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To our knowledge, no prior multicenter clinical trial has reported interobserver agreement of (18)F-FDG PET/CT scans for staging of clinical N0 neck in head and neck cancer. Methods: A total of 287 participants were recruited. For visual analysis, positive nodal uptake of (18)F-FDG was defined as uptake visually greater than activity seen in the blood pool. Results: The negative predictive value of the (18)F-FDG PET/CT for N0 clinical neck was 86% or above for visual assessment (95% CI, 86%–88%) for the 2 central readers and above 90% (95% CI, 90%–95%) for SUV(max) for central reads and site reads dichotomized at the optimal cutoff value of 1.8 and the prespecified cutoff value of 3.5, respectively. The κ coefficients between the 2 expert readers and between central reads and site reads varied between 0.53 and 0.78. Conclusion: The NPV of the (18)F-FDG PET/CT for N0 clinical neck was 86% or above for visual assessment and above 90% for SUV(max) cut points of 1.8 and 3.5 with moderate to substantial agreements.

The number of cases of dementia has dramatically increased over the last decade. Imaging of the brain with PET has been used for many years, but in the past decade the radiopharmaceuticals and technology available for imaging dementia have vastly improved. In recent years, the U.S. Food and Drug Administration has approved 3 PET radiopharmaceuticals for detecting amyloid in brain, and tau PET radiopharmaceuticals are being investigated in clinical trials for use in dementia imaging. This paper will discuss different forms of dementia that can be imaged with PET, review common radiopharmaceuticals used for imaging dementia, and provide technical recommendations for performing the studies.

Over the past 20 y, PET/CT has had many technologic and developmental advancements for patient care. PET/CT has evolved from being used as a diagnosis and staging tool to now having an impact on treating cancer through a collaboration with radiation oncology. There are multiple considerations when integrating PET/CT into radiation therapy planning, such as the needs of the PET/CT center, the types of scans to offer, workflow considerations between the PET/CT center and the radiation therapy planning center, PET/CT center growth and demand on schedules, and the impact PET/CT will have on radiation treatment planning. Careful planning and implementation are important in offering patients optimum care that integrates PET/CT in radiation therapy planning.

We have previously reported that PET using (18)F-fluoride (NaF PET) for assessment of osseous metastatic disease was associated with substantial changes in intended management in Medicare beneficiaries participating in the National Oncologic PET Registry (NOPR). Here, we use Medicare administrative data to examine the association between NaF PET results and hospice claims within 180 d and 1-y survival. Methods: We classified NOPR NaF PET results linked to Medicare claims by imaging indication (initial staging [IS]; detection of suspected first osseous metastasis [FOM]; suspected progression of osseous metastasis [POM]; or treatment monitoring [TM]) and type of cancer (prostate, lung, breast, or other). Results were classified as definitely positive scan findings versus probably positive scan findings versus negative scan findings for osseous metastasis for IS and FOM; more extensive disease versus no change or less extensive disease for POM; and worse prognosis versus no change or better prognosis for TM, based on the postscan assessment. Our study included 21,167 scans obtained from 2011 to 2014 of consenting NOPR participants aged 65 y or older. Results: The relative risk of hospice claims within 180 d of a NaF PET scan was 2.0–7.5 times higher for patients with evidence of new or progressing osseous metastasis than for those without, depending on indication and cancer type (all P < 0.008). The percentage difference in hospice claims for those with a finding of new or more advanced osseous disease ranged from 3.9% for IS prostate patients to 28% for FOM lung patients. Six-month survival was also associated with evidence of new or increased osseous disease; risk of death was 1.8–5.1 times as likely (all P ≤ 0.0001), with percentage differences of approximately 30% comparing positive and negative scans in patients with lung cancer imaged for IS or FOM. Conclusion: Our analyses demonstrated that NaF PET scan results are highly associated with subsequent hospice claims and, ultimately, with patient survival. NaF PET provides important information on the presence of osseous metastasis and prognosis to assist patients and their physicians when making decisions on whether to select palliative care and transition to hospice or whether to continue treatment.

The Centers for Medicare and Medicaid Services coverage includes 3 posttherapy 18F-FDG PET/CT scans per patient and per tumor type. Any additional follow-up 18F-FDG PET/CT scans will be reimbursed at the discretion of a local Medicare administrator, if deemed medically necessary. This study aimed to investigate common clinical indications for performing a fourth or additional follow-up 18F-FDG PET/CT scans that could affect the management of patients. Methods: This was a retrospective institutional review of 433 oncology patients (203 men; mean age, 55 y), including a total of 1,659 fourth or subsequent follow-up PET/CT scans after completion of primary treatment. Twelve indications for performing a fourth or subsequent follow-up PET/CT scan were determined, and the impact of each of the 12 indications on patients' management was evaluated. Results: The primary tumors were breast cancer (92 patients, 426 scans), non-Hodgkin lymphoma (77 patients, 208 scans), Hodgkin disease (41 patients, 182 scans), colorectal cancer (70 patients, 286 scans), melanoma (69 patients, 271 scans), and lung cancer (84 patients, 286 scans). The indications were categorized in 4 groups: PET/CT for diagnosis of tumor recurrence (303/1,659, 18.3%), PET/CT before starting therapy for tumor recurrence (64/1,659, 3.9%), PET/CT to assess therapy response for tumor recurrence (507/1,659, 30.6%), and follow-up PET/CT after completion of treatment for tumor recurrence (785/1,659, 47.3%). Overall, fourth and subsequent follow-up 18F-FDG PET/CT scans resulted in change in management in 31.6% of the scans (356 of 1,128) when the scans were obtained for medical necessities (indications 1-11), and in 5.6% of the scans (30/531) when the scans were obtained without any medical necessity (indication 12). Conclusion: The fourth and subsequent PET/CT scans obtained after completion of primary treatment led to a change in management in 31.6% of the scans when acquired for appropriate clinical reasons. Performing follow-up PET/CT without appropriate medical reason had a low impact on patients' management and should be avoided.

We have previously reported that PET with (18)F-fluoride (NaF PET) for assessment of osseous metastatic disease led to changes in intended management in a substantial fraction of patients with prostate or other types of cancer participating in the National Oncologic PET Registry. This study was performed to assess the concordance of intended patient management after NaF PET and inferred management based on analysis of Medicare claims. Methods: We analyzed linked post–NaF PET data of consenting National Oncologic PET Registry participants age 65 y or older from 2011 to 2014 and their corresponding Medicare claims. Post–NaF PET treatment plans, including combinations of 2 modes of therapy, were assessed for their concordance with clinical actions inferred from Medicare claims. NaF PET studies were stratified by indication (initial staging [IS] or suspected first osseous metastasis [FOM]) and cancer type (prostate, lung, or other cancers). Agreement was assessed between post–NaF PET intended management plans for treatment (surgery, radiotherapy, or systemic therapy) within 90 d for lung and 180 d for prostate or other cancers, and for watching (the absence of treatment claims for ≥60 d) as compared with claims-inferred care. Results: Actions after 9,898 scans were assessed. After NaF PET for IS, there was claims agreement for planned surgery in 76.0% (19/25) lung, 75.4% (98/130) other cancers, and 58.9% (298/506) prostate cancer. Claims confirmed chemotherapy plans after NaF PET done for IS or FOM in 81.0% and 73.5% for lung cancer (n = 148 and 136) and 69.4% and 67.5% for other cancers (n = 111 and 228). For radiotherapy plans, agreement ranged from 80.0% to 84.4% after IS and 68.4% to 74.0% for suspected FOM. Concordance was greatest for androgen deprivation therapy (ADT) (86.0%, n = 308) alone or combined with radiotherapy in prostate cancer IS (80.8%, n = 517). In prostate FOM, the concordance across all treatment plans was lower if the patients had ADT claims within 180 d before NaF PET. Agreement with nontreatment plans was high for FOM (87.2% in other cancers and 78.6% if no prior ADT in prostate) and low after IS (40.7%–62.5%). Conclusion: Concordance of post–NaF PET plans and claims was substantial and higher overall for IS than for FOM.

The purpose of this study was to evaluate the added value of a fourth and subsequent follow-up PET/CT scans to clinical assessment and impact on patient management in patients with colorectal cancer. Methods: This was an institutional review board–approved, retrospective study. Eight hundred twenty-two patients with biopsy-proven colorectal cancer, who underwent 18F-FDG PET/CT, were identified from 2000 to 2012. Among these, 73 (8.9%) patients underwent 4 or more follow-up PET/CT scans, with a total of 313 fourth and subsequent follow-up PET/CT scans. Median follow-up from the fourth follow-up PET/CT scan was 41.7 mo. The added value of each follow-up PET/CT scan, for clinical assessment and the treatment changes subsequent to each follow-up PET/CT scan, was established. Overall survival prediction was established using Kaplan–Meier plots with a Mantel–Cox log-rank test. Results: Of the 313 fourth and subsequent follow-up PET/CT scans, 174 (55.6%) were interpreted as positive and 139 (44.4%) were interpreted as negative for recurrence or metastases. Thirty-four (46.6%) patients died during the study period. PET/CT identified recurrence or metastasis in 40.0% of scans obtained without prior clinical suspicion and ruled out disease in 23.6% of scans obtained with prior clinical suspicion. The PET/CT scan resulted in treatment change after 34.2% (107/313) of the scans. New treatment was initiated after 24.0% (75/313) of the scans, and treatment was changed after 8.0% (25/313) scans. There was a statistically significant difference in the overall survival between patients with a positive and all negative fourth and subsequent follow-up PET/CT scans at the patient level (log-rank, P = 0.001). Conclusion: The fourth and subsequent 18F-FDG PET/CT scans obtained after primary treatment completion add value to clinical assessment and the management plan and provide prognostic information in patients with colorectal cancer.

Founded in 1951, the Joint Commission, formerly known as the Joint Commission on Accreditation of Healthcare Organizations and, previous to that, the Joint Commission on Accreditation of Hospitals, is a United States–based nonprofit organization that accredits more than 20,000 health care

The Centers for Medicare and Medicaid Services recently ruled that only 3 posttherapy follow-up 18F-FDG PET/CT scans are funded for a tumor type per patient and any additional follow-up PET/CT scans will be funded at the discretion of the local Medicare administrator. The purpose of this study was to evaluate the added value of 4 or more follow-up PET/CT scans to clinical assessment and impact on patient management. Methods: This was an institutional review board–approved, retrospective study. A total of 1,171 patients with biopsy-proven lung cancer who had undergone 18F-FDG PET/CT at a single tertiary center from 2001 to 2013 were identified. Among these, 85 patients (7.3%) had undergone 4 or more follow-up PET/CT scans, for a total of 285 fourth and subsequent follow-up PET/CT scans. Median follow-up from the fourth follow-up PET/CT scan was 31.4 mo (range, 0–155.2 mo). The follow-up PET/CT scan results were correlated with clinical assessment and treatment changes. Results: Of the 285 fourth and subsequent follow-up PET/CT scans, 149 (52.28%) were interpreted as positive and 136 (47.7%) as negative for recurrence or metastasis. A total of 47 patients (55.3%) died during the study period. PET/CT identified recurrence or metastasis in 44.3% of scans performed without prior clinical suspicion and ruled out recurrence or metastasis in 24.2% of scans performed with prior clinical suspicion. The PET/CT scan resulted in a treatment change in 28.1% (80/285) of the patients. New treatment was initiated for 20.4% (58/285) of the scans, treatment was changed in 5.6% (16/285), and ongoing treatment was stopped in 2.1% (6/285). Conclusion: The fourth and subsequent 18F-FDG PET/CT scans performed during follow-up after completion of primary treatment added value to clinical assessment and changed management 28.1% of the time.

18 F-FDG PET/CT is used in the follow-up of patients with head and neck squamous cell cancer (HNSCC). However, its impact on clinical decision making and patient outcome is not fully established. The objective of this study was to determine the prognostic value of 18 F-FDG PET/CT for overall survival (OS) of HNSCC patients when performed in addition to clinical assessment between 4 and 24 mo after treatment. Methods: This was a retrospective study at a single tertiary center. The institutional review board approved this study, and the requirement to obtain informed consent was waived. The study included 134 biopsy-proven HNSCC patients with 227 followup PET/CT scans. The primary outcome measure was OS. Median follow-up was 40 mo (range, 7–145 mo). Survival is presented as Kaplan–Meier plots with Mantel–Cox log-rank test. The multivariate Cox model included clinical covariates. Results: Of the 227 PET/CT scans, 41 (18%) were positive for tumor and 186 (82%) were negative for tumor. PET/CT identified recurrence in 5% (9/194) of scans performed without prior clinical concern and ruled out tumor in 51.5% (17/33) of scans performed to evaluate clinical suspicion or uncertainty of recurrence. The median survival of PET-positive and -negative groups from the date of the scan was 20 and 30.5 mo, respectively (P , 0.0001). There was a significant difference in OS from the scan date between patients who had a positive PET/CT result for tumor and those who had a negative result (log-rank, P , 0.0001), with a hazard ratio of 29.74. Human papillomavirus status (P 5 0.001) and PET/CT result (P 5 0.04) were the only factors significantly associated with OS, adjusted for all other covariates. Conclusion: 18FFDG PET/CT performed between 4 and 24 mo after treatment adds value to clinical assessment at the time of the study, especially when there is clinical suspicion or uncertainty, and can serve as a prognostic marker of OS in HNSCC.

Oncologic 18F-FDG PET/CT is rapidly gaining acceptance in clinical practice. However, the referring physician’s attitude toward the usefulness of this diagnostic modality is unknown. This survey was undertaken to collect information regarding the current perspective of referring physicians on oncologic PET/CT. Methods: We conducted a prospective worldwide, Web-based survey of physicians who manage cancer patients. A total of 963 referring physicians completed a 20-question survey focused on their experience with oncologic 18F-FDG PET/CT. Attention was directed toward their confidence about indications, their satisfaction with related educational resources, the quality of interaction with interpreting physicians, and practical problems encountered. The respondents included oncologists (38.5%, n = 371), hematologists (16.4%, n = 158), radiation oncologists (9.0%, n = 87), surgeons (30.3%, n = 292), and other physicians (5.7%, n = 55). Results: Only 25.2% of respondents considered the oncologic 18F-FDG PET/CT indications to be well established and defined. Frequent uncertainty about the need for a PET scan was indicated by 62.3% of the respondents. High cost and overinterpretation of findings were the most commonly reported concerns (47.0% and 40.9%, respectively). The experience and skill level of the interpreting physician was considered very important by 96.8% of the surveyed physicians. Conclusion: Referring physicians expressed considerable uncertainty about the appropriate use of oncologic PET/CT. Additional major concerns are procedure costs and quality of interpretation. The responses suggest a strong need for efforts to educate referring and interpreting physicians about the appropriate use of 18F-FDG PET/CT in oncology.

18F-FDG metabolic tumor volume (MTV) and total glycolytic activity (TGA) have been proposed as potential prognostic imaging markers for patient outcome in human solid tumors. The purpose of this study was to establish whether MTV and TGA add prognostic information to clinical staging in patients with oral and oropharyngeal squamous cell carcinomas (SCCs). Methods: The Institutional Review Board approved this Health Insurance Portability and Accountability Act–compliant single-institution retrospective study. Forty-five patients with histologically proven oral or oropharyngeal SCC underwent PET/CT for initial cancer staging and were included in the study. MTV was measured using a gradient-based method (PET Edge) and fixed-threshold methods at 38%, 50%, and 60% of maximum standardized uptake value (SUV). The TGA is defined as MTV × mean SUV. Bland–Altman analysis was used to establish the reliability of the methods of segmentation. Outcome endpoints were overall survival (OS) and progression-free survival. Cox proportional hazards univariate and multivariate regression analyses were performed. Results: In Cox regression models, MTV and TGA were the only factors significantly associated with survival outcome after adjusting for all other covariates including American Joint Committee on Cancer (AJCC) stage, with hazards ratio of 1.06 (95% confidence interval, 1.01–1.10; P = 0.006) and 1.00 (95% confidence interval, 1.00–1.01; P = 0.02). The model fit was significantly better when MTV was added to AJCC stage in model I (χ2 value change, 1.16–6.71; P = 0.01) and when TGA was added to AJCC stage in model II (χ2 value change, 1.16–4.37; P = 0.04). The median cutoff point of 7.7 mL for primary tumor MTV was predictive of time to OS (log rank P = 0.04). The median cutoff point of 55 g for PET Edge primary tumor TGA was predictive of time to OS (log rank P = 0.08), though the result was not statistically significant. Conclusion: Gradient-based segmentations of primary tumor MTV and TGA are potential 18F-FDG markers for time to survival in patients with oral and oropharyngeal SCC and may provide prognostic information in addition to AJCC stage. These exploratory imaging markers need validation in larger cohort studies.