PET/CT at the BC Cancer Agency: What a Referring Physician...

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

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

DISCLOSURES

• None

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

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

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

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

WHICH COMMON MEDICATION MY LIMIT THE

SENSITIVITY OF PET IMAGING?

1. Metoprolol

2. Metformin

3. Warfarin

4. Hydrochlorothiazide

WHAT IS THE APPROXIMATE LIMIT OF

RESOLUTION OF CURRENT CLINICAL PET/CT

SCANNERS?

1. 2-4mm

2. 8-10mm

3. 12-15mm

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

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

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

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

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

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 …)

FUNDAMENTALS OF FDG PET IMAGING

H2 (18O) + H-1 + energy H2 + (18F)

18F + glucose FDG

FUNDAMENTALS OF PET IMAGING

• FDG dispensed

• Injected into patient

• 1 hour uptake

FUNDAMENTALS OF PET IMAGING

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

FUNDAMENTALS OF PET IMAGING

β decay with positron emission

Annihilation with an electron

Release of 511keV photons at ≈180°

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

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

PET/CT IN BC

• Two scanners located at BCCA

• 7000+ scans this year

• Urgent scans can currently be completed within about 2 weeks

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.

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

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.

ESOPHAGEAL CARCINOMA

• 79 yo ♀ with abdominal pain, hyponatremia

ESOPHAGEAL CARCINOMA

• 79 yo ♀ with abdominal pain, hyponatremia

ESOPHAGEAL CARCINOMA

• Staging examination Post chemo/rads pre surgery

ESOPHAGEAL CARCINOMA

• Post gastric pull up – CT in June NAD; CT in August ?local recurrence

ESOPHAGEAL CARCINOMA

• Post gastric pull up – CT in June NAD; CT in August ?local recurrence

ESOPHAGEAL CARCINOMA

• Post gastric pull up – CT in June NAD; CT in August ?local recurrence

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)

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

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

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

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.

31 YO MALE WITH RECTAL BLEEDING

31 YO MALE WITH RECTAL BLEEDING

CT July 22, 2014

31 YO MALE WITH RECTAL BLEEDING

31 YO MALE WITH RECTAL BLEEDING

MRI July 28, 2014

31 YO MALE WITH RECTAL BLEEDING

31 YO MALE WITH RECTAL BLEEDING

31 YO MALE WITH RECTAL BLEEDING

31 YO MALE WITH RECTAL BLEEDING

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.

CERVICAL CARCINOMA

CERVICAL CARCINOMA

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:

HEAD AND NECK

Image courtesy of Dr. M.Martin

HEAD AND NECK

Images courtesy of Dr. M.Martin

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.

SOLITARY PULMONARY NODULE

size matters…

LUNG

LUNG

LUNG

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.

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

DEAUVILLE CRITERIA

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.

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.

• 2006 – 36 yo female with a nevus on her central upper back

- excision showed a .98mm melanoma – T1

• 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

• 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

•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

•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

Feb 2012

•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

July 2013

July 2013

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)

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.

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.

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

FDG PET/CT SCANS BY CLINICAL INDICATION

0

1000

2000

3000

4000

5000

6000

7000

8000

9000

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

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)*

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.

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.

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:

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

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

METFORMIN

• FDG excretion

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

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

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

WHICH COMMON MEDICATION MY LIMIT THE

SENSITIVITY OF PET IMAGING?

1. Metoprolol

2. Metformin

3. Warfarin

4. Hydrochlorothiazide

WHAT IS THE APPROXIMATE LIMIT OF

RESOLUTION OF CURRENT CLINICAL PET/CT

SCANNERS?

1. 2-4mm

2. 8-10mm

3. 12-15mm

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

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

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

MAXIMIZING THE UTILITY

• If in doubt, email or call

Pete.tonseth@bccancer.bc.ca

604 877 6000 (675348) Vancouver

250 519 5500 (695403) Victoria

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

pete.tonseth@bccancer.bc.ca