Epithelioid hemangioendothelioma: evaluation by 18F-FDG PET/CT

Purpose: The purpose of this study was to evaluate the imaging characteristics of epithelioid hemangioendothelioma (EHE) on staging F-18-FDG PET/CT. Materials and methods: An IRB-approved retrospective review was conducted for patients with biopsy-proven EHE who underwent FDG PET/CT at our institution between 2005 and 2019. Patients with a history of surgery, chemotherapy, or radiotherapy prior to PET/CT were excluded. PET/CT exams were analyzed, noting metabolic activity, distribution of involvement, and CT morphologic features. PET/CT findings were correlated with comparative CT and MRI performed within three months. Results: There were 35 patients [21 females, 14 males; average age 55.1 +/- 16.9 years (range 15-82 years)]. 18/35 patients (52%) had more than one organ affected on PET/CT. The most common sites were liver [21/35 (60%)], lung [(19/35 (54%)], bone [5/35 (14%)], lymph nodes [4/35 (11%)], and vasculature [4/35 (11%)]. Most patients [30/35, (86%)] presented with multiple lesions. The average largest lesion dimension was 4.0 +/- 3.6 cm (range 0.6-15.0 cm). The average SUVmax of the most metabolically active lesion at any site was 5.3 +/- 3.3 (range 1.2-17.1), and for bone was 7.9 +/- 5.4 (range 3.5-17.1), liver was 5.1 +/- 2.1 (range 2.6-10.5), and lung was 3.0 +/- 1.9 (range 1.2-8.5). Of patients with pulmonary lesions, 9/19 (47%) showed calcification, and 4/19 (21%) had nodules that were either non FDG-avid or too small for accurate SUV assessment. Of patients with hepatic lesions, 11/21 (52%) demonstrated capsular retraction, and 12/21 (57%) were found to have additional hepatic lesions on contrast-enhanced CT or MRI that were occult on PET/CT. Conclusion: EHE demonstrates variable, but most commonly moderate FDG activity on PET/CT. The most common sites of disease are the liver, lungs, and bones, and most patients present with multiple lesions and more than one organ involved. Given the intrinsic metabolic activity and multi-organ involvement, FDG PET/CT represents an attractive modality for EHE evaluation. However, it may be best used in combination with CT or MRI given that EHE pulmonary or hepatic lesions may be missed by PET/CT.