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FDG-PET/CT is evolving from a valid qualitative clinical tool to a quantitative clinical and research tool.
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The requisites for quantification in FDG-PET/CT include standardization of protocols, equipment, QC procedures of the equipment, validated postprocessing software, and qualified staff.
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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.
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Various
Standardization and Quantification in FDG-PET/CT Imaging for Staging and Restaging of Malignant Disease
Section snippets
Key points
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,
References (53)
- et al.
Measurement of clinical and subclinical tumour response using [18F]-fluorodeoxyglucose and positron emission tomography: review and 1999 EORTC recommendations. European organization for research and treatment of cancer (EORTC) PET study group
Eur J Cancer
(1999) - et al.
Tumor treatment response based on visual and quantitative changes in global tumor glycolysis using PET-FDG imaging. The visual response score and the change in total lesion glycolysis
Clin Positron Imaging
(1999) - et al.
New response evaluation criteria in solid tumours: revised RECIST guideline (version 1.1)
Eur J Cancer
(2009) - et al.
Utilidad de la PET-TC en la valoración de la respuesta precoz al tratamiento en el linfoma B difuso de célula grandes. Resultados preliminares
Rev Esp Med Nucl Imagen Mol
(2012) - et al.
18F-fluorodeoxyglucose positron emission tomography in evaluating treatment response to imatinib or other drugs in gastrointestinal stromal tumors: a systematic review
Clin Imaging
(2012) - et al.
Accuracy of the Easytouch blood glucose self-monitoring system: a study of 516 cases
Clin Chim Acta
(2004) - et al.
FDG dose extravasations in PET/CT: frequency and impact on SUV measurements
Front Oncol
(2011) - et al.
Strategies for motion tracking and correction in PET
PET Clin
(2007) Use of dual-point fluorodeoxyglucose imaging to enhance sensitivity and specificity
Semin Nucl Med
(2012)- et al.
Initial experience with the EANM accreditation procedure of FDG PET/CT devices
Eur J Cancer
(2011)
Recommendations on the use of 18F-FDG PET in oncology
J Nucl Med
Intensity of 18fluorodeoxyglucose uptake in positron emission tomography distinguishes between indolent and aggressive non-Hodgkin's lymphoma
J Clin Oncol
Correlating metabolic activity on 18F-FDG PET/CT with histopathologic characteristics of osseous and soft-tissue sarcomas: a retrospective review of 136 patients
AJR Am J Roentgenol
18F-FDG PET of common enhancing malignant brain tumors
AJR Am J Roentgenol
Is quantitation necessary for oncological PET studies? For
Eur J Nucl Med Mol Imaging
Methodological considerations in quantification of oncological FDG PET studies
Eur J Nucl Med Mol Imaging
Report on the first international workshop on interim-PET scan in lymphoma
Leuk Lymphoma
Comparison of F-18 FDG and C-11 methionine PET/CT for the evaluation of recurrent primary brain tumors
Clin Nucl Med
The applications of PET in clinical oncology
J Nucl Med
Metabolic monitoring of breast cancer chemohormonotherapy using positron emission tomography: initial evaluation
J Clin Oncol
Bone metastases in patients with metastatic breast cancer: morphologic and metabolic monitoring of response to systemic therapy with integrated PET/CT
Radiology
Standard uptake value predicts survival in non-small cell lung cancer
Ann Thorac Surg
Impact of maximum standardized uptake value (SUVmax) evaluated by 18-Fluoro-2-deoxy-D-glucose positron emission tomography/computed tomography (18F-FDG-PET/CT) on survival for patients with advanced renal cell carcinoma: a preliminary report
BMC Cancer
Maximum standard uptake value of 18F-fluorodeoxyglucose positron emission tomography is a prognostic factor for progression-free survival of newly diagnosed patients with diffuse large B cell lymphoma
Ann Hematol
A systematic review of the factors affecting accuracy of SUV measurements
AJR Am J Roentgenol
18F-FDG PET/CT as an indicator of progression-free and overall survival in osteosarcoma
J Nucl Med
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The authors have nothing to disclose.