First Experience Using 18F-Flubrobenguane PET Imaging in Patients with Suspected Pheochromocytoma or Paraganglioma

Pheochromocytomas and paragangliomas are a rare tumor entity originating from adrenomedullary chromaffin cells in the adrenal medulla or in sympathetic, paravertebral ganglia outside the medulla. Small lesions are especially difficult to detect by conventional CT or MRI and even by SPECT with the currently available radiotracers (e.g., metaiodobenzylguanidine [MIBG]). The novel PET radiotracer F-18-flubrobenguane could change the diagnostic paradigm in suspected pheochromocytomas and paragangliomas because of its homology with MIBG and the general advantages of PET imaging. The aim of this retrospective analysis was to evaluate F-18-flubrobenguane in pheochromocytomas and paragangliomas and to investigate the biodistribution in patients. Methods: Twenty-three patients with suspected pheochromocytoma or paraganglioma underwent PET/CT or PET/MRI at 63 +/- 24 min after injection of 256 +/- 33 MBq of F-18-flubrobenguane. The SUVmean and SUVmax of organs were measured with spheric volumes of interest. Threshold-segmented volumes of interest were used to measure the SUVmean or SUVmax of the tumor lesions. One reader evaluated all cross-sectional imaging datasets (CT or MRI) separately, as well as the PET hybrid datasets, and reported the lesion number and size. The diagnostic certainty for a positive lesion was scored on a 3-point scale. Results: 18 F-flubrobenguane showed a reproducible, stable biodistribution, with the highest SUVmax and SUVmean being in the thyroid gland (30.3 +/- 2.2 and 22.5 +/- 1.6, respectively), pancreas (12.2 +/- 0.8 and 9.5 +/- 0.7, respectively), and tumor lesions (16.8 +/- 1.7 and 10.1 +/- 1.1, respectively) and the lowest SUVmax and SUVmean being in muscle (1.1 +/- 0.06 and 0.7 +/- 0.04, respectively) and the lung (2.5 +/- 0.17 and 1.85 +/- 0.13, respectively). In a subgroup analysis, a significantly higher average SUVmean was seen for both pheochromocytoma and paraganglioma than for healthy adrenal glands (11.9 +/- 2.0 vs. 9.9 +/- 1.5 vs. 3.7 +/- 0.2, respectively). In total, 47 lesions were detected. The reader reported more and smaller lesions with higher certainty in PET hybrid imaging than in conventional imaging; however, statistical significance was not reached. Of the 23 (23/47, 49%) lesions smaller than 1 cm, 61% (14/23) were found on hybrid imaging only. Conclusion: Our preliminary data suggest F-18-flubrobenguane PET to be a new, effective staging tool for patients with pheochromocytoma or paraganglioma. Major advantages are the fast acquisition and high spatial resolution of PET imaging and the intense uptake in tumor lesions, facilitating detection. Further studies are warranted to define the role of F-18-flubrobenguane PET, particularly in comparison to standard diagnostic procedures such as MRI or I-123-MIBG SPECT/CT.