Discussion Points

Thursday April 3

• FDG Uptake time: 60 minutes, 90 minutes , 2 hours or beyond, best overall compromise, any cancers for which extended uptake time should be routine
• Patient activity during and before the FDG uptake period, when is it OK for people to get up and around after FDG infusion for body oncology studies
• Should everyone get a sedative or anxiolytic, or which particular patients
• Does an all protein diet the day before the scan really suppress heart uptake
• Special instructions for head & neck cancer patients (no talking/swallowing), when before and after FDG infusion
• IV for injecting FDG, should an IV always be placed
• Same IV or different IV for contrast
• When to give the oral contrast, how to get uniform opacification
• Getting patients to hold still during the scan, should restraints be used
• Dealing with diabetics, fasting, insulin, ect.
• Patients on insulin pumps
• Brown fat uptake. Warm room, warm blankets, anxiolytics vs beta blockers
• Hydration: oral vs IV, how much
• Hydration/Lasix for getting urinary tracer activity down
• PET imaging time per bed position for body studies vs neck
• Matrix for body vs neck (128 vs 256) PET acquisition
• Crainocaudad vs caudocranial PET acquisition for different disease indications
• dual time point for lung nodules vs extrapulmonary findings
• dual time point vs routine long uptake time
• Breath holding for small pulmonary nodules. Do you really need a full inspiration breath hold or is an on-the-fly mid expiratory breath hold OK on current 16+ CTs
• If you need a full inspiration breath hold, for which cancers (for lung cancer, sarcomas, rectal but not lymphoma, for example)
• Is quiet breathing OK, on 16 to 64 slice CT for say, lymphoma
• Should arms be up as much as possible
• How much beam current do you really need for the lungs, how much detail of the pulmonary markings need to be seen. Is under 200 mA OK, under 100 mA and how does this relate to determining if a pulmonary nodule is speculated, detecting fat planes, ect.
• If lymph node size is important in staging (that is if the node is enlarged even if it is not abnormal on the PET images, it is still suspicious), then do you need IV contrast to properly assess lymph node size in the mediastinum, the hila. Does T-staging lung, esophageal, breast, require IV contrast
• For restaging is lymph node size important, necrosis, extanodal spread, and is IV contrast important here as well
• Bronchoavelolar carcinoma: how much image quality to characterize, is breath hold required
• Slice thickness of images for the lungs
• Is interstitial spread of tumor really an issue requiring high detail lung images
• Should there always be lung algorithm recon images made, not just soft tissue algo
• if a separate breath hold acquisition is performed, should this be precontrast or during arterial phase
• IV contrast abdomen and pelvis- but how much and what phases. Is portal venous phase enough. Any need for 3 minute delay scans through kidneys
• What diseases should a late arterial phase be added to a portal venous phase
• How much beam current is needed for abdomen, esp in light of detecting small liver lesions, seeing peritoneal carcinomatosis, peritoneal implants, ect
• Should the entire colon be entirely opacified with positive oral contrast, any diseases in which this should be the case colon
• Negative oral contrast, does it require IV to work best
• Efforts to reduce bladder tracer activity: catheter vs hydration with Lasix, which diseases should reduction of bladder tracer activity be routine
• Recon slice thickness for Abdomen and Pelvis (noise vs slice thickness vs detail)
• Breath hold for the abdomen and pelvis, is on the fly mid expiratory OK or do you really need a full expiratory breath hold
• Any special recons other than soft tissue algorithm
• For dedicated head & neck PET/CT, how sharp do the CT images have to be, as sharp as a CT alone, how much beam current should be used
• IV contrast: should this be used always for staging, for restaging
• Bolus timing for IV contrast, best way to insure venous and arterial opacification
• how important is tumor blush from IV contrast in determining T stage in head and neck, should the amount of IV contrast used be based on getting good pathologic tumor blush
• how important is IV contrast in assessing extranodal spread in head and neck
• Slice thickness reconstruction and image recon algorithm for neck
• Preferred window and level settings for reviewing CT part of PET/CT with neck
• Proper head position for head & neck cancer PET/CT acquisition
• What to do about tooth amalgam artifact. Scan twice with different head positions?
• Difference between and dedicated neck CT acquisition and neck as part of a whole torso exam, that is, what is acceptable CT technique with say routine lymphoma vs primary head and neck cancer (CT zoom, head positioning, arms up vs down, ect)
• When can you scan just the neck and when do you add on an additional chest or whole torso PET/CT for a primary head & neck cancer (squamous vs other cell types)
• Positive oral contrast: thin barium vs water soluble, which preferred for which patients
• Density and distribution problems with oral contrast, how do you get uniform opacification in small bowel since you have captive patient for 60+ minutes .
• Negative oral contrast, does it work better with IV contrast
• Positive vs negative oral contrast in thin people with no internal fat
• Rectal contrast-which situations should it be used
• Stomach, should it be distended with contrast or water routinely
• Total IV contrast load (volume and iodine content) when doing a torso scan, dedicated head & neck acquisition
• When is too much IV contrast enhancement
• IV contrast infusion rates. When to do rates higher than 3 ml/sec
• Contrast enhanced CT for attenuation correction. Can this be used routinely and would problems be expected at high (4 or 5 ml/sec) infusion rates
• Eliminating venous contrast related artifacts in the infusion route deep veins, saline chase vs caudocranial scan
• Chasing the contrast bolus: methods to maintain equal venous and arterial opacification over entire torso scanned
• Would it be helpful to have the contrast injector integrated into the PET/CT operating system, or is a separate unit not too much trouble
• are there different work flow schemes such as doing the image archiving at the end of the day? Is PACS make things easier or harder
• how important is image recon time, does that really gum things up if it is slow
• is FDG uptake time get in the way, so even if we want to go longer it gums things up
• table and restraint devices needed of RT planning scans
• lasers for positioning, do you really need them
• scanner gantry width, is more really needed, how wide would be enough
• scanning protocols, do the RT folks want things different in terms of image quality and use of contrast
• respiratory gating, a necessity-for which type of RT planning is gating needed
• image recon formats needed for RT planning
• feature that would facilitate moving images from PET/CT to the RT planning software
• how RT planning scans change work flow and timing
• coordinating patient throughput in a busy center and the nature of ancillary individuals (assistants, nurses, ect) needed to help. What sort of things from industry (scanners, FDG suppliers) would help make thing better and more efficient
• dual time point or high count scanning, changes in work flow design to accommodate
• are there different work flow schemes such as doing the image archiving at the end of the day? Is PACS make things easier or harder?
• how important is image recon time, does that really complicate throughput and work efficiency if image recon time is long. How long is too long for image recon time
• is FDG uptake time get in the way, even if you have enough uptake rooms, by requiring extended patient monitoring
• monitoring devices in scanners needed to improve patient safety and work efficiency
• coordinating patient throughput, including interview, injection, uptake period management, scan, post scan management.
• what are the roles of the technologist vs some things others could be doing to help out, roughly how many technologists and ancillary personnel do you need per scanner

Friday April 4

Axial Coverage on PET/CT

Is there greater axial coverage than really needed due to the PET/CT CT code descriptors?