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To assess clinical significance of incidental focal colorectal 18F-FDG uptake on PET/CT, and to determine significant SUVmax.Records of patients who had undergone both PET/CT and colonoscopy within 2 weeks of interval were reviewed. Adenomas were considered advanced when they were villous, ‡10 mmin size, or with high grade dysplasia. Colorectal cancers and advanced adenomas were collectively referred to as advanced colorectal neoplasms.In patients with incidental uptake, 49 of 95 (51.5%) had advanced colorectal neoplasm, and in those without uptake, only 6 out of 146 (4.1%) were found to have advanced colorectal neoplasms on colonoscopy (P < 0.001). The sensitivity, specificity, PPV, NPV, and accuracy of incidental focal 18 F-FDG uptake for advanced colorectal neoplasms were 89.1%, 75.3%, 51.6%, 95.9%, and 78.4% respectively, and for detecting only the colorectal cancer, 89.2%, 69.6%, 34.7%, 97.3%, and 72.6%. The significant SUVmax cut off value for advanced colorectal neoplasms (AUC 0.755, P < 0.001) was 4.35 (75.5%, 65.2%, 69.8%, 71.4%, and 70.5%). For colorectal cancer, 5.05 was the significant SUVmax cut off value (AUC 0.817, P < 0.001) (84.8%%, 71.0%, 80.9%, 89.8%, and 75.8%).Incidental focal colorectal 18F-FDG uptake on PET/CT with SUVmax ‡4.35 increases the possibility of advanced colorectal neoplasia which warrants further evaluation with colonoscopy.