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Review
. 2022 Feb 7:2:825486.
doi: 10.3389/fnume.2022.825486. eCollection 2022.

Normal Variants, Pitfalls and Artifacts in Ga-68 DOTATATE PET/CT Imaging

Nico Malan  1 , Mboyo-Di-Tamba Vangu  1
Affiliations
Review

Normal Variants, Pitfalls and Artifacts in Ga-68 DOTATATE PET/CT Imaging

Nico Malan et al. Front Nucl Med. .

Abstract

Indium 111 DTPA Octreotide (Octreoscan) has been the pillar of Somatostatin receptor (SSTRs) imaging in nuclear medicine for over three decades. The advent of PET/CT brought new analogs of somatostatin that have higher affinity and improved resolution due to their labeling to Gallium 68 for positron imaging. The most used analogs include DOTATATE, DOTATOC and DOTANOC. However, Gallium 68-1,4,7,10-tetraazacyclododecane-1,4,7,10-tetraacetic acid (DOTA)-octreotate (DOTATATE) is probably the most common non-FDG (fluoro-2-deoxy glucose) PET tracer alongside PSMA (prostate specific membrane antigen). In contrast to F18-labeled FDG, it does not require proximity to a cyclotron due to the availability of the Ga68 generator. DOTATATE is a somatostatin analog which allows whole body imaging of somatostatin receptors on cell surfaces. 68Ga-DOTA compounds provide the imaging standard for well-differentiated (Grade 1 and low grade 2) neuro-endocrine tumors (NETs) and is utilized in the staging and characterization and restaging of patients with NETs. 68Ga DOTATATE has a complementary role with 18F-FDG where tumors may exhibit varying degrees of differentiation. It furthermore has application as a prelude to therapy in selecting patients for peptide receptor radionuclide therapy using a theranostic approach. A sound knowledge of the normal biodistribution of the radiotracer is imperative for optimal patient outcome and to avoid potential false positives such as inflammation, normal pancreatic uncinate process uptake and osteoblastic activity. In this review, we will describe the normal appearances of the 68Ga DOTATATE and the potential pitfalls with the support of images to aid in improving interpretation of this crucial innovative tool in the management of individuals with tumors expressing SSTRs.

Keywords: Ga68-DOTATATE; PET/CT; neuro-endocrine tumors; normal biodistribution; pitfalls; positron emission tomography/computer tomography; variants.

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Conflict of interest statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Figures

Figure 1
Figure 1
Maximal intensity projection image demonstrating the normal biodistribution of 68Ga-DOTATATE.
Figure 2
Figure 2
Transaxial CT (A) and PET images (B) localizing low grade diffuse activity in the prostate gland (SUVmax 2.8).
Figure 3
Figure 3
This image demonstrates the misregistration as a result of respiratory motion in a patient with hepatomegaly and extensive liver metastases in both the left and right lobes of the liver. Activity appears to be in relation to the lung [(A–C)—transaxial CT, PET and fused PET/CT images respectively], however the activity on PET (F) on CT window of the same region (E) does not show focal lung lesions. (D) shows the maximal intensity projection image of the region.
Figure 4
Figure 4
Transaxial CT (A) and fused PET/CT (B) images showing the increased activity in the uncinate process as indicated by the cross-hairs.
Figure 5
Figure 5
(A–C) show the fused PET/CT images of the spenuncle in the axial, saggital and coronal orientations respectively. The maximal intensity projection image (D) shows the focal activity below the spleen as indicated by the cross-hairs.
Figure 6
Figure 6
Transaxial CT (A) and fused PET/CT (B) images show a fracture of the right 7th rib with associated increased Ga68-DOTATATE uptake.
Figure 7
Figure 7
Transaxial CT (A) and fused PET/CT (B) images demonstrate low grade uptake (SUVmax 2.1) in a patient known with fibrocavitatory pulmonary tuberculosis—the patient was recently started on treatment for tuberculosis.
See this image and copyright information in PMC

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