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Click 59 year old male with Non small cell lung cancer with metastasis. Contrast-enhanced Chest, Abdomen and Pelvis CT Scan (Diagnostic scan- Figure 4): There is a 2.9 cm mass in the left upper lobe anteriorly with a smaller satellite nodule. Supraclavicular/left axillary nodes are present. There is a 3.6 cm necrotic aorta pulmonary nodes which is inseparable from the ascending aorta and suspicious for infiltration of the wall. Further necrotic left hilar nodes. Hepatic metastases in both lobes, largest 5.3 cms in segments 7/6. Enlarged retrocrural node. Widespread bone metastases but particularly T7/8/9 /11; left scapula/glenoid; 8 left rib; right 7 rib /right ilium and L 4.

Click 59 year old male with Non small cell lung cancer with metastasis. Gadolinium-enhanced lumbo-sacral spine MRI (Figure-3): Sequences: Axial T1W, T2W ; Sagittal T1W, T2W , T1W Tirm; Coronal T1W (precontrast), T2W, T1W STIR post contrast. Findings: Sagittal T1W and T2W images show multiple hypointense on T1W and isointense on T2W at L3, L4 and L5 vertebral bodies. Coronal T1W pre-contrast image shows an expansile isointense lesion involving the right iliac bone with extension into the adjacent right sacrum. Coronal T1W (STIR) post contrast image shows intense enhancement involving the right iliac crest and sacrum with extension into the right gluteal and right piriformis muscles.

Click 59 year old male with Non small cell lung cancer with metastasis. 18F-DG Whole-body PET/CT Scan (Baseline scan- Figure 4): Whole body FDG PET/CT from vertex to mid thigh with low dose unenhanced CT for attenuation correction and image fusion (including MIP images at the end of the scan). Findings: There are tracer avid nodes in the left supraclavicular fossa and left axilla. A large tracer avid mass is seen in the left upper lobe (maximum SUV 17.4). There is a small right upper lobe nodule which shows low grade FDG uptake (maximum SUV 1.3). Multiple FDG avid nodes are seen in the mediastinum (prevascular and AP window regions). There are multiple FDG avid lesions in the liver, largest in the right lobe (maximum SUV 15.4). The medial limb of left adrenal gland is bulky but non avid. There is a tracer avid right retrocrural node. There is a tracer avid soft tissue deposit in the upper back.There is a large tracer avid lytic lesion involving the left scapula with extension to adjacent soft tissues. Further FDG avid lesions are seen in the C5 spinous process, at multiple levels in the thoracolumbar spine, in the right sacrum and right sacro-iliac joint, both iliac bones, right proximal femur and right pubic bone. There is an expansile lesion involving the left 8th rib which is tracer avid.

Click 59 year old male with Non small cell lung cancer with metastasis. 18F-DG Whole-body PET/CT Scan (Follow-up scan after 4th cycle of chemotherapy-Figure 6a): Whole body FDG PET/CT from vertex to mid thigh with low dose unenhanced CT for attenuation correction and image fusion (MIP images at the beginnoing of the scan). Findings: The current study was compared with the previous FDG PET CT study. The previously identified lesion in the left upper lobe shows reduced uptake (maximum SUV 2.6 previously and now 1.2). Two fresh nodules are seen in the left upper lobe, the more posterior of which shows low-grade FDG uptake (maximum SUV 1.2). There is fresh pleural thickening in the left lung and this takes up FDG (maximum SUV 1.8, inflammatory change ?). The previously noted mild FDG uptake in consolidation and small right upper lobe nodules has partially resolved. The intensity of uptake within the aortopulmonary nodes has reduced. The activity noted in segments six and seven of the liver has reduced. Most of the previous sites of FDG avid skeletal disease show reduction of tracer uptake. There is, however, increased uptake in the left acetabulum (maximum SUV previously 4.2 and now 5.2) and within the L3 vertebral body. Fresh FDG uptake is seen within the left ischium at a site of previously identified sclerosis.

Click 59 year old male with Non small cell lung cancer with metastasis. 18F-DG Whole-body PET/CT Scan (Follow-up scan after 6th cycle of chemotherapy-Figure 6b): Whole body FDG PET/CT from vertex to mid thigh with low dose unenhanced CT for attenuation correction and image fusion (including MIP images at the end of the scan). Findings: The current PET scan was compared to previous study. There is ongoing FDG uptake in the left upper lobe spiculated nodule (SUV max 1.3; previous SUV max 2.6), measuring 1.2 cm. There to further nodules seen in the left upper lobe posteriorly which essentially remained unchanged in size and metabolic activity (SUV max 1.2; 1 cm). There was subpleural activity posteriorly (SUV max 2.7), previous radiotherapy?.There is mild FDG uptake (SUV max 2.5) in the liver lesion (segment 06/07). There is increased FDG activity in L2, L3 vertebra (SUV max 7.7: L3 vertebra), there is L4 sclerosis with minimal activity anteriorly. There is uptake seen in the left acetabulum anteriorly. Ongoing activity is noted in the roof of the left acetabulum (SUV max 8.4; previous 4.2), left femoral neck, and left ischium (SUV max 8.4). There is no abnormal activity seen elsewhere. Conclusion: Compared to previous study, there is no fresh lesion. The metabolic activity in the bone disease shows an increase which is most likely due to a ``flare`` phenomenon.

Click 59 year old male with Non small cell lung cancer with metastasis. 18F-DG Whole-body PET/CT Scan (Follow-up scan after 1 month -Figure 7): Whole body FDG PET/CT from vertex to mid thigh with low dose unenhanced CT for attenuation correction and image fusion. Findings: There is FDG uptake in the abnormal soft tissue in the AP window. There is focal uptake in the liver lesions. There is increased uptake in the left neck of femur, left hemipelvis, L2 and L3. No uptake in the left scapula or right hemipelvis lesions. Conclusion: Compared to the previous PET CT, there is relapse with new avidity in the AP window and liver lesions.