Introduction: Adrenal tumours can either be benign or malignant, hormone secreting or not, and they can be discovered through clinical examination of the patient or by pure chance. 

Increased knowledge in the area, plus the widespread use of imaging techniques, have resulted in a rising number of patients with adrenal tumours that subsequently need to be diagnosed. Improved imaging is needed for primary aldosteronism (PA) and adrenocortical carcinoma (ACC) but the positron emission tomography (PET) tracer currently in use, [¹¹C]metomidate (MTO), has many important limitations. This thesis aims to improve adrenocortical PET imaging.

Methods: Paper 1 investigated the pre-clinical properties of Para-Chloro-2-[¹⁸F]fluoroethyl-etomidate (CETO), by autoradiography, binding studies, ex vivo biodistribution on rats and in vivo imaging using mice and one non-human primate (NHP). Paper II investigated the clinical properties of [¹⁸F]CETO and included patients with various kinds of adrenocortical tumours, and healthy volunteers. Metabolic and kinetic analyses were performed and three out of five healthy volunteers also underwent [¹⁵O]water PET/CT to measure adrenal blood flow. Test-retest was performed on all healthy volunteers.  Paper III assessed the in vivo and in-human radiation dosimetry of [¹⁸F]CETO. Ex vivo uptake data from rats and in vivo PET/CT from NHP and humans were used to calculate residence times. Paper IV evaluated the use of the block-sequential regularized expectation maximization (BSREM) reconstruction algorithm (Q.Clear, GE Healthcare, Milwaukee, USA) for [¹¹C]MTO PET/CT in patients with PA.

Results: Papers I and II demonstrated that [¹⁸F]CETO is highly specific to the adrenal cortex both in vitro and in vivo. The non-specific binding of [¹⁸F]CETO in the liver was significantly lower than that of [¹¹C]MTO. [¹⁸F]CETO metabolizes rapidly and the single tissue irreversible (1T1k) kinetic model provided the best fit.  [¹⁵O]water PET/CT results indicated that the adrenal [¹⁸F]CETO uptake was flow limited. Several retest values, including adrenal blood flow, were lower than the test values. Paper III found that the effective dose based on human data was 18.2 μSv/MBq and that the adrenal glands were the limiting organ regardless of species used. Paper IV showed that the BSREM reconstruction algorithm improves image quality, without compromising SUVmax quantification, and a β-value between 70 and 130 was found optimal.

Conclusion: [¹⁸F]CETO PET/CT is a promising method for adrenocortical imaging and is safe for clinical imaging in terms of radiation dose. [¹⁸F]CETO PET/CT should be further investigated in patients with PA or ACC, preferably in conjunction with BSREM reconstruction.