Society of Nuclear Medicine
2 Procedure Guideline for Tumor Imaging Using FDG
3 PET/CT4
1
Version 0.7 5
6 Authors: Dominique Delbeke, MD, PhD, Chair (Vanderbilt University Medical Center, 7 Nashville, TN);
R. Edward Coleman, MD (Duke University Medical Center, Durham, NC); 8 Milton J. Guiberteau, MD
(Christus St. Joseph Hospital, Houston, TX); Manuel L. Brown, MD 9 (Henry Ford Hospital, Detroit, MI);
Henry D. Royal, MD (Mallinckrodt Institute of Radiology,
10 St. Louis, MO); Barry A. Siegel, MD (Mallinckrodt Institute of Radiology, St. Louis, MO); 11 David W.
Townsend, PhD (University of Tennessee, Knoxville, TN); Lincoln L. Berland, MD 12 (University of
Alabama Hospital, Birmingham, AL); J. Anthony Parker, MD (Beth Israel 13 Deaconess Hospital, Boston,
MA); Karl Hubner; MD (University of Tennessee Medical Center, 14 Knoxville, TN); Michael G. Stabin, PhD
(Vanderbilt University, Nashville, TN); George Zubal, 15 PhD (Yale University, New Haven, CT); Marc
Kachelriess, PhD (Institute of Medical Physics, 16 University of Erlangen-Nurnberg, Erlangen, Germany);
Valerie Cronin, CNMT (Mercy Hospital, 17 Buffalo, NY) 18 19 I. Purpose 20 21 The purpose of this guideline
is to assist physicians in recommending, performing, interpreting, 22 and reporting the results of
18
F-fluoro-2-deoxyglucose (FDG) positron emission 23 tomography/computed tomography (PET/CT) for
oncologic imaging of adult and pediatric 24 patients. 25 26 II. Background Information and Definitions 27
28 Positron emission tomography (PET) is a tomographic scintigraphic technique in which a 29
computer-generated image of local radioactive tracer distribution in tissues is produced through
The Society of Nuclear Medicine (SNM) has written and approved these guidelines as an educational tool
designed to promote the cost-effective use of high-quality nuclear medicine procedures or in the conduct of
research and to assist practitioners in providing appropriate care for patients. The guidelines should not be
deemed inclusive of all proper procedures nor exclusive of other procedures reasonably directed to obtaining
the same results. They are neither inflexible rules nor requirements of practice and are not intended nor
should they be used to establish a legal standard of care. For these reasons, SNM cautions against the use of
these guidelines in litigation in which the clinical decisions of a practitioner are called into question.
The ultimate judgment about the propriety of any specific procedure or course of action must be made by the
physician when considering the circumstances presented. Thus, an approach that differs from the guidelines
is not necessarily below the standard of care. A conscientious practitioner may responsibly adopt a course of
action different from that set forth in the guidelines when, in his or her reasonable judgment, such course of
action is indicated by the condition of the patient, limitations on available resources, or advances in
knowledge or technology subsequent to publication of the guidelines.
All that should be expected is that the practitioner will follow a reasonable course of action based on current
knowledge, available resources, and the needs of the patient to deliver effective and safe medical care. The
sole purpose of these guidelines is to assist practitioners in achieving this objective.
Advances in medicine occur at a rapid rate. The date of a guideline should always be considered in
determining its current applicability.
30 the detection of annihilation photons that are emitted when radionuclides introduced in the body 31 decay and
release positrons. FDG-PET is a tomographic imaging technique that utilizes a 32 radiolabeled analog of
glucose, F-fluoro-2-deoxyglucose (FDG), to image relative glucose 33 utilization rates in various tissues.
Because glucose utilization is increased in many malignancies, 34 FDG-PET is a sensitive method for detecting,
staging and monitoring the effects of therapy of 35 many malignancies. CT is a tomographic imaging technique
that uses X-rays to produce 36 anatomic images. This anatomic information is used to detect and to help
determine the location 37 and extent of malignancies. Combined PET/CT devices provide both the metabolic
information 38 from FDG-PET and the anatomic information from CT in a single examination. As shown in 39
some clinical scenarios, the information obtained by PET/CT appears to be more accurate in 40 evaluating
patients with known or suspected malignancy than that from either PET or CT alone or 41 PET and CT obtained
separately but interpreted side-by-side. 42 43 FDG-PET and CT are proven diagnostic procedures. Although
techniques for registration and 44 fusion of images obtained from separate PET and CT scanners have been
available for several 45 years, the readily apparent and documented advantages of having PET and CT in a single
device 46 have resulted in rapid dissemination of this technology in the United States. This Procedure 47
Guideline pertains only to combined PET/CT devices. 48 49 Definitions
18
50 A. PET/CT Scanner: An integrated device containing both a CT scanner and a PET scanner
51 with a
single patient table, thus capable of obtaining a CT scan, a PET scan, or both. If the 52 patient does not move
between the scans, the reconstructed PET and CT images will be 53 registered and aligned. 54 55 B. PET/CT
Registration: The process of taking PET and CT images and aligning them for the 56 purpose of combined
image display (fusion) and image analysis. 57 58 C. PET/CT Fusion images: The combined display of registered
PET and CT image sets. 59 Superimposed data are typically displayed with the PET data color-coded onto the
CT data in 60 gray scale. 61 62 D. PET/CT acquisitions can include the whole body, an extended portion of the
body or a 63 limited portion of the body. These acquisitions are defined in Current Procedural 64 Terminology
2005 as follows: 65
66 1. Whole-Body Tumor Imaging: from the top of the head through the feet. 67
68 2. Skull Base-Mid-Thigh Tumor Imaging 69
70 3. Limited Area Tumor Imaging 71 72 E. Methods of attenuation correction: 73
74 1. CT transmission imaging with PET/CT scanners. 75
76 2. Transmission scan using isotopic source: not commonly used with PET/CT scanners.
77 78
79 III. Examples of Clinical or Research Applications 80 81 Indications for FDG-PET/CT include, but are
not limited to, the following: 82 83 A. Differentiation of benign from malignant lesions 84 85 B. Searching for
an unknown primary tumor when metastatic disease is discovered as the first 86 manifestation of cancer or
when the patient presents with a paraneoplastic syndrome. 87 88 C. Staging patients with known malignancies.
89 90 D. Monitoring the effect of therapy on known malignancies. 91 92 E. Determining if residual
abnormalities detected on physical examination or on other imaging 93 studies following treatment represent
tumor or post-treatment fibrosis or necrosis. 94 95 F. Detecting tumor recurrence, especially in the presence of
elevated tumor markers. 96 97 G. Selection of region of tumor most likely to yield diagnostic information for
biopsy. 98 99 H. Guiding radiation therapy planning.
100 101 I. Non-oncologic applications such as evaluation of infection and atherosclerosis 102 103 FDG-PET/CT
is not equally effective for all malignancies but many other tracers are 104 available, which are not yet
approved by the Food and Drug Administration or 105 reimbursable by the Medicare program. The scientific
literature concerning its utility 106 continues to evolve rapidly. 107 108 IV. Procedure 109 110 A. Patient
Preparation 111 112 The optimum preparation for patients about to undergo PET/CT imaging is evolving. The
major 113 goals of preparation are to minimize tracer uptake in normal tissues, such as the myocardium and 114
skeletal muscle, while maintaining uptake in target tissues (neoplastic disease). The following is 115 a
commonly used protocol. 116 117 1. Pregnancy and breast-feeding: see the Society of Nuclear Medicine
Procedure Guidelines 118 for General Imaging 119 120 2. Pre-arrival 121 122 Patients should be instructed to
fast and not consume beverages, except water, for at least 123 4-6 hours prior to the administration of FDG to
decrease physiologic glucose levels and 124 to reduce serum insulin levels to near basal levels. Oral hydration
with water is 125 encouraged. Intravenous fluids containing dextrose or parenteral feedings should also be 126
withheld for 4-6 hours. 127 If intravenous contrast material is to be used, patients should be screened for history
of 128 iodinated contrast allergy, use of metformin for treatment of diabetes mellitus, and renal
129 disease. Intravenous contrast material should not be administered if the serum creatinine 130 level is above
2.0 mg/dl. 131 132 3. Pre-injection 133 134 a. For brain imaging, the patient should be in a quiet and dimly lit
room for FDG 135 administration and the subsequent uptake phase. 136 b. For body imaging, the patient should
remain seated or recumbent for FDG 137 administration and the subsequent uptake phase to avoid muscular
uptake. 138 c. The blood glucose level should be checked prior to FDG administration. Tumor 139 uptake of
FDG is reduced in hyperglycemic states. Most institutions reschedule the 140 patient if the blood glucose level is
greater than 150-200 mg/dL. Lowering serum 141 glucose by administration of insulin can be considered, but the
administration of 142 FDG should be delayed following insulin administration (with the duration of the 143 delay
dependent on the type and route of administration of insulin). 144 d. For either a CT scan done for attenuation
correction/anatomical localization (AC/AL) 145 or a diagnostic CT scan of the abdomen and/or pelvis, an
intraluminal gastrointestinal 146 contrast agent may be administered to provide adequate visualization of the 147
gastrointestinal tract unless medically contraindicated or unnecessary for the clinical 148 indication (see section
E.2.b). 149 150 B. Information Pertinent to Performing the Procedure 151 152 See also Procedure Guidelines
for General Imaging 153 154 1. A focused history including the type and site of malignancy, date of diagnosis and
155 treatment (biopsy results, surgery, radiation, chemotherapy, administration of bone 156 marrow stimulants
and steroids), and current medications. 157 158 2. History of diabetes, fasting state, recent infection 159 160 3.
Patient’s ability to lie still for the duration of the acquisition (15-45 min) 161 162 4. History of claustrophobia 163
164 5. Patient’s ability to put his/her arms overhead 165 166 C. Precautions 167 168 See the Society of Nuclear
Medicine Procedure Guidelines for General Imaging. 169 170 D. Radiopharmaceutical (see Tables 1 and 2)
171 172 173 Table 1: Radiation Dosimetry for Adults 174
175 * Voiding interval 3.5 h. The changes in bladder wall dose are approximately linear with changes 176 in the
void interval: therefore for a voiding interval of 2.0 h the dose to the bladder wall would 177 change by a factor
2/3.5. 178 International Commission on Radiological Protection. ICRP publication 80: Radiation Dose To 179
Patients From Radiopharmaceuticals. Elsevier, St. Louis, MO, 2000 page 49 180 181 Table 2: Radiation
Dosimetry for Children 182 (5 year old) 183
Radiopharmaceutical
Administered
Activity MBq
(mCi)
Organ Receiving the
Largest Radiation Dose
mGy per MBq (rad per
mCi)
Effective Dose
mSv per MBq
(rem per mCi)
18F-fluoro-2-deoxyglucose
370 – 740 i.v.
0.16
Bladder*
(0.59)
0.019
(FDG)
(10 – 20)
Radiopharmaceutical
18F-fluoro-2-deoxyglucose
Administered
Activity
MBq/kg
(mCi/kg)
5.18 – 7.4 i.v.
Organ Receiving the
Largest Radiation Dose
mGy per MBq (rad per
mCi)
(0.070)
Effective Dose
mSv per MBq
(rem per mCi)
0.32
0.050
Bladder*
(0.14 – 0.20)
(1.2)
(0.18)Dose
Administered
Organ Receiving
the
Effective
Activity MBq
Largest Radiation Dose
mSv per MBq
(mCi) training
mGy
per MBq (rad per
(rem per mCi)
Table 3: Summary of PET/CT On-the-Job
requirements
mCi)
Training
ABMS Board **PET/CT
***CT
PET/CT CT CME
Certification Interpretations
Interpretations
CME
(supervised)
(supervised)
18F-fluoro-2-deoxyglucose
370
– 740 i.v.
0.16
0.019
(FDG)
Nuclear
ABNM
150
500 Bladder*
8 credits
100 credits
Medicine
(10 – 20)
(0.59) ICRP publication
(0.070)
184 * Voiding interval 2.0 h 185 International Commission
on Radiological Protection.
80:
*Diagnostic
ABR
150
35
credits
Radiation Dose To 186 Patients From Radiopharmaceuticals. Elsevier, St. Louis, MO, 2000 page 49. 187 188
Administered
Organ Receiving the
Dose
With PET/CT, theRadiologist
radiation dose to the patient is theActivity
combination of theLargest
radiation
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189 theEffective
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(recent CT)
mSv
per
MBq
radiopharmaceutical
and the radiation dose from theMBq/kg
CT portion of the study.
190MBq
Radiation
in diagnostic CT
mGy per
(rad dose
per
Radiopharmaceutical
*Nuclearattention ABR
150
8 credits
(rem
per mCi)
has attracted considerable
in recent years, in
191
particular
for
pediatric
examinations.
It
can
be very
(mCi/kg)
mCi)
Radiologist
misleading to quote a ‘representative’ 192 dose for a CT scan because of the wide diversity of applications,
(recent
CT)
18F-fluoro-2-deoxyglucose
5.18CT
– 7.4
i.v.
0.32
protocols and CT systems.
193 This also applies to the
component
of a PET/CT
study. For example 0.050
a body
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ABR
&
150
8 credits
(FDG)
Bladder*
scan may 194 include
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the radiation dose to 195 the
(recent CT)
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(0.14 – 0.20)
(1.2) 196 range from (0.18)
patient or aimed to optimize the CT for diagnostic purposes.
The effective dose could
Diagnostic
ABR
150
500
35 credits 100 credits
approximately 5 to 80 mSv (0.5 to 8.0 rem) for these options. It is therefore 197 advisable to estimate CT dose
Radiologist
specific to the CT Table
system3:and
protocol.of 198
199 Pediatric
and training
adolescent
patients should have their CT
Summary
PET/CT
On-the-Job
requirements
(no recent
examinations performed
at
mAs
200
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for
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size,
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PET/CT
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radiation dose to the 201 patient increases
significantly
as
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decreases.
202 203 E. Image
Certification Interpretations
Interpretations
CME
Acquisition 204 205 See also the Society of Nuclear(supervised)
Medicine PET tumor
imaging guidelines, the sections on
(supervised)
206 “Specifications
of
the
examination”
and
”Documentation”
from
the
ACR
207 for the
Nuclear
ABNM
150
500 Practice Guideline
8 credits
100 credits
Performance of Computed
Tomography
of
the
Extracranial
Head
and
Neck
in
Adults
208
and
Children,
ACR
Medicine
Practice Guideline*Diagnostic
for the Performance
ABRof Pediatric and
150Adult Thoracic
35 credits
Radiologist
(recent CT)
*Nuclear
ABR
150
8 credits
Radiologist
(recent CT)
*Radiologist
ABR &
150
8 credits
(recent CT)
ABNM
Diagnostic
ABR
150
500
35 credits 100 credits
Radiologist
(no recent
CT)
(FDG)
Radiopharmaceutical
209 Computed Tomography (CT), ACR Practice Guideline for the Performance of Computed 210 Tomography
(CT) of the Abdomen and Computed Tomography (CT) of the Pelvis. 211 212 1. Field of view, positioning and
pre-acquisition preparation: 213 214 a. Skull base-proximal thigh imaging is generally recommended to survey
the body in 215 the search for areas of abnormal FDG accumulation for most tumor types. Such 216 PET/CT
scans are typically acquired from the external auditory meatus to the mid217 thigh region. For tumors with a high
likelihood of scalp, skull, or brain involvement 218 and/or lower extremity involvement, whole-body tumor
imaging is performed. 219 220 b. Limited area tumor imaging can be considered when critical abnormalities are
likely 221 to be localized in a known region of the body (e.g., solitary pulmonary nodule, 222 probable lung
cancer, evaluation of hilar lymph node involvement, diagnosis of head 223 and neck cancer; monitoring therapy of
locally advanced breast cancer, etc). 224 However, performing whole-body tumor imaging offers the advantage of
staging the 225 entire body. 226 227 c. For optimal imaging of the body, the arms should be elevated over the
head if 228 tolerated by the patient. Arms along the side may produce beam hardening artifacts 229 over the torso.
However, for optimal imaging of the head and neck, the arms should 230 be positioned along the side. 231 232 d.
The patient should void the bladder prior to the acquisition of the images to limit the 233 radiation dose to the
renal collecting system and bladder. 234 235 e. All metallic objects should be removed from the patient whenever
possible. 236 237 2. Protocol for CT Imaging: 238 239 The CT component of a PET/CT examination can be
performed either for attenuation 240 correction and anatomic localization (AC/AL) or as an optimized diagnostic
CT scan. An 241 AC/AL CT is one that has not necessarily been optimized as an diagnostic CT 242
examination, whereas a diagnostic CT is one where such optimization has been attempted. 243 In some
circumstances, both an initial CT acquisition for AC/AL (before the PET data 244 acquisition) and a diagnostic
CT (after the PET data acquisition) are performed. 245 Optimization of CT technique with PET/CT continues to
evolve. 246 247 a. If the CT scan is obtained for AC/AL, low mAs setting is recommended to decrease 248 the
radiation dose to the patient. 249 250 b. For an optimized diagnostic CT scan, standard CT mAs settings is
recommended to 251 optimize the spatial resolution of the CT scan. Tube current modulation may be used 252 to
minimize radiation dose to the patient. In some cases intravenous and/or oral 253 contrast may be used. A separate
CT acquisition may be necessary to acquire an 254 optimized diagnostic CT that is requested for a particular
region of the body. 255 For many indications, the examination is performed with intravenous contrast 256
material using appropriate injection techniques. High intravascular concentrations of 257 intravenous contrast
agents may cause an attenuation-correction artifact on the PET 258 image, but the impact is usually modest. This
artifact is minimized on scanners using
259 appropriate correction factors. 260 261 262 c. For either a CT scan done for AC/AL or an optimized
diagnostic CT scan of the 263 abdomen and/or pelvis, an intraluminal gastrointestinal non-caloric contrast agent
264 may be administered to provide adequate visualization of the gastrointestinal tract 265 unless medically
contraindicated or unnecessary for the clinical indication. This may 266 be a positive contrast agent such as
dilute barium, oral iodinated contrast agent, or a 267 negative contrast agent such as water. Collections of highly
concentrated barium or 268 iodinated contrast agents can result in an attenuation-correction artifact that leads to a
269 significant overestimation of the regional FDG concentration; other dilute positive 270 and negative oral
agents cause less overestimation and do not affect PET image 271 quality. 272 273 274 d. Breathing protocol for
CT transmission scanning: For PET/CT, the position of the 275 diaphragm should match as closely as possible on
the PET emission and the CT 276 transmission images. Although a diagnostic CT scan of the chest is typically
acquired 277 during end-inspiration breath holding, this is not optimal for PET/CT, since it may 278 result in
substantial respiratory motion misregistration on the PET and the CT 279 images. Some facilities perform CT
transmission scans during breath holding at mid280 inspiration volume, and others prefer that the patient continue
shallow breathing 281 during the CT acquisition. Respiratory motion results in inaccurate localization of 282
lesions at the base and periphery of the lungs or the dome of the liver, or near any 283 lung-soft tissue interface,
and may result in spurious SUV determinations. 284
Motion correction or respiratory gating is
recommended if available. 285 286 3. Protocol for PET emission imaging: 287 288 a. The radiopharmaceutical
should be injected at a site contralateral to the site of 289 concern. Emission images are obtained at least 45
minutes following 290 radiopharmaceutical injection. The optimal FDG distribution phase is controversial. 291
Many centers start the acquisition of the images at 60 or 90 minutes following FDG 292 administration. Some
centers obtain a second set of images to assess the change in 293 uptake with time. The FDG uptake time should
be constant whenever possible and 294 certainly if two studies are compared with semi-quantitative parameters,
especially 295 SUV. 296 297 b. Emission image acquisition time varies from 2 to 5 minutes or longer per bed
position 298 for body imaging and is based on the administered activity, patient body weight, and 299 the
sensitivity of the PET tomograph (as determined largely by detector composition 300 and acquisition method).
Typically, for imaging skull to mid-thigh, the total 301 acquisition time ranges from 15-45 minutes. The imaging
time is typically prolonged 302 for acquisition of brain images or for images of limited region of interest. 303 304
c. Semi-quantitative estimation of tumor glucose metabolism using the standardized 305 uptake value (SUV) is
based on relative lesion radioactivity measured on images 306 corrected for attenuation and normalized for the
injected dose and body weight, lean 307 body mass or body surface area. This measurement is performed on a
static emission 308 image typically acquired more than 45 minutes post-injection.
309 310 The accuracy of SUV measurements depends on the accuracy of the calibration of the 311 PET
tomograph, among other factors. The reproducibility of SUV measurements 312 depends on the reproducibility of
clinical protocols, for example dose infiltration, 313 time of imaging after FDG administration, type of
reconstruction algorithms, type of 314 attenuation maps, size of the region of interest changes in uptake by
organs other 315 than the tumor, methods of analysis (e.g., max, mean), etc. 316 317 d. Semi-quantitative
estimation of tumor metabolism can be based on the ratio of FDG 318 uptake in a lesion relative to internal
reference regions, such as the blood pool, 319 mediastinum, liver, cerebellum, etc. 320 321 F. Interventions 322
323 1. Intense urinary bladder tracer activity degrades image quality and can confound 324 interpretation of
findings in the pelvis. Hydration and a loop diuretic, without or with 325 bladder catheterization, may be used to
reduce accumulated urinary tracer activity in the 326 bladder. Bladder catheterization with a 3-way flushing
catheter running a continuous 327 bladder flush after injection until imaging has been used successfully to clear
bladder 328 activity. 329 330 2. Keeping the patient in a warm room 30-60 minutes prior to injection and until
the 331 time of FDG injection , particularly in cold climates and air conditioned environment, 332 will help
minimize brown fat uptake. Lorazepam or diazepam given prior to injection of 333 FDG may reduce uptake by
brown adipose tissue or skeletal muscle. Beta-blockers may 334 also reduce uptake by brown fat. 335 336 G.
Processing 337 338 1. PET Reconstruction: PET emission data consist of the number of events along lines-of339
response (LOR) between detector pairs. The emission data must be corrected for detector 340 efficiency
(normalization), system dead time, random coincidences, scatter, attenuation 341 and sampling non-uniformity.
Some of these corrections (e.g. attenuation) can be 342 incorporated directly into the reconstruction process.
Scanners with retractable septa can 343 acquire data in both 2D and 3D mode, while scanners without septa
acquire data in 3D 344 mode only. Data sets acquired in 3D can either be rebinned into 2D data and reconstucted
345 with a 2D algorithm, or reconstructed with a fully 3D algorithm. Iterative reconstruction 346 approaches are
now widely available for clinical applications in both 2D and 3D, largely 347 replacing the direct, filtered
backprojection methods used previously. For a given 348 algorithm, the appropriate reconstruction parameters
will depend upon the acquisition 349 mode, type of scanner and the imaging task. It is considered good practice to
archive 350 reconstructions both with and without attenuation correction to resolve issues arising 351 from
potential artifacts generated by the CT-based attenuation correction procedure. The 352 reconstructed image
volume can be displayed as transaxial, coronal and sagittal planes, 353 and also as a rotating
maximum-intensity-projection (MIP) image. 354 355 2. CT reconstruction: CT sinograms are reconstructed by
filtered backprojection at full 356 field of view for the data used for attenuation correction of the PET emission
data, and 357 separately for CT interpretation using appropriate zoom, slice thickness and overlap, and 358
reconstruction algorithms for the particular region of the body scanned. The filtered
359 backprojection can be either 2D after appropriate portions of the spiral CT data are 360 collected into axial
and/or tilted planes, or fully in 3D. In addition to the reconstruction 361 kernel that adjusts in-plane features such
as spatial resolution and noise texture, 362 longitudinal filtration (along the z-axis) is used to modify the
z-resolution and the slice 363 sensitivity profiles. Further there are techniques to emphasize certain image
features, e.g., 364 bone, lung or head algorithms. For attenuation correction, only the standard kernels are 365
used. Since CT volumes today are nearly isotropic, reslicing such as coronal, sagittal or 366 even curved displays
are often preferred. Advanced display techniques such as volume 367 rendering, maximum/minimum intensity
projections applied to complete volume or to 368 thick, arbitrarily oriented sections are often used. Organ- and
task-specific automatic or 369 semi-automatic segmentation algorithms and special evaluations algorithms are in
routine 370 use also. 371 372 3. Display: With an integrated PET/CT system, typically the software packages
provide 373 registered and aligned CT images, FDG-PET images and fusion images in the axial, 374 coronal, and
sagittal planes, as well as maximum-intensity-projection (MIP) images for 375 review in the 3D-cine mode.
FDG-PET images with and without attenuation correction 376 should be available for review. 377 378 H.
Interpretation Criteria 379 380 1. Normal physiologic uptake of FDG can be seen to some extent in every
viable tissue, 381 including the brain, myocardium (where the uptake is significant in some patients despite 382
prolonged fasting), breast, liver, spleen, stomach, intestines, kidneys and urine, muscle, 383 lymphoid tissue (e.g.,
tonsils), bone marrow, salivary glands, thymus, uterus, ovaries, 384 testes, and brown adipose tissue (see section
K). 385 386 2.
For whole-body surveys, studies have shown that FDG-PET imaging of the brain is 387
relatively insensitive for the detection of cerebral metastases, owing to high physiologic 388 FDG uptake in the
gray matter. 389 390 3. Increased uptake of FDG can be seen in neoplasms, granulation tissue (e.g., healing
391 wounds), infections and other inflammatory processes. 392 393 4. Although the pattern of FDG uptake and
specific CT findings as well as correlation with 394 history, physical examination and other imaging modalities
are usually the most helpful 395 in differentiating benign from malignant lesions, semi-quantitative estimates
(e.g., SUV) 396 may also be of value, especially for evaluating changes with time or therapy . 397 398 I.
Reporting 399 400 See the Society of Nuclear Medicine Procedure Guideline for General Imaging: 401 402 1.
Study Identification: 403 404 2. Clinical Information: 405 406 a. Indication for the study 407 408 b. Relevant
history
409 410 c. Information needed for billing 411 412 3. Procedure Description and Imaging protocol: 413 414 a.
Radiopharmaceutical, including administered activity, route of administration, and 415 FDG uptake time. 416
417 b. Other drugs administered and procedures performed: such as: placement of 418 intravenous line,
hydration, insertion of Foley catheter (size of catheter), administration 419 of furosemide (amount and time),
muscular relaxants, pain medications, sedation 420 procedures (briefly describe the procedure and state type of
medication and time of 421 sedation in relation to the radiotracer injection, state patient condition at the
conclusion 422 of the PET imaging study). 423 424 c. Field of view and patient positioning: whole-body,
skull-base to mid-thigh or limited 425 area, position of the arms. 426 427 d. Baseline glucose level. 428 429 e.
CT transmission protocol (for AC/AL or diagnostic CT protocol with or without oral 430 and intravenous contrast
using the appropriate CT protocol for the clinical scenario and 431 body region of interest). 432 433 f. PET
emission protocol: see General Imaging Procedure Guidelines. 434 435 4. Description of Findings: 436 437 a.
Quality of the study: for example, limited due to motion, muscular uptake, 438 hyperglycemia, etc. 439 440 b.
Describe location, extent and intensity of abnormal FDG uptake in relation to normal 441 comparable tissues and
describe the relevant morphologic findings related to PET 442 abnormalities on the CT images. An estimate of
the intensity of FDG uptake can be 443 provided with the SUV; however, the intensity of uptake may be
described as mild, 444 moderate or intense or in relation to the background uptake in normal hepatic 445
parenchyma (average SUVweight: 2.0-3.0, maximum SUV: 3.0-4.0). The integrated 446 PET/CT report should
include any detected incidental findings on the CT scan that are 447 relevant to patient care. If the CT scan was
requested and performed as a diagnostic 448 examination, the CT component of the study may be reported
separately, if necessary 449 to satisfy regulatory, administrative or reimbursement requirements. In that case, the
450 PET/CT report can refer to the diagnostic CT scan report for findings not related to the 451 PET/CT
combined findings. 452 453 c. Limitations 454 Where appropriate, identify factors that can limit the sensitivity
and specificity of the 455 examination (e.g., small lesions, inflammatory process). 456 457 d. Clinical Issues
458 The report should address or answer any pertinent clinical questions raised in the 459 request for imaging
examination. 460 461 f. Comparative Data 462 Comparisons with previous examinations and reports when
possible should be a part of 463 the radiologic consultation and report. Integrated PET/CT studies are more
valuable 464 when correlated with previous diagnostic CT, previous PET, previous PET/CT, 465 previous MRI,
and all appropriate imaging studies and clinical data that are relevant. 466 When PET/CT is performed for
monitoring therapy, a comparison of extent and 467 intensity of uptake may be summarized as metabolic
progressive disease, metabolic 468 stable disease, metabolic partial response or metabolic complete response. The
469 European Organization for Research and Treatment of Cancer (EORTC) has published 470 criteria for these
categories, although these criteria have not yet been validated in 471 outcome studies. A change of intensity of
uptake with semi-quantitative 472 measurements, expressed in absolute values and percent change, may be
appropriate in 473 some clinical scenarios. However, the technical protocol and analysis of images need to 474 be
consistent in the two sets of images as described in section E.3. 475 476 5. Impression (Conclusion or Diagnosis)
477 478 a. A precise diagnosis should be given whenever possible. 479 480 b. A differential diagnosis should be
given when appropriate. 481 482 c. When appropriate, recommend follow-up and additional diagnostic studies to
clarify 483 or confirm the impression. 484 485 J. Quality Control 486 487 1. Radiopharmaceuticals 488 489 See
the Society of Nuclear Medicine Procedure Guideline for Use of 490 Radiopharmaceuticals. 491 492 2.
Instrumentation Specifications 493 494 See ACR section on “Equipment specifications” and “Quality Control”
from the ACR 495 Practice Guideline for the Performance of Computed Tomography of the Extracranial Head 496
and Neck in Adults and Children, ACR Practice Guideline for the Performance of Pediatric 497 and Adult Thoracic
Computed Tomography (CT), ACR Practice Guideline for the 498 Performance of Computed Tomography (CT) of
the Abdomen and Computed Tomography 499 (CT) of the Pelvis. 500 501 a. Equipment Performance
Guidelines 502 503 For patient imaging, state-of-the-art scanners meet or exceed the following 504 specifications:
505 506 For the CT scanner: See ACR guidelines. 507
508 For the PET scanner: These specifications are based on manufacturers figures measured 509 according to
NEMA 2001 protocols; the Uniformity estimate is based on the NEMA 510 1994 protocol. For LSO-based
scanners, a modified NEMA protocol is defined to 511 account for the natural radioactive background from LSO.
512 513 In-plane spatial resolution: < 6.5 mm 514 Axial resolution: < 6.5 mm 515 Sensitivity (3D): > 4.0
cps/kBq 516 Sensitivity (2D): >1.0 cps/kBq 517 Uniformity: < 5% 518 519 For the combined PET/CT scanner:
520 Maximum co-scan range (CT and PET): > 160 cm 521 Maximum patient weight: >350 lb 522 Patient port
diameter: at least > 59 cm 523 524 All currently-available commercial PET/CT scanners meet or exceed these 525
specifications. 526 527 The CT imaging field-of-view should be at least 50 cm diameter to minimize artifacts 528
from CT-based attenuation correction due to mismatch between the CT and PET 529 imaging fields. 530 531 A
workstation with the capability to display CT, PET and fused images with 532 different percentages of CT and
PET blending should also be available. The 533 workstation should allow multiplanar display with linked CT and
PET cursors. Post534 collection registration of the PET and CT datasets and registration with other imaging 535
studies including non-rigid registration is desirable. 536 537 b. Equipment Quality Control 538 539 PET
performance monitoring should be in accordance with the ACR Technical Standard 540 for Medical Nuclear
Physics Performance Monitoring of Nuclear Medicine Imaging 541 Equipment. 542 543 CT monitoring should be
in accordance with the ACR Technical Standard for Medical 544 Physics Performance Monitoring of Computed
Tomography (CT) Equipment. 545 546 The QC Procedures for PET/CT should incorporate both the CT
Procedures and the PET 547 Procedures according to the ACR Technical Standards. The QC Procedures for the
CT 548 should include air and water calibrations in Hounsfield Units for a range of kV. The QC 549 Procedures
for PET should include a calibration measurement of activity in a phantom 550 containing a known concentration,
generally as a function of axial position within the 551 scanner field-of-view. A daily check on the stability of the
individual detectors should 552 also be performed to identify detector failures and drifts. 553 554 In addition, for
PET/CT, a check on the alignment between the CT and PET scanners 555 should be performed periodically.
Such a gantry alignment check should determine an 556 offset between the CT and PET scanners that is
incorporated into the fused image 557 display to ensure accurate image alignment.
558 559 3. An emergency cart containing appropriate medications and resuscitation equipment must 560 be
readily available to treat adverse contrast reactions. 561 562 K. Sources of Error 563 564 Processes other than
malignancies may cause false-positive and false-negative results. The 565 following list, although not
all-inclusive, includes the most commonly encountered causes: 566 567 1. False-positive findings 568 569 a.
Physiologic uptake that may lead to false-positive interpretations 570 • Salivary glands and lymphoid tissue in the
head and neck 571 • Thyroid 572 • Brown adipose tissue 573 • Thymus especially in children 574 • Lactating
breast 575 • Areola 576 • Skeletal and smooth muscle (e.g., neck, paravertebral, hyperinsulinemia) 577 •
Gastrointestinal (e.g., esophagus, stomach, bowel) 578 • Urinary tract structures (containing excreted FDG) 579 •
Female genital tract (e.g., uterus during menses, corpus luteum cyst) 580 581 b. Inflammatory processes 582 •
Postsurgical inflammation/infection/hematoma, biopsy site, amputation site 583 • Post-radiation (e.g., radiation
pneumonitis) 584 • Post-chemotherapy 585 • Local inflammatory disease, especially granulomatous processes
(e.g., sarcoidosis, 586 fungal and mycobacterial disease) 587 • Ostomy site (e.g., trachea, colon) and drainage
tubes 588 • Injection site 589 • Thyroiditis 590 • Esophagitis, gastritis, inflammatory bowel disease 591 • Acute
and occasionally chronic pancreatitis 592 • Acute cholangitis and cholecystitis 593 • Osteomyelitis, recent
fracture sites, joint prostheses 594 • Lymphadenitis 595 596 c. Benign neoplasms 597 • Pituitary adenoma 598 •
Adrenal adenoma 599 • Thyroid follicular adenoma 600 • Salivary glands tumors (e.g., Warthin’s, pleomorphic
adenoma) 601 • Colonic adenomatous polyps and villous adenoma 602 • Ovarian thecoma and cystadenoma 603
• Giant cell tumor 604 • Aneurysmal bone cyst 605 • Leiomyoma 606
607 d. Hyperplasia/dysplasia 608 • Graves disease 609 • Cushing’s disease 610 • Bone marrow hyperplasia (e. g.,
anemia, cytokine therapy) 611 • Thymic rebound hyperplasia (after chemotherapy) 612 • Fibrous dysplasia 613 •
Paget’s disease 614 615 e. Ischemia 616 • Hibernating myocardium 617 618 f. Artifacts 619 • Misalignment
between PET and CT data can cause attenuation correction artifacts. 620 PET images without attenuation
correction and fusion images can be used to help 621 identify these artifacts. 622 • Inaccuracies in converting
from polychromatic CT energies to the 511 keV energy 623 of annihilation radiation can cause artifacts around
metal or dense barium, although 624 these artifacts are less common with newer conversion algorithms. 625 626
4. False-negative findings 627 628 • Small size (< 2 x resolution of the system) 629 • Tumor necrosis 630 •
Recent chemotherapy or radiotherapy 631 • Recent high-dose steroid therapy 632 • Hyperglycemia and
hyperinsulinemia 633 • Some low-grade tumors (e.g., sarcoma, lymphoma, brain tumor) 634 • Tumors with large
mucinous components 635 • Some hepatocellular carcinomas, especially well-differentiated tumors 636 • Some
genitourinary carcinoma, especially well-differentiated tumors 637 • Prostate carcinoma, especially
well-differentiated tumors 638 • Some neuroendocrine tumors, especially well-differentiated tumors 639 • Some
thyroid carcinomas, especially well-differentiated tumors 640 • Some bronchioloalveolar carcinomas 641 • Some
lobular carcinoma of the breast 642 • Some skeletal metastases, especially osteoblastic/sclerotic tumors 643 •
Some osteosarcoma 644 645 V. Qualification of Personnel 646 647 A. Physicians 648 649 The use of PET/CT
technology is becoming common practice. Because it is inefficient to 650 have PET/CT images interpreted by two
different imaging experts and then to have their 651 observations subsequently integrated, there is a need to define
the training for persons who 652 can interpret and integrate both components of PET/CT scans. Regardless of
previous 653 training, imaging experts interpreting PET/CT scans should have appropriate training in both 654
PET and CT imaging. In most instances, it is not feasible for a practicing diagnostic 655 radiologist to exactly
duplicate the PET training that a nuclear medicine physician receives
656 during a nuclear medicine residency, nor is it possible for a practicing nuclear medicine 657 physician to
duplicate the CT training obtained in a diagnostic radiology residency. Ideally, a 658 diagnostic radiologist who has
not received training and experience in PET should have 659 similar training experience as a nuclear medicine
physician, and a nuclear medicine physician 660 should ideally have training experience in CT similar to that of a
diagnostic radiologist. 661 662 An article summarizing the discussions surrounding issues relating to imaging with
PET, CT 663 and PET/CT has been recently published by a collaborative working group with 664 representatives
from the American College of Radiology (ACR), the Society of Nuclear 665 Medicine (SNM), and the Society of
Computed Body Tomography and Magnetic Resonance 666 (SCBT/MR) (J Nucl Med. 2005 Jul; 46(7):1225-1239).
These organizations agree that only 667 appropriately trained, qualified physicians should interpret PET/CT.
Traditionally, 668 appropriate training has been quantified by the number of CME credits and the number of 669
cases interpreted. The training recommendations from the collaborative working group are 670 summarized in
Table 3. Alternative approaches such as determining the accuracy of each 671 physician’s interpretation compared
to his or her peers using a workstation simulator and a 672 report generation and scoring system may have equal or
greater validity. 673 674 In the future, the requirements of radiology and nuclear medicine residency training
programs 675 will include training in interpretation and supervision of integrated PET/CT studies. 676 Certifying
and recertifying examinations will include testing on CT, PET and PET/CT. 677 Eligibility for taking the
recertification examinations will mandate participation in the 678 maintenance of certification (MOC) program and
will include training in interpretation of 679 PET, CT and PET/CT. Some components of the MOC will include
evaluation of the accuracy 680 of each physician’s interpretation of images compared to his or her peers using a
workstation 681 simulator and a report generation and scoring system. Performing and interpreting 682 physicians
should participate in and be able to show evidence of continuing medical 683 education in the techniques and
interpretation related to the procedures discussed in this 684 guideline. Where Maintenance of Certification
programs exist physicians should show 685 evidence of participation. 686 687 If there are no physicians available
with the training for interpretation of integrated PET/CT 688 studies, the PET scans should be interpreted by
nuclear medicine physicians with expertise in 689 PET and the CT scans should be interpreted by diagnostic
radiologists with expertise in CT. 690 Strong opinions have been expressed that a single report should be issued to
avoid 691 inconsistencies, confusion and redundancy, although reimbursement issues are still debated.
692
693
Radiopharmaceutical
Administered
Activity MBq
(mCi)
Organ Receiving the
Largest Radiation Dose
mGy per MBq (rad per
mCi)
Effective Dose
mSv per MBq
(rem per mCi)
18F-fluoro-2-deoxyglucose
370 – 740 i.v.
0.16
Bladder*
(0.59)
0.019
(FDG)
(10 – 20)
Radiopharmaceutical
18F-fluoro-2-deoxyglucose
Administered
Activity
MBq/kg
(mCi/kg)
Organ Receiving the
Largest Radiation Dose
mGy per MBq (rad per
mCi)
5.18 – 7.4 i.v.
0.32
Bladder*
(1.2)
(FDG)
(0.14 – 0.20)
(0.070)
Effective Dose
mSv per MBq
(rem per mCi)
0.050
(0.18)
694 695 *Radiologists/Nuclear
Radiologists with recent experience on body CT (100 body CT 696 cases/yr for
Table 3: Summary of PET/CT On-the-Job training requirements
the past 5 years).
697
698
**
Supervision
should
be performed by qualified
physicians
or
Training
ABMS Board
**PET/CT
***CT nuclear medicine
PET/CT
CT CME
diagnostic 699 radiologists, who
have interpreted
more than 500 PET/CT
studies 700 701
Certification
Interpretations
Interpretations
CME*** Supervision
should be performed by qualified diagnostic radiologists
defined
as
in
the
702
ACR
Practice
Guidelines for
(supervised)
(supervised)
Performing and Interpreting Diagnostic Computed 703 Tomography. CT cases should include a reasonable
Nuclear
ABNM
150
500
8 credits
100 credits
distribution of
head and neck, chest, 704 abdomen and pelvis. 705 706 B. Technologists 707 708 PET/CT
Medicine
technology presents similar practice issues regarding the education, training, and 709 certification of technologists
*Diagnostic
ABR
150
35 credits
to become appropriately
Radiologist qualified and competent to perform 710 PET/CT imaging. Additional issues arise in
ensuring competency
standardizing the 711 educational experience of these individuals, as well as barriers placed
(recent CT)
by licensure *Nuclear
and 712 regulation
at the state level.
ABR
150The Society of Nuclear Medicine Technologist
8 credits Section 713
(SNMTS) along
with
the
American
Society
of
Radiologic
Technologists
(ASRT)
have
come
714 together to
Radiologist
develop a master
plan
and
set
into
motion
mechanisms
to
sort
out
the
practice
715
issues
surrounding
PET/CT.
(recent CT)
This master *Radiologist
plan was crafted during
is known as the PET/CT
ABR &a stakeholders
150 meeting held 716 in July 2002, which
8 credits
Consensus Conference.
The
recommendations
717
from
this
meeting
are
located
in
the
reference
PET/CT
(recent CT)
ABNM
Consensus Conference
J
Nucl
Med
718
Technol
2002:30;
201-204
as
well
as
accessible
on
the
SNM
website.
Diagnostic
ABR
150
500
35 credits 100
credits719
720 It is the Radiologist
responsibility of the professional associations to establish standards, delineate 721 mechanisms for
obtaining the(no
training
recentnecessary to promote a qualified and competent 722 workforce to perform these procedures,
as well as toCT)
partner with organizations that can assist
723 in sorting out these practice issues. To address educational needs, the ASRT and SNMTS 724 spearheaded
the development of a PET/CT Curriculum, which was endorsed by numerous 725 professional organizations, and
distributed to each state radiation control board and every 726 program director in the country, as well as being is
posted on the SNM ( www.snm.org) and 727 ASRT (www.asrt.org) websites. 728 729 The Nuclear Medicine
Technology Certification Board (NMTCB) has developed a PET 730 specialty examination, which is open to
certified/registered nuclear medicine technologists, 731 registered radiologic technologists, CT technologists, and
registered radiation therapists, as 732 long as fulfilling the required prerequisites, as defined on the NMTCB
(www.nmtcb.org) 733 website. The American Registry of Radiologic Technologists (ARRT) has adapted its CT
734 certification examination and has allowed certified/registered nuclear medicine technologists 735 to sit for
this examination, whom have met the required prerequisites. Eligibility criteria are 736 located on the ARRT
(www.arrt.org) website. 737 738 Licensure and regulation are definitely impacting the opportunities that nuclear
medicine 739 technologists have in obtaining CT experience to sit for the ARRT CT examination, as well 740 as
Radiologic Technologists from gaining the PET experience to sit for the NMTCB PET 741 examination. The
SNMTS is approaching these issues through both the legislative and 742 regulatory pathways. The SNMTS has
been promoting the Consumer Assurance of 743 Radiologic Excellence bills pending before the US Congress.
The CARE bills would 744 establish minimum education and credentialing standards for those who perform
medical 745 imaging and therapeutic procedures. The second pathway recognizes the regulatory route in 746
addressing these practice issues, through a collaborative liaison relationship that has been 747 established with the
Conference of Radiation Control Program Directors (CRCPD, 748 www.crcpd.org), the professional organization
of state radiation regulators. 749 750 C. Qualified Medical Physicist 751 752 A Qualified Medical Physicist is an
individual who is competent to practice independently 753 one or more of the subfields in medical physics. The
SNM considers certification and 754 continuing education in the appropriate subfield(s) to demonstrate that an
individual is 755 competent to practice one or more of the subfield(s) in medical physics and to be a Qualified 756
Medical Physicist. The SNM recommends that the individual be certified in the appropriate 757 subfield(s) by
the American Board of Radiology (ABR) or the American Board of Science in 758 Nuclear Medicine (ABSNM).
759 760 The appropriate subfields of medical physics are: 761 ABR: ”Medical Nuclear Physics” with initially at
least 15 hours of continuing education 762 credits in CT imaging physics, or 763 “Diagnostic Radiological
Physics” with initially at least 15 hours of continuing education 764 credit in PET imaging physics. or 765
ABSNM: “Nuclear Medicine Physics and Instrumentation” with initially at least 15 hours of 766 continuing
education credits in CT imaging physics. 767 768 The Qualified Medical Physicist must have at least 40 hours of
practical experience providing 769 physics support for both the PET and CT scanning components in an
established PET/CT 770 center. 771
772 A Qualified Medical Physicist's continuing education should be in accordance with the ACR 773 Practice
Guideline for Continuing Education and should accumulate at least 15 hours in PET 774 and CT imaging physics
combined in a 3-year period. 775 776 The Qualified Medical Physicist or other qualified scientist performing
physics services in 777 support of PET/CT facilities should meet all of the following criteria: 778 779 1. Advanced
training directed at the specific area of responsibility (e.g., medical physics, 780 health physics or instrumentation.)
781 782 2. Licensure, if required by state regulations. 783 784 3. Documented regular participation in continuing
education in the area of specific 785 involvement to maintain competency. 786 787 4. Knowledge of radiation
safety and protection and of all rules and regulations 788 applying to the area of practice. 789 790 VI. Issues
Requiring Further Clarification 791 792 A. Use of AC/AL CT, or optimized diagnostic CT, or both may depend
upon the indication. The 793 selection of CT protocol to be used with PET/CT is under evolution. 794 795 B.
The role of re-registration to correct for respiratory and other motion artifacts. 796 797 C. The role of axial
collimation. 798 799 D. The role of respiratory gating for PET or CT or both. 800 801 E. Optimal distribution time
for FDG, scan time per bed position, image regularization 802 (smoothing), reconstruction algorithm, and best
method for CT-based attenuation 803 correction (CT-AC). 804 805 F. Optimal methods for semi-quantitative
measurements (e.g, SUV). 806 807 VII. Concise Bibliography 808 809 1. Antoch G, Freundenberg LS, Egelhof
T, et al. Focal tracer uptake: a potential artifact in 810 contrast-enhanced dual-modality PET/CT scans. J Nucl
Med 2002; 43(10): 1339-1342. 811 812 2. Antoch G, Freudenberg LS, Stattaus J, et al. Whole-body positron
emission tomography-CT: 813 optimized CT using oral and IV contrast materials. AJR Am J Roentgenol. 2002;
179(6): 814 1555-1560. 815 816 3. Antoch G, Jentzen W, Freundenberg LS, et al. Effect of oral contrast agents on
computed 817 tomography-based positron emission tomography attenuation correction in dual-modality 818
positron emission tomography/computed tomography imaging. Invest Radiol 2003; 38(12): 819 784-789. 820
821 4. Beyer T, Townsend DW, Brun T, Kinahan PE, Charron M, Roddy R, Jerin J, Young, J, Byars 822 L, Nutt R.
A combined PET/CT scanner for clinical oncology. J Nucl Med. 2000 Aug; 41(8): 823 1369-1379. 824 825 5.
Cohade C, Osman M, Nakamoto Y, et al. Initial experience with oral contrast in PET/CT: 826 phantom and
clinical studies. J Nucl Med 2003; 44(3): 412-416. 827 828 6. Coleman RE, Delbeke D, Guiberteau MJ, Conti PS,
Royal HD, Weinreb JC, Siegel BA, 829 Federle MF, Townsend DW, Berland LL. Concurrent PET/CT with an
Integrated Imaging 830 System: Intersociety Dialogue from the Joint Working Group of the American College of
831 Radiology, the Society of Nuclear Medicine, and the Society of Computed Body 832 Tomography and
Magnetic Resonance. J Nucl Med. 2005 Jul; 46(7): 1225-1239. 833 834 7. Czernin J (guest editor). PET/CT:
Imaging structure and function. J Nucl Med 2004;45 835 (Suppl1):1S-103S. 836 837 8. Dizendorf E, Hany TF,
Buck A, et al. Cause and magnitude of the error induced by 838 oral CT contrast agent in CT-based
attenuation correction of PET emission studies. 839 Eur J Nucl Med 2003; 44(5): 732-738. 840 841 9.
Donnelly LF. Lessons from history. Pediatr Radiol. 2002 Apr;32(4):287-92. 842 843 10. Fearon T, Vucich J.
Pediatric patient exposures from CT examinations: GE CT/T 844 9800 scanner. Am J Roentgenol. 1985
Apr;144(4):805-9. 845 846 11. Gambhir SS, Czernin J, Schimmer J, et al. A tabulated summary of the FDG PET
literature. J 847 Nucl Med 2001; 42 (Suppl): 1S-93S. 848 849 12. Kinahan PE, Hasegawa BH, and Beyer T.
X-ray Based Attenuation Correction for 850 PET/CT Scanners. Seminars in Nuclear Medicine
2003;33:166-179. 851 852 13. Nakamoto Y, Chin BB, Kraitchman DL, et al. Effects of nonionic intravenous
contrast 853 agents at PET/CT imaging: phantom and canine studies. Radiology 2003; 227(3): 817-824. 854 855
14. Osman MM, Cohade C, Nakamoto Y, Wahl RH. Clinically significant inaccurate 856 localization of lesions
with PET/CT: Frequency in 300 patients. J Nucl Med 2003; 44:240857 243. 858 859 15. Paquet N, Albert A,
Foidart J, Hustinx R. Within-patient variability of 18F-FDG: 860 Standardized uptake values in normal tissues. J
Nucl Med 2004; 45:784-788. 861 862 16. PET/CT Consensus Conference: SNMTS; American Society of
Radiologic Technologists. 863 Fusion imaging; a new type of technologist for a new time of technology. July 31,
2002. J 864 Nucl Med Techol 2002; 30:201-204. 865 866 17. Thie J. Understanding the standardized uptake
value, its methods, and implications for usage. 867 J Nucl Med 2004; 45:1431-1434. 868
869 18. Townsend DW, Beyer T, Blodgett TM. PET/CT scanners: a hardware approach to image 870 fusion.
Semin Nucl Med. 2003; 33 (3): 193-204. 871 872 19. Weber WA. Use of PET for monitoring therapy and
predicting outcome. J Nucl Med 2005; 873 46:983-995. 874 875 20. Yau YY, Chan WS, Tam YM, Vernon P,
Wong S, Coel M, Chu SK. Application of 876 intravenous contrast in PET/CT: does it really introduce significant
attenuation correction 877 error? J Nucl Med. 2005 Feb; 46(2): 283-291. 878 879 21. Young H, Baum R,
Cremerius U, Herholz K, Hoekstra O, Lammertsma AA, Pruim J,Price P. 880 Measurement of clinical and
subclinical tumour response using [18F]-fluorodeoxyglucose 881 and positron emission tomography: review and
1999 EORTC recommendations. European 882 Organization for Research and Treatment of Cancer (EORTC) PET
Study Group. Eur J 883 Cancer. 1999 Dec; 35(13): 1773-1782. 884 885 VIII. Last House of Delegates Approval
Date: 886 887 888 IX. Next Anticipated Approval Date: 889 890 891 X. Appendix: Description of Guideline
Development Process 892 893 A. Committee on Guidelines 2005-2006 894 895 Helena R. Balon, MD, Chair;
Terence Beven, MD; David R. Brill, MD; Kevin J. Donohoe, 896 MD; Paul E. Christian, CNMT; Peter Conti, MD,
PhD; Edward E. Eikman, MD; Josef 897 Machac, MD; J. Anthony Parker, MD, PhD; Henry D. Royal, MD; Paul
D. Shreve, MD; 898 Barry L. Shulkin, MD; and Mark D. Wittry, MD. 899 900 B. Task Force Members
901 Dominique Delbeke, MD, PhD, Chair; R. Edward Coleman, MD; Milton J. Guiberteau, MD; 902 Manuel L.
Brown, MD; Henry D. Royal, MD; Barry A. Siegel, MD; David W. Townsend, 903 PhD; Lincoln L. Berland,
MD; J. Anthony Parker, MD; Karl Hubner; MD; Michael G. 904 Stabin, PhD; George Zubal, PhD; Marc
Kachelreiss, PhD; Valerie Cronin, CNMT 905 906 C. History of Board of Directors Approval Dates 907 908 D.
Revision History. 909 910 1. Version 0.0 – 0.3 911 a. Names of each detailed reviewer and the percentage of
lines with which each 912 reviewer agreed: 913 914 Comments for Versions 0.0-0.3 not available – sent directly
to Task Force Chair. 915 916 b. Names of other reviewers: 917
918 Helena R. Balon, MD 919 920 2. Version 0.4 921 922 a. Names of each detailed reviewer and the percentage
of lines with which the reviewer 923 agreed: 924 925 Michael G. Stabin, PhD (99.6%); J. Anthony Parker, MD
(93.7%); Karl Hubner, MD 926 (97.7%); Lincoln L. Berland, MD (99.4%); Barry A. Siegel, MD (94.6%); David
W. 927 Townsend, PhD (98.7%) 928 929 b. Names of other reviewers: 930 931 Paul Shreve, MD (90.4%); Barry
Shulkin, MD (97.2%); Helena R. Balon, MD 932 (99.1%); Kevin J. Donohoe, MD (94.6%); Edward E. Eikman,
MD (99.7%); Misty 933 Long, R.T. (99.7%) 934 935 c. Line-by-line listing of all comments and the action taken
on each comment (Fully 936 Implemented; Partially Implemented; Not Implemented) 937 938 See Line-by-Line
Comment Report on file – Procedure Guideline for V0.4 939 940 d. Date completed: September 22, 2005 941
942 3. Version 0.5 943 944 a. Names of each detailed reviewer and the percentage of lines with which the
reviewer 945 agreed: 946 947 b. Names of other reviewers (sample of 100 SNM members): 948 949 Paul Shreve,
MD (99.5%); Johannes Czernin, MD (99.6%); Einat Even-Sapir, MD, 950 PhD (97.8%); Wolfgang Weber, MD
(98.0%); Lorraine Fig, MD (98.2%); William 951 Martin, MD (98.0%); David Schuster, MD (98.6%); Michael
Graham, PhD, MD 952 (91.6%); Tim Turkington, PhD (99.7%); Masanori Ichise, MD (97.4%); C. Oliver 953
Wong, MD, PhD (74.4%); David Mankoff, MD (85.9%); Paul Kinahan, PhD 954 (97.5%); Terence Wong, MD,
PhD (99.4%); Ora Israel, MD (99.8%); Val Lowe, MD 955 (90.5%); Michael Gelfand (96.8%); Stephen
Bacharach, PhD (98.1%); Farrokh 956 Dehdashti, MD (99.3%); Cindi Luckett-Gilbert, CNMT (99.2%); Lyn
Mehlberg, 957 CNMT (98.1%); Ron Tikofsky, PhD (87.1%) 958 959 c. Line-by-line listing of all comments and
the action taken on each comment (Fully 960 Implemented; Partially Implemented; Not Implemented) 961 962
See Line-by-Line Comment Report on file – Procedure Guideline for V0.5 963 964 d. Date completed:
October 26, 2005 965 966 4. Version 0.6 967
968 a. Names of each detailed reviewer and the percentage of lines with which the reviewer 969 agreed: 970 971
J. Anthony Parker, MD (99.9%); Barry A. Siegel, MD (96.4%); Milton J. Guiberteau, 972 MD (99.9%) 973 974
b. Names of other reviewers 975 976 Helena R. Balon, MD (98.9%); David W. Townsend, PhD (99.9%) 977 978
c. Line-by-line listing of all comments and the action taken on each comment (Fully 979 Implemented; Partially
Implemented; Not Implemented) 980 981 See Line-by-Line Comment Report on file – Procedure Guideline
for V0.6 982 983 d. Date completed: November 18, 2005 984 985