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Positron emission tomography (PET) is a nuclear medicine examination involving the injection of radiotracers that provide a functional assessment of biochemical, physiologic, and pathophysiologic processes. PET radiotracers contain radioactive elements that undergo positron decay and subsequent annihilation with nearby electrons to produce two 511-keV photons traveling in opposite directions at 180 degrees from each other. Modern PET cameras implementing coincidence detection with the help of computer software use this opposite photon trajectory to reconstruct a spatial distribution. Computed tomography (CT) complements the examination to provide anatomic correlation and attenuation correction. Hybrid or fusion PET-CT imaging has become a crucial imaging tool utilized for detection, staging, and treatment follow-up of various benign andmalignant conditions. F18-fludeoxyglucose (F18-FDG) is the most commonly used PET radiotracer. A glucose analog, F18-FDG capitalizes on the known propensity for malignant cells to overutilize glucose by favoring glycolytic metabolism.1 Otto Warburg discovered this principle in the 1930s, and it is known as theWarburg effect.2 The predisposition for malignant tumors to demonstrate hypermetabolism of glucose provides the basis for F18-FDG PET cancer imaging. While highly sensitive and versatile for imaging a variety of solid and hematologic tumors, F18-FDG has certain limitations, including lack of target specificity because of the ubiquitous utilization of glucose in the body and poor sensitivity for tumors with more indolent behavior and lower utilization of glucose. These F18-FDG limitations have prompted development of several new target-specific radiotracers with more specific mechanisms of localization.1 One such PET radiotracer is gallium (Ga)-68 DOTATATE that is commonly used in the imaging of neuroendocrine tumors. Our case demonstrates how a negative F18-FDG PET-CT examination does not necessarily equate to benignity and how not all malignant lesions are hypermetabolic. We illustrate the importance of understanding the mechanism of localization for PET radiotracers in the evaluation and characterization of unknown lesions.

Pulmonary Carcinoid and the Importance of Correct Radiotracer Selection