Influence of the scan time point when assessing hypoxia in 18F-fluoromisonidazole PET: 2 vs. 4 h



18F-fluoromisonidazole (18F-FMISO) is the most widely used positron emission tomography (PET) tracer for imaging tumor hypoxia. Previous reports suggested that the time from injection to the scan may affect the assessment of 18F-FMISO uptake. Herein, we directly compared the images at 2 h and 4 h after a single injection of 18F-FMISO.


Twenty-three patients with or suspected of having a brain tumor were scanned twice at 2 and 4 h following an intravenous injection of 18F-FMISO. We estimated the mean standardized uptake value (SUV) of the gray matter and white matter and the gray-to-white matter ratio in the background brain tissue from the two scans. We also performed a semi-quantitative analysis using the SUVmax and maximum tumor-to-normal ratio (TNR) for the tumor.


At 2 h, the SUVmean of gray matter was significantly higher than that of white matter (median 1.23, interquartile range (IQR) 1.10–1.32 vs. 1.04, IQR 0.95–1.16, p < 0.0001), whereas at 4 h, it significantly decreased to approach that of the white matter (1.10, IQR 1.00–1.23 vs. 1.02, IQR 0.93–1.13, p = NS). The gray-to-white matter ratio thus significantly declined from 1.17 (IQR 1.14–1.19) to 1.09 (IQR 1.07–1.10) (p < 0.0001). All 7 patients with glioblastoma showed significant increases in the SUVmax (2.20, IQR 1.67–3.32 at 2 h vs. 2.65, IQR 1.74–4.41 at 4 h, p = 0.016) and the TNR (1.75, IQR 1.40–2.38 at 2 h vs. 2.34, IQR 1.67–3.60 at 4 h, p = 0.016).


In the assessment of hypoxic tumors, 18F-FMISO PET for hypoxia imaging should be obtained at 4 h rather than 2 h after the injection.

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  1. 1.

    Hirata K, Yamaguchi S, Shiga T, Kuge Y, Tamaki N. The roles of hypoxia imaging using (18)F-fluoromisonidazole positron emission tomography in glioma treatment. J Clin Med. 2019;8.

  2. 2.

    Tamaki N, Hirata K. Tumor hypoxia: a new PET imaging biomarker in clinical oncology. Int J Clin Oncol. 2016;21:619–25.

    CAS  Article  PubMed  Google Scholar 

  3. 3.

    Kobayashi H, Hirata K, Yamaguchi S, Terasaka S, Shiga T, Houkin K. Usefulness of FMISO-PET for glioma analysis. Neurol Med Chir. 2013;53:773–8.

    Article  Google Scholar 

  4. 4.

    Janssen HL, Haustermans KM, Balm AJ, Begg AC. Hypoxia in head and neck cancer: how much, how important? Head Neck. 2005;27:622–38.

    CAS  Article  PubMed  Google Scholar 

  5. 5.

    Eschmann SM, Paulsen F, Bedeshem C, Machulla HJ, Hehr T, Bamberg M, et al. Hypoxia-imaging with (18)F-misonidazole and PET: changes of kinetics during radiotherapy of head-and-neck cancer. Radiother Oncol. 2007;83:406–10.

    CAS  Article  PubMed  Google Scholar 

  6. 6.

    Rasey JS, Koh WJ, Evans ML, Peterson LM, Lewellen TK, Graham MM, et al. Quantifying regional hypoxia in human tumors with positron emission tomography of [18F]fluoromisonidazole: a pretherapy study of 37 patients. Int J Radiat Oncol Biol Phys. 1996;36:417–28.

    CAS  Article  Google Scholar 

  7. 7.

    Koh WJ, Rasey JS, Evans ML, Grierson JR, Lewellen TK, Graham MM, et al. Imaging of hypoxia in human tumors with [F-18]fluoromisonidazole. Int J Radiat Oncol Biol Phys. 1992;22:199–212.

    CAS  Article  Google Scholar 

  8. 8.

    Rajendran JG, Wilson DC, Conrad EU, Peterson LM, Bruckner JD, Rasey JS, et al. [(18)F]FMISO and [(18)F]FDG PET imaging in soft tissue sarcomas: correlation of hypoxia, metabolism and VEGF expression. Eur J Nucl Med Mol Imaging. 2003;30:695–704.

    CAS  Article  PubMed  Google Scholar 

  9. 9.

    Valk PE, Mathis CA, Prados MD, Gilbert JC, Budinger TF. Hypoxia in human gliomas: demonstration by PET with fluorine-18-fluoromisonidazole. J Nucl Med. 1992;33:2133–7.

    CAS  PubMed  Google Scholar 

  10. 10.

    Toyonaga T, Yamaguchi S, Hirata K, Kobayashi K, Manabe O, Watanabe S, et al. Hypoxic glucose metabolism in glioblastoma as a potential prognostic factor. Eur J Nucl Med Mol Imaging. 2017;44:611–9.

    CAS  Article  PubMed  Google Scholar 

  11. 11.

    Bruehlmeier M, Roelcke U, Schubiger PA, Ametamey SM. Assessment of hypoxia and perfusion in human brain tumors using PET with 18F-fluoromisonidazole and 15O-H2O. J Nucl Med. 2004;45:1851–9.

    PubMed  Google Scholar 

  12. 12.

    Cher LM, Murone C, Lawrentschuk N, Ramdave S, Papenfuss A, Hannah A, et al. Correlation of hypoxic cell fraction and angiogenesis with glucose metabolic rate in gliomas using 18F-fluoromisonidazole, 18F-FDG PET, and immunohistochemical studies. J Nucl Med. 2006;47:410–8.

    CAS  PubMed  Google Scholar 

  13. 13.

    Spence AM, Muzi M, Swanson KR, O’Sullivan F, Rockhill JK, Rajendran JG, et al. Regional hypoxia in glioblastoma multiforme quantified with [18F]fluoromisonidazole positron emission tomography before radiotherapy: correlation with time to progression and survival. Clin Cancer Res. 2008;14:2623–30.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  14. 14.

    Swanson KR, Chakraborty G, Wang CH, Rockne R, Harpold HL, Muzi M, et al. Complementary but distinct roles for MRI and 18F-fluoromisonidazole PET in the assessment of human glioblastomas. J Nucl Med. 2009;50:36–44.

    Article  PubMed  Google Scholar 

  15. 15.

    Szeto MD, Chakraborty G, Hadley J, Rockne R, Muzi M, Alvord EC Jr, et al. Quantitative metrics of net proliferation and invasion link biological aggressiveness assessed by MRI with hypoxia assessed by FMISO-PET in newly diagnosed glioblastomas. Cancer Res. 2009;69:4502–9.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  16. 16.

    Kawai N, Maeda Y, Kudomi N, Miyake K, Okada M, Yamamoto Y, et al. Correlation of biological aggressiveness assessed by 11C-methionine PET and hypoxic burden assessed by 18F-fluoromisonidazole PET in newly diagnosed glioblastoma. Eur J Nucl Med Mol Imaging. 2011;38:441–50.

    CAS  Article  PubMed  Google Scholar 

  17. 17.

    Yamamoto Y, Maeda Y, Kawai N, Kudomi N, Aga F, Ono Y, et al. Hypoxia assessed by 18F-fluoromisonidazole positron emission tomography in newly diagnosed gliomas. Nucl Med Commun. 2012;33:621–5.

    CAS  Article  PubMed  Google Scholar 

  18. 18.

    Yamaguchi S, Hirata K, Toyonaga T, Kobayashi K, Ishi Y, Motegi H, et al. Change in 18F-fluoromisonidazole PET is an early predictor of the prognosis in the patients with recurrent high-grade glioma receiving bevacizumab treatment. PLoS One. 2016;11:e0167917.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  19. 19.

    Louis DN, Ohgaki H, Wiestler OD, Cavenee WK, Burger PC, Jouvet A, et al. The 2007 WHO classification of tumours of the central nervous system. Acta Neuropathol. 2007;114:97–109.

    Article  PubMed  PubMed Central  Google Scholar 

  20. 20.

    Louis DN, Perry A, Reifenberger G, von Deimling A, Figarella-Branger D, Cavenee WK, et al. The 2016 World Health Organization classification of tumors of the central nervous system: a summary. Acta Neuropathol. 2016;131:803–20.

    Article  Google Scholar 

  21. 21.

    Hirata K, Terasaka S, Shiga T, Hattori N, Magota K, Kobayashi H, et al. (1)(8)F-Fluoromisonidazole positron emission tomography may differentiate glioblastoma multiforme from less malignant gliomas. Eur J Nucl Med Mol Imaging. 2012;39:760–70.

    CAS  Article  PubMed  Google Scholar 

  22. 22.

    Toyonaga T, Hirata K, Yamaguchi S, Hatanaka KC, Yuzawa S, Manabe O, et al. F-fluoromisonidazole positron emission tomography can predict pathological necrosis of brain tumors. Eur J Nucl Med Mol Imaging. 2016.

  23. 23.

    Kanoto M, Kirii K, Hiraka T, Toyoguchi Y, Sugai Y, Matsuda K, et al. Correlation between hypoxic area in primary brain tumors and WHO grade: differentiation from malignancy using 18F-fluoromisonidazole positron emission tomography. Acta Radiol. 2018;59:229–35.

    Article  PubMed  Google Scholar 

  24. 24.

    Kobayashi K, Hirata K, Yamaguchi S, Manabe O, Terasaka S, Kobayashi H, et al. Prognostic value of volume-based measurements on (11)C-methionine PET in glioma patients. Eur J Nucl Med Mol Imaging. 2015;42:1071–80.

    CAS  Article  PubMed  Google Scholar 

  25. 25.

    Evans SM, Judy KD, Dunphy I, Jenkins WT, Hwang WT, Nelson PT, et al. Hypoxia is important in the biology and aggression of human glial brain tumors. Clin Cancer Res. 2004;10:8177–84.

    CAS  Article  PubMed  Google Scholar 

  26. 26.

    Lally BE, Rockwell S, Fischer DB, Collingridge DR, Piepmeier JM, Knisely JP. The interactions of polarographic measurements of oxygen tension and histological grade in human glioma. Cancer J. 2006;12:461–6.

    Article  Google Scholar 

  27. 27.

    Collingridge DR, Piepmeier JM, Rockwell S, Knisely JP. Polarographic measurements of oxygen tension in human glioma and surrounding peritumoural brain tissue. Radiother Oncol. 1999;53:127–31.

    CAS  Article  Google Scholar 

  28. 28.

    Rasey JS, Nelson NJ, Chin L, Evans ML, Grunbaum Z. Characteristics of the binding of labeled fluoromisonidazole in cells in vitro. Radiat Res. 1990;122:301–8.

    CAS  Article  Google Scholar 

  29. 29.

    Kavanagh MC, Sun A, Hu Q, Hill RP. Comparing techniques of measuring tumor hypoxia in different murine tumors: Eppendorf pO2 Histograph, [3H]misonidazole binding and paired survival assay. Radiat Res. 1996;145:491–500.

    CAS  Article  Google Scholar 

  30. 30.

    Lee ST, Scott AM. Hypoxia positron emission tomography imaging with 18f-fluoromisonidazole. Semin Nucl Med. 2007;37:451–61.

    Article  PubMed  Google Scholar 

  31. 31.

    Masaki Y, Shimizu Y, Yoshioka T, Tanaka Y, Nishijima K, Zhao S, et al. The accumulation mechanism of the hypoxia imaging probe “FMISO” by imaging mass spectrometry: possible involvement of low-molecular metabolites. Sci Rep. 2015;5:16802.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  32. 32.

    Watanabe S, Shiga T, Hirata K, Magota K, Okamoto S, Toyonaga T, et al. Biodistribution and radiation dosimetry of the novel hypoxia PET probe [(18)F]DiFA and comparison with [(18)F]FMISO. EJNMMI Res. 2019;9:60.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  33. 33.

    Oliver L, Olivier C, Marhuenda FB, Campone M, Vallette FM. Hypoxia and the malignant glioma microenvironment: regulation and implications for therapy. Curr Mol Pharmacol. 2009;2:263–84.

    CAS  Article  Google Scholar 

  34. 34.

    Flynn JR, Wang L, Gillespie DL, Stoddard GJ, Reid JK, Owens J, et al. Hypoxia-regulated protein expression, patient characteristics, and preoperative imaging as predictors of survival in adults with glioblastoma multiforme. Cancer. 2008;113:1032–42.

    Article  PubMed  PubMed Central  Google Scholar 

  35. 35.

    Bekaert L, Valable S, Lechapt-Zalcman E, Ponte K, Collet S, Constans JM, et al. [18F]-FMISO PET study of hypoxia in gliomas before surgery: correlation with molecular markers of hypoxia and angiogenesis. Eur J Nucl Med Mol Imaging. 2017;44:1383–92.

    CAS  Article  PubMed  Google Scholar 

  36. 36.

    Gray LH, Conger AD, Ebert M, Hornsey S, Scott OC. The concentration of oxygen dissolved in tissues at the time of irradiation as a factor in radiotherapy. Br J Radiol. 1953;26:638–48.

    CAS  Article  PubMed  Google Scholar 

  37. 37.

    Ji Z, Long H, Hu Y, Qiu X, Chen X, Li Z, et al. Expression of MDR1, HIF-1alpha and MRP1 in sacral chordoma and chordoma cell line CM-319. J Exp Clin Cancer Res. 2010;29:158.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  38. 38.

    Sato J, Kitagawa Y, Watanabe S, Asaka T, Ohga N, Hirata K, et al. (18)F-Fluoromisonidazole positron emission tomography (FMISO-PET) may reflect hypoxia and cell proliferation activity in oral squamous cell carcinoma. Oral Surg Oral Med Oral Pathol Oral Radiol. 2017;124:261–70.

    Article  PubMed  Google Scholar 

  39. 39.

    Stupp R, Brada M, van den Bent MJ, Tonn JC, Pentheroudakis G. High-grade glioma: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol. 2014;25(Suppl 3):iii93–101.

    Article  PubMed  Google Scholar 

  40. 40.

    Thakkar JP, Dolecek TA, Horbinski C, Ostrom QT, Lightner DD, Barnholtz-Sloan JS, et al. Epidemiologic and molecular prognostic review of glioblastoma. Cancer Epidemiol Biomark Prev. 2014;23:1985–96.

    CAS  Article  Google Scholar 

  41. 41.

    Thorwarth D, Eschmann SM, Paulsen F, Alber M. A kinetic model for dynamic [18F]-Fmiso PET data to analyse tumour hypoxia. Phys Med Biol. 2005;50:2209–24.

    Article  PubMed  Google Scholar 

  42. 42.

    Grunbaum Z, Freauff SJ, Krohn KA, Wilbur DS, Magee S, Rasey JS. Synthesis and characterization of congeners of misonidazole for imaging hypoxia. J Nucl Med. 1987;28:68–75.

    CAS  PubMed  Google Scholar 

  43. 43.

    Grkovski M, Emmas SA, Carlin SD. (18)F-fluoromisonidazole kinetic modeling for characterization of tumor perfusion and hypoxia in response to antiangiogenic therapy. J Nucl Med. 2017;58:1567–73.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  44. 44.

    Peeters SG, Zegers CM, Lieuwes NG, van Elmpt W, Eriksson J, van Dongen GA, et al. A comparative study of the hypoxia PET tracers [(1)(8)F]HX4, [(1)(8)F]FAZA, and [(1)(8)F]FMISO in a preclinical tumor model. Int J Radiat Oncol Biol Phys. 2015;91:351–9.

    CAS  Article  PubMed  Google Scholar 

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We thank the staff members of the Department of Nuclear Medicine, the Central Institute of Isotope Science, the Department of Cancer Pathology, Hokkaido University, and the Department of Radiology, Hokkaido University Hospital, for their support of this work.


This research was supported in part by a Grant-in-Aid for General Scientific Research from the Japan Society for the Promotion of Science (Ko.Ke., 19K17127).

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Correspondence to Kenji Hirata.

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All procedures involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the principles of the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards. A portion of our results were presented at the SNMMI 2018 Conference (J Nucl Med May 1, 2015, vol. 56 no. supplement 3373).

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Kobayashi, K., Manabe, O., Hirata, K. et al. Influence of the scan time point when assessing hypoxia in 18F-fluoromisonidazole PET: 2 vs. 4 h. Eur J Nucl Med Mol Imaging 47, 1833–1842 (2020).

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  • Fluoromisonidazole
  • Positron emission tomography
  • Glioblastoma
  • Hypoxia
  • Scan timing
  • This article is part of the Topical Collection on Oncology – Brain