Image-guided biopsy: What the interventional radiologist needs to know about PET/CT

Positron emission tomography (PET)/computed tomography (CT) with fluorine 18 fluorodeoxyglucose (FDG) is increasingly used in evaluation of oncology patients. Because PET/CT can demonstrate malignancy before morphologic changes are evident, application of PET/CT information to image-guided biopsy can facilitate early histologic diagnosis and staging. However, because FDG uptake is not specific to cancer, PET/CT findings may raise questions about whether uptake in a lesion is an indication for biopsy. To properly select patients for image-guided biopsy, interventional radiologists should be familiar with the biologic significance of FDG uptake and various causes of false-positive uptake. PET/CT images may also become a source of confusion in the interpretation of biopsy results. Various causes of false-positive and false-negative FDG uptake need to be considered, especially when there is a discrepancy between biopsy results and PET/CT findings. False-negative FDG uptake can result from cancers that are too small to be observed or not FDG avid. False-positive FDG uptake can be due to underlying inflammation from recent treatment. Conversely, complete resolution of FDG uptake in a treated lesion does not necessarily indicate absence of viable cells. When questions about PET/CT findings arise in the context of image-guided biopsy, discussion with experienced nuclear imaging physicians is essential.