EuroNet-Paediatric Hodgkin’s Lymphoma GroupImaging Manual Confidential EuroNet-PHL-C2 final 2.0, 2015-09-15 Page 6 of 18 b) Acquisition starts 60 ± 10 min p.i. of FDG (essential

Confidential

EuroNet-PHL-C2 final 2.0, 2015-09-15 Page 1 of 18

Inter-group chairpersons

Prof. Dr. Dieter Körholz

(Coordinating chairperson) Universitätsklinikum Giessen und Marburg GmbH; Standort Giessen - Zentrum für Kinderhämatologie und –onkologie

Feulgenstr. 12, 35392 Giessen

Germany

Sponsor

Prof. Dr. W. Hamish Wallace

Royal Hospital for Sick Children, Sciennes Road, Edinburgh EH9 1LF, Scotland, UK.

Prof. Dr. Judith Landman-Parker

Service d’hématologie et d’oncologie pédiatrique Hôpital Trousseau AP-HP Paris, France

Justus-Liebig-University of Giessen

Medizinische Fakultät Rudolf-Buchheim-Str. 6 35392 Giessen Germany

EudraCT number: 2012-004053-88

Date of Version: 2015-09-15

EuroNet-Paediatric Hodgkin’s Lymphoma Group

Second International Inter-Group Study

for Classical Hodgkin’s Lymphoma in Children and Adolescents

Imaging Manual

EuroNet-PHL-C2

Imaging Manual Confidential


Table of Contents

1. REFERENCE IMAGING CENTRES .......................................................................................... 3

2. SUMMARY ................................................................................................................................. 3

2.1. DATES OF IMAGING ................................................................................................................. 3

2.2. RECOMMENDED IMAGING OPTIONS FOR IM1, IM2, IM3 AND IMR DEPENDING ON

AVAILABLE IMAGING FACILITIES .......................................................................................... 4

2.3. PET – PATIENT PREPARATION AND ACQUISITION ............................................................ 5

2.4. IMAGE TRANSFER ................................................................................................................... 6

2.5. EVALUATION OF EXAMINATIONS AND REPORTING .......................................................... 6

3. DETAILED INFORMATION ............................................................................................................. 6

3.1. FDG-PET /CT, PET/MRI OR PET EXAMINATIONS ..................................................................... 6

3.2. F-18-FDG DOSAGE AND RADIATION PROTECTION ISSUES ................................................. 6

3.3. ADDITIONAL RECOMMENDATIONS FOR PET .......................................................................... 7

3.4. ADDITIONAL REQUIREMENTS FOR MRI AND CT .................................................................... 8

3.5. IMAGE TRANSFER ....................................................................................................................... 10

3.6. ASSESSMENT OF INVOLMENT AND RESPONSE BY CENTRAL REVIEW BOARD .......... 10

3.6.1. INITIAL STAGING ...................................................................................................................... 10

3.6.1.1. INDEPENDENT LYMPH NODE REGIONS .......................................................................... 11

3.6.1.2. DEFINITION OF INVOLVEMENT .......................................................................................... 12

3.6.1.3. DEFINITION OF BULK – MEASUREMENT OF LARGEST NODAL TUMOR MASS ...... 13

3.6.2. EARLY AND LATE RESPONSE ASSESSMENT (ERA/LRA) ............................................... 14

3.6.2.1. DEFINITION OF RESPONSE GROUPS AT ERA ............................................................... 16

4. REFERENCES ............................................................................................................................... 17



1. REFERENCE IMAGING CENTRES

2. SUMMARY

2.1. Dates of imaging

Table 1: Dates of Cross sectional imaging and FDG-PET

Dates Which patients When

Im1 –initial staging all Before start of treatment

Im2 - After 2 OEPA

Early response assessment (ERA)

all Day 14 – 17 after the last dose of prednisone in the second cycle

Im3 - End of ChT

Late response assessment (LRA)

TL-2 or TL-3

only if qPET+ at Im2

Day 14 – 17 after the last dose of prednisone in the last cycle

ImR at diagnosis of relapse or progression

Patients with biopsy confirmed relapse/progression

After relapse is confirmed by biopsy

Reference nuclear physician

Prof. Dr. Regine Kluge

Klinik und Poliklinik für Nuklearmedizin

Universitätsklinikum Leipzig

Liebigstraße 18, D-04103 Leipzig, Germany

Tel.: +49-341- 97 18 031 or 97 18 000,

Fax: +49-341- 97 18 009

[email protected]

Reference Radiologists

Dr. D. Stoevesandt and Prof. Dr. Rolf Peter Spielmann

Universitätsklinikum der Martin-Luther-Universität Halle-Wittenberg

Universitätsklinik und Poliklinik für Diagnostische Radiologie

Ernst-Grube-Straße 40

06120 Halle (Saale), Germany

Tel.: +49-345-5572441

Fax: +49-345-5572157

[email protected]

[email protected]



Table 2: Imaging during Follow-up

Diagnostics Year 1 Years 2. + 3. Years 4. + 5.

Chest x-ray 6 months and 12 months after end of treatment

Every four months

Ultrasound neck, abdomen and pelvis

6 months and 9 months after end of treatment

Every four months Every six months

Chest CT in patients with initial lung involvement

3 months and 12 months after end of treatment*

MRI of all initially involved regions

3 months and 12 months after end of treatment*

Please note: FDG-PET is not recommended at regular follow-up visits

2.2. Recommended imaging options for Im1, Im2, Im3 and ImR depending on

available imaging facilities

The following three options - ordered by preference – are allowed according to local

availability.

a) Neck and Torso PET/MRI with i.v. contrast

− Acquisition from skull base to mid thighs. Respiratory triggering is recommended for

chest and abdomen.

− An additional diagnostic quality chest CT in end-inspiration is required at Im1 for

lung evaluation (only if chest-CT was not performed within two (to three) weeks prior

to diagnosis of Hodgkin`s lymphoma).

− In case of lung involvement chest CT in end-inspiration is required also at Im2 (Im3

if applicable).

− At Im1 liver and spleen ultrasound is required.

− At Im1 in case of suspected skeletal involvement an additional bone scintigraphy is

required, if no corresponding CT is performed for the respective region of a PET

positive lesion.



b) Neck and Torso PET/CT with i.v. contrast and X-ray-dose optimization protocol

(follow local or national protocols and guidelines)

− Acquisition from skull base to mid thighs

− At Im1 additional diagnostic quality chest CT in end-inspiration is required for lung

evaluation at Im1, preferentially added immediately after end of the whole-body scan

(only if a chest-CT has not been performed within two (to three) weeks prior to

diagnosis of Hodgkin`s lymphoma).

− In case of lung involvement additional CT of the lungs in end-inspiration is added at

Im2 (Im3 if applicable).


− No bone scintigraphy is required.

c) ONLY if A and B are not available: PET/CT (low dose) without contrast (not

recommended!) or PET only

− Acquisition of PET from skull base to mid thighs is required at Im1 and Im2 and for

qPET positive patients also at Im3.

− At Im1 additional diagnostic quality chest CT with i.v. contrast in end-inspiration is

required (only if a chest-CT has not been performed within two (to three) weeks prior

to diagnosis of Hodgkin`s lymphoma). In case of lung involvement additional CT of

the lungs in end-inspiration is added at Im2 (Im3 if applicable).

− At Im1 additional MRI with i.v. contrast of neck, abdomen and pelvis is required. At

Im2 and Im3 additional MRIs are required only for initially involved regions.


− At Im1 in case of suspected skeletal involvement an additional bone scintigraphy is

required, if no corresponding CT is performed for the respective region of a PET

positive lesion.

2.3. PET – Patient preparation and acquisition

a) Premedication with oral non-selective β-blockers is strongly recommended in

patients > 10 years of age and without contraindications.

- One hour prior to FDG-application

- 1mg/kg BW Propranolol, do not exceed 40 mg

- Off-label use requires informed consent



b) Acquisition starts 60 ± 10 min p.i. of FDG (essential for qPET evaluation!)

c) Head and spine in neutral position. Position arms up over the head at Im1 if

possible. Identical position of arms at Im1, Im2 and Im3.

2.4. Image reconstruction and transfer

All images (including PET/MRI or PET/CT (, and if applicable CT, MRI or bone scan) for

reference evaluation will be transferred to the central server (Hermes Medical Solutions;

Sweden). Please send data in DICOM format reconstructed with an algorithm according to

EANM Guideline e.g. OSEM (15)

Recommended: Direct transfer from the local centre to the central server. (contact:

[email protected] (Refer to Hodgkin Project) If direct transfer not feasible:

Transfer via CD to study office in Halle (until end of October 2015, afterwards to study office

in Gießen, see address Prof. Körholz), from where images are stored on the central server,

NOTE: This may trigger delays compromising treatment delivery.

2.5. Evaluation of examinations and reporting

All study specific evaluations for staging and response evaluation (see Section 3+4+5

below) are performed at central review. Central review is provided by the EuroNet-PHL

study centre in Gießen/Halle/Leipzig except for Austria (Vienna).

Images are evaluated and reported by the local nuclear physician and radiologist as per local

standard. Local findings are forwarded to the Central review.

3. DETAILED INFORMATION

3.1. FDG-PET /CT, PET/MRI or PET examinations

Please follow the guidelines of the European Association of Nuclear Medicine for F-18-FDG

examinations for patient preparation, data acquisition (1) and image reconstruction (15) .

3.2. F-18-FDG dosage and radiation protection issues

- Don’t exceed F-18-FDG doses as recommended in the EANM dosage card (2-4) and

national reference levels. Please Note: Use the lowest activity appropriate for

your technical setting to achieve good image quality. The value for the "minimum

recommended activity" is reduced to 14 MBq for 3D- and to 26 MBq for 2D-

acquisitions (3).



- Please use 3D-acquisition if possible.

- Use PET/MRI (option A) or low-dose PET/CT with i.v. contrast agent (option B)

or – if both entities are not available – combine FDG-PET with MRI imaging

(option C). For detection of lung involvement additional chest CT is required at

Im1 and – in case of lung involvement – also at Im2.

- Use of bone scintigraphy is limited to patients with FDG-PET positive skeletal

lesions and without available CT of these lesions. Please follow the guidelines

for paediatric bone scanning (5) and use Tc-99m-diphosphonate doses as

recommended in the EANM dosage card (4).

- PET is not recommended for routine follow-up.

3.3. Additional recommendations for PET

a) Avoid uptake in brown fat tissue

Enhanced FDG uptake in brown adipose tissue is a problem in children and adolescents.

Since head and neck area and upper mediastinum are frequently involved in Hodgkin’s

lymphoma special care has to be taken to avoid this artificial FDG-uptake. Especially at

Im2 and Im3 residual tumour tissue cannot be adequately evaluated if it is surrounded by

enhanced uptake in brown fat, which may cause unclear or even false-positive interim

PET results (Note: qPET results are essential for the decision on radiotherapy). The

following measures are strongly recommended:

- Keep the patient warm. Please inform parental guardian or the responsible

nurse to keep the patient warm on the way to the PET facility. Please provide a

warm and draught-free room for patient preparation. If necessary, use hot

(unsweetened) tea or blankets.

- Ask the patient to come one hour in advance for application of β-blocker.

- Since glucose uptake of brown fat is stimulated by the sympathetic nervous

system it can be considerably reduced by non-selective β-blockers such as

Propranolol (6-8). We recommend propranolol (oral administration) at a

dose of 1 mg/kg, not exceeding – a maximum of 40 mg one hour before

application of FDG if no contraindications are present and for patients over 10

years of age. (Please note: Propranolol in this indication is off-label use).



b) Patient positioning

Please position the patient’s head and spine in a neutral position (Don’t use pillows!).

This is necessary for proper evaluation of the tumour involvement in upper and lower neck

areas at Im1 and for standardization of head and neck positioning for direct slice-by-slice

image comparison at Im2 and Im3.

Please position both arms over the head at Im1 if possible. Please use identical

position of arms at Im1, Im2 and Im3. This is required for the slice-by-slice comparison

of the follow-up images. If for example a patient at Im1 was not able to put the right arm

over the head due to recent axillary biopsy the right arm should be positioned identically

at Im2 and Im3.

c) PET acquisition

Start PET acquisition 60 ± 10 minutes after i.v. application of F-18-FDG. Don’t exceed a

time interval of 50 – 70 (90) minutes. An accurate timing is important since FDG uptake in

tumour lesions increases with time (9) while it is constant in the liver (10) and therefore

qPET values might artificially increase with long intervals.

d) PET reconstruction

The reconstruction algorithm influences the detectability and interpretation, the SUVmax

and SUVpeak of small lesions (16). Please use OSEM reconstruction or other

reconstruction setting as indicated in the EANM guidelines (15, Appendix II). In addition

(not instead of) you are welcome to send PSF/UHD reconstructed images

3.4. . Additional requirements for MRI and CT

PET-CT: Tube current as low as possible

− usage of local body-weight adjusted low dose protocol with i.v. contrast in the

parenchymal phase

− reconstruction FOV adapted to patient size (markedly < 500 mm)

− reconstruction of 5 mm or thinner slices in transversal orientation

− (4mm or thinner if patient < 15 kg)

− additional image reconstruction in 5 mm slices in coronal orientation (if possible

separately for neck, thorax and abdomen)

− in case of spinal involvement additional reconstruction in sagittal image orientation

(3mm or thinner slice thickness).



Diagnostic chest-CT:

1. Usage of local dose optimizing protocol with i.v. contrast in inspiration (mAs suggestion

see (11)

2. Recommended use of breast protection shield

3. reconstruction of 5 or thinner mm slices in transversal orientation (4mm or thinner if

patient < 15 kg). Recommended two data sets (“soft tissue” and “sharp” algorithm).

4. additional image reconstruction in 5 mm slices in coronal orientation (alternative:

primary data with slice thickness ≤ 1mm)

Other MRI or CT imaging

1. all images to be sent send as DICOM to the central server (Hermes Med. Sol. Sweden)

– see image transfer

2. local reports send to secured fax number: +49 345 557 2389

Suggestions for MRI-imaging

For whole-body (PET)/MRI we propose as basic sequences T2-weighted inversion

recovery (TIRM) sequences in transversal AND coronal plane and diffusion weighted

sequence (DWI) in a transversal plane. (12).

Regional MRI-imaging

1. Neck: ≤ 5mm (T1-weighted transversal AND coronal, T2--weighted transversal, T2-

weighted inversion recovery (TIRM) coronal AND diffusion imaging transversal)

2. Chest:

a. Body mass < 30 kg use slice thickness ≤ 6 mm

b. Body mass ≥ 30kg use slice thickness. ≤ 8 mm

Gap (< 20% if possible < 10%), (T2 transversal AND coronal (if possible with fat

saturation), T1 transversal with and without i.v. contrast agent, if possible T1 coronal).

ECG and respiratory triggering (or breathhold) is recommended for chest imaging

3. Abdomen:

c. Body mass < 30 kg use slice thickness ≤ 6 mm

d. Body mass ≥ 30kg use slice thickness. ≤ 8 mm



Gap < 20% if possible < 10%, (T2 transversal AND coronal, T1 transversal with and without

i.v. contrast agent (dynamic liver imaging if possible) if possible T1 coronal).

Respiratory triggering (or breathhold) is recommended for imaging of the abdomen.

3.5. Image transfer

Decision on stage, treatment level and response is made by central review. Central review is

provided by the EuroNet-PHL study centre in Gießen/Halle/Leipzig (or for patients from

Austria: Vienna).

For the reference reading all images (i.e. all data and all slices) at Im1, Im2, Im3 and ImR

(PET/MRI, PET/CT, PET, MRI, CT, bone scan) have to be transferred in DICOM format to a

central server. This server is operated and technically supported by Hermes Med. Sol.

Stockholm, Sweden.

A data transfer network between most involved clinics was established with support from the

European Union (EAHC funded project “Paediatric Hodgkin Network”). Images can be sent

via:

- Hermes application X-port (program installed on the client PC)

- Hermes application Gold3Upload (program on the server)

- Any sFTP capable software

For all three options a personal account is needed. The data transfer is encrypted and

secured via https. The process is approved by the responsible data safety authority in

Germany (see data protection plan, version 2012-1-27). For organization and technical

support of image transfer contact HERMES Medical Solutions, Skeppsbron 44 1130

Stockholm, Sweden; +46 8 19 03 25; [email protected], refer to ‘’Hodgkin

project“

3.6. Assessment of involvement and response by Central Review Board

3.6.1. Initial staging

Every patient requires a FDG-PET examination before starting any therapy (imaging1 = Im1).

In exceptional emergency cases FDG-PET should be performed as soon as possible after

starting prednisone prephase.

The process described below is done by central review.



At central review in the study office at Gießen/Halle/Leipzig (Austria: Vienna) the images are

evaluated in 28 regions (Table 3). During the interdisciplinary tumour board CT or MRI findings

for each region are presented by the radiologist and PET findings by the nuclear physician.

Thereafter, status of each region (involved or not involved) is assessed according to the

definitions described below (see also protocol section). Based on these results, stage is

determined and volume of the largest nodal mass (see below) is measured.

3.6.1.1. Independent Lymph node regions

Please also refer to section 12.2.2 of trial protocol and for a more detailed region description refer to Appendix 1: Definition of independent lymph node regions and extranodal lesions.

Independent lymph node regions are:

- Waldeyer’s ring (left and right)

- cervical (left and right) with sub-regions relevant for irradiation:

o upper neck: above upper margin of the hyoid bone

o lower neck: below upper margin of the hyoid bone above lower margin of

cricoid cartilage

- supraclavicular (left and right) (below lower margin of cricoid cartilage above fossa

jugularis or lateral above Vena subclavia)

- infraclaviular (left and right): (below M. pectoralis major or minor)

- axillar (left and right): lateral of the M. pectoralis major or minor

- lung hilus (left and right): bronchopulmonary lymph nodes

- mediastinum with sub-regions relevant for irradiation:

o upper mediastinum: fossa jugularis to carina

o lower mediastinum: below carina to upper edge of the diaphragm

- supradiaphragmatic (left and right): diaphragmatic recesses (below upper edge of the

diaphragm but still above diaphragm)

- spleen

- splenic hilus

- liver hilus (porta hepatis)

- mesenteric: mesentery or mesocolon

- paraortic:

o upper (above the renal hilus)

o lower (at or below the renal hilus)

- iliac (left and right): below aortic bifurcation to inguinal ligament

- inguinal (left and right): below inguinal ligament



3.6.1.2. Definition of involvement

Please also refer to section 12.1 of trial protocol

Lymph node involvement If the largest diameter of a lymph node or a lymph node conglomerate

is smaller than 1 cm the region is considered not involved – independent of the PET result. Small

tumour lesions do not impair therapy results according to previous experience.

− If a lymph node or a lymph node conglomerate has a diameter of 1.0 – 2.0 cm the region

is considered involved only if it is FDG-PET positive.

− If the largest diameter of a lymph node or a lymph node conglomerate exceeds 2.0 cm the

region is considered involved – independent of the PET result.

Waldeyer’s ring

Involvement is defined by clinical assessment preferably by ENT physician. Biopsy is not required.

Spleen involvement

Spleen involvement is assumed if

− focal PET positive lesion are confirmed by CT or MRI or ultrasound

or

− tumour suspicious multiple small focal changes in the spleen structure are detected by

ultrasound – irrespective of the FDG-PET result.

Note: Exclusive spleen involvement without other lymphatic disease is classified as stage I. Assessment of E-lesions

An E-lesion is a per continuum infiltration from a lymph node mass into extra-lymphatic structures or organs (e.g. lung, bone).

Pleura involvement

Involvement of the pleura is assumed if

− an adjacent nodal lesion infiltrates the pleura or chest wall AND

− the infiltrate and/or the adjacent nodal lesion is PET positive

− Note that a pleural effusion is not considered to be an E-lesion,

Pericardial involvement

Pericardial involvement is assumed if

− adjacent nodal lesion infiltrates the pericardium AND



− the infiltrate and/or the adjacent nodal lesion is PET positive

− Note that - a pericardial effusion is not considered to be an E-lesion.

Organ involvement

Disseminated organ involvement always implies stage IV.

Lung involvement

Disseminated lung involvement is assumed if

− there are more than two foci >2 mm and <10 mm within the whole lung

or

− at least one intrapulmonary focus has a diameter of ≥10 mm

− (Please note: If all lesions are exclusively on one side of the lung, only this side is involved)

Even if only one additional smaller focus (>2mm) is found on the other side of the lung,

both sides are considered involved). Completely calcified nodules are not considered to

be caused by Hodgkin’s disease.

Liver involvement

Liver involvement is assumed if focal PET positive lesions are confirmed by CT or MRI or ultrasound.

Skeletal involvement

Bone marrow involvement is assumed, if

− More than 2 lymphoma-typical PET-positive lesions are found in skeleton, irrespective

of positivity in CT or MRI (13)

Bone involvement is assumed, if

− a PET positive skeletal lesion is located in spine, pelvis or upper parts of femora or

humeri and shows tumour-typical correlation in CT

(or increased uptake in bone scan if CT is not assessable)

3.6.1.3. Definition of bulk – Measurement of largest nodal tumor mass

Bulk is present if the volume of the largest contiguous lymph node mass is ≥ 200 ml



Please note: In the mediastinum the total volume of the initial tumour mass in the upper,

middle and lower mediastinum and both hili and both supradiaphragmatic recesses is

considered contiguous due to the complex anatomic structure.

Volumes are measured in CT or MRI based on the largest perpendicular diameters on

multiplanar reconstruction mode (A*B*C / 2).

3.6.2. Early and Late response assessment (ERA/LRA)

Every patient requires an imaging (= Im2) after the second cycle of OEPA. The PET

examination has to be done at day 14 – 17 after last dose of Prednisone/Prednisolone, which

is day 28 – 31 of the second OEPA.

Im3 for late response assessment is performed only in patients in treatment level TL-2 and TL-

3 with a positive qPET (see below) at Im2.

Response PET examinations are evaluated in direct comparison with the staging PET.

Images have to be co-registered and displayed in corresponding transversal, coronal and

sagittal slices (Hermes Hybrid viewer e.g.). Assessment of PET/MRI or PET/CT examinations

is done by synchronized evaluation of PET images, MRI or CT images and fused images. Use

same camera systems, if possible.

All initially involved regions are systematically checked to detect visibly enhanced FDG uptake

in a residual tumour mass. In all regions with a visibly detectable residual FDG uptake the

qPET value is determined by:

qPET

For qPET calculation a special software application is used (qPET, Hermes Med. Sol.). The

area with enhanced FDG uptake is labelled. The program automatically outlines the contour

of the volume with enhanced uptake, identifies the voxel with the highest SUV and checks the

surrounding of this voxel to identify the four hottest connected voxels. These four voxels are

highlighted and their mean SUV value is calculated to determine the SUVpeak of the tumour

residuum.



Figure 1: Semiautomatic region growing and calculation of SUVpeak

Residuum using qPET software

(Hermes Med. Sol. Sweden

To calculate the SUVmean of the liver a predefined squared box with a volume of 30 ml is

placed in the middle of the liver. In case of focal lesions in the liver the volume of interest has

to be placed outside of these lesions. The mean SUV of this volume is calculated automatically

Figure 2: Semiautomatic calculation of SUVmeanLiver.

A detailed explanation of the qPET method and its use for response evaluation in lymphoma

patients has been published (14).



3.6.2.1. Definition of response groups at ERA (LRA)

If no tumour progression is detected, response groups are defined as follows:

Inadequate response (IR)

− Visual Deauville 4+ which corresponds to ERA qPET-positive ≥ 1.3 and/or

− Poor bulk response (volume reduction < 50 %) and/or

− A nodal site has a largest diameter of ≥ 2 cm and is not assessable by qPET due to brown

fatty tissue.

Adequate response (AR)

− No IR criterion is fulfilled

Please Note: At Im3 enhanced residual uptake is considered only in residual tumour masses

≥ 1cm. At LRA the threshold is at visual Deauville 3+ which corresponds to LRA qPET-

positive ≥ 0,95.



4. REFERENCES

(1) Stauss J, Franzius C, Pfluger T, Juergens KU, Biassoni L, Begent J, Kluge R, Amthauer H,

Voelker T, Højgaard L, Barrington S, Hain S, Lynch T, Hahn K; European Association of

Nuclear Medicine. Guidelines for 18F-FDG PET and PET-CT imaging in paediatric oncology.

Eur J Nucl Med Mol Imaging 2008;35(8):1581-8

(2) Lassmann M; L. Biassoni; M. Monsieurs; C. Franzius; F. Jacobs; EANM Dosimetry and

Paediatrics Committees.The new EANM paediatric dosage card. Eur J Nucl Med Mol Imaging.

2008;35(9):1748.

(3) Lassmann M, Biassoni L, Monsieurs M, Franzius C; EANM Dosimetry and Paediatrics

Committees.The new EANM paediatric dosage card: additional notes with respect to F-18. Eur

J Nucl Med Mol Imaging. 2008;35(9):1666-8

(4) Lassmann M, Treves ST; EANM/SNMMI Paediatric Dosage Harmonization Working

Group.Paediatric radiopharmaceutical administration: harmonization of the 2007 EANM

paediatric dosage card (version 1.5.2008) and the 2010 North American consensus

guidelines.Eur J Nucl Med Mol Imaging. 2014;41:1036-41

(5) Stauss J, Hahn K, Mann M, De Palma D. Guidelines for paediatric bone scanning with

99mTc-labelled radiopharmaceuticals and 18F-fluoride. Eur J Nucl Med Mol Imaging.

2010;37(8):1621-8.

(6) Agarwal A, Nair N, Baghel NS. A novel approach for reduction of brown fat uptake on FDG

PET. Br J Radiol. 2009;82(980):626-31

(7) Parysow O, Mollerach AM, Jager V, Racioppi S, San Roman J, Gerbaudo VH. Low-dose

oral propranolol could reduce brown adipose tissue F-18 FDG uptake in patients undergoing

PET scans. Clin Nucl Med. 2007;32(5):351-7.

(8) Söderlund V, Larsson SA, Jacobsson H. Reduction of FDG uptake in brown adipose tissue

in clinical patients by a single dose of propranolol. Eur J Nucl Med Mol Imaging.

2007;34(7):1018-22.

(9) Shinya T, Fujii S, Asakura S, Taniguchi T, Yoshio K, Alafate A, Sato S, Yoshino T,

Kanazawa S. Dual-time-point F-18 FDG PET/CT for evaluation in patients with malignant

lymphoma. Ann Nucl Med. Epub 2012 Jun 13



(10) Laffon E, Adhoute X, de Clermont H, Marthan R. Is liver SUV stable over time in ¹⁸F-FDG

PET imaging? J Nucl Med Technol. 2011;39(4):258-63.

(11) Stöver B, Rogalla P. CT examinations in children; Radiologe. 2008 Mar;48(3):243-8.

(12) Hirsch FW, Sattler B, Sorge I, Kurch L, Viehweger A, Ritter L, Werner P, Jochimsen T,

Barthel H, Bierbach U, Till H, Sabri O, Kluge R. PET/MR in children. Initial clinical experience

in paediatric oncology using an integrated PET/MR scanner. Pediatr Radiol. 2013;43:860-75

(13) Purz S, Mauz-Körholz C, Körholz D, Hasenclever D, Krausse A, Sorge I, Ruschke K,

Stiefel M, Amthauer H, Schober O, Kranert WT, Weber WA, Haberkorn U, Hundsdörfer P,

Ehlert K, Becker M, Rössler J, Kulozik AE, Sabri O, Kluge R. [18F]Fluorodeoxyglucose positron

emission tomography for detection of bone marrow involvement in children and adolescents

with Hodgkin's lymphoma. J Clin Oncol. 2011;29:3523-8

(14) Hasenclever D, Kurch L, Mauz-Körholz C, Elsner A, Georgi T, Wallace H, Landman-

Parker J, Moryl-Bujakowska A, Cepelová M, Karlén J, Álvarez Fernández-Teijeiro A,

Attarbaschi A, Fosså A, Pears J, Hraskova A, Bergsträsser E, Beishuizen A, Uyttebroeck A,

Schomerus E, Sabri O, Körholz D, Kluge R. qPET - a quantitative extension of the Deauville

scale to assess response in interim FDG-PET scans in lymphoma. Eur J Nucl Med Mol

Imaging. 2014;41:1301-8

(15) Boellaard R, Delgado-Bolton R, Oyen WJ, Giammarile F, Tatsch K, Eschner W,

Verzijlbergen FJ, Barrington SF, Pike LC, Weber WA, Stroobants S, Delbeke D, Donohoe

KJ, Holbrook S, Graham MM, Testanera G, Hoekstra OS, Zijlstra J, Visser E, Hoekstra CJ,

Pruim J, Willemsen A, Arends B, Kotzerke J, Bockisch A, Beyer T, Chiti A, Krause BJ. Eur J

Nucl Med Mol Imaging. 2015 Feb;42(2):328-54

(16) Kuhnert G, Boellaard R, Sterzer S, Kahraman D, Scheffler M, Wolf J, Dietlein M,

Drzezga A, Kobe C Eur J Nucl Med Mol Imaging. 2015 Aug 18.

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EuroNet-Paediatric Hodgkin’s Lymphoma GroupImaging Manual Confidential EuroNet-PHL-C2 final 2.0, 2015-09-15 Page 6 of 18 b) Acquisition starts 60 ± 10 min p.i. of FDG (essential