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Procedure Guideline for Tumor Imaging with 18F-FDG PET/CT 1.0*

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Procedure Guideline for Tumor Imaging with 18F-FDG PET/CT 1.0* Procedure Guideline for Tumor Imaging with 18F-FDG PET/CT 1.0* Dominique Delbeke1, R. Edward Coleman2, Milton J. Guiberteau3, Manuel L. Brown4, Henry D. Royal5, Barry A. Siegel5, David W. Townsend6, Lincoln L. Berland7, J. Anthony Parker8, Karl Hubner9, Michael G. Stabin10, George Zubal11, Marc Kachelriess12, Valerie Cronin13, and Scott Holbrook14 1Vanderbilt University Medical Center, Nashville, Tennessee; 2Duke University Medical Center, Durham, North Carolina; 3Christus St. Joseph Hospital, Houston, Texas; 4Henry Ford Hospital, Detroit, Michigan; 5Mallinckrodt Institute of Radiology, St. Louis, Missouri; 6University of Tennessee, Knoxville, Tennessee; 7University of Alabama Hospital, Birmingham, Alabama; 8Beth Israel Deaconess Hospital, Boston, Massachusetts; 9University of Tennessee Medical Center, Knoxville, Tennessee; 10Vanderbilt University, Nashville, Tennessee; 11Yale University, New Haven, Connecticut; 12Institute of Medical Physics, University of Erlangen-Nurnberg, Erlangen, Germany; 13Mercy Hospital, Buffalo, New York; and 14Precision Nuclear, Gray, Tennessee I. PURPOSE available for several years, the readily apparent and doc- umented advantages of having PET and CT in a single device The purpose of these guidelines is to assist physicians in have resulted in the rapid dissemination of this technology recommending, performing, interpreting, and reporting the in the United States. This Procedure Guideline pertains results of 18F-FDG PET/CT for oncologic imaging of adult only to combined PET/CT devices. and pediatric patients. II. BACKGROUND INFORMATION AND DEFINITIONS Definitions PET is a tomographic scintigraphic technique in which a A. A PET/CT scanner is an integrated device containing computer-generated image of local radioactive tracer dis- both a CT scanner and a PET scanner with a single tribution in tissues is produced through the detection of patient table and therefore capable of obtaining a CT annihilation photons that are emitted when radionuclides scan, a PET scan, or both. If a patient does not move introduced into the body decay and release positrons. 18F- between the scans, the reconstructed PET and CT FDG PET is a tomographic imaging technique that uses a images will be spatially registered. radiolabeled analog of glucose, 18F-FDG, to image relative B. PET/CT registration is the process of aligning PET glucose use rates in various tissues. Because glucose use is and CT images for the purposes of combined image increased in many malignancies, 18F-FDG PET is a sensi- display (fusion) and image analysis. tive method for detecting, staging, and monitoring the C. PET/CT fusion is the combined display of registered effects of therapy of many malignancies. CT is a tomo- PET and CT image sets. Superimposed data typically graphic imaging technique that uses an x-ray beam to are displayed with the PET data color coded to the produce anatomic images. This anatomic information is CT data in gray scale. used to detect and to help determine the location and extent D. PET/CT acquisitions can include the whole body, an of malignancies. Combined PET/CT devices provide both extended portion of the body, or a limited portion of the metabolic information from 18F-FDG PET and the the body. These acquisitions are defined in Current anatomic information from CT in a single examination. As Procedural Terminology 2005 as follows: shown in some clinical scenarios, the information obtained 1. Whole-body tumor imaging: from the top of the by PET/CT appears to be more accurate in evaluating pa- head through the feet tients with known or suspected malignancies than does the 2. Skull base–to–midthigh tumor imaging information obtained from either PET or CT alone or the 3. Limited-area tumor imaging results obtained from PET and CT separately but inter- E. Methods of attenuation correction: preted side by side. 1. CT transmission imaging with PET/CT scanners 18F-FDG PET and CT are proven diagnostic procedures. 2. Transmission scanning with an isotopic source: Although techniques for registration and fusion of images not commonly used with PET/CT scanners obtained from separate PET and CT scanners have been Received Mar. 10, 2006; accepted Mar. 10, 2006. For correspondence or reprints contact: Dominique Delbeke, Vanderbilt III. EXAMPLES OF CLINICAL OR RESEARCH University Medical Center, 21st Ave. S. and Garland, Nashville, TN 37232- APPLICATIONS 2675. E-mail: [email protected] 18 *YOU CAN ACCESS THIS ACTIVITY THROUGH THE SNM WEB SITE Indications for F-FDG PET/CT include but are not (http://www.snm.org/guidelines). limited to the following: A. Differentiating benign from malignant lesions a. For brain imaging, the patient should be in a quiet B. Searching for an unknown primary tumor when and dimly lit room for 18F-FDG administration metastatic disease is discovered as the first manifes- and the subsequent uptake phase. tation of cancer or when the patient presents with a b. For body imaging, the patient should remain seated paraneoplastic syndrome or recumbent for 18F-FDG administration and the C. Staging known malignancies subsequent uptake phase to avoid muscular uptake. D. Monitoring the effect of therapy on known malig- c. The blood glucose level should be checked before nancies 18F-FDG administration. Tumor uptake of 18F-FDG E. Determining whether residual abnormalities detected is reduced in hyperglycemic states. Most institu- on physical examination or on other imaging studies tions reschedule the patient if the blood glucose after treatment represent tumor or posttreatment fi- level is greater than 150–200 mg/dL. Reducing the brosis or necrosis serum glucose level by administering insulin can F. Detecting tumor recurrence, especially in the pres- be considered, but the administration of 18F-FDG ence of elevated levels of tumor markers should be delayed after insulin administration (with G. Selecting the region of a tumor most likely to yield the duration of the delay being dependent on the diagnostic information for biopsy type and route of administration of insulin). H. Guiding radiation therapy planning d. For either a CT scan done for attenuation cor- I. Nononcologic applications, such as evaluation of rection/anatomic localization (AC/AL) or a diag- infection and atherosclerosis nostic CT scan of the abdomen or pelvis, an intraluminal gastrointestinal contrast agent may 18F-FDG PET/CT is not equally effective for all malig- be administered to provide adequate visualization nancies, but other tracers are available; however, many of of the gastrointestinal tract unless it is medically these are not yet approved by the U.S. Food and Drug contraindicated or unnecessary for the clinical Administration or reimbursable by the Medicare program. indication (see Section E.2.b.). The scientific literature concerning its utility continues to evolve rapidly. B. Information Pertinent to Performing Procedure See also the Society of Nuclear Medicine Procedure Guidelines for General Imaging. IV. PROCEDURE 1. Focused history, including the type and site of malig- A. Patient Preparation nancy, dates of diagnosis and treatment (biopsy results, The optimum preparation for patients about to undergo surgery, radiation, chemotherapy, and administration PET/CT is evolving. The major goals of preparation are to of bone marrow stimulants and steroids), and current minimize tracer uptake in normal tissues, such as the medications. myocardium and skeletal muscle, while maintaining uptake 2. History of diabetes, fasting state, and recent infection in target tissues (neoplastic disease). The following is a 3. Patient’s ability to lie still for the duration of the commonly used protocol. acquisition (15–45 min) 4. History of claustrophobia 1. Pregnancy and breast-feeding: see the Society of Nuclear 5. Patient’s ability to put his or her arms overhead Medicine Procedure Guidelines for General Imaging 2. Before arrival Patients should be instructed to fast and not con- C. Precautions sume beverages, except for water, for at least 4–6 h See the Society of Nuclear Medicine Procedure Guide- before the administration of 18F-FDG to decrease lines for General Imaging. physiologic glucose levels and to reduce serum insu- lin levels to near basal levels. Oral hydration with D. Radiopharmaceutical water is encouraged. Intravenous fluids containing With PET/CT, the radiation dose to the patient (Table 1) dextrose or parenteral feedings also should be with- is the combination of the radiation dose from the PET held for 4–6 h. radiopharmaceutical and the radiation dose from the CT When intravenous contrast material is to be used, portion of the study. Radiation dose in diagnostic CT has patients should be screened for a history of iodinated attracted considerable attention in recent years, in particular contrast material allergy, use of metformin for the for pediatric examinations. It can be very misleading to treatment of diabetes mellitus, and renal disease. state a ‘‘representative’’ dose for a CT scan because of the Intravenous contrast material should not be adminis- wide diversity of applications, protocols, and CT systems. tered when the serum creatinine level is above 2.0 This caveat also applies to the CT component of a PET/CT mg/dL. study. For example, a body scan may include various portions 3. Before injection of the body and may use protocols aimed to reduce the TABLE 1 18F-FDG Radiation Dosimetry for Adults and Children Organ receiving the largest radiation dose, Effective dose, Patient Intravenously administered activity mGy/MBq (rads/mCi) mSv/MBq (rems/mCi) Adult 370–740 MBq (10–20 mCi) Bladder, 0.16* (0.59) 0.019 (0.070) Child (5 y old) 5.18–7.4 MBq/kg (0.14–0.20 mCi/kg) Bladder, 0.32y (1.2) 0.050 (0.18) *Voiding interval, 3.5 h. Changes in bladder wall dose are approximately linear with changes in voiding interval; therefore, for a voiding interval of 2.0 h, dose to bladder wall would change by a factor of 2/3.5. yVoiding interval, 2.0 h. Data are from International Commission on Radiological Protection. Radiation Dose to Patients from Radiopharmaceuticals.
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