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Oncology PET Studies
SYNOPTIC - STRUCTURED REPORT - KEY ELEMENTS
STRUCTURED TEMPLATES
The written report is the final product of the Nuclear Medicine consultation. Reports must contain specific information to identify the patient, the specific procedure, indications for the examination, radiopharmaceutical used and activity administered, route of administration, interval between tracer administration and imaging, succinct technical information about data acquisition and processing (especially the use and dose of additional drugs such as adenosine, CCK, morphine, lasix, etc), specific image and data analysis findings, and a conclusion.
The report should be concise, clear and specific. Standard anatomic designations and physiologic descriptors should be used. Jargon terms, such as "defect" or "photopenia", should not appear in the report. When possible, lesions should be specifically enumerated, physical size measured, and uptake quantified. When lesions are very numerous, the major areas of involvement should be specifically identified. When previous examinations are available, the improvement, progression or stability of disease should be identified. Examples of specific reports are contained with a description of each of the imaging procedures.
GENERAL STRUCTURE
The following elements should be included in all reports:
Patient identifier: Name, gender, birth date, medical record number
Date procedure started and date reported
Procedure Title
Indication: Brief statement of clinical problem and question to be answered
Technical factors: Radiopharmaceutical, dose, route of administration, type of scan, interval between injection and imaging, interventions
Reference to prior examination of the same type
Reference to other procedures
Findings: Address clinical question first.
Interpretation: As definitive as possible and avoid repetition of findings.
[18F]FDG PET/CT PERFORMED [date] – Example 1
Clinical Statement: [55] year old [woman/man] with lymphoma and renal failure (dialysis dependent for 2 years) for staging.
Radiopharmceutical: [XX] mCi [18F]FDG
Comparison: [none]
Correlation: CT Scan performed [DATE]
Technique: Following intravenous administration of [18F]FDG and a waiting time of [60] minutes, images were recorded from the [mid skull] to the [mid thigh] on the [YYY] PET/CT scanner. Oral contrast was administered during the uptake interval.
Plasma Glucose at the time of injection was [XX] mg/dL.
The standardized uptake values are normalized to the patient’s body weight, and indicate the highest activity concentration (SUVmax) at a given site.
Findings:
Head/Face: [Physiologic uptake in the brain and large salivary glands]
Neck: [There is no abnormal uptake in the thyroid]
Chest: [Intense focal uptake is present in both axillae, SUV 15.2. The uptake sites correspond to enlarged (3x4cm) axillary nodes seen on CT. Physiologic [18F]FDG uptake is seen in the myocardium, and residual blood pool
Lungs: [No Abnormal Uptake]
Pleura/Pericardium: [No Abnormal Uptake]
Thoracic Nodes: [No abnormal uptake]
Abdomen and Pelvis: [The kidneys are not seen on the PET scan. The kidneys appear small on CT. Physiologic uptake is present in the bowel, liver (average SUV -2.5), spleen, and excreted activity is seen in the urinary bladder]
Bones and Soft Tissues: [No abnormal uptake]
Impression: Focal uptake in axillary
[18F]FDG PET/CT PERFORMED [date] – Example 2
Clinical Statement: 50-year-old male with metastatic melanoma of unknown primary.
Radiopharmaceutical: 15.9 mCi F-18 FDG.
Technique: Following intravenous injection of F-18 FDG and an approximately 60 minute uptake period, images were acquired on the Biograph PET/CT. Low dose CT and PET images were obtained from mid skull to the upper thighs. Oral contrast was also administered. The CT protocol used in the PET/CT scanner is used for attenuation correction and anatomic localization of PET abnormalities. Blood glucose level at the time of this test was: 112 mg/dl.
Comparison: PET/CT from November 5, 2008.
Correlation: CT of the chest, abdomen and pelvis from March 3, 2009 and MR of the right foot from February 28, 2009
Findings: In the plantar side of the right foot a hypermetabolic mass is identified with a SUV max of 19.5 (previously 29.8). The mass increased in size from 3.2 x 2.8 cm to 4.4 x 4.0 cm. No other hypermetabolic foci are identified in the lower extremities. Asymmetry of uncertain significance is seen in the ischial tuberosities, probably benign. No other focus of concern is identified. No subcutaneous masses. Liver, spleen, kidneys, pancreas and adrenal glands are unremarkable on the limited CT. There is physiologic radiotracer uptake in the visualized parts of the brain, heart, liver, spleen and bowel. No focal activity is observed in the lungs. Excreted tracer is visualized in the kidneys and urinary bladder. Activity at the right upper arm represents contamination.
Interpretation: Since November 5, 2008. 1. Decreasing hypermetabolic activity but increasing size of the right plantar mass. 2. Asymmetry in both ischial bones with increased uptake in the left tuberosity of uncertain significance, likely benign.