Eur J Nucl
Med Mol Imaging. 2015; 42(2): 328–354. Ronald Boellaard,
Eur J Nucl Med Mol Imaging. 2015; 42(2): 328–354.
The purpose of these guidelines is to assist physicians in recommending, performing, interpreting and reporting the results of FDG PET/CT for oncological imaging of adult patients. PET is a quantitative imaging technique and therefore requires a common quality control (QC)/quality assurance (QA) procedure to maintain the accuracy and precision of quantitation. Repeatability and reproducibility are two essential requirements for any quantitative measurement and/or imaging biomarker. Repeatability relates to the uncertainty in obtaining the same result in the same patient when he or she is examined more than once on the same system. However, imaging biomarkers should also have adequate reproducibility, i.e. the ability to yield the same result in the same patient when that patient is examined on different systems and at different imaging sites. Adequate repeatability and reproducibility are essential for the clinical management of patients and the use of FDG PET/CT within multicentre trials. A common standardised imaging procedure will help promote the appropriate use of FDG PET/CT imaging and increase the value of publications and, therefore, their contribution to evidence-based medicine. Moreover, consistency in numerical values between platforms and institutes that acquire the data will potentially enhance the role of semiquantitative and quantitative image interpretation. Precision and accuracy are additionally important as FDG PET/CT is used to evaluate tumour response as well as for diagnosis, prognosis and staging. Therefore both the previous and these new guidelines specifically aim to achieve standardised uptake value harmonisation in multicentre settings.
Keywords: FDG, PET/CT, Imaging procedure, Tumour, Oncology, Quantification
The European Association of Nuclear Medicine (EANM) is a professional nonprofit medical association that facilitates communication worldwide among individuals pursuing clinical and research excellence in nuclear medicine. The EANM was founded in 1985.
These guidelines are intended to assist practitioners in providing appropriate nuclear medicine care for patients. They are not inflexible rules or requirements of practice and are not intended, nor should they be used, to establish a legal standard of care.
The ultimate judgment regarding the propriety of any specific procedure or course of action must be made by medical professionals taking into account the unique circumstances of each case. Thus, there is no implication that an approach differing from the guidelines, standing alone, is below the standard of care. To the contrary, a conscientious practitioner may responsibly adopt a course of action different from that set out in the guidelines when, in the reasonable judgment of the practitioner, such course of action is indicated by the condition of the patient, limitations of available resources or advances in knowledge or technology subsequent to publication of the guidelines.
The practice of medicine involves not only the science but also the art of dealing with the prevention, diagnosis, alleviation and treatment of disease. The variety and complexity of human conditions make it impossible to always reach the most appropriate diagnosis or to predict with certainty a particular response to treatment. Therefore, it should be recognised that adherence to these guidelines will not ensure an accurate diagnosis or a successful outcome. 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.
18F-FDG (FDG) PET imaging is a noninvasive diagnostic tool that provides tomographic images and can be used to obtain quantitative parameters concerning the metabolic activity of target tissues. 18F is a cyclotron-produced radioisotope of fluorine that emits positrons and has a short half-life (109.7 min). It allows labelling of numerous molecular tracers that can be imaged within a few hours (typically <3 h) after injection. FDG is an analogue of glucose and is taken up by living cells via cell membrane glucose transporters and subsequently incorporated into the first step of the normal glycolytic pathway.
PET is a tomographic technique that measures the three-dimensional distribution of positron-emitting labelled radiotracers. PET allows noninvasive quantitative assessment of biochemical and functional processes. The most commonly used tracer at present is the 18F-labelled glucose analogue FDG. FDG accumulation in tissue is proportional to the amount of glucose utilisation. Increased consumption of glucose is characteristic of most cancers and is in part related to overexpression of the GLUT glucose transporters and increased hexokinase activity. FDG PET has been proven to be a sensitive imaging modality for detection, staging and restaging and therapy response assessment in oncology [1–13]. FDG PET/CT provides essential information for radiation treatment planning, helping with critical decisions when delineating tumour volumes [14, 15].
CT uses a combined X-ray transmission source and detector system rotating around the subject to generate tomographic images. CT allows not only attenuation correction but also the visualisation of morphological and anatomical structures with a high spatial resolution. Anatomical and morphological information derived from CT can be used to improve the localisation, extent and characterisation of lesions detected by FDG PET. These guidelines focus on the use of FDG PET/CT in oncology, where PET/CT continues to gain importance. Recently, combined or integrated PET and MRI systems (PET/MRI) have come onto the market. PET/MRI technology is, however, still in development and is not yet widely available [16, 17]. Therefore, this version of the guidelines does not address FDG PET/MRI, although currently the quantitative performance of FDG PET/MRI is being explored as a scientific project within EANM Research Limited (EARL).
The purpose of these guidelines is to assist physicians in recommending, performing, interpreting and reporting the results of FDG PET/CT for oncological imaging of adult and paediatric patients. PET is a quantitative imaging technique and therefore requires a common quality control (QC)/quality assurance (QA) procedure to maintain the accuracy and precision of quantitation . Repeatability and reproducibility are two essential requirements for any quantitative measurement and/or imaging biomarker. Repeatability relates to the uncertainty in obtaining the same result in the same patient when he or she is examined more than once on the same system. However, imaging biomarkers should also have adequate reproducibility, i.e. the ability to yield the same result in the same patient when that patient is examined on different systems and at different imaging sites. Adequate repeatability and reproducibility are essential for the clinical management of patients and the use of FDG PET/CT within multicentre trials. A common standardised imaging procedure will help promote the appropriate use of FDG PET/CT imaging and increase the value of publications and, therefore, their contribution to evidence-based medicine. Moreover, consistency in numerical values between platforms and institutes that acquire the data will potentially enhance the role of semi-quantitative and quantitative image interpretation. Precision and accuracy are additionally important as FDG PET/CT is used to evaluate tumour response as well as for diagnosis, prognosis and staging. Therefore both the previous and these new guidelines specifically aim to achieve standardised uptake value (SUV) harmonisation in multicentre settings.
These guidelines address general information about FDG PET/CT and are provided to help the physician, physicist and technologist perform, interpret and document quantitative FDG PET/CT examinations, but concentrate on harmonisation/standardisation of diagnostic quality and quantitative information in oncology imaging of adult patients. These guidelines present a standardised imaging procedure for static FDG PET/CT data acquisition, QC and QA. Quantification of FDG PET/CT is defined as quantification using SUVs  because the SUV represents the most commonly used semiquantitative parameter for analysis of tracer uptake. Furthermore, this new version of the guidelines only addresses combined or integrated whole-body 3D PET/CT systems.
These guidelines build upon the earlier published European procedure guidelines for quantitative FDG PET and PET/CT for tumour imaging  and the SNMMI procedure guidelines for tumour imaging with 18F-FDG PET/CT 1.0 . For a detailed history of the document, refer to section History of the document. For FDG PET/CT studies in paediatric patients, refer to the specific guidelines .
Common clinical indications
FDG PET/CT is a rapidly evolving imaging modality at both the national and the international levels, with some striking differences between individual countries. FDG PET/CT has become one of the cornerstones of patient management in oncology.
Indications for FDG PET/CT include [10–12, 20, 21], but are not limited to, the following:
Other documents include further indications for FDG PET/CT [10, 20]. The clinical utility of this valuable technology continues to expand in oncology and therefore an exhaustive list of appropriate indications would not be possible or remain final for long.
FDG PET/CT also has an increasingly relevant role in inflammation and infection imaging , cardiology and neurology. In these areas the FDG PET/CT procedure may require specific elements not addressed in these guidelines.
There is consistent progress in the field, with regular new literature and registration of FDG for several indications by the European Medicines Agency. In the United States, FDG is approved by the Food and Drug Administration for all oncological indications.
Qualifications and responsibilities of personnel
In Europe, the certified nuclear medicine physician who performed the study and signed the report is responsible for the procedure, according to national laws and rules. In the United States, see the SNMMI Guideline for General Imaging .
Procedure/specification of the examination
The request for the examination should include sufficient medical information to demonstrate medical necessity and should at least include the diagnosis and questions to be answered.
Review of the medical history
The medical record should be reviewed with a special focus on the diagnosis (type of cancer and known sites), oncological history and relevant comorbidity (especially infection/inflammation and diabetes mellitus). A short interview with the patient and/or family can help clarify some of these issues. Relevant laboratory tests should be considered. The results of prior imaging studies should be available to review, including planar radiography, CT, MRI, bone scanning and FDG PET/CT. Relevant prior studies should be directly compared with current imaging findings when possible. The following list shows all aspects that should be considered in the review:
Patient preparation and precautions
The main purpose of patient preparation to reduce tracer uptake in normal tissue (kidneys, bladder, skeletal muscle, myocardium, brown fat) while maintaining and optimising tracer uptake in the target structures (tumour tissue) and keeping patient radiation exposure levels as low as reasonably possible (ALARA). A generally applicable protocol is outlined below.
Pregnancy (suspected or confirmed)
For any diagnostic procedure in a female patient known or suspected to be pregnant, a clinical decision is necessary in which the benefits are weighed against the possible harm. The International Commission on Radiological Protection (ICRP) reports that for an adult patient the administration of 259 MBq (7 mCi) of FDG results in an absorbed radiation dose of 4.7 mGy to the nongravid uterus (i.e. 1.8 × 10−2 mGy/MBq) . Direct measurements of FDG uptake in a case study suggested somewhat higher doses than are currently provided in standard models . A pregnancy test may help with the decision, provided the 10 day postovulation blackout is understood. In the event of doubt and in the absence of an emergency, the 10 day rule should be adopted. In Europe, national guidelines may apply.
The ICRP does not recommend interruption of breastfeeding after FDG administration since little FDG is excreted in the milk . However, as the lactating breast accumulates FDG , it is suggested that contact between mother and child be limited for 12 h after injection of FDG to reduce the radiation dose that the infant receives from external exposure to radiation emitted by the mother. It is recommended that the infant be breastfed just before injection, to maximise the time between the injection and the next feed. Breast milk may be expressed and fed to the infant via a bottle for 12 h to help minimise the interruption in close, prolonged contact between the infant and the mother.
Instructions to patients
Nondiabetic patients should not consume any food, simple carbohydrates or liquids other than plain (unflavoured) water for at least 4 h prior to the start of the FDG PET/CT study (i.e. with respect to the time of injection of FDG). In practice, this means that patients scheduled to undergo the FDG PET/CT study in the morning should not eat after midnight and preferably should have only a light meal (no alcohol and only a small amount of carbohydrates) during the evening prior to the FDG PET/CT study. Those scheduled for an afternoon FDG PET/CT study may have a light breakfast at least 4 h prior to the time of their PET/CT examination appointment. Medication can be taken as prescribed.
Serum glucose level before FDG administration
The main objectives of patient preparation with at least 4 h of fasting are to ensure low blood glucose and low insulinaemia, as insulin is directly responsible for glucose uptake by nontumour cells . Although efforts should be made to decrease blood glucose to normal levels (typically 4 – 7 mmol/L) and insulinaemia to low levels, if the study is indicated in a patient with unstable (“brittle”) or poorly controlled diabetes (often associated with infection), hyperglycaemia should not represent an absolute contraindication to the study, as fasting hyperglycaemia does not hamper the clinical value of FDG PET . Therefore we recommend the same advice and suggest recording the blood glucose level and any other information that could be relevant for interpretation of the examination.
Blood glucose level must be measured prior to administering FDG. A glucose meter (or glucometer) or a similar bedside device capable of performing overall blood glucose measurements can be used for this purpose, but a blood glucose test must be performed with a calibrated and validated method if plasma glucose level is to be used for correction of SUV measurements .
It is good practice to check the blood glucose of the patient on arrival at the imaging centre to ensure the level is not too low (not below 4 mmol/L, about 70 mg/dL) or too high, since this may avoid an unnecessary wait. For diabetic patients, it is suggested that blood glucose level is checked upon arrival in order to initiate, if necessary, manoeuvres to lower the blood glucose level as soon as possible. Certain patients can be asked to arrive at the imaging centre earlier than usual to allow more time to correct possible hyperglycaemic situations.
For clinical studies:
For research studies:
It should be stated whether the SUV reported is corrected for glucose and, if so, values should be given with and without glucose correction. Glucose levels should be recorded and reported, to allow the calculation of glucose corrected SUV post hoc. SUV may be reported with glucose correction although this is not common practice in many clinical centres. Note that specifically in response assessment studies, blood glucose levels may change with therapy, and it is strongly recommended that blood glucose levels be measured using validated and calibrated methods (no bedside devices) during sequential FDG PET/CT studies. There are few studies in the literature using glucose normalised SUVs and there is no clear evidence that glucose normalisation improves response monitoring or prediction of outcome as compared to uncorrected SUVs. It is also unclear whether the concept of glucose normalisation is valid for malignant tumours. Glucose normalisation implies that glucose metabolic rates are tightly regulated. In some malignancies with unregulated glucose metabolic rates, uncorrected SUVs can be more stable than glucose corrected SUVs .
Reduction of the blood glucose level by administration of insulin can be considered, but the FDG PET/CT study should also be postponed depending on the type and route of the administration of insulin. Insulin should not be given to reduce glucose levels (this leads to greater muscle uptake of FDG) unless the interval between administration of insulin and administration of FDG is more than 4 h. The preferred route of administration is a subcutaneous injection. If insulin is administered it should be rapid-acting insulin (which reaches the bloodstream 15 min after injection, peaks at 60 min and is effective for 2 – 4 h). Other insulin types that are not recommended for immediate or delayed FDG PET/CT imaging are: regular or short-acting insulin (which reaches the bloodstream 30 min after injection, peaks at 2 – 3 h and is effective for 3 – 6 h), intermediate-acting insulin (effective for 12 – 18 h) or long-acting insulin (effective for 24 h). It is also possible to lower blood glucose in patients just above the cut-off threshold by asking them to hydrate while ambulating and recheck the blood glucose periodically until an acceptable level has been achieved. Recently, intravenous administration of insulin before FDG administration has been discussed, but it has not yet been validated .
The following recommendations apply to patients with diabetes mellitus:
Type II diabetes mellitus (controlled by oral medication)
Type I diabetes mellitus and insulin-dependent type II diabetes mellitus
FDG imaging can be performed in patients with kidney failure, although the image quality may be suboptimal and prone to interpretation pitfalls .
Recommendations for image optimisation in specific circumstances, and extra notes
Recommendations for FDG dose and administered activity
Recommendations for FDG administered activity
The minimum recommended administered FDG activity and PET acquisition duration for each bed position must be adjusted so that the product of the FDG activity and PET acquisition duration is equal to or greater than the specifications set out below. Therefore, one may decide to apply a higher activity and reduce the duration of the study or, preferably, to use a reduced activity and increase the study duration, thereby keeping ALARA principles in mind as well.
In these guidelines two recommendations are provided for determining the minimum FDG administered dose in adults, which assume a linear and a quadratic  relationship, respectively, between PET acquisition time per bed position, patient weight and recommended FDG activity. Compared with linear activity prescription, the quadratic scheme results in a slightly higher administered activity for patients >75 kg; this compensates for the lower signal to noise ratio (and hence degraded image quality) due to excessive attenuation, which occurs when linear activity prescription is applied.
The following specifications are given when imaging sites prefer the use of a linear relationship for pragmatic reasons (minimum acceptable administered activity recommendation):
Alternative: This alternative includes using a quadratic relationship between recommended administered FDG activity, weight and duration of emission acquisition . In this case use the above equations to determine the administered activity for a 75 kg patient. Next, multiply this activity by the square of the patient weight/75. This will provide the minimum administered activity.
Specific notes and pitfalls to be considered:
For children and adolescents, administered FDG activity should adhere to the EANM or SNMMI recommendations on paediatric radiopharmaceutical administration [51, 52] or national activity limits, if national limits are lower. Furthermore, there are specific guidelines for FDG PET/CT in paediatric oncology .
Materials for preparation and administration of FDG and contrast agent
The following materials and set-up are recommended:
Procedure for preparation and administration of FDG and contrast agent
PET acquisition protocol
CT protocols for the FDG PET/CT study
PET image reconstruction
The PET emission data must be corrected for geometrical response and detector efficiency (normalisation), system dead time, random coincidences, scatter and attenuation.
It is good clinical practice to perform reconstructions with and without attenuation correction to identify potential reconstruction artefacts caused by the CT-AC. Both attenuation-corrected (AC-PET) and non-attenuation-corrected PET (NAC-PET) images should be available for interpretation and lesions seen on the AC-PET images may need to be checked on the NAC-PET images, particularly when adjacent to highly attenuating materials, such as contrast agent or metal implants.
Further standardisation of reconstruction settings is necessary to obtain standardised and harmonised SUV recoveries. This requires reconstruction settings to be chosen so as to achieve matching convergence and spatial resolution across various systems and sites, especially within a multicentre setting [48, 58, 59]. These reconstruction settings should thus be chosen to meet the multicentre QC harmonising specifications for both calibration QC and image quality/SUV recovery QC, for example as described on the EARL website . Indicative reconstruction settings for each system type are provided on request through the EARL website .
It may be appropriate to perform multiple PET reconstructions with different reconstruction settings. For quantitative assessment of the FDG PET/CT study, the EARL-approved reconstruction settings, which meet the standardised performance standards, should be used. An additional reconstruction designed for optimal visual assessment may be performed for qualitative interpretation only. This reconstruction may be performed, for example, in order to maximise lesion detectability or to meet local preferences for visual interpretation of the FDG PET/CT study, as was suggested and demonstrated by Lasnon et al. . Similar strategies may be applied for different PET/CT systems as well, provided quantitative interpretations/analyses are performed using the EARL-approved reconstruction settings.
CT image reconstruction
For diagnostic CT scans, acquisition parameters should be determined according to specific or national radiology society guidelines. The CT data that are acquired during the PET/CT study are usually reconstructed using filtered back projection. Recently introduced iterative reconstruction methods for CT data may be applied, if available on the PET/CT system. Depending on the CT protocol and the clinical case, separate CT reconstructions may be performed for diagnostic purposes and CT-AC. The reconstructions will probably differ in their slice thickness, slice overlap, filter etc. In addition to the reconstruction kernel that modulates the image characteristics within the slices (i.e. spatial resolution, edge enhancement and noise texture), a longitudinal filter in the z-dimension is often used to optimise the resolution in the axial direction and to modify the slice sensitivity profiles. The measured attenuation values (μ) are normalised to the density of water (μ water) in order to assign a device-independent numerical value in the framework of the reconstruction:
CT value = Hounsfield units = 1,000(μ − μ water)/μ water
In modern CT systems the spatial resolution in the z-direction is almost as high as the transaxial resolution and nearly isotropic, allowing high-quality images in the coronal and sagittal views. Additionally, postprocessing such as volume rendering or maximum intensity projections benefit from using the high-quality reconstructed CT data.
Image analysis and interpretation
Image analysis and SUV calculations
FDG PET images should be displayed with and without attenuation correction. On all slices (of the attenuation-corrected data) quantitative information with respect to size and FDG uptake can be retrieved. Images must be evaluated using software that is able to display fused PET and CT data and use an SUV scale. Monitors used for image viewing should be approved for clinical use in radiology and nuclear medicine. Characteristics and settings of the monitor should be in line with published standards (e.g. the Medical Electrical Safety Standards, IEC 60601-1/EN 60601-1; the Medical ECM Standards, IEC 60601-1-2, EN 60601-1-2; or national guidelines). Moreover, viewing conditions (e.g. background light) must be appropriate to ensure adequate image inspection. Image data should be stored on an approved PACS system and in DICOM format; further details and recommendations regarding image data format can be found in the QIBA FDG PET/CT profile .
The presence or absence of abnormal FDG accumulation on the PET images, especially focal accumulation, in combination with intensity of uptake and anatomical size should be evaluated. Absence of tracer accumulation in anatomical abnormalities seen on the CT scan or other imaging may be particularly significant. When appropriate, the report should correlate PET/CT findings with those of other diagnostic tests, interpret them in that context and consider them in relation to the clinical data. For response assessment, the images should be viewed over the same dynamic grey scale or colour scale range, i.e. a fixed colour scale; for example, from SUV = 0 to SUV = 10 using an inverse linear scale.
Both uncorrected and attenuation-corrected images may need to be reviewed to identify artefacts caused by contrast agents, metal implants and/or patient motion. In clinical trials, criteria for visual analysis should be defined a priori within the study protocol.
SUV is increasingly used in clinical studies in addition to visual assessments. SUV is a measurement of the uptake in a tumour normalised on the basis of a distribution volume. Most of the published literature relates to SUV (normalised to body weight) measurements. SUV normalised to lean body mass (LBM) is referred to as SUL , and is a recommended quantitative measure of FDG uptake. SUL should preferably be calculated alongside SUV, as follows:
SUL = ActVOI (kBq/mL)/Actadministered (MBq)/LBM (kg)
The following calculation is applied in the case of plasma glucose correction:
SULglu = ActVOI (kBq/mL) × Glucplasma (mmol/L)/Actadministered (MBq)/LBM (kg) × 5.0 (mmol/L)
where ActVOI is the activity concentration measured in the volume of interest (VOI) and Actadministered is the net administered activity corrected for the physical decay of FDG to the start of acquisition and corrected for the residual activity in the syringe and/or administration lines and system. LBM is calculated according to the formula of Janmahasatian et al. :
LBMM = 9,270 × weight/(6,680 + 216 × BMI)
LBMF = 9,270 × weight/(8,780 + 244 × BMI)
where LBMM and LBMF are the LBM for males and females, and BMI is body mass index (weight/height2), and weight and height are in kilograms and metres, respectively. These formulas are clearly more realistic than the previously used James formulas [63, 64], which fail at weights greater than about 120 kg . Patient height, weight and gender should be reported to allow other SUV normalisations, such as weight and body surface area. In these cases LBM is replaced by body weight and body surface area, respectively, in the SUL equations given above.
The use of SUL is preferred for response assessment studies when large changes in body weight may occur during the course of the treatment. As stated above, it is recommended plasma glucose levels be measured using validated methodology and that SUL be calculated with and without plasma glucose correction in all response monitoring studies. Note that the measured glucose content (Glucplasma) is normalised for an overall population average of 5.0 mmol/L so that the SULs with and without correction for glucose content (SULglu and SUL, respectively) are numerically practically identical (on average) .
Physiological FDG distribution and interpretation criteria
Accumulation of FDG can normally be seen in the brain, heart, kidneys and urinary tract at 60 min after injection . The brain has a high uptake of FDG (about 7 % of injected activity). The myocardium in a typical fasting state primarily uses free fatty acids, but after glucose load it uses glucose. In the fasting state, FDG uptake in the myocardium should be low, but this is variable. Unlike glucose, FDG is excreted by the kidneys into the urine and accumulates in the urinary tract. There is some degree of FDG accumulation in muscles that can be increased following exercise and serum insulin. Uptake in the gastrointestinal tract varies from patient to patient and may be increased, for example, in patients taking metformin. Uptake is common in lymphoid tissue in Waldeyer’s ring and in the lymphoid tissue of the terminal ileum and caecum. Physiological thymic uptake may be present, especially in children and young adults. Uptake in brown fat may be observed more commonly in young patients and when the ambient temperature is low. No physiological uptake is noted in bone itself (unless free 18F-fluoride is present as a contaminant), but bone marrow uptake can be present to a variable degree in patients receiving growth factors (granulocyte colony-stimulating factor, G-CSF, and granulocyte macrophage CSF, GM-CSF) as well as in patients with marrow proliferation for other reasons such as infection, inflammation or anaemia, and following chemotherapy.
Documentation and reporting
The report is the main mode of communication between the physician interpreting the imaging study and the referring physician, and frequently leads to relevant changes in patient management . The SNMMI has recently published reporting recommendations for oncological FDG PET/CT imaging .
Abnormalities of immediate clinical importance should be directly or verbally communicated to the appropriate health-care provider if a delay in treatment might result in significant morbidity. An example of such an abnormality would be a lesion with a high risk of pathological fracture. Other clinically significant unexpected findings should also be communicated verbally. Reporting of abnormalities requiring urgent attention should be consistent with the policy of the interpreting physician’s local organisation.
Written documentation of verbal reporting should be made in the medical record, usually as part of the PET/CT report [75, 76].
Contents of the report
The report should include the full name of the patient, medical record number and date of birth. The protocol name of the examination should also be included, as well as the date and time of its performance. The electronic medical record usually provides these data, as well as a unique study number.
At a minimum, the clinical history should include age, gender, weight, height, reason for referral and the specific question to be answered. If known, the diagnosis and a brief treatment history should be provided. The results of relevant diagnostic tests and prior imaging findings should be summarised. Information relevant for reimbursement should also be included.
The type and date of comparison studies should be stated. If no comparison studies are available, a statement should be made to that effect.
Blood glucose level before FDG administration should be documented.
Study-specific information should include the radiopharmaceutical, the amount of injected activity in megabecquerels and/or millicuries, the route of administration (intravenous) and the date and time of administration. The anatomical site of administration is optional, but should be recorded. The name, dose and route of administration of regulated nonradioactive drugs and agents should also be stated. The type of PET/CT system should be specified, but specific equipment information is optional.
A description of the procedure should include the time the patient was examined or the time interval between administration of FDG and the start time of the acquisition. The part of the body that was covered should be described from the start to the end point. The position of the patient (supine or prone) and the position of the arms (elevated or by the sides) should be stated if nonstandard.
Description of the CT part of the examination may be limited to a statement that a low-mAs CT was performed for attenuation correction and anatomical registration of the emission images. However, findings should be reported. If the CT examination was optimised for diagnosis, then a more complete description of the CT protocol and anatomical findings should be provided. Dosimetric parameters should be included as required by regulations; here, DICOM structured reports may facilitate the extraction of the relevant dose information. The report should state whether CT with or without CT contrast agent was used for CT attenuation correction.
Routine processing parameters are usually not stated in the report, but any special circumstances requiring additional processing, such as motion correction, should be described.
Description of the findings
It is good practice to provide a structured report with concise concluding statements intended to answer the specific clinical question(s) posed, if possible. Nevertheless, there is great variation in the style of reporting. Recommendations with regard to biopsy, alternative radiological studies and follow-up should also be included in the conclusion as appropriate . The interpretation provided by an imaging physician is the chief manifestation of the physician’s expertise. Its content affects patient management and clinical outcomes, and it is also a legal document .
Summary and diagnosis/impression
The Royal College of Radiologists provides recommendations on reporting that include relevant aspects that should be taken into account :
For further reading see also the SNMMI’s reporting guidance for oncological FDG PET/CT imaging , the Royal College of Radiologists’ recommendations on reporting  and the SNMMI’s Procedure Standard for General Imaging.
Definitions of volumes of interest
Recommended tumour uptake metrics
Some considerations with respect to semiautomated percentage threshold-based delineation methods
The isocontour described as VOI41 corresponds best with the actual dimensions of the tumour, but only for higher tumour-to-background values and nonheterogeneous tracer uptakes. This VOI method, however, does not always result in useful tumour definitions because of noise, tracer uptake inhomogeneities in tumour and background and sometimes low tumour-to-background ratios. In that case, a VOI based on a higher isocontour value (e.g. VOI50) should be chosen for all subsequent studies in the same patient when studies are performed for tumour response assessment.
When VOIs are generated semiautomatically, it is not always possible to generate a reliable VOI if there is a high background or an area of high uptake (bladder, heart) close to/adjacent to the lesion, or if there is low uptake in the lesion. Therefore, semiautomatically generated VOIs must be checked visually. Moreover, in the event of tracer uptake heterogeneity, these VOIs may only delineate the most metabolically active part of the tumour. If the VOIs are not reliable and/or do not correspond visually with the lesion, only the maximum SUV (normalised to body weight) and SUL and possibly 3D SUVpeak and SULpeak should be used for reporting.
Other tumour segmentation methods have been described for MTV assessment and/or tumour delineation for radiotherapy planning in the literature, such as contrast-oriented methods [48, 83–85], gradient-based methods , iterative methods  and fuzzy clustering/segmentation methods . These, however, are not routinely used and not widely available for determining SUVs, although several methods do outperform the simple percentage threshold-based methods .
The authors realise the importance of using more accurate and improved delineation methods than those recommended above and, indeed, the use of more advanced methods is encouraged . In particular when FDG PET/CT-based tumour delineations are used for radiotherapy planning, the delineation methods used and the tumour segmentation obtained should be critically reviewed and supervised. Specific guidelines for the use of FDG PET/CT in radiotherapy have been published elsewhere [14, 15, 90–92]. VOI methods other than those recommended in these guidelines may be used provided that at least the maximum uptake (SULmax), and possibly the SULpeak, are always determined and reported as well.
Liver uptake assessment
As suggested by Wahl et al. , assessment of liver SUL or SUV may be a useful quality index of an FDG PET/CT study. Liver measurements may be assessed by placing a spherical VOI of diameter 3 cm in the right upper lobe of the liver, avoiding malignancies and organ boundaries, as indicated also in the QIBA FDG PET/CT profile . Liver SULs or SUVs should be reported along with lesion SUL or SUV data. The study protocol or clinical guidelines should define acceptable levels for liver SUL and required actions when specifications are not met. For clinical studies that are quantitatively assessed, mean liver SULs are expected to be within 1.0 and 2.2 (and mean liver SUVs within 1.3 and 3.0) . Liver SULs outside this range may indicate incorrect FDG administration or technical issues, and the use of quantitative analysis of the study should be reconsidered and the uncertainties discussed in the study report.
Mediastinal uptake assessment
Measurement of the mediastinal blood pool can be very useful for assessing what is considered normal or physiological FDG uptake. In recent years, it has been used for the interim evaluation of response to therapy in lymphoma. It is calculated by drawing several VOIs inside the thoracic aorta and measuring the (mean) uptake inside the vessel, taking care not to include in the VOI the vessel wall, where uptake can be slightly higher when there is vascular inflammation. Blood pool SUL measurements are expected to be around 1.2 (and blood pool SUVs around 1.6) [61, 93, 94].
Quality control and interinstitution PET/CT system performance harmonisation
PET/CT system quality control
The impacts of various technical, physics-related and biological factors have been described extensively . The use of SUVs in multicentre oncology FDG PET/CT studies requires a standardised interinstitution calibration procedure in order to facilitate the exchangeability of SUVs between institutions. It is also important that all participating institutions employ similar methodologies. In order to ensure the comparability of SUVs, a minimum set of QC procedures must be performed, including:
Note that these QC measures do not replace any QC measures required by national law or legislation or those recommended by local nuclear medicine societies. A brief summary of PET and PET/CT QC procedures, specifically recommended here to ensure accurate SUV quantification, is given below.
The aim of daily QC is to determine whether the PET/CT system is functioning well, and specifically to check for detector failure and/or electronic drift. Most commercial systems are equipped with an automatic or semiautomatic procedure for performing daily QC. For some systems, the daily QC includes tuning of hardware and/or settings (such as gains). Thus both the procedure and its name differ among systems. In all cases all daily QC measures and/or daily set-up/tuning measurements should be performed according to the manufacturer’s specifications. Users should check whether the daily QC meets the specifications. When available, a daily PET/CT study of a cylindrical phantom filled with a 68Ge or another long-lived positron-emitting isotope may be acquired . This test enables assessment and reduction of longitudinal variability due to calibration error and/or PET/CT system sensitivity drifts. Inspection of uniformity and quantitative accuracy of the reconstructed PET image may help identify technical failures that were not detected using the routine daily QC procedures. In addition, when possible, sinogram data should be inspected to check for detector failure.
Calibration QC and cross-calibration of PET/CT systems
The aim of cross-calibration is to determine the correct and direct (cross- or relative) calibration of the PET/CT system with the institution’s own dose calibrator or against another one which is used to determine patient-specific FDG activities . If FDG activity is ordered directly from and supplied by an external supplier, cross-calibration of the PET/CT system should be carried out using a calibration sample supplied by that provider. At the time of writing this version of the guidelines, standard calibration sources for both dose calibrators and PET/CT systems are not yet widely available, although some initiatives are being undertaken . Therefore, at present these guidelines recommend a proper cross-calibration between the dose calibrator used for patient administered activity and the PET/CT system as a minimal standard. Calibration QC procedure, SOP and specifications are provided in the UPICT oncology FDG PET/CT protocol  and by EARL .
Image quality and recovery coefficient harmonisation
Although correct cross-calibration is guaranteed using the QC procedure described above, differences in SUV quantification may still occur between centres as a result of differences in the reconstruction and data analysis methodology [60, 98]. To this end an IQRC QC procedure has been developed:
The main aim of the IQRC QC procedure is to guarantee comparable quantitative PET/CT system performance with respect to SUV recovery and quantification. Details on the IQRC QC procedure, SOP and standardised specifications are provided by EARL .
Minimum frequency of PET/CT system QC procedures
CT quality control (CT-QC)
Several documents and reports on CT quality control (CT-QC) have been published and are listed below for readers’ information. An overview of CT-QC is given in, for example, the “Equipment Specifications” and “Quality Control” sections of the American College of Radiology Practice Guideline for the Performance of Computed Tomography of the Extracranial Head and Neck in Adults and Children, the American College of Radiology Practice Guideline for the Performance of Pediatric and Adult Thoracic Computed Tomography (CT), and the American College of Radiology Practice Guideline for the Performance of Computed Tomography (CT) of the Abdomen and Computed Tomography (CT) of the Pelvis and in IPEM report 91. In addition, CT performance monitoring guidelines are given in the American College of Radiology Technical Standard for Medical Physics Performance Monitoring of Computed Tomography (CT) Equipment.
Additional QC measures
Radiation exposure to the patient
At the time of writing this new version of the FDG PET/CT guidelines for tumour imaging, several international collaborative activities are being undertaken to optimise the use of FDG PET/CT as a quantitative imaging biomarker. During the drafting of the guidelines we took the following (draft) documents into consideration: (1) the QIBA FDG PET/CT profile  and (2) the UPICT oncology FDG PET/CT protocol . In both documents presently being drafted and revised, clear definitions and general recommendations for both system performance and image procedures are provided. The EANM guidelines presented here use these general recommendations and attempt to translate them into standardised imaging procedure standards applicable to the earlier published European FDG PET/CT guidelines. It should be noted that both the previous EANM guidelines and this new version specifically aim to obtain harmonised SUV data in a multicentre setting. Moreover, the present new version provides an update of the earlier version and attempts to address some new insights and technological developments.
History of the document
These guidelines are a joint project of the EANM Oncology Committee, the EANM Physics Committee and the SNMMI Committee on Guidelines. These guidelines provide an update of the previously published FDG PET and PET/CT: EANM Procedure Guidelines for Tumour PET Imaging: version 1.0, and the SNMMI Procedure Guidelines for Tumour Imaging with 18F-FDG PET/CT 1.0, and address new technologies and developments. There have been major changes in some sections, but others may have hardly been changed. Indeed, there is similarity with the previous version and certain sections have not been altered. Moreover, consideration is given to compliance with international initiatives, such as those by the Quantitative Imaging Biomarkers Alliance (QIBA) [30, 56]. In addition, the previous and this version of the guidelines are based on the following three documents:
The procedure guidelines for tumour imaging with FDG PET/CT of the SNMMI: “Procedure guideline for tumour imaging with 18F-FDG PET/CT 1.0.” .
The German guidelines for FDG-PET/CT in oncology of the Deutsche Gesellschaft für Nuklearmedizin: “FDG-PET/CT in der Onkologie” .
The Netherlands protocol for standardisation of quantitative whole-body FDG PET/CT: “Applications of F18-FDG-PET in Oncology and Standardisation for Multi-Centre Studies” .
An overview of other and previously published guidelines [10, 21, 61, 68, 78, 99–106] or recommendations can be found in the supplement issue of the Journal of Nuclear Medicine 2009 .
We thank the authors of the EANM FDG PET/CT guidelines version 1.0 for their valuable contributions, which in part are also incorporated in this new version of the guidelines. We acknowledge the support of Richard P. Baum, Emile FI Comans, Adriaan A. Lammertsma, Markus N. Lonsdale, Paul K. Marsden, Felix M. Mottaghy, Mike O’Doherty, Anne M. Paans, Cornelia Schaefer-Prokop. Moreover, we thank the EANM committees and national delegates for their critical review of the manuscript. Finally, we gratefully acknowledge the extensive support of the EANM Office in Vienna during the development of these guidelines and thank Andrea Bauer, Katharina Leissing, Vera Buhmann, Sabine Ettinger and Terez Sera.
Conflicts of interest
Ronald Boellaard has research grants from Philips Healthcare and Philips Research and is a member of the scientific advisory board of EARL. Wim J.G. Oyen has research grants from Siemens and is a member of the scientific advisory board of EARL. Klaus Tatsch is CEO of EARL. Fred J. Verzijlbergen is a member of the scientific advisory board of EARL. Wolfgang A. Weber is a member of the advisory board of GE Healthcare. Scott Holbrook is an employee of and has stock in Precision Nuclear LLC and Invivo Molecular Imaging LLC. Thomas Beyer has research grants from Siemens. Arturo Chiti has received travel grants from GE Healthcare and is a member of the scientific advisory board of EARL. Bernd J. Krause is a consultant for GE Healthcare, has received a GE Healthcare travel grant and has received a research grant from Bayer.
1It should be noted that the entity “effective dose” does not necessarily reflect the radiation risk associated with this nuclear medicine examination. The effective dose values given in these guidelines are used to compare the exposure due to different medical procedures. To assess the risk associated with this procedure, it is mandatory to adjust the radiation-associated risk factors at least according to the gender and age distribution of the institution’s patient population.
1. Avril NE, Weber WA. Monitoring response to treatment in patients utilizing PET. Radiol Clin North Am. 2005;43(1):189–204. doi: 10.1016/j.rcl.2004.09.006. [PubMed] [CrossRef] [Google Scholar]
2. Bastiaannet E, Groen H, Jager PL, et al. The value of FDG-PET in the detection, grading and response to therapy of soft tissue and bone sarcomas; a systematic review and meta-analysis. Cancer Treat Rev. 2004;30(1):83–101. doi: 10.1016/j.ctrv.2003.07.004. [PubMed] [CrossRef] [Google Scholar]
3. Borst GR, Belderbos JSA, Boellaard R, et al. Standardised FDG uptake: a prognostic factor for inoperable non-small cell lung cancer. Eur J Cancer. 2005;41(11):1533–1541. doi: 10.1016/j.ejca.2005.03.026. [PubMed] [CrossRef] [Google Scholar]
4. Erdi YE. The use of PET for radiotherapy. Curr Med Imaging Rev. 2007;3(1):3–16. [Google Scholar]
5. Geus-Oei LF, van der Heijden HF, Corstens FH, Oyen WJ. Predictive and prognostic value of FDG-PET in nonsmall-cell lung cancer: a systematic review. Cancer. 2007;110(8):1654–1664. doi: 10.1002/cncr.22979. [PubMed] [CrossRef] [Google Scholar]
6. Hoekstra CJ, Stroobants SG, Smit EF, et al. Prognostic relevance of response evaluation using [F-18]-2-fluoro-2-deoxy-D-glucose positron emission tomography in patients with locally advanced non-small-cell lung cancer. J Clin Oncol. 2005;23(33):8362–8370. doi: 10.1200/JCO.2005.01.1189. [PubMed] [CrossRef] [Google Scholar]
7. Larson SM, Schwartz LH. 18F-FDG PET as a candidate for “qualified biomarker”: functional assessment of treatment response in oncology. J Nucl Med. 2006;47(6):901–903. [PubMed] [Google Scholar]
8. Vansteenkiste JF, Stroobants SG. The role of positron emission tomography with 18F-fluoro-2-deoxy-D-glucose in respiratory oncology. Eur Respir J. 2001;17(4):802–820. doi: 10.1183/09031936.01.17408020. [PubMed] [CrossRef] [Google Scholar]
9. Weber WA. Use of PET for monitoring cancer therapy and for predicting outcome. J Nucl Med. 2005;46(6):983–995. [PubMed] [Google Scholar]
10. Fletcher JW, Djulbegovic B, Soares HP, et al. Recommendations on the use of F-18-FDG PET in oncology. J Nucl Med. 2008;49(3):480–508. doi: 10.2967/jnumed.107.047787. [PubMed] [CrossRef] [Google Scholar]
11. Delgado-Bolton RC, Fernández-Pérez C, González-Maté A, Carreras JL. Meta-analysis of the performance of 18F-FDG PET in primary tumor detection in unknown primary tumors. J Nucl Med. 2003;44(8):1301–14. [PubMed]
12. Delgado-Bolton RC, Carreras JL, Pérez-Castejón MJ. A systematic review of the efficacy of F-18-FDG PET in unknown primary tumors. Curr Med Imaging Rev. 2006;2(2):215–25.
13. Jiménez-Requena F, Delgado-Bolton RC, Fernández-Pérez C, et al. Meta-analysis of the performance of (18)F-FDG PET in cutaneous melanoma. Eur J Nucl Med Mol Imaging. 2010;37(2):284–300. [PMC free article] [PubMed]
14. Grégoire V, Chiti A. PET in radiotherapy planning: particularly exquisite test or pending and experimental tool? Radiother Oncol. 2010;96(3):275–276. doi: 10.1016/j.radonc.2010.07.015. [PubMed] [CrossRef] [Google Scholar]
15. Thorwarth D, Beyer T, Boellaard R, et al. Integration of FDG-PET/CT into external beam radiation therapy planning: technical aspects and recommendations on methodological approaches. Nuklearmedizin. 2012;51(4):140–153. doi: 10.3413/Nukmed-0455-11-12. [PubMed] [CrossRef] [Google Scholar]
16. Bailey DL, Barthel H, Beuthin-Baumann B, et al. Combined PET/MR: Where are we now? Summary report of the second international workshop on PET/MR imaging April 8-12, 2013, Tubingen, Germany. Mol Imaging Biol. 2014;16(3):295–310. [PubMed] [Google Scholar]
17. Bailey DL, Barthel H, Beyer T, et al. Summary report of the first international workshop on PET/MR imaging, March 19–23, 2012, Tubingen, Germany. Mol Imaging Biol. 2013;15(4):361–371. doi: 10.1007/s11307-013-0623-1. [PMC free article] [PubMed] [CrossRef] [Google Scholar]
18. Busemann SE, Plachcinska A, Britten A. Acceptance testing for nuclear medicine instrumentation. Eur J Nucl Med Mol Imaging. 2010;37(3):672–681. doi: 10.1007/s00259-009-1348-x. [PubMed] [CrossRef] [Google Scholar]
19. Thie JA. Understanding the standardized uptake value, its methods, and implications for usage. J Nucl Med. 2004;45(9):1431–1434. [PubMed] [Google Scholar]
20. Boellaard R, O’Doherty MJ, Weber WA, et al. FDG PET and PET/CT: EANM procedure guidelines for tumour PET imaging: version 1.0. Eur J Nucl Med Mol Imaging. 2010;37(1):181–200. doi: 10.1007/s00259-009-1297-4. [PMC free article] [PubMed] [CrossRef] [Google Scholar]
21. Delbeke D, Coleman RE, Guiberteau MJ, et al. Procedure guideline for tumor imaging with 18F-FDG PET/CT 1.0. J Nucl Med. 2006;47(5):885–895. [PubMed] [Google Scholar]
22. Stauss J, Franzius C, Pfluger T, et al. Guidelines for 18F-FDG PET and PET-CT imaging in paediatric oncology. Eur J Nucl Med Mol Imaging. 2008;35(8):1581–1588. doi: 10.1007/s00259-008-0826-x. [PubMed] [CrossRef] [Google Scholar]
23. Jamar F, Buscombe J, Chiti A, et al. EANM/SNMMI guideline for 18F-FDG use in inflammation and infection. J Nucl Med. 2013;54(4):647–658. doi: 10.2967/jnumed.112.112524. [PubMed] [CrossRef] [Google Scholar]
25. ICRP Radiation dose to patients from radiopharmaceuticals. Addendum 3 to ICRP Publication 53. ICRP Publication 106. Approved by the Commission in October 2007. Ann ICRP. 2008;38(1-2):1–197. doi: 10.1016/j.icrp.2008.08.002. [PubMed] [CrossRef] [Google Scholar]
26. Zanotti-Fregonara P, Jan S, Taieb D, et al. Absorbed 18F-FDG dose to the fetus during early pregnancy. J Nucl Med. 2010;51(5):803–805. doi: 10.2967/jnumed.109.071878. [PubMed] [CrossRef] [Google Scholar]
27. Hicks RJ, Binns D, Stabin MG. Pattern of uptake and excretion of (18)F-FDG in the lactating breast. J Nucl Med. 2001;42(8):1238–1242. [PubMed] [Google Scholar]
28. Belohlavek O, Jaruskova M. [18F]FDG-PET scan in patients with fasting hyperglycaemia. Q J Nucl Med Mol Imaging. 2014 (in press)
29. Dai KS, Tai DY, Ho P, et al. Accuracy of the EasyTouch blood glucose self-monitoring system: a study of 516 cases. Clin Chim Acta. 2004;349(1–2):135–41. [PubMed]
31. Huang SC. Anatomy of SUV. Standardized uptake value. Nucl Med Biol. 2000;27(7):643–646. doi: 10.1016/S0969-8051(00)00155-4. [PubMed] [CrossRef] [Google Scholar]
32. Caobelli F, Pizzocaro C, Paghera B, Guerra UP. Proposal for an optimized protocol for intravenous administration of insulin in diabetic patients undergoing (18)F-FDG PET/CT. Nucl Med Commun. 2013;34(3):271–275. doi: 10.1097/MNM.0b013e32835d1034. [PubMed] [CrossRef] [Google Scholar]
33. Minamimoto R, Takahashi N, Inoue T. FDG-PET of patients with suspected renal failure: standardized uptake values in normal tissues. Ann Nucl Med. 2007;21(4):217–222. doi: 10.1007/s12149-007-0012-4. [PubMed] [CrossRef] [Google Scholar]
34. Rakheja R, Ciarallo A, Alabed YZ, Hickeson M. Intravenous administration of diazepam significantly reduces brown fat activity on 18F-FDG PET/CT. Am J Nucl Med Mol Imaging. 2011;1(1):29–35. [PMC free article] [PubMed] [Google Scholar]
35. Soderlund V, Larsson SA, Jacobsson H. Reduction of FDG uptake in brown adipose tissue in clinical patients by a single dose of propranolol. Eur J Nucl Med Mol Imaging. 2007;34(7):1018–1022. doi: 10.1007/s00259-006-0318-9. [PubMed] [CrossRef] [Google Scholar]
36. Sturkenboom MG, Hoekstra OS, Postema EJ, Zijlstra JM, Berkhof J, Franssen EJ. A randomised controlled trial assessing the effect of oral diazepam on 18F-FDG uptake in the neck and upper chest region. Mol Imaging Biol. 2009;11(5):364–368. doi: 10.1007/s11307-009-0207-2. [PMC free article] [PubMed] [CrossRef] [Google Scholar]
37. Coulden R, Chung P, Sonnex E, Ibrahim Q, Maguire C, Abele J. Suppression of myocardial 18F-FDG uptake with a preparatory “Atkins-style” low-carbohydrate diet. Eur Radiol. 2012;22(10):2221–2228. doi: 10.1007/s00330-012-2478-2. [PubMed] [CrossRef] [Google Scholar]
38. Lum DP, Wandell S, Ko J, Coel MN. Reduction of myocardial 2-deoxy-2-[18F]fluoro-D-glucose uptake artifacts in positron emission tomography using dietary carbohydrate restriction. Mol Imaging Biol. 2002;4(3):232–237. doi: 10.1016/S1095-0397(01)00062-0. [PubMed] [CrossRef] [Google Scholar]
39. Varrone A, Asenbaum S, Vander BT, et al. EANM procedure guidelines for PET brain imaging using [18F]FDG, version 2. Eur J Nucl Med Mol Imaging. 2009;36(12):2103–2110. doi: 10.1007/s00259-009-1264-0. [PubMed] [CrossRef] [Google Scholar]
40. Bui KL, Horner JD, Herts BR, Einstein DM. Intravenous iodinated contrast agents: risks and problematic situations. Cleve Clin J Med. 2007;74(5):361–4, 367. [PubMed]
43. European Society of Urogenital Radiology. ESUR guidelines on contrast media. http://www.esur.org/guidelines. Accessed 23 Nov 2014
44. Antoch G, Kuehl H, Kanja J, et al. Dual-modality PET/CT scanning with negative oral contrast agent to avoid artifacts: introduction and evaluation. Radiol. 2004;230(3):879–885. doi: 10.1148/radiol.2303021287. [PubMed] [CrossRef] [Google Scholar]
45. de Groot EH, Post N, Boellaard R, Wagenaar NR, Willemsen AT, van Dalen JA. Optimized dose regimen for whole-body FDG-PET imaging. EJNMMI Res. 2013;3(1):63. doi: 10.1186/2191-219X-3-63. [PMC free article] [PubMed] [CrossRef] [Google Scholar]
48. Boellaard R, Krak NC, Hoekstra OS, Lammertsma AA. Effects of noise, image resolution, and ROI definition on the accuracy of standard uptake values: a simulation study. J Nucl Med. 2004;45(9):1519–1527. [PubMed] [Google Scholar]
49. Boellaard R, Oyen WJ, Hoekstra CJ, et al. The Netherlands protocol for standardisation and quantification of FDG whole body PET studies in multi-centre trials. Eur J Nucl Med Mol Imaging. 2008;35(12):2320–2333. doi: 10.1007/s00259-008-0874-2. [PubMed] [CrossRef] [Google Scholar]
50. Masuda Y, Kondo C, Matsuo Y, Uetani M, Kusakabe K. Comparison of imaging protocols for 18F-FDG PET/CT in overweight patients: optimizing scan duration versus administered dose. J Nucl Med. 2009;50(6):844–848. doi: 10.2967/jnumed.108.060590. [PubMed] [CrossRef] [Google Scholar]
51. Lassmann M, Treves ST. Paediatric radiopharmaceutical administration: harmonization of the 2007 EANM paediatric dosage card (version 1.5.2008) and the 2010 North American consensus guidelines. Eur J Nucl Med Mol Imaging. 2014;41(5):1036–1041. doi: 10.1007/s00259-014-2731-9. [PubMed] [CrossRef] [Google Scholar]
52. Treves ST, Lassmann M. International guidelines for pediatric radiopharmaceutical administered activities. J Nucl Med. 2014;55(6):869–870. doi: 10.2967/jnumed.114.139980. [PubMed] [CrossRef] [Google Scholar]
53. Osman MM, Chaar BT, Muzaffar R, et al. 18F-FDG PET/CT of patients with cancer: comparison of whole-body and limited whole-body technique. AJR Am J Roentgenol. 2010;195(6):1397–1403. doi: 10.2214/AJR.09.3731. [PubMed] [CrossRef] [Google Scholar]
54. Beyer T, Antoch G, Muller S, et al. Acquisition protocol considerations for combined PET/CT imaging. J Nucl Med. 2004;45 Suppl 1:25S–35. [PubMed]
55. Mawlawi O, Erasmus JJ, Munden RF, et al. Quantifying the effect of IV contrast media on integrated PET/CT: clinical evaluation. AJR Am J Roentgenol. 2006;186(2):308–319. doi: 10.2214/AJR.04.1740. [PubMed] [CrossRef] [Google Scholar]
57. Otsuka H, Graham MM, Kubo A, Nishitani H. The effect of oral contrast on large bowel activity in FDG-PET/CT. Ann Nucl Med. 2005;19(2):101–108. doi: 10.1007/BF03027388. [PubMed] [CrossRef] [Google Scholar]
58. Boellaard R. Standards for PET image acquisition and quantitative data analysis. J Nucl Med. 2009;50 Suppl 1:11S–20. [PubMed]
59. Westerterp M, Pruim J, Oyen W, et al. Quantification of FDG PET studies using standardised uptake values in multi-centre trials: effects of image reconstruction, resolution and ROI definition parameters. Eur J Nucl Med Mol Imaging. 2007;34(3):392–404. doi: 10.1007/s00259-006-0224-1. [PubMed] [CrossRef] [Google Scholar]
60. Lasnon C, Desmonts C, Quak E, et al. Harmonizing SUVs in multicentre trials when using different generation PET systems: prospective validation in non-small cell lung cancer patients. Eur J Nucl Med Mol Imaging. 2013;40(7):985–996. doi: 10.1007/s00259-013-2391-1. [PMC free article] [PubMed] [CrossRef] [Google Scholar]
61. Wahl RL, Jacene H, Kasamon Y, Lodge MA. From RECIST to PERCIST: evolving considerations for PET response criteria in solid tumors. J Nucl Med. 2009;50 Suppl 1:122S–50. [PMC free article] [PubMed]
62. Janmahasatian S, Duffull SB, Ash S, Ward LC, Byrne NM, Green B. Quantification of lean bodyweight. Clin Pharmacokinet. 2005;44(10):1051–1065. doi: 10.2165/00003088-200544100-00004. [PubMed] [CrossRef] [Google Scholar]
63. Hallynck TH, Soep HH, Thomis JA, Boelaert J, Daneels R, Dettli L. Should clearance be normalised to body surface or to lean body mass? Br J Clin Pharmacol. 1981;11(5):523–526. doi: 10.1111/j.1365-2125.1981.tb01163.x. [PMC free article] [PubMed] [CrossRef] [Google Scholar]
64. James W. Research on obesity. London: Her Majesty’s Stationery Office; 1976. [Google Scholar]
65. Tahari AK, Chien D, Azadi JR, Wahl RL. Optimum lean body formulation for correction of standardized uptake value in PET imaging. J Nucl Med. 2014;55(9):1481–1484. doi: 10.2967/jnumed.113.136986. [PMC free article] [PubMed] [CrossRef] [Google Scholar]
66. Cook GJ, Fogelman I, Maisey MN. Normal physiological and benign pathological variants of 18-fluoro-2-deoxyglucose positron-emission tomography scanning: potential for error in interpretation. Semin Nucl Med. 1996;26(4):308–314. doi: 10.1016/S0001-2998(96)80006-7. [PubMed] [CrossRef] [Google Scholar]
68. Young H, Baum R, Cremerius U, et al. Measurement of clinical and subclinical tumour response using [18F]-fluorodeoxyglucose and positron emission tomography: review and 1999 EORTC recommendations. European Organization for Research and Treatment of Cancer (EORTC) PET Study Group. Eur J Cancer. 1999;35(13):1773–1782. doi: 10.1016/S0959-8049(99)00229-4. [PubMed] [CrossRef] [Google Scholar]
69. Itti E, Meignan M, Berriolo-Riedinger A, et al. An international confirmatory study of the prognostic value of early PET/CT in diffuse large B-cell lymphoma: comparison between Deauville criteria and DeltaSUVmax. Eur J Nucl Med Mol Imaging. 2013;40(9):1312–1320. doi: 10.1007/s00259-013-2435-6. [PubMed] [CrossRef] [Google Scholar]
70. Chung HH, Kwon HW, Kang KW, et al. Prognostic value of preoperative metabolic tumor volume and total lesion glycolysis in patients with epithelial ovarian cancer. Ann Surg Oncol. 2012;19(6):1966–1972. doi: 10.1245/s10434-011-2153-x. [PubMed] [CrossRef] [Google Scholar]
71. Zhang H, Wroblewski K, Liao S, et al. Prognostic value of metabolic tumor burden from (18)F-FDG PET in surgical patients with non-small-cell lung cancer. Acad Radiol. 2013;20(1):32–40. doi: 10.1016/j.acra.2012.07.002. [PubMed] [CrossRef] [Google Scholar]
73. Andrade RS, Heron DE, Degirmenci B, et al. Posttreatment assessment of response using FDG-PET/CT for patients treated with definitive radiation therapy for head and neck cancers. Int J Radiat Oncol Biol Phys. 2006;65(5):1315–1322. doi: 10.1016/j.ijrobp.2006.03.015. [PubMed] [CrossRef] [Google Scholar]
74. Kawabe J, Higashiyama S, Yoshida A, Kotani K, Shiomi S. The role of FDG PET-CT in the therapeutic evaluation for HNSCC patients. Jpn J Radiol. 2012;30(6):463–470. doi: 10.1007/s11604-012-0076-5. [PubMed] [CrossRef] [Google Scholar]
75. Coleman RE, Hillner BE, Shields AF, et al. PET and PET/CT reports: observations from the National Oncologic PET Registry. J Nucl Med. 2010;51(1):158–163. doi: 10.2967/jnumed.109.066399. [PubMed] [CrossRef] [Google Scholar]
76. Niederkohr RD, Greenspan BS, Prior JO, et al. Reporting guidance for oncologic 18F-FDG PET/CT imaging. J Nucl Med. 2013;54(5):756–761. doi: 10.2967/jnumed.112.112177. [PubMed] [CrossRef] [Google Scholar]
77. Padhani AR. Imaging in the evaluation of cancer. In: Nicholson T, editor. Recommendations for cross-sectional imaging in cancer management. 2. London: The Royal College of Radiologists; 2014. [Google Scholar]
78. Juweid ME, Stroobants S, Hoekstra OS, et al. Use of positron emission tomography for response assessment of lymphoma: consensus of the Imaging Subcommittee of International Harmonization Project in Lymphoma. J Clin Oncol. 2007;25(5):571–578. doi: 10.1200/JCO.2006.08.2305. [PubMed] [CrossRef] [Google Scholar]
79. Meignan M, Gallamini A, Haioun C. Report on the First International Workshop on Interim-PET-Scan in Lymphoma. Leuk Lymphoma. 2009;50(8):1257–1260. doi: 10.1080/10428190903040048. [PubMed] [CrossRef] [Google Scholar]
80. Barrington SF, Mikhaeel NG, Kostakoglu L, et al. Role of imaging in the staging and response assessment of lymphoma: consensus of the International Conference on Malignant Lymphomas Imaging Working Group. J Clin Oncol. 2014. doi:10.1200/JCO.2013.53.5229 [PMC free article] [PubMed]
81. Krak NC, Boellaard R, Hoekstra OS, Twisk JWR, Hoekstra CJ, Lammertsma AA. Effects of ROI definition and reconstruction method on quantitative outcome and applicability in a response monitoring trial. Eur J Nucl Med Mol Imaging. 2005;32(3):294–301. doi: 10.1007/s00259-004-1566-1. [PubMed] [CrossRef] [Google Scholar]
82. Frings V, de Langen AJ, Smit EF, et al. Repeatability of metabolically active volume measurements with 18F-FDG and 18F-FLT PET in non-small cell lung cancer. J Nucl Med. 2010;51(12):1870–1877. doi: 10.2967/jnumed.110.077255. [PubMed] [CrossRef] [Google Scholar]
83. Frings V, van Velden FH, Velasquez LM, et al. Repeatability of metabolically active tumor volume measurements with FDG PET/CT in advanced gastrointestinal malignancies: a multicenter study. Radiology. 2014;273(2):539–548. doi: 10.1148/radiol.14132807. [PubMed] [CrossRef] [Google Scholar]
84. Schaefer A, Nestle U, Kremp S, et al. Multi-centre calibration of an adaptive thresholding method for PET-based delineation of tumour volumes in radiotherapy planning of lung cancer. Nuklearmedizin. 2012;51(3):101–110. doi: 10.3413/Nukmed-0452-11-12. [PubMed] [CrossRef] [Google Scholar]
85. Schaefer A, Kremp S, Hellwig D, Rube C, Kirsch CM, Nestle U. A contrast-oriented algorithm for FDG-PET-based delineation of tumour volumes for the radiotherapy of lung cancer: derivation from phantom measurements and validation in patient data. Eur J Nucl Med Mol Imaging. 2008;35(11):1989–1999. doi: 10.1007/s00259-008-0875-1. [PubMed] [CrossRef] [Google Scholar]
86. Geets X, Lee JA, Bol A, Lonneux M, Gregoire V. A gradient-based method for segmenting FDG-PET images: methodology and validation. Eur J Nucl Med Mol Imaging. 2007;34(9):1427–1438. doi: 10.1007/s00259-006-0363-4. [PubMed] [CrossRef] [Google Scholar]
87. van Dalen JA, Hoffmann AL, Dicken V, et al. A novel iterative method for lesion delineation and volumetric quantification with FDG PET. Nucl Med Commun. 2007;28(6):485–493. doi: 10.1097/MNM.0b013e328155d154. [PubMed] [CrossRef] [Google Scholar]
88. Hatt M, Lamare F, Boussion N, et al. Fuzzy hidden Markov chains segmentation for volume determination and quantitation in PET. Phys Med Biol. 2007;52(12):3467–3491. doi: 10.1088/0031-9155/52/12/010. [PMC free article] [PubMed] [CrossRef] [Google Scholar]
89. Cheebsumon P, Yaqub M, van Velden FH, Hoekstra OS, Lammertsma AA, Boellaard R. Impact of [18F]FDG PET imaging parameters on automatic tumour delineation: need for improved tumour delineation methodology. Eur J Nucl Med Mol Imaging. 2011;38(12):2136–2144. doi: 10.1007/s00259-011-1899-5. [PMC free article] [PubMed] [CrossRef] [Google Scholar]
90. Chiti A, Kirienko M, Grégoire V. Clinical use of PET-CT data for radiotherapy planning: what are we looking for? Radiother Oncol. 2010;96(3):277–279. doi: 10.1016/j.radonc.2010.07.021. [PubMed] [CrossRef] [Google Scholar]
91. Grégoire V, Chiti A. Molecular imaging in radiotherapy planning for head and neck tumors. J Nucl Med. 2011;52(3):331–334. doi: 10.2967/jnumed.110.075689. [PubMed] [CrossRef] [Google Scholar]
92. Sattler B, Lee JA, Lonsdale M, Coche E. PET/CT (and CT) instrumentation, image reconstruction and data transfer for radiotherapy planning. Radiother Oncol. 2010;96(3):288–297. doi: 10.1016/j.radonc.2010.07.009. [PubMed] [CrossRef] [Google Scholar]
93. Boktor RR, Walker G, Stacey R, Gledhill S, Pitman AG. Reference range for intrapatient variability in blood-pool and liver SUV for 18F-FDG PET. J Nucl Med. 2013;54(5):677–682. doi: 10.2967/jnumed.112.108530. [PubMed] [CrossRef] [Google Scholar]
94. Meignan M, Barrington S, Itti E, Gallamini A, Haioun C, Polliack A. Report on the 4th International Workshop on Positron Emission Tomography in Lymphoma held in Menton, France, 3-5 October 2012. Leuk Lymphoma. 2014;55(1):31–37. doi: 10.3109/10428194.2013.802784. [PubMed] [CrossRef] [Google Scholar]
95. Lockhart CM, MacDonald LR, Alessio AM, McDougald WA, Doot RK, Kinahan PE. Quantifying and reducing the effect of calibration error on variability of PET/CT standardized uptake value measurements. J Nucl Med. 2011;52(2):218–224. doi: 10.2967/jnumed.110.083865. [PMC free article] [PubMed] [CrossRef] [Google Scholar]
96. Greuter HN, Boellaard R, van Lingen A, Franssen EJ, Lammertsma AA. Measurement of 18F-FDG concentrations in blood samples: comparison of direct calibration and standard solution methods. J Nucl Med Technol. 2003;31(4):206–209. [PubMed] [Google Scholar]
98. Lasnon C, Hicks RJ, Beauregard JM, et al. Impact of point spread function reconstruction on thoracic lymph node staging with 18F-FDG PET/CT in non-small cell lung cancer. Clin Nucl Med. 2012;37(10):971–976. doi: 10.1097/RLU.0b013e318251e3d1. [PubMed] [CrossRef] [Google Scholar]
99. Krause BJ, Beyer T, Bockisch A, et al. FDG-PET/CT in oncology. German guideline. Nuklearmedizin. 2007;46(6):291–301. doi: 10.3413/nukmed-282. [PubMed] [CrossRef] [Google Scholar]
100. Bourguet P, Blanc-Vincent MP, Boneu A, et al. Summary of the standards, options and recommendations for the use of positron emission tomography with 2-[18F]fluoro-2-deoxy-D-glucose (FDP-PET scanning) in oncology (2002) Br J Cancer. 2003;89(Suppl 1):S84–S91. doi: 10.1038/sj.bjc.6601088. [PMC free article] [PubMed] [CrossRef] [Google Scholar]
101. Coleman RE, Delbeke D, Guiberteau MJ, et al. Concurrent PET/CT with an integrated imaging system: intersociety dialogue from the joint working group of the American College of Radiology, the Society of Nuclear Medicine, and the Society of Computed Body Tomography and Magnetic Resonance. J Nucl Med. 2005;46(7):1225–1239. [PubMed] [Google Scholar]
102. Lammertsma AA, Hoekstra CJ, Giaccone G, Hoekstra OS. How should we analyse FDG PET studies for monitoring tumour response? Eur J Nucl Med Mol Imaging. 2006;33(Suppl 1):16–21. doi: 10.1007/s00259-006-0131-5. [PubMed] [CrossRef] [Google Scholar]
103. Miller JC, Fischman AJ, Aquino SL, Blake MA, Thrall JH, Lee SI. FDG-PET CT for tumor imaging. J Am Coll Radiol. 2007;4(4):256–259. doi: 10.1016/j.jacr.2006.10.011. [PubMed] [CrossRef] [Google Scholar]
104. Schelbert HR, Hoh CK, Royal HD, et al. Procedure guideline for tumor imaging using fluorine-18-FDG. Society of Nuclear Medicine. J Nucl Med. 1998;39(7):1302–1305. [PubMed] [Google Scholar]
105. Shankar LK, Hoffman JM, Bacharach S, et al. Consensus recommendations for the use of 18F-FDG PET as an indicator of therapeutic response in patients in National Cancer Institute Trials. J Nucl Med. 2006;47(6):1059–1066. [PubMed] [Google Scholar]
106. Zijlstra JM, Comans EF, van Lingen A, et al. FDG PET in lymphoma: the need for standardization of interpretation. An observer variation study. Nucl Med Commun. 2007;28(10):798–803. doi: 10.1097/MNM.0b013e3282eff2d5. [PubMed] [CrossRef] [Google Scholar]
When a patient lies flat on her back facing up she is in which position?
The supine position (/səˈpaɪn/ or /ˈsuːpaɪn/) means lying horizontally with the face and torso facing up, as opposed to the prone position, which is face down. When used in surgical procedures, it grants access to the peritoneal, thoracic and pericardial regions; as well as the head, neck and extremities.
When a patient has impaired hearing which of the following strategies is least likely to be helpful?
When a patient has impaired hearing, which of the following strategies is LEAST likely to be helpful? Shout loudly with your lips close to the patient's ear.
When taking a radiograph of a patient with a new tracheostomy in diagnostic imaging the following precautions must be observed?
When taking a radiograph of a patient with a new tracheostomy in diagnostic imaging, the following precautions must be observed:1. Monitor patient closely for respiratory distress. 2. Ensure that suction equipment is available and functioning.
When opening a sterile pack the first corner of the wrap is opened?
Grab the outer surface's outermost tip (corner of folded drape) and open the flap away from you. The one-inch border on the sterile field is considered non-sterile. Make sure your arm is not over the sterile field. The inside of the sterile packaging is your sterile drape.