Cancer Imaging (2005) 5, 58–65
Functional imaging techniques for evaluation of
Rodney J Hicks
The Centre for Molecular Imaging, The Peter MacCallum Cancer Centre, Melbourne, Australia; Department of
Medicine, St Vincent’s Medical School, The University of Melbourne, Australia
Corresponding address: Rodney J Hicks, The Centre for Molecular Imaging, The Peter MacCallum Cancer Centre,
12 Cathedral Place, East Melbourne VIC 2002, Australia. E-mail: email@example.com
Date accepted for publication 5 April 2005
Sarcomas are often characterised by significant histopathologic heterogeneity, both between and within tumours.
This heterogeneity reflects physiologic, biochemical and genetic processes that are amenable to characterisation by
functional imaging. Although anatomically based imaging modalities such as plain radiography, X-ray computed
tomography (CT) and magnetic resonance imaging (MRI) remain the primary diagnostic modalities for staging
sarcomas, nuclear medicine approaches including gamma camera scintigraphy and positron emission tomography
(PET) are being used increasingly to provide complementary information in specific clinical situations. These include
biopsy guidance within anatomically complex masses, staging, therapeutic response assessment and evaluation of
residual mass lesions after treatment. This review aims to address the range of nuclear medicine techniques available
for evaluation of bone and soft tissue sarcomas. A subsequent review discusses the clinical application of these
techniques with a particular focus on PET.
Keywords: PET; FDG; Tl-201; bone scintigraphy; In-111 octreotide.
Anatomical imaging techniques including radiography,
ultrasound, computer X-ray tomography (CT) and
magnetic resonance imaging (MRI) currently play a
dominant role in the evaluation of suspected and known
sarcomas. These modalities allow definition of intra-
lesional structural characteristics, and of the relationship
between tumour boundaries and adjacent normal tissues
including bone and neurovascular structures. For this
purpose, MRI is now probably the major diagnostic
tool. Regional anatomical information is important
to determine the need for and method of biopsy, and
to guide subsequent loco-regional therapies, including
radiotherapy and surgery. However, tissue heterogeneity,
which is a common feature of sarcomas, can make
selection of the most appropriate biopsy site problematic
(Fig. 1). It can also make interpretation of anatomical
imaging results difficult following therapy. This is an
important potential limitation since the behaviour of
sarcomas, their prognosis and determination of the
most appropriate management are influenced by the
highest histological grade of tumour that is present.
Furthermore, for staging purposes, sensitive and specific
whole-body screening capability is required.
likely begins with altered cell cycle regulation related to
genetic damage. This, in turn, will often alter cellular
function characteristics including enzymatic, cytosolic
and cell-surface protein expression. These changes
alter biochemical characteristics of the cancer cell and
secondarily influence tissue physiology. It is only when
the volume of abnormal cells becomes large enough to be
detected by an imaging technique, direct visualisation or
palpation, that a mass lesion becomes evident. Although
this is a very simplistic account of tumorigenesis, it
makes the point that anatomical imaging can only be
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1470-7330/05/010058 + 08
c ? 2005 International Cancer Imaging Society
Functional imaging techniques for evaluation of sarcomas 59
expected to characterise the later consequences, and not
the intrinsic drivers of tumour development.
Nuclear medicine techniques potentially offer unique
information regarding tumour biology and thereby, pro-
vide complementary information to anatomical imaging,
particularly within heterogeneous lesions. Based on the
tracer kinetic model, developed by Georg von Hevesy
early last century, nuclear medicine techniques involve
administration of ‘radiotracers’ in minute amounts in
order to mimic the fate of related, non-radioactive
chemicals. Accordingly, nuclear medicine tests are
extremely safe with an extremely low incidence of
allergic reactions or other side effects.
tissue mass in the left thigh demonstrated marked
heterogeneity of FDG uptake in the mass with small
foci of very intense uptake superimposed on an
overall pattern of only mildly to moderately increased
activity. The reference transaxial CT and PET images
correspond to the focus of highest FDG uptake seen
on the right lateral maximum intensity projection
images (horizontal arrow). Biopsy would normally
have been directed at this site. However, multiple
cutaneous metastases were identified (arrow heads).
Note that the intensity of uptake at metastatic sites is
similar to the intense primary tumoral uptake sites,
consistent with the notion that the most metabolically
active tumour sites are also the most aggressive and
Combined PET/CT imaging of a large soft
The importance of functional imaging
for sarcoma evaluation
Altered tissue physiology and biochemistry provide
potential means for differentiating benign from malignant
mesenchymal lesions and underpin functional imaging
techniques. However, it needs to be recognised that
functional imaging is not the exclusive domain of
nuclear medicine techniques. For example, dynamic-
contrast CTand MRIexploit the hypervascularity
and altered endothelial function of tumours, including
sarcomas, and have emerged as important functional
imaging techniques, eroding the traditional role of
standard nuclear medicine techniques for assessing
tumoral perfusion and ‘blood volume’. Alteration in
tissue biochemistry is less easily evaluated by anatomical
imaging techniques than by nuclear medicine. However,
magnetic resonance spectroscopy (MRS) is now pro-
viding important information regarding the biochemical
signature of sarcomas, albeit with a highly restricted
sampling volume. Characterisation of the whole-
body distribution of biochemical processes is currently
primarily the domain of nuclear medicine. This has led
to the widespread use of the term ‘metabolic imaging’ in
place of ‘nuclear medicine’ in recent times.
One of the most important characteristics of sarcomas
is heightened proliferative activity. Increased mitochon-
drial numbers, increased protein synthesis, acceler-
ated glycolysis, alteration in glucose-transporter protein
expression are but a few of the biochemical correlates
of this process. Most functional imaging techniques that
are in current use for the evaluation of sarcoma rely
on detection of the secondary metabolic consequences
of heightened proliferation and some newer techniques
directly trace cellular proliferation. The ability to directly
and indirectly evaluate cellular proliferation over time
provides an expanding opportunity for the use of
measure of therapeutic response.
More specific characterisation of malignant transfor-
mation may also be possible by identification of the key
drivers of this process including: alteration in cell surface
receptors and transport protein complexes; up-regulation
or down-regulation of key cytosolic enzymes; and altered
Specific nuclear medicine
Vascular phase imaging
Although contrast enhancement of anatomical imaging
techniques provides excellent assessment of tumour vas-
cularity, administration of any radiotracer in a sufficient
activity and with suitable imaging characteristics can
also allow assessment of regional perfusion. The blood
flow phase of bone scanning is an example of this
technique and provides additional diagnostic information
to the subsequent metabolic phase of the investigation.
For example, incorporation of information from the
blood-flow and blood-pool phases substantially improves
specificity and overall accuracy of bone scanning in the
detection of bone tumours.
The best validated nuclear medicine technique for
quantitatively evaluating the perfusion of sarcomas is,
60 R J Hicks
however, positron emission tomography (PET) with
oxygen-15 (15O) water. Osteosarcoma, chondrosar-
coma, Ewing’s sarcoma, malignant fibrous histiocytoma,
rhabdomyosarcoma all tend to be highly vascular.
Although many other sarcomas are also hypervascular,
benign lesions can also have this characteristic. Osteoid
osteomas, and inflammatory lesions such as osteomyelitis
and recent fracture are examples. The pattern of perfusion
abnormality can be helpful in differentiating benign from
malignant processes with increased peripheral perfusion
being more common in aggressive tumours than benign
lesions. Tumour vascularity will generally decrease with
effective therapy either returning to similar levels seen
in adjacent bone or soft tissue or becoming relatively
avascular if healing fibrosis occurs.
scans of a patient with recurrence of osteosarcoma
in the left thigh and metastases to lung and bone
are demonstrated. Although201Tl demonstrates the
peripheral and lung lesions quite well, the contrast is
less than that observed on bone scanning, potentially
limiting its sensitivity for other metastatic sites. The
high uptake in abdominal and pelvic structures
obscure the iliac and sacral metastases that are clearly
seen on bone scan.
99mTc MDP bone (left) and201Tl (right)
The technical and logistic advantages of dynamic-
contrast CT and MRI (DC-MRI) will likely make
these the preferred functional imaging techniques for
characterisation of tumoral perfusion with15O water
studies reserved for research applications in specialised
facilities with the expertise and resources required to
perform such studies.
Bone-forming tumours, particularly osteosarcoma, are
characterised by malignant osteoid formation while other
sarcomas can secondarily invade bone, invoking reactive
Evaluation of bone involvement remains an important
indication for radionuclide bone scanning in known or
suspected cases of sarcoma. The whole body screening
capability of this scan provides cost-effective screening
for metastatic spread or multifocal bone pathologies.
Bone seeking radiotracers include
diphosphonate (MDP) and18F fluoride, which can be
imaged by PET. High
tissue sarcomas is uncommon except in osteosarcoma
metastases. Bone scanning still has a role in the follow-
up of patients with osteosarcoma (Fig. 2). With respect to
other primary bone sarcomas, the intensity of osteoblastic
activity with Ewing’s sarcoma is variable but tends
to be less than with osteosarcoma. In our experience,
high bone tracer uptake in relationship to chondroid-
matrix lesions increases the likelihood of malignant
transformation but is not specific for malignancy. Lack
of abnormality on the bone uptake phase of the study
favours a benign or mature bone process. Malignant
fibrous histiocytoma in bone usually invokes moderately
intense osteoblastic activity at the bone–tumour interface
but the tumour, itself, does not usually concentrate bone-
While a decrease in bone turnover throughout a lesion
following therapy strongly suggests therapeutic response,
the converse is not as predictive of lack of response.
Increased osteoblastic activity may accompany bone
healing following successful treatment: this is often
termed a ‘flare’ response.
99mTc MDP uptake in soft
Metabolic imaging with single-photon agents
The term metabolic imaging is pertinent to radiotracers
that have active uptake into tumours based on basal
metabolic rates or increased proliferative activity.
Thallium-201 (201Tl), a mono-cationic analogue of
potassium ATPase pump. Enhanced metabolic activ-
ity often increases activity of this pump and therefore
malignant tumours frequently concentrate this tracer
perfusion probably also plays a role in the increased
uptake of201Tl in tumours.201Tl was first reported
as a tumour-imaging radiotracer following serendipitous
discovery of uptake in a lung cancer during myocardial
perfusion scanningand since then has been evaluated
Functional imaging techniques for evaluation of sarcomas 61
in a range of malignancies including glioma, lymphoma,
and carcinoma of the lung, breast and thyroid. High
affinity for201Tl has also been observed in various bone
(Fig. 2) and soft tissue sarcomas (Fig. 3). An early
study involving 38 patients with surgically proven bone
and soft tissue sarcomas found increased uptake in all
cases. A subsequent Japanese study demonstrated
abnormal201Tl uptake in all 30 patients with newly
diagnosed osteosarcoma. The ability of
detect osteosarcoma involving pagetic bone has also
been documented. Soft tissue tumours, including
leiomyosarcoma and malignant hemangioendothelioma,
have also been identified on201Tl imaging. Increased
201Tl uptake in a lesion is not, however, unequivocal
evidence of a malignant aetiology. Various granuloma-
tous diseases can have increased uptake early, possibly
reflecting third space trapping, but retention is usually
quite low, and therefore either both early and delayed,
or only delayed imaging, is recommended for assessing
the likelihood of malignancy in lesions with equivocal
anatomical features. It is also important to recognise that
sarcomas containing a large amount of acellular matrix
material, such as myxoid liposarcomas or chondroid
matrix tumours, can be false negative on201Tl imaging.
Recognition of the likelihood of these entities based on
anatomical imaging appearances can allow for either
omission of201Tl scintigraphy or complementary use of
additional isotopic studies more suited to the detection of
these acellular matrix components (see below).
ment of a long-standing mass in the medial aspect
of the left thigh, thought previously to represent
a lipoma. The upper part of the mass had char-
acteristics of fat on CT and MRI while the lower
part had features suggesting sarcomatous degen-
eration. The upper part of the tumour (arrow)
part had heterogeneous uptake, most marked in the
inferior aspect. The latter site was chosen for biopsy
and demonstrated high-grade liposarcoma. Following
neoadjuvant radiotherapy only low-grade tumour
elements remained in the mid-part of the tumour.
201Tl uptake whereas the lower
99mTc sestamibi (MIBI) and99mTc tetrofosmin are
other myocardial blood-flow imaging agents that have
been shown to actively concentrate in tumour cells. The
higher photon energy and shorter half-life of99mTc offer
theoretical advantages compared to201Tl but efflux of
these radiopharmaceuticals mediated by p-glycoprotein,
a membrane-associated channel involved in multi-drug
resistance (MDR), may limit their clinical utility.
Enhanced uptake of99mTc MIBI in malignant tumours
is thought to reflect increased numbers of mitochondria
in cancer cells. A decrease in
may reflect favourable therapeutic response. Unlike
99mTc MIBI,99mTc tetrofosmin does not accumulate
significantly in mitochondriaand therefore may
provide different information regarding cell viability
following therapy. However, for tumour visualisation
both agents appear to perform comparably. Similarly
a comparison of99mTc MIBI and201Tl also suggests
that the diagnostic performance of these tracers is
comparable. Despite concerns regarding the influence
of MDR on the negative predictive value of
MIBI scans, a series of 84 patients with musculoskeletal
tumours (31 malignant and 53 benign) demonstrated
a negative predictive value of 88%. A comparison
of99mTc MIBI and FDG PET imaging in 48 patients
with suspected recurrent or residual musculoskeletal
sarcoma demonstrated that PET had a significantly higher
sensitivity (98% vs. 82%) and a non-significantly higher
specificity (90% vs. 80%) than MIBI. For these
reasons, we currently use either201Tl or FDG PET for
appendicular sarcomas and FDG PET for sarcomas of the
abdomen and pelvis (due to the high background uptake
in normal organs by the available SPECT tracers).
99mTc MIBI uptake
Metabolic imaging with PET
The use of metabolic tracers imaged with PET is
playing an increasing role in oncology. The most
([18F]FDG), which is an analogue of glucose that is
transported into cells, phosphorylated and trapped within
cancer cells more avidly than by normal cells. Up-
regulation of glucose transporters is probably a major
factor driving this process. The intensity of FDG-
uptake has been shown to correlate with histologic
grade and proliferative activity in a range of cancer
[18F]FDG has been shown to concentrate in a wide
range of sarcomas. A recent meta-analysis of the use of
FDG PET for the detection of sarcoma pooled results
from 29 studies that met predefined inclusion criteria
gave a sensitivity, specificity and accuracy of 91%,
85% and 88%, respectively. However, the ability of
FDG PET to differentiate between benign and malignant
lesions has been variable in individual studies. Using
quantitative measurement of glucose metabolic rate,
a small study in 19 malignant and 7 benign bone
tumours was unable to reliably characterise lesions.
The dynamic acquisition protocol used for this study
62 R J Hicks
only evaluated the uptake characteristics over the first
50 min after injection of radiotracer. There is now
evidence that the peak intensity of FDG uptake in benign
lesions is reached by around 30 min after injection,
whereas the peak uptake of FDG is delayed to around
4 h in malignant soft tissue lesions. Accordingly,
characterisation of the initial phase of FDG uptake, even
if quantitative, may not have as great discriminatory
power as delayed imaging. This raises the possibility
that ‘dual-phase’ FDG PET scanning may be a helpful
technique for helping to differentiate between malignant
and inflammatory lesions. With this technique, a standard
whole-body screening study would be performed at
around 1 h after injection; this is a practical time-
point in a clinical PET facility. If there is an isolated
focus of FDG uptake that could reflect an inflammatory
or malignant condition, a delayed single bed position
acquisition could be acquired at 3–4 h post-injection. An
increase in the measured FDG uptake would increase
the likelihood of malignancy, whereas washout would
favour an inflammatory basis. The most common method
of measurement of FDG uptake from static images is
the so-called ‘standardised uptake value’ (SUV). This
methodology calibrates uptake in any given tissue against
a known sample and corrects for the mass of the patient,
the administered dose of activity and radioactive decay.
Assuming a uniform distribution of FDG throughout the
body, a SUV of 1.0 would be obtained. However, tissues
that actively concentrate FDG have SUVs of significantly
higher than this, and generally in excess of 2.5. Arguing
against a semi-quantitative approach as opposed to
formal quantitative analysis of glucose metabolism, a
previous study comparing dynamic and delayed static
quantitative measure and histopathological malignancy
grade than with SUV measurementand another that
demonstrated that a fully quantitative approach provided
better discrimination of grades I and III than did SUV
analysis. However, for practical reasons, we favour a
delayed whole-body imaging protocol in clinical practice
and are encouraged by a methodological study performed
by investigators at the University of Washington who
demonstrated an excellent correlation co-efficient of 0.94
between an SUV obtained by summing the last 30 min of
a dynamic imaging series with a full dynamic acquisition
obtained over 60 min, even though this study may
also suffer from the limitations of progressively rising
SUV over time in malignant lesions but not in benign
Relative hypoxia in tumours appears to be an
important stimulus for up-regulation of the primary
glucose transporter in cancer cells, GLUT 1, and of
expression of the rate-limiting enzyme of glycolysis,
hexokinase. Hypoxia may therefore be an important
reason for the high FDG in many sarcomas. However,
hypoxia can also be more directly evaluated by PET
using [18F]fluoromisonidazole (FMISO), an imidazole
compound that is specifically trapped within hypoxic
cells. Since hypoxia decreases the sensitivity of tissues
to radiation and thus lessens the efficacy of radiotherapy,
PET scanning with FMISO may provide useful informa-
tion in selecting the most appropriate form of adjuvant
therapy for bone and soft tissue tumours.
Increased protein synthesis in tumours can be assessed
using a range of radiopharmaceuticals based on naturally
occurring amino acids. These can be labelled with single
photon agents or with positron emitting radionuclides.
The most intensively evaluated agent is carbon-11
methionine, a PET agent. Incorporation of this
agent in tumour tissues is correlated with proliferative
activity. A decrease in protein synthesis may precede
and be more predictive of therapeutic response than
changes in [18F]FDG uptake and retention. [11C]Tyrosine
has been compared to FDG in 55 patients with soft
tissue sarcoma, 28 of whom had follow-up imaging
after treatment. In this study, FDG correlated better
with tumour grade but [11C]tyrosine uptake seemed
to provide better prediction of therapeutic response.
[18F]Fluoroethyltyrosine represents a new radiolabelled
amino acid suitable for imaging using PET. Its role in
sarcoma imaging is currently unclear.
Similarly, new tracers for evaluating cellular prolifer-
ation have recently been described. Currently, the best
characterised of these is [18F]fluorothymidine (FLT).
There is relatively little experience with this agent in
sarcomas but preliminary studies suggest that it may have
a role in tumour grading. Our own experience also
suggests that it may be helpful for assessing therapeutic
response (Fig. 4).
FLT PET scans demonstrate a decrease in uptake in
the actively proliferating components of a large, het-
erogenous mass completely filling the right hemitho-
rax in an adolescent with previous radiotherapy
for a synovial sarcoma of the left hip. The loss
of bone marrow uptake in the left femur (arrows)
is consistent with ablation of haemopoietic cells by
Baseline (left) and follow-up (right)18F
Functional imaging techniques for evaluation of sarcomas 63
chondroid matrix tumour in the right shoulder in a
middle-aged female. Foci of high [99mTc(V)]DMSA
(right) and201Tl (left) uptake suggested a probable
chondrosarcoma. Subsequent histopathology indi-
cated a high-grade chondrosarcoma. (b) An exo-
phytic chondroid lesion in proximal left tibia had
recently caused pain in a male in his twenties. High
[99mTc(V)]DMSA (right) was apparent over the cap of
the lesion but the201Tl scan (left) was negative. While
high DMSA uptake generally indicates malignant
degeneration in adult patients, benign exostoses
usually have uptake as long as skeletal growth is
present and for a few years after normal epiphyseal
fusion. The resected specimen confirmed a low-grade
(a) Plain X-ray and MRI suggested a
Indirect imaging of acellular matrix
As discussed above, false negative metabolic imaging
studies can occur with some high-grade sarcomas if
the metabolic signal from the malignant cell lineage is
significantly diluted by the presence of abundant acellular
matrix material within the tumour mass. In many series
chondroid matrix tumours account for a significant
proportion of the relatively few false negative201Tl,
99mTc MIBI and FDG PET scans. The large amount of
chondroid matrix that can be present in these tumours and
the relatively scant malignant cells, even when the cells
are poorly differentiated, makes this observation easy
to comprehend. Nevertheless, since the classification of
chondroid matrix tumours as being benign or malignant
has significant prognostic and management implications,
a non-invasive technique that could make this distinction
accurately would be of benefit. The demonstration that
[99mTc(V)]DMSA is actively concentrated in almost all
chondrosarcomas and not by the majority of benign
chondrogenic tumourssuggests that this may be
a useful technique for this dichotomisation. Our own
experience with combined201Tl and [99mTc(V)]DMSA
suggests that high-grade chondrosarcomas generally have
high uptake of both tracers, whereas intermediate- and
low-grade chondrosarcomas are generally only positive
on the [99mTc(V)]DMSA scan (Fig. 5). Most benign
lesions are negative on both. The exception is that a
positive [99mTc(V)]DMSA scan can occur in adolescents
and young adults (up to around the age of 30), in
whom there is presumably ongoing active growth of
the benign lesion. Although the exact mechanism of
uptake of [99mTc(V)]DMSA scan in chondrosarcomas
is not clear, the intensity of uptake suggests that it
must be in the chondroid matrix but reflect biochemical
difference in the nature of the matrix in benign and
malignant lesions. Given the uptake of [99mTc(V)]DMSA
scan in amyloid, this may relate to the valency of
the protein component. Immature osteoid is a possible
target and would explain the false-positive results in
actively growing osteochondromas and enchondromas in
adolescents and young adults. However, uptake of this
agent has also been described in other sarcomas without a
significant acellular matrix componentand therefore
the possibility that it might reflect intense direct uptake
in the malignant chondrocytes cannot be excluded. We
routinely perform [99mTc(V)]DMSA scanning in patients
with chondroid matrix tumours that are negative on201Tl
or FDG PET imaging.
Myxoid tumours are also recognised to lead to false-
negative metabolic imaging studies with201Tl,67Ga and
FDG PET. Avid uptake of [99mTc]pertechnetate has been
described in myxoid sarcomas. The pertechnetate
uptake by myxoid tumours is a delayed rather than an
acute phenomenon and therefore more likely reflects
binding of tracer to the myxomatous elements rather
than passive third-space trapping. Our imaging protocol
is to do dynamic blood flow and early blood pool
images followed by 2–3 h delayed scanning. We
routinely perform [99mTc]pertechnetate scans for soft
tissue sarcomas that are negative from201Tl or FDG PET
64 R J Hicks
Immunological and receptor imaging
Advances in the understanding of the molecular biology
of tumour cells coupled with improved methods for
radiolabelling of biological compounds will increasingly
allow development of specific radiotracers for targeting
sarcomas. Monoclonal antibodies to cell surface antigens
are an example of this type of approach. The anti-3F8
monoclonal antibody directly against gangliosides has
affinity for a range of sarcomas including malignant
fibrous histiocytoma. However, the relatively large
molecular size of monoclonal antibodies can limit tissue
penetration and, therefore, contrast between blood and
Peptides that act as receptor ligands and cell messenger
proteins offer attractive prospects for tumour imaging.
For example, [111In]pentreotide binds particularly to
subclass 2 somatostatin receptors and has been shown to
be taken up in osteosarcoma. This interesting paper
demonstrated a higher sensitivity for primary tumours
than for metastatic sites and tumours with high uptake
had a better response to chemotherapy than lesions
without uptake, suggesting that somatostatin receptor
expression may provide useful biological behaviour
As the growth factors, autocrine and paracrine
substances that regulate tumour growth of bone and
soft tissue sarcomas become better understood, it may
be possible to radiolabel these to allow metabolic
Oligonucleotides including anti-sense codons that form
triplexes within the groove of double-stranded DNA
potentially allow detection of specific genetic sequences
within cells. Where an aberrant gene is implicated in
tumorigenesis, a radiolabelled anti-sense-oligonucleotide
could be used to target tumour cells. This approach is
at a very early stage of development. Its potential has
recently been demonstrated using optical imaging in a
rat model. Although it is feasible to label anti-sense
oligonucleotides with radioisotopes suitable for SPECT
or PET imaging, this approach is considered likely to
be more effective for therapeutic intervention than for
diagnostic imaging due to the very low concentration
of potential target genes within tumour cells. A type
of ionising radiation called an Auger electron is ideally
suited to therapeutic application of this type. The Auger
electrons emitted from a range of radionuclides such as
iodine-125 (125I) travel only a few micrometres from
where they arise. Oligonucleotides labelled with these
agents are capable of inducing lethal double-stranded
DNA breaks at specific sites in the chromosome. The
sensitivity of PET may make it feasible to image such
genomic targeting using124I.
The wide range of nuclear medicine techniques available
for evaluation of sarcomas reflects the wide diversity
of biological features that characterise sarcomas. The
choice of investigation should be guided by the clinical
question that needs to be answered and the results of
other investigations that are more routinely performed.
Nevertheless, nuclear medicine techniques in general,
and PET in particular, are an important component of the
diagnostic armamentarium used for evaluation of known
or suspected sarcoma.
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