pet/ct at the bc cancer agency: what a referring physician...
TRANSCRIPT
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PET/CT at the BC Cancer Agency: What a
Referring Physician Needs to Know
Dr. Pete Tonseth, Radiologist/Nuclear Medicine Physician,
BC Cancer Agency Vancouver Centre
November 1, 2014 www.fpon.ca
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R.Petter Tonseth BSc. MD FRCP(C)
Radiologist/Nuclear Medicine Physician
BCCA Centre of Excellence for Functional Cancer Imaging
Vancouver, BC
November 1, 2014
PET/CT AT BCCA What a referring physician needs to know
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DISCLOSURES
• None
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GENERAL PRACTICE 1989-1999
• Tahsis, Mayne Island, Saanichton
• Yellowknife, Alice Springs
• ClassAfloat
• Lindblad Expeditions
• sailed offshore in 1997 and
won the lottery…or
lost my mind
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RADIOLOGY/NUCLEAR MEDICINE
• UBC Radiology/NM Residency 1999 - 2004
• locums for multiple sites in BC
• Perth Radiological Clinic 2004 - 2011
• NightHawk Radiology Services
• BCCA Centre of Excellence for Functional Cancer Imaging
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WHAT IS THE CURRENT AVERAGE WAIT TIME
FOR AN URGENT PET/CT SCAN AT THE BCCA?
1. 1 week
2. 2 weeks
3. 4 weeks
4. 6 weeks
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ON AVERAGE, HOW LONG DO PATIENTS SPEND
AT THE BCCA FOR A PET/CT APPOINTMENT?
1. 30 minutes
2. 1 hour
3. 2 hours
4. 4 hours
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WHICH COMMON MEDICATION MY LIMIT THE
SENSITIVITY OF PET IMAGING?
1. Metoprolol
2. Metformin
3. Warfarin
4. Hydrochlorothiazide
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WHAT IS THE APPROXIMATE LIMIT OF
RESOLUTION OF CURRENT CLINICAL PET/CT
SCANNERS?
1. 2-4mm
2. 8-10mm
3. 12-15mm
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HOW COMFORTABLE DO YOU FEEL WITH YOUR
KNOWLEDGE OF APPROPRIATE INDICATIONS
FOR, AND LIMITATIONS OF, PET/CT?
1. Not at all
2. A little
3. Somewhat
4. Comfortable
5. Very comfortable
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OBJECTIVES
1. Provide an overview of the Functional Imaging Department at BCCA
2. Provide a brief review of PET imaging
3. Review the currently funded indications for PET/CT at BCCA
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OBJECTIVES
1. Provide an overview of the Functional Imaging Department at BCCA
2. Provide a brief review of PET imaging
3. Review the currently funded indications for PET/CT at BCCA
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OBJECTIVES
1. Provide an overview of the Functional Imaging Department at BCCA
2. Provide a brief review of PET imaging
3. Review the currently funded indications for PET/CT at BCCA
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POSITRON EMITTING ISOTOPES
Nuclide Half-life
18F 110 min
68Ga 68 min
11C 20.3 min
13N 10 min
15O 2.07 min
82Rb 1.25 min
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FUNCTIONAL IMAGING WITH PET
Cell proliferation (18F-thymidine …)
Hypoxia (18F-FMISO, 18F-EF5 …)
Blood flow (15O-butanol, H215O, 11CO, 13NH4 …)
Drug kinetics (11C-cocaine, 13N-cisplatin, 18F-FU…)
Protein synthesis (11C-methionine, 11C-tyrosine…)
Gene expression (18F-antisense oligonucleotides…)
Metabolism (15O2, 11C-choline, 18F-FDG …)
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FUNDAMENTALS OF FDG PET IMAGING
H2 (18O) + H-1 + energy H2 + (18F)
18F + glucose FDG
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FUNDAMENTALS OF PET IMAGING
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• FDG dispensed
• Injected into patient
• 1 hour uptake
FUNDAMENTALS OF PET IMAGING
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FDG METABOLISM
glucose
glucose 6-phosphate
pyruvate lactate
gylcolysis
TCA cycle
hexokinase
HOCH2
H 18
F
H
OH H HO
H
OH
H O
[18F]fluorodeoxyglucose
(FDG)
FDG
FDG 6-
phosphate
X
Image courtesy of Dr.D.Wilson
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FUNDAMENTALS OF PET IMAGING
β decay with positron emission
Annihilation with an electron
Release of 511keV photons at ≈180°
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FUNDAMENTALS OF PET IMAGING
• Patient positioned
• Coincidence detection
• Image reconstruction
• Patients are in the department for ≈ 2h
Phelps M E PNAS 2000;97:9226-9233
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OBJECTIVES
1. Provide an overview of the Functional Imaging Department at BCCA
2. Provide a brief review of PET imaging
3. Review the currently funded indications for PET/CT at BCCA
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PET/CT IN BC
• Two scanners located at BCCA
• 7000+ scans this year
• Urgent scans can currently be completed within about 2 weeks
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BCCA Indications for FDG-PET in the Clinical Management of Adult Cancer Patients:
Brain 1.Evaluation of recurrent brain tumor versus post-treatment necrosis. Breast Carcinoma 1.Evaluation of possible metastases when it cannot otherwise be confirmed and patient management would be significantly influenced (eg. equivocal conventional imaging studies and clinical suspicion or laboratory evidence of recurrence with negative conventional imaging). 2.Evaluation of response to therapy if it cannot be determined by other means and would significantly impact patient management. NOTE: No defined indications in screening, routine evaluation of primary breast cancer, initial staging of axillary lymph nodes or in the routine assessment of response.
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Retrospective Analysis of 18F-FDG PET/CT for Staging Asymptomatic Breast Cancer
Patients Younger Than 40 Years.
Riedl CC1, Slobod E1, Jochelson M2, Morrow M3, Goldman DA4, Gonen M4, Weber WA2, Ulaner GA5.
18F-FDG PET/CT in Staging Patients with Locally Advanced or
Inflammatory Breast Cancer: Comparison to Conventional Staging
David Groheux1,2, Sylvie Giacchetti3, Marc Delord4, Elif Hindié2,5, Laetitia Vercellino1, Caroline Cuvier3,
Marie-Elisabeth Toubert1, Pascal Merlet1,6, Christophe Hennequin7, and Marc Espié3
1Department of Nuclear Medicine, Saint-Louis Hospital, Paris, France; 2B2T, Doctoral School, IUH, University of Paris VII, France;
3Breast Diseases Unit, Department of Medical Oncology, Saint-Louis Hospital, Paris, France; 4Department of Biostatistics and
Bioinformatics, Institut Universitaire d’Hématologie, Paris, France; 5Department of Nuclear Medicine, Haut-Lévêque Hospital, CHU
Bordeaux, University Bordeaux-Segalen, Bordeaux, France; 6Service Hospitalier Frédéric Joliot, SHFJ/I2BM/DSVCEA, Orsay,
France; and 7Department of Radiation Oncology, Saint-Louis Hospital, Paris, France
J Nucl Med 2013; 54:5–11 DOI: 10.2967/jnumed.112.106864
J Nucl Med October 1, 2014 vol. 55 no. 10 1578-1583
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BCCA Indications for FDG-PET in the Clinical Management of Adult Cancer Patients:
Esophageal Carcinoma a. Base-line evaluation of medically fit patient considered eligible for surgical esophagectomy. b. Evaluation post-radical chemotherapy and radiotherapy for patient deemed eligible for radical resection of residual disease.
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ESOPHAGEAL CARCINOMA
• 79 yo ♀ with abdominal pain, hyponatremia
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ESOPHAGEAL CARCINOMA
• 79 yo ♀ with abdominal pain, hyponatremia
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ESOPHAGEAL CARCINOMA
• Staging examination Post chemo/rads pre surgery
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ESOPHAGEAL CARCINOMA
• Post gastric pull up – CT in June NAD; CT in August ?local recurrence
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ESOPHAGEAL CARCINOMA
• Post gastric pull up – CT in June NAD; CT in August ?local recurrence
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ESOPHAGEAL CARCINOMA
• Post gastric pull up – CT in June NAD; CT in August ?local recurrence
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BCCA Indications for FDG-PET in the Clinical Management of Adult Cancer Patients:
Colorectal Carcinoma Determination of stage in patient with potentially resectable recurrence.(including rising CEA)
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FUNDED INDICATIONS FOR PET/CT IN
COLORECTAL CARCINOMA:
ONTARIO
• determining management and prognosis if conventional imaging is equivocal for the presence
of metastatic disease
• to determine the site of recurrence in the setting of rising CEA when a conventional workup
fails to unequivocally identify metastatic disease
• in the preoperative management assessment of colorectal cancer liver metastases prior to
surgical resection
www.cancercare.on.ca
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FUNDED INDICATIONS FOR PET/CT IN
COLORECTAL CARCINOMA:
USA
www.snm.org/docs/PET.../OncologyPracticeGuidelineSummary.pdf
Preoperative evaluation of patients with potentially resectable metastatic disease
Determining location of tumours when rising CEA level suggests recurrence
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FUNDED INDICATIONS FOR PET/CT IN
COLORECTAL CARCINOMA:
AUSTRALIA
www.msac.gov.au/.../MSAC35a_PET_CRC_print250608new.pdf
Prior to resection of primary or limited metastatic disease
Suspected recurrence or residual on structural imaging after definitive therapy
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CURRENT UK INDICATIONS FOR PET/CT IN
COLORECTAL CARCINOMA
The Royal College of Physicians and The Royal College of Radiologists. Evidence-based indications for
the use of PET-CT in the United Kingdom 2012. London: The Royal College of Physicians and The
Royal College of Radiologists, 2012.
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31 YO MALE WITH RECTAL BLEEDING
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31 YO MALE WITH RECTAL BLEEDING
CT July 22, 2014
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31 YO MALE WITH RECTAL BLEEDING
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31 YO MALE WITH RECTAL BLEEDING
MRI July 28, 2014
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31 YO MALE WITH RECTAL BLEEDING
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31 YO MALE WITH RECTAL BLEEDING
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31 YO MALE WITH RECTAL BLEEDING
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31 YO MALE WITH RECTAL BLEEDING
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BCCA Indications for FDG-PET in the Clinical Management of Adult Cancer Patients:
Gynecologic (cervical) 1.Staging of locally advanced cervical cancer. 2.Staging of recurrent disease in patients being considered for pelvic exenteration. NOTE: No defined indications in endometrial, ovarian or vulvar cancers.
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CERVICAL CARCINOMA
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CERVICAL CARCINOMA
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Head and Neck Cancer (non-CNS, non-thyroid) 1.Diagnosis of primary site in patients presenting with squamous cell carcinoma metastatic to cervical lymph nodes with no obvious primary on conventional work-up. 2.Staging in patients with nasopharyngeal carcinoma and N2 or N3 nodal disease. 3.Staging in patients with level IV cervical lymph node metastases. 4.Diagnosis of suspected recurrence in the absence of other definitive evidence in patients being considered for salvage therapy. 5.Evaluation of cervical lymph nodes in patients for whom radical neck dissection is a part of the treatment plan for advanced primary disease. 6. Evaluation at 3 months post radiotherapy treatment
BCCA Indications for FDG-PET in the Clinical Management of Adult Cancer Patients:
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HEAD AND NECK
Image courtesy of Dr. M.Martin
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HEAD AND NECK
Images courtesy of Dr. M.Martin
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BCCA Indications for FDG-PET in the Clinical Management of Adult Cancer Patients:
Lung (non-small cell lung cancer) 1.Undiagnosed solitary lung nodule in patients at high risk from trans-thoracic needle biopsy 2.Staging of patients with clinical Stage I and IIA lesions 3.Staging of potentially resectable Stage IIB and III disease 4.Planning for radical radiotherapy 5.Staging prior to resection of solitary lung metastasis NOTE: No defined indications exist for bronchial carcinoid or small cell lung cancer.
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SOLITARY PULMONARY NODULE
size matters…
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LUNG
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LUNG
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LUNG
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BCCA Indications for FDG-PET in the Clinical Management of Adult Cancer Patients:
Lymphoma 1.Post-chemotherapy for patients with advanced stage aggressive non-Hodgkin lymphoma (including primary mediastinal large B cell lymphoma) and Hodgkin lymphoma with residual CT abnormalities or initial bulky (bulky = 10 cm or larger in any single diameter) disease to assess need for radiation therapy 2. Staging of Hodgkin lymphoma 3. Staging of aggressive non-Hodgkin lymphoma 4.PET to plan duration of chemotherapy for patients with limited stage (IA or IIA, non- bulky) Hodgkin lymphoma. 5.PET to plan duration and type of treatment for limited stage (IA or IIA, non-bulky) aggressive histology (diffuse large B cell, mantle cell, peripheral T cell) lymphoma. NOTE: No defined indication in the routine evaluation of low grade lymphomas.
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Role of Imaging in the Staging and Response Assessment of Lymphoma: Consensus of the
International Conference on Malignant Lymphomas Imaging Working Group
Sally F. Barrington, N. George Mikhaeel, Lale Kostakoglu, Michel Meignan, Martin Hutchings,Stefan P. Mu ̈eller, Lawrence H. Schwartz, Emanuele
Zucca, Richard I. Fisher, Judith Trotman,Otto S. Hoekstra, Rodney J. Hicks, Michael J. O’Doherty, Roland Hustinx, Alberto Biggi, and Bruce D. Cheson Published Ahead of Print on August 11, 2014 as 10.1200/JCO.2013.53.5229 The latest version is at http://jco.ascopubs.org/cgi/doi/10.1200/JCO.2013.53.5229
FDG PET/CT predictive role in follicular lymphoma.
Lopci E1, Zanoni L, Chiti A, Fonti C, Santi I, Zinzani PL, Fanti S.
Eur J Nucl Med Mol Imaging. 2012 May;39(5):864-71. doi: 10.1007/s00259-012-2079-y. Epub 2012 Feb 22.
Prognostic value of PET-CT after first-line therapy in patients with follicular
lymphoma: a pooled analysis of central scan review in three multicentre studies
Dr Judith Trotman FRACP a Corresponding AuthorEmail Address, Stefano Luminari MD b, Sami Boussetta MS c, Annibale
Versari MD d, Jehan Dupuis MD e, Christelle Tychyj MD f, Luigi Marcheselli MS b, Alina Berriolo-Riedinger MD g, Antonella
Franceschetto MD b, Anne Julian MD h, Fabien Ricard MD i, Luca Guerra MD k, Prof Corinne Haioun MD l, Irene Biasoli MD n,
Prof Hervé Tilly MD o, Prof Massimo Federico MD b, Prof Gilles Salles MD j, Prof Michel Meignan MD m
The Lancet Haematology, Early Online Publication, 18 September 2014 doi:10.1016/S2352-3026(14)70008-0Cite or Link Using DOI
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DEAUVILLE CRITERIA
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Melanoma 1.Evaluation of patients with Stage III (Any T, N1-3, M0) disease for whom radical surgery is planned. 2.Evaluation of patients with Stage IV disease (initial or recurrent) for whom surgery for limited metastatic disease is planned. NOTE: No defined indication in patients with Stage I and II melanoma or for unknown primary site in metastatic melanoma.
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INDICATIONS
FOR PET/CT IN MELANOMA
Alberta
Stage I, II- Further imaging (CT scan, PET, MRI) only to evaluate specific signs or symptoms
Stage III - Consider baseline imaging (abdominal/chest imaging: x-ray, CT ± PET) and to
evaluate specific signs or symptoms.
Stage IV - Recommend abdominal and pelvic CT with MRI or CT of head, and/or PET
Ontario
- PET is recommended for staging of high-risk patients with potentially resectable disease.
- PET is not recommended for the diagnosis of sentinel lymph node micrometastatic disease
or for staging of I, IIa, or IIb melanoma
- A recommendation cannot be made for or against the use of PET for the assessment of
treatment response in malignant melanoma due to insufficient evidence.
- A recommendation cannot be made for or against the use of PET for routine surveillance
due to insufficient evidence.
- PET is recommended for evaluation of isolated metastases at time of recurrence when
contemplating metastectomy.
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• 2006 – 36 yo female with a nevus on her central upper back
- excision showed a .98mm melanoma – T1
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• 2006 – 36 yo female with a nevus on her central upper back
- excision showed a .98mm melanoma – T1
• 2011 – January - facial rash prompted malignant work up - CXR
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• 2006 – 36 yo female with a nevus on her central upper back
- excision showed a .98mm melanoma – T1
• 2011 – January - facial rash prompted malignant work up - CXR
July - CT abdo for an unrelated complaint - lung nodules
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•2006 – 36 yo female with a nevus on her central upper back
- excision showed a .98mm melanoma – T1
•2011 – January - facial rash prompted malignant work up - CXR
July - CT abdo for an unrelated complaint - lung nodules
- CT chest – right axillary mass
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•2006 – 36 yo female with a nevus on her central upper back
excision showed a .98mm melanoma – T1
•2011 – January - facial rash prompted malignant work up - CXR
July - CT abdo - lung nodules
- CT chest – right axillary mass - melanoma met
November - CT - NAD
•2012 – January - axillary dissection - 3/15 nodes positive,
extranodal disease
February – PET/CT
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Feb 2012
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•2011 – January - facial rash prompted malignant work up - CXR
July - CT abdo - lung nodules
- CT chest – right axillary mass - melanoma met
November - CT - NAD
•2012 – January - axillary dissection - 3/15 nodes positive,
extranodal disease
February – PET/CT
•2013 – February 5 - follow up for dermatomyositis – no skin lesions
February 20 – ultrasound – palpable thigh lump vascular
February 21 – CT – no evidence of other metastases
July 26 – PET/CT
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July 2013
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July 2013
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Sarcoma 1.Evaluation of primary soft tissue mass prior to biopsy to identify high grade areas and guide biopsy. 2.Staging of locally advanced (10 cm or greater in maximum dimension) high grade soft tissue sarcomas. 3.Staging of Ewing’s sarcoma and rhabdomyosarcoma in adults. 4.Detection of suspected local recurrence of soft tissue sarcoma after definitive treatment. 5.Evaluating early response of gastrointestinal stromal tumors (GIST) to treatment with imatinib mesylate (Gleevec)
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Testicular Carcinoma (germ cell) 1.As an adjunct to initial staging of patients with Stage II seminomatous (SGCT) and non-seminomatous germ cell tumors (NSGCT) 2.Post-treatment evaluation of residual masses. 3.Detection of recurrent disease in the setting of rising tumor markers and absence of radiologic evidence of disease. NOTE: No defined indication in prostate, renal cell, or bladder carcinoma.
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Thyroid Carcinoma 1.Detection of suspected recurrence post-definitive therapy based on rising thyroglobulin levels in the circumstance of a negative radio-iodine study (papillary and follicular carcinomas) NOTE: No defined indication in the evaluation of thyroid nodules or anaplastic thyroid carcinoma.
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Other cancers given specific clinical indications, as approved by the BC Cancer Agency, on an individual basis. It is well recognized in clinical practice that there may be clinical scenarios that do not meet specific guidelines but where expert medical opinion indicates the procedure could have a major impact on patient management. PET scan referrals in these cases will be reviewed on an individual basis by physician representatives from the appropriate Provincial Tumor Group and the Functional Imaging department. If approved by consensus, the patient will be offered participation in the study.
http://www.bccancer.bc.ca/PPI/PET/indications.htm
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FDG PET/CT SCANS BY CLINICAL INDICATION
0
1000
2000
3000
4000
5000
6000
7000
8000
9000
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FDG PET/CT SCANS - TOTAL POPULATION /
HEALTH AUTHORITY
0%
5%
10%
15%
20%
25%
30%
35%
40%
Interior Fraser Vancouver Coastal Vancouver Island Northern
PET-CT Scans Percentage
Total Population Percentage (2010)*
*Data from http://www.bcstats.gov.bc.ca/data/sep/ha/hcommuns.csv
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Interior 11%
Fraser 38%
Vancouver Coastal
29%
Vancouver Island
17%
Northern 5%
PET/CT Scans by Health Authority in BC
Interior 16%
Fraser 36%
Vancouver Coastal
25%
Vancouver Island 17%
Northern 6%
Population by Health Authority in BC (2010)*
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Other clinical studies under way:
[18 F]-6-L-FLUORODIHYDROXYPHENYLALANINE (18F-FDOPA) POSITRON
EMISSION TOMOGRAPHY (PET) IN NEUROENDOCRINE TUMOURS
PRE-OPERATIVE PARATHYROID IMAGING: A COMPARISON OF 11C
METHIONINE PET, 18F-FDG PET AND SPEC-CT FOR THE DETECTION OF
HYPERFUNCTIONAL PARATHYROID TISSUES
18F- SODIUM FLUORIDE PET IMAGING AS A REPLACEMENT FOR BONE
SCINTIGRAPHY
DETECTION OF HYPOXIA AND BLOOD FLOW USING PET AND CT SCANS IN
PATIENTS WITH ADVANCED NON-SMALL CELL LUNG CANCER RECEIVING
CHEMOTHERAPY WITH AND WITHOUT BEVACIZUMAB – CONTINUATION OF A
PILOT STUDY.
IMAGING TUMOR HYPOXIA WITH 18F-EF5 PET IN METASTATIC CLEAR CELL
OVARIAN CANCERS.
A PHASE II CLINICAL TRIAL TO EVALUATE 18F-FLUOROESTRADIOL
POSITRON EMISSION TOMOGRAPHY / COMPUTERIZED TOMOGRAPHY
(PET/CT) GUIDED HORMONAL THERAPY FOR PATIENTS WITH RECURRENT
OR METASTATIC BREAST CANCER
PATIENT-SPECIFIC DOSIMETRY FOR Y-90 LIVER RADIOEMBOLISATION
THERAPY BASED ON QUANTITATIVE IMAGING STUDIES: SPECT/CT OF MAA-
TC-99M AND PET/CT OF Y-90.
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Other clinical studies under way:
[18 F]-6-L-FLUORODIHYDROXYPHENYLALANINE (18F-FDOPA) POSITRON
EMISSION TOMOGRAPHY (PET) IN NEUROENDOCRINE TUMOURS
PRE-OPERATIVE PARATHYROID IMAGING: A COMPARISON OF 11C
METHIONINE PET, 18F-FDG PET AND SPEC-CT FOR THE DETECTION OF
HYPERFUNCTIONAL PARATHYROID TISSUES
18F- SODIUM FLUORIDE PET IMAGING AS A REPLACEMENT FOR BONE
SCINTIGRAPHY
DETECTION OF HYPOXIA AND BLOOD FLOW USING PET AND CT SCANS IN
PATIENTS WITH ADVANCED NON-SMALL CELL LUNG CANCER RECEIVING
CHEMOTHERAPY WITH AND WITHOUT BEVACIZUMAB – CONTINUATION OF A
PILOT STUDY.
IMAGING TUMOR HYPOXIA WITH 18F-EF5 PET IN METASTATIC CLEAR CELL
OVARIAN CANCERS.
A PHASE II CLINICAL TRIAL TO EVALUATE 18F-FLUOROESTRADIOL
POSITRON EMISSION TOMOGRAPHY / COMPUTERIZED TOMOGRAPHY
(PET/CT) GUIDED HORMONAL THERAPY FOR PATIENTS WITH RECURRENT
OR METASTATIC BREAST CANCER
PATIENT-SPECIFIC DOSIMETRY FOR Y-90 LIVER RADIOEMBOLISATION
THERAPY BASED ON QUANTITATIVE IMAGING STUDIES: SPECT/CT OF MAA-
TC-99M AND PET/CT OF Y-90.
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Medullary Thyroid Carcinoma
Staging
Localization of clinically or biochemically (elevated calcitonin) suspected recurrent disease
Carcinoid Tumors
Staging
Localization of recurrent disease
Surgical planning
Pheochromocytoma and Paraganglioma
Diagnosis
Staging
Localization of recurrent disease
Pancreatic Islet Cell Tumours, Including Insulinoma
Diagnosis
Staging
Surgical planning
Neuroblastoma
Staging
Localization of recurrent disease
Other specific clinical indications of suspected or biopsy proven neuroendocrine neoplasia
as approved by the BC Cancer Agency, on an individual basis.
BCCA Indications for F-DOPA PET in the Clinical Management of Adult Cancer Patients:
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F-DOPA PET/CT BY CLINICAL INDICATION
0
10
20
30
40
50
60
Carcinoid Tumour Medullary Thyroid Carcinoma
Other Pancreatic Islet Cell Tumour, Including
Insulinoma
Pheochromocytoma and Paraganglioma
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0
5
10
15
20
25
30
35
40
45
Interior Fraser Vancouver Coastal Vancouver Island Northern
F-DOPA PET/CT SCANS BY HEALTH AUTHORITY
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METFORMIN
• FDG excretion
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1) Referring doctor not informing patients that we are a Clinical Trial. Please look on our website (www.bccancer.bc.ca) and read the consent form. 2) Missing height & weight 3) Full patient’s address & current phone number 4) Not indicating which hospital(s) patient had DI/NucMed tests done or not indicating the correct hospital (please send supporting documentation - most reqs are sent in isolation) 5) Missing doctor’s MSP or use college ID instead. We can’t decipher your signature. (We guess from imaging reports which doctors should get a copy of the PET/CT report) 6) Patient’s legal name ( as appears on reports) 7) Reason for request – staging? Pre-op? therapy assessment? (Will help expedite request if we know why. More info we have, the easier for triaging) 8) Dates of last treatment (RT/chemo dates); if PET/CT has to be done after or in between – Please indicate when the PET/CT needs to be done. 9) More than 1 weeks notice when at all possible. 10) Sometimes req’s indicate patient is not diabetic when they are – please list their diabetes medication and indicate type 1 or 2 diabetes.
Mary’s Top Ten
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WHAT IS THE CURRENT AVERAGE WAIT TIME
FOR AN URGENT PET/CT SCAN AT THE BCCA?
1. 1 week
2. 2 weeks
3. 4 weeks
4. 6 weeks
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ON AVERAGE, HOW LONG DO PATIENTS SPEND
AT THE BCCA FOR A PET/CT APPOINTMENT?
1. 30 minutes
2. 1 hour
3. 2 hours
4. 4 hours
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WHICH COMMON MEDICATION MY LIMIT THE
SENSITIVITY OF PET IMAGING?
1. Metoprolol
2. Metformin
3. Warfarin
4. Hydrochlorothiazide
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WHAT IS THE APPROXIMATE LIMIT OF
RESOLUTION OF CURRENT CLINICAL PET/CT
SCANNERS?
1. 2-4mm
2. 8-10mm
3. 12-15mm
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HOW COMFORTABLE DO YOU FEEL WITH YOUR
KNOWLEDGE OF APPROPRIATE INDICATIONS
FOR, AND LIMITATIONS OF, PET/CT?
1. Not at all
2. A little
3. Somewhat
4. Comfortable
5. Very comfortable
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MAXIMIZING THE UTILITY
• PET/CT before chemo or 6 weeks after completion
• Wait as long as possible after radiotherapy ( inflammatory changes can last months)
• 8-10mm resolution limit
• Metformin – interferes with bowel evaluation
• Mucinous colon and lobular breast - may have lower sensitivity
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MAXIMIZING THE UTILITY
• Fill in the requisition:
http://www.bccancer.bc.ca/HPI/PET/patientreferral.htm
• Follow the indications:
http://www.bccancer.bc.ca/PPI/PET/indications.htm
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MAXIMIZING THE UTILITY
• If in doubt, email or call
604 877 6000 (675348) Vancouver
250 519 5500 (695403) Victoria
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THANK YOU
http://www.bccancer.bc.ca/HPI/PET/default.htm
http://www.bccancer.bc.ca/HPI/PET/patientreferral.htm
R. Petter Tonseth BSc., MD, FRCPC
Radiologist / Nuclear Medicine Physician
BCCA Centre of Excellence for Functional Cancer Imaging