FDG PET and PET/CT: EANM procedure guidelines for tumour PET imaging: version 1.0

The aim of this guideline is to provide a minimum standard for the acquisition and interpretation of PET and PET/CT scans with [18F]-fluorodeoxyglucose (FDG). This guideline will therefore address general information about [18F]-fluorodeoxyglucose (FDG) positron emission tomography-computed tomography (PET/CT) and is provided to help the physician and physicist to assist to carrying out, interpret, and document quantitative FDG PET/CT examinations, but will concentrate on the optimisation of diagnostic quality and quantitative information

Reduced parahippocampal and lateral temporal GABA(A)-[C-11]flumazenil binding in major depression: preliminary results

Purpose: Major depressive disorder (MDD) has been related to both a dysfunctional γ-amino butyric acid (GABA) system and to hyperactivity of the hypothalamic-pituitary-adrenal axis (HPA). Although GABA has been suggested to inhibit HPA axis activity, their relationship has never been studied at the level of the central GAB

Estimation of image derived input functions using a reconstruction based partial volume correction algorithm: Methodology and evaluation in [11C]flumazenil studies

Introduction: The availability of image derived input functions (IDIF) obviates the need for arterial blood sampling and thereby facilitates clinical use of quantitative PET studies. The aim of this study was to develop a method for deriving IDIFs using reconstruction-based partial volume correction (PVC) [1]. Methods: PET and arterial blood data from nine dynamic [11C]flumazenil scans, acquired using an ECAT EXACT HR+ scanner and an on-line blood sampler, were used to develop and evaluate the method. Scans were reconstructed using both standard (no PVC) ordered subset expectation maximization (OSEM, 2 iterations, 16 subsets) and a PVC-OSEM algorithm, which corrects for the spatial resolution of the scanner. Number of iterations and width of PVC kernel were varied. The following regions of interest (ROIs) Methods: were evaluated for defining cerebral arteries: (a) pixel value threshold, (b) variable number of 'hottest' pixels per plane, (c) region growing, (d) cluster analysis, and (e) MR-based ROI. ROIs were defined on a pseudo blood volume image, generated by summation of early frames (<60s). ROIs were copied to all frames and IDIFs were extracted from both OSEM and PVC-OSEM images. For each IDIF the following parameters were derived: (a) area under the curve (AUC) for peak (1-2 min), (b) AUC for tail (2-60 min), (c) volume of distribution (Vd) obtained from parametric Logan images, and (d) Vd and K1 obtained from parametric basis function method (BFM) images. In each case, Results: were compared with those using on-line measured arterial input functions. Results: For PVC-OSEM, the optimal trade-off between computational time and signal-to-noise ratio was obtained for 4 iterations and 16 subsets. A 5.5 mm Gaussian resolution kernel gave optimal recovery correction. The best IDIF was obtained using the 'four hottest pixels per plane' over the blood pool in the region below the base of the skull. Compared with standard OSEM, use of PVC-OSEM improved mean (SD) AUC from 0.46 (0.06) to 1.15 (0.11) for the peak and from 0.82 (0.06) to 0.94 (0.12) for the tail part of the input function, respectively. Results: of the comparison between OSEM and PVC-OSEM for Vd and K1 are shown in Table 1 and Figure 1. Discussion and Conclusions: Excellent correlations were obtained between Vd and K1 values based on IDIFs and those based on on-line sampled input functions. Definition of an accurate IDIF may be sensitive to patient movement and future studies need to focus on motion correction Methods:. Nevertheless, this study shows the feasibility of deriving accurate IDIFs from dynamic PET scans using reconstruction-based PVC

Standardised FDG uptake: A prognostic factor for inoperable non-small cell lung cancer

The aim of this study was to investigate the relationship between standardised uptake value (SUV) obtained from [18F]fluorodeoxyglucose positron emission tomography (FDG PET) and treatment response/survival of inoperable non-small cell lung cancer (NSCLC) patients treated with high dose radiotherapy. Fifty-one patients were included recording stage, performance, weight loss, tumour volume, histology, lymph node involvement, SUV, and delivered radiation dose. The maximum SUV (SUVmax) within the primary tumour was a sensitive and specific factor for predicting treatment response. Apart from SUVmax, stage and performance were also independent predictive factors for treatment response. In a multivariate disease-specific survival (DSS) analysis, SUVmax (P = 0.01), performance status (P = 0.008) and stage (P = 0.04) were prognostic factors. For overall survival (OS), SUVmax (P = 0.001) and performance (P = 0.06) were important prognostic factors. SUVmax was an important prognostic factor for survival of inoperable NSCLC patients and a predictive factor for treatment response. Although the number of patients was small, the treatment was not homogeneous and the use of FDG SUV may have had constraints, we still conclude that the FDG SUV is potentially a good indicator for selecting patients for different treatment strategies

Determinants of Diagnostic Performance Of [F-18]Fluorodeoxyglucose Positron Emission Tomography for Axillary Staging in Breast Cancer

OBJECTIVE: To prospectively investigate determinants of the accuracy of staging axillary lymph nodes in breast cancer using [F-18]fluorodeoxyglucose positron emission tomography (FDG PET). METHODS: Patients with primary operable breast cancer underwent FDG PET of the chest followed by sentinel node biopsy (SNB, n = 47) and/or complete axillary lymph node dissection (ALND, n = 23). PET scans were independently interpreted by three observers in a blinded fashion with respect to the FDG avidity of the primary tumor and the axillary status. The results were compared to histopathological analyses of the axillary lymph nodes. Clinicians were blinded to the PET results. RESULTS: Axillary lymph node specimens and FDG PET scans were evaluated in 70 patients (59% cT1). Overall, 32 (46%) had lymph node metastases as established by SNB (18/47) or ALND (14/23), 20 of which were confined to a single node. The overall sensitivity of FDG PET was 25%, with a specificity of 97%. PET results were false-negative in all 18 positive SNBs and true-positive in 8/14 in the ALND group. The performance of FDG PET depended on the axillary tumor load and the FDG avidity of the primary tumor. Intense uptake in the primary tumor was found in only 57% of the patients, and this was independent of the size. There was excellent interobserver agreement of visual assessment of FDG uptake in primary tumor and axillary lymph nodes. CONCLUSIONS: The sensitivity of FDG PET to detect occult axillary metastases in operable breast cancer was low, and it was a function of axillary tumor load and FDG avidity of the primary tumor. Even though the clinical relevance of occult disease detected by SNB needs to be confirmed, it is suggested that FDG PET in these patients should be focused on exploiting its nearly perfect specificity and the potential prognostic relevance of variable FDG uptake

Comparison of plasma input and reference tissue models for analysing [(11)C]flumazenil studies

A single-tissue compartment model with plasma input is the established method for analysing [(11)C]flumazenil ([(11)C]FMZ) studies. However, arterial cannulation and measurement of metabolites are time-consuming. Therefore, a reference tissue approach is appealing, but this approach has not been fully validated for [(11)C]FMZ. Dynamic [(11)C]FMZ positron emission tomography scans with arterial blood sampling were performed in nine drug-free depressive patients and eight healthy subjects. Regions of interest were defined on co-registered magnetic resonance imaging scans and projected onto dynamic [(11)C]FMZ images. Using a Hill-type metabolite function, single (1T) and reversible two-tissue (2T) compartmental models were compared. Simplified reference tissue model (SRTM) and full reference tissue model (FRTM) were investigated using both pons and (centrum semiovale) white matter as reference tissue. The 2T model provided the best fit in 59% of cases. Two-tissue V(T) values were on average 1.6% higher than 1T V(T) values. Owing to the higher rejection rate of 2T fits (7.3%), the 1T model was selected as plasma input method of choice. SRTM was superior to FRTM, irrespective whether pons or white matter was used as reference tissue. BP(ND) values obtained with SRTM correlated strongly with 1T V(T) (r=0.998 and 0.995 for pons and white matter, respectively). Use of white matter as reference tissue resulted in 5.5% rejected fits, primarily in areas with intermediate receptor density. No fits were rejected using pons as reference tissue. Pons produced 23% higher BP(ND) values than white matter. In conclusion, for most clinical studies, SRTM with pons as reference tissue can be used for quantifying [(11)C]FMZ bindin

18FDG positron emission tomography versus 67Ga scintigraphy as prognostic test during chemotherapy for non-Hodgkin's lymphoma

A prospective study was performed, comparing gallium scintigraphy ( 67Ga) and positron emission tomography (PET) using fluorine-18 fluorodeoxyglucose (18FDG), to monitor the response of aggressive non-Hodgkin's lymphoma during treatment. 67Ga and 18FDG scans were performed in 26 patients after two cycles of CHOP (cyclophosphamide, doxorubicin, vincristine, prednisone) therapy. The scans were reviewed independently by four experienced nuclear physicians, who were blinded for the alternative scan technique and follow-up. Eleven out of 26 patients remained free from progression with a mean follow up of 25 ± 5 months, whereas 14 patients relapsed, and one died of lung cancer. Interobserver variation was significantly greater for 67Ga than for 18FDG PET. Some 64% of patients who had a negative early restaging 18FDG PET remained free from progression versus 50% of patients with negative 67Ga scans. Only 25% of patients with a positive PET remained disease free versus 42% of 67Ga-positive patients. Time to progression was associated with 18FDG PET results, but not with those by 67Ga. 18FDG PET had better test characteristics than 67Ga for the evaluation of early response in aggressive non-Hodgkin's lymphoma patients

Positron emission tomography using 2-deoxy-2-[18 F]-fluoro-D-glucose for response monitoring in locally advanced gastroesophageal cancer; a comparison of different analytical methods

Purpose: To determine the ability of 2-deoxy-2-[18F] -fluoro-D-glucose (FDG) positron emission tomography (PET) to monitor response in locally advanced gastroesophageal cancer (LAGEC). Additionally, optimal FDG-PET methods for response monitoring were selected. Procedures: Sequential dynamic FDG-PET scans were performed in 13 patients with LAGEC (T2-3N0-1M0-1a) treated with neoadjuvant cisplatin and gemcitabine plus granulocyte macrophage colony stimulating growth factor at a three weekly schedule. The standard FDG-PET method, nonlinear regression (NLR), was compared with computed tomography (CT), endoscopic-ultrasound (EUS), and histopathology as well as with 21 simplified analytical FDG-PET methods. Results: Five out of 12 operated tumors responded histopathologically with less than 10% residual tumorcells (42%). These had a higher decrease in FDG uptake compared with nonresponders (P = 0.008). Early (after two cycles) and late (after completed induction therapy) response evaluation showed a specificity of 86% and 100%, respectively, and a sensitivity of 100%. Both FDG-PET and EUS were superior to CT. From 21 methods analyzing FDG uptake, the quantitative Patlak analysis, the simplified kinetic method (SKM), and the semiquantitative standardized uptake value corrected for bodyweight (SUV-BW) seemed to correlate best with NLR. Conclusions: FDG-PET reliably predicted response in LAGEC. FDG-PET measurements using Patlak analysis or the more clinical applicable SKM and SUV-BW were acceptable alternatives to NLR