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How We Read Oncologic FDG PET/CT

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      Abstract

      18F-fluorodeoxyglucose (FDG) PET/CT is a pivotal imaging modality for cancer imaging, assisting diagnosis, staging of patients with newly diagnosed malignancy, restaging following therapy and surveillance. Interpretation requires integration of the metabolic and anatomic findings provided by the PET and CT components which transcend the knowledge base isolated in the worlds of nuclear medicine and radiology, respectively. In the manuscript we detail our approach to reviewing and reporting a PET/CT study using the most commonly used radiotracer, FDG. This encompasses how we display, threshold intensity of images and sequence our review, which are essential for accurate interpretation. For interpretation, it is important to be aware of benign variants that demonstrate high glycolytic activity, and pathologic lesions which may not be FDG-avid, and understand the physiologic and biochemical basis of these findings. Whilst FDG PET/CT performs well in the conventional imaging paradigm of identifying, counting and measuring tumour extent, a key paradigm change is its ability to non-invasively measure glycolytic metabolism. Integrating this “metabolic signature” into interpretation enables improved accuracy and characterisation of disease providing important prognostic information that may confer a high management impact and enable better personalised patient care.

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      Regulation of cancer cell metabolism.

      Interest in the topic of tumour metabolism has waxed and waned over the past century of cancer research. The early observations of Warburg and his contemporaries established that there are fundamental differences in the central metabolic pathways operating in malignant tissue. However, the initial hypotheses that were based on these observations proved inadequate to explain tumorigenesis, and the oncogene revolution pushed tumour metabolism to the margins of cancer research. In recent years, interest has been renewed as it has become clear that many of the signalling pathways that are affected by genetic mutations and the tumour microenvironment have a profound effect on core metabolism, making this topic once again one of the most intense areas of research in cancer biology.
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        Role of imaging in the staging and response assessment of lymphoma: consensus of the International Conference on Malignant Lymphomas Imaging Working Group.

        Recent advances in imaging, use of prognostic indices, and molecular profiling techniques have the potential to improve disease characterization and outcomes in lymphoma. International trials are under way to test image-based response–adapted treatment guided by early interim positron emission tomography (PET)–computed tomography (CT). Progress in imaging is influencing trial design and affecting clinical practice. In particular, a five-point scale to grade response using PET-CT, which can be adapted to suit requirements for early- and late-response assessment with good interobserver agreement, is becoming widely used both in practice- and response-adapted trials. A workshop held at the 11th International Conference on Malignant Lymphomas (ICML) in 2011 concluded that revision to current staging and response criteria was timely. An imaging working group composed of representatives from major international cooperative groups was asked to review the literature, share knowledge about research in progress, and identify key areas for research pertaining to imaging and lymphoma. A working paper was circulated for comment and presented at the Fourth International Workshop on PET in Lymphoma in Menton, France, and the 12th ICML in Lugano, Switzerland, to update the International Harmonisation Project guidance regarding PET. Recommendations were made to optimize the use of PET-CT in staging and response assessment of lymphoma, including qualitative and quantitative methods. This article comprises the consensus reached to update guidance on the use of PET-CT for staging and response assessment for [18F]fluorodeoxyglucose-avid lymphomas in clinical practice and late-phase trials.
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          Harmonizing FDG PET quantification while maintaining optimal lesion detection: prospective multicentre validation in 517 oncology patients

          Purpose Point-spread function (PSF) or PSF + time-of-flight (TOF) reconstruction may improve lesion detection in oncologic PET, but can alter quantitation resulting in variable standardized uptake values (SUVs) between different PET systems. This study aims to validate a proprietary software tool (EQ.PET) to harmonize SUVs across different PET systems independent of the reconstruction algorithm used. Methods NEMA NU2 phantom data were used to calculate the appropriate filter for each PSF or PSF+TOF reconstruction from three different PET systems, in order to obtain EANM compliant recovery coefficients. PET data from 517 oncology patients were reconstructed with a PSF or PSF+TOF reconstruction for optimal tumour detection and an ordered subset expectation maximization (OSEM3D) reconstruction known to fulfil EANM guidelines. Post-reconstruction, the proprietary filter was applied to the PSF or PSF+TOF data (PSFEQ or PSF+TOFEQ). SUVs for PSF or PSF+TOF and PSFEQ or PSF+TOFEQ were compared to SUVs for the OSEM3D reconstruction. The impact of potential confounders on the EQ.PET methodology including lesion and patient characteristics was studied, as was the adherence to imaging guidelines. Results For the 1380 tumour lesions studied, Bland-Altman analysis showed a mean ratio between PSF or PSF+TOF and OSEM3D of 1.46 (95 %CI: 0.86–2.06) and 1.23 (95 %CI: 0.95–1.51) for SUVmax and SUVpeak, respectively. Application of the proprietary filter improved these ratios to 1.02 (95 %CI: 0.88–1.16) and 1.04 (95 %CI: 0.92–1.17) for SUVmax and SUVpeak, respectively. The influence of the different confounding factors studied (lesion size, location, radial offset and patient’s BMI) was less than 5 %. Adherence to the European Association of Nuclear Medicine (EANM) guidelines for tumour imaging was good. Conclusion These data indicate that it is not necessary to sacrifice the superior lesion detection and image quality achieved by newer reconstruction techniques in the quest for harmonizing quantitative comparability between PET systems. Electronic supplementary material The online version of this article (doi:10.1007/s00259-015-3128-0) contains supplementary material, which is available to authorized users.
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            Author and article information

            Affiliations
            [1 ]Centre for Molecular Imaging, Dept of Cancer Imaging, Peter MacCallum Cancer Centre, 305 Grattan Street, Melbourne, 3000 Australia
            [2 ]Sir Peter MacCallum Department of Oncology and Department of Medicine, University of Melbourne, Melbourne, Australia
            Contributors
            ORCID: http://orcid.org/0000-0001-8622-159X, +613 8559 5510 , michael.hofman@petermac.org
            +613 8559 5510 , rod.hicks@petermac.org
            Journal
            Cancer Imaging
            Cancer Imaging
            Cancer Imaging
            BioMed Central (London )
            1740-5025
            1470-7330
            18 October 2016
            18 October 2016
            2016
            : 16
            27756360
            5067887
            91
            10.1186/s40644-016-0091-3
            © The Author(s). 2016

            Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

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            © The Author(s) 2016

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