), diffuse (n = 14), and mixed (n = 1; focal and diffuse). With regard to colorectal tumor detection, 6 subjects (4.2%) with focal or localized type of uptake were considered at risk of false-positive tumor identification, and 15 subjects (10.4%) with diffuse type of uptake were considered at risk of their tumors being missed at the site of FDG uptake. To confirm the feasibility of our criteria, this classification should be tested with a larger number of subjects.