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      The use of positron emission tomography/computed tomography imaging in radiation therapy: a phantom study for setting internal target volume of biological target volume

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          Fluorodeoxyglucose ( 18F-FDG) positron emission tomography/computed tomography (PET/CT) is an important method for detecting tumours, planning radiotherapy treatment, and evaluating treatment responses. However, using the standardized uptake value (SUV) threshold with PET imaging may be suitable not to determine gross tumour volume but to determine biological target volume (BTV). The aim of this study was to extract internal target volume of BTV from PET images.


          Three spherical densities of 18F-FDG were employed in a phantom with an air or water background with repetitive motion amplitudes of 0–30 mm. The PET data were reconstructed with attenuation correction (AC) based on CT images obtained by slow CT scanning (SCS) or helical CT scanning (HCS). The errors in measured SUV max and volumes calculated using SUV threshold values based on SUV max (TH max) in experiments performed with varying extents of respiratory motion and AC were analysed.


          A partial volume effect (PVE) was not observed in spheres with diameters of ≥ 28 mm. When calculating SUV max and TH max, using SCS for AC yielded smaller variance than using HCS ( p < 0.05). For spheres of 37- and 28-mm diameters in the phantom with either an air or water background, significant differences were observed when mean TH max of 30-, 20-, or 10-mm amplitude were compared with the stationary conditions ( p < 0.05). The average TH max values for 37-mm and 28-mm spheres with an air background were 0.362 and 0.352 in non-motion, respectively, and the mean TH max values for 37-mm and 28-mm spheres with a water background were 0.404 and 0.387 in non-motion and 0.244 and 0.263 in motion, respectively. When the phantom background was air, regardless of sphere concentration or size, TH max was dependent only on motion amplitude.


          We found that there was no PVE for spheres with ≥ 28-mm diameters, and differences between SUV max and TH max were reduced by using SCS for AC. In the head-and-neck and the abdomen, the standard values of TH max were 0.25 and 0.40 with and without respiratory movement, respectively. In the lungs, the value of TH max became the approximate expression depending on motion amplitude.

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          Most cited references 27

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          Segmentation of lung lesion volume by adaptive positron emission tomography image thresholding.

           H. Yeung,  Y Erdi,  O Mawlawi (1997)
          It is common protocol in radionuclide therapies to administer a tracer dose of a radiopharmaceutical, determine its lesion uptake and biodistribution by gamma imaging, and then use this information to determine the most effective therapeutic dose. This treatment planning approach can be used to quantitate accurately the activity and volume of lesions and organs with positron emission tomography (PET). In this article, the authors focus on the specification of appropriate volumes of interest (VoI) using PET in association with computed tomography (CT). The authors have developed an automatic image segmentation schema to determine the VoI of metastases to the lung from PET images, under conditions of variable background activity. An elliptical Jaszczak phantom containing a set of spheres with volumes ranging from 0.4 to 5.5 mL was filled with F-18 activity (2-3 microCi/mL) corresponding to activities clinically observed in lung lesions. Images were acquired with a cold background and then with variable source-to-background (S/B) ratios of: 7.4, 5.5, 3.1, and 2.8. Lesion VoI analysis was performed on 10 patients with 17 primary or metastatic lung lesions, applying the optimum threshold values derived from the phantom experiments. Initial volume estimates for lung lesions were determined from CT images. Approximate S/B ratios were obtained for the corresponding lesions on F-18-fluoro-2-deoxy-D-glucose (18FDG)-PET images. From the CT estimate of the lesion size and the PET estimate of the S/B ratio, the appropriate optimum threshold could be chosen. The threshold was applied to the PET images to obtain lesion activity and a final estimate of the lesion volume. Phantom data analysis showed that image segmentation converged to a fixed threshold value (from 36% to 44%) for sphere volumes larger than 4 mL, with the exact value depending on the S/B ratios. For patients, the use of optimum threshold schema demonstrated a good correlation (r = 0.999) between the initial volume from CT and the final volume derived from the 18FDG-PET scan (P < 0.02). The mean difference for those volumes was 8.4%. The adaptive thresholding method applied to PET scans enables the definition of tumor VoI, which hopefully leads to accurate tumor dosimetry. This method can also be applied to small lesions (<4 mL). It should enable physicians to track objectively changes in disease status that could otherwise be obscured by the uncertainties in the region-of-interest drawing, even when the scans are delineated by the same physician.
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            Use of PET and PET/CT for radiation therapy planning: IAEA expert report 2006-2007.

            Positron Emission Tomography (PET) is a significant advance in cancer imaging with great potential for optimizing radiation therapy (RT) treatment planning and thereby improving outcomes for patients. The use of PET and PET/CT in RT planning was reviewed by an international panel. The International Atomic Energy Agency (IAEA) organized two synchronized and overlapping consultants' meetings with experts from different regions of the world in Vienna in July 2006. Nine experts and three IAEA staff evaluated the available data on the use of PET in RT planning, and considered practical methods for integrating it into routine practice. For RT planning, (18)F fluorodeoxyglucose (FDG) was the most valuable pharmaceutical. Numerous studies supported the routine use of FDG-PET for RT target volume determination in non-small cell lung cancer (NSCLC). There was also evidence for utility of PET in head and neck cancers, lymphoma and in esophageal cancers, with promising preliminary data in many other cancers. The best available approach employs integrated PET/CT images, acquired on a dual scanner in the radiotherapy treatment position after administration of tracer according to a standardized protocol, with careful optimization of images within the RT planning system and carefully considered rules for contouring tumor volumes. PET scans that are not recent or were acquired without proper patient positioning should be repeated for RT planning. PET will play an increasing valuable role in RT planning for a wide range of cancers. When requesting PET scans, physicians should be aware of their potential role in RT planning.
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              18F-FDG PET definition of gross tumor volume for radiotherapy of non-small cell lung cancer: is a single standardized uptake value threshold approach appropriate?

              PET with (18)F-FDG has been used in radiation treatment planning for non-small cell lung cancer (NSCLC). Thresholds of 15%-50% the maximum standardized uptake value (SUV(max)) have been used for gross tumor volume (GTV) delineation by PET (PET(GTV)), with 40% being the most commonly used value. Recent studies indicated that 15%-20% may be more appropriate. The purposes of this study were to determine which threshold generates the best volumetric match to GTV delineation by CT (CT(GTV)) for peripheral NSCLC and to determine whether that threshold can be generalized to tumors of various sizes. Data for patients who had peripheral NSCLC with well-defined borders on CT and SUV(max) of greater than 2.5 were reviewed. PET/CT datasets were reviewed, and a volume of interest was determined to represent the GTV. The CT(GTV) was delineated by using standard lung windows and reviewed by a radiation oncologist. The PET(GTV) was delineated automatically by use of various percentages of the SUV(max). The PET(GTV)-to-CT(GTV) ratios were compared at various thresholds, and a ratio of 1 was considered the best match, or the optimal threshold. Twenty peripheral NSCLCs with volumes easily defined on CT were evaluated. The SUV(max) (mean +/- SD) was 12 +/- 8, and the mean CT(GTV) was 198 cm(3) (97.5% confidence interval, 5-1,008). The SUV(max) were 16 +/- 5, 13 +/- 9, and 3.0 +/- 0.4 for tumors measuring greater than 5 cm, 3-5 cm, and less than 3 cm, respectively. The optimal thresholds (mean +/- SD) for the best match were 15% +/- 6% for tumors measuring greater than 5 cm, 24% +/- 9% for tumors measuring 3-5 cm, 42% +/- 2% for tumors measuring less than 3 cm, and 24% +/- 13% for all tumors. The PET(GTV) at the 40% and 20% thresholds underestimated the CT(GTV) for 16 of 20 and 14 of 20 lesions, respectively. The mean difference in the volumes (PET(GTV) minus CT(GTV) [PET(GTV) - CT(GTV)]) at the 20% threshold was 79 cm(3) (97.5% confidence interval, -922 to 178). The PET(GTV) at the 20% threshold overestimated the CT(GTV) for all 4 tumors measuring less than 3 cm and underestimated the CT(GTV) for all 6 tumors measuring greater than 5 cm. The CT(GTV) was inversely correlated with the PET(GTV) - CT(GTV) at the 20% threshold (R(2) = 0.90, P < 0.0001). The optimal threshold was inversely correlated with the CT(GTV) (R(2) = 0.79, P < 0.0001). No single threshold delineating the PET(GTV) provides accurate volume definition, compared with that provided by the CT(GTV), for the majority of NSCLCs. The strong correlation of the optimal threshold with the CT(GTV) warrants further investigation.

                Author and article information

                Radiat Oncol
                Radiat Oncol
                Radiation Oncology (London, England)
                BioMed Central (London )
                8 January 2015
                8 January 2015
                : 10
                : 1
                [ ]Department of Radiological Technology, Public Central Hospital of Matto Ishikawa, 3-8, Kuramitsu, Hakusan City, Ishikawa Pref 924-8588 Japan
                [ ]Department of Quantum Medical Technology, Division of Health Sciences, Graduate School of Medical Science, Kanazawa University, Ishikawa, Japan
                [ ]PET Imaging Center, Public Central Hospital of Matto Ishikawa, Ishikawa, Japan
                [ ]Department of Nuclear Medicine, Kanazawa University Hospital, Ishikawa, Japan
                © Kawakami et al.; licensee BioMed Central. 2014

                This is an Open Access article distributed under the terms of the Creative Commons Attribution License (, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver ( applies to the data made available in this article, unless otherwise stated.

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                Oncology & Radiotherapy

                pet/ct, btv, respiratory motion, itv, attenuation correction


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