Microsoft PowerPoint - Fletcher

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Microsoft PowerPoint - Fletcher

  1. 1. 1 PET/CT Dual ModalityPET/CT Dual Modality ImagingImaging –– A Win or Loss forA Win or Loss for Nuclear MedicineNuclear Medicine James W. Fletcher, M.D.James W. Fletcher, M.D. Professor of RadiologyProfessor of Radiology Director, Division of Nuclear Medicine/PETDirector, Division of Nuclear Medicine/PET Indiana/Purdue UniversityIndiana/Purdue University Indiana University School of MedicineIndiana University School of Medicine Some ObservationsSome Observations Clinical PET imaging performed with FDGClinical PET imaging performed with FDG has largely been the domain of nuclearhas largely been the domain of nuclear medicine since clinical units becamemedicine since clinical units became available in the early 1990s.available in the early 1990s. PET technology has been developedPET technology has been developed almost exclusively by professionals in thealmost exclusively by professionals in the field of nuclear medicine.field of nuclear medicine. Some ObservationsSome Observations More PET/CT dual modality imaging unitsMore PET/CT dual modality imaging units are now being sold than dedicated PETare now being sold than dedicated PET units.units. The advantages of PET/CT are inherent inThe advantages of PET/CT are inherent in the marriage of two modalities capable ofthe marriage of two modalities capable of providing the ideal combination ofproviding the ideal combination of structural and metabolic information.structural and metabolic information. Some ObservationsSome Observations PET/CT dual modality imaging is replacingPET/CT dual modality imaging is replacing dedicated PET.dedicated PET. Are there still clinical applications forAre there still clinical applications for dedicated PET?dedicated PET? PET/CECT is beginning to replacePET/CECT is beginning to replace dedicated CECT in the management ofdedicated CECT in the management of patients with cancerpatients with cancer –– ““one stopone stop”” oncologiconcologic imaging.imaging. Some ObservationsSome Observations The advantages of PET/CT associatedThe advantages of PET/CT associated improvements in ability to localize andimprovements in ability to localize and characterize disease have begun to becharacterize disease have begun to be recognized and embraced by a far largerrecognized and embraced by a far larger medical community than nuclear medicine.medical community than nuclear medicine. The Old ParadigmThe Old Paradigm As long as PET/CT dualAs long as PET/CT dual--modality imagingmodality imaging remained in the introductory mode thatremained in the introductory mode that used the CT component for justused the CT component for just attenuation correction and localization ofattenuation correction and localization of 18F18F--FDG PET abnormalities, diagnosticFDG PET abnormalities, diagnostic-- quality CT scans were not generated andquality CT scans were not generated and a formal interpretation of the CTa formal interpretation of the CT information was not required.information was not required.
  2. 2. 2 The Nuclear Medicine HedgeThe Nuclear Medicine Hedge “…….A non-contrast CT examination was performed to provide PET attenuation correction and more precise anatomic localization of identified PET abnormalities.” PossiblePossible Interpretations/ImplicationsInterpretations/Implications The CT image data is not of diagnosticThe CT image data is not of diagnostic quality and I am not going to interpret it.quality and I am not going to interpret it. The CT image data is good enough forThe CT image data is good enough for interpretation, but I am going to ignore itinterpretation, but I am going to ignore it and not report any CT findings.and not report any CT findings. The CT image data is good enough forThe CT image data is good enough for interpretation, but I am ignoring and notinterpretation, but I am ignoring and not reporting it because I have not beenreporting it because I have not been trained in crosstrained in cross--sectional imaging.sectional imaging. The New ParadigmThe New Paradigm Dual modality PET/CT is now routinelyDual modality PET/CT is now routinely performed with instruments capable ofperformed with instruments capable of providing diagnostic quality CT imageproviding diagnostic quality CT image data.data. Dual modality PET/CECT is beingDual modality PET/CECT is being performed at an increasing rate using bothperformed at an increasing rate using both IV and oral contrast agents.IV and oral contrast agents. ““oneone--stop oncologic imagingstop oncologic imaging”” The New Nuclear Medicine HedgeThe New Nuclear Medicine Hedge “…….A contrast CT examination was also performed using IV and oral contrast and the findings of this exam will be provided in a separate report. The CT exam was also used to provide PET attenuation correction and more precise anatomic localization of identified PET abnormalities” PossiblePossible Interpretations/ImplicationsInterpretations/Implications I will interpret the CT image data andI will interpret the CT image data and provide the results in a separate report.provide the results in a separate report. I am doing this for billing purposes.I am doing this for billing purposes. I am proficient in interpreting both PET and CT.I am proficient in interpreting both PET and CT. Someone else will interpret the CT imageSomeone else will interpret the CT image data and provide the results in a separatedata and provide the results in a separate report.report. I am ignoring and not reporting it because I have notI am ignoring and not reporting it because I have not been trained in crossbeen trained in cross--sectional imaging.sectional imaging. PossiblePossible Interpretations/ImplicationsInterpretations/Implications Because I can not interpret CT and theBecause I can not interpret CT and the radiologists here can not interpret PET it isradiologists here can not interpret PET it is reasonable to separate the results into tworeasonable to separate the results into two independent reports.independent reports. The results of the two separate reports willThe results of the two separate reports will somehow be integrated for the benefit of thesomehow be integrated for the benefit of the patient and referring physician.patient and referring physician.
  3. 3. 3 Problems with Dual ReportingProblems with Dual Reporting If it works at allIf it works at all ---- it probably will only workit probably will only work in an academic environment.in an academic environment. Diagnostic quality CT (CECT) image dataDiagnostic quality CT (CECT) image data must be provided to interpretingmust be provided to interpreting physicians via export to other imagephysicians via export to other image workstations (PACS).workstations (PACS). There is no PACS Standard for fusedThere is no PACS Standard for fused image data.image data. Hardware integrated images, othogonal projections,Hardware integrated images, othogonal projections, dual modality stack review are not available.dual modality stack review are not available. Ideal SolutionIdeal Solution To ensure that the patients who are examinedTo ensure that the patients who are examined with PET/CT receive the best possible care, thewith PET/CT receive the best possible care, the physician professionals interpreting thesephysician professionals interpreting these clinical studies will need to be proficient in bothclinical studies will need to be proficient in both PET and CT.PET and CT. At the highest level of integration, theseAt the highest level of integration, these physician professionals will evaluate and reportphysician professionals will evaluate and report on both the diagnosticon both the diagnostic--quality CT image dataquality CT image data and the PET image data.and the PET image data. This can be achieved only by professionals whoThis can be achieved only by professionals who are trained and experienced in both modalities.are trained and experienced in both modalities. The PET/CT GameThe PET/CT Game WinnersWinners Possess necessary trainingPossess necessary training and experience to beand experience to be proficient in interpretation ofproficient in interpretation of both PET and CT imageboth PET and CT image data by reason of properlydata by reason of properly structured GME programsstructured GME programs Obtain necessary trainingObtain necessary training and skills via CME andand skills via CME and supervised clinicalsupervised clinical experienceexperience Pass examinationPass examination LosersLosers Fail to restructure currentFail to restructure current GME programs toGME programs to incorporate appropriateincorporate appropriate missing elements and meetmissing elements and meet newly defined criteria fornewly defined criteria for proficiency in both PET andproficiency in both PET and CTCT Avoid necessary trainingAvoid necessary training and skills via CME andand skills via CME and supervised clinicalsupervised clinical experienceexperience No examinationNo examination PrizesPrizes IncreasedIncreased RVUsRVUs, technical and, technical and professional revenueprofessional revenue Full participation in evolving specialty ofFull participation in evolving specialty of ““molecularmolecular oncologiconcologic imagingimaging”” New valuable skills and knowledge forNew valuable skills and knowledge for nuclear medicine professionalsnuclear medicine professionals Partnership inPartnership in oncologiconcologic managementmanagement (and research) team(and research) team Pathways for PersonnelPathways for Personnel QualificationsQualifications ACR/SNM/SCBT&MR White paperACR/SNM/SCBT&MR White paper ACR Practice Guideline for CTACR Practice Guideline for CT SNM Guideline for PET/CTSNM Guideline for PET/CT Soon to be released and includes personnelSoon to be released and includes personnel qualifications statementsqualifications statements
  4. 4. 4 J Nucl Med 2005; 48: 1225-1239, July, 2005 SNM White PaperSNM White Paper ““As stated in the Prologue of this article,As stated in the Prologue of this article, training requirements for those seeking totraining requirements for those seeking to perform and interpret the results ofperform and interpret the results of PET/CT are controversial, and agreementPET/CT are controversial, and agreement between the ACR and the SNM has notbetween the ACR and the SNM has not been reached.been reached.”” SNM White PaperSNM White Paper ““The SNM considers the amount of onThe SNM considers the amount of on--thethe--job training in CT presentedjob training in CT presented in this proposal to be adequate for radiologists without recentin this proposal to be adequate for radiologists without recent CTCT experience and for nuclear medicine physicians to supervise andexperience and for nuclear medicine physicians to supervise and interpret a CT study performed concurrently with a PET studyinterpret a CT study performed concurrently with a PET study regardless of the protocol used.regardless of the protocol used. The ACR position is that the training outlined in this section mThe ACR position is that the training outlined in this section may well beay well be sufficient to allow adequate interpretation of the CT componentsufficient to allow adequate interpretation of the CT component ofof PET/CT for anatomic localization only, but it is not consistentPET/CT for anatomic localization only, but it is not consistent with thewith the existing ACR Practice Guideline for Performing and Interpretingexisting ACR Practice Guideline for Performing and Interpreting Diagnostic Computed Tomography and as such does not prescribeDiagnostic Computed Tomography and as such does not prescribe sufficient training for the performance and interpretation of disufficient training for the performance and interpretation of diagnosticagnostic CT. Thus, the ACR has not approved or endorsed the trainingCT. Thus, the ACR has not approved or endorsed the training requirements for diagnostic purposes.requirements for diagnostic purposes.”” The White Paper HedgeThe White Paper Hedge ““However, because PET/CT is a new andHowever, because PET/CT is a new and rapidly evolving technology, there mayrapidly evolving technology, there may well be a need to consider newwell be a need to consider new requirements for CT interpretation in therequirements for CT interpretation in the specific setting of hybrid technologiesspecific setting of hybrid technologies used by imaging specialists. Collaborativeused by imaging specialists. Collaborative discussions continue.discussions continue.”” Feasibility?Feasibility? ““In most instances, it is not feasible for aIn most instances, it is not feasible for a practicing diagnostic radiologist topracticing diagnostic radiologist to duplicate exactly the PET training that aduplicate exactly the PET training that a nuclear medicine physician receivesnuclear medicine physician receives during a nuclear medicine residency or forduring a nuclear medicine residency or for a practicing nuclear medicine physician toa practicing nuclear medicine physician to duplicate the CT training obtained in aduplicate the CT training obtained in a diagnostic radiology residency.diagnostic radiology residency.””
  5. 5. 5 Requirement ComparisonRequirement Comparison 150150 150150 3535 AA BB RR 10010088500500 AA BB NN MM CTCT CMECME PET/CTPET/CT CMECME Number ofNumber of supervised CTsupervised CT examinationsexaminations Number ofNumber of supervisedsupervised PET/CTPET/CT InterpretationsInterpretations ACR PRACTICE GUIDELINE FORACR PRACTICE GUIDELINE FOR PERFORMING AND INTERPRETINGPERFORMING AND INTERPRETING DIAGNOSTIC COMPUTED TOMOGRAPHY (CT)DIAGNOSTIC COMPUTED TOMOGRAPHY (CT) ““For nonFor non--radiologists, the completion of anradiologists, the completion of an accredited residency program in theaccredited residency program in the specialty practiced plus 200 hours ofspecialty practiced plus 200 hours of Category I CME in the performance andCategory I CME in the performance and interpretation of CT in theinterpretation of CT in the subspecialtysubspecialty where CT reading occurs, and 500 caseswhere CT reading occurs, and 500 cases interpreted and reported during the pastinterpreted and reported during the past 36 months in a supervised situation.36 months in a supervised situation.”” How Much Training & ExperienceHow Much Training & Experience Are Really Necessary?Are Really Necessary? The White Paper HedgeThe White Paper Hedge ““However, because PET/CT is a new andHowever, because PET/CT is a new and rapidly evolving technology, there mayrapidly evolving technology, there may well be a need to consider newwell be a need to consider new requirements for CT interpretation in therequirements for CT interpretation in the specific setting of hybrid technologiesspecific setting of hybrid technologies used by imaging specialists. Collaborativeused by imaging specialists. Collaborative discussions continue.discussions continue.”” What DoWhat Do YouYou Need to Know?Need to Know? Understand CT technologyUnderstand CT technology mAmA,, KvKv, pitch; Protocols; Radiation Dose, pitch; Protocols; Radiation Dose Understand use of oral and IV contrastUnderstand use of oral and IV contrast Contrast reaction managementContrast reaction management Normal crossNormal cross--sectional anatomysectional anatomy OncologicOncologic ImagingImaging Characteristics of various tumors on CTCharacteristics of various tumors on CT AppearanceAppearance Pattern of spreadPattern of spread Behavior with contrastBehavior with contrast What Else Do You Need to Know?What Else Do You Need to Know? Recognize ArtifactsRecognize Artifacts Pertinent IncidentalsPertinent Incidentals Pulmonary nodulesPulmonary nodules Aortic aneurysmsAortic aneurysms PEPE ?? CholelithiasisCholelithiasis?? ?? DiverticulitisDiverticulitis?? ? Hernias?? Hernias? …………………………..
  6. 6. 6 You Need to Know EnoughYou Need to Know Enough…….. What are Sources of CME?What are Sources of CME? There are a lotThere are a lot ACR, RSNA, SNM, CTISUSACR, RSNA, SNM, CTISUS Web basedWeb based Journal basedJournal based Professional meetingsProfessional meetings Regional educational programsRegional educational programs Where to go from here?Where to go from here? Decide if you want to become qualified toDecide if you want to become qualified to interpret and report both PET and CT.interpret and report both PET and CT. Begin process of accumulating CME hoursBegin process of accumulating CME hours via existing pathways.via existing pathways. Initiate mechanism to begin supervisedInitiate mechanism to begin supervised review of CT (PET) examinations.review of CT (PET) examinations.

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