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25 18F-FDG-Directed Surgery and 18F-FDG-Directed Interventional Procedures
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427
F-FDG-avid
18
lesions, but not specifi ed for
DTCM for GDP: T/B ratio
DTCM for BDP: T/B ratio
Reported T/B ratios: 1.78:1
GDP
BDP
IOST: NS
IPT: NS
IPOSIT: ND
(74 and
185 MBq)
which probe type
and 1.53:1 for
DTCM for GDP: T/B ratio
DTCM for BDP: T/B ratio
HEGDP
BDP
IOST:
178–240 min
(±3.2) mCi
Reported identifi ed 3 of 5
IPT: NS
(Mean, 540
F-FDG-avid lesions, but not
specifi ed for which probe type
18
IPOSIT: ND
(±118)
MBq)
F-FDG-avid
18
Reported range T/B ratios:
1.2:1–10:1 for
lesions, but not specifi ed for
which probe type
F-FDG-avid lesions
18
Reported mean(range) T/B
Reported mean(range) T/B
ratios in vivo: 1.40:1
(0.76:1–2.59:1) for
F-FDG-avid lesions
18
ratios ex vivo: 2.44:1
(1.18:1–7.89:1) for
GDP DTCM for GDP: T/B ratio
IOST:
≈30 min
IPT: NS
(4.5–14.2)
mCi (Mean,
265
(165–526)
MBq)
F-FDG-
18
avid lesions (cumulatively
from in situ and ex vivo T/B
ratios
ratio ≥ 1.5:1
Reported T/B ratio ≥ 1.5:1
identifi ed 40 of 40
Reported mean (range) T/B
HEGDP DTCM for HEGDP: T/B
IOST: 1–4 h
IPT: NS
IPOSIT: ND
Range,
7–10 mCi
(Range,
259–
370 MBq)
F-FDG-
18
F-FDG-avid lesions
18
Reported mean (range) T/B
ratios ex vivo: 2.1:1
(1.5:1–3.3:1) for
ratios in situ:
1.9:1 (1.4:1–2.5:1) for
(continued)
avid lesions
2 Cervical 2 and 5 mCi
Taiwan
Yen [ 32 ] 2004 Taoyuan,
5 Melanoma Mean, 14.6
Francisco,
36 ] 2005 San
Franc [
CA, USA
10 Thyroid Mean, 7.2
France
37 , 41 ] 2005, 2007 Nantes,
[
Kraeber-
Bodéré
lymphoma,
melanoma,
40 Breast, colorectal,
Monica, CA,
USA
38 , 43 ] 2006 Santa
Gulec [
seminoma, thyroid
428
https://t.me/med1917
Injection-to-
S.P. Povoski et al.
F-FDG-
18
F-FDG- avid
18
F-FDG-avid lesions with
18
DTCM for GDP: Three-
sigma criteria and T/B ratio
lesions
avid lesions
Reported range T/B ratios:
ex vivo for primary tumor site
IPT: NS
in 10 of 10 cases and T/B
IPOSIT: ND
nodes in 8 of 10 cases
ratio ≥ 2.0:1 ex vivo for lymph
ratio ≥ 1.5:1
Reported T/B ratio ≥ 1.5:1
HEGDP DTCM for HE GDP: T/B
IOST: 2–6 h
IPT: NS
IPOSIT: ND
Detection threshold criteria
method (DTCM) and ndings
for
Probe
operation start
time
Injection-to-
probing time
Injection-to-
postoperative
specimen
Reported T/B ratio ≥ 3.0:1
probe(s)
GDP DTCM for GDP: T/B ratio
type(s)
IOST: “within
4 h”
imaging time
1.5 to 3.8 for
identifi ed 24 of 25
GDP
IOST: NS
HEGDP
IPT: mean
F-FDG-avid
18
DTCM for HEGDP:
three-sigma criteria and T/B
ratio
Reported
(range): 286
(176–532)
minutes
IPOSIT: mean
F-FDG-avid lesions was
18
lesions identifi ed in 156 of
157 patients, but the details
for identifi cation of the
(range): 389
(86–741)
minutes on
diagnostic
not specifi cally delineated
scanner and
according to probe type or
DTCM
mean (range):
458 (272–656)
minutes on
micro scanner
F-FDG dose
18
Known malignancies
in patients evaluated
Number of
patients
(370 MBq)
10 Lung 10 mCi
USA
Range,
5–15 mCi
(Range,
185–
555 MBq)
breast, carcinoma of
unknown primary,
colorectal, gastric,
GIST, head and neck,
lung, lymphoma,
25 Adrenocortical,
USA
melanoma, ovarian,
thyroid
Mean, 15.1
(4.6–26.1)
mCi (Mean,
559
(170–966)
colorectal, eccrine,
endometrial, head
and neck, lung
lymphoma,
157 Breast, cervical,
OH, USA
2007–2015 Columbus,
MBq)
melanoma, ovarian,
plasmacytoma,
sarcoma, thyroid,
urothelial
Table 25.1 (continued)
42 , 43 ] 2007 Goshen, IN,
Nwogu [ 40 ] 2006 Buffalo, NY,
Primary
author Reference(s) Year(s) Location(s)
Gulec [
6 , 44 ,
Povoski [
46 – 51 , 53 , 54 , 56 , 67 , 71 , 73 – 76 ]
25 18F-FDG-Directed Surgery and 18F-FDG-Directed Interventional Procedures
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429
F-FDG-
18
DTCM for HEGDP: NS
DTCM for BDP: T/B
HEGDP
BDP
IOST: NS
IPT: mean
Range,
1–3 mCi
identifi ed 16 of 17
ratio ≥ 1.5:1
Reported T/B ratio ≥ 1.5:1
(range): 184
(19–365)
minutes
(Range,
36.6–
110.6 MBq)
18
avid lesions for BDP
Reported mean (range) T/B
ratios ex vivo: 6.6:1
IPOSIT: ND
F-FDG-
avid lesions for BDP
(1.3:1–17.2:1) for
probing performed, and only
postoperative specimen
imaging performed)
ND ND (no intraoperative
IOST: ND
IPT: ND
IPOSIT:
median
(0.92–1.24)
mCi
(Median, 36
F-FDG-avid lesion(s)
18
was identifi ed in 5 of 5 cases
on postoperative specimen
imaging
The
(range): 180
(150–300)
minutes
(34–46)
MBq)
F-FDG-avid lesion(s)
18
was identifi ed in 5 of 5 cases
on postoperative specimen
probing performed, and only
postoperative specimen
imaging performed)
The
imaging
ND ND (no intraoperative
IOST: ND
IPT: ND
IPOSIT: mean
(range): 195
(169–223)
minutes
Range,
15–20 mCi
(Range,
555–
740 MBq)
(continued)
F-FDG-avid lesions
18
Reported that HEGDP
correctly identifi ed 14
HEGDP DTCM for HEGDP: NS
IOST: 3–4 h
IPT: NS
IPOSIT: ND
Range,
10–12 mCi
(Range,
370–
444 MBq)
esophageal, gastric,
gastroesophageal,
melanoma, thyroid
17 Breast, colorectal,
Germany
Piert [ 45 , 52 ] 2007 Munich,
5 Lung Median, 0.97
The
Netherlands
55 ] 2008 Maastricht,
[
Van
Baardwijk
polyps
5 Colorectal, colonic
NY, USA
57 ] 2009 New York,
Gollub [
lymphoma,
10 Breast, gastric,
Florida,
[ 58 ] 2009 Miami,
a
Molina
melanoma
USA
430
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S.P. Povoski et al.
F-FDG-
18
F-FDG-avid
18
F-FDG-avid lesions with
18
lesions, with T/B
ratio ≥ 5.0:1 in all cases
identifi ed in 4
ratio ≥ 1.5:1
Detection threshold criteria
method (DTCM) and ndings
for
probe(s)
Reported T/B ratio ≥ 1.5:1
ratio
18
Reported T/B ratios: 4.4:1
F-FDG-avid
lesions
and 2.2:1 for
ratio
avid lesions
identifi ed 14 of 16
Reported T/B ratio ≥ 1.5:1
F-FDG-avid
18
lesions
Reported range T/B ratios:
1.5–2.5 for
Injection-to-
HEGDP DTCM for HEGDP: T/B
Probe
type(s)
IOST: 3 h
IPT: NS
operation start
time
Injection-to-
probing time
Injection-to-
postoperative
specimen
imaging time
F-FDG dose
18
Known malignancies
in patients evaluated
Number of
patients
IPOSIT: ND
body weight
(5 MBq/kg
3 Testicular 0.14 mCi/kg
body weight)
HEGDP DTCM for HEGDP: T/B
IOST: NS
IPT: NS
IPOSIT: ND
16.6 mCi
(422 and
HEGDP DTCM for HEGDP: T/B
IOST: 3–5 h
IPT: NS
IPOSIT: ND
614 MBq)
Mean, 10.0
(9.5–10.5)
mCi (Mean,
thyroid
2 Melanoma 11.4 and
7 Colorectal, ovarian,
370
(352–389)
MBq)
Table 25.1 (continued)
Primary
De Jong [ 61 ] 2010 Groningen,
author Reference(s) Year(s) Location(s)
Germany
Francisco,
62 ] 2010 San
Lee [
CA, USA
Spain
64 ] 2011 Barcelona,
García [
25 18F-FDG-Directed Surgery and 18F-FDG-Directed Interventional Procedures
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F-FDG-avid
F-FDG-avid
18
ratio >1.3:1
Reported mean (range) T/B
ratios ex vivo for confi rmed
lesions
tumor sites: 1.51:1 (1.17:1–
4.03:1) for
18
Reported mean (range) T/B
ratios ex vivo for confi rmed
benign sites: 1.14 (1.01
:1–1.48:1) for
lesions
DTCM for GDP: NS
DTCM for HEGDP: NS
No specifi c probe
localization data was
F-FDG-avid
18
reported
lesions in 9 of 9 patients
Reported that HEGDP
identifi ed
F-FDG-avid lesion identifi able
18
431
HEGDP DTCM for HEGDP: T/B
IOST: mean
(range): 228
(134–395)
minutes
IPT: NS
IPOSIT: ND
(6.1–15.4)
mCi (Mean,
363
(227–570)
MBq)
12 Thyroid Mean, 9.8
GDP
HEGDP
least 2 h”
4 Thyroid NS IOST: “at
IPT: NS
HEGDP DTCM for HEGDP: NS
IPOSIT: ND
IOST: ≈4 h
IPT: NS
IPOSIT: ND
0.095 mCi/
kg body
weight
(3.5 MBq/kg
esophageal, skin,
lymphoma,
melanoma, thyroid
9 Breast, colorectal,
body weight)
F-FDG fl uorine-18 fl uorodeoxyglucose, GDP gamma detection probe, GIST gastro-
18
F-FDG-avid lesion
18
F-FDG-directed surgery (and with 2 patients having no
18
Seoul, and
Jeju, Korea
Kim [ 65 ] 2011 Dauegu,
AK, USA
68 ] 2012 Little Rock,
Francis [
Hershey, PA,
USA
The
Netherlands
70 ] 2012 Amsterdam,
Vos [
F-FDG-directed surgery)
25.1 in which there were multiple reports from the same institution and in which it appeared that the study patients were derived from the same
18
25.1 represent those reported series with greater than one reported patient in their series, and for which any additional references representing single
F-FDG-avid lesions identifi ed from among a total of 10 patients undergoing
18
Personal communication from Manuel A. Molina (Lakeland Regional Cancer Center, Lakeland, Florida, USA, manmolina@hotmail.com, February 25, 2015) confi rms a total
standardized uptake value, T/B ratio target-to-background ratio for detection of
overall patient population, these reported series were combined under the name of the predominant primary author from that institution, and the total “number of patients” from
that institution was estimated as based upon the available data within all the reports from that same institution which appeared to be derived from the same overall patient
population
case reports and/or review papers from the same institution were also added to any reported series with greater than one reported patient in their series
For all reported series in Table
All reported series in Table
Abbreviations : BDP beta plus detection probe, DTCM detection threshold criteria method,
intestinal stromal tumor, HEGDP high-energy gamma detection probe (“PET probe”), IOST injection-to-operation start time, IPOSI injection-to-postoperative specimen imaging
time, IPT injection-to-probing time, MBq megabecquerels, mCi millicuries, NS not clearly specifi ed in the reported series, ND not done in the reported series, SUVmax maximum
of 14
a
with the HEGDP at the time of
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18
Injection-to-scan
F-FDG-
avid lesion
SUVmax
time
Injection- to-
procedure time
F-FDG dose
18
Known malignancies
in patients evaluated
NS
IST:
60–180 min
IPT: NS
Range, 0.08–
0.19 mCi/kg
body weight
(Range,
3–7 MBq/kg
lung, lymphoma,
melanoma, ovarian,
sarcoma
3.9–19.1
IST:
61–78 min
IPT: ≈120 min
body weight)
Mean, 20.6
(16.6–23.9) mCi
(Mean, 762
lung, melanoma,
ovarian, lymphoma
1.5–23.1
IST:
78–130 min
IPT: ≈120 min
Mean, 14.7
(10.4–16.8) mCi
(Mean, 544
(614–884) MBq)
(385–622) MBq)
esophageal, lung,
ovarian, sarcoma
NS
IST:
40–143 min
(for pre-
ablation scan)
IPT: NS
Pre-ablation
dose: median, 4.2
(3. 6–4.4) mCi
(median, 155
(133–163) MBq)
endometrial, head
and neck,
hepatocellular, lung,
melanoma, pancreas,
IST: NS (for
post-ablation
assessment
scan)
Post-ablation
assessment dose:
median 8.4
(7.6–8.8) mCi
(median 310
sarcoma
S.P. Povoski et al.
3.5–27.6
IST:
≈60 –90 min
IPT: NS
(281–326) MBq)
Range, 8–12 mCi
(Range,
296–444 MBq)
unknown primary,
cervical, colorectal,
gastric, head and
neck, lung,
lymphoma,
melanoma, other,
prostate,
Number of
patients
Interventional
procedure
Biopsies 28 Breast, cervical,
F-FDG-directed diagnostic and interventional procedures
18
Switzerland
Biopsies 12 Breast, colorectal,
USA
12 Breast, colorectal,
Biopsies and
ablations
USA
Ablations 23 Colorectal,
USA
Biopsies 126 Breast, carcinoma of
Parcanà, Brazil
2011–2014 Boston, MA,
79 , 80 ] 2009, 2010 Bern,
81 ] 2011 Boston, MA,
82 , 83 , 89 ,
90 ]
85 , 86 ] 2013 New York, NY,
[ 87 , 91 ] 2013, 2014 Curitiba,
a
Primary
Table 25.2 All reported published series for real-time
author Reference(s) Year(s) Location(s)
Klaeser [
Tatli [
Shyn [
Ryan [
Cerci
25 18F-FDG-Directed Surgery and 18F-FDG-Directed Interventional Procedures
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NS
1.9–44.4
IST: 60 min
IPT: NS
IST:
35–183 min
IPT: NS
5 mCi
(185 MBq)
Mean, 6.9
(3.9–13.2) mCi
(Mean, 255
(144–288) MBq)
lymphoma, prostate
endometrial,
esophageal, gastric,
germ cell, head and
neck, lung,
lymphoma,
melanoma, pancreas,
plasmacytoma,
prostate, renal cell,
sarcoma, skin, small
bowel, thyroid, vulva
433
Biopsies 4 Esophageal,
Biopsies 105 Breast, colorectal,
CA, USA
USA
95 ] 2014 New York, NY,
Aparici [ 88 , 92 , 93 ] 2013, 2014 San Francisco,
Cornelis [
25.2 in which there were multiple reports from the same institution and in which it appeared that the study patients were derived from the same
25.2 represent those reported series with greater than one reported patient in their series, and for which any additional references representing single
F-FDG fl uorine-18 fl uorodeoxyglucose, IPT injection-to-procedure time, IST injection-to-scan time, MBq megabecquerels, mCi millicuries, NS not clearly
18
overall patient population, these reported series were combined under the name of the predominant primary author from that institution, and the total “number of patients” from
that institution was estimated as based upon the available data within all the reports from that same institution which appeared to be derived from the same overall patient
population
case reports and/or review papers from the same institution were also added to any reported series with greater than one reported patient in their series
For all reported series in Table
All reported series in Table
Abbreviations :
specifi ed in the reported series, SUVmax maximum standardized uptake value
Cerci et al. [ 91 ] mention “update of our group’s result” as “217 PET/CT-guided biopsies performed,” but without formal presentation of accompanying data
a
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S.P. Povoski et al.
Subsequent to the fi rst report of 18 F-FDGdirected surgery in 1999 [ 6 , 26 , 27 ], multiple
groups of investigators from across the globe
have collectively investigated the utility of realtime 18 F-FDG-directed surgery and real-time
18 F-FDG-directed diagnostic and therapeutic
interventional procedures in regard to a wide
range of solid malignancies, including colorectal
cancer, gastric cancer, gastroesophageal cancer,
pancreatic cancer, melanoma, lymphoma, breast
cancer, ovarian cancer, endometrial cancer, cervical cancer, vulvar cancer, testicular cancer, prostate cancer, head and neck malignancies
(squamous cell cancer of the oral cavity, oropharynx, hypopharynx, and laryngeal regions, iodinenegative recurrent papillary thyroid cancer, and
recurrent medullary thyroid cancer), lung cancer,
squamous cell cancer of the skin, GIST (gastrointestinal stromal tumor tumors), sarcoma, adrenocortical carcinoma, and carcinoma of unknown
primary [ 6 , 28 – 95 ]. Table 25.1 summarizes all
reported real-time 18 F-FDG-directed surgery
series in the literature [ 6 , 26 – 76 ]. Table 25.2
summarizes all reported real-time 18 F-FDGdirected diagnostic and therapeutic interventional
procedure series in the literature [ 6 , 77 – 95 ]. It is
worth noting a substantial portion of the clinical
investigations into the use of 18 F-FDG for realtime detection and guidance during cancer surgery for a variety of solid malignancies have been
conducted at the Ohio State University
(Columbus, Ohio, USA) [ 6 , 26 – 28 , 44 , 46 – 51 ,
53 , 54 , 56 , 59 , 67 , 71 – 76 ].
Our own experience with utilizing 18 F-FDG
for real-time cancer detection and guidance
within the operating room at the Ohio State
University (Columbus, Ohio, USA) [ 6 , 26 – 28 ,
44 , 46 – 51 , 53 , 54 , 56 , 59 , 67 , 71 – 76 ] has strength-
ened our long-standing contention regarding the
importance of implementing a multimodal imaging and detection approach to 18 F-FDG-directed
surgery [ 50 , 67 , 74 , 76 ]. Since 2005, the general
structure of this multimodal approach has incorporated various components, including (1) sameday preoperative patient diagnostic whole-body
PET/CT imaging, (2) intraoperative gamma
detection probe assessment, (3) specimen imaging of surgically resected specimens with both a
clinical PET/CT unit and a micro PET/CT unit,
(4) radioactivity counting of selected portion of
surgically resected specimens by an automatic
gamma well counter, and (5) same-day postoperative patient diagnostic limited fi eld-of-view
PET/CT imaging [
67 ].
On the day of the anticipated 18 F-FDGdirected surgery procedure, patients fasted for a
minimum of 6 h before undergoing the same-day
preoperative diagnostic whole-body 18 F-FDG
PET/CT scan [ 67 , 74 ]. Each patient received a
same-day, single-dose, preoperative, intravenous
injection of 18 F-FDG, consisting of an averaged
recommended dose in the range of approximately
15 mCi (555 MBq). The 18 F-FDG dosing at the
Ohio State University (Columbus, Ohio, USA)
was based upon the standard-of-care practice
guidelines set in the USA by the Society of
Nuclear Medicine, the American College of
Radiology, and the Society for Pediatric
Radiology for diagnostic 18 F-FDG PET/CT
image acquisition (i.e., 10–20 mCi (370–
740 MBq) of 18 F-FDG in adults) [ 128 , 129 ]. The
same-day, single-dose, preoperative, intravenous
dose of 18 F-FDG was generally administered
approximately 75 min prior to the planned time
of the same-day preoperative diagnostic wholebody 18 F-FDG PET/CT scan, which was
performed within the time frame recognized by
the standard-of-care practice guidelines set in the
USA by the Society of Nuclear Medicine, the
American College of Radiology, and the Society
for Pediatric Radiology for diagnostic
18
F-FDG
PET/CT image acquisition [ 128 , 129 ]. The same-
day preoperative diagnostic whole-body 18 F-FDG
PET/CT scan usually consisted of 6–8 fi eld-ofview PET bed positions and with 2 min of PET
imaging for each fi eld-of-view PET bed position.
Patients then proceeded to the operating room for
their anticipated surgical procedure and completed standard postoperative recovery in the
postanesthesia care unit. The same-day postoperative diagnostic limited fi eld-of-view 18 F-FDG
PET/CT scan was generally restricted to those
fi eld-of-view PET bed positions encompassing
the immediate area of the surgical fi eld (usually
consisting of 1–3 fi eld-of-view PET bed positions, in order to limit overall patient radiation
25 18F-FDG-Directed Surgery and 18F-FDG-Directed Interventional Procedures
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435
exposure for the CT portion of the PET/CT, and
with 10 min of PET imaging for each fi eld-ofview PET bed position).
Our multimodal imaging and detection
approach to 18 F-FDG-directed surgery at the
Ohio State University (Columbus, Ohio, USA)
[ 50 , 67 , 74 , 76 ] demonstrated technical and logis-
tical feasibility for coordination of services by
the surgeon, nuclear medicine physician, and
pathologist in a same-day fashion. It allowed for
(1) real-time intraoperative staging of the extent
of disease; (2) real-time intraoperative surgical
planning and execution of the necessary and most
appropriate operation, determination of the extent
of surgical resection, and determination of the
completeness of surgical resection; (3) real-time
pathologic evaluation of intact surgical resected
specimens for the confi rmation of completeness
of surgical resection and for surgical margin
assessment; and (4) real-time pathologic evaluation of diagnostically biopsied tissues for confi rmation of correctness of tissue diagnosis.
25.6 Timing Issues Related
18
F-FDG-Directed Surgery:
to
Impact of Length of Time
18
from Injection of
F-FDG
to the Performance
of Intraoperative Gamma
Detection Probing
Numerous investigators have evaluated the concept of delayed phase and dual-time-point diagnostic 18 F-FDG PET imaging [ 74 ] in which a
portion of the diagnostic 18 F-FDG PET imaging
sequence is extended temporally out further than
is generally recommended by the standardof- care practice guidelines for diagnostic
18 F-FDG PET/CT image acquisition [ 128 , 129 ].
Remarkably, several of these groups of investigators have performed delayed phase diagnostic
18 F-FDG PET imaging out to ultra-extended
injection-to-scan acquisition time intervals ranging to 6–9 h after the initial 18 F-FDG injection
dose is administered [ 31 , 74 , 130 – 134 ].
In contrast to the innumerous work done on
extended injection-to-scan acquisition time
18
intervals for diagnostic
F-FDG PET imaging,
there has been very little data or discussion in the
literature regarding the equivalent scenario of
extended injection-to-probing time intervals as it
pertains to gamma detection probing of patients
intravenously injected with 18 F-FDG [ 31 , 38 , 42 ,
43 , 74 ]. Therefore, it is reasonable to say that the
optimal length of time from the injection of 18 FFDG to the performance of intraoperative gamma
detection probing has yet to be determined.
In 2004, Higashi et al. [ 31 , 74 ] examined the
question of “appropriate timing” for “postinjection” gamma detection probing using phantom
studies and a limited series of 3 patients with
“superfi cially located malignant lesions.” For the
phantom studies, they used 5 liter plastic barrels
fi lled with saline containing varying-dose “background” 18 F-FDG as the “body trunk” phantom,
0.2 liter plastic bottles fi lled with saline containing varying-dose 18 F-FDG as the “kidney” phantom, and 2 fi xed-dose 18 F-FDG sources to simulate
“superfi cially located tumor nodules.” For the 3
patients with “superfi cially located malignant
lesions,” they performed “preoperative” gamma
detection probing at the skin surface at 1, 3, 5, 6,
and/or 7 h after receiving an intravenous injection
of 2–10 mCi (74–370 MBq) of 18 F-FDG (and for
which no intraoperative gamma detection probing
was undertaken). In their limited patient data set,
they showed that the tumor-to-background ratios
of 18 F-FDG by gamma detection probing at the
skin surface remained relatively stable at the measured time intervals and remained relatively stable
up to the 7-h postinjection time interval. However,
they were concerned that the overall lower
18
FFDG count rates encountered at time intervals of
6–7 h postinjection of 18 F-FDG, secondary to the
normal physical decay pattern of 18 F-FDG,
“would be problematic” when applied to a clinical
application of intraoperative gamma detection
probing. Therefore, they concluded that the clinical application of intraoperative gamma detection
probing was “more suitable” at 1–3 h postinjection of 18 F-FDG as compared to 6–7 h postinjection of 18 F-FDG.
In 2006 and 2007, Gulec et al. [ 38 , 42 , 43 , 74 ]
reported on two consecutive series of patients,
including 40 patients undergoing intraoperative
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S.P. Povoski et al.
gamma detection probing after receiving an intravenous injection of 7–10 mCi (259–370 MBq) of
18 F-FDG [ 38 ] and 25 patients undergoing intraoperative gamma detection probing after receiving an intravenous injection of 5–15 mCi
(185–555 MBq) of 18 F-FDG [ 42 ]. In both series,
Gulec et al. [ 38 , 42 , 43 ] reported observing a
nonsignifi cant trend toward an increased tumorto- background ratio of 18 F-FDG as the duration
of time from the 18 F-FDG injection to performing
intraoperative gamma detection probing
increased, with satisfactory count rates and lesion
detection capabilities up to 6 h of time after injection of 18 F-FDG. Therefore, regarding intraoperative gamma detection probing during
18 F-FDG-directed surgery, they concluded that
longer injection-to-probing time intervals “accentuated” the tumor-to-background ratio of 18 FFDG and resulted in “better lesion detection”
[ 38 , 42 ]. However, they also stated that “more
delayed intervals between FDG injection and
imaging might compromise image quality as a
result of lower count rates” [ 42 ].
Most recently, in 2014, our group at the Ohio
State University (Columbus, Ohio, USA) [ 74 ]
examined the question of extended injection-toscan acquisition time intervals in a retrospective
data analysis of a subset of patients undergoing
18 F-FDG-directed surgery. This data analysis
specifi cally looked at preoperative 18 F-FDG
PET/CT imaging and postoperative 18 F-FDG
PET/CT imaging of 32 individual 18 F-FDG-avid
lesions (from among a total of 7 patients) which
were not surgically manipulated or altered dur-
18
ing
F-FDG-directed surgery, and, for which, all
of these 32 individual 18 F-FDG-avid lesions
were visualized on both same-day preoperative
18 F- FDG PET/CT imaging and same-day postoperative 18 F-FDG PET/CT imaging. In this retrospective data analysis, both 18 F-FDG-avid
lesions and their corresponding background tissues were assessed on same-day preoperative
and postoperative 18 F-FDG PET/CT scans. This
data analysis demonstrated several important
time- dependent observations. First, 18 F-FDG
PET/CT imaging performed at extended injection-to-scan acquisition times of up to a mean
time of 530 min (i.e., approximately fi ve half-
18
lives for
F-FDG) was able to maintain a designation of good/adequate diagnostic image
quality deemed necessary for clinical interpretation. Second, the mean 18 F-FDG-avid lesion
SUV
value increased signifi cantly from pre-
max
operative to postoperative 18 F- FDG PET/CT
imaging (mean 18 F-FDG-avid lesion SUV
max
value; 7.7 preoperative to 11.3 postoperative; P
<0.001). Third, mean background SUV
max
value
decreased signifi cantly from preoperative to
postoperative 18 F-FDG PET/CT imaging (mean
background SUV
value; 2.3 preoperative to
max
2.1 postoperative; P = 0.017). Fourth, the mean
lesion-to-background SUV
ratio increased
max
signifi cantly from preoperative to postoperative
18 F-FDG PET/CT imaging (mean lesion-tobackground SUV
ratio; 3.7 preoperative to 5.8
max
postoperative; P <0.001).
The far-reaching implications of these collective time-dependent observations [ 74 ] appear
highly infl uential for guiding future direction in
18 F-FDG-directed procedural and surgical applications, as well as 18 F-FDG PET/CT oncologic
imaging. First and foremost, these timedependent observations justify the more widespread and integrated, real-time use of diagnostic
18 F-FDG PET/CT imaging in conjunction with
18 F-FDG-directed interventional radiology diagnostic biopsy procedures and therapeutic ablation
procedures, as well as with 18 F-FDG-directed
surgical procedures. These sorts of integrated,
real-time utilities for diagnostic
18
F-FDG PET/
CT imaging would facilitate periprocedural verifi cation of appropriate tissue targeting during
18 F-FDG-directed interventional radiology diagnostic biopsy procedures and therapeutic ablation
procedures and for perioperative verifi cation of
appropriate tissue targeting and completeness of
resection during 18 F-FDG-directed surgical procedures. Secondly but still importantly, these
time-dependent observations could have farreaching impact on potentially reshaping future
thinking regarding what represents the “most
optimal” injection-to-scan acquisition time interval for all routine diagnostic 18 F-FDG PET/CT
oncologic imaging.
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