Jnm112177 1.6

Journal of Nuclear Medicine, published on April 10, 2013 as doi:10.2967/jnumed.112.112177
Reporting Guidance for Oncologic 18F-FDG PET/CT Imaging Ryan D. Niederkohr1, Bennett S. Greenspan2, John O. Prior3, Heiko Schöder4, Marc A. Seltzer5,Katherine A. Zukotynski6,7, and Eric M. Rohren8 1Department of Nuclear Medicine, Kaiser Permanente Medical Center, Santa Clara, California; 2Department of Radiology, MedicalCollege of Georgia/Georgia Regents University, Augusta, Georgia; 3Department of Nuclear Medicine, Lausanne University Hospital,Lausanne, Switzerland; 4Department of Radiology, Memorial Sloan-Kettering Cancer Center, New York, New York; 5Department ofRadiology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire; 6Department of Medical Imaging, University of Toronto,Toronto, Ontario, Canada; 7Department of Radiology, Harvard Medical School, Boston, Massachusetts; and 8Department ofDiagnostic Radiology and Nuclear Medicine, University of Texas M.D. Anderson Cancer Center, Houston, Texas Learning Objectives: On successful completion of this activity, participants should be able to discuss (1) the elements of a concise and complete oncologic18F-FDG PET/CT report; (2) the importance of obtaining and including in the report a focused history of the patient malignancy and treatments; and (3) theimportance of interpreting both the 18F-FDG PET and the CT findings of PET/CT and of integrating both the metabolic and the anatomic components in thereport.
Financial Disclosure: The authors of this article have indicated no relevant relationships that could be perceived as a real or apparent conflict of interest.
CME Credit: SNMMI is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to sponsor continuing education for physicians.
SNMMI designates each JNM continuing education article for a maximum of 2.0 AMA PRA Category 1 Credits. Physicians should claim only creditcommensurate with the extent of their participation in the activity. For CE credit, participants can access this activity through the SNMMI Web site () through May 31, 2016.
addressed the topic of reporting quality in the medical lit- The written report (or its electronic counterpart) is the primary erature. Studying the process and quality of reporting not mode of communication between the physician interpreting an only is a necessity but also provides a unique opportunity to imaging study and the referring physician. The content of this examine and refine the role imaging physicians play in report not only influences patient management and clinical outcomes but also serves as legal documentation of servicesprovided and can be used to justify medical necessity, billing The number of combined PET/CT studies performed accuracy, and regulatory compliance. Generating a high-quality annually has markedly increased over the last decade. It is es- PET/CT report is perhaps more challenging than generating timated that between 2001 and 2010, the number of active a report for other imaging studies because of the complexity of PET/CT systems in the United States increased by approxi- this hybrid imaging modality. This article discusses the essential mately 10-fold (from approximately 200 to more than 2,000), elements of a concise and complete oncologic 18F-FDG PET/ and the number of PET examinations performed in the United CT report and illustrates these elements through examples States increased nearly 7-fold (from about 250,000 to more taken from routine clinical practice.
than 1.7 million) (4). At some institutions, PET/CT is now the most frequently performed nuclear medicine imaging study, surpassing myocardial perfusion imaging among others. This dramatic increase in PET/CT volume highlights the growingclinical acceptance and importance of hybrid anatomic andfunctional imaging.
At present, most PET/CT scans include imaging of the t most facilities, the written report (or its electronic neck, chest, abdomen, and pelvis. The interpreting physician counterpart) is the primary mode of communication be- must review both the PET and the CT components of the tween the physician interpreting an imaging study and the study and must integrate the anatomic and metabolic findings referring physician. This report often serves as the basis for into a single unified report. This merging of large diagnostic medical treatment decisions (1) and is used by third-party datasets from both the PET and the CT components magnifies payers to justify medical necessity for the study and validity the importance of careful and concise reporting.
of reimbursement (2). Several authors have previously In practice, PET/CT reports vary widely in format, content, and quality. This variance may, at least in part, stem from thedifferent training backgrounds of the physicians interpreting Received Jan. 16, 2013; revision accepted Mar. 29, 2013.
For correspondence or reprints contact: Ryan Niederkohr, Kaiser Permanente PET/CT studies today (i.e., primary training in diagnostic Medical Center, 700 Lawrence Expressway, Department 120, Santa Clara, CA radiology or nuclear medicine). A recent review of data from the National Oncologic PET Registry evaluated PET reports from a broad spectrum of practices throughout the United COPYRIGHT ª 2013 by the Society of Nuclear Medicine and Molecular States. The authors of this study defined “essential elements” ONCOLOGIC PET/CT REPORTING GUIDANCE • Niederkohr et al.
Copyright 2013 by Society of Nuclear Medicine.
for a PET report and found that essential elements were miss- ing guidelines for all diagnostic imaging studies (17,18). Other ing from many PET reports. Of note, certain critical elements organizations, including the World Health Organization, Na- (e.g., study indication, treatment history, comparison to prior tional Center for Health Statistics, American Medical Associ- imaging studies, and time from radiopharmaceutical injection ation (for Current Procedural Terminology coding), and to imaging) were missing from over 40% of reports (5).
Centers for Medicare and Medicaid Services (for clinical Despite the importance of proper reporting, education on laboratory improvement amendments), have additional key reporting technique varies widely among radiology and nuclear elements related to coding and billing and to justification medicine training programs (6). Reporting quality can be dif- of medical necessity (5). Table 1 provides a summary of all ½Table 1Š ficult to define and therefore difficult to teach. Nevertheless, it elements considered essential to 18F-FDG PET/CT reporting.
is clear that certain elements should be included in a PET/CTreport so that clinical, regulatory, and financial requirements are met. The objectives of this article are to describe the ele- ments of a concise and complete oncologic 18F-FDG PET/CT report and to illustrate these elements through examples taken Results in the literature suggest that the availability of clinical history increases the accuracy of radiologic imageinterpretation (19–22). When referring a patient for PET/ CT imaging, the referring physician should provide an ap- propriate indication for the study and clearly state the pri- The accuracy of image interpretation and the quality of mary clinical questions to be answered by the scan. Such the diagnostic report are critical to the continued success of information helps the interpreting physicians to provide an PET/CT in the medical community. When referring physi- accurate, clinically relevant report. When the clinical infor- cians receive a high-quality, clinically relevant report their mation provided by the referring physician is inadequate, re- confidence in (and subsequent use of) this imaging modality view of the medical record (facilitated by the increasing use may increase. Unfortunately, the converse is also true: when of electronic medical record systems) is strongly encouraged.
referring physicians receive reports that are confusing or Documentation in the report that this clinical information was contribute little to patient care, the value of PET/CT is di- reviewed informs the referring physician of the key factors minished and the test could potentially be considered un- that were considered by the physician interpreting the imag- necessary. Therefore, it is imperative that reports be of high quality, both for optimal patient outcome and for the long-term The level of detail in the clinical history section of success and viability of PET/CT as an imaging modality.
the report can vary depending on personal preference, but In addition, the imaging report should be considered the following data should be included: the indication for the a legal document that can be used as the basis for (or scan, the tumor type and site of disease, a brief statement defense of) litigation in medical malpractice cases. Issues regarding previous or ongoing treatment (e.g., chemotherapy surrounding the diagnosis of cancer (e.g., delay in cancer or the type and date of previous radiation or surgery), and any diagnosis; misdiagnosis of extent of cancer spread result- specific clinical questions raised by the referring clinician.
ing in undertreatment or unnecessary treatment; or false- Explicit use of terminology that conforms with national or positive diagnosis of cancer) are among the most common local regulatory requirements is strongly advised (e.g., Centers reasons for malpractice litigation in radiology, in addition for Medicare and Medicaid Services guidelines in the United to the appropriate detection of incidental or unexpected States favor use of terminology such as initial treatment findings (7–13). Particular attention to these questions is strategy and subsequent treatment strategy) (23). Additional needed in oncologic PET/CT imaging, because the scan pertinent medical or surgical history that may have relevance covers a large body region. Inaccurate, inadequate, or vague to PET/CT interpretation should be mentioned (e.g., sarcoido- reporting increases the imaging physician’s risk of adverse liti- sis or rheumatoid arthritis). Examples of clinical history state- gation outcomes whereas accurate, concise, and clear reporting ments include the following: “58-y-old man with diffuse large B-cell lymphoma. PET/CT performed for initial staging beforetherapy (development of initial treatment strategy)”; “68-y-old man with stage III diffuse large B-cell lymphoma, treated with 6 cycles of R-CHOP chemotherapy completed July 7, 2012.
The Society of Nuclear Medicine and Molecular Imaging PET/CT performed to assess treatment response (development (SNMMI), American College of Radiology (ACR), and of subsequent treatment strategy)”; “60-y-old woman with European Association of Nuclear Medicine (EANM) (in stage I colorectal cancer, 1 y after right hemicolectomy in June addition to national societies of individual countries) have 2011 with no adjuvant chemotherapy, now with rising CEA.
published practice guidelines specific to 18F-FDG PET and CT of the abdomen and pelvis on May 5, 2012, showed no PET/CT that list the essential elements that should be in- evidence of recurrence of metastasis. PET/CT obtained to eval- cluded in the imaging report of such studies (14–16). In uate for residual or recurrent malignancy (development of sub- addition, SNMMI and ACR have also published general report- THE JOURNAL OF NUCLEAR MEDICINE • Vol. 54 • No. 5 • May 2013 Essential Elements of 18F-FDG PET/CT Reporting Indication for studyCancer type and site, if applicableBrief review of treatment history, if applicable Radiopharmaceutical nameRadiopharmaceutical dose/activityRoute of radiopharmaceutical administrationUptake time (i.e., from radiopharmaceutical injection to imaging)Blood glucose levelAncillary medications administered, if applicablePrecise body region scannedCT technique (including whether oral or intravenous contrast was used; Whether comparison was made with prior PET or PET/CT studies; Whether correlation was made with prior non-PET imaging studies (e.g., CT or MR imaging); include dates when available Location, size/extent, and intensity of sites of abnormal 18F-FDG uptakeAbnormal PET findings correlated with concurrent CT images or correlative Incidental PET findingsIncidental CT findings Clear identification of study as normal vs. abnormalInterpretation of findings, rather than just restatement of findingsSuccinct differential diagnosis provided, if applicableRecommendations for follow-up studies, if applicableDocumentation of communication of urgent or emergent findings to propriate anatomic nomenclature. For example, at some This section documents how the study was generated so institutions some patients with cancers of the head and neck that comparison with subsequent studies can be performed.
are scanned from the skull vertex to the upper pelvis. True The following information should be included in the technique whole-body scans (often performed on patients with mela- section of every report: radiopharmaceutical name, adminis- noma or myeloma) typically extend from the skull vertex tered activity, route of administration, and uptake time (i.e., time from injection to imaging). Precise radiopharmaceu- In certain cases, PET/CT protocols may include additional tical dose (if necessary, corrected for residual activity in the acquisitions such as delayed imaging. Certain patients may syringe or intravenous tubing; for example, “9.6 mCi [355 be scanned in specific positions, such as prone positioning, or MBq]” rather than “approximately 10 mCi [370 MBq]” and using an immobilization device or face mask for radiation precise uptake time (e.g., “68 min” rather than “approxi- treatment planning. These additions to the standard PET/CT mately 60 min”) should be reported since both parameters acquisition should be described. If SUVs are reported in the affect semiquantitative measures (e.g., standardized uptake findings section of the report, the technique section should value [SUV]) and may affect comparison with future or prior specify which SUV parameter (e.g., maximum, peak, nor- studies. Any ancillary medications administered before the malized to body weight, lean body mass, or body surface study should also be listed (e.g., furosemide, 20 mg intrave- nously, given 30 min after 18F-FDG injection, or lorazepam, 1 Finally, the PET/CT report should clearly describe the CT mg orally, given 1 h before tracer injection). SNMMI, ACR, technique. In particular, the report should clearly state whether and EANM guidelines recommend measuring and reporting the CT technique was fully optimized (e.g., with full tube blood glucose levels (in units appropriate for the locale) for current and intravenous or oral contrast as appropriate) or patients undergoing 18F-FDG PET or PET/CT (14–16).
whether a low-dose, non–contrast-enhanced technique was Regardless of whether the PET/CT is coded as a limited used primarily for anatomic localization and attenuation cor- or regional study (e.g., “brain only or skull vertex through rection. If contrast was used, the type and volume of contrast adrenal glands”), “skull base to mid thigh,” or “true whole- agent should be stated. The term nondiagnostic CT should be body study (skull vertex to feet),” the actual axial coverage avoided since even low-dose, unenhanced CT scans contain of the scan should be documented in the report using ap- valuable diagnostic information that should be reported and ONCOLOGIC PET/CT REPORTING GUIDANCE • Niederkohr et al.
used in the interpretation of the PET portion of the PET/CT This format generally begins with a description of the examination. Details regarding adverse reactions to con- primary PET findings, including positive and negative trast material (including signs, symptoms, and treatment) findings that are directly relevant to the clinical question and any significant deviation from standard protocol and that describe the primary or dominant sites of disease.
should be included in the report. In some states or coun- This is followed by a description of PET findings suspected tries, the inclusion of CT parameters (i.e., kVp and mAs) to represent disease spread to regional lymph nodes or distant or patient radiation exposure estimate from the CT com- sites. Next, incidental PET findings are described (i.e., 18F- ponent of the examination (e.g., CT dose index in mGy or FDG–avid lesions suspected to represent a benign or malig- dose–length product in mGyÁcm) may be required by law.
nant process unrelated to the primary cancer being studied, Maximal SUV (based on actual body weight) is reported.
such as incidental pituitary adenoma, Warthin tumor, sus- An example technique section is as follows: pected colon polyp, or diffuse thyroidal 18F-FDG uptake sug-gestive of thyroiditis). This is followed by a description of Radiopharmaceutical: 18F FDG, 373 MBq (10.1 mCi) incidental CT findings (e.g., enlarged but non–18F-FDG-avid lymph nodes; lung abnormalities such as emphysema, pneu- Blood glucose at time of 18F-FDG injection: 95 mg/dL mothorax, and nonavid lung nodules; vascular abnormalities such as aortic dilation or aneurysm; adrenal nodules; renalmasses or stones; and gallstones). Small pulmonary nodules Time from 18F-FDG injection to scan: 65 min without visible 18F-FDG uptake should also be mentioned, as PET/CT images were acquired from the skull base through they may require follow-up. Mentioning prominent physio- the upper thighs; CT images were acquired at a 5-mm slice logic activity that is still within the range of normal variants thickness using a low tube current technique and without (e.g., gastrointestinal tract labeling or brown fat uptake) the use of oral or intravenous contrast agent Anatomic Site. Findings are organized by anatomic region (e.g., head and neck, chest, abdomen and pelvis, musculo- skeletal), with both PET and CT findings described within The interpreting physician should compare the current each anatomic subsection. Some physicians adopt a “struc- imaging study with prior studies whenever possible. Results tured” format within each section whereby individual organs in the literature have shown that comparison with prior or organ systems are routinely listed, followed by a statement imaging improves diagnostic accuracy (19,20). Even when describing the presence or absence of pathology.
the final diagnosis is uncertain, documentation of stability Hybrid. Some physicians report PET/CT findings using versus change over time can be helpful to the referring a combination of the order of importance and anatomic site physician. Comparison should be made with prior PET/ styles. The report is organized by anatomic region (e.g., head CT studies, but current findings should also be correlated and neck, chest, abdomen and pelvis, musculoskeletal), with with findings of other recent imaging studies such as CT, findings in each section organized by order of importance. Such MR imaging, or other nuclear medicine studies (e.g., bone reports have a predictable overall structure and are presented scanning or radioiodine scanning) when applicable. The in a clear fashion with compartmentalized information. This dates of any other imaging studies used for comparison or format may be preferred by some referring physicians because correlation should be listed. If no previous imaging studies it more closely matches reports associated with anatomic are available, this should be stated.
imaging modalities such as CT and MR imaging.
General Guidance of Reporting of Findings. In any It is important to have a consistent organizational organizational scheme the location, extent, and intensity of scheme when reporting imaging findings. There are 3 abnormal radiotracer activity should be reported using standard principal styles of reporting: “order of importance,” “anatomic anatomic descriptors. The use of a standardized radiology lexicon (e.g., RadLex in North American English) is encour- Order of Importance. Findings are described in the order aged (24). Areas of abnormal radiotracer activity should be of relevance to the clinical care of the patient. In its simplest correlated anatomically with the concurrent CT scan or other form, such a report may follow the TNM staging classifica- tion for the type of tumor being evaluated. In other cases, it It is appropriate to provide size measurements for nodules may begin with the largest or most clinically significant site and masses, either as a single transaxial diameter or in 2 or 3 of disease, followed by additional findings of less immediate orthogonal directions. If a single linear measurement is importance. Once the most important PET findings (along reported there should be a descriptor indicating whether it with corresponding anatomic descriptors from the CT portion represents the short or long axis. When PET/CT is used as of the study) have been reported, there should be a description a follow-up study to anatomic imaging (e.g., CT alone), effort of significant CT findings that are not 18F-FDG–avid, fol- should be made to compare anatomic information (i.e., lowed by incidental findings (on PET or CT) that are unlikely increasing, stable, or decreasing lesion size) in addition to reporting the metabolic findings on PET.
THE JOURNAL OF NUCLEAR MEDICINE • Vol. 54 • No. 5 • May 2013 The intensity of 18F-FDG uptake within a lesion may be more than 50% of cases, though this study was limited by reported using either qualitative (e.g., mild, moderate, or in- several factors including retrospective design (29). Additional tense) terminology or using semiquantitative measures such imaging studies may be needed to clarify areas of diagnostic as the SUV. Both approaches have strengths and weaknesses.
uncertainty on the PET/CT, especially when this is critical for Use of SUV may be preferable in many situations, as it is patient management. However, such recommendations for ad- more amenable to interstudy comparison and has prognostic ditional imaging should be issued sparingly because indiscrim- value in some cancers. However, there are different ways inate additional imaging may lead to unnecessary health care of calculating and reporting SUV that should be standardized costs, patient anxiety or inconvenience, and potential compli- (e.g., mean vs. maximum SUV; SUV normalized to true body cations as the result of these additional tests (29,30). It may weight vs. lean body weight), and interpreting physicians also put referring physicians in a position where they feel need to be aware of limitations in SUV measurements and medicolegally obligated to order the recommended tests, and potential sources for error that may adversely affect SUV the recommended tests could also potentially be construed as accuracy and reproducibility (25–27). Use of qualitative ter- inappropriate self-referral as has been reported by some minology may avoid these potential pitfalls of SUV, but such authors (30,31). The recommendation for additional imaging terminology may be interpreted variably from reader to should be tailored to institutional preferences and may depend reader and the absence of a quantitative parameter may on the level of imaging expertise among both imaging physi- make interstudy comparison difficult or impossible.
cians and referring physicians (28).
Regardless of the aforementioned approaches, we rec- The language used in the impression should be as clear ommend that abnormal 18F-FDG uptake be compared with and unambiguous as possible. For instance, terms such as uptake in a normal reference region. For example, abnormal absent, excludes, and definite are clear and can be expected 18F-FDG uptake in a lesion can be characterized by com- to be interpreted similarly by referring physicians and im- paring it with uptake in normal liver, with “mild” meaning aging physicians. Diagnostic uncertainty can be expressed less intense than normal liver uptake, “moderate” meaning using terms such as probably benign or probably malignant; similar in intensity to normal liver uptake, and “intense” however, such terms may have different probabilistic mean- meaning substantially higher than normal liver uptake. Le- ings to different people, which may lead to misunderstanding sion SUV can also be compared with SUV within a refer- among physicians and patients (32). Therefor, if these terms ence region of interest in the liver or mediastinal blood-pool are used, their meaning should be explained to referring physicians. The term equivocal or indeterminate should bereserved for scenarios in which a likelihood of malignancy The impression is probably the most important section of There is an increasing emphasis on the standardization of an imaging report. Many referring physicians begin their reporting with respect to assessment of treatment response.
reading of the report with the impression, and they read the Current best practices in reporting emphasize consistency findings section only as time allows. It is essential that all in communication so that clinical decisions can be made important information is presented in the impression in a on the basis of imaging results. In clinical reports, the clear and succinct way. The impression section should be language of response assessment (e.g., complete response, a brief and concise interpretation of findings, not simply partial response, stable disease, or progressive disease) is a restatement of findings. Lengthy discussion should be derived from the World Health Organization criteria and RECIST criteria, which were developed for trial-based imag- The impression should allow the reader to clearly identify ing using anatomic imaging modalities (33,34). To capture whether the PET/CT findings are normal or abnormal, and the full breadth of information in a PET/CT scan, future it should answer the specific clinical questions raised by the iterations of response assessment criteria will need to incor- referring physician. The impression should provide a clear porate parameters in addition to size, including intensity of diagnosis or a brief list of differential diagnoses with level of uptake and possibly volumetric metabolic data. Several pro- likelihood. For follow-up scans after therapy, both the meta- posals for characterizing metabolic response have been put bolic response and anatomic response may be reported in the forward, including the Cheson and Deauville/London criteria impression, particularly if these responses are discordant.
(specific to lymphoma) and PERCIST (35–39,40,41).
Some imaging physicians recommend additional imaging Although the proposed criteria for metabolic response studies, tissue sampling, or follow-up for specific findings in have many potential advantages, there are several issues the impression section. A 2009 study found that the frequency that currently limit widespread use of these metrics in clinical of recommendations for additional imaging in radiology reports. First, many of these metrics have not been rigorously reports has nearly doubled since 1995 (28), and a 2013 study validated in clinical outcome studies. Second, some of these found that recommendations for additional imaging were metrics are disease-specific (e.g., Deauville/London and Che- found in 29.6% of oncologic PET/CT reports (29). The latter son criteria for lymphoma), precluding application to other study reported no adverse impact on patient management or tumor types. Third, criteria that classify metabolic response outcome by not issuing or following these recommendations in based on percent changes in SUV or other metrics are ONCOLOGIC PET/CT REPORTING GUIDANCE • Niederkohr et al.
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