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High Quality PET/CT Report Elements And PET/CT team steps learning 2010 4.7 高價健檢篩癌 沒必要 ! 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!那我們這些儀器與人如何? nDont worry, be happy. nWe have our knowledge and confidence! We fight for and service for our patients as well as for our clinical doctors. Dont be afraid! 其實早在二年前核醫月會 tumor scan演講中我已提到: n先做低階檢查再做高階正子檢查 nex. GI tumor: occult blood ;tumor marker; sonography; endoscopic biopsy and even CT, MRI, coloscopy are firstly chosen before doing PET scan or tumor scan because the problem of FDG uptake, for lymph node metastases it is not bad study. PET/CT風險:隨時間久我們愈知愈 多其偽陽性與偽陰性愈知不可膨風 nLow to intermediate pt FDG avid nExposure to high dose radiation nSuggestion of biopsy or others. nHigh price study in normal pt. nMisleading clinician wrong direction. nEven suggest surgery; biopsy but exposure pt to near unrecovery situation. nNon FDG avid tumor: prostate;BAC hepatoma, GIST,NET,teratoma (for C11-Acetate PET has advantage over F18-DG in false negative studies). For normal and healthy patient, PET/CT? Shin Kon hospital PET/CT n1.1% screening rate for cancer n5% false positive rate annually. n0.5 cm tumor about 10 mSv. nMRI is good at no radiation but poor detection in lung, GI and colon cancer. Family history is important. False positive findings nInflammation nLymphadenopathy. nOvulation nBrown fat nPost radiotherapy in oral cancer. nFibrosis or any increased metabolic activity non cancer situation. 醫病新觀念:人不是物體,醫生不能 只考慮修復身體,不同人對自己的身 體有不同的感受,醫師必需了解進而 尊重這些不同的觀念進而將之放進 醫病關係中.醫療勢必要從一種權威 的命令,控制朝雙向協商,理解的服 務本質調整,使病人相信與安心,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!(quality). According to PET PROS (professional resources and outreach source) guideline(SNM) n高價健檢,身體擔風險. n美國多年來一直不贊成健檢用 PET/CT原因就在此. n尚未克服false positive and false negative problem in FDG. 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! Elements of PET/CT report: nClinical history(3+5) nProcedure(7+3+2) nComparison(2) nFindings(3) nImpression nSample normal reports Clinical history(3+5) nIndication for study: tumor type ;abnormality to be evaluated, and specific clinical question: (For diagnosis,staging,restaging,respons e to therapy). nRelevant history: biopsy results, chemotherapy,radiotherapy, other treatment; medical/surgery history. nInformation needed for billing:ex. Indeterminate nodule found on chest nCT, PET/CT for solitary pulm. nodule Procedure(7+3+2) nPET/CT radiopharmaceutical; dose; route and injection site; scan coverage;uptake time; serum blood sugar level; medication nCT noncontrast, iodinated iv contrast type and amount,oral contrast type and amount. nNotes: explanation for deviation from standart protocol; special tx like O2 supplement, treatment of contrast reaction. For PET/CT procedure nScan field for reginal or whole body scan should describe beginning and ending anatomic region. A range of 60 to 90 mins is between injection to scanning. Localization time shorter or longer than ususal should be mentioned. Blood sugar level should be comply with ACR guidelines. For interpretation of current study, we can also have this at delayed scan For medication and intervention nProtocol like anxiolytics and fusosemide the type, dose, and route administration should be noted. Any iv as procedure should be described, like urinary catheter. Any oral premedication regimen should be noted. Other details.4D R/T; dedicated brain imaging, or any delayed additional acquisitions. Or immobilization devices should be mentioned. For CT procedure nFor low dose CT(non diagnostic CT) should mentioned the details to the technique used 40 mAs,120 kVp. nFor anatomical localization for non FDG avid site like soft tissue mass or cystic lesions, the tissue of characterization by density, or pattern of enhancement should be metioned at compasion with PET. Additional notes. nAny adverse reation and treatment should be noted. Any deviation from standard protocol should be included in the official report. n Detail of such interventions are also typically kept in a separate nurses note or incident report. Comparison(2) nPrior PET or PET/CT studies. Dates should be described for comparison nOther studies: CT;MRI; mammography and nuclear medicine.or even plain film Findings(3) nOrder of importance format nAnatomic site format nHybrid format According to priority and anatomic site for dominant findings (TNM or primary lesion or recurrent disease); metastases (nodal or extranodal site of metastases) and other abnormal PET findings (like second primary tumors or diffuse thyroid activity). Incidental CT findings: lung nodule w/o FDG uptake, renal mass Normal physiologic FDG uptake: brown fat; prominent muscle or intestinal uptake. Anatomic site format nBegin with significant PET and CT findings and follow by relevant CT only findings and incidental observations. For each Head and neck; chest; abdomen and pelvis; musculoskeletal. Synthesis of priority and anatomic site(combination:assures of overall structure and consistency) and general report notes(RADLEX). General reporting notes. nOr RECIST: size measurements in 2 or 3 orthogonal directions, a statement that it is in the short or long axis. Do not let your report led to confusion and frustration of the clinicians by different measurement of PET or CT in tumor size, especially. Assure a consistency message. PET and CT report are read independently! Impression nIt is most important because most clinician start to read your report only at this! It is essential that all the important information discovered in the study is presented here in a clear and succinct way. Brief with concise; answer clinical question; give a precise diagnosis; when it is not possible, a clear and organized differential diagnosis should be given. It may be appropriate to discuss the use of additional imaging study or follow up. colloquial nDefinite evidence of malignancy nProbable malignancy in without evidence of metastases. nFor follow up scans after therapy, both metabolic response and anatomic response should be commented. nIf appear benign, Negative study for malignancy is better than no evidence for active malignancy because can be misinterpreted by the referring physician. Certain terminology: must care be exercised nAbsent; excludes; unlikely, probable, certain and definite are common used in referring physician, but other terms are understood quite differently like :unlikely, highly suggestive, compatible with or worrisome or suspicious. Clinician most like: definitely benign; probably benign equivocal, probably malignant or almost certainly malignant or definitely malignant. Vague language only confuses the referring physician and can result in sub-optimal patient care. nDefinite finding use right and specific words. Uncertainty should also essential that the uncertainty be clearly communicatedknowing this limitation of imaging studies and result must be taken in context of each situation, help clinician convey the necessary information and without causing unnecessary anxiety to the patient. Sample normal reports:1+1 nSynthesis of priority and anotomic site styles, nEven neither pt had PET findings suggesting disease recurrency, there is still a number of relevant positive and negative findings conveyed in each report. case 1:negative have to do with lymph nodes and spleen. Case 2: SPN though negative on PET, there is still TNM to chest subsection framed in context. Sample normal reports:1+1 Sample normal reports:1+1 nPET CT Reporting Form n Famous center PET CT Reporting Form nReport accuracy rate list below: doctor introduction 論PET/CT center 之團 隊合作與醫病新關係 How to reconstruction your gr? Team work for PET/CT center Assessment what? Many things you can guess! Persistent monitoring for: Delegation are sharing order. Open mind and feedback in time. Solve problems. 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