High Quality PET/CT High Quality PET/CT Report ElementsReport Elements

And PET/CT team steps learningAnd PET/CT team steps learning

2010 4.7 2010 4.7 高價健檢篩癌 沒必高價健檢篩癌 沒必要要 !!

和信醫院二十週年黃達夫院長說例行性篩檢更可靠不承擔風險 !

沒必要沒必要 !! 那我們這些儀器與人如何那我們這些儀器與人如何 ??

Don’t worry, be happy. Don’t worry, be happy. We have our knowledge andWe have our knowledge and

confidence!confidence!

We fight for and service for our We fight for and service for our patients as well as for our patients as well as for our clinical doctors. Don’t be afraid!clinical doctors. Don’t be afraid!

其實早在二年前核醫月會 其實早在二年前核醫月會 tumtumor scanor scan 演講中我已提到演講中我已提到 :: 先做低階檢查再做高階正子檢查先做低階檢查再做高階正子檢查 ex. GI tumor: occult blood ;tumor maex. GI tumor: occult blood ;tumor ma

rker; sonography; endoscopic biopsy rker; sonography; endoscopic biopsy and even CT, MRI, coloscopy are firsand even CT, MRI, coloscopy are firstly chosen before doing PET scan or tly chosen before doing PET scan or tumor scan because the problem of tumor scan because the problem of FDG uptake, for lymph node metastaFDG uptake, for lymph node metastases it is not bad study.ses it is not bad study.

PET/CTPET/CT 風險風險 :: 隨時間久我們愈知隨時間久我們愈知愈多其偽陽性與偽陰性愈知不可膨愈多其偽陽性與偽陰性愈知不可膨風風

Low to intermediate pt FDG avidLow to intermediate pt FDG avid Exposure to high dose radiationExposure to high dose radiation Suggestion of biopsy or others.Suggestion of biopsy or others. High price study in normal pt.High price study in normal pt. Misleading clinician wrong direction.Misleading clinician wrong direction. Even suggest surgery; biopsy but exposurEven suggest surgery; biopsy but exposur

e pt to near unrecovery situation.e pt to near unrecovery situation. Non FDG avid tumor: prostate;BACNon FDG avid tumor: prostate;BAC hepatoma, GIST,NET,teratoma…hepatoma, GIST,NET,teratoma… (for C11-Acetate PET has advantage over(for C11-Acetate PET has advantage over F18-DG in false negative studies). F18-DG in false negative studies). For normal and healthy patient, PET/CT?For normal and healthy patient, PET/CT?

Shin Kon hospital PET/CTShin Kon hospital PET/CT

1.1% screening rate for cancer1.1% screening rate for cancer 5% false positive rate annually.5% false positive rate annually. >0.5 cm tumor about 10 mSv.>0.5 cm tumor about 10 mSv. MRI is good at no radiation butMRI is good at no radiation but

poor detection in lung, GI and copoor detection in lung, GI and colon cancer.lon cancer.

Family history is important.Family history is important.

False positive findingsFalse positive findings

InflammationInflammation Lymphadenopathy.Lymphadenopathy. OvulationOvulation Brown fatBrown fat Post radiotherapy in oral cancer.Post radiotherapy in oral cancer. Fibrosis or any increased metabFibrosis or any increased metab

olic activity non cancer situation.olic activity non cancer situation.

醫病新觀念醫病新觀念 :: 人不是物體人不是物體 ,, 醫生不醫生不能只考慮修復身體能只考慮修復身體 ,, 不同人對自己不同人對自己的身體有不同的感受的身體有不同的感受 ,, 醫師必需了醫師必需了解進而尊重這些不同的觀念進而將解進而尊重這些不同的觀念進而將之放進醫病關係中之放進醫病關係中 .. 醫療勢必要從醫療勢必要從一種權威的命令一種權威的命令 ,, 控制朝雙向協商控制朝雙向協商 ,,理解的服務本質調整理解的服務本質調整 ,, 使病人相信使病人相信與安心與安心 ,, 試想若我們的報告作到連試想若我們的報告作到連病人都瞭解那麼更何況臨床醫師病人都瞭解那麼更何況臨床醫師 !!(quality).(quality).

According to PET PROS According to PET PROS (professional resources and (professional resources and outreach source) guideline(SNM)outreach source) guideline(SNM)

高價健檢高價健檢 ,, 身體擔風險身體擔風險 .. 美國多年來一直不贊成健檢用美國多年來一直不贊成健檢用 PEPE

T/CTT/CT 原因就在此原因就在此 .. 尚未克服尚未克服 false positive and falsefalse positive and false negative problem in FDG.negative problem in FDG. 但是既然經已經做了我們應該給但是既然經已經做了我們應該給

病人與醫師最盡心適合的報告病人與醫師最盡心適合的報告 !!

Elements of PET/CT report:Elements of PET/CT report:

Clinical history(3+5)Clinical history(3+5) Procedure(7+3+2)Procedure(7+3+2) Comparison(2)Comparison(2) Findings(3)Findings(3) ImpressionImpression Sample normal reportsSample normal reports

Clinical history(3+5) Clinical history(3+5) Indication for study: tumor type ;abnIndication for study: tumor type ;abn

ormality to be evaluated, and specifiormality to be evaluated, and specific clinical question: (For diagnosis,stac clinical question: (For diagnosis,staging,restaging,response to therapy).ging,restaging,response to therapy).

Relevant history: biopsy results, cheRelevant history: biopsy results, chemotherapy,radiotherapy, other treatmotherapy,radiotherapy, other treatment; medical/surgery history.ment; medical/surgery history.

Information needed for billing:ex. IndInformation needed for billing:ex. Indeterminate nodule found on chesteterminate nodule found on chest

CT, PET/CT for solitary pulm. noduleCT, PET/CT for solitary pulm. nodule

Procedure(7+3+2) Procedure(7+3+2) PET/CT radiopharmaceutical; dose;PET/CT radiopharmaceutical; dose;

route and injection site; scan cover route and injection site; scan coverage;uptake time; serum blood sugaage;uptake time; serum blood sugar level; medicationr level; medication

CT noncontrast, iodinated iv contraCT noncontrast, iodinated iv contrast type and amount,oral contrast tyst type and amount,oral contrast type and amount.pe and amount.

Notes: explanation for deviationNotes: explanation for deviation from standart protocol; special txfrom standart protocol; special tx like O2 supplement, treatment of colike O2 supplement, treatment of co

ntrast reaction.ntrast reaction.

For PET/CT procedureFor PET/CT procedure

Scan field for reginal or whole body scScan field for reginal or whole body scan should describe beginning and endian should describe beginning and ending anatomic region. A range of 60 to 9ng anatomic region. A range of 60 to 90 mins is between injection to scanning.0 mins is between injection to scanning. Localization time shorter or longer tha Localization time shorter or longer than ususal should be mentioned.n ususal should be mentioned.

Blood sugar level should be comply with Blood sugar level should be comply with ACR guidelines. For interpretation of cACR guidelines. For interpretation of current study, we can also have this at durrent study, we can also have this at delayed scanelayed scan

For medication and For medication and interventionintervention

Protocol like anxiolytics and fusoseProtocol like anxiolytics and fusosemide the type, dose, and route admimide the type, dose, and route administration should be noted. Any iv anistration should be noted. Any iv as procedure should be described, lis procedure should be described, like urinary catheter. Any oral premeke urinary catheter. Any oral premedicationdication

regimen should be noted.regimen should be noted.Other details.4D R/T; dedicated brain Other details.4D R/T; dedicated brain

imaging, or any delayed additional aimaging, or any delayed additional acquisitions. Or immobilization deviccquisitions. Or immobilization devices should be mentioned.es should be mentioned.

For CT procedureFor CT procedure

For low dose CT(non diagnostic CFor low dose CT(non diagnostic CT) should mentioned the details to T) should mentioned the details to the technique used 40 mAs,120 kthe technique used 40 mAs,120 kVp.Vp.

For anatomical localization for non For anatomical localization for non FDG avid site like soft tissue masFDG avid site like soft tissue mass or cystic lesions, the tissue of chs or cystic lesions, the tissue of characterization by density, or patteraracterization by density, or pattern of enhancement should be n of enhancement should be

metioned at compasion with PET.metioned at compasion with PET.

Additional notes.Additional notes.

Any adverse reation and treatment Any adverse reation and treatment should be noted. Any deviation froshould be noted. Any deviation from standard protocol should be inclm standard protocol should be included in the official report.uded in the official report.

Detail of such interventions are alsDetail of such interventions are also typically kept in a separate nurseo typically kept in a separate nurse’s note or incident report.’s note or incident report.

Comparison(2)Comparison(2)

Prior PET or PET/CT studies. Prior PET or PET/CT studies. Dates should be described for Dates should be described for comparisoncomparison

Other studies: CT;MRI; Other studies: CT;MRI; mammography and nuclear mammography and nuclear medicine.or even plain film…medicine.or even plain film…

Findings(3)Findings(3)

Order of importance formatOrder of importance format Anatomic site formatAnatomic site format Hybrid formatHybrid format According to priority and anatomic site for According to priority and anatomic site for

dominant findings (TNM or primary lesion dominant findings (TNM or primary lesion or recurrent disease); metastases (nodal oor recurrent disease); metastases (nodal or extranodal site of metastases) and other r extranodal site of metastases) and other abnormal PET findings (like second primarabnormal PET findings (like second primary tumors or diffuse thyroid activity). Incidey tumors or diffuse thyroid activity). Incidental CT findings: lung nodule w/o FDG uptntal CT findings: lung nodule w/o FDG uptake, renal massake, renal mass

Normal physiologic FDG uptake: brown faNormal physiologic FDG uptake: brown fat; prominent muscle or intestinal uptake.t; prominent muscle or intestinal uptake.

Anatomic site formatAnatomic site format Begin with significant PET and CT Begin with significant PET and CT

findings and follow by relevant CT findings and follow by relevant CT onlyonly

findings and incidental observations. findings and incidental observations. ForFor

each Head and neck; chest; each Head and neck; chest; abdomen and pelvis; abdomen and pelvis; musculoskeletal.musculoskeletal.

Synthesis of priority and anatomic Synthesis of priority and anatomic site(combination:assures of overall site(combination:assures of overall structure and consistency) and structure and consistency) and general report notes(RADLEX).general report notes(RADLEX).

General reporting notes.General reporting notes.

Or RECIST: size measurementsOr RECIST: size measurements in 2 or 3 orthogonal directions, ain 2 or 3 orthogonal directions, a statement that it is in the short or long statement that it is in the short or long

axis. Do not let your report led to axis. Do not let your report led to confusion and frustration of the confusion and frustration of the clinicians by different measurement of clinicians by different measurement of PET or CT in tumor size, especially.PET or CT in tumor size, especially.

Assure a consistency message.Assure a consistency message. PET and CT report are read PET and CT report are read

independently!independently!

ImpressionImpression It is most important because most It is most important because most

clinician start to read your report only clinician start to read your report only at this! It is essentialat this! It is essential

that all the important informationthat all the important information discovered in the study is presented discovered in the study is presented

here in a clear and succinct way. here in a clear and succinct way. Brief with concise; answer clinical Brief with concise; answer clinical question; give a precise diagnosis; question; give a precise diagnosis; when it is not possible, a clear and when it is not possible, a clear and organized differential diagnosis organized differential diagnosis should be given. It may be should be given. It may be appropriate to discuss the use of appropriate to discuss the use of additional imaging study or follow up.additional imaging study or follow up.

colloquialcolloquial Definite evidence of malignancyDefinite evidence of malignancy Probable malignancy in … Probable malignancy in …

without evidence of metastases.without evidence of metastases. For follow up scans after For follow up scans after

therapy, both metabolic therapy, both metabolic response and anatomic response and anatomic response should be commented.response should be commented.

If appear benign, Negative study If appear benign, Negative study for malignancy is better than no for malignancy is better than no evidence for active malignancy evidence for active malignancy because can be misinterpreted because can be misinterpreted by the referring physician.by the referring physician.

Certain terminology: must Certain terminology: must care be exercised…care be exercised…

Absent; excludes; unlikely, probable, Absent; excludes; unlikely, probable, certain and definite are common used in certain and definite are common used in referring physician, but other terms are referring physician, but other terms are understood quite differently likeunderstood quite differently like

:unlikely, highly suggestive, compatible :unlikely, highly suggestive, compatible with or worrisome orwith or worrisome or

suspicious. Clinician most like:suspicious. Clinician most like: definitely benign; probably benigndefinitely benign; probably benign equivocal, probably malignant orequivocal, probably malignant or almost certainly malignant or definitely almost certainly malignant or definitely malignant.malignant.

Vague language only confuses Vague language only confuses the referring physician and can the referring physician and can result in sub-optimal patient care.result in sub-optimal patient care. Definite finding use right and specific Definite finding use right and specific

words. Uncertainty should also words. Uncertainty should also essential that the uncertainty be essential that the uncertainty be clearly communicated..knowing this clearly communicated..knowing this limitation of imaging studies andlimitation of imaging studies and

result must be taken in context of result must be taken in context of each situation, help clinician convey each situation, help clinician convey the necessary information and the necessary information and without causing unnecessary anxiety without causing unnecessary anxiety to the patient. to the patient.

Sample normal reports:1+1Sample normal reports:1+1

Synthesis of priority and anotomic sitSynthesis of priority and anotomic site styles, e styles,

Even neither pt had PET findings suEven neither pt had PET findings suggesting disease recurrency, there is ggesting disease recurrency, there is still a number of relevant positive anstill a number of relevant positive and negative findings conveyed in each d negative findings conveyed in each report. case 1:negative have to do wireport. case 1:negative have to do with lymph nodes and spleen. Case 2: th lymph nodes and spleen. Case 2: SPN though negative on PET, there iSPN though negative on PET, there is still TNM to chest subsection frames still TNM to chest subsection framed in context.d in context.

Sample normal reports:1+1 Sample normal reports:1+1

Sample normal reports:1+1Sample normal reports:1+1

PET CT Reporting Form PET CT Reporting Form

Famous center PET CT ReportiFamous center PET CT Reporting Formng Form

Report accuracy rate list below:Report accuracy rate list below:

doctor introductiondoctor introduction

論論 PET/CT center PET/CT center 之團之團隊合作與醫病新關係隊合作與醫病新關係

How to reconstruction your gr?How to reconstruction your gr?

Team work for PET/CT centerTeam work for PET/CT center

Assessment what?Assessment what?

Many things you can guess!Many things you can guess!

Persistent monitoring for:Persistent monitoring for:

Delegation are sharing order.Delegation are sharing order.

Open mind and feedback in Open mind and feedback in time. Solve problems.time. Solve problems.

Routine and daily life.Routine and daily life.