Elsevier

PET Clinics

Volume 9, Issue 2, April 2014, Pages 117-127
PET Clinics

Standardization and Quantification in FDG-PET/CT Imaging for Staging and Restaging of Malignant Disease

https://doi.org/10.1016/j.cpet.2013.10.003Get rights and content

Section snippets

Key points

  • FDG-PET/CT is evolving from a valid qualitative clinical tool to a quantitative clinical and research tool.

  • The requisites for quantification in FDG-PET/CT include standardization of protocols, equipment, QC procedures of the equipment, validated postprocessing software, and qualified staff.

  • When using serial standardized uptake value measurements to assess response to therapy, imaging should be performed on the same scanner using the same image acquisition and reconstruction protocols.

  • Various

Quantification with SUV measurements in FDG-PET/CT studies

SUV represents an index for FDG accumulation in tissue. Quantitative FDG-PET using SUV was introduced in the early 1990s by Strauss and Conti.10 In 1993 Wahl and colleagues11 published an initial report describing a rapid and significant decline in SUV in responder women with newly diagnosed breast cancer treated with chemo- and/or hormonotherapy. Since then, numerous studies have been published showing the usefulness of SUV for monitoring response or predicting outcome in most FDG avid tumors.

Assessment of treatment response in oncology with FDG-PET/CT using SUV measurements

Current response evaluation criteria in solid tumors (RECIST) rely mainly on anatomic size of the tumor. The changes after treatment are categorized in 4 types of response: complete response, partial response, stable disease, and progressive disease.19 The RECIST guidelines can be used successfully to monitor treatments that are able to shrink tumor lesions, such as cytotoxic agents. However, they have major limitations, especially in evaluating early effects to therapy or new targeted

Quantification in FDG-PET: the requisites

The requisites for quantification in FDG-PET/CT include standardization of protocols, quality control (QC) procedures of equipment, image quality analysis, adequate postprocessing tools, and qualified staff.

Errors in quantification in FDG-PET/CT: what can we do?

Factors affecting quantification (SUVs) and their impact have been discussed extensively in numerous articles. Briefly, errors have been categorized as technical, physical, and biological (Fig. 4),16, 35 which are explained in the following section to avoid or minimize their impact.

FDG-PET/CT in multicentric clinical trials

Standardization of protocols in PET/CT centers facilitates participation in multicentric clinical trials.

There are several kinds of PET/CT accreditation bodies that grant acceptance of PET/CT centers after a technical evaluation of the site information: equipment (including quality assurance [QA]), capabilities of electronic transfer, and the standard of care. The submission of a phantom scan is usually required periodically to check accuracy of the scanner SUV calibration.50, 51

Official

Summary and next steps

FDG-PET/CT is evolving from a valid qualitative clinical tool to a quantitative clinical and research tool.

The present article reviews the requisites for quantification in FDG-PET/CT that include standardization of protocols, equipment QC procedures of the equipment, validated postprocessing software, and qualified staff. When using serial SUV measurements to assess response to therapy, imaging should be performed on the same scanner using the same image acquisition and reconstruction

Acknowledgments

We would like to thank all the professionals involved in standardization and quantification in our institution. We are very grateful to Manel Roca, M. Angels Hernández, and Rafael Puchal for their contribution in setting up and maintaining the standardized protocols in radiopharmacy. We would also like to thank Cristina Picón and Ismael Sancho from the Medical Physics Department for their support. Finally, we would like to express much appreciation for the commitment of physicians,

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