Essential Elements of 18F-FDG PET/CT Reporting
Element | Description |
Clinical history | Indication for study |
Cancer type and site, if applicable | |
Brief review of treatment history, if applicable | |
Technique/procedure | Radiopharmaceutical name |
Radiopharmaceutical dose/activity | |
Route of radiopharmaceutical administration | |
Uptake time (i.e., from radiopharmaceutical injection to imaging) | |
Blood glucose level | |
Ancillary medications administered, if applicable | |
Precise body region scanned | |
CT technique (including whether oral or intravenous contrast was used; if used, name and volume of agent) | |
Comparison studies | Whether comparison was made with prior PET or PET/CT studies; include dates when available |
Whether correlation was made with prior non-PET imaging studies (e.g., CT or MR imaging); include dates when available | |
Findings | Location, size/extent, and intensity of sites of abnormal 18F-FDG uptake |
Abnormal PET findings correlated with concurrent CT images or correlative imaging studies, if applicable | |
Incidental PET findings | |
Incidental CT findings | |
Impression | Clear identification of study as normal vs. abnormal |
Interpretation of findings, rather than just restatement of findings | |
Succinct differential diagnosis provided, if applicable | |
Recommendations for follow-up studies, if applicable | |
Documentation of communication of urgent or emergent findings to referring physician or surrogate |