Schwannoma of the extremities: the role of PET in preoperative planning

The aim of this study was to determine the relative utility of various preoperative diagnostic imaging modalities for the evaluation of benign schwannoma, including positron emission tomography (PET) utilising-fluorine-18 fluoro-2-deoxy-D-glucose (FDG) and fluorine-18 alpha -methyl tyrosine (FMT), computed tomography (CT), magnetic resonance imaging (MRI) and digital subtraction angiography (DSA). We retrospectively reviewed imaging findings in 22 patients with 25 histopathologically documented benign schwannomas of the extremities. Pre-operative imaging included: FDG-PET (n=22), FMT-PET (n=17), MRI (n=25), CT (n=16) and DSA (n=17). All 22 lesions examined by PET with FDG and/or FMT showed accumulation. The standardised uptake values (SUVs) for FDG-PET for the 22 examined tumours ranged from 0.33 to 3.7, and eight of them (36.4%) were assessed as malignant on the basis of their uptake. The SUVs for FMT ranged from 0.44 to 1.47, and 15 out of the 17 evaluated (88.2%) showed values indicating the tumour to be benign. CT demonstrated variable attenuation and contrast enhancement. MRI signal characteristics were relatively consistent: iso-signal or darker than skeletal muscle on T1-weighted and iso-signal or brighter than subcutaneous fat on T2-weighted images. The venous tumour staining depicted on DSA was found to be significantly correlated with FDG accumulation. All tumours but one were treated by surgical enucleation. One tumour suspected to be malignant on the basis of imaging findings was treated with primary wide resection. Although CT, MRI and PET studies are all useful for the detection and localisation of schwannoma, our findings suggest that, among the imaging modalities studied, FMT-PET may be the most reliable technique for the differentiation of benign schwannoma from malignancy.