In this episode we will be looking at PET/CT and the evaluation of different therapeutic interventions. More and more, the interest in PET/CT is not only in the initial evaluation of disease, but also in the subsequent evaluation of therapy response. We will look at the literature to discuss the different recommended standards for defining the disease’s response as complete, partial, stable, or progressive.
A journal article I read recently had several amusing examples of ”unremarkable” words. This illustrates how easy it is for reports to contain phrases that only the writer can clearly understand. While some issues are caused by dictation technology and the tendency of us humans to occasionally “zone out,” we can still improve the quality of our reports by following templates and a list of required elements. In this episode, I’ll illustrate this process using a typical report from our site.
In this episode, I’ll discuss the issues of unclear language in written reports. With the growing use of EMR and demands for quick turnaround time, we’re spending less face time with our colleagues. This episode I’ll particularly focus on some studies concerning terminology, and how synonyms can make it difficult to determine to what degree an abnormality is present.
In this episode I’ll discuss prostate cancer and PET. Prostate imaging with PET remains unapproved for reimbursement by CMS, and we’ll examine several reasons why this is the case. One of the major limitations has to do with the tracers available, and along those lines I’ll talk about radiopharmaceuticals currently under investigation.
I’ll continue the discussion of head and neck malignancies and reporting. Every PET/CT report needs to discuss the Tumor (T), the presence of regional lymph nodes, and the presence of metastases. A well-written and organized report will make your clinical and surgery colleagues quite happy with the results.
Today I’ll continue our discussion of head and neck cancer and PET/CT by going through a number of studies important to both. Several of these studies provide illuminating data by comparing PET/CT to either PET or CT data alone, including data from high-contrast CT. We’ll see how PET/CT can increase the confidence of the radiologist and even find disease in head and neck patients otherwise considered cured.
In this episode, I’m going to discuss head and neck cancer, including normal variations, clinical indications, and my favorite topic, radiation therapy planning with PET. Head and neck cancer is not as common as other cancers, but the high morbidity and mortality rates make it an important topic. I’ll also discuss the patient preparation and overall procedure used at our site with head and neck cases.
As we continue our discussion of lung cancer, I want to cover how radiation therapy and PET are becoming linked. I’ll discuss the three key volumes used for any plan, the most important of which is the Gross Tumor Volume (GTV) that the therapist delineates using imaging. In lung cancer, PET can have a particular influence on the size of the GTV, either by increasing or decreasing this volume. For example, PET can detect regional lymph nodes in non-small cell lung cancer patients.
Today I’m going to continue my discussion of PET and lung cancer by going through a number of interesting studies. I’ve spoken before about the pitfalls of SUV, but there is research that shows that the SUV combined with Hounsfield units can be very helpful when studying adrenal lesions. Due to a lack of standardized criteria, it is difficult to completely quantify PET’s ability to help categorize patient response, yet the data shows that PET is very useful in therapy response and predicting patient survival.
Today I’ll continue my discussion of PET and lung cancer. The SUV can be a valuable tool to use as a baseline and for follow-up, but essentially an SUV measurement on its own isn’t really better than visual analysis. I’ll discuss the various pitfalls of SUV, as well as tips for examining both solitary pulmonary nodules and the mediastinum.
In this episode, I will discuss the history of approved reimbursements from CMS, from the 1998 approval for solitary pulmonary nodules to more recent changes in terminology that affect our billing. Lung cancer has a high mortality rate in both men and women, and the current statistics on the subject are striking. I will also go into detail about how our site uses PET with lung cancer cases.
In this follow-up to Pediatric PET, I’ll move to discussing specific applications and disease states. In pediatrics, it is particularly important to minimize dose, since the patient will hopefully have many more years to live. I’ll talk about how standalone PET, and the new developments in PET/MR, can potentially help reduce the frequency of using diagnostic CT.
Today I want to talk about pediatric PET, and the issues we encounter before any images even get to the radiologist. It may sound simplistic, but children are not little adults, and often patient sedation is required. Because of this, it’s best to coordinate exams close to each other in time, and in the same room if possible. Overall, we want to minimize sedation time, dose, delays between scans, and patient discomfort. And of course, don’t forget about the parents!
In this third look at fusing anatomic and physiological data, I want to examine why SPECT/CT has not enjoyed the popularity of PET/CT. SPECT/CT can offer many of the same benefits as PET/CT, such as improved image quality, and it has some interesting brachytherapy applications, Later in this podcast, I will also examine the future of PET/MR.
In this episode, I continue my discussion of the advancements made by hardware fusion. The adoption of the combined PET/CT instrument gave us dramatic decreases in imaging time, reduced dose, and most importantly, gains in image quality. Even with these advancements, software fusion remains important for the future, since it allows comparison of images from different time points.
We’ve already benefited a great deal from fusion thanks to the clinical context it provides for surgery and radiation therapy. In this episode, I’m going to discuss both software and hardware fusion and the advancements made by these techniques. Software techniques have improved with deformable registration, and the combined instrument in hardware is really very useful for improving image quality.
A good technologist can really be an important asset in a PET/CT department like ours. A great technologist should first and foremost reduce patient anxiety, but in this episode I’ll also talk about how a careful and educated technologist is needed to get both complete and accurate images.
During radiotherapy treatment planning, communication between imaging experts and radiation therapists proves to be essential. We as radiologists can help with the displayed image contrast and the different algorithms for segmentation. The radiation therapy experts can tell us about when and how to measure the success of radiation therapy. It turns out that therapeutic response can be measured a number of ways.
A recent talk I presented had me further examining how clinicians, radiologists, and radiation therapists interact during the treatment planning process. I’ll illustrate with a prostate treatment example and later touch on the importance of image quality as it relates to SPECT and PET. A healthy collaboration is essential to maximizing treatment dose, sparing normal tissues, and increasing the chances of a positive outcome.
Dr. Faulhaber continues his thoughts on SNM 2010 with a review of radiopharmaceuticals. He then discusses trends in scanning instruments towards minimum dose, maximum speed, and increased image quality. Dr. Faulhaber also explores the improvements in imaging software and the exciting trend of server-based imaging using cloud technology.
The annual SNM meeting on June 5th in Salt Lake City is fast approaching. My preparations for the meeting will keep me busy for the next few weeks, but I will return to podcasting later in June.
Look for my SNM 2010 Review podcast to hear my reflections on the important news from this year’s event.
Thanks for listening.
-Peter
Dr. Faulhaber concludes his three-part series on non-oncologic brain imaging by discussing refractory seizures. He covers the techniques for evaluating intractable epilepsy, including the role of PET in brain surgery guidance. Dr. Faulhaber also discusses why interictal PET combined with ictal and interictal SPECT will have a better chance of finding an epileptogenic focus. He then discusses the importance of co-registering these scans with software and using subtraction techniques.
Dr. Faulhaber continues his three-part series on non-oncologic brain imaging by covering a wide range of dementia. He examines the challenge of diagnosing from a broad spectrum of symptomatic criteria and looks at the dangers of treating one type of dementia as if it were another. Dr. Faulhaber concludes by examining the promising new agents being used for dementia PET imaging, which offer hope for more accurate diagnoses.
Dr. Faulhaber begins a three-part series on non-oncologic brain imaging. He summarizes the CMS approval process, which has led to the evaluation of Alzheimer’s Dementia (AD) with PET. He also examines how imaging can help aid in the early diagnosis and in distinguishing between AD and mild cognitive impairment. Early detection and treatment to delay the onset of AD could potentially have a significant impact on the cost of care, which is currently estimated at 150 billion dollars.
Dr. Faulhaber concludes his four-part series for clinical staff by looking at the challenges of radiation therapy. He emphasizes the extreme importance of clear communication among the various clinical teams in understanding the plan and possible treatment protocols. For example, using a flat versus a curved table can have a significant impact on the success of the radiation therapy. Dr. Faulhaber also examines the various methods of drawing PET tumor volumes, including constant threshold edge detection and the more accurate gradient edge detection.
Dr. Faulhaber continues his four-part series for the nurses, technologists, and physicians directly taking care of the patient. He describes the patient’s physiologic parameters that affect what lesions and tumors can and cannot be seen. He also discusses the value of respiratory gating to overcome blurring and the difficulties of minimizing errors when evaluating SUVs.
Dr. Faulhaber continues his four-part series for the nurses, technologists, and physicians directly taking care of the patient. He describes many of the terms, mechanical functions, and time requirements involved in using a PET/CT scanner. Dr. Faulhaber also covers the potential exposure of patients and clinical staff to radiological dose.
Dr. Faulhaber begins a four-part series for the entire clinical staff–the nurses, technologists, and physicians directly taking care of the patient. Having some PET background is important, because the patient today is likely to be more sophisticated and educated about treatment and terminology. Dr. Faulhaber begins with an explanation of PET scanners and positron emitters.
Dr. Faulhaber begins a two-part session by exploring, “Why bother doing respiratory gating?” and the refinements in PET in “stopping” the motion and seeing the lesion better. He also discusses FDG and how imaging techniques have changed with improvements in hardware, software, and fusion.
Dr. Faulhaber explores what information (such as malignancy, grade, or previous treatment/surgery) should be specified when a clinician orders a PET, and what information (such as dose, glucose level, and type of scan) should be returned in the final PET report.
Dr. Faulhaber examines how PET has developed clinically as the approval process of CMS has increased. He begins with a brief review of the value of PET over time and the impact of Fluorine-18 tagged with Glucose as a very powerful imaging agent.
The initial episodes of Clinical PET Cast have been well received. Upcoming programs will cover such wide-ranging topics as:
In the future, I am hoping to expand CPC to include a video podcast companion. Your feedback will help me direct these plans and to guide the current podcast into areas most relevant to our practices. Either leave a voicemail at 216-455-0777 or email clinicalpetcast@gmail.com.
-Thanks for listening, Peter
Dr. Faulhaber discusses the concept of quantitation and in particular the Standard Uptake Value or SUV. Clinical PET relies on semi-quantitative methods which are based on the data acquired from the patient, and how that data is corrected for attenuation.
Dr. Faulhaber continues this two-part session by examining specific regions of the body that can be quite confounding in the anatomic and physiologic variation. He begins with the head & neck, a very difficult area to interpret.
Dr. Peter Faulhaber examines the normal distribution on a PET scan of FDG and what variables to consider. FDG uptake may vary considerably depending on factors from the patient’s recent activity such as eating, exercise, and excretion. He also examines the factors that influence uptake on vital organs.
This podcast is the first in a series by Dr. Peter Faulhaber, a radiologist at University Hospitals in Cleveland, Ohio. Dr. Faulhaber offers his perspective on various issues of Positron Emission Tomography from a hands-on clinical-based practical approach, based on 30 years of experience.
Clinical PET Cast is an educational resource for radiologists and other medical professionals regarding PET imaging. Peter Faulhaber is director of Clinical PET at University Hospitals Case Medical Center and Associate Professor of Radiology at Case Western Reserve University in Cleveland, Ohio. He is a leader in clinical PET with 30 years of experience in the field. The focus of this program is to increase knowledge in the clinical applications and principles of PET imaging.
Peter Faulhaber, MD is a Radiologist at University Hospitals in Cleveland, OH.
