George David

Incidental PET/CT findings in the cancer patient: How should they be managed?

BACKGROUND Despite a paucity of evidence-based guidelines, the use of PET/CT (positron emission tomography/computed tomography) in the management of cancer patients is increasing. As widespread clinical application increases, unexpected radiographic findings are occasionally identified. These incidental findings are often suspicious for a second primary malignancy. The purpose of this study was to determine the clinical impact of these incidental PET/CT findings. METHODS A query of our prospectively acquired Nuclear Medicine database was performed to identify patients with a known malignancy being staged or serially imaged with PET/CT. Patients with incidental findings suggestive of a second primary malignancy were selected. Statistical analysis was performed to determine the ability of PET/CT to identify a second primary malignancy. All PET/CT were interpreted by board certified nuclear radiologists. RESULTS Of 3,814 PET/CT scans performed on 2,219 cancer patients at our institution from January 1, 2005, to December 29, 2008, 272 patients (12% of all patients) had findings concerning for a second primary malignancy. An invasive work-up was performed on 49% (133/272) of these patients, while 15% (40/272) had no further evaluation due to an advanced primary malignancy. The remaining 36% (99/272) had no further evaluation secondary to a low clinical suspicion determined by the treating team, a clinical plan of observation, or patients lost to follow-up. Of the 133 patients evaluated further, clinicians identified a second primary malignancy in 41 patients (31%), benign disease in 62 patients (47%), and metastatic disease from their known malignancy in 30 patients (23%). The most common sites for a proven second primary malignancy were: lung (N = 10), breast (N = 7), and colon (N = 5). Investigation of these lesions was performed using several techniques, including 24 endoscopies (6 malignant). A surgical procedure was performed in 74 patients (29 malignant), and a percutaneous biopsy was performed on 34 patients (12 malignant). The overall positive predictive value for PET/CT to detect a second primary malignancy was 31% in this subgroup. At a median follow-up of 22 months, 9 of 41 patients with a second primary were dead of a malignancy, 20 were alive with disease, and 12 had no evidence of disease. CONCLUSION Incidental PET/CT findings consistent with a second primary are occasionally encountered in cancer patients. In our data, approximately half of these findings were benign, a third were consistent with a second primary malignancy or a metastatic focus, and the remainder were never evaluated due to physician and patient decision. Advanced primary tumors are unlikely to be impacted by a second primary tumor suggesting that this subset of patients will not benefit from further investigation. Our data suggests that, despite the high rate of false positivity, incidental PET/CT findings should be investigated when the results will impact treatment algorithms. The timing and route of investigation should be dictated by clinical judgment and the status of the primary tumor. Further investigation will need to be performed to determine the long-term clinical impact of incidentally identified second primary malignancies.

The predictive value of incidental PET/CT findings suspicious for breast cancer in women with non-breast malignancies

BACKGROUND On occasion, patients followed with positron emission tomographic (PET)/computed tomographic (CT) imaging for nonbreast malignancies will have incidental breast findings concerning for second primary breast cancers. The aim of this study was to determine the predictive value of PET/CT imaging to identify breast cancers in these patients. METHODS Patients with primary nonbreast malignancies and findings concerning for second primary breast cancers were identified from a prospectively acquired nuclear medicine database from January 2005 to July 2008. Chart reviews were then performed. RESULTS Nine hundred two women underwent PET/CT imaging to evaluate nonbreast malignancies. Nine women (1%) had concerning breast findings, and 5 (56%) had subsequent breast cancer diagnoses. The positive predictive value of PET/CT imaging in these patients was 63%. Evidence of compliance with current screening guidelines was present in only 22% of these patients. CONCLUSIONS The data suggest that findings concerning for an additional primary breast cancer should be evaluated and that age-appropriate screening tools should not be abandoned.

Mammographic x-ray unit kilovoltage test tool based on k-edge absorption effect

A simple tool to determine the peak kilovoltage (kVp) of a mammographic x-ray unit has been designed. Tool design is based on comparing the effect of k-edge discontinuity of the attenuation coefficient for a series of element filters. Compatibility with the mammography accreditation phantom (MAP) to obtain a single quality control film is a second design objective. When the attenuation of a series of sequential elements is studied simultaneously, differences in the absorption characteristics due to the k-edge discontinuities are more evident. Specifically, when the incident photon energy is higher than the k-edge energy of a number of the elements and lower than the remainder, an inflection may be seen in the resulting attenuation data. The maximum energy of the incident photon spectra may be determined based on this inflection point for a series of element filters. Monte Carlo photon transport analysis was used to estimate the photon transmission probabilities for each of the sequential k-edge filter elements. The photon transmission corresponds directly to optical density recorded on mammographic x-ray film. To observe the inflection, the element filters chosen must have k-edge energies that span a range greater than the expected range of the end point energies to be determined. For the design, incident x-ray spectra ranging from 25 to 40 kVp were assumed to be from a molybdenum target. Over this range, the k-edge energy changes by approximately 1.5 keV between sequential elements. For this design 21 elements spanning an energy range from 20 to 50 keV were chosen. Optimum filter element thicknesses were calculated to maximize attenuation differences at the k-edge while maintaining optical densities between 0.10 and 3.00. Calculated relative transmission data show that the kVp could be determined to within +/-1 kV. To obtain experimental data, a phantom was constructed containing 21 different elements placed in an acrylic holder. MAP images were used to determine appropriate exposure techniques for a series of end point energies from 25 to 35 kVp. The average difference between the kVp determination and the calibrated dial setting was 0.8 and 1.0 kV for a Senographe 600 T and a Senographe DMR, respectively. Since the k-edge absorption energies of the filter materials are well known, independent calibration or a series of calibration curves is not required.

Mini-micro-mainframe computer marriage: Combining technologies in a radiology results reporting system

The minicomputer-based information system in the Department of Radiology at the Medical College of Georgia Hospital and Clinics was placed in service in February, 1982. This system represents a sizable investment in minicomputer hardware in addition to more than 6 years of software customization. One serious deficiency in the original system was the lack of a radiology results reporting facility. Several options were considered to provide the department with this capability. The most obvious option was retiring the existing system and replacing it with one of a number of commercial products already offering results reporting. In-house development of a reporting facility lent itself more readily to microcomputers than to the existing minicomputer system. Due to system customization, economic and time constraints, it was decided to merge an in-house developed microcomputer-based report module into our existing minicomputer system. The minicomputer was able to communicate with and transfer files to and from both micro and mainframe systems. Combining technologies allowed us to continue taking advantage of our sizable investment in money, time, and customization while providing a microcomputer-based report module. Radiology reports are now typed on microcomputer word processors and bulk transferred to the minicomputer. The minicomputer provides access to both unapproved and approved reports on system terminals throughout the department. It also enhances reports by merging patient demographics and registration information. Using existing communications facilities to the hospital mainframe system, reports are provided throughout the institution.

Adding a microcomputer bar-code network to a minicomputer-based radiology information system

A bar-code terminal network under software control of a microcomputer was added to the minicomputer-based radiology information system at the Medical College of Georgia in Augusta. The bar-code network was specifically installed to address the inherent inaccuracies occuring when procedure information was entered at the time of registration before procedures were actually performed. Technologists now enter procedure data into bar-code terminals after procedures are performed, substantially reducing database errors. This approach allowed us to take advantage of a microcomputer product without the necessity of completely converting our highly customized information system software from minito microcomputer.

Using a computer to manage the radiation safety and quality control activities in diagnostic radiology

Software has been developed to aid in the management of a radiation safety quality control program in diagnostic radiology. The core of the system is a data base of radiation safety activities. Software design goals were the prioritization, scheduling, and reporting of these activities. Computerization has helped organize the timely performance of surveys necessary for compliance with regulatory and accreditation agencies. Clear, concise program documentation and reporting are also provided.