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PET/CT Dual Modality PET/CT Dual Modality Imaging Imaging –– A Win or Loss for A Win or Loss for

Nuclear MedicineNuclear MedicineJames W. Fletcher, M.D.James W. Fletcher, M.D.Professor of RadiologyProfessor of Radiology

Director, Division of Nuclear Medicine/PETDirector, Division of Nuclear Medicine/PETIndiana/Purdue University Indiana/Purdue University

Indiana University School of MedicineIndiana University School of Medicine

Some ObservationsSome Observations

Clinical PET imaging performed with FDG Clinical PET imaging performed with FDG has largely been the domain of nuclear has largely been the domain of nuclear medicine since clinical units became medicine since clinical units became available in the early 1990s.available in the early 1990s.PET technology has been developed PET technology has been developed almost exclusively by professionals in the almost exclusively by professionals in the field of nuclear medicine.field of nuclear medicine.

Some ObservationsSome Observations

More PET/CT dual modality imaging units More PET/CT dual modality imaging units are now being sold than dedicated PET are now being sold than dedicated PET units.units.The advantages of PET/CT are inherent in The advantages of PET/CT are inherent in the marriage of two modalities capable of the marriage of two modalities capable of providing the ideal combination of providing the ideal combination of structural and metabolic information.structural and metabolic information.

Some ObservationsSome Observations

PET/CT dual modality imaging is replacing PET/CT dual modality imaging is replacing dedicated PET.dedicated PET.

Are there still clinical applications for Are there still clinical applications for dedicated PET?dedicated PET?

PET/CECT is beginning to replace PET/CECT is beginning to replace dedicated CECT in the management of dedicated CECT in the management of patients with cancer patients with cancer –– ““one stopone stop”” oncologic oncologic imaging.imaging.

Some ObservationsSome Observations

The advantages of PET/CT associated The advantages of PET/CT associated improvements in ability to localize and improvements in ability to localize and characterize disease have begun to be characterize disease have begun to be recognized and embraced by a far larger recognized and embraced by a far larger medical community than nuclear medicine.medical community than nuclear medicine.

The Old ParadigmThe Old Paradigm

As long as PET/CT dualAs long as PET/CT dual--modality imaging modality imaging remained in the introductory mode that remained in the introductory mode that used the CT component for just used the CT component for just attenuation correction and localization of attenuation correction and localization of 18F18F--FDG PET abnormalities, diagnosticFDG PET abnormalities, diagnostic--quality CT scans were not generated and quality CT scans were not generated and a formal interpretation of the CT a formal interpretation of the CT information was not required. information was not required.

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The Nuclear Medicine HedgeThe Nuclear Medicine Hedge

“…….A non-contrast CT examination was performed to provide PET attenuation correction and more precise anatomic localization of identified PET abnormalities.”

Possible Possible Interpretations/ImplicationsInterpretations/Implications

The CT image data is not of diagnostic The CT image data is not of diagnostic quality and I am not going to interpret it.quality and I am not going to interpret it.The CT image data is good enough for The CT image data is good enough for interpretation, but I am going to ignore it interpretation, but I am going to ignore it and not report any CT findings.and not report any CT findings.The CT image data is good enough for The CT image data is good enough for interpretation, but I am ignoring and not interpretation, but I am ignoring and not reporting it because I have not been reporting it because I have not been trained in crosstrained in cross--sectional imaging.sectional imaging.

The New ParadigmThe New Paradigm

Dual modality PET/CT is now routinely Dual modality PET/CT is now routinely performed with instruments capable of performed with instruments capable of providing diagnostic quality CT image providing diagnostic quality CT image data.data.Dual modality PET/CECT is being Dual modality PET/CECT is being performed at an increasing rate using both performed at an increasing rate using both IV and oral contrast agents.IV and oral contrast agents.

““oneone--stop oncologic imagingstop oncologic imaging””

The New Nuclear Medicine HedgeThe New Nuclear Medicine Hedge

“…….A contrast CT examination was also performed using IV and oral contrast and the findings of this exam will be provided in a separate report. The CT exam was also used to provide PET attenuation correction and more precise anatomic localization of identified PET abnormalities”

Possible Possible Interpretations/ImplicationsInterpretations/Implications

I will interpret the CT image data and I will interpret the CT image data and provide the results in a separate report.provide the results in a separate report.

I am doing this for billing purposes.I am doing this for billing purposes.I am proficient in interpreting both PET and CT.I am proficient in interpreting both PET and CT.

Someone else will interpret the CT image Someone else will interpret the CT image data and provide the results in a separate data and provide the results in a separate report.report.

I am ignoring and not reporting it because I have not I am ignoring and not reporting it because I have not been trained in crossbeen trained in cross--sectional imaging.sectional imaging.

Possible Possible Interpretations/ImplicationsInterpretations/Implications

Because I can not interpret CT and the Because I can not interpret CT and the radiologists here can not interpret PET it is radiologists here can not interpret PET it is reasonable to separate the results into two reasonable to separate the results into two independent reports.independent reports.

The results of the two separate reports will The results of the two separate reports will somehow be integrated for the benefit of the somehow be integrated for the benefit of the patient and referring physician.patient and referring physician.

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Problems with Dual ReportingProblems with Dual Reporting

If it works at all If it works at all ---- it probably will only work it probably will only work in an academic environment.in an academic environment.Diagnostic quality CT (CECT) image data Diagnostic quality CT (CECT) image data must be provided to interpreting must be provided to interpreting physicians via export to other image physicians via export to other image workstations (PACS).workstations (PACS).There is no PACS Standard for fused There is no PACS Standard for fused image data.image data.

Hardware integrated images, othogonal projections, Hardware integrated images, othogonal projections, dual modality stack review are not available.dual modality stack review are not available.

Ideal SolutionIdeal SolutionTo ensure that the patients who are examined To ensure that the patients who are examined with PET/CT receive the best possible care, the with PET/CT receive the best possible care, the physician professionals interpreting these physician professionals interpreting these clinical studies will need to be proficient in both clinical studies will need to be proficient in both PET and CT. PET and CT. At the highest level of integration, these At the highest level of integration, these physician professionals will evaluate and report physician professionals will evaluate and report on both the diagnosticon both the diagnostic--quality CT image data quality CT image data and the PET image data. and the PET image data. This can be achieved only by professionals who This can be achieved only by professionals who are trained and experienced in both modalities. are trained and experienced in both modalities.

The PET/CT GameThe PET/CT GameWinnersWinners

Possess necessary training Possess necessary training and experience to be and experience to be proficient in interpretation of proficient in interpretation of both PET and CT image both PET and CT image data by reason of properly data by reason of properly structured GME programsstructured GME programsObtain necessary training Obtain necessary training and skills via CME and and skills via CME and supervised clinical supervised clinical experienceexperience

Pass examinationPass examination

LosersLosersFail to restructure current Fail to restructure current GME programs to GME programs to incorporate appropriate incorporate appropriate missing elements and meet missing elements and meet newly defined criteria for newly defined criteria for proficiency in both PET and proficiency in both PET and CTCTAvoid necessary training Avoid necessary training and skills via CME and and skills via CME and supervised clinical supervised clinical experienceexperience

No examinationNo examination

PrizesPrizes

Increased Increased RVUsRVUs, technical and , technical and professional revenueprofessional revenueFull participation in evolving specialty of Full participation in evolving specialty of ““molecular molecular oncologiconcologic imagingimaging””New valuable skills and knowledge for New valuable skills and knowledge for nuclear medicine professionalsnuclear medicine professionalsPartnership in Partnership in oncologiconcologic management management (and research) team(and research) team

Pathways for Personnel Pathways for Personnel QualificationsQualifications

ACR/SNM/SCBT&MR White paper ACR/SNM/SCBT&MR White paper ACR Practice Guideline for CTACR Practice Guideline for CTSNM Guideline for PET/CTSNM Guideline for PET/CT

Soon to be released and includes personnel Soon to be released and includes personnel qualifications statementsqualifications statements

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J Nucl Med 2005; 48: 1225-1239, July, 2005

SNM White PaperSNM White Paper

““As stated in the Prologue of this article, As stated in the Prologue of this article, training requirements for those seeking to training requirements for those seeking to perform and interpret the results of perform and interpret the results of PET/CT are controversial, and agreement PET/CT are controversial, and agreement between the ACR and the SNM has not between the ACR and the SNM has not been reached.been reached.””

SNM White PaperSNM White Paper““The SNM considers the amount of onThe SNM considers the amount of on--thethe--job training in CT presented job training in CT presented in this proposal to be adequate for radiologists without recent in this proposal to be adequate for radiologists without recent CT CT experience and for nuclear medicine physicians to supervise and experience and for nuclear medicine physicians to supervise and interpret a CT study performed concurrently with a PET study interpret a CT study performed concurrently with a PET study regardless of the protocol used. regardless of the protocol used.

The ACR position is that the training outlined in this section mThe ACR position is that the training outlined in this section may well be ay well be sufficient to allow adequate interpretation of the CT component sufficient to allow adequate interpretation of the CT component of of PET/CT for anatomic localization only, but it is not consistent PET/CT for anatomic localization only, but it is not consistent with the with the existing ACR Practice Guideline for Performing and Interpreting existing ACR Practice Guideline for Performing and Interpreting Diagnostic Computed Tomography and as such does not prescribe Diagnostic Computed Tomography and as such does not prescribe sufficient training for the performance and interpretation of disufficient training for the performance and interpretation of diagnostic agnostic CT. Thus, the ACR has not approved or endorsed the training CT. Thus, the ACR has not approved or endorsed the training requirements for diagnostic purposes.requirements for diagnostic purposes.””

The White Paper HedgeThe White Paper Hedge

““However, because PET/CT is a new and However, because PET/CT is a new and rapidly evolving technology, there may rapidly evolving technology, there may well be a need to consider new well be a need to consider new requirements for CT interpretation in the requirements for CT interpretation in the specific setting of hybrid technologies specific setting of hybrid technologies used by imaging specialists. Collaborative used by imaging specialists. Collaborative discussions continue.discussions continue.””

Feasibility?Feasibility?

““In most instances, it is not feasible for a In most instances, it is not feasible for a practicing diagnostic radiologist to practicing diagnostic radiologist to duplicate exactly the PET training that a duplicate exactly the PET training that a nuclear medicine physician receives nuclear medicine physician receives during a nuclear medicine residency or for during a nuclear medicine residency or for a practicing nuclear medicine physician to a practicing nuclear medicine physician to duplicate the CT training obtained in a duplicate the CT training obtained in a diagnostic radiology residency.diagnostic radiology residency.””

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Requirement ComparisonRequirement Comparison

150150

150150

3535AABBRR

10010088500500

AABBNNMM

CT CT CMECME

PET/CT PET/CT CMECME

Number of Number of supervised CT supervised CT examinationsexaminations

Number of Number of supervised supervised

PET/CT PET/CT InterpretationsInterpretations

ACR PRACTICE GUIDELINE FOR ACR PRACTICE GUIDELINE FOR PERFORMING AND INTERPRETING PERFORMING AND INTERPRETING

DIAGNOSTIC COMPUTED TOMOGRAPHY (CT)DIAGNOSTIC COMPUTED TOMOGRAPHY (CT)

““For nonFor non--radiologists, the completion of an radiologists, the completion of an accredited residency program in the accredited residency program in the specialty practiced plus 200 hours of specialty practiced plus 200 hours of Category I CME in the performance and Category I CME in the performance and interpretation of CT in the interpretation of CT in the subspecialtysubspecialtywhere CT reading occurs, and 500 cases where CT reading occurs, and 500 cases interpreted and reported during the past interpreted and reported during the past 36 months in a supervised situation.36 months in a supervised situation.””

How Much Training & Experience How Much Training & Experience Are Really Necessary?Are Really Necessary? The White Paper HedgeThe White Paper Hedge

““However, because PET/CT is a new and However, because PET/CT is a new and rapidly evolving technology, there may rapidly evolving technology, there may well be a need to consider new well be a need to consider new requirements for CT interpretation in the requirements for CT interpretation in the specific setting of hybrid technologies specific setting of hybrid technologies used by imaging specialists. Collaborative used by imaging specialists. Collaborative discussions continue.discussions continue.””

What Do What Do YouYou Need to Know?Need to Know?

Understand CT technologyUnderstand CT technologymAmA, , KvKv, pitch; Protocols; Radiation Dose , pitch; Protocols; Radiation Dose

Understand use of oral and IV contrastUnderstand use of oral and IV contrastContrast reaction managementContrast reaction management

Normal crossNormal cross--sectional anatomysectional anatomyOncologicOncologic ImagingImaging

Characteristics of various tumors on CTCharacteristics of various tumors on CTAppearanceAppearancePattern of spreadPattern of spreadBehavior with contrastBehavior with contrast

What Else Do You Need to Know?What Else Do You Need to Know?

Recognize ArtifactsRecognize ArtifactsPertinent IncidentalsPertinent Incidentals

Pulmonary nodulesPulmonary nodulesAortic aneurysmsAortic aneurysmsPEPE? ? CholelithiasisCholelithiasis??? ? DiverticulitisDiverticulitis??? Hernias?? Hernias?…………………………..

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You Need to Know EnoughYou Need to Know Enough…….. What are Sources of CME?What are Sources of CME?

There are a lotThere are a lotACR, RSNA, SNM, CTISUSACR, RSNA, SNM, CTISUS

Web basedWeb basedJournal basedJournal basedProfessional meetingsProfessional meetingsRegional educational programs Regional educational programs

Where to go from here?Where to go from here?

Decide if you want to become qualified to Decide if you want to become qualified to interpret and report both PET and CT.interpret and report both PET and CT.Begin process of accumulating CME hours Begin process of accumulating CME hours via existing pathways.via existing pathways.Initiate mechanism to begin supervised Initiate mechanism to begin supervised review of CT (PET) examinations. review of CT (PET) examinations.