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Principles and Practice of PET/CT EANM® Eu ne rope edici an Association of Nuclear M Publications · Brochures Principles and Practice of PET/CT Part 2 A Technologist‘s Guide Produced with the kind Support of Editors Giorgio Testanera Wim J.M. van den Broek Rozzano (MI), Italy Nijmegen, The Netherlands Contributors Ambrosini, Valentina (Italy) Kaufmann, Philipp A. (Switzerland) Beijer, Emiel (The Netherlands) Krause, Bernd J. (Germany) Bomanji, Jamshed B. (UK) Królicki, Leszek (Poland) Booij, Jan (The Netherlands) Kunikowska, Jolanta (Poland) Bozkurt, Murat Fani (Turkey) Mottaghy, Felix Manuel (Germany) Carreras Delgado, José L. (Spain) Nobili, Flavio (Italy) Chiti, Arturo (Italy) Oyen, Wim J.G. (The Netherlands) Darcourt, Jacques (France) Pagani, Marco (Italy) Decristoforo, Clemens (Austria) Papathanasiou, Nikolaos D. (Greece) Delgado-Bolton, Roberto C. (Spain) Petyt, Gregory (France) Dennan, Suzanne (Ireland) Poepperl, Gabriele (Germany) Elsinga, Philip H. (The Netherlands) Prompers, Leonne (The Netherlands) Fanti, Stefano (Italy) Schwarzenboeck, Sarah (Germany) Gaemperli, Oliver (Switzerland) Semah, Franck (France) Giammarile, Francesco (France) Souvatzoglou, Michael (Germany) Giurgola, Francesca (Italy) Tarullo, Gianluca (Italy) Grugni, Stefano (Italy) Tatsch, Klaus (Germany) Halders, Servé (The Netherlands) Testanera, Giorgio (Italy) Hanin, François-Xavier (Belgium) Urbach, Christian (The Netherlands) Houzard, Claire (France) Vaccaro, Ilaria (Italy) Jamar, François (Belgium) 2 Contents Foreword 5 Suzanne Dennan Introduction 6 Wim van den Broek and Giorgio Testanera Chapter 1 – Principles of PET radiochemistry 8 1.1 Introduction to PET radiochemistry 8 Clemens Decristoforo 1.2 Common practice in PET tracer quality control 10 Gianluca Tarullo and Stefano Grugni 1.3 Basics of 18F and 11C radiopharmaceutical chemistry 18 Philip H. Elsinga EANM 1.4 [18F]FDG synthesis 26 Francesca Giurgola, Ilaria Vaccaro and Giorgio Testanera 1.5 68Ga-peptide tracers 32 Jamshed B. Bomanji and Nikolaos D. Papathanasiou Chapter 2 – Clinical applications of PET/CT in oncology 43 2.1 Introduction 43 Wim J.G. Oyen and Arturo Chiti 2.2 Head and neck cancer 44 Murat Fani Bozkurt 2.3 Lung cancer 50 Francesco Giammarile and Claire Houzard 2.4 Breast cancer 60 Leonne Prompers, Emiel Beijer, Christian Urbach, Servé Halders and Felix Manuel Mottaghy 2.5 Prostate cancer 67 Sarah Schwarzenboeck, Michael Souvatzoglou and Bernd J. Krause 2.6 Lymphomas 80 Roberto C. Delgado-Bolton and José L. Carreras Delgado 2.7 Digestive tract tumours 89 Jolanta Kunikowska and Leszek Królicki 2.8 Neuroendocrine tumour 102 Valentina Ambrosini and Stefano Fanti 3 Contents Chapter 3 – Clinical applications of PET/CT in infection and in%ammation 110 François-Xavier Hanin and François Jamar Chapter 4 – Clinical applications of PET/CT in cardiology 121 Oliver Gaemperli and Philipp A. Kaufmann Chapter 5 – Clinical applications of PET/CT in neurology 139 5.1 Introduction to brain PET 139 Jacques Darcourt 5.2 Dementia and related disorders 141 Flavio Nobili 5.3 Psychiatry 146 Marco Pagani 5.4 Movement disorders 150 Jan Booij 5.5 Brain tumours 153 Klaus Tatsch and Gabriele Poepperl 5.6 Epilepsy 159 Franck Semah and Gregory Petyt Imprint 163 4 Foreword Suzanne Dennan The EANM Technologist Committee has I am grateful for the e&orts and hard work of produced a highly successful “Technologist’s the authors, who have ensured the outstand- Guide” on an annual basis since 2004. The ing quality of this PET/CT book. I am very much “Technologist’s Guide” aims to develop exper- indebted to the editors, Giorgio Testanera and tise in key and developing areas of nuclear Wim van den Broek, for their enthusiasm and medicine and to promote high standards dedication in preparing and editing this guide of professional practice. In recent years, the within a record short time for our annual se- rapid advancement of PET/CT techniques has ries. Special thanks are due to Siemens Medical increased the requirement for involvement for their support and generous sponsorship of of competent and re%ective personnel in the the three-part PET/CT series. management and care of patients undergoing PET/CT examinations. I am con*dent that this PET/CT book will be EANM of immense help to all professionals working In 2010, the Technologist Committee decided in PET/CT departments and also to those who that the next three guides would be dedicated would like to develop their understanding of to the topic of hybrid PET/CT imaging. Part 1 PET/CT. It is hoped that this eighth “Tech- of the PET/CT series focussed on the principles nologist’s Guide” will prove to be a useful and and practice of PET/CT and included topics comprehensive tool that will contribute to the ranging from practical radiation protection, quality of the PET/CT patient service. I look quality assurance and quality control to pa- forward to the next PET/CT book in 2012. tient care. It is a great privilege to introduce part 2 of the PET/CT series, devoted to PET Suzanne Dennan radiochemistry and to the clinical applications Chair, EANM Technologist Committee of PET/CT in oncology, cardiology, infection, in%ammation and neurology. 5 Introduction Wim van den Broek and Giorgio Testanera Owing primarily to the wide availability of lent overview of all the issues and aspects 18F-FDG, PET/CT has established its place in related to the preparation of PET tracers. the diagnosis and management of several prominent diseases, especially in the *eld t Chapter 2 presents the clinical applications of oncology. In recent years, an increasing of PET/CT in oncology, with a review of the number of alternative new PET radiopharma- strengths, weaknesses, current evidence ceuticals have become commercially avail- and future directions of this imaging tech- able, opening the way to new applications nique over a wide range of tumours. of PET/CT imaging. Since a greater variety of biological functions can be visualised by PET/ t PET/CT applications in the detection and CT with these new positron radiopharmaceu- follow-up of infection and in%ammatory ticals, the number of PET/CT applications will disease are rather new and still unrecog- increase in cardiology and neurology as well nised by some. Chapter 3 reviews the main as in oncology. indications for 18F-FDG PET/CT in this *eld and discusses the advantages and pitfalls This second PET/CT Technologist’s Guide will compared with imaging using labelled be of value not only for nuclear medicine white blood cells. technologists but also for other professionals working with PET/CT. As the *rst book cov- t The introduction of new PET tracers such ered instrumentation, protocol optimisation, as 82Rb and the increasing availability of radiation protection and patient care issues, PET devices in combination with high-end this book provides the reader with informa- CT scanners is opening the way for increas- tion on the principles of PET radiochemistry ing use of PET/CT in cardiology. Chapter 4 and the current state of clinical applications discusses the clinical applications in the of PET/CT in the *elds of oncology, cardiology, *eld and covers patient preparation and infection and in%ammation and neurology. PET/CT protocols. t The *rst chapter covers the principles of t Imaging of the brain with PET/CT is still an PET radiochemistry. In addition to present- open *eld with many possibilities. Thanks ing the basic knowledge on PET chemis- to the large number of PET tracers for brain try, it also discusses the regulatory rules imaging that are either already available or which require increasing awareness of the expected to become available. This *nal challenges involved in the production and chapter o&ers an overview of the current quality assurance of PET radiopharmaceuti- applications of PET/CT imaging in di&erent cals. This chapter o&ers the reader an excel- brain diseases. 6 Introduction After the broad view o&ered by the *rst two working in the area of PET/CT imaging will volumes on technology, radiation protec- ultimately ensure high-quality diagnosis of tion, patient care and clinical applications of disease. The importance of such collaboration PET/CT, the third book in this series, to be pub- also applies to this booklet, in which the good lished in 2012, will address the great challenge quality re%ects the excellent teamwork be- posed by multimodality approaches involv- tween the EANM Radiopharmacy, Oncology, ing PET/CT. In particular, it will consider the Cardiovascular and Neurology Committees radiotherapy applications of PET/CT imaging. and Task Group on Infection and In%amma- tion and the EANM Technologist Committee. The ultimate quality of PET/CT imaging de- pends on the expert input of a number of We hope that you enjoy reading this book and professionals, including physicians, physicists, that it will prove a valuable resource for all pro- EANM chemists, pharmacists and technologists. Only fessionals who work in the area of PET/CT or good teamwork between the professionals are interested in this topic. 7 Chapter 1 – Principles of PET radiochemistry 1.1 Introduction to PET radiochemistry Clemens Decristoforo PET/CT has seen tremendous growth over re- cently by drafting Guidelines and Guidance cent years, mainly driven by the wide use and documents on Good Radiopharmacy Prac- availability of 18F-FDG. Imaging with 18F-FDG tice for the Small-Scale Preparation of Radio- has now become the clinical standard for a pharmaceuticals. number of indications, especially in oncol- ogy. However, a major potential of molecular The role of the technologist in such
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