Chapter 1: The science and the scan
"Boring, But Necessary"
- Hybrid Imaging System
- Anatomic & Functional Exam
- The Machine
- “Whole Body” vs. “Skull Base to Mid-Thigh”
- Three Sets of Images
Produced
- Glucose Analog
- Malignancy & Glucose Metabolism
- Mechanisms for Increased Intracellular Glucose
- Why 18F-FDG Works
- Whole Body Assessment
- The “You’re Kidding Me!” Effect
- Post-Therapeutic Scar vs. Active Malignancy
- Detecting Malignancy
- Staging Malignancy
- Assess Response to Therapy
- Detecting Recurrence
- Not All Cancer is FDG-Avid
- Normal FDG-Uptake vs. Pathologic Uptake
- Technical Limitations
- Poor Patient Preparation
- Misregistration
- Brown Fat Activation
- SUV Problems
- Fields of View Discrepancy
- PET/CT Artifacts
- Timing of Exam After Therapy
- CT Images
- Non-Attenuation Corrected Images
- Attenuation Corrected Images
- Maximum Intensity Projection (MIP)
- Fusion of Images
- All Images Viewed in 3 Planes
7. Contrast Media: Oral & I.V.
- Who Gets Oral Contrast?
- Who Gets IV Contrast?
- Oral Contrast “Cocktail” Recipe
8. What the Patient Should Expect
- Documenting Height & Weight
- Private Resting Room
- Drinking PO Contrast
- FDG Injection
- Delay Between Injection & Scan
9. Safety Concerns with PET/CT Imaging
- Radiation Exposure to Patient
- Radiation Exposure to Patient’s Contacts
- Patient Contact with Pregnant Women
- Breastfeeding
Chapter 2: PET/CT Problems Which Limit Interpretation
"Something just doesn't seem right here"
- Optimizing Glucose & Insulin Levels
- Fasting Prior to Exam
- Diabetic Patients
- Low Carbohydrate Diet
- Hydration
- Strenuous Exercise
- Voiding Prior to Exam
- Patient Instruction Sheet
- Definition
- Distribution / Appearance
- Don’t Miss the Hidden Nod
- Reporting Language
- Prevention
3. Timing of PET/CT Exam After Therapy
- “Rule of 3”
- Chemotherapy: 1 month
- Surgery: 2 months
- Radiation: 3 months
- Etiology: Hybrid Imaging
- Patient Movement
- Respiratory Motion
- Breathing Techniques
- Bowel Peristalsis
- False Positives
- False Negatives
- Reporting Language
- Beam Hardening
- Diaphragmatic Mismatch
- Linear Hand Motion
- Attenuation Correction
- Differing Fields of View
- Poor Patient Preparation
- FDG Extravasation
- Extensive Brown Fat
- Metformin-Induced Bowel Uptake
- Marked Reactive Marrow Uptake
- Extensive Tumor Uptake in
- Different Types of SUV Measurements
- Factors that Influence SUV Measurements
- What SUV Number Indicates Malignancy?
- What Percent Change in SUV on a Follow Up Exam is Significant?
- How to Compare Exams With Very Different Background Metabolic Activities?
Chapter 3: The Standardized Uptake Value (SUV)
"The good, the bad & the ugly"
1. What is the SUV & Why Used?
- Quantitative vs. Qualitative Assessment
- Unitless Measurement
- Formula
- SUV = ?
- Patient Preparation
- Time Between FDG Injection & Scan
- Partial Volume Effects
- Extravasation
- Patient Weight
- Size & Position of ROI
- Attenuation Correction Artifacts
- Consensus?
- Body Weight
- Lean Body Mass
- Ideal Body Weight
- Body Surface Area
- Maximum vs. Mean
- Average SUV’s by Organ
4. Interpreting the SUV: Threshold Values, “Oncologic Plausibility” & Relative Uptake
- Precise Threshold Values?
- “Oncologic Plausibility”
- Relative Uptake
- Assessing Nodes in Lymphoma Cases
- Assessing Nodes in Non-Lymphoma Cases
- Potential Lesions in Solid Organs
- Pulmonary Nodules
5. What % Change in SUV on a Follow Up Exam is Clinically Significant?
- The Problem
- Current Recommendations
6. How to Compare Sequential Exams With Very Different Background Activities?
- Differing Background Metabolic Activities
- When Qualitative Assessment is Required
- Reporting Language
7. Should We Just Abandon the SUV?
- Pros & Cons
- “Qualitative” Definitions
- Mild
- Moderate
- Intense
- Final Recommendations
Chapter 4: Our Systematic Approach to Reading a PET/CT
"Eat your vegetables"
1. Reading Station & Reading Software
- Reading Station
- Monitor Set-Up
- PET/CT Reading Software
- Hanging Protocol
- Reading in Context (“Oncologic Plausibility”)
- Measure Size on CT, Not on PET Images
- Abnormality Seen Only on First PET Image
- Assess the Patient’s Main Pathology Last
- Beware the Ureter
3. Excellent Views: The MIP, Coronal & Sagittal Images
- 3-D Rotating MIP & Coronal “Quick MIP”
- Coronal PET
- Sagittal PET
4. Written Annotations While Reading
- Numbers, Numbers & More Numbers
- Size & SUV Annotation System
- Sample Annotation Sheet
- Goals of Reporting
- Lawyers, Lawyers & Lawyers
- Sample PET/CT Report
- Negative Exam
- Positive Exam
- Patient Questionnaire
- Technologist’s Data Sheet
- Huge Exam: Requires Systematic Approach
- Our “12-Step Reading System”
- “The Read” in Action: Sample Case (Video)
- Annotations for Sample Case
- Final Report for Sample Case
Chapter 5: Normal Physiologic Distribution of FDG
"The essentials"
- To Locate Cancer, First Eliminate:
- Normal FDG-Avid “Structures”
- Benign FDG-Avid “Findings”
Chapter 6: Benign FDG-Avid "Findings" & Common Diagnostic Challenges
"Separating the Expert from the Not-So-Expert"
3. Chest
- Inflammatory Lymph Nodes
- Thymic Rebound
- Pleura: Talc Pleurodesis vs. Malignancy vs. Inflammation
-
Radiation-Induced Lung Disease
- Radiation Pneumonitis
- Radiation Fibrosis
- "Post-Therapeutic Inflammatory Changes" / Scarring of the Lung
- Atelectasis / Infiltrate
- Lipomatous Hypertrophy of the Inter-Atrial Septum
- Elastofibroma Dorsi
- Site of Prior Chest Port
- Esophagitis vs. Neoplasm
- Subcutaneous & Intramuscular Medical Injections
- Injected FDG-Blood Clot
4. Abdomen & Pelvis
- The Heterogeneous Liver
- Liver Ablation
- Hypermetabolic Geographic Fatty Infiltration
- Hypermetabolic Hepatic Adenoma
- FDG-Avid Adrenal Gland Algorithm
- Therapy-Induced Splenic Activation
- Peritoneal Carcinomatosis
- Pre-Sacral Soft Tissue After Rectal Surgery
- Gallbladder: Cholecystitis vs. Malignancy
- Inguinal Herniorraphy
- Bladder in Inguinal Canal
- Uterine Fibroid
- Tampon
5. Miscellaneous (continued)
-
Vascular Uptake
- Atherosclerosis
- Vasculitis
- Vascular Grafts
-
Value of NAC PET Images
- Resolving AC Artifacts
- Lung Nodule Identification
-
Non-Malignant, Yet Clinically Significant, FDG-Avid CT Abnormalies
- Acute Diverticulitis
- Colitis
- Cholecystitis
- Pneumonia
- Abscess
- Pancreatitis
- Skeletal Abnormalities [See Chapter 7]
Chapter 7: The Bones
"...is connected to the..."
Chapter 8: The Cancers
"Putting it all together"
Introduction
“I know it when I see it.”
Supreme Court Justice Potter Stewart,
when asked to define “pornography”.
Unfortunately, this statement also reflects the criteria used by most radiologists to identify active malignancy on a PET/CT scan. The actual diagnostic criteria they rely upon are difficult to articulate, vary considerably and are inconsistently applied.
Why PETCTMD?
Because “I know it when I see it” is insufficient.
Despite a plethora of textbooks, medical conferences, scientific journals and an array of information (and misinformation) on the web, there still exists no comprehensive resource designed specifically for the working PET/CT radiologist.
Even the most comprehensive of the PET/CT textbooks simply do not address how to read & interpret a PET/CT scan.
If you are a physicist or academic clinician fascinated by cyclotrons, photomultiplier tubes, positron annihilation, rates of decay, coincidence detection, and chi square analyses, the existing resources out there will serve you well.
But if you are a working radiologist struggling on an early Monday morning to decide whether a small lymph node is simply reactive or evidence of impending death, you are on your own.
What is PETCTMD?
Finally, in one location, a comprehensive resource designed exclusively for the PET/CT radiologist.
- Step-By-Step Teaching Guide: Designed to make an expert of the novice PET/CT reader — utilizing thousands of high-resolution images from hundreds of cases.
- Problem Solving Tool for Advanced Diagnostic Challenges: Even very experienced readers struggle with challenging PET/CT issues. Each challenge is addressed in detail, using specific diagnostic algorithms and case examples.
- Complete PET/CT Reference Guide: The only one of its kind in the field — an indispensible tool for both the expert and beginner.
- The Language of Reporting: We provide very specific reporting language – phrases valuable to your patients and referring clinicians, but not to your neighbor malpractice attorney.
Why a Website?
In today’s digital age, textbooks and eBooks are obsolete. Our information is always current, and our cases/images regularly updated.
A website also permits us to present many thousands of images – a volume simply not possible to include in printed format.
Lastly, this digital format permits you to help us improve this site. Your feedback permits us to immediately edit and modify where you think we can do a better job.
We truly hope PETCTMD will be of great service to you, your patients and your referring clinicians.
Where you think this site can be improved, please let us know.
Thanks!
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Steven A. Christie, M.D.
Director of Oncologic Imaging
PETCTMD
Steven A. Christie, M.D.
Dr. Steven Christie, the author of PETCTMD, specializes in oncologic radiology and body imaging. He received his B.A. from the University of Pennsylvania and his M.D. from the University of Miami.
He completed his radiology residency and musculoskeletal/MRI fellowship at the University of Miami/Jackson Memorial Hospital. Dr. Christie finished his training at the Sylvester Comprehensive Cancer Center, with advanced work in the field of PET/CT, specializing in oncologic radiology. He is a Diplomate of the American Board of Radiology.
Dr. Christie is also an attorney, a member of the Florida Bar and a graduate of the University of Miami School of Law.
Dr. Christie serves as the Director of Oncologic Imaging for PETCTMD and is the Chief of Radiology for Oncology & Radiation Associates, in Miami, FL.
He and his wife, Dr. Grazie Christie, live in Miami and are the proud parents of five children.
- Care has been taken to confirm the accuracy of the information presented herein. Medicine, however, is a constantly evolving science. Many physicians and scientists, in good faith, disagree on many critical issues surrounding image interpretation and its application to medical care. In light of these fact, and with the understanding that normal human error is intrinsic in the evolving fields of medicine and science, neither the authors nor the publisher nor any other party who has been involved in the preparation or publication of this work warrants that the information contained herein is in every respect accurate or complete, and they are not responsible for any errors or omissions or for the results obtained from use of such information. Readers are strongly encouraged to confirm the information contained herein with other sources.
- This website is not a substitute for individual patient assessment based on a professional’s own evaluation of the patient and the patient’s unique clinical history and presentation. This website is merely a reference tool, and does not provide specific medical advice or guidance for any particular case. Healthcare professionals, not PETCTMD, are solely responsible for all medical judgments regarding patient care or radiologic interpretation, and are solely responsible for the use of this product – including all medical judgments and for any resulting diagnosis and treatments.
- Use of this website is an explicit agreement that application of any information contained herein remains the sole professional responsibility of the practitioner.
- Due to the very large volume of material covered herein, we have limited PETCTMD to the field of Oncology (dementia and cardiac imaging are not included).
- On very rare occasion, a few images have been digitally modified for teaching purposes.
Copyright © 2016 PETCTMD, LLC
Copyright © 2016 PETCTMD, LLC. All rights reserved. This website and its contents are protected by copyright. No part of this book, eBook or website (including text, images and graphics) may be reproduced in any form by any means, electronic or mechanical, including photocopying, printing, recording or by any information and retrieval system, without written permission from the copyright owner. To request permission, please contact PETCT MD via email at scmd@me.com.