Canadian Partnership for Quality Radiotherapy



Canadian Partnership for Quality RadiotherapyTechnical Quality Control Guidelinesfor use of Positron Emission Tomography – Computed Tomography (PET/CT) in Radiation Treatment PlanningA guidance document on behalf of:Canadian Association of Radiation OncologyCanadian Organization of Medical PhysicistsCanadian Association of Medical Radiation TechnologistsCanadian Partnership Against CancerSeptember 20, 2019PET.2019.09.01cpqr.caDisclaimerAll information contained in this document is intended to be used at the discretion of each individual centre to help guide quality and safety program improvement. There are no legal standards supporting this document; specific federal or provincial regulations and license conditions take precedence over the content of this document. As a living document, the information contained within this document is subject to change at any time without notice. In no event shall the Canadian Partnership for Quality Radiotherapy (CPQR) or its partner associations, the Canadian Association of Radiation Oncology (CARO), the Canadian Organization of Medical Physicists (COMP), and the Canadian Association of Medical Radiation Technologists (CAMRT), be liable for any damages, losses, expenses, or costs whatsoever arising in connection with the use of this document.Expert ReviewersRan Klein, PhDDepartment of Nuclear Medicine, The Ottawa Hospital, Ottawa, Ontario, CanadaMike Oliver, PhD, MCCPMHealth Sciences North, Sudbury, Ontario, CanadaDan La Russa, PhD, FCCPMRadiation Medicine Program, The Ottawa Hospital, Ontario, CanadaJohn Agapito, MS, MCCPMWindsor Regional Hospital, Windsor, Ontario, CanadaStewart Gaede, PhD, MCCPMLondon Health Sciences Centre, London, Ontario, CanadaJeanPierre Bissonnette, PhD, MCCPM, FCOMPPrincess Margaret Cancer Centre, Toronto, Ontario, CanadaArman Rahmim, PhD, DABSNMBC Cancer, Vancouver, British Columbia, CanadaCarlos Uribe, PhD, MCCPMBC Cancer, Vancouver, British Columbia, CanadaIntroductionThe Canadian Partnership for Quality Radiotherapy (CPQR) is an alliance amongst the three key national professional organizations involved in the delivery of radiation treatment in Canada: the Canadian Association of Radiation Oncology (CARO), the Canadian Organization of Medical Physicists (COMP), and the Canadian Association of Medical Radiation Technologists (CAMRT), together with financial and strategic backing from the Canadian Partnership Against Cancer (CPAC) which works with Canada’s cancer community to reduce the burden of cancer on Canadians. The vision and mandate of the CPQR is to support the universal availability of high quality and safe radiotherapy for all Canadians through system performance improvement and the development of consensus-based guidelines and indicators to aid in radiation treatment program development and evaluation.This document contains detailed performance objectives and safety criteria for Positron Emission Tomography for Radiation – Computed Tomography Treatment Planning (PET/CT for RTP). Please refer to the overarching document Technical Quality Control Guidelines for Canadian Radiation Treatment Centres ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"SiS2hKfU","properties":{"formattedCitation":"({\\i{}1})","plainCitation":"(1)","noteIndex":0},"citationItems":[{"id":2520,"uris":[""],"uri":[""],"itemData":{"id":2520,"type":"webpage","title":"Canadian Partnership for Quality Radiotherapy, Technical Quality Control","URL":"","language":"en-US","accessed":{"date-parts":[["2019",6,9]]}}}],"schema":""} (1) for a programmatic overview of technical quality control, and a description of how the performance objectives and criteria listed in this document should be interpreted.In the RTP process, physiological information from positron emission tomography (PET) can be used to inform target delineation and identify metabolically active regions for possible dose escalation. Information from PET scans can also be used to help spare healthy tissue, further boosting the probability of complication-free cure. PET based radiation treatment planning, however, is a relatively new application that is not yet commonly utilized and requires quality control measures that are incremental to that of routine diagnostic PET. This report reviews current quality control guidelines for combined PET and x-ray CT for radiation treatment planning to produce a consolidated list of quality control tests for PET-based radiation treatment planning. These incremental quality control activities are relatively few and should not pose a major obstacle for expending the use of PET to radiation treatment planning.System DescriptionRadiation therapy aims to accurately deposit a prescribed amount of radiation dose to target volumes while sparing surrounding disease-free tissues. To achieve this goal, the radiological properties of the patient anatomy must be accurately represented in the treatment planning system for dose-calculation purposes. This anatomical information, along with delineated target and avoidance structures, is routinely derived from CT-simulator images. Modern, hybrid PET/CT system combine a PET sub-system to generate 3D images of functional processes in the body and a co-registered CT sub-system. The CT generates attenuation images for anatomical lesion localization while allowing for accurate photon attenuation correction of the PET images. These hybrid systems are often equipped with fully diagnostic CT scanners that can also serve as CT-simulators for RTP. With the addition of a flat table top and isocentre lasers, these hybrid systems could well fulfill the requirements for CT simulation. Four perceived methods of PET/CT for RTP can be envisioned in order of technical complexity and treatment accuracy:Side-by-side visualization of the diagnostic PET/CT data and a second CT-simulator image, whereby the radiation oncologist manually definition of treatment volumes on the CT-simulator image using the PET/CT for guidance, as accurate image registration is challenging. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"rbVdrHnh","properties":{"formattedCitation":"({\\i{}2})","plainCitation":"(2)","noteIndex":0},"citationItems":[{"id":1868,"uris":[""],"uri":[""],"itemData":{"id":1868,"type":"article-journal","title":"PET/CT and radiotherapy: data transfer, radiotherapy workflow and quality assurance","container-title":"The quarterly journal of nuclear medicine and molecular imaging: official publication of the Italian Association of Nuclear Medicine (AIMN) [and] the International Association of Radiopharmacology (IAR), [and] Section of the Society of...","page":"476-489","volume":"54","issue":"5","source":"PubMed","abstract":"The development of new technologies in radiation therapy has made it possible to introduce more sophisticated techniques that can deliver the prescribed dose with more conformation and accuracy and to apply dose escalation protocols without increasing the risk of healthy tissue damage. This has consented the simultaneous delivery of different dose levels to different parts of the target, making it possible to boost those tumour sub-volumes that are considered more radio resistant. The use of PET for radiotherapy planning purposes has become increasingly important in the last few years, because of its ability to provide valuable biologic and functional data. PET imaging can affect the treatment strategy definition and improve the target delineation and the assessment of therapy response. The most attractive aspect is the perspective to deliver differential doses inside target volumes for areas of different biologic behaviour based on functional imaging, moving closer to the goals of biologically conformal radiation therapy. Each single step of PET/CT-guided radiotherapy workflow, needs to be performed following high standard procedures, within a rigorous and appropriate quality assurance protocol to minimize the sources of errors and to maximize the efficacy of PET imaging in radiation therapy, ensuring safe and effective use of the technology. The present paper focuses on aspects concerning the use of PET/CT in radiation treatment process, with the aim to delineate different possible approaches to its clinical application and to highlight the critical aspects of the various subprocesses.","ISSN":"1824-4785","note":"PMID: 20927015","title-short":"PET/CT and radiotherapy","journalAbbreviation":"Q J Nucl Med Mol Imaging","language":"eng","author":[{"family":"Fioroni","given":"F."},{"family":"Iotti","given":"C."},{"family":"Paiusco","given":"M."},{"family":"Versari","given":"A."},{"family":"Grassi","given":"E."},{"family":"Salvo","given":"D."},{"family":"Iori","given":"M."}],"issued":{"date-parts":[["2010",10]]}}}],"schema":""} (2) This method relies on existing practices and does not leverage the full power of modern PET/CT for RTP and simulation. It is limited by low operator reproducibility and accuracy.Software based registration of the PET/CT study with the CT-simulator image to guide the definition of treatment volumes. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"OvQBcpXk","properties":{"formattedCitation":"({\\i{}3})","plainCitation":"(3)","noteIndex":0},"citationItems":[{"id":2518,"uris":[""],"uri":[""],"itemData":{"id":2518,"type":"article-journal","title":"Use of image registration and fusion algorithms and techniques in radiotherapy: Report of the AAPM Radiation Therapy Committee Task Group No. 132","container-title":"Medical Physics","page":"e43-e76","volume":"44","issue":"7","source":" (Crossref)","DOI":"10.1002/mp.12256","ISSN":"00942405","title-short":"Use of image registration and fusion algorithms and techniques in radiotherapy","journalAbbreviation":"Med. Phys.","language":"en","author":[{"family":"Brock","given":"Kristy K."},{"family":"Mutic","given":"Sasa"},{"family":"McNutt","given":"Todd R."},{"family":"Li","given":"Hua"},{"family":"Kessler","given":"Marc L."}],"issued":{"date-parts":[["2017",7]]}}}],"schema":""} (3) In theory, this approach overcomes the above limitations. Registration between images is usually achieved by affine registration between the two CTs and is aided by consistent patient positioning in the RT posture. While deformable, non-rigid image registration that can compensate for inconsistent patient positioning is an ongoing topic of research, routine clinical application is not yet widely feasible. Thus, inaccurate image registration limits the accuracy of target delineation and subsequent treatment planning.Acquisition of the PET/CT data with the patient in the RTP configuration and using this data for target volume delineation and planning without the need for an additional CT-simulator image. This method aims to fully exploit the information in PET/CT both for target delineation and RTP dose calculations, but also requires a flat table top and a wall-mounted laser alignment system be installed in the PET/CT imaging suite to accurately register the patient in the treatment planning system and RT treatment machine. To date, widespread adoption of PET/CT-simulators has been limited by workflow constraints and lack of reimbursement. Nevertheless, this method is proposed as a feasible option due to the recent trend towards clinical utilization of PET/CT-simulators, the decreased cost in FDG, and because the QC testing required for this method encompasses the requirements for methods 1 and 2 above. It should be appreciated, however, that incorporating the entire RT simulation process into the PET/CT image acquisition workflow, which often includes the design and application of immobilization devices and patient indexing, can result in prolonged PET/CT appointment times. This will undoubtedly reduce patient throughput on PET imaging systems and risk increases to staff exposures ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"FGKf3nPg","properties":{"formattedCitation":"({\\i{}4})","plainCitation":"(4)","noteIndex":0},"citationItems":[{"id":2469,"uris":[""],"uri":[""],"itemData":{"id":2469,"type":"article-journal","title":"Workflow and radiation safety implications of (18)F-FDG PET/CT scans for radiotherapy planning","container-title":"Journal of Nuclear Medicine Technology","page":"175-177","volume":"40","issue":"3","source":"PubMed","abstract":"The use of (18)F-FDG PET/CT for radiotherapy planning may lead to better tumor volume definition. Reproduction of the patient's position when setting up an (18)F-FDG PET/CT scan for radiotherapy planning is more accurate if a radiation therapist is involved. The aim of this study was to compare setup time and staff radiation dose between radiation therapists and nuclear medicine technologists.\nMETHODS: Forty patients with newly diagnosed head and neck or non-small cell lung cancer were prospectively recruited into this study. Twenty patients (10 with head and neck cancer and 10 with non-small cell lung cancer) underwent (18)F-FDG PET/CT for radiotherapy planning, and 20 patients (10 with head and neck cancer and 10 with non-small cell lung cancer) underwent (18)F-FDG PET/CT for staging. Setup time was measured, and a radiation monitor recorded the highest dose (μSv/h) to staff during setup.\nRESULTS: For radiation therapists, the mean setup time for a lung scan (in min:s) was 5:22 ± 2:11 (range, 2:22-9:23), with a highest dose of 4.94 ± 3.78 μSv (range, 2.02-15.23 μSv), and the mean setup time for a head and neck scan was 4:49 ± 1:45 (range, 2:03-8:21), with a highest dose of 3.93 ± 1.45 μSv (range, 1.19-6.83 μSv). For nuclear medicine technologists, the mean setup time for a lung scan was 1:58 ± 0:24 (range, 1:17-2:38), with a highest dose of 3.30 ± 1.28 μSv (range, 1.92-5.47 μSv), and the mean setup time for a head and neck scan was 2:12 ± 0:38 (range, 1:03-3:16), with a highest dose of 3.10 ± 1.78 μSv (range, 1.56-7.49 μSv).\nCONCLUSION: This study showed that setup time and operator radiation dose were greater for radiation therapists setting up planning (18)F-FDG PET/CT scans than for nuclear medicine technologists setting up routine (18)F-FDG PET/CT scans. These results have implications for scheduling of radiotherapy planning PET/CT; however, the additional radiation dose was not considered to be significant.","DOI":"10.2967/jnmt.111.099440","ISSN":"1535-5675","note":"PMID: 22582005","journalAbbreviation":"J Nucl Med Technol","language":"eng","author":[{"family":"Sam","given":"Sithoeun"},{"family":"Shon","given":"Ivan Ho"},{"family":"Vinod","given":"Shalini K."},{"family":"Lin","given":"Peter"},{"family":"Lin","given":"Michael"}],"issued":{"date-parts":[["2012",9]]}}}],"schema":""} (4).A viable alternative to combining the RT simulation and PET/CT image acquisition processes is to first perform RTP on a CT simulator and then replicate patient positioning in the PET/CT. These procedures should include steps for converting the PET/CT system to accommodate a flat table top and patient immobilization device that can be rapidly consistently, and safely deployed. Special considerations should be given to potentially smaller bore sizes of PET/CT systems that may limit patient positioning. This approach to acquiring PET/CT images will facilitate accurate image registration for treatment planning CT images ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"rmsJdyjc","properties":{"formattedCitation":"({\\i{}5}\\uc0\\u8211{}{\\i{}7})","plainCitation":"(5–7)","noteIndex":0},"citationItems":[{"id":2000,"uris":[""],"uri":[""],"itemData":{"id":2000,"type":"book","title":"The role of PET/CT in Radiation Treatment Planning fo Cancer Treatment Planning","publisher":"International Atomic Energy Agency","publisher-place":"Vienna","source":"Open WorldCat","event-place":"Vienna","abstract":"This publication is a resource for nuclear medicine and radiation oncology on the coupling of positron emission tomography and X ray computed tomography (PET/CT) to more accurately identify cancer cells within the body. Besides, although radiation therapy plays an important role in cancer treatment as an effective non-invasive therapy, damage to normal cells in the vicinity of tumor cells may be detrimental to the patient's health and recovery. The joint use of PET and CT provides superior imaging of the existing disease and, therefore, promises to minimize adverse effects of radiation therapy. By more precisely marking the presence of cancerous cells, thereby facilitating more precise irradiation, it also enables an increase in the dose of radiation therapy delivered to the malignant cells, which leads to better tumor control and improved survival of patients.","URL":"","note":"OCLC: 822579697","language":"en","author":[{"literal":"Agence internationale de l'énergie atomique"}],"issued":{"date-parts":[["2008"]]},"accessed":{"date-parts":[["2018",4,20]]}}},{"id":2517,"uris":[""],"uri":[""],"itemData":{"id":2517,"type":"article-journal","title":"Use of PET and PET/CT for Radiation Therapy Planning: IAEA expert report 2006–2007","container-title":"Radiotherapy and Oncology","page":"85-94","volume":"91","issue":"1","source":" (Crossref)","abstract":"Positron Emission Tomography (PET) is a signi?cant advance in cancer imaging with great potential for optimizing radiation therapy (RT) treatment planning and thereby improving outcomes for patients. The use of PET and PET/CT in RT planning was reviewed by an international panel. The International Atomic Energy Agency (IAEA) organized two synchronized and overlapping consultants’ meetings with experts from different regions of the world in Vienna in July 2006. Nine experts and three IAEA staff evaluated the available data on the use of PET in RT planning, and considered practical methods for integrating it into routine practice. For RT planning, 18F ?uorodeoxyglucose (FDG) was the most valuable pharmaceutical. Numerous studies supported the routine use of FDG-PET for RT target volume determination in nonsmall cell lung cancer (NSCLC). There was also evidence for utility of PET in head and neck cancers, lymphoma and in esophageal cancers, with promising preliminary data in many other cancers. The best available approach employs integrated PET/CT images, acquired on a dual scanner in the radiotherapy treatment position after administration of tracer according to a standardized protocol, with careful optimization of images within the RT planning system and carefully considered rules for contouring tumor volumes. PET scans that are not recent or were acquired without proper patient positioning should be repeated for RT planning. PET will play an increasing valuable role in RT planning for a wide range of cancers. When requesting PET scans, physicians should be aware of their potential role in RT planning.","DOI":"10.1016/j.radonc.2008.11.008","ISSN":"01678140","title-short":"Use of PET and PET/CT for Radiation Therapy Planning","journalAbbreviation":"Radiotherapy and Oncology","language":"en","author":[{"family":"MacManus","given":"Michael"},{"family":"Nestle","given":"Ursula"},{"family":"Rosenzweig","given":"Kenneth E."},{"family":"Carrio","given":"Ignasi"},{"family":"Messa","given":"Cristina"},{"family":"Belohlavek","given":"Otakar"},{"family":"Danna","given":"Massimo"},{"family":"Inoue","given":"Tomio"},{"family":"Deniaud-Alexandre","given":"Elizabeth"},{"family":"Schipani","given":"Stefano"},{"family":"Watanabe","given":"Naoyuki"},{"family":"Dondi","given":"Maurizio"},{"family":"Jeremic","given":"Branislav"}],"issued":{"date-parts":[["2009",4]]}}},{"id":2600,"uris":[""],"uri":[""],"itemData":{"id":2600,"type":"article-journal","title":"Task Group 174 Report: Utilization of [ ¹⁸ F]Fluorodeoxyglucose Positron Emission Tomography ([ ¹⁸ F]FDG-PET) in Radiation Therapy","container-title":"Medical Physics","source":" (Crossref)","abstract":"The use of positron emission tomography (PET) in Radiation Therapy (RT) is rapidly increasing in the areas of staging, segmentation, treatment planning and response assessment. The most common radiotracer is 18F-fluorodeoxyglucose ([18F]FDG), a glucose analogue with demonstrated efficacy in cancer diagnosis and staging. However, diagnosis and RT planning are different endeavors with unique requirements, and very little literature is available for guiding physicists and clinicians in the utilization of [18F]FDG-PET in RT. The two goals of this report are to educate and provide recommendations. The report provides background and education on current PET imaging systems, PET tracers, intensity quantification, and current utilization in RT (staging, segmentation, image registration, treatment planning and therapy response assessment). Recommendations are provided on acceptance testing, annual and monthly quality assurance, scanning protocols to ensure consistency between inter-patient scans and intra-patient longitudinal scans, reporting of patient and scan parameters in literature, requirements for incorporation of [18F]FDG-PET in treatment planning systems, and image registration. The recommendations provided here are minimum requirements and are not meant to cover all aspects of the use of [18F]FDG-PET for RT.","URL":"","DOI":"10.1002/mp.13676","ISSN":"00942405","title-short":"Task Group 174 Report","journalAbbreviation":"Med. Phys.","language":"en","author":[{"family":"Das","given":"Shiva K."},{"family":"McGurk","given":"Ross"},{"family":"Miften","given":"Moyed"},{"family":"Sasa","given":"Mutic"},{"family":"Bowsher","given":"James"},{"family":"Bayouth","given":"John"},{"family":"Erdi","given":"Yusuf"},{"family":"Mawlawi","given":"Osama"},{"family":"Boellaard","given":"Ronald"},{"family":"Bowen","given":"Stephen R."},{"family":"Xing","given":"Lei"},{"family":"Bradley","given":"Jeffrey"},{"family":"Schoder","given":"Heiko"},{"family":"Yin","given":"Fang-Fang"},{"family":"Sullivan","given":"Daniel C."},{"family":"Kinahan","given":"Paul"}],"issued":{"date-parts":[["2019",6,22]]},"accessed":{"date-parts":[["2019",7,2]]}}}],"schema":""} (5–7).QA of PET/CT-simulators is largely similar to the QA of CT-simulators, with the addition of PET dedicated QC tests. Since rigorous technical quality control guidelines for CT simulators have already been established by CPQR ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"0GIZo0oJ","properties":{"formattedCitation":"({\\i{}8})","plainCitation":"(8)","noteIndex":0},"citationItems":[{"id":2510,"uris":[""],"uri":[""],"itemData":{"id":2510,"type":"report","title":"Technical Quality Control Guidelines for Computed Tomography Simulators","publisher":"Canadian Partnership for Quality Radiotherapy","page":"14","source":"Zotero","number":"CTS.2016.07.02","language":"en","issued":{"date-parts":[["2016",7,19]]}}}],"schema":""} (8) and are actively being maintained they should be complimented for PET/CT (rather than duplicated), to avoid inconsistencies as these guidelines evolve over time. PET/CT devices are rarely dedicated to RT and therefore may reside in the diagnostic imaging department (e.g. Nuclear Medicine or Radiology). Sharing of responsibilities between departments and close coordination is essential to ensure quality of the overall PET/CT-simulator process.GlossaryCT – x-ray computed tomographyFWHM – Full Width at Half MaximumFWTM – Full Width at Tenth MaximumNECR – Noise Equivalent Count RatePET – Positron emission tomographyQC – quality controlROI – Region of InterestRT – Radiation treatmentRTP – Radiation treatment planningTQC – Technical quality control (documents)Related Technical Quality Control GuidelinesPerformance testingPerformance tests should be referred to when selecting a system, when performing acceptance evaluation of newly installed equipment, and prior to the end of a manufacturer’s warranty period. The National Electrical Measurements Association (NEMA) has developed standard NU-2-2012 ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"aGeHuYCt","properties":{"formattedCitation":"({\\i{}10})","plainCitation":"(10)","noteIndex":0},"citationItems":[{"id":1968,"uris":[""],"uri":[""],"itemData":{"id":1968,"type":"article","title":"NEMA NU-2-2012 Performance Measurements of Positron Emission Tomographs (PETs)","publisher":"National Electrical Manufacturers Association","URL":"","issued":{"date-parts":[["2013"]]},"accessed":{"date-parts":[["2018",4,6]]}}}],"schema":""} (10) which has become the de facto standard for evaluating the performance of PET systems. The standard describes equipment and procedures for measuring system performance parameters including spatial resolution, scatter fraction, count losses, random events measurement, activity sensitivity, corrections accuracy and image quality. The NEMA standard was updated to version NU-2-2018 ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"qhiOvwGS","properties":{"formattedCitation":"({\\i{}11})","plainCitation":"(11)","noteIndex":0},"citationItems":[{"id":2473,"uris":[""],"uri":[""],"itemData":{"id":2473,"type":"article","title":"NEMA NU 2-2018 Performance Measurements of Positron Emission Tomographs (PET)","publisher":"National Electrical Manufacturers Association","URL":"","issued":{"date-parts":[["2018"]]},"accessed":{"date-parts":[["2019",5,4]]}}}],"schema":""} (11) adding two new procedures to assess coincidence timing resolution on PET systems with time-of-flight capability, and to assess co-registration accuracy of hybrid PET/CT systems; the latter is of particular interest in using PET for RTP. Likewise, performance testing of CT equipment are detailed by the American Association of Physicists in Medicine (AAPM) ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"dt8s8U20","properties":{"formattedCitation":"({\\i{}12})","plainCitation":"(12)","noteIndex":0},"citationItems":[{"id":2015,"uris":[""],"uri":[""],"itemData":{"id":2015,"type":"report","title":"AAPM Reports - Specification and Acceptance Testing of Computed Tomography Scanners","publisher":"American Association of Physicists in Medicine","page":"95","URL":"","number":"39","author":[{"family":"Lin","given":"Pei-Jan","suffix":"Paul"},{"family":"Beck","given":"Thomas","suffix":"J"},{"family":"Borras","given":"Caridad"},{"family":"Gerald","given":"Cohen"},{"family":"Jucius","given":"Robert","suffix":"A."},{"family":"Kriz","given":"Robert","suffix":"J."},{"family":"Nickloff","given":"Edward","suffix":"L."},{"family":"Rothenberg","given":"Lawrence N."},{"family":"Strauss","given":"Keith","suffix":"J."},{"family":"Villafana","given":"Theodore"}],"issued":{"date-parts":[["1993",5]]},"accessed":{"date-parts":[["2018",4,23]]}}}],"schema":""} (12), International Electrotechnical Commission (IEC) ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"VakRMIXU","properties":{"formattedCitation":"({\\i{}13})","plainCitation":"(13)","noteIndex":0},"citationItems":[{"id":2017,"uris":[""],"uri":[""],"itemData":{"id":2017,"type":"webpage","title":"IEC 60601-2-44:2009 | IEC Webstore","URL":"","accessed":{"date-parts":[["2018",4,23]]}}}],"schema":""} (13) and other similar professional body recommendation documents. These tests are also summarized in ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"pmY1d4f4","properties":{"formattedCitation":"({\\i{}14})","plainCitation":"(14)","noteIndex":0},"citationItems":[{"id":1959,"uris":[""],"uri":[""],"itemData":{"id":1959,"type":"book","title":"Quality assurance for PET and PET/CT Systems","publisher":"International Atomic Energy Agency","publisher-place":"Vienna","source":"Open WorldCat","event-place":"Vienna","abstract":"This publication provides guidelines for the implementation of quality assurance and control programs concerning the combined medical diagnostic modality of positron emission tomography (PET) and computed tomography (CT). These independent, but complementary, imaging techniques are in frequent and increasing use within the fields of diagnostic imaging, oncology, cardiology and neurology, where they allow physicians to locate and diagnose malignant diseases accurately. This publication establishes guidelines for acceptance testing and routine quality control as necessary for optimal clinical performance. Specific topics of discussion include frameworks for reference values, tolerances and action levels, minimal required configurations with corresponding performances characteristics, and the management of ancillary equipment.","URL":"","ISBN":"978-92-0-103609-4","note":"OCLC: 822579368","language":"en","author":[{"literal":"Agence internationale de l'énergie atomique"}],"issued":{"date-parts":[["2009"]]},"accessed":{"date-parts":[["2018",4,6]]}}}],"schema":""} (14).Acceptance Testing and CommissioningNewly acquired or substantially modified PET/CT systems should be tested to ensure performance complies with vendor and tender stated specifications ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"JIuFlx1c","properties":{"formattedCitation":"({\\i{}15},{\\i{}16})","plainCitation":"(15,16)","noteIndex":0},"citationItems":[{"id":2467,"uris":[""],"uri":[""],"itemData":{"id":2467,"type":"book","title":"Commissioning of radiotherapy treatment planning systems: testing for typical external beam treatment techniques: report of the coordinated research project (CRP) on development of procedures for quality assurance of dosimetry calculations in radiotherapy","publisher":"International Atomic Energy Agency","publisher-place":"Vienna","source":"Open WorldCat","event-place":"Vienna","ISBN":"978-92-0-100508-3","note":"OCLC: 779533810","title-short":"Commissioning of radiotherapy treatment planning systems","language":"en","author":[{"literal":"International Atomic Energy Agency"}],"issued":{"date-parts":[["2008"]]}}},{"id":2512,"uris":[""],"uri":[""],"itemData":{"id":2512,"type":"report","title":"Technical Quality Control Guidelines for Canadian Radiation Treatment Centres","publisher":"Canadian Partnership for Quality Radiotherapy","page":"18","number":"TPS.2015.02.02","language":"English: en-CA","issued":{"date-parts":[["2015",2,28]]}}}],"schema":""} (15,16). Through active participation in the acceptance testing, users may also become familiar with the system. Commissioning follows acceptance testing with a comprehensive battery of performance tests to establish base-line performance metrics against which subsequent tests may be compared to ensure stable and acceptable performance of the system over its lifetime.System Upgrades and MaintenanceSpecial consideration should be given in the case of a PET/CT system servicing and upgrades. Acceptance or preventive maintenance tests provided by the PET/CT manufacturer under an institutional service contract agreement should ensure that the PET/CT system is at optimal functionality. However, monthly tests should be performed after any hardware upgrade and monthly/annual QC should be done after PET/CT console software upgrade. Routine QCRoutine QC is performed to ensure system stability from time of commissioning and to proactively determine the need for service. Periodic (e.g. daily, monthly, quarterly) QC tests are typically defined by the manufacturer and may differ from general guidelines due to technology (e.g. solid-state vs photomultiplier tube-based detection) and feasibility considerations (e.g. automated QC). Routine QC guidelines have been established by multiple professional groups with a consensus statement on Diagnostic Imaging Requirements put out by the Joint Commission on the Accreditation of Healthcare Organizations as an umbrella list of QA requirements ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"tvfdOv11","properties":{"formattedCitation":"({\\i{}9})","plainCitation":"(9)","noteIndex":0},"citationItems":[{"id":1978,"uris":[""],"uri":[""],"itemData":{"id":1978,"type":"report","title":"Diagnostic Imaging Requirements","publisher":"Joint Commission on the Accreditation of Healthcare Organizations","page":"6","genre":"Recommendations","abstract":"Diagnostic Imaging Standards","URL":"","language":"en","issued":{"date-parts":[["2015",8,15]]},"accessed":{"date-parts":[["2018",4,12]]}}}],"schema":""} (9). The Canadian Partnership for Quality Radiotherapy has established its own Technical Quality Control (TQC) Guidelines as summary standards of test frequency and tolerances. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"cBism2A5","properties":{"formattedCitation":"({\\i{}17})","plainCitation":"(17)","noteIndex":0},"citationItems":[{"id":2707,"uris":[""],"uri":[""],"itemData":{"id":2707,"type":"article-journal","title":"Production, review, and impact of technical quality control guidelines in a national context","container-title":"Journal of Applied Clinical Medical Physics","page":"3-15","volume":"17","issue":"6","source":"PubMed Central","abstract":"A close partnership between the Canadian Partnership for Quality Radiotherapy (CPQR) and the Canadian Organization of Medical Physicist's (COMP) Quality Assurance and Radiation Safety Advisory Committee (QARSAC) has resulted in the development of a suite of Technical Quality Control (TQC) guidelines for radiation treatment equipment; they outline specific performance objectives and criteria that equipment should meet in order to assure an acceptable level of radiation treatment quality. The adopted framework for the development and maintenance of the TQCs ensures the guidelines incorporate input from the medical physics community during development, measures the workload required to perform the QC tests outlined in each TQC, and remain relevant (i.e., “living documents”) through subsequent planned reviews and updates. The framework includes consolidation of existing guidelines and/or literature by expert reviewers, structured stages of public review, external field‐testing, and ratification by COMP. This TQC development framework is a cross‐country initiative that allows for rapid development of robust, community‐driven living guideline documents that are owned by the community and reviewed to keep relevant in a rapidly evolving technical environment. Community engagement and uptake survey data shows 70% of Canadian centers are part of this process and that the data in the guideline documents reflect, and are influencing, the way Canadian radiation treatment centers run their technical quality control programs. For a medium‐sized center comprising six linear accelerators and a comprehensive brachytherapy program, we evaluate the physics workload to 1.5 full‐time equivalent physicists per year to complete all QC tests listed in this suite., PACS number(s): 87.55.Qr, 87.56.Fc, 87.56.‐v","DOI":"10.1120/jacmp.v17i6.6422","ISSN":"1526-9914","note":"PMID: 27929477\nPMCID: PMC5690511","journalAbbreviation":"J Appl Clin Med Phys","author":[{"family":"Nielsen","given":"Michelle K."},{"family":"Malkoske","given":"Kyle E."},{"family":"Brown","given":"Erika"},{"family":"Diamond","given":"Kevin"},{"family":"Frenière","given":"Normand"},{"family":"Grant","given":"John"},{"family":"Pomerleau‐Dalcourt","given":"Natalie"},{"family":"Schella","given":"Jason"},{"family":"Schreiner","given":"L. John"},{"family":"Tant?t","given":"Laurent"},{"family":"Villarreal‐Barajas","given":"J. Eduardo"},{"family":"Bissonnette","given":"Jean‐Pierre"}],"issued":{"date-parts":[["2016",11,8]]}}}],"schema":""} (17)Recommendations from major international professional bodies (listed in Table 1) were included in this review. A summary of recommended routine QC activities and frequencies is summarized in the Test Tables section along with references in which greater details on the QC test may be found. Tolerances from TQCs were used if available, otherwise the strictest values from the reviewed literature were adopted. The list is intended to serve as a guideline and may not be optimal for all equipment types and all applications. For comprehensive instructions for performing PET/CT QA, the reader is referred to references ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"1H7x9X5c","properties":{"formattedCitation":"({\\i{}14},{\\i{}18})","plainCitation":"(14,18)","noteIndex":0},"citationItems":[{"id":1959,"uris":[""],"uri":[""],"itemData":{"id":1959,"type":"book","title":"Quality assurance for PET and PET/CT Systems","publisher":"International Atomic Energy Agency","publisher-place":"Vienna","source":"Open WorldCat","event-place":"Vienna","abstract":"This publication provides guidelines for the implementation of quality assurance and control programs concerning the combined medical diagnostic modality of positron emission tomography (PET) and computed tomography (CT). These independent, but complementary, imaging techniques are in frequent and increasing use within the fields of diagnostic imaging, oncology, cardiology and neurology, where they allow physicians to locate and diagnose malignant diseases accurately. This publication establishes guidelines for acceptance testing and routine quality control as necessary for optimal clinical performance. Specific topics of discussion include frameworks for reference values, tolerances and action levels, minimal required configurations with corresponding performances characteristics, and the management of ancillary equipment.","URL":"","ISBN":"978-92-0-103609-4","note":"OCLC: 822579368","language":"en","author":[{"literal":"Agence internationale de l'énergie atomique"}],"issued":{"date-parts":[["2009"]]},"accessed":{"date-parts":[["2018",4,6]]}}},{"id":1974,"uris":[""],"uri":[""],"itemData":{"id":1974,"type":"report","title":"ACR-AAPM Technical Standard for Medical Nuclear Physics Performance Monitoring of PET Imaging Equipment","publisher":"ACR-AAPM","source":"Zotero","language":"en","issued":{"date-parts":[["2016"]]}}}],"schema":""} (14,18).Table SEQ Table \* ARABIC 1: List of related quality control references reviewedTitleRevision yearProfessional BodyModalityReferenceTask Group 174 Report: Utilization of [18F]Fluorodeoxyglucose Positron Emission Tomography ([18F]FDG-PET) in Radiation Therapy2019American Association of Physicists in MedicinePET-CT ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"OzVfmV2J","properties":{"formattedCitation":"({\\i{}7})","plainCitation":"(7)","noteIndex":0},"citationItems":[{"id":2600,"uris":[""],"uri":[""],"itemData":{"id":2600,"type":"article-journal","title":"Task Group 174 Report: Utilization of [ ¹⁸ F]Fluorodeoxyglucose Positron Emission Tomography ([ ¹⁸ F]FDG-PET) in Radiation Therapy","container-title":"Medical Physics","source":" (Crossref)","abstract":"The use of positron emission tomography (PET) in Radiation Therapy (RT) is rapidly increasing in the areas of staging, segmentation, treatment planning and response assessment. The most common radiotracer is 18F-fluorodeoxyglucose ([18F]FDG), a glucose analogue with demonstrated efficacy in cancer diagnosis and staging. However, diagnosis and RT planning are different endeavors with unique requirements, and very little literature is available for guiding physicists and clinicians in the utilization of [18F]FDG-PET in RT. The two goals of this report are to educate and provide recommendations. The report provides background and education on current PET imaging systems, PET tracers, intensity quantification, and current utilization in RT (staging, segmentation, image registration, treatment planning and therapy response assessment). Recommendations are provided on acceptance testing, annual and monthly quality assurance, scanning protocols to ensure consistency between inter-patient scans and intra-patient longitudinal scans, reporting of patient and scan parameters in literature, requirements for incorporation of [18F]FDG-PET in treatment planning systems, and image registration. The recommendations provided here are minimum requirements and are not meant to cover all aspects of the use of [18F]FDG-PET for RT.","URL":"","DOI":"10.1002/mp.13676","ISSN":"00942405","title-short":"Task Group 174 Report","journalAbbreviation":"Med. Phys.","language":"en","author":[{"family":"Das","given":"Shiva K."},{"family":"McGurk","given":"Ross"},{"family":"Miften","given":"Moyed"},{"family":"Sasa","given":"Mutic"},{"family":"Bowsher","given":"James"},{"family":"Bayouth","given":"John"},{"family":"Erdi","given":"Yusuf"},{"family":"Mawlawi","given":"Osama"},{"family":"Boellaard","given":"Ronald"},{"family":"Bowen","given":"Stephen R."},{"family":"Xing","given":"Lei"},{"family":"Bradley","given":"Jeffrey"},{"family":"Schoder","given":"Heiko"},{"family":"Yin","given":"Fang-Fang"},{"family":"Sullivan","given":"Daniel C."},{"family":"Kinahan","given":"Paul"}],"issued":{"date-parts":[["2019",6,22]]},"accessed":{"date-parts":[["2019",7,2]]}}}],"schema":""} (7)Technical Quality Control Guidelines for Computed Tomography Simulators2016Canadian Partnership for Quality RadiotherapyCT-simulator ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"cKpDN9wY","properties":{"formattedCitation":"({\\i{}8})","plainCitation":"(8)","noteIndex":0},"citationItems":[{"id":2510,"uris":[""],"uri":[""],"itemData":{"id":2510,"type":"report","title":"Technical Quality Control Guidelines for Computed Tomography Simulators","publisher":"Canadian Partnership for Quality Radiotherapy","page":"14","source":"Zotero","number":"CTS.2016.07.02","language":"en","issued":{"date-parts":[["2016",7,19]]}}}],"schema":""} (8)Technical standard for medical nuclear physics performance monitoring of PET imaging equipment 2016American College of Radiologists & American Association of Physicists in MedicinePET ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"B4McTiad","properties":{"formattedCitation":"({\\i{}18})","plainCitation":"(18)","noteIndex":0},"citationItems":[{"id":1974,"uris":[""],"uri":[""],"itemData":{"id":1974,"type":"report","title":"ACR-AAPM Technical Standard for Medical Nuclear Physics Performance Monitoring of PET Imaging Equipment","publisher":"ACR-AAPM","source":"Zotero","language":"en","issued":{"date-parts":[["2016"]]}}}],"schema":""} (18)Diagnostic Imaging Requirements 2015Joint Commission on the Accreditation of Healthcare OrganizationsPET, CT, MRI, NM ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"2Yjvbdfd","properties":{"formattedCitation":"({\\i{}9})","plainCitation":"(9)","noteIndex":0},"citationItems":[{"id":1978,"uris":[""],"uri":[""],"itemData":{"id":1978,"type":"report","title":"Diagnostic Imaging Requirements","publisher":"Joint Commission on the Accreditation of Healthcare Organizations","page":"6","genre":"Recommendations","abstract":"Diagnostic Imaging Standards","URL":"","language":"en","issued":{"date-parts":[["2015",8,15]]},"accessed":{"date-parts":[["2018",4,12]]}}}],"schema":""} (9)Routine quality control recommendations for nuclearmedicine instrumentation2010European Association of Nuclear MedicinePET, Dose calibrator ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"8MSkA1Ye","properties":{"formattedCitation":"({\\i{}19})","plainCitation":"(19)","noteIndex":0},"citationItems":[{"id":1960,"uris":[""],"uri":[""],"itemData":{"id":1960,"type":"article-journal","title":"Routine quality control recommendations for nuclear medicine instrumentation","container-title":"European Journal of Nuclear Medicine and Molecular Imaging","page":"662-671","volume":"37","issue":"3","source":"CrossRef","DOI":"10.1007/s00259-009-1347-y","ISSN":"1619-7070, 1619-7089","language":"en","author":[{"literal":"On behalf of the EANM Physics Committee:"},{"literal":"With contribution from the EANM Working Group on Nuclear Medicine Instrumentation Quality Control:"},{"family":"Busemann Sokole","given":"Ellinor"},{"family":"P?achcínska","given":"Anna"},{"family":"Britten","given":"Alan"},{"family":"Lyra Georgosopoulou","given":"Maria"},{"family":"Tindale","given":"Wendy"},{"family":"Klett","given":"Rigobert"}],"issued":{"date-parts":[["2010",3]]}}}],"schema":""} (19)PET/CT and radiotherapy: data transfer, radiotherapy workflow and quality assurance2010-PET, CT, RTP ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"1odXGwq5","properties":{"formattedCitation":"({\\i{}2})","plainCitation":"(2)","noteIndex":0},"citationItems":[{"id":1868,"uris":[""],"uri":[""],"itemData":{"id":1868,"type":"article-journal","title":"PET/CT and radiotherapy: data transfer, radiotherapy workflow and quality assurance","container-title":"The quarterly journal of nuclear medicine and molecular imaging: official publication of the Italian Association of Nuclear Medicine (AIMN) [and] the International Association of Radiopharmacology (IAR), [and] Section of the Society of...","page":"476-489","volume":"54","issue":"5","source":"PubMed","abstract":"The development of new technologies in radiation therapy has made it possible to introduce more sophisticated techniques that can deliver the prescribed dose with more conformation and accuracy and to apply dose escalation protocols without increasing the risk of healthy tissue damage. This has consented the simultaneous delivery of different dose levels to different parts of the target, making it possible to boost those tumour sub-volumes that are considered more radio resistant. The use of PET for radiotherapy planning purposes has become increasingly important in the last few years, because of its ability to provide valuable biologic and functional data. PET imaging can affect the treatment strategy definition and improve the target delineation and the assessment of therapy response. The most attractive aspect is the perspective to deliver differential doses inside target volumes for areas of different biologic behaviour based on functional imaging, moving closer to the goals of biologically conformal radiation therapy. Each single step of PET/CT-guided radiotherapy workflow, needs to be performed following high standard procedures, within a rigorous and appropriate quality assurance protocol to minimize the sources of errors and to maximize the efficacy of PET imaging in radiation therapy, ensuring safe and effective use of the technology. The present paper focuses on aspects concerning the use of PET/CT in radiation treatment process, with the aim to delineate different possible approaches to its clinical application and to highlight the critical aspects of the various subprocesses.","ISSN":"1824-4785","note":"PMID: 20927015","title-short":"PET/CT and radiotherapy","journalAbbreviation":"Q J Nucl Med Mol Imaging","language":"eng","author":[{"family":"Fioroni","given":"F."},{"family":"Iotti","given":"C."},{"family":"Paiusco","given":"M."},{"family":"Versari","given":"A."},{"family":"Grassi","given":"E."},{"family":"Salvo","given":"D."},{"family":"Iori","given":"M."}],"issued":{"date-parts":[["2010",10]]}}}],"schema":""} (2)Quality assurance for PET and PET/CT systems2009International Atomic Energy AgencyPET, CT ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"xQLmCPBY","properties":{"formattedCitation":"({\\i{}14})","plainCitation":"(14)","noteIndex":0},"citationItems":[{"id":1959,"uris":[""],"uri":[""],"itemData":{"id":1959,"type":"book","title":"Quality assurance for PET and PET/CT Systems","publisher":"International Atomic Energy Agency","publisher-place":"Vienna","source":"Open WorldCat","event-place":"Vienna","abstract":"This publication provides guidelines for the implementation of quality assurance and control programs concerning the combined medical diagnostic modality of positron emission tomography (PET) and computed tomography (CT). These independent, but complementary, imaging techniques are in frequent and increasing use within the fields of diagnostic imaging, oncology, cardiology and neurology, where they allow physicians to locate and diagnose malignant diseases accurately. This publication establishes guidelines for acceptance testing and routine quality control as necessary for optimal clinical performance. 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The development of on-board imaging and other image-guidance methods significantly improve our ability to better target a radiation beam to the tumor volume. In reality, however, accurate definition of the location and boundary of the tumor target is still problematic. Biological and physiological imaging promises to solve the problem in a fundamental way and plays a more and more important role in patient staging, treatment planning and therapeutic assessment in radiation therapy clinics. Indeed, the last decade have witnessed a dramatic increase in the use of PET and CT in radiotherapy practice. To ensure safe and effective use of nuclide imaging, a rigorous quality assurance (QA) protocol of the imaging tools and integration of the imaging data must be in place. The application of nuclide imaging in radiation oncology occurs at different levels of sophistication Quantitative use of the imaging data in treatment planning through image registration and standardized uptake value (SUV) calculation is often involved. Thus QA should not be limited to the performance of the scanner, but also include the process of implementing image data in the treatment planning, such as data transfer, image registration, and quantitation of data for delineation of tumors and sensitive structures. This presentation will discuss various aspects of the nuclide imaging as applied to radiotherapy and describe the QA procedures necessary for the success of biological image guided radiation therapy.","DOI":"10.1016/j.ijrobp.2007.05.091","ISSN":"0360-3016","note":"PMID: 18406935\nPMCID: PMC2600917","journalAbbreviation":"Int J Radiat Oncol Biol Phys","author":[{"family":"Xing","given":"Lei"}],"issued":{"date-parts":[["2008"]]}}}],"schema":""} (20)Routine quality control of clinical nuclear medicine instrumentation: A brief review2008-PET, CT, Dose calibrator ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"QiuDgjDP","properties":{"formattedCitation":"({\\i{}21})","plainCitation":"(21)","noteIndex":0},"citationItems":[{"id":1906,"uris":[""],"uri":[""],"itemData":{"id":1906,"type":"article-journal","title":"Routine Quality Control of Clinical Nuclear Medicine Instrumentation: A Brief Review","container-title":"Journal of nuclear medicine : official publication, Society of Nuclear Medicine","page":"1114-1131","volume":"49","issue":"7","source":"PubMed Central","abstract":"This article reviews routine quality-control (QC) procedures for current nuclear medicine instrumentation, including the survey meter, dose calibrator, well counter, intraoperative probe, organ (“thyroid”) uptake probe, γ-camera, SPECT and SPECT/CT scanner, and PET and PET/CT scanner. It should be particularly useful for residents, fellows, and other trainees in nuclear medicine, nuclear cardiology, and radiology. The procedures described and their respective frequencies are presented only as general guidelines.","DOI":"10.2967/jnumed.107.050203","ISSN":"0161-5505","note":"PMID: 18587088\nPMCID: PMC2703015","title-short":"Routine Quality Control of Clinical Nuclear Medicine Instrumentation","journalAbbreviation":"J Nucl Med","author":[{"family":"Zanzonico","given":"Pat"}],"issued":{"date-parts":[["2008",7]]}}}],"schema":""} (21)Quality assurance for computed-tomography simulators and the computed-tomography-simulation process: Report of the AAPM Radiation Therapy Committee Task Group N. 662003American Association of Physicists in MedicineCT-simulator ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"tK9E2sbN","properties":{"formattedCitation":"({\\i{}22})","plainCitation":"(22)","noteIndex":0},"citationItems":[{"id":1966,"uris":[""],"uri":[""],"itemData":{"id":1966,"type":"article-journal","title":"Quality assurance for computed-tomography simulators and the computed-tomography-simulation process: Report of the AAPM Radiation Therapy Committee Task Group No. 66","container-title":"Medical Physics","page":"2762-2792","volume":"30","issue":"10","source":"CrossRef","DOI":"10.1118/1.1609271","ISSN":"00942405","title-short":"Quality assurance for computed-tomography simulators and the computed-tomography-simulation process","language":"en","author":[{"family":"Mutic","given":"Sasa"},{"family":"Palta","given":"Jatinder R."},{"family":"Butker","given":"Elizabeth K."},{"family":"Das","given":"Indra J."},{"family":"Huq","given":"M. Saiful"},{"family":"Loo","given":"Leh-Nien Dick"},{"family":"Salter","given":"Bill J."},{"family":"McCollough","given":"Cynthia H."},{"family":"Van Dyk","given":"Jacob"}],"issued":{"date-parts":[["2003",9,24]]}}}],"schema":""} (22)In order to comprehensively assess the use of PET/CT for RTP performance, additional tests, as outlined in related CPQR Technical Quality Control (TQC) guidelines must also be completed and documented, as applicable. Related TQC guidelines, available at cpqr.ca, include:Treatment Planning SystemsComputed Tomography SimulatorsData Management SystemsTQC guidelines are referred to throughout as a primary source to avoid conflicting instructions as these live documents are updated.Test TablesTables 2-7 list required QC tests by frequencies and tabulate incremental changes for RTP ( - incremental tests for RTP, - tests performed more frequently for RTP) versus those listed in the CPQR Technical Quality Control Guidelines for CT simulators ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"888yytL9","properties":{"formattedCitation":"({\\i{}8})","plainCitation":"(8)","noteIndex":0},"citationItems":[{"id":2510,"uris":[""],"uri":[""],"itemData":{"id":2510,"type":"report","title":"Technical Quality Control Guidelines for Computed Tomography Simulators","publisher":"Canadian Partnership for Quality Radiotherapy","page":"14","source":"Zotero","number":"CTS.2016.07.02","language":"en","issued":{"date-parts":[["2016",7,19]]}}}],"schema":""} (8). Table SEQ Table \* ARABIC 2:?Daily/Weekly Quality Control TestsDesignatorToleranceFor RTPDaily* Alternate to cover all peak kilovoltage (kVp) values used clinically??Can be performed weekly if system is found to be stable but needed on days system will be used for RTP.PT-D1PET Detector Stability Manufacturer’s recommendationPT-D2Daily coincidence timing resolution tests in TOF PETsManufacturer’s recommendationCT-D1Lasers (alignment, spacing, motion) ?±1 mmCT-D2CT number for water – mean (accuracy) *?0±4 HUCT-D3CT number for water – standard deviation (noise) *?Reproducible (±10% or 0.2 HU from baseline value, whichever is larger) CT-D4CT number for water – mean vs. position (uniformity) * ±2 HUCT-D5Respiratory monitoring system FunctionalCT-D6Audio/video coaching systems (if applicable) FunctionalPT-W1Adjustment of gains of photomultiplier tubesManufacturer’s recommendationOT-D1Dose calibrator constancy (clock accuracy, high voltage, zero adjustment, background activity, constancy) ±5%Notes on Daily/Weekly TestsDaily/Weekly QC TestsThis refers to daily incidence of PET and CT daily and weekly quality control.PT-D1 – 2 and PT-W1As per manufacturer instructions, these tests are typically semi-automated and only require confirmation that the test has passed, and no visual artifacts are visible in the recorded sinograms. The tests measure the stability of the PET detectors. On scanners with TOF, it measures the capability of the system to estimate the difference in arrival times of the two annihilation photons. The weekly test updates the detector gains to compensate for changes in the crystals’ behavior over time. See references ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"tGvxmPV0","properties":{"formattedCitation":"({\\i{}14})","plainCitation":"(14)","noteIndex":0},"citationItems":[{"id":1959,"uris":[""],"uri":[""],"itemData":{"id":1959,"type":"book","title":"Quality assurance for PET and PET/CT Systems","publisher":"International Atomic Energy Agency","publisher-place":"Vienna","source":"Open WorldCat","event-place":"Vienna","abstract":"This publication provides guidelines for the implementation of quality assurance and control programs concerning the combined medical diagnostic modality of positron emission tomography (PET) and computed tomography (CT). These independent, but complementary, imaging techniques are in frequent and increasing use within the fields of diagnostic imaging, oncology, cardiology and neurology, where they allow physicians to locate and diagnose malignant diseases accurately. This publication establishes guidelines for acceptance testing and routine quality control as necessary for optimal clinical performance. Specific topics of discussion include frameworks for reference values, tolerances and action levels, minimal required configurations with corresponding performances characteristics, and the management of ancillary equipment.","URL":"","ISBN":"978-92-0-103609-4","note":"OCLC: 822579368","language":"en","author":[{"literal":"Agence internationale de l'énergie atomique"}],"issued":{"date-parts":[["2009"]]},"accessed":{"date-parts":[["2018",4,6]]}}}],"schema":""} (14) and ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"nppwTZaq","properties":{"formattedCitation":"({\\i{}20})","plainCitation":"(20)","noteIndex":0},"citationItems":[{"id":1870,"uris":[""],"uri":[""],"itemData":{"id":1870,"type":"article-journal","title":"Quality assurance of PET/CT for radiation therapy","container-title":"International journal of radiation oncology, biology, physics","page":"S38-S42","volume":"71","issue":"1 Suppl","source":"PubMed Central","abstract":"Recent advances in radiation delivery techniques, such as intensity-modulated radiation therapy, provide unprecedented ability to exquisitely control the 3D dose distribution. The development of on-board imaging and other image-guidance methods significantly improve our ability to better target a radiation beam to the tumor volume. In reality, however, accurate definition of the location and boundary of the tumor target is still problematic. Biological and physiological imaging promises to solve the problem in a fundamental way and plays a more and more important role in patient staging, treatment planning and therapeutic assessment in radiation therapy clinics. Indeed, the last decade have witnessed a dramatic increase in the use of PET and CT in radiotherapy practice. To ensure safe and effective use of nuclide imaging, a rigorous quality assurance (QA) protocol of the imaging tools and integration of the imaging data must be in place. The application of nuclide imaging in radiation oncology occurs at different levels of sophistication Quantitative use of the imaging data in treatment planning through image registration and standardized uptake value (SUV) calculation is often involved. Thus QA should not be limited to the performance of the scanner, but also include the process of implementing image data in the treatment planning, such as data transfer, image registration, and quantitation of data for delineation of tumors and sensitive structures. This presentation will discuss various aspects of the nuclide imaging as applied to radiotherapy and describe the QA procedures necessary for the success of biological image guided radiation therapy.","DOI":"10.1016/j.ijrobp.2007.05.091","ISSN":"0360-3016","note":"PMID: 18406935\nPMCID: PMC2600917","journalAbbreviation":"Int J Radiat Oncol Biol Phys","author":[{"family":"Xing","given":"Lei"}],"issued":{"date-parts":[["2008"]]}}}],"schema":""} (20) for more details.CT-D1 - 6Refer to TQC for Computed Tomography Simulators ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"kPQpp5r6","properties":{"formattedCitation":"({\\i{}8})","plainCitation":"(8)","noteIndex":0},"citationItems":[{"id":2510,"uris":[""],"uri":[""],"itemData":{"id":2510,"type":"report","title":"Technical Quality Control Guidelines for Computed Tomography Simulators","publisher":"Canadian Partnership for Quality Radiotherapy","page":"14","source":"Zotero","number":"CTS.2016.07.02","language":"en","issued":{"date-parts":[["2016",7,19]]}}}],"schema":""} (8).OT-D1As per manufacturer instructions, follow the daily quality control procedure using a long-lived radionuclide source (e.g. 137Cs) to test accuracy and stability. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"Dx1r5t1V","properties":{"formattedCitation":"({\\i{}19})","plainCitation":"(19)","noteIndex":0},"citationItems":[{"id":1960,"uris":[""],"uri":[""],"itemData":{"id":1960,"type":"article-journal","title":"Routine quality control recommendations for nuclear medicine instrumentation","container-title":"European Journal of Nuclear Medicine and Molecular Imaging","page":"662-671","volume":"37","issue":"3","source":"CrossRef","DOI":"10.1007/s00259-009-1347-y","ISSN":"1619-7070, 1619-7089","language":"en","author":[{"literal":"On behalf of the EANM Physics Committee:"},{"literal":"With contribution from the EANM Working Group on Nuclear Medicine Instrumentation Quality Control:"},{"family":"Busemann Sokole","given":"Ellinor"},{"family":"P?achcínska","given":"Anna"},{"family":"Britten","given":"Alan"},{"family":"Lyra Georgosopoulou","given":"Maria"},{"family":"Tindale","given":"Wendy"},{"family":"Klett","given":"Rigobert"}],"issued":{"date-parts":[["2010",3]]}}}],"schema":""} (19)Table SEQ Table \* ARABIC 3:?Monthly Quality Control TestsDesignatorToleranceFor RTPMonthly (or after system maintenance)? Perform whenever tabletop is removed and reinstalledCT-M1Tabletop level accuracy?±2 mmCT-M2Lasers (orthogonality/orientation)± 1mm over the length of laser projectionCT-M3Tabletop displacement accuracy?±1 mmG-M1RecordsCompleteNotes on Monthly TestsCT-M1 - 3Refer to TQC for Computed Tomography Simulators ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"40Y414Bm","properties":{"formattedCitation":"({\\i{}8})","plainCitation":"(8)","noteIndex":0},"citationItems":[{"id":2510,"uris":[""],"uri":[""],"itemData":{"id":2510,"type":"report","title":"Technical Quality Control Guidelines for Computed Tomography Simulators","publisher":"Canadian Partnership for Quality Radiotherapy","page":"14","source":"Zotero","number":"CTS.2016.07.02","language":"en","issued":{"date-parts":[["2016",7,19]]}}}],"schema":""} (8).G-M1Documentation relating to the daily quality control checks, preventive maintenance, service calls, and subsequent checks must be complete, legible, and the operator identified. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"JDu9VkEG","properties":{"formattedCitation":"({\\i{}16})","plainCitation":"(16)","noteIndex":0},"citationItems":[{"id":2512,"uris":[""],"uri":[""],"itemData":{"id":2512,"type":"report","title":"Technical Quality Control Guidelines for Canadian Radiation Treatment Centres","publisher":"Canadian Partnership for Quality Radiotherapy","page":"18","number":"TPS.2015.02.02","language":"English: en-CA","issued":{"date-parts":[["2015",2,28]]}}}],"schema":""} (16)Table SEQ Table \* ARABIC 4:?Quarterly Quality Control TestsDesignatorToleranceFor RTPQuarterly (or after system maintenance)PT-Q1PET System normalization and calibrationVisual acceptance.The new calibration should be checked with a reconstructed image of the flood phantom applying all the corrections. The mean measured SUV in a region of 10 cm in the center of the phantom should be 1.0 ± 0.1.Calibration constant change <5% from previous. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"d6F1Mdka","properties":{"formattedCitation":"({\\i{}23},{\\i{}24})","plainCitation":"(23,24)","noteIndex":0},"citationItems":[{"id":2716,"uris":[""],"uri":[""],"itemData":{"id":2716,"type":"article-journal","title":"Quantifying and Reducing the Effect of Calibration Error on Variability of PET/CT Standardized Uptake Value Measurements","container-title":"Journal of nuclear medicine : official publication, Society of Nuclear Medicine","page":"218-224","volume":"52","issue":"2","source":"PubMed Central","abstract":"The purpose of this study was to measure the errors introduced by regular calibration of PET/CT scanners and to minimize the effect of calibration error on standardized uptake value measurements.","DOI":"10.2967/jnumed.110.083865","ISSN":"0161-5505","note":"PMID: 21233174\nPMCID: PMC4491194","journalAbbreviation":"J Nucl Med","author":[{"family":"Lockhart","given":"Catherine M."},{"family":"MacDonald","given":"Lawrence R."},{"family":"Alessio","given":"Adam M."},{"family":"McDougald","given":"Wendy A."},{"family":"Doot","given":"Robert K."},{"family":"Kinahan","given":"Paul E."}],"issued":{"date-parts":[["2011",2]]}}},{"id":2712,"uris":[""],"uri":[""],"itemData":{"id":2712,"type":"article-journal","title":"Measuring temporal stability of positron emission tomography standardized uptake value bias using long-lived sources in a multicenter network","container-title":"Journal of Medical Imaging","page":"1","volume":"5","issue":"01","source":" (Crossref)","DOI":"10.1117/1.JMI.5.1.011016","ISSN":"2329-4302","journalAbbreviation":"J. Med. Imag.","language":"en","author":[{"family":"Byrd","given":"Darrin"},{"family":"Christopfel","given":"Rebecca"},{"family":"Arabasz","given":"Grae"},{"family":"Catana","given":"Ciprian"},{"family":"Karp","given":"Joel"},{"family":"Lodge","given":"Martin A."},{"family":"Laymon","given":"Charles"},{"family":"Moros","given":"Eduardo G."},{"family":"Budzevich","given":"Mikalai"},{"family":"Nehmeh","given":"Sadek"}],"issued":{"date-parts":[["2018",1,4]]}}}],"schema":""} (23,24)PT-Q2Uniformity of reconstructed PET imageWithin 5% of baseline valuePT-Q3PET and CT registration±1 pixel or ±1 mmCT-Q1CT number accuracy (>4 materials)±5 HUCT-Q23D low contrast resolutionReproducible (set action level at time of acceptance) CT-Q33D high contrast spatial resolution (at 10 and 50% modulation transfer function [MTF])Reproducible (±0.5 lp/cm or ±15% of the established baseline value, whichever is greater)CT-Q4Slice thickness (sensitivity profile)Reproducible(±0.5 mm from baseline for slices ≥2 mm±50% from baseline for slices of 1 to 2 mm±0.5 mm from baseline for slices <1 mm)CT-Q5Amplitude and periodicity of motion surrogate with monitoring software and/or CT console1 mm, 0.1 sCT-Q64D-CT reconstruction FunctionalCT-Q7Amplitude of moving target(s) measured with 4D-CT <2 mmCT-Q8Spatial integrity and positioning of moving target(s) at each 4D respiratory phase 2 mm (FWHM) difference from baseline measurement (increased for amplitudes larger than 2 cm) CT-Q9Mean CT number and standard deviation of moving target(s) at each respiratory phase (±10 HU) and (±10%) from baseline measurement (increased for amplitudes larger than 2 cm) CT-Q104D-CT intensity projection image reconstruction (Avg, MIP, MinIP) 2 mm (FWHM) difference from baseline measurement (increased for amplitudes larger than 2 cm) CT-Q114D data import to treatment planning systemFunctionalOT-Q1Dose calibrator linearity and geometry accuracyManufacturer’s recommendationNotes on Quarterly TestsPT-Q1This test measures the crystal efficiency and is used to correct for crystal non-uniformities that degrade the images. The scanner is also cross-calibrated with the dose calibrator to ensure that SUV calculations are accurate, and the images are quantitative. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"T3Izi2kG","properties":{"formattedCitation":"({\\i{}14})","plainCitation":"(14)","noteIndex":0},"citationItems":[{"id":1959,"uris":[""],"uri":[""],"itemData":{"id":1959,"type":"book","title":"Quality assurance for PET and PET/CT Systems","publisher":"International Atomic Energy Agency","publisher-place":"Vienna","source":"Open WorldCat","event-place":"Vienna","abstract":"This publication provides guidelines for the implementation of quality assurance and control programs concerning the combined medical diagnostic modality of positron emission tomography (PET) and computed tomography (CT). These independent, but complementary, imaging techniques are in frequent and increasing use within the fields of diagnostic imaging, oncology, cardiology and neurology, where they allow physicians to locate and diagnose malignant diseases accurately. This publication establishes guidelines for acceptance testing and routine quality control as necessary for optimal clinical performance. Specific topics of discussion include frameworks for reference values, tolerances and action levels, minimal required configurations with corresponding performances characteristics, and the management of ancillary equipment.","URL":"","ISBN":"978-92-0-103609-4","note":"OCLC: 822579368","language":"en","author":[{"literal":"Agence internationale de l'énergie atomique"}],"issued":{"date-parts":[["2009"]]},"accessed":{"date-parts":[["2018",4,6]]}}}],"schema":""} (14) The test is performed using a cylindrical uniform phantom of known activity concentration (depending on the manufacturer’s recommendations it can be a pre-manufactured 68Ge phantom or a fillable one with 18F). The normalization data is acquired according to the manufacturer’s instructions. A calibration factor relating the detected events to the known activity concentration is also calculated. The test passes when a reconstructed image using the new established normalization and calibration factor parameters is visually uniform, and the measured SUVmean in a big field of view inside the phantom is close to 1. Data should also be compared with previous measurements to detect big shifts in calibration, which could indicate procedural errors in the test. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"29uwkyX3","properties":{"formattedCitation":"({\\i{}23},{\\i{}24})","plainCitation":"(23,24)","noteIndex":0},"citationItems":[{"id":2716,"uris":[""],"uri":[""],"itemData":{"id":2716,"type":"article-journal","title":"Quantifying and Reducing the Effect of Calibration Error on Variability of PET/CT Standardized Uptake Value Measurements","container-title":"Journal of nuclear medicine : official publication, Society of Nuclear Medicine","page":"218-224","volume":"52","issue":"2","source":"PubMed Central","abstract":"The purpose of this study was to measure the errors introduced by regular calibration of PET/CT scanners and to minimize the effect of calibration error on standardized uptake value measurements.","DOI":"10.2967/jnumed.110.083865","ISSN":"0161-5505","note":"PMID: 21233174\nPMCID: PMC4491194","journalAbbreviation":"J Nucl Med","author":[{"family":"Lockhart","given":"Catherine M."},{"family":"MacDonald","given":"Lawrence R."},{"family":"Alessio","given":"Adam M."},{"family":"McDougald","given":"Wendy A."},{"family":"Doot","given":"Robert K."},{"family":"Kinahan","given":"Paul E."}],"issued":{"date-parts":[["2011",2]]}}},{"id":2712,"uris":[""],"uri":[""],"itemData":{"id":2712,"type":"article-journal","title":"Measuring temporal stability of positron emission tomography standardized uptake value bias using long-lived sources in a multicenter network","container-title":"Journal of Medical Imaging","page":"1","volume":"5","issue":"01","source":" (Crossref)","DOI":"10.1117/1.JMI.5.1.011016","ISSN":"2329-4302","journalAbbreviation":"J. Med. Imag.","language":"en","author":[{"family":"Byrd","given":"Darrin"},{"family":"Christopfel","given":"Rebecca"},{"family":"Arabasz","given":"Grae"},{"family":"Catana","given":"Ciprian"},{"family":"Karp","given":"Joel"},{"family":"Lodge","given":"Martin A."},{"family":"Laymon","given":"Charles"},{"family":"Moros","given":"Eduardo G."},{"family":"Budzevich","given":"Mikalai"},{"family":"Nehmeh","given":"Sadek"}],"issued":{"date-parts":[["2018",1,4]]}}}],"schema":""} (23,24)PT-Q2The cylindrical phantom from the PT-Q1 test is used to measure the response of the system to the homogeneous activity distribution. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"Aygg77Db","properties":{"formattedCitation":"({\\i{}14})","plainCitation":"(14)","noteIndex":0},"citationItems":[{"id":1959,"uris":[""],"uri":[""],"itemData":{"id":1959,"type":"book","title":"Quality assurance for PET and PET/CT Systems","publisher":"International Atomic Energy Agency","publisher-place":"Vienna","source":"Open WorldCat","event-place":"Vienna","abstract":"This publication provides guidelines for the implementation of quality assurance and control programs concerning the combined medical diagnostic modality of positron emission tomography (PET) and computed tomography (CT). These independent, but complementary, imaging techniques are in frequent and increasing use within the fields of diagnostic imaging, oncology, cardiology and neurology, where they allow physicians to locate and diagnose malignant diseases accurately. This publication establishes guidelines for acceptance testing and routine quality control as necessary for optimal clinical performance. Specific topics of discussion include frameworks for reference values, tolerances and action levels, minimal required configurations with corresponding performances characteristics, and the management of ancillary equipment.","URL":"","ISBN":"978-92-0-103609-4","note":"OCLC: 822579368","language":"en","author":[{"literal":"Agence internationale de l'énergie atomique"}],"issued":{"date-parts":[["2009"]]},"accessed":{"date-parts":[["2018",4,6]]}}}],"schema":""} (14) An image of the phantom is reconstructed with all the corrections enabled (i.e. deadtime, attenuation, scatter, etc) and using the parameters of the institution’s standard clinical protocol. For each transaxial slice in the image, a grid of 10 mm x 10 mm squares is drawn. The maximum, minimum, and mean concentration c of each grid k in each of the i image slices is recorded. The maximum value of non-uniformity across all images (NUi) should be reported where:NUi=MAXMAXck-AVE(ck)AVE(ck)×100AVEck-MIN(ck)AVE(ck)×100PT-Q3This test ensures that the functional information of PET is correctly aligned with the anatomical information from CT. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"yI1VIPVB","properties":{"formattedCitation":"({\\i{}14})","plainCitation":"(14)","noteIndex":0},"citationItems":[{"id":1959,"uris":[""],"uri":[""],"itemData":{"id":1959,"type":"book","title":"Quality assurance for PET and PET/CT Systems","publisher":"International Atomic Energy Agency","publisher-place":"Vienna","source":"Open WorldCat","event-place":"Vienna","abstract":"This publication provides guidelines for the implementation of quality assurance and control programs concerning the combined medical diagnostic modality of positron emission tomography (PET) and computed tomography (CT). These independent, but complementary, imaging techniques are in frequent and increasing use within the fields of diagnostic imaging, oncology, cardiology and neurology, where they allow physicians to locate and diagnose malignant diseases accurately. This publication establishes guidelines for acceptance testing and routine quality control as necessary for optimal clinical performance. Specific topics of discussion include frameworks for reference values, tolerances and action levels, minimal required configurations with corresponding performances characteristics, and the management of ancillary equipment.","URL":"","ISBN":"978-92-0-103609-4","note":"OCLC: 822579368","language":"en","author":[{"literal":"Agence internationale de l'énergie atomique"}],"issued":{"date-parts":[["2009"]]},"accessed":{"date-parts":[["2018",4,6]]}}}],"schema":""} (14) The alignment depends on the mechanical components of the PET/CT scanner. Additional corrections are made via a software calculated transformation matrix that translates and rotates one image domain to the other one. The procedure varies based on the manufacturer. Typically, a phantom containing small 68Ge sources placed at different positions within the FOV is scanned both on CT and PET. Weights are added on top of the bed to simulate the effect of having a patient on top of it. The transformation matrix is calculated such that the centroids of the different sources in both scanning modalities are registered.The new NEMA NU 2-2018 document ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"LC0FSldg","properties":{"formattedCitation":"({\\i{}11})","plainCitation":"(11)","noteIndex":0},"citationItems":[{"id":2473,"uris":[""],"uri":[""],"itemData":{"id":2473,"type":"article","title":"NEMA NU 2-2018 Performance Measurements of Positron Emission Tomographs (PET)","publisher":"National Electrical Manufacturers Association","URL":"","issued":{"date-parts":[["2018"]]},"accessed":{"date-parts":[["2019",5,4]]}}}],"schema":""} (11) has added a new standard for PET/CT coregistration. It uses fiducial markers of sources like 18F or 22Na with materials that are greater than 500 Hounsfield Units in the CT scan. The location of the centroids in the two images are checked to determine the coregistration error CE for each of the fiducial markers:CE= xcentPET-xcentCT2+ ycentPET-ycentCT2+zcentPET-zcentCT2 As this document is still very recent, not all current PET/CT scanners follow this exact procedure.CT-Q1 - 11Refer to TQC for Computed Tomography Simulators ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"BAC0Bno8","properties":{"formattedCitation":"({\\i{}8})","plainCitation":"(8)","noteIndex":0},"citationItems":[{"id":2510,"uris":[""],"uri":[""],"itemData":{"id":2510,"type":"report","title":"Technical Quality Control Guidelines for Computed Tomography Simulators","publisher":"Canadian Partnership for Quality Radiotherapy","page":"14","source":"Zotero","number":"CTS.2016.07.02","language":"en","issued":{"date-parts":[["2016",7,19]]}}}],"schema":""} (8).OT-Q1The linearity test measures the response to radionuclides over a big range of activities that will be used in the department. A vial containing a high amount of activity is measured several times until the activity has decayed to a low value. We recommend performing the test with a starting activity on the order of a few GBq and decay until the activity is less than 1 MBq. The measured activity in the dose calibrator is compared to the predicted activity based on the half-life of the decay. This response is expected to follow the identity line in a plot of measured activity vs. predicted activity. Alternatively, specially designed attenuation sleeves (calibrated for the test isotope) can be use as a surrogate for activity decay. The geometry test allows determining if the correct activity values are measured regardless of the sample size geometry. For this, all the different syringes and vials used to draw-up injected doses are tested. For each of the volumes, an initial value of activity is measured. This is then followed by subsequent measurements in which a saline solution or water is added to the syringe/vial to increase the volume. In all cases, the activity is expected to be within 5% of the initial values. If variations >±5% exist derive a calibration factor to be applied clinically. Ensure no change from baseline. Likewise, using a syringe test stability of the activity reading as the source is gradually withdrawn from the ionization chamber. Ensure that activity readings are consistent across >5 cm of displacement, and that response is consistent with baseline.Details may be found in reference ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"UfrvNDiH","properties":{"formattedCitation":"({\\i{}19})","plainCitation":"(19)","noteIndex":0},"citationItems":[{"id":1960,"uris":[""],"uri":[""],"itemData":{"id":1960,"type":"article-journal","title":"Routine quality control recommendations for nuclear medicine instrumentation","container-title":"European Journal of Nuclear Medicine and Molecular Imaging","page":"662-671","volume":"37","issue":"3","source":"CrossRef","DOI":"10.1007/s00259-009-1347-y","ISSN":"1619-7070, 1619-7089","language":"en","author":[{"literal":"On behalf of the EANM Physics Committee:"},{"literal":"With contribution from the EANM Working Group on Nuclear Medicine Instrumentation Quality Control:"},{"family":"Busemann Sokole","given":"Ellinor"},{"family":"P?achcínska","given":"Anna"},{"family":"Britten","given":"Alan"},{"family":"Lyra Georgosopoulou","given":"Maria"},{"family":"Tindale","given":"Wendy"},{"family":"Klett","given":"Rigobert"}],"issued":{"date-parts":[["2010",3]]}}}],"schema":""} (19).Table SEQ Table \* ARABIC 5:?Annual Quality Control TestsDesignatorToleranceFor RTPAnnuallyPT-A1Safety: mechanical and electricalManufacturer’s recommendationPT-A2PET Spatial resolutionManufacturer’s SpecificationsPT-A3PET SensitivityManufacturer’s SpecificationsPT-A4PET image quality phantom (hot spheres, cold rods, quantitative accuracy)BaselinePT-A5PET count rate performance (scatter fraction, count losses, randoms)Manufacturer’s SpecificationsPT-A6Time-of-Flight resolution (if applicable)BaselineCT-A1Patient dose from CT, CTDI (or X-ray source radiation profile width); adult and pediatric±10% from baselineCT-A2X ray generation: kVp, HVL, mAs linearity ±2 kVp, ±10% difference from baseline measurement (HVL and mAs)CT-A3Gantry tilt (if applicable)± 0.5%CT-A44D low contrast resolution at each respiratory phase Reproducible (set action level at time of acceptance) CT-A54D high contrast spatial resolution at each respiratory phase Reproducible (set action level at time of acceptance)CT-A64D slice thickness (sensitivity profile) at each respiratory phase Reproducible (set action level at time of acceptance)CT-A7Simulated planning ±2 mmG-A1RecordsCompleteG-A2Independent quality control review CompleteG-A3Review of long-term trends for quantitative Daily and Monthly testsCompleteOtherO-A1Computer monitor display accuracyManufacturer’s recommendationO-A2Patient weight scale accuracy and precision±0.1 kg for weights <100 kg±0.2 kg for weights ≥100 kgO-A3Patient height measurement device±5 mmNotes on Annual TestsPT-A1This test ensures that the PET/CT scanner mechanical and electrical components are operating as indicated by the manufacturer. Follow any manufacturer’s recommendations and inspect the housing, bed motion, controls, connectors, and any accessories that are connected to the scanner. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"93KQ1mNh","properties":{"formattedCitation":"({\\i{}14},{\\i{}18},{\\i{}25})","plainCitation":"(14,18,25)","noteIndex":0},"citationItems":[{"id":1959,"uris":[""],"uri":[""],"itemData":{"id":1959,"type":"book","title":"Quality assurance for PET and PET/CT Systems","publisher":"International Atomic Energy Agency","publisher-place":"Vienna","source":"Open WorldCat","event-place":"Vienna","abstract":"This publication provides guidelines for the implementation of quality assurance and control programs concerning the combined medical diagnostic modality of positron emission tomography (PET) and computed tomography (CT). 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The procedure involves scanning 3-point sources of 18F that are prepared from a high activity concentration in capillary tubes. The tubes are placed in three different positions within the FOV but are always in the same longitudinal plane. The positioning of the sources within the FOV has been updated between different versions of the NEMA standards so is important to check with the manufacturer to determine which version of the standards should be followed. The acquired images are reconstructed with a pixel size of 1/3 of the expected scanner resolution (typically less than 1.5 mm per pixel). Profiles of the sources are generated in all the different directions. The full width at half maximum (FWHM) and full width at tenth of maximum (FWTM) are calculated. The radial and tangential resolutions are averaged. The FWHM should not exceed the specifications provided by the manufacturer. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"mmclPcwC","properties":{"formattedCitation":"({\\i{}11},{\\i{}14},{\\i{}18})","plainCitation":"(11,14,18)","noteIndex":0},"citationItems":[{"id":2473,"uris":[""],"uri":[""],"itemData":{"id":2473,"type":"article","title":"NEMA NU 2-2018 Performance Measurements of Positron Emission Tomographs (PET)","publisher":"National Electrical Manufacturers Association","URL":"","issued":{"date-parts":[["2018"]]},"accessed":{"date-parts":[["2019",5,4]]}}},{"id":1959,"uris":[""],"uri":[""],"itemData":{"id":1959,"type":"book","title":"Quality assurance for PET and PET/CT Systems","publisher":"International Atomic Energy Agency","publisher-place":"Vienna","source":"Open WorldCat","event-place":"Vienna","abstract":"This publication provides guidelines for the implementation of quality assurance and control programs concerning the combined medical diagnostic modality of positron emission tomography (PET) and computed tomography (CT). These independent, but complementary, imaging techniques are in frequent and increasing use within the fields of diagnostic imaging, oncology, cardiology and neurology, where they allow physicians to locate and diagnose malignant diseases accurately. This publication establishes guidelines for acceptance testing and routine quality control as necessary for optimal clinical performance. Specific topics of discussion include frameworks for reference values, tolerances and action levels, minimal required configurations with corresponding performances characteristics, and the management of ancillary equipment.","URL":"","ISBN":"978-92-0-103609-4","note":"OCLC: 822579368","language":"en","author":[{"literal":"Agence internationale de l'énergie atomique"}],"issued":{"date-parts":[["2009"]]},"accessed":{"date-parts":[["2018",4,6]]}}},{"id":1974,"uris":[""],"uri":[""],"itemData":{"id":1974,"type":"report","title":"ACR-AAPM Technical Standard for Medical Nuclear Physics Performance Monitoring of PET Imaging Equipment","publisher":"ACR-AAPM","source":"Zotero","language":"en","issued":{"date-parts":[["2016"]]}}}],"schema":""} (11,14,18)PT-A3This test determines the rate of detected true coincidences per unit of radioactivity concentration (e.g. kcps/MBq) for a standard line source configuration. Several scans of a line source with different aluminum sleeves that increase the thickness of absorbing material are used to extrapolate the value to the one where no attenuating material is present. The procedure is performed at the center of the FOV and at 10 cm from the central axis. The sensitivity is expected to be equal or greater than the specified by the scanner manufacturer. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"W1sLtBrM","properties":{"formattedCitation":"({\\i{}11},{\\i{}14},{\\i{}18})","plainCitation":"(11,14,18)","noteIndex":0},"citationItems":[{"id":2473,"uris":[""],"uri":[""],"itemData":{"id":2473,"type":"article","title":"NEMA NU 2-2018 Performance Measurements of Positron Emission Tomographs (PET)","publisher":"National Electrical Manufacturers Association","URL":"","issued":{"date-parts":[["2018"]]},"accessed":{"date-parts":[["2019",5,4]]}}},{"id":1959,"uris":[""],"uri":[""],"itemData":{"id":1959,"type":"book","title":"Quality assurance for PET and PET/CT Systems","publisher":"International Atomic Energy Agency","publisher-place":"Vienna","source":"Open WorldCat","event-place":"Vienna","abstract":"This publication provides guidelines for the implementation of quality assurance and control programs concerning the combined medical diagnostic modality of positron emission tomography (PET) and computed tomography (CT). These independent, but complementary, imaging techniques are in frequent and increasing use within the fields of diagnostic imaging, oncology, cardiology and neurology, where they allow physicians to locate and diagnose malignant diseases accurately. This publication establishes guidelines for acceptance testing and routine quality control as necessary for optimal clinical performance. Specific topics of discussion include frameworks for reference values, tolerances and action levels, minimal required configurations with corresponding performances characteristics, and the management of ancillary equipment.","URL":"","ISBN":"978-92-0-103609-4","note":"OCLC: 822579368","language":"en","author":[{"literal":"Agence internationale de l'énergie atomique"}],"issued":{"date-parts":[["2009"]]},"accessed":{"date-parts":[["2018",4,6]]}}},{"id":1974,"uris":[""],"uri":[""],"itemData":{"id":1974,"type":"report","title":"ACR-AAPM Technical Standard for Medical Nuclear Physics Performance Monitoring of PET Imaging Equipment","publisher":"ACR-AAPM","source":"Zotero","language":"en","issued":{"date-parts":[["2016"]]}}}],"schema":""} (11,14,18)PT-A4The purpose of this test is to generate images that simulate a real patient scan with hot and cold lesions and with scatter from outside of the FOV. The quality of the image is assessed from the contrast and background variability, accuracy of the attenuation and scatter corrections, and from the accuracy of the radioactivity quantification. The procedure involves scanning the NEMA IEC body phantom that includes six spheres of different sizes. The two biggest spheres are filled with water that does not contain radioactivity; while the other four are filled with a solution that has a concentration of 8 times the one in the background (some manufacturers also suggest using a 4:1 ratio). A line source is placed inside a cylindrical plastic phantom to generate some scatter out of the FOV. The images should be reconstructed as recommended by the manufacturer for a standard whole-body protocol. The slice in which the contrast of cold and hot spheres is highest is selected to draw regions of interest around each of the spheres. The diameters of the ROIs should be as close to the inner diameter of the sphere as possible. ROIs of the same sizes (both cold and hot spheres) are drawn on the same slice and on the background region (see NEMA standards for location of ROIs). The same ROIs are then copied to four neighboring slices giving a total of 60 background ROIs for each size of sphere; 12 on each of the 5 slices. The average number of counts in each hot, background, and cold spheres in combination with the known activity concentrations are used to calculate the contrast and background variability. An ROI with a diameter of 3.0 cm is drawn on the lung insert for each of the slices. If the scatter and attenuation correction are perfect, this value is expected to be close to zero. Another 12 circular 3.0 cm diameter ROIs placed over the background region are used to calculate a percentage relative error for the lung insert and for each slice. This is the ratio of the average counts in the lung ROI to the corresponding average in the background for the 12 ROIs. Lastly, accuracy in activity quantification is measured from the known activity in the background at the time of the phantom filling procedure and comparing it to the average radioactivity concentration measured from the image by averaging the 12 3.7 cm diameter background ROIs.See references ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"9PlnRyr4","properties":{"formattedCitation":"({\\i{}11},{\\i{}14},{\\i{}18})","plainCitation":"(11,14,18)","noteIndex":0},"citationItems":[{"id":2473,"uris":[""],"uri":[""],"itemData":{"id":2473,"type":"article","title":"NEMA NU 2-2018 Performance Measurements of Positron Emission Tomographs (PET)","publisher":"National Electrical Manufacturers Association","URL":"","issued":{"date-parts":[["2018"]]},"accessed":{"date-parts":[["2019",5,4]]}}},{"id":1959,"uris":[""],"uri":[""],"itemData":{"id":1959,"type":"book","title":"Quality assurance for PET and PET/CT Systems","publisher":"International Atomic Energy Agency","publisher-place":"Vienna","source":"Open WorldCat","event-place":"Vienna","abstract":"This publication provides guidelines for the implementation of quality assurance and control programs concerning the combined medical diagnostic modality of positron emission tomography (PET) and computed tomography (CT). 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A small scatter fraction (ratio of scatter photons to the sum of true coincidences and scatter) is desired. The count rate performance provides information regarding the quantitative accuracy at low and high count rates. The noise equivalent count rate (NECR) is typically used to represent the count rate performance as a function of the activity concentration. The peak NECR and the corresponding activity concentration serve as a guide to optimize the injected activity to patients. The calculation assumes Poisson statistics, and considers the contribution of true, scattered, and random events to the total coincidence rate.The method of measurement involves a 70 cm long line source that is placed inside and off-centre of a plastic cylinder. The manufacturer’s specifications for the initial radioactivity concentration within the line source should be followed. Different acquisitions are taken at intervals of less than half of the half-life of the radioisotope (e.g. 18F), but with a higher frequency around the peak of the NECR curve. Each acquisition has a duration that should be less than ? of the half-life of the radioisotope. The analysis might be slightly different between systems that allow the measurement of randoms compared to the ones that do not. Pixels that are more than 12 cm away from the center of each sinogram (i.e. one sinogram per acquisition) are set to zero. Then, the maximum pixel on each projection (row) of the sinogram is shifted to the center of the sinogram and all the projections are added. A profile of total counts as a function of distance from the center of the sinogram is made. The sum of scatter and randoms, the total counts, and the unscattered counts can be determined from that profile. The scatter fraction is then calculated for each slice and each acquisition. The NECR for each acquisition j is calculated based on the trues, total, and randoms of each slice i as:NECRi,j=Rti,j2(Rtoti,j+κRri,j)where Rt is the rate of true coincidences, Rtot is the total count rate, and Rr represents the randoms count rate. The value of κ is given according toκ=0→equipment without randoms subtraction1→equipment with randoms subtraction The total system NECR for an acquisition j is the sum of NECRi,j over all the slices i.The scatter fraction, peak NECR, and the radioactivity concentration to reach the peak NECR should meet the manufacturers specifications.See references ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"tprSQvcT","properties":{"formattedCitation":"({\\i{}11},{\\i{}14},{\\i{}18})","plainCitation":"(11,14,18)","noteIndex":0},"citationItems":[{"id":2473,"uris":[""],"uri":[""],"itemData":{"id":2473,"type":"article","title":"NEMA NU 2-2018 Performance Measurements of Positron Emission Tomographs (PET)","publisher":"National Electrical Manufacturers Association","URL":"","issued":{"date-parts":[["2018"]]},"accessed":{"date-parts":[["2019",5,4]]}}},{"id":1959,"uris":[""],"uri":[""],"itemData":{"id":1959,"type":"book","title":"Quality assurance for PET and PET/CT Systems","publisher":"International Atomic Energy Agency","publisher-place":"Vienna","source":"Open WorldCat","event-place":"Vienna","abstract":"This publication provides guidelines for the implementation of quality assurance and control programs concerning the combined medical diagnostic modality of positron emission tomography (PET) and computed tomography (CT). These independent, but complementary, imaging techniques are in frequent and increasing use within the fields of diagnostic imaging, oncology, cardiology and neurology, where they allow physicians to locate and diagnose malignant diseases accurately. This publication establishes guidelines for acceptance testing and routine quality control as necessary for optimal clinical performance. Specific topics of discussion include frameworks for reference values, tolerances and action levels, minimal required configurations with corresponding performances characteristics, and the management of ancillary equipment.","URL":"","ISBN":"978-92-0-103609-4","note":"OCLC: 822579368","language":"en","author":[{"literal":"Agence internationale de l'énergie atomique"}],"issued":{"date-parts":[["2009"]]},"accessed":{"date-parts":[["2018",4,6]]}}},{"id":1974,"uris":[""],"uri":[""],"itemData":{"id":1974,"type":"report","title":"ACR-AAPM Technical Standard for Medical Nuclear Physics Performance Monitoring of PET Imaging Equipment","publisher":"ACR-AAPM","source":"Zotero","language":"en","issued":{"date-parts":[["2016"]]}}}],"schema":""} (11,14,18) for further details.PT-A6This test determines the capability of the system to measure the difference in arrival time of two coincidence events. Follow the manufacturer’s recommendations to perform this test. A typical measurement uses a line source of 18F in an aluminum tube positioned at the center of the scanner. The system records coincidences with time of arrival and generates some histograms for it. The timing resolution is calculated as the FWHM on this histogram. The timing resolution should not exceed the manufacturer’s specifications. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"GSsDRKuz","properties":{"formattedCitation":"({\\i{}11},{\\i{}14},{\\i{}18})","plainCitation":"(11,14,18)","noteIndex":0},"citationItems":[{"id":2473,"uris":[""],"uri":[""],"itemData":{"id":2473,"type":"article","title":"NEMA NU 2-2018 Performance Measurements of Positron Emission Tomographs (PET)","publisher":"National Electrical Manufacturers Association","URL":"","issued":{"date-parts":[["2018"]]},"accessed":{"date-parts":[["2019",5,4]]}}},{"id":1959,"uris":[""],"uri":[""],"itemData":{"id":1959,"type":"book","title":"Quality assurance for PET and PET/CT Systems","publisher":"International Atomic Energy Agency","publisher-place":"Vienna","source":"Open WorldCat","event-place":"Vienna","abstract":"This publication provides guidelines for the implementation of quality assurance and control programs concerning the combined medical diagnostic modality of positron emission tomography (PET) and computed tomography (CT). These independent, but complementary, imaging techniques are in frequent and increasing use within the fields of diagnostic imaging, oncology, cardiology and neurology, where they allow physicians to locate and diagnose malignant diseases accurately. This publication establishes guidelines for acceptance testing and routine quality control as necessary for optimal clinical performance. Specific topics of discussion include frameworks for reference values, tolerances and action levels, minimal required configurations with corresponding performances characteristics, and the management of ancillary equipment.","URL":"","ISBN":"978-92-0-103609-4","note":"OCLC: 822579368","language":"en","author":[{"literal":"Agence internationale de l'énergie atomique"}],"issued":{"date-parts":[["2009"]]},"accessed":{"date-parts":[["2018",4,6]]}}},{"id":1974,"uris":[""],"uri":[""],"itemData":{"id":1974,"type":"report","title":"ACR-AAPM Technical Standard for Medical Nuclear Physics Performance Monitoring of PET Imaging Equipment","publisher":"ACR-AAPM","source":"Zotero","language":"en","issued":{"date-parts":[["2016"]]}}}],"schema":""} (11,14,18)CT-A1 - 7Refer to TQC for Computed Tomography Simulators ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"kymIqRVe","properties":{"formattedCitation":"({\\i{}8})","plainCitation":"(8)","noteIndex":0},"citationItems":[{"id":2510,"uris":[""],"uri":[""],"itemData":{"id":2510,"type":"report","title":"Technical Quality Control Guidelines for Computed Tomography Simulators","publisher":"Canadian Partnership for Quality Radiotherapy","page":"14","source":"Zotero","number":"CTS.2016.07.02","language":"en","issued":{"date-parts":[["2016",7,19]]}}}],"schema":""} (8) and ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"cHSabJHz","properties":{"formattedCitation":"({\\i{}22})","plainCitation":"(22)","noteIndex":0},"citationItems":[{"id":1966,"uris":[""],"uri":[""],"itemData":{"id":1966,"type":"article-journal","title":"Quality assurance for computed-tomography simulators and the computed-tomography-simulation process: Report of the AAPM Radiation Therapy Committee Task Group No. 66","container-title":"Medical Physics","page":"2762-2792","volume":"30","issue":"10","source":"CrossRef","DOI":"10.1118/1.1609271","ISSN":"00942405","title-short":"Quality assurance for computed-tomography simulators and the computed-tomography-simulation process","language":"en","author":[{"family":"Mutic","given":"Sasa"},{"family":"Palta","given":"Jatinder R."},{"family":"Butker","given":"Elizabeth K."},{"family":"Das","given":"Indra J."},{"family":"Huq","given":"M. Saiful"},{"family":"Loo","given":"Leh-Nien Dick"},{"family":"Salter","given":"Bill J."},{"family":"McCollough","given":"Cynthia H."},{"family":"Van Dyk","given":"Jacob"}],"issued":{"date-parts":[["2003",9,24]]}}}],"schema":""} (22).GA1 – 3Refer to TQC for Computed Tomography Simulators ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"R88LnrzM","properties":{"formattedCitation":"({\\i{}8})","plainCitation":"(8)","noteIndex":0},"citationItems":[{"id":2510,"uris":[""],"uri":[""],"itemData":{"id":2510,"type":"report","title":"Technical Quality Control Guidelines for Computed Tomography Simulators","publisher":"Canadian Partnership for Quality Radiotherapy","page":"14","source":"Zotero","number":"CTS.2016.07.02","language":"en","issued":{"date-parts":[["2016",7,19]]}}}],"schema":""} (8) and ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"nKWRqvCE","properties":{"formattedCitation":"({\\i{}16})","plainCitation":"(16)","noteIndex":0},"citationItems":[{"id":2512,"uris":[""],"uri":[""],"itemData":{"id":2512,"type":"report","title":"Technical Quality Control Guidelines for Canadian Radiation Treatment Centres","publisher":"Canadian Partnership for Quality Radiotherapy","page":"18","number":"TPS.2015.02.02","language":"English: en-CA","issued":{"date-parts":[["2015",2,28]]}}}],"schema":""} (16).O-A1Clinical computer monitor displays should be tested and calibrated at least annually using a dedicated light measurement device and according to its manufacturer procedure. As a minimum, displays that have obvious discoloring, non-uniform luminance >30% or that deviate from DICOM luminance response accuracy by >10% and cannot be calibrated should be replaced. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"gMJFdjKj","properties":{"formattedCitation":"({\\i{}26})","plainCitation":"(26)","noteIndex":0},"citationItems":[{"id":2524,"uris":[""],"uri":[""],"itemData":{"id":2524,"type":"report","title":"Display Quality Assurance, The Report of AAPM Task Group 270","call-number":"ISBN: 978-1-936366-66-8","number":"TG 270","language":"ENGLISH","author":[{"family":"Bevins","given":"Nicholas B"},{"family":"Flynn","given":"Michael J"},{"family":"Silosky","given":"Michael S"},{"family":"Marsh","given":"Rebeccam M"},{"family":"Walz-Flannigan","given":"Alisa I"},{"family":"Badano","given":"Aldo"}],"issued":{"date-parts":[["2019",1]]}}}],"schema":""} (26)O-A2No regulatory guidelines or standards could be found for quality control of medical weight scales. But vendor provided instructions require testing using standard weights on the order of typical patient weights (e.g. 100 kg). Testing should be performed on an annual basis, after relocating the device or after service. Errors should not exceed 0.1 kg for weights <100kg of 0.2 kg for larger weights.O-A3No guidelines or standards could be found for quality control of height measurements devices. Accuracy should be tested annually, after relocating or after service using an independent measuring device such as a measuring tape.Table SEQ Table \* ARABIC 7:?Patient-Specific Quality Control TestsDesignatorToleranceFor RTPCase-by-Case PS1Correct patientMatched patient identifying informationPS2Correct patient preparationMatched to requisitionPS3Correct patient positioningMatched to treatment planPS4Correct imaging protocol and parametersMatched to requisition and technologist worksheetPS5PET/CT Image registrationAdequate co-registrationPS6Image qualityDiagnostic image qualityNotes on Patient-Specific TestsAt least three forms should be filled to ensure that the PET/CT procedure is going to be performed optimally:A screening form should be filled by the booking clerk ensuring that contains information regarding patient medication, diabetes, claustrophobia, concerns lying flat for the PET/CT scan, and for females, whether they are pregnant or breastfeeding.A questionnaire form to be filled by the patient and to be presented on the day of the appointment. This form should include some questions regarding the patient’s clinical history (e.g. asthmatic, diabetic, smoke status). It should contain information about any implants or other foreign objects within the patient’s body. In addition, it should include a small questionnaire in the type of “checkboxes” to ensure that the patient has fasted before the appointment (if required), is well hydrated, and has listed his current medications.A PET/CT technologist worksheet that includes patient information such as name, date of birth, and age. The technologists should record the patient’s weight and height, glucose level, allergies, radioisotope to be administered, and should record the initial activity in the syringe, and the residual after injection with its respective times of measurement. Additionally, the volume of radiotracer and the site of injection should also be recorded. The scan protocol, including the scan range (e.g. whole-body vs. vertex to thighs) should be pre-established before the patient arrives at the facility and should be written in this technologist worksheet.These forms should be used to ensure that the tests from REF _Ref15460406 \h Table 7 and described below are correctly performed.PS1The name, date of birth, and other medical information should be checked with the patient prior to beginning any procedure. At least two extra patient provided information should match the medical requisition. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"OPqQ78U0","properties":{"formattedCitation":"({\\i{}27})","plainCitation":"(27)","noteIndex":0},"citationItems":[{"id":2009,"uris":[""],"uri":[""],"itemData":{"id":2009,"type":"article-journal","title":"FDG PET/CT: EANM procedure guidelines for tumour imaging: version 2.0","container-title":"European Journal of Nuclear Medicine and Molecular Imaging","page":"328-354","volume":"42","issue":"2","source":"Crossref","abstract":"The purpose of these guidelines is to assist physicians in recommending, performing, interpreting and reporting the results of FDG PET/CT for oncological imaging of adult patients. PET is a quantitative imaging technique and therefore requires a common quality control (QC)/quality assurance (QA) procedure to maintain the accuracy and precision of quantitation.","DOI":"10.1007/s00259-014-2961-x","ISSN":"1619-7070, 1619-7089","title-short":"FDG PET/CT","language":"en","author":[{"family":"Boellaard","given":"Ronald"},{"family":"Delgado-Bolton","given":"Roberto"},{"family":"Oyen","given":"Wim J. G."},{"family":"Giammarile","given":"Francesco"},{"family":"Tatsch","given":"Klaus"},{"family":"Eschner","given":"Wolfgang"},{"family":"Verzijlbergen","given":"Fred J."},{"family":"Barrington","given":"Sally F."},{"family":"Pike","given":"Lucy C."},{"family":"Weber","given":"Wolfgang A."},{"family":"Stroobants","given":"Sigrid"},{"family":"Delbeke","given":"Dominique"},{"family":"Donohoe","given":"Kevin J."},{"family":"Holbrook","given":"Scott"},{"family":"Graham","given":"Michael M."},{"family":"Testanera","given":"Giorgio"},{"family":"Hoekstra","given":"Otto S."},{"family":"Zijlstra","given":"Josee"},{"family":"Visser","given":"Eric"},{"family":"Hoekstra","given":"Corneline J."},{"family":"Pruim","given":"Jan"},{"family":"Willemsen","given":"Antoon"},{"family":"Arends","given":"Bertjan"},{"family":"Kotzerke","given":"J?rg"},{"family":"Bockisch","given":"Andreas"},{"family":"Beyer","given":"Thomas"},{"family":"Chiti","given":"Arturo"},{"family":"Krause","given":"Bernd J."}],"issued":{"date-parts":[["2015",2]]}}}],"schema":""} (27)PS2Refer to the PET/CT technologists form and check that the imaging protocol and patient preparation, conform to requisition. If the patient is unable to comply, special accommodations may be required. If ambiguity exists, consult with the reporting physicians and/or on service referring physician. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"KzoUj8d0","properties":{"formattedCitation":"({\\i{}27})","plainCitation":"(27)","noteIndex":0},"citationItems":[{"id":2009,"uris":[""],"uri":[""],"itemData":{"id":2009,"type":"article-journal","title":"FDG PET/CT: EANM procedure guidelines for tumour imaging: version 2.0","container-title":"European Journal of Nuclear Medicine and Molecular Imaging","page":"328-354","volume":"42","issue":"2","source":"Crossref","abstract":"The purpose of these guidelines is to assist physicians in recommending, performing, interpreting and reporting the results of FDG PET/CT for oncological imaging of adult patients. PET is a quantitative imaging technique and therefore requires a common quality control (QC)/quality assurance (QA) procedure to maintain the accuracy and precision of quantitation.","DOI":"10.1007/s00259-014-2961-x","ISSN":"1619-7070, 1619-7089","title-short":"FDG PET/CT","language":"en","author":[{"family":"Boellaard","given":"Ronald"},{"family":"Delgado-Bolton","given":"Roberto"},{"family":"Oyen","given":"Wim J. G."},{"family":"Giammarile","given":"Francesco"},{"family":"Tatsch","given":"Klaus"},{"family":"Eschner","given":"Wolfgang"},{"family":"Verzijlbergen","given":"Fred J."},{"family":"Barrington","given":"Sally F."},{"family":"Pike","given":"Lucy C."},{"family":"Weber","given":"Wolfgang A."},{"family":"Stroobants","given":"Sigrid"},{"family":"Delbeke","given":"Dominique"},{"family":"Donohoe","given":"Kevin J."},{"family":"Holbrook","given":"Scott"},{"family":"Graham","given":"Michael M."},{"family":"Testanera","given":"Giorgio"},{"family":"Hoekstra","given":"Otto S."},{"family":"Zijlstra","given":"Josee"},{"family":"Visser","given":"Eric"},{"family":"Hoekstra","given":"Corneline J."},{"family":"Pruim","given":"Jan"},{"family":"Willemsen","given":"Antoon"},{"family":"Arends","given":"Bertjan"},{"family":"Kotzerke","given":"J?rg"},{"family":"Bockisch","given":"Andreas"},{"family":"Beyer","given":"Thomas"},{"family":"Chiti","given":"Arturo"},{"family":"Krause","given":"Bernd J."}],"issued":{"date-parts":[["2015",2]]}}}],"schema":""} (27)PS3Ensure that patient positioning conforms to treatment plan including use of all immobilization devices and appropriate position indexing. These parameters should be available in the technologist worksheet form. Perform the scout/topogram acquisition and ensure that positioning and FOV are set as defined in the technologist worksheet before continuing the PET/CT acquisition. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"f0h8pD7y","properties":{"formattedCitation":"({\\i{}7})","plainCitation":"(7)","noteIndex":0},"citationItems":[{"id":2600,"uris":[""],"uri":[""],"itemData":{"id":2600,"type":"article-journal","title":"Task Group 174 Report: Utilization of [ ¹⁸ F]Fluorodeoxyglucose Positron Emission Tomography ([ ¹⁸ F]FDG-PET) in Radiation Therapy","container-title":"Medical Physics","source":" (Crossref)","abstract":"The use of positron emission tomography (PET) in Radiation Therapy (RT) is rapidly increasing in the areas of staging, segmentation, treatment planning and response assessment. The most common radiotracer is 18F-fluorodeoxyglucose ([18F]FDG), a glucose analogue with demonstrated efficacy in cancer diagnosis and staging. However, diagnosis and RT planning are different endeavors with unique requirements, and very little literature is available for guiding physicists and clinicians in the utilization of [18F]FDG-PET in RT. The two goals of this report are to educate and provide recommendations. The report provides background and education on current PET imaging systems, PET tracers, intensity quantification, and current utilization in RT (staging, segmentation, image registration, treatment planning and therapy response assessment). Recommendations are provided on acceptance testing, annual and monthly quality assurance, scanning protocols to ensure consistency between inter-patient scans and intra-patient longitudinal scans, reporting of patient and scan parameters in literature, requirements for incorporation of [18F]FDG-PET in treatment planning systems, and image registration. The recommendations provided here are minimum requirements and are not meant to cover all aspects of the use of [18F]FDG-PET for RT.","URL":"","DOI":"10.1002/mp.13676","ISSN":"00942405","title-short":"Task Group 174 Report","journalAbbreviation":"Med. Phys.","language":"en","author":[{"family":"Das","given":"Shiva K."},{"family":"McGurk","given":"Ross"},{"family":"Miften","given":"Moyed"},{"family":"Sasa","given":"Mutic"},{"family":"Bowsher","given":"James"},{"family":"Bayouth","given":"John"},{"family":"Erdi","given":"Yusuf"},{"family":"Mawlawi","given":"Osama"},{"family":"Boellaard","given":"Ronald"},{"family":"Bowen","given":"Stephen R."},{"family":"Xing","given":"Lei"},{"family":"Bradley","given":"Jeffrey"},{"family":"Schoder","given":"Heiko"},{"family":"Yin","given":"Fang-Fang"},{"family":"Sullivan","given":"Daniel C."},{"family":"Kinahan","given":"Paul"}],"issued":{"date-parts":[["2019",6,22]]},"accessed":{"date-parts":[["2019",7,2]]}}}],"schema":""} (7)PS4Image acquisition parameters should be preconfigured on the acquisition system for all common procedures and documented in a clinical protocol. The scanning protocol should be written in advance in the technologist’s worksheet. Before performing the scout acquisition, the selection of the protocol should be checked to match what is specified in the technologist form. If deviations from preconfigured protocols are required, these should be documented by the technologists. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"d4RFLH8I","properties":{"formattedCitation":"({\\i{}27})","plainCitation":"(27)","noteIndex":0},"citationItems":[{"id":2009,"uris":[""],"uri":[""],"itemData":{"id":2009,"type":"article-journal","title":"FDG PET/CT: EANM procedure guidelines for tumour imaging: version 2.0","container-title":"European Journal of Nuclear Medicine and Molecular Imaging","page":"328-354","volume":"42","issue":"2","source":"Crossref","abstract":"The purpose of these guidelines is to assist physicians in recommending, performing, interpreting and reporting the results of FDG PET/CT for oncological imaging of adult patients. PET is a quantitative imaging technique and therefore requires a common quality control (QC)/quality assurance (QA) procedure to maintain the accuracy and precision of quantitation.","DOI":"10.1007/s00259-014-2961-x","ISSN":"1619-7070, 1619-7089","title-short":"FDG PET/CT","language":"en","author":[{"family":"Boellaard","given":"Ronald"},{"family":"Delgado-Bolton","given":"Roberto"},{"family":"Oyen","given":"Wim J. G."},{"family":"Giammarile","given":"Francesco"},{"family":"Tatsch","given":"Klaus"},{"family":"Eschner","given":"Wolfgang"},{"family":"Verzijlbergen","given":"Fred J."},{"family":"Barrington","given":"Sally F."},{"family":"Pike","given":"Lucy C."},{"family":"Weber","given":"Wolfgang A."},{"family":"Stroobants","given":"Sigrid"},{"family":"Delbeke","given":"Dominique"},{"family":"Donohoe","given":"Kevin J."},{"family":"Holbrook","given":"Scott"},{"family":"Graham","given":"Michael M."},{"family":"Testanera","given":"Giorgio"},{"family":"Hoekstra","given":"Otto S."},{"family":"Zijlstra","given":"Josee"},{"family":"Visser","given":"Eric"},{"family":"Hoekstra","given":"Corneline J."},{"family":"Pruim","given":"Jan"},{"family":"Willemsen","given":"Antoon"},{"family":"Arends","given":"Bertjan"},{"family":"Kotzerke","given":"J?rg"},{"family":"Bockisch","given":"Andreas"},{"family":"Beyer","given":"Thomas"},{"family":"Chiti","given":"Arturo"},{"family":"Krause","given":"Bernd J."}],"issued":{"date-parts":[["2015",2]]}}}],"schema":""} (27)PS5Accurate registration between PET and CT scans must be ensured during PET image reconstruction. If significant patient motion has occurred between scans (especially at targets of interest) repetition of scans on a limited FOV should be considered. Rigid motion correction can be considered if appropriate, but small corrections are discouraged, as they typically exacerbate misregistration. This can be tested by generating fused images of PET and CT and visually inspecting for mismatch artifacts. The patient should not be removed from the scanner until the images have been checked to avoid having to obtain an extra CT following the ALARA principle. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"CnmOgBxO","properties":{"formattedCitation":"({\\i{}27})","plainCitation":"(27)","noteIndex":0},"citationItems":[{"id":2009,"uris":[""],"uri":[""],"itemData":{"id":2009,"type":"article-journal","title":"FDG PET/CT: EANM procedure guidelines for tumour imaging: version 2.0","container-title":"European Journal of Nuclear Medicine and Molecular Imaging","page":"328-354","volume":"42","issue":"2","source":"Crossref","abstract":"The purpose of these guidelines is to assist physicians in recommending, performing, interpreting and reporting the results of FDG PET/CT for oncological imaging of adult patients. PET is a quantitative imaging technique and therefore requires a common quality control (QC)/quality assurance (QA) procedure to maintain the accuracy and precision of quantitation.","DOI":"10.1007/s00259-014-2961-x","ISSN":"1619-7070, 1619-7089","title-short":"FDG PET/CT","language":"en","author":[{"family":"Boellaard","given":"Ronald"},{"family":"Delgado-Bolton","given":"Roberto"},{"family":"Oyen","given":"Wim J. G."},{"family":"Giammarile","given":"Francesco"},{"family":"Tatsch","given":"Klaus"},{"family":"Eschner","given":"Wolfgang"},{"family":"Verzijlbergen","given":"Fred J."},{"family":"Barrington","given":"Sally F."},{"family":"Pike","given":"Lucy C."},{"family":"Weber","given":"Wolfgang A."},{"family":"Stroobants","given":"Sigrid"},{"family":"Delbeke","given":"Dominique"},{"family":"Donohoe","given":"Kevin J."},{"family":"Holbrook","given":"Scott"},{"family":"Graham","given":"Michael M."},{"family":"Testanera","given":"Giorgio"},{"family":"Hoekstra","given":"Otto S."},{"family":"Zijlstra","given":"Josee"},{"family":"Visser","given":"Eric"},{"family":"Hoekstra","given":"Corneline J."},{"family":"Pruim","given":"Jan"},{"family":"Willemsen","given":"Antoon"},{"family":"Arends","given":"Bertjan"},{"family":"Kotzerke","given":"J?rg"},{"family":"Bockisch","given":"Andreas"},{"family":"Beyer","given":"Thomas"},{"family":"Chiti","given":"Arturo"},{"family":"Krause","given":"Bernd J."}],"issued":{"date-parts":[["2015",2]]}}}],"schema":""} (27)PS6Global image quality QC tests include checking for artifacts, verifying FOV coverage, appropriate CT contrast (if applicable), and that correct series description names have been set on the images so that nuclear medicine physicians can easily understand what they are looking at. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"nS53nhDX","properties":{"formattedCitation":"({\\i{}27})","plainCitation":"(27)","noteIndex":0},"citationItems":[{"id":2009,"uris":[""],"uri":[""],"itemData":{"id":2009,"type":"article-journal","title":"FDG PET/CT: EANM procedure guidelines for tumour imaging: version 2.0","container-title":"European Journal of Nuclear Medicine and Molecular Imaging","page":"328-354","volume":"42","issue":"2","source":"Crossref","abstract":"The purpose of these guidelines is to assist physicians in recommending, performing, interpreting and reporting the results of FDG PET/CT for oncological imaging of adult patients. PET is a quantitative imaging technique and therefore requires a common quality control (QC)/quality assurance (QA) procedure to maintain the accuracy and precision of quantitation.","DOI":"10.1007/s00259-014-2961-x","ISSN":"1619-7070, 1619-7089","title-short":"FDG PET/CT","language":"en","author":[{"family":"Boellaard","given":"Ronald"},{"family":"Delgado-Bolton","given":"Roberto"},{"family":"Oyen","given":"Wim J. G."},{"family":"Giammarile","given":"Francesco"},{"family":"Tatsch","given":"Klaus"},{"family":"Eschner","given":"Wolfgang"},{"family":"Verzijlbergen","given":"Fred J."},{"family":"Barrington","given":"Sally F."},{"family":"Pike","given":"Lucy C."},{"family":"Weber","given":"Wolfgang A."},{"family":"Stroobants","given":"Sigrid"},{"family":"Delbeke","given":"Dominique"},{"family":"Donohoe","given":"Kevin J."},{"family":"Holbrook","given":"Scott"},{"family":"Graham","given":"Michael M."},{"family":"Testanera","given":"Giorgio"},{"family":"Hoekstra","given":"Otto S."},{"family":"Zijlstra","given":"Josee"},{"family":"Visser","given":"Eric"},{"family":"Hoekstra","given":"Corneline J."},{"family":"Pruim","given":"Jan"},{"family":"Willemsen","given":"Antoon"},{"family":"Arends","given":"Bertjan"},{"family":"Kotzerke","given":"J?rg"},{"family":"Bockisch","given":"Andreas"},{"family":"Beyer","given":"Thomas"},{"family":"Chiti","given":"Arturo"},{"family":"Krause","given":"Bernd J."}],"issued":{"date-parts":[["2015",2]]}}}],"schema":""} (27)Ancillary equipmentPET images are typically reported as standard uptake values (SUV) which have been shown to be accurate within ±10% across a wide range of scanner models with appropriate QA and method standardization. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"ZsRvZwEM","properties":{"formattedCitation":"({\\i{}28})","plainCitation":"(28)","noteIndex":0},"citationItems":[{"id":2685,"uris":[""],"uri":[""],"itemData":{"id":2685,"type":"article-journal","title":"EANM/EARL FDG-PET/CT accreditation - summary results from the first 200 accredited imaging systems","container-title":"European Journal of Nuclear Medicine and Molecular Imaging","page":"412-422","volume":"45","issue":"3","source":"PubMed Central","abstract":"Purpose\nFrom 2010 until July 2016, the EANM Research Ltd. (EARL) FDG-PET/CT accreditation program has collected over 2500 phantom datasets from approximately 200 systems and 150 imaging sites worldwide. The objective of this study is to report the findings and impact of the accreditation program on the participating PET/CT systems.\n\nMethods\nTo obtain and maintain EARL accredited status, sites were required to complete and submit two phantom scans - calibration quality control (CalQC), using a uniform cylindrical phantom and image quality control (IQQC), using a NEMA NU2–2007 body phantom. Average volumetric SUV bias and SUV recovery coefficients (RC) were calculated and the data evaluated on the basis of quality control (QC) type, approval status, PET/CT system manufacturer and submission order.\n\nResults\nSUV bias in 5% (n?=?96) of all CalQC submissions (n?=?1816) exceeded 10%. After corrective actions following EARL feedback, sites achieved 100% compliance within EARL specifications. 30% (n?=?1381) of SUVmean and 23% (n?=?1095) of SUVmax sphere recoveries from IQQC submissions failed to meet EARL accreditation criteria while after accreditation, failure rate decreased to 12% (n?=?360) and 9% (n?=?254), respectively. Most systems demonstrated longitudinal SUV bias reproducibility within ±5%, while RC values remained stable and generally within ±10% for the four largest and ±20% for the two smallest spheres.\n\nConclusions\nRegardless of manufacturer or model, all investigated systems are able to comply with the EARL specifications. Within the EARL accreditation program, gross PET/CT calibration errors are successfully identified and longitudinal variability in PET/CT performances reduced. The program demonstrates that a harmonising accreditation procedure is feasible and achievable.\n\nElectronic supplementary material\nThe online version of this article (10.1007/s00259-017-3853-7) contains supplementary material, which is available to authorized users.","DOI":"10.1007/s00259-017-3853-7","ISSN":"1619-7070","note":"PMID: 29192365\nPMCID: PMC5787222","journalAbbreviation":"Eur J Nucl Med Mol Imaging","author":[{"family":"Kaalep","given":"Andres"},{"family":"Sera","given":"Terez"},{"family":"Oyen","given":"Wim"},{"family":"Krause","given":"Bernd J."},{"family":"Chiti","given":"Arturo"},{"family":"Liu","given":"Yan"},{"family":"Boellaard","given":"Ronald"}],"issued":{"date-parts":[["2018"]]}}}],"schema":""} (28) Because SUV is computed based on patient weight, periodic QA should be applied to patient weight scales as recommended by the vendor. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"jUFXHLuK","properties":{"formattedCitation":"({\\i{}7})","plainCitation":"(7)","noteIndex":0},"citationItems":[{"id":2600,"uris":[""],"uri":[""],"itemData":{"id":2600,"type":"article-journal","title":"Task Group 174 Report: Utilization of [ ¹⁸ F]Fluorodeoxyglucose Positron Emission Tomography ([ ¹⁸ F]FDG-PET) in Radiation Therapy","container-title":"Medical Physics","source":" (Crossref)","abstract":"The use of positron emission tomography (PET) in Radiation Therapy (RT) is rapidly increasing in the areas of staging, segmentation, treatment planning and response assessment. The most common radiotracer is 18F-fluorodeoxyglucose ([18F]FDG), a glucose analogue with demonstrated efficacy in cancer diagnosis and staging. However, diagnosis and RT planning are different endeavors with unique requirements, and very little literature is available for guiding physicists and clinicians in the utilization of [18F]FDG-PET in RT. The two goals of this report are to educate and provide recommendations. The report provides background and education on current PET imaging systems, PET tracers, intensity quantification, and current utilization in RT (staging, segmentation, image registration, treatment planning and therapy response assessment). Recommendations are provided on acceptance testing, annual and monthly quality assurance, scanning protocols to ensure consistency between inter-patient scans and intra-patient longitudinal scans, reporting of patient and scan parameters in literature, requirements for incorporation of [18F]FDG-PET in treatment planning systems, and image registration. The recommendations provided here are minimum requirements and are not meant to cover all aspects of the use of [18F]FDG-PET for RT.","URL":"","DOI":"10.1002/mp.13676","ISSN":"00942405","title-short":"Task Group 174 Report","journalAbbreviation":"Med. Phys.","language":"en","author":[{"family":"Das","given":"Shiva K."},{"family":"McGurk","given":"Ross"},{"family":"Miften","given":"Moyed"},{"family":"Sasa","given":"Mutic"},{"family":"Bowsher","given":"James"},{"family":"Bayouth","given":"John"},{"family":"Erdi","given":"Yusuf"},{"family":"Mawlawi","given":"Osama"},{"family":"Boellaard","given":"Ronald"},{"family":"Bowen","given":"Stephen R."},{"family":"Xing","given":"Lei"},{"family":"Bradley","given":"Jeffrey"},{"family":"Schoder","given":"Heiko"},{"family":"Yin","given":"Fang-Fang"},{"family":"Sullivan","given":"Daniel C."},{"family":"Kinahan","given":"Paul"}],"issued":{"date-parts":[["2019",6,22]]},"accessed":{"date-parts":[["2019",7,2]]}}}],"schema":""} (7) Precision on the order of ±1 kg corresponds to 1-2% patient weight error and is on par with clinical sources of variability including patient clothing, bowel content and hydration state, but ±0.2 kg is readily achievable with clinical devices and routine QC. Likewise, PET images are often scaled to standard uptake based on lean-body mass (SUL), which are computed based on patient height. Height measurement apparatuses should be accurate to within 5 mm. Dose calibrators are used to measure the patient administered activities which factors into the SUV calculation and they serve as a reference for calibration of the PET system. Therefore, they must undergo routine QC to ensure consistency. If multiple dose calibrators are in use, cross calibration must also be ensured. Vendor recommendations should be followed, while professional society guidelines also layout periodic QC including consistency, accuracy, linearity, and geometric and positioning sensitivity testing ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"ixVsBbre","properties":{"formattedCitation":"({\\i{}19})","plainCitation":"(19)","noteIndex":0},"citationItems":[{"id":1960,"uris":[""],"uri":[""],"itemData":{"id":1960,"type":"article-journal","title":"Routine quality control recommendations for nuclear medicine instrumentation","container-title":"European Journal of Nuclear Medicine and Molecular Imaging","page":"662-671","volume":"37","issue":"3","source":"CrossRef","DOI":"10.1007/s00259-009-1347-y","ISSN":"1619-7070, 1619-7089","language":"en","author":[{"literal":"On behalf of the EANM Physics Committee:"},{"literal":"With contribution from the EANM Working Group on Nuclear Medicine Instrumentation Quality Control:"},{"family":"Busemann Sokole","given":"Ellinor"},{"family":"P?achcínska","given":"Anna"},{"family":"Britten","given":"Alan"},{"family":"Lyra Georgosopoulou","given":"Maria"},{"family":"Tindale","given":"Wendy"},{"family":"Klett","given":"Rigobert"}],"issued":{"date-parts":[["2010",3]]}}}],"schema":""} (19). Synchronization of clocks between dose calibrators and PET imaging devices is required for accurate radionuclide decay correction and may be aided by automated device clock synchronization with a centralized time server. Regardless, daily QC of dose calibrator and PET times is recommended, with an emphasis when adjusting to daylight savings times.Image transfer and compatibilityWidespread adoption of DICOM standards for image and RTP transfer has aided compatibility between imaging, diagnostic visualization and treatment planning systems. Target volumes can therefore be delineated on either diagnostic imaging or treatment planning workstations depending on the preferred tools and workflow. Nevertheless, commissioning of new systems should entail validation of proper data transfer including specific emphasis on image orientation, pixel size, spatial positioning offsets and image unit scaling (e.g. SUV). Validations should replicate the clinical workflow and can utilize phantom scans or a patient scans augmented with physical markers that are visible in the image. Marker locations, sizes and separation can be measured in images and validated against the empirical setup. Suitable markers include:Radioactive point sources (e.g. 22Na)Radioactive dilution standards (e.g. sealed vials with known dilutions of FDG) for validating activity quantification.Thin metal wires that are visible on CT, but do not introduce missioning acceptance testing and routine QC testing for RTP systems are detailed in the AAPM TG-53 report ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"7mdNxYh3","properties":{"formattedCitation":"({\\i{}29})","plainCitation":"(29)","noteIndex":0},"citationItems":[{"id":1976,"uris":[""],"uri":[""],"itemData":{"id":1976,"type":"article-journal","title":"American Association of Physicists in Medicine Radiation Therapy Committee Task Group 53: Quality assurance for clinical radiotherapy treatment planning","container-title":"Medical Physics","page":"1773-1829","volume":"25","issue":"10","source":"CrossRef","DOI":"10.1118/1.598373","ISSN":"00942405","title-short":"American Association of Physicists in Medicine Radiation Therapy Committee Task Group 53","language":"en","author":[{"family":"Fraass","given":"Benedick"},{"family":"Doppke","given":"Karen"},{"family":"Hunt","given":"Margie"},{"family":"Kutcher","given":"Gerald"},{"family":"Starkschall","given":"George"},{"family":"Stern","given":"Robin"},{"family":"Van Dyke","given":"Jake"}],"issued":{"date-parts":[["1998",10]]}}}],"schema":""} (29) and in the IAEA Technical document N. 1583 ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"1XKCXXSz","properties":{"formattedCitation":"({\\i{}15})","plainCitation":"(15)","noteIndex":0},"citationItems":[{"id":2467,"uris":[""],"uri":[""],"itemData":{"id":2467,"type":"book","title":"Commissioning of radiotherapy treatment planning systems: testing for typical external beam treatment techniques: report of the coordinated research project (CRP) on development of procedures for quality assurance of dosimetry calculations in radiotherapy","publisher":"International Atomic Energy Agency","publisher-place":"Vienna","source":"Open WorldCat","event-place":"Vienna","ISBN":"978-92-0-100508-3","note":"OCLC: 779533810","title-short":"Commissioning of radiotherapy treatment planning systems","language":"en","author":[{"literal":"International Atomic Energy Agency"}],"issued":{"date-parts":[["2008"]]}}}],"schema":""} (15).Image reconstruction and processingImage reconstruction and processing parameters can influence image characteristics including target to background uptake ratio, spatial resolution and noise. These in turn may influence the perceived target size and intensity. For consistent volume delineation, image reconstruction and processing methodologies should be carefully derived, validated and preserved. As patients may be imaged on different scanners during the course of their treatment a need to harmonize image reconstruction and processing across the patient catchment region is ideal, especially for quantitative assessment of tumor response to treatments including RT. This Changes to methodology should be coordinated between the imaging and radiation therapy teams.AcknowledgementsCPQR would like to thank the many people who participated in the production of this guideline. These include: Michelle Nielsen and David Sasaki (associate editors); the Quality Assurance and Radiation Safety Advisory Committee; the COMP Board of Directors, Erika Brown and the CPQR Steering Committee, and all individuals that submitted comments during the community review of this guideline. References ADDIN ZOTERO_BIBL {"uncited":[],"omitted":[],"custom":[]} CSL_BIBLIOGRAPHY 1. Canadian Partnership for Quality Radiotherapy, Technical Quality Control. . Fioroni F, Iotti C, Paiusco M, et al. PET/CT and radiotherapy: data transfer, radiotherapy workflow and quality assurance. Q J Nucl Med Mol Imaging Off Publ Ital Assoc Nucl Med AIMN Int Assoc Radiopharmacol IAR Sect Soc Of. 2010;54:476-489.3. Brock KK, Mutic S, McNutt TR, Li H, Kessler ML. Use of image registration and fusion algorithms and techniques in radiotherapy: Report of the AAPM Radiation Therapy Committee Task Group No. 132. Med Phys. 2017;44:e43-e76.4. Sam S, Shon IH, Vinod SK, Lin P, Lin M. Workflow and radiation safety implications of (18)F-FDG PET/CT scans for radiotherapy planning. J Nucl Med Technol. 2012;40:175-177.5. Agence internationale de l’énergie atomique. The role of PET/CT in Radiation Treatment Planning fo Cancer Treatment Planning. Vienna: International Atomic Energy Agency; 2008.6. MacManus M, Nestle U, Rosenzweig KE, et al. Use of PET and PET/CT for Radiation Therapy Planning: IAEA expert report 2006–2007. Radiother Oncol. 2009;91:85-94.7. Das SK, McGurk R, Miften M, et al. Task Group 174 Report: Utilization of [ 18 F]Fluorodeoxyglucose Positron Emission Tomography ([ 18 F]FDG-PET) in Radiation Therapy. Med Phys. June 2019.8. Technical Quality Control Guidelines for Computed Tomography Simulators. Canadian Partnership for Quality Radiotherapy; 2016:14.9. Diagnostic Imaging Requirements. Joint Commission on the Accreditation of Healthcare Organizations; 2015:6.10. NEMA NU-2-2012 Performance Measurements of Positron Emission Tomographs (PETs). 2013.11. NEMA NU 2-2018 Performance Measurements of Positron Emission Tomographs (PET). 2018.12. Lin P-J Paul, Beck T J, Borras C, et al. AAPM Reports - Specification and Acceptance Testing of Computed Tomography Scanners. American Association of Physicists in Medicine; 1993:95.13. IEC 60601-2-44:2009 | IEC Webstore. . Agence internationale de l’énergie atomique. Quality assurance for PET and PET/CT Systems. Vienna: International Atomic Energy Agency; 2009.15. International Atomic Energy Agency. Commissioning of radiotherapy treatment planning systems: testing for typical external beam treatment techniques: report of the coordinated research project (CRP) on development of procedures for quality assurance of dosimetry calculations in radiotherapy. Vienna: International Atomic Energy Agency; 2008.16. Technical Quality Control Guidelines for Canadian Radiation Treatment Centres. Canadian Partnership for Quality Radiotherapy; 2015:18.17. Nielsen MK, Malkoske KE, Brown E, et al. Production, review, and impact of technical quality control guidelines in a national context. J Appl Clin Med Phys. 2016;17:3-15.18. ACR-AAPM Technical Standard for Medical Nuclear Physics Performance Monitoring of PET Imaging Equipment. ACR-AAPM; 2016.19. On behalf of the EANM Physics Committee:, With contribution from the EANM Working Group on Nuclear Medicine Instrumentation Quality Control:, Busemann Sokole E, et al. Routine quality control recommendations for nuclear medicine instrumentation. Eur J Nucl Med Mol Imaging. 2010;37:662-671.20. Xing L. Quality assurance of PET/CT for radiation therapy. Int J Radiat Oncol Biol Phys. 2008;71:S38-S42.21. Zanzonico P. Routine Quality Control of Clinical Nuclear Medicine Instrumentation: A Brief Review. J Nucl Med Off Publ Soc Nucl Med. 2008;49:1114-1131.22. Mutic S, Palta JR, Butker EK, et al. Quality assurance for computed-tomography simulators and the computed-tomography-simulation process: Report of the AAPM Radiation Therapy Committee Task Group No. 66. Med Phys. 2003;30:2762-2792.23. Lockhart CM, MacDonald LR, Alessio AM, McDougald WA, Doot RK, Kinahan PE. Quantifying and Reducing the Effect of Calibration Error on Variability of PET/CT Standardized Uptake Value Measurements. J Nucl Med Off Publ Soc Nucl Med. 2011;52:218-224.24. Byrd D, Christopfel R, Arabasz G, et al. Measuring temporal stability of positron emission tomography standardized uptake value bias using long-lived sources in a multicenter network. J Med Imaging. 2018;5:1.25. Technical Quality Control Guidelines for Safety Systems at Radiation Treatment Centres. Canadian Partnership for Quality Radiotherapy; 2016:15.26. Bevins NB, Flynn MJ, Silosky MS, Marsh RM, Walz-Flannigan AI, Badano A. Display Quality Assurance, The Report of AAPM Task Group 270.; 2019.27. Boellaard R, Delgado-Bolton R, Oyen WJG, et al. FDG PET/CT: EANM procedure guidelines for tumour imaging: version 2.0. Eur J Nucl Med Mol Imaging. 2015;42:328-354.28. Kaalep A, Sera T, Oyen W, et al. EANM/EARL FDG-PET/CT accreditation - summary results from the first 200 accredited imaging systems. Eur J Nucl Med Mol Imaging. 2018;45:412-422.29. Fraass B, Doppke K, Hunt M, et al. American Association of Physicists in Medicine Radiation Therapy Committee Task Group 53: Quality assurance for clinical radiotherapy treatment planning. Med Phys. 1998;25:1773-1829.30. Delbeke D, Coleman RE, Guiberteau MJ, et al. Procedure Guideline for Tumor Imaging with 18F-FDG PET/CT 1.0. J Nucl Med. 2006;47:885-95.31. Fendler WP, Eiber M, Beheshti M, et al. 68Ga-PSMA PET/CT: Joint EANM and SNMMI procedure guideline for prostate cancer imaging: version 1.0. Eur J Nucl Med Mol Imaging. 2017;44:1014-1024.32. Berthelsen AK, Holm S, Loft A, Klausen TL, Andersen F, H?jgaard L. PET/CT with intravenous contrast can be used for PET attenuation correction in cancer patients. Eur J Nucl Med Mol Imaging. 2005;32:1167-1175.33. Aristophanous M, Berbeco RI, Killoran JH, et al. Clinical Utility of 4D FDG-PET/CT Scans in Radiation Treatment Planning. Int J Radiat Oncol. 2012;82:e99-e105.34. Chi A, Nguyen NP. 4D PET/CT as a Strategy to Reduce Respiratory Motion Artifacts in FDG-PET/CT. Front Oncol. 2014;4.35. Geiger GA, Kim MB, Xanthopoulos EP, et al. Stage Migration in Planning PET/CT Scans in Patients Due to Receive Radiotherapy for Non–Small-Cell Lung Cancer. Clin Lung Cancer. 2014;15:79-85.36. Everitt S, Herschtal A, Callahan J, et al. High rates of tumor growth and disease progression detected on serial pretreatment fluorodeoxyglucose-positron emission tomography/computed tomography scans in radical radiotherapy candidates with nonsmall cell lung cancer. Cancer. 116:5030-5037.37. Mayo CS, Moran JM, Bosch W, et al. American Association of Physicists in Medicine Task Group 263: Standardizing Nomenclatures in Radiation Oncology. Int J Radiat Oncol ? Biol ? Phys. 2018;100:1057-1066.38. Kisilev P, Walach E, Barkan E, Ophir B, Alpert S, Hashoul SY. From medical image to automatic medical report generation. IBM J Res Dev. 2015;59:2:1-2:7.39. International Atomic Energy Agency. PET/CT atlas on quality control and image artefacts.; 2014.40. de Jong EEC, van Elmpt W, Hoekstra OS, et al. Quality assessment of positron emission tomography scans: recommendations for future multicentre trials. Acta Oncol. 2017;56:1459-1464.41. Daisaki H, Tateishi U, Terauchi T, et al. Standardization of image quality across multiple centers by optimization of acquisition and reconstruction parameters with interim FDG-PET/CT for evaluating diffuse large B cell lymphoma. Ann Nucl Med. 2013;27:225-232.42. Sunderland JJ, Christian PE. Quantitative PET/CT Scanner Performance Characterization Based Upon the Society of Nuclear Medicine and Molecular Imaging Clinical Trials Network Oncology Clinical Simulator Phantom. J Nucl Med. 2015;56:145-152.43. PET phantom instructions for evaluation of PET image quality. American College of Radiology; 2010:15.44. EARL Homepage. . deKemp R, Caldwell C, Farncombe T, et al. PET imaging standards and quality assurance for the multi-center trials of the Ontario Clinical Oncology Group (OCOG). J Nucl Med. 2006;47:365P-365P.Appendix A - CLINICAL QUALITYPatient preparationSpecific patient preparation consideration should be given depending on the PET tracer, disease state patient and clinical task. Specific guidelines for tracers and indications are continuously being developed by professional bodies. The Society of Nuclear Medicine and Molecular Imaging (SNMMI) and the European Association of Nuclear Medicine (EANM) commonly publish joint guidelines which are freely available through their respective websites, including for FDG ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"5SHQaiWJ","properties":{"formattedCitation":"({\\i{}27},{\\i{}30})","plainCitation":"(27,30)","noteIndex":0},"citationItems":[{"id":1964,"uris":[""],"uri":[""],"itemData":{"id":1964,"type":"article-journal","title":"Procedure Guideline for Tumor Imaging with 18F-FDG PET/CT 1.0","container-title":"Journal of Nuclear Medicine","page":"885-95","volume":"47","issue":"5","source":"Zotero","language":"en","author":[{"family":"Delbeke","given":"Dominique"},{"family":"Coleman","given":"R Edward"},{"family":"Guiberteau","given":"Milton J"},{"family":"Brown","given":"Manuel L"},{"family":"Royal","given":"Henry D"},{"family":"Siegel","given":"Barry A"},{"family":"Townsend","given":"David W"},{"family":"Berland","given":"Lincoln L"},{"family":"Parker","given":"J Anthony"},{"family":"Hubner","given":"Karl"},{"family":"Stabin","given":"Michael G"},{"family":"Zubal","given":"George"},{"family":"Kachelriess","given":"Marc"},{"family":"Cronin","given":"Valerie"},{"family":"Holbrook","given":"Scott"}],"issued":{"date-parts":[["2006",2,11]]}}},{"id":2009,"uris":[""],"uri":[""],"itemData":{"id":2009,"type":"article-journal","title":"FDG PET/CT: EANM procedure guidelines for tumour imaging: version 2.0","container-title":"European Journal of Nuclear Medicine and Molecular Imaging","page":"328-354","volume":"42","issue":"2","source":"Crossref","abstract":"The purpose of these guidelines is to assist physicians in recommending, performing, interpreting and reporting the results of FDG PET/CT for oncological imaging of adult patients. PET is a quantitative imaging technique and therefore requires a common quality control (QC)/quality assurance (QA) procedure to maintain the accuracy and precision of quantitation.","DOI":"10.1007/s00259-014-2961-x","ISSN":"1619-7070, 1619-7089","title-short":"FDG PET/CT","language":"en","author":[{"family":"Boellaard","given":"Ronald"},{"family":"Delgado-Bolton","given":"Roberto"},{"family":"Oyen","given":"Wim J. G."},{"family":"Giammarile","given":"Francesco"},{"family":"Tatsch","given":"Klaus"},{"family":"Eschner","given":"Wolfgang"},{"family":"Verzijlbergen","given":"Fred J."},{"family":"Barrington","given":"Sally F."},{"family":"Pike","given":"Lucy C."},{"family":"Weber","given":"Wolfgang A."},{"family":"Stroobants","given":"Sigrid"},{"family":"Delbeke","given":"Dominique"},{"family":"Donohoe","given":"Kevin J."},{"family":"Holbrook","given":"Scott"},{"family":"Graham","given":"Michael M."},{"family":"Testanera","given":"Giorgio"},{"family":"Hoekstra","given":"Otto S."},{"family":"Zijlstra","given":"Josee"},{"family":"Visser","given":"Eric"},{"family":"Hoekstra","given":"Corneline J."},{"family":"Pruim","given":"Jan"},{"family":"Willemsen","given":"Antoon"},{"family":"Arends","given":"Bertjan"},{"family":"Kotzerke","given":"J?rg"},{"family":"Bockisch","given":"Andreas"},{"family":"Beyer","given":"Thomas"},{"family":"Chiti","given":"Arturo"},{"family":"Krause","given":"Bernd J."}],"issued":{"date-parts":[["2015",2]]}}}],"schema":""} (27,30) and 68Ga-PSMA ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"teS4cmBr","properties":{"formattedCitation":"({\\i{}31})","plainCitation":"(31)","noteIndex":0},"citationItems":[{"id":2506,"uris":[""],"uri":[""],"itemData":{"id":2506,"type":"article-journal","title":"68Ga-PSMA PET/CT: Joint EANM and SNMMI procedure guideline for prostate cancer imaging: version 1.0","container-title":"European Journal of Nuclear Medicine and Molecular Imaging","page":"1014-1024","volume":"44","issue":"6","source":" (Crossref)","DOI":"10.1007/s00259-017-3670-z","ISSN":"1619-7070, 1619-7089","title-short":"68Ga-PSMA PET/CT","journalAbbreviation":"Eur J Nucl Med Mol Imaging","language":"en","author":[{"family":"Fendler","given":"Wolfgang P."},{"family":"Eiber","given":"Matthias"},{"family":"Beheshti","given":"Mohsen"},{"family":"Bomanji","given":"Jamshed"},{"family":"Ceci","given":"Francesco"},{"family":"Cho","given":"Steven"},{"family":"Giesel","given":"Frederik"},{"family":"Haberkorn","given":"Uwe"},{"family":"Hope","given":"Thomas A."},{"family":"Kopka","given":"Klaus"},{"family":"Krause","given":"Bernd J."},{"family":"Mottaghy","given":"Felix M."},{"family":"Sch?der","given":"Heiko"},{"family":"Sunderland","given":"John"},{"family":"Wan","given":"Simon"},{"family":"Wester","given":"Hans-Jürgen"},{"family":"Fanti","given":"Stefano"},{"family":"Herrmann","given":"Ken"}],"issued":{"date-parts":[["2017",6]]}}}],"schema":""} (31). For accurate SUV/SUL scaling, patient weight and height should be measured with a high-quality scale. In addition, the activity administered to the patient must be accurately measured including the residual activity in the syringe after injection as well as time of injection (for radioactive decay correction).CT Contrast AgentThe use of CT contrast agents is commonly applied for improved organ delineation in RTP. Concerns regarding suboptimal attenuation correction from contrast CT have been largely addressed except for cases of high concentration (e.g. arterial phase) ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"XtHWOuGk","properties":{"formattedCitation":"({\\i{}27},{\\i{}30})","plainCitation":"(27,30)","noteIndex":0},"citationItems":[{"id":1964,"uris":[""],"uri":[""],"itemData":{"id":1964,"type":"article-journal","title":"Procedure Guideline for Tumor Imaging with 18F-FDG PET/CT 1.0","container-title":"Journal of Nuclear Medicine","page":"885-95","volume":"47","issue":"5","source":"Zotero","language":"en","author":[{"family":"Delbeke","given":"Dominique"},{"family":"Coleman","given":"R Edward"},{"family":"Guiberteau","given":"Milton J"},{"family":"Brown","given":"Manuel L"},{"family":"Royal","given":"Henry D"},{"family":"Siegel","given":"Barry A"},{"family":"Townsend","given":"David W"},{"family":"Berland","given":"Lincoln L"},{"family":"Parker","given":"J Anthony"},{"family":"Hubner","given":"Karl"},{"family":"Stabin","given":"Michael G"},{"family":"Zubal","given":"George"},{"family":"Kachelriess","given":"Marc"},{"family":"Cronin","given":"Valerie"},{"family":"Holbrook","given":"Scott"}],"issued":{"date-parts":[["2006",2,11]]}}},{"id":2009,"uris":[""],"uri":[""],"itemData":{"id":2009,"type":"article-journal","title":"FDG PET/CT: EANM procedure guidelines for tumour imaging: version 2.0","container-title":"European Journal of Nuclear Medicine and Molecular Imaging","page":"328-354","volume":"42","issue":"2","source":"Crossref","abstract":"The purpose of these guidelines is to assist physicians in recommending, performing, interpreting and reporting the results of FDG PET/CT for oncological imaging of adult patients. PET is a quantitative imaging technique and therefore requires a common quality control (QC)/quality assurance (QA) procedure to maintain the accuracy and precision of quantitation.","DOI":"10.1007/s00259-014-2961-x","ISSN":"1619-7070, 1619-7089","title-short":"FDG PET/CT","language":"en","author":[{"family":"Boellaard","given":"Ronald"},{"family":"Delgado-Bolton","given":"Roberto"},{"family":"Oyen","given":"Wim J. G."},{"family":"Giammarile","given":"Francesco"},{"family":"Tatsch","given":"Klaus"},{"family":"Eschner","given":"Wolfgang"},{"family":"Verzijlbergen","given":"Fred J."},{"family":"Barrington","given":"Sally F."},{"family":"Pike","given":"Lucy C."},{"family":"Weber","given":"Wolfgang A."},{"family":"Stroobants","given":"Sigrid"},{"family":"Delbeke","given":"Dominique"},{"family":"Donohoe","given":"Kevin J."},{"family":"Holbrook","given":"Scott"},{"family":"Graham","given":"Michael M."},{"family":"Testanera","given":"Giorgio"},{"family":"Hoekstra","given":"Otto S."},{"family":"Zijlstra","given":"Josee"},{"family":"Visser","given":"Eric"},{"family":"Hoekstra","given":"Corneline J."},{"family":"Pruim","given":"Jan"},{"family":"Willemsen","given":"Antoon"},{"family":"Arends","given":"Bertjan"},{"family":"Kotzerke","given":"J?rg"},{"family":"Bockisch","given":"Andreas"},{"family":"Beyer","given":"Thomas"},{"family":"Chiti","given":"Arturo"},{"family":"Krause","given":"Bernd J."}],"issued":{"date-parts":[["2015",2]]}}}],"schema":""} (27,30). Venous phase and delayed enhancement CT-contrast imaging may produce small changes in SUV ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"abW8Z9iY","properties":{"formattedCitation":"({\\i{}32})","plainCitation":"(32)","noteIndex":0},"citationItems":[{"id":2070,"uris":[""],"uri":[""],"itemData":{"id":2070,"type":"article-journal","title":"PET/CT with intravenous contrast can be used for PET attenuation correction in cancer patients","container-title":"European Journal of Nuclear Medicine and Molecular Imaging","page":"1167-1175","volume":"32","issue":"10","source":"PubMed","abstract":"PURPOSE: If the CT scan of a combined PET/CT study is performed as a full diagnostic quality CT scan including intravenous (IV) contrast agent, the quality of the joint PET/CT procedure is improved and a separate diagnostic CT scan can be avoided. CT with IV contrast can be used for PET attenuation correction, but this may result in a bias in the attenuation factors. The clinical significance of this bias has not been established. Our aim was to perform a prospective clinical study where each patient had CT performed with and without IV contrast agent to establish whether PET/CT with IV contrast can be used for PET attenuation without reducing the clinical value of the PET scan.\nMETHODS: A uniform phantom study was used to document that the PET acquisition itself is not significantly influenced by the presence of IV contrast medium. Then, 19 patients referred to PET/CT with IV contrast underwent CT scans without, and then with contrast agent, followed by an 18F-fluorodeoxyglucose whole-body PET scan. The CT examinations were performed with identical parameters on a GE Discovery LS scanner. The PET data were reconstructed with attenuation correction based on the two CT data sets. A global comparison of standard uptake value (SUV) was performed, and SUVs in tumour, in non-tumour tissue and in the subclavian vein were calculated. Clinical evaluation of the number and location of lesions on all PET/CT scans was performed twice, blinded and in a different random order, by two independent nuclear medicine specialists.\nRESULTS: In all patients, the measured global SUV of PET images based on CT with IV contrast agent was higher than the global activity using non-contrast correction. The overall increase in the mean SUV (for two different conversion tables tested) was 4.5+/-2.3% and 1.6+/-0.5%, respectively. In 11/19 patients, focal uptake was identified corresponding to malignant tumours. Eight out of 11 tumours showed an increased SUVmax (2.9+/-3.1%) on the PET images reconstructed using IV contrast. The clinical evaluation performed by the two specialists comparing contrast and non-contrast CT attenuated PET images showed weighted kappa values of 0.92 (doctor A) and 0.82 (doctor B). No contrast-introduced artefacts were found.\nCONCLUSION: This study demonstrates that CT scans with IV contrast agent can be used for attenuation correction of the PET data in combined modality PET/CT scanning, without changing the clinical diagnostic interpretation.","DOI":"10.1007/s00259-005-1784-1","ISSN":"1619-7070","note":"PMID: 15909196","journalAbbreviation":"Eur. J. Nucl. Med. Mol. Imaging","language":"eng","author":[{"family":"Berthelsen","given":"A. K."},{"family":"Holm","given":"S."},{"family":"Loft","given":"A."},{"family":"Klausen","given":"T. L."},{"family":"Andersen","given":"F."},{"family":"H?jgaard","given":"L."}],"issued":{"date-parts":[["2005",10]]}}}],"schema":""} (32). Nevertheless, with the added information of PET for RTP, the need for CT contrast may be reduced. At the expense of extra scan time and radiation exposure to the patient, two CT scans may also be obtained: without and with contrast.Patient PositioningUtilization of diagnostic PET for RT simulation is typically ill-advised due to differences in patient positioning between imaging and therapy sessions. PET acquisition on a flat table top and with appropriate immobilization devices is preferable as this enables better software-based registration between the PET and simulation CTs. Ideally RTP and simulation should be performed using hardware registered PET and CT (i.e. hybrid systems), and with appropriate patient positioning by a qualified radiation therapist. The use of fiducial markers, a flat bed, patient immobilization devices and dedicated laser alignment hardware should be integrated into the PET process for optimal registration with RT delivery devices. The PET/CT patient positioning should replicate that of RT as nearly as possible using identical apparatuses. PET/CT registrationFor accurate attenuation correction and SUV quantification, it is assumed that hardware registration between PET and CT is sufficient. Nevertheless, in the presence of patient motion this assumption may be violated (typically regionally). PET/CT registration QA should be performed in every case prior to patient removal from the PET imaging bed, as is common practice in diagnostic imaging ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"pgvBladx","properties":{"formattedCitation":"({\\i{}30})","plainCitation":"(30)","noteIndex":0},"citationItems":[{"id":1964,"uris":[""],"uri":[""],"itemData":{"id":1964,"type":"article-journal","title":"Procedure Guideline for Tumor Imaging with 18F-FDG PET/CT 1.0","container-title":"Journal of Nuclear Medicine","page":"885-95","volume":"47","issue":"5","source":"Zotero","language":"en","author":[{"family":"Delbeke","given":"Dominique"},{"family":"Coleman","given":"R Edward"},{"family":"Guiberteau","given":"Milton J"},{"family":"Brown","given":"Manuel L"},{"family":"Royal","given":"Henry D"},{"family":"Siegel","given":"Barry A"},{"family":"Townsend","given":"David W"},{"family":"Berland","given":"Lincoln L"},{"family":"Parker","given":"J Anthony"},{"family":"Hubner","given":"Karl"},{"family":"Stabin","given":"Michael G"},{"family":"Zubal","given":"George"},{"family":"Kachelriess","given":"Marc"},{"family":"Cronin","given":"Valerie"},{"family":"Holbrook","given":"Scott"}],"issued":{"date-parts":[["2006",2,11]]}}}],"schema":""} (30). Repeat imaging of body regions in which gross misregistration is apparent may be undertaken as required. Manual alignment may be appropriate, but adjustment of small misregistrations are not recommended as they may introduce errors due to human factors.PET and CT misregistration in the lung and liver regions is unavoidable due to the long imaging time of PET (2-3 min per bed position) vs that of CT. Normal breath-hold techniques during the CT acquisition are recommended ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"9jk7k9vc","properties":{"formattedCitation":"({\\i{}30})","plainCitation":"(30)","noteIndex":0},"citationItems":[{"id":1964,"uris":[""],"uri":[""],"itemData":{"id":1964,"type":"article-journal","title":"Procedure Guideline for Tumor Imaging with 18F-FDG PET/CT 1.0","container-title":"Journal of Nuclear Medicine","page":"885-95","volume":"47","issue":"5","source":"Zotero","language":"en","author":[{"family":"Delbeke","given":"Dominique"},{"family":"Coleman","given":"R Edward"},{"family":"Guiberteau","given":"Milton J"},{"family":"Brown","given":"Manuel L"},{"family":"Royal","given":"Henry D"},{"family":"Siegel","given":"Barry A"},{"family":"Townsend","given":"David W"},{"family":"Berland","given":"Lincoln L"},{"family":"Parker","given":"J Anthony"},{"family":"Hubner","given":"Karl"},{"family":"Stabin","given":"Michael G"},{"family":"Zubal","given":"George"},{"family":"Kachelriess","given":"Marc"},{"family":"Cronin","given":"Valerie"},{"family":"Holbrook","given":"Scott"}],"issued":{"date-parts":[["2006",2,11]]}}}],"schema":""} (30), but the use of 4D CT should be considered in cases where accurate target delineation in respiratory-motion-affected regions is vital.Respiratory MotionGated PET (4D) is recommended to account for reciprocating organ and target motion in lung, heart, diaphragm and upper abdominal regions ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"C7ev3dH3","properties":{"formattedCitation":"({\\i{}5},{\\i{}33},{\\i{}34})","plainCitation":"(5,33,34)","noteIndex":0},"citationItems":[{"id":1993,"uris":[""],"uri":[""],"itemData":{"id":1993,"type":"article-journal","title":"Clinical Utility of 4D FDG-PET/CT Scans in Radiation Treatment Planning","container-title":"International Journal of Radiation Oncology*Biology*Physics","page":"e99-e105","volume":"82","issue":"1","source":"ScienceDirect","abstract":"Purpose\nThe potential role of four-dimensional (4D) positron emission tomography (PET)/computed tomography (CT) in radiation treatment planning, relative to standard three-dimensional (3D) PET/CT, was examined.\nMethods and Materials\nTen patients with non–small-cell lung cancer had sequential 3D and 4D [18F]fluorodeoxyglucose PET/CT scans in the treatment position prior to radiation therapy. The gross tumor volume and involved lymph nodes were contoured on the PET scan by use of three different techniques: manual contouring by an experienced radiation oncologist using a predetermined protocol; a technique with a constant threshold of standardized uptake value (SUV) greater than 2.5; and an automatic segmentation technique. For each technique, the tumor volume was defined on the 3D scan (VOL3D) and on the 4D scan (VOL4D) by combining the volume defined on each of the five breathing phases individually. The range of tumor motion and the location of each lesion were also recorded, and their influence on the differences observed between VOL3D and VOL4D was investigated.\nResults\nWe identified and analyzed 22 distinct lesions, including 9 primary tumors and 13 mediastinal lymph nodes. Mean VOL4D was larger than mean VOL3D with all three techniques, and the difference was statistically significant (p < 0.01). The range of tumor motion and the location of the tumor affected the magnitude of the difference. For one case, all three tumor definition techniques identified volume of moderate uptake of approximately 1 mL in the hilar region on the 4D scan (SUV maximum, 3.3) but not on the 3D scan (SUV maximum, 2.3).\nConclusions\nIn comparison to 3D PET, 4D PET may better define the full physiologic extent of moving tumors and improve radiation treatment planning for lung tumors. In addition, reduction of blurring from free-breathing images may reveal additional information regarding regional disease.","DOI":"10.1016/j.ijrobp.2010.12.060","ISSN":"0360-3016","journalAbbreviation":"International Journal of Radiation Oncology*Biology*Physics","author":[{"family":"Aristophanous","given":"Michalis"},{"family":"Berbeco","given":"Ross I."},{"family":"Killoran","given":"Joseph H."},{"family":"Yap","given":"Jeffrey T."},{"family":"Sher","given":"David J."},{"family":"Allen","given":"Aaron M."},{"family":"Larson","given":"Elysia"},{"family":"Chen","given":"Aileen B."}],"issued":{"date-parts":[["2012",1,1]]}}},{"id":1994,"uris":[""],"uri":[""],"itemData":{"id":1994,"type":"article-journal","title":"4D PET/CT as a Strategy to Reduce Respiratory Motion Artifacts in FDG-PET/CT","container-title":"Frontiers in Oncology","volume":"4","source":"PubMed Central","abstract":"The improved accuracy in tumor identification with FDG-PET has led to its increased utilization in target volume delineation for radiotherapy treatment planning in the treatment of lung cancer. However, PET/CT has constantly been influenced by respiratory motion-related image degradation, which is especially prominent for small lung tumors in the peri-diaphragmatic regions of the thorax. Here, we describe the current findings on respiratory motion-related image degradation in PET/CT, which may bring uncertainties to target volume delineation for image guided radiotherapy (IGRT) for lung cancer. Furthermore, we describe the evidence suggesting 4D PET/CT to be one strategy to minimize the impact of respiratory motion-related image degradation on tumor target delineation for thoracic IGRT. This, in our opinion, warrants further investigation in future IGRT-based lung cancer trials.","URL":"","DOI":"10.3389/fonc.2014.00205","ISSN":"2234-943X","note":"PMID: 25136514\nPMCID: PMC4120690","journalAbbreviation":"Front Oncol","author":[{"family":"Chi","given":"Alexander"},{"family":"Nguyen","given":"Nam P."}],"issued":{"date-parts":[["2014",8,4]]},"accessed":{"date-parts":[["2018",4,20]]}}},{"id":2000,"uris":[""],"uri":[""],"itemData":{"id":2000,"type":"book","title":"The role of PET/CT in Radiation Treatment Planning fo Cancer Treatment Planning","publisher":"International Atomic Energy Agency","publisher-place":"Vienna","source":"Open WorldCat","event-place":"Vienna","abstract":"This publication is a resource for nuclear medicine and radiation oncology on the coupling of positron emission tomography and X ray computed tomography (PET/CT) to more accurately identify cancer cells within the body. Besides, although radiation therapy plays an important role in cancer treatment as an effective non-invasive therapy, damage to normal cells in the vicinity of tumor cells may be detrimental to the patient's health and recovery. The joint use of PET and CT provides superior imaging of the existing disease and, therefore, promises to minimize adverse effects of radiation therapy. By more precisely marking the presence of cancerous cells, thereby facilitating more precise irradiation, it also enables an increase in the dose of radiation therapy delivered to the malignant cells, which leads to better tumor control and improved survival of patients.","URL":"","note":"OCLC: 822579697","language":"en","author":[{"literal":"Agence internationale de l'énergie atomique"}],"issued":{"date-parts":[["2008"]]},"accessed":{"date-parts":[["2018",4,20]]}}}],"schema":""} (5,33,34). In conjunction with appropriate therapy delivery equipment, target tracking and/or dose rate modulation can be used to deliver more accurate and conformal dose distributions. Although new data driven or device-less methods that estimate the respiratory wave function using the projection data of PET are being introduced into clinical systems, gated PET typically relies on external respiratory triggering hardware (e.g. optical tracking or pressure belt) to assign detected events to corresponding phases in the respiratory cycle. Respiratory equipment at the delivery unit may differ and may not provide identical information regarding the magnitude of motion. Equipment specific QA is required to ensure adequate correlation between gating systems for optimal dose delivery. With list-mode data acquisition being a standard feature of modern PET systems, PET reconstruction of static (3D) and respiratory gated (4D) images is possible from a single PET acquisition. To compensate for lower count-statistics per gate, however, it may be desirable to acquire motion effected body regions with longer time per bed-stop, especially in the presence of small, low intensity targets. Moving objects are blurred in static images, typically making lung lesions appear fainter and larger, but motion correction software is becoming increasingly available to reconstruct motion frozen PET using preserving 100% of the data.While other types of motion, such as cardiac contraction, gross patient motion and organ creep are measurable, they are largely ignored in the context of RT.Time to TherapyDue to the dynamic nature of cancer, the time between diagnostic and/or pre-treatment imaging and delivery of therapy may be a critical factor for accurate target delineation. Geiger et al. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"LjgdfL9C","properties":{"formattedCitation":"({\\i{}35})","plainCitation":"(35)","noteIndex":0},"citationItems":[{"id":2063,"uris":[""],"uri":[""],"itemData":{"id":2063,"type":"article-journal","title":"Stage Migration in Planning PET/CT Scans in Patients Due to Receive Radiotherapy for Non–Small-Cell Lung Cancer","container-title":"Clinical Lung Cancer","page":"79-85","volume":"15","issue":"1","source":"Crossref","abstract":"Currently, controversy surrounds how long a delay is needed to affect the results of radiochemotherapy in patients with nonesmall-cell lung cancer. The present ?ndings suggest that delays of just 6 weeks may degrade treatment ef?cacy. In 26% of the patients, TNM stage progression changed treatment intent after a repeat PET/CT scan taken, on median, 45 days after the initial scan.","DOI":"10.1016/j.cllc.2013.08.004","ISSN":"15257304","language":"en","author":[{"family":"Geiger","given":"Geoffrey A."},{"family":"Kim","given":"Miranda B."},{"family":"Xanthopoulos","given":"Eric P."},{"family":"Pryma","given":"Daniel A."},{"family":"Grover","given":"Surbhi"},{"family":"Plastaras","given":"John P."},{"family":"Langer","given":"Corey J."},{"family":"Simone","given":"Charles B."},{"family":"Rengan","given":"Ramesh"}],"issued":{"date-parts":[["2014",1]]}}}],"schema":""} (35) and Everitt et al. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"mBOI4cIF","properties":{"formattedCitation":"({\\i{}36})","plainCitation":"(36)","noteIndex":0},"citationItems":[{"id":2106,"uris":[""],"uri":[""],"itemData":{"id":2106,"type":"article-journal","title":"High rates of tumor growth and disease progression detected on serial pretreatment fluorodeoxyglucose-positron emission tomography/computed tomography scans in radical radiotherapy candidates with nonsmall cell lung cancer","container-title":"Cancer","page":"5030-5037","volume":"116","issue":"21","source":"Wiley Online Library","abstract":"BACKGROUND: The authors studied growth and progression of untreated nonsmall cell lung cancer (NSCLC) by comparing diagnostic and radiotherapy (RT) planning fluorodeoxyglucose (FDG)-positron emission tomography (PET)/computed tomography (CT) scans before proposed radical chemo-RT. METHODS: Patients enrolled on a prospective clinical trial were eligible for this analysis if they underwent 2 pretreatment whole body FDG-PET/CT scans, >7 days apart. Scan 1 was performed for diagnosis/disease staging and scan 2 for RT planning. Interscan comparisons included disease stage, metabolic characteristics, tumor doubling times, and change in treatment intent. RESULTS: Eighty-two patients underwent planning PET/CT scans between October 2004 and February 2007. Of these, 28 patients (61% stage III, 18% stage II) had undergone prior staging PET/CT scans. The median interscan period was 24 days (range, 8-176 days). Interscan disease progression (TNM stage) was detected in 11 (39%) patients. The probability of upstaging within 24 days was calculated to be 32% (95% confidence interval [CI], 18%-49%). Treatment intent changed from curative to palliative in 8 (29%) cases, in 7 because of PET. For 17 patients who underwent serial PET/CT scans under standardized conditions, there was a mean relative interscan increase of 19% in tumor maximum standardized uptake value (SUV) (P = .022), 16% in average SUV (P = .004), and 116% in percentage injected dose (P = .002). Estimated doubling time of FDG avid tumor was 66 days (95% CI, 51-95 days). CONCLUSIONS: Rapid tumor progression was detected in patients with untreated, predominantly stage III, NSCLC on serial FDG-PET/CT imaging, highlighting the need for prompt diagnosis, staging, and initiation of therapy in patients who are candidates for potentially curative therapy. Cancer 2010. ? 2010 American Cancer Society.","DOI":"10.1002/cncr.25392","ISSN":"1097-0142","language":"en","author":[{"family":"Everitt","given":"Sarah"},{"family":"Herschtal","given":"Alan"},{"family":"Callahan","given":"Jason"},{"family":"Plumridge","given":"Nikki"},{"family":"Ball","given":"David"},{"family":"Kron","given":"Tomas"},{"family":"Schneider‐Kolsky","given":"Michal"},{"family":"Binns","given":"David"},{"family":"Hicks","given":"Rodney J."},{"family":"MacManus","given":"Michael"}]}}],"schema":""} (36) demonstrated that in non-small-cell lung cancer over the course of even a few weeks, a significant number of patient were upstaged due to increases in tumor FDG avidity, tumor size, number of nodes and metastatic state. These changes in staging influenced the intent to treat from curative to palliative within several weeks and are consistent with previous findings in both lung and other cancers ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"mGvBaarv","properties":{"formattedCitation":"({\\i{}35})","plainCitation":"(35)","noteIndex":0},"citationItems":[{"id":2063,"uris":[""],"uri":[""],"itemData":{"id":2063,"type":"article-journal","title":"Stage Migration in Planning PET/CT Scans in Patients Due to Receive Radiotherapy for Non–Small-Cell Lung Cancer","container-title":"Clinical Lung Cancer","page":"79-85","volume":"15","issue":"1","source":"Crossref","abstract":"Currently, controversy surrounds how long a delay is needed to affect the results of radiochemotherapy in patients with nonesmall-cell lung cancer. The present ?ndings suggest that delays of just 6 weeks may degrade treatment ef?cacy. In 26% of the patients, TNM stage progression changed treatment intent after a repeat PET/CT scan taken, on median, 45 days after the initial scan.","DOI":"10.1016/j.cllc.2013.08.004","ISSN":"15257304","language":"en","author":[{"family":"Geiger","given":"Geoffrey A."},{"family":"Kim","given":"Miranda B."},{"family":"Xanthopoulos","given":"Eric P."},{"family":"Pryma","given":"Daniel A."},{"family":"Grover","given":"Surbhi"},{"family":"Plastaras","given":"John P."},{"family":"Langer","given":"Corey J."},{"family":"Simone","given":"Charles B."},{"family":"Rengan","given":"Ramesh"}],"issued":{"date-parts":[["2014",1]]}}}],"schema":""} (35). Hence the clinical workflow should target RT delivery within two weeks of PET/CT for RTP.ProtocolsPatient mispositioning, inaccurate communication and operator error remain large sources of variability in RTP and can be mitigated using clear, predefined protocols. Protocols should be body site specific and should contain instructions regarding patient positioning, immobilization devices, setup instructions, image acquisition protocols and parameters, scan limits, use of contrast agents and any additional special instructions ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"GW5C4ZDA","properties":{"formattedCitation":"({\\i{}22})","plainCitation":"(22)","noteIndex":0},"citationItems":[{"id":1966,"uris":[""],"uri":[""],"itemData":{"id":1966,"type":"article-journal","title":"Quality assurance for computed-tomography simulators and the computed-tomography-simulation process: Report of the AAPM Radiation Therapy Committee Task Group No. 66","container-title":"Medical Physics","page":"2762-2792","volume":"30","issue":"10","source":"CrossRef","DOI":"10.1118/1.1609271","ISSN":"00942405","title-short":"Quality assurance for computed-tomography simulators and the computed-tomography-simulation process","language":"en","author":[{"family":"Mutic","given":"Sasa"},{"family":"Palta","given":"Jatinder R."},{"family":"Butker","given":"Elizabeth K."},{"family":"Das","given":"Indra J."},{"family":"Huq","given":"M. Saiful"},{"family":"Loo","given":"Leh-Nien Dick"},{"family":"Salter","given":"Bill J."},{"family":"McCollough","given":"Cynthia H."},{"family":"Van Dyk","given":"Jacob"}],"issued":{"date-parts":[["2003",9,24]]}}}],"schema":""} (22). Image acquisition parameters should be preconfigured as imaging protocols on the modality workstation to reduce errors due to human factors and improve workflow. Likewise, contrast and/or tracer injection systems should be preconfigured.NomenclatureBecause PET/CT for RTP involves multidisciplinary interactions, it is especially important that effective communication be facilitated using standardized nomenclature such as proposed in the AAPM TG-263 report ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"IsAnwAIu","properties":{"formattedCitation":"({\\i{}37})","plainCitation":"(37)","noteIndex":0},"citationItems":[{"id":2040,"uris":[""],"uri":[""],"itemData":{"id":2040,"type":"article-journal","title":"American Association of Physicists in Medicine Task Group 263: Standardizing Nomenclatures in Radiation Oncology","container-title":"International Journal of Radiation Oncology ? Biology ? Physics","page":"1057-1066","volume":"100","issue":"4","source":"","DOI":"10.1016/j.ijrobp.2017.12.013","ISSN":"0360-3016","note":"PMID: 29485047","title-short":"American Association of Physicists in Medicine Task Group 263","journalAbbreviation":"International Journal of Radiation Oncology ? Biology ? Physics","language":"English","author":[{"family":"Mayo","given":"Charles S."},{"family":"Moran","given":"Jean M."},{"family":"Bosch","given":"Walter"},{"family":"Xiao","given":"Ying"},{"family":"McNutt","given":"Todd"},{"family":"Popple","given":"Richard"},{"family":"Michalski","given":"Jeff"},{"family":"Feng","given":"Mary"},{"family":"Marks","given":"Lawrence B."},{"family":"Fuller","given":"Clifton D."},{"family":"Yorke","given":"Ellen"},{"family":"Palta","given":"Jatinder"},{"family":"Gabriel","given":"Peter E."},{"family":"Molineu","given":"Andrea"},{"family":"Matuszak","given":"Martha M."},{"family":"Covington","given":"Elizabeth"},{"family":"Masi","given":"Kathryn"},{"family":"Richardson","given":"Susan L."},{"family":"Ritter","given":"Timothy"},{"family":"Morgas","given":"Tomasz"},{"family":"Flampouri","given":"Stella"},{"family":"Santanam","given":"Lakshmi"},{"family":"Moore","given":"Joseph A."},{"family":"Purdie","given":"Thomas G."},{"family":"Miller","given":"Robert C."},{"family":"Hurkmans","given":"Coen"},{"family":"Adams","given":"Judy"},{"family":"Wu","given":"Qing-Rong Jackie"},{"family":"Fox","given":"Colleen J."},{"family":"Siochi","given":"Ramon Alfredo"},{"family":"Brown","given":"Norman L."},{"family":"Verbakel","given":"Wilko"},{"family":"Archambault","given":"Yves"},{"family":"Chmura","given":"Steven J."},{"family":"Dekker","given":"Andre L."},{"family":"Eagle","given":"Don G."},{"family":"Fitzgerald","given":"Thomas J."},{"family":"Hong","given":"Theodore"},{"family":"Kapoor","given":"Rishabh"},{"family":"Lansing","given":"Beth"},{"family":"Jolly","given":"Shruti"},{"family":"Napolitano","given":"Mary E."},{"family":"Percy","given":"James"},{"family":"Rose","given":"Mark S."},{"family":"Siddiqui","given":"Salim"},{"family":"Schadt","given":"Christof"},{"family":"Simon","given":"William E."},{"family":"Straube","given":"William L."},{"family":"James","given":"Sara T. St"},{"family":"Ulin","given":"Kenneth"},{"family":"Yom","given":"Sue S."},{"family":"Yock","given":"Torunn I."}],"issued":{"date-parts":[["2018",3,15]]}}}],"schema":""} (37). Standardized nomenclature may incrementally benefit multi-center clinical trials and development of artificial intelligence based applications ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"ZARnptcr","properties":{"formattedCitation":"({\\i{}38})","plainCitation":"(38)","noteIndex":0},"citationItems":[{"id":1738,"uris":[""],"uri":[""],"itemData":{"id":1738,"type":"article-journal","title":"From medical image to automatic medical report generation","container-title":"IBM Journal of Research and Development","page":"2:1-2:7","volume":"59","issue":"2/3","source":"CrossRef","DOI":"10.1147/JRD.2015.2393193","ISSN":"0018-8646, 0018-8646","author":[{"family":"Kisilev","given":"P."},{"family":"Walach","given":"E."},{"family":"Barkan","given":"E."},{"family":"Ophir","given":"B."},{"family":"Alpert","given":"S."},{"family":"Hashoul","given":"S. Y."}],"issued":{"date-parts":[["2015",3]]}}}],"schema":""} (38).Overall System TestIntegration of all the components in an RT workflow should be tested with a system level validation test whenever changes are made to equipment, software, or workflow. System tests should use a validation phantom and a typical clinical workflow to test object alignment and orientation, image acquisition, image transfer, image processing, treatment planning, transfer of plan to therapy device, treatment delivery verification including image guidance and creation of documents. Delivery of the desired radiation plan may be validated using dosimetry equipment but is beyond the scope of this document.Roles and ResponsibilitiesEven when the intention of a PET/CT study is for RTP, best practice is that a nuclear medicine and radiology trained physician reviews the study in a timely manner to evaluate disease progression and to detect incidental findings. Quality assurance is an institutional responsibility and therefore requires the collaboration of all care providers and support staff. Physicists are charged with ensuring optimal functioning of instrumentation and software but are rarely present during the immediate course of clinical care. Technologists are often the first to witness anomalies, whether it is patient compliance, equipment failure or inappropriate requisitions. It is vital that technologists are empowered to resolve errors when appropriate and to freely communicate concerns and observations within the circle of care. Imaging physicians and radiation oncologists routinely view image and other clinical data and are therefore well positioned to identify errors and artifacts and a timely manner. Thus, they should be well trained to identify these anomalies and to draw attention to them in a timely manner. The biomedical engineering team is charged with ensuring that maintenance is performed to the highest standard and in coordination with the manufacturer’s guidelines. Finally, the management team is essential to emphasizing the value of quality and supporting it with adequate resources. Reference ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"1NRAYgrv","properties":{"formattedCitation":"({\\i{}39})","plainCitation":"(39)","noteIndex":0},"citationItems":[{"id":2504,"uris":[""],"uri":[""],"itemData":{"id":2504,"type":"book","title":"PET/CT atlas on quality control and image artefacts.","source":"Open WorldCat","ISBN":"978-92-0-101014-8","note":"OCLC: 884315537","language":"en","author":[{"literal":"International Atomic Energy Agency"}],"issued":{"date-parts":[["2014"]]}}}],"schema":""} (39) is a good resource that presents different image artifacts and discusses possible parative studiesAs with any comparative study, it is assumed that patient preparation, image acquisition and image reconstruction parameters are well controlled. Nevertheless, previously published multicenter clinical trials have demonstrated that compliance with professional guidelines may be low and could introduce undesired variability to the study data ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"B071OqRf","properties":{"formattedCitation":"({\\i{}40})","plainCitation":"(40)","noteIndex":0},"citationItems":[{"id":2006,"uris":[""],"uri":[""],"itemData":{"id":2006,"type":"article-journal","title":"Quality assessment of positron emission tomography scans: recommendations for future multicentre trials","container-title":"Acta Oncologica","page":"1459-1464","volume":"56","issue":"11","source":"Crossref","abstract":"Background: Standardization protocols and guidelines for positron emission tomography (PET) in multicenter trials are available, despite a large variability in image acquisition and reconstruction parameters exist. In this study, we investigated the compliance of PET scans to the guidelines of the European Association of Nuclear Medicine (EANM). From these results, we provide recommendations for future multicenter studies using PET. Material and methods: Patients included in a multicenter randomized phase II study had repeated PET scans for early response assessment. Relevant acquisition and reconstruction parameters were extracted from the digital imaging and communications in medicine (DICOM) header of the images. The PET image parameters were compared to the guidelines of the EANM for tumor imaging version 1.0 recommended parameters.\nResults: From the 223 included patients, 167 baseline scans and 118 response scans were available from 15 hospitals. Scans of 19% of the patients had an uptake time that fulfilled the Uniform Protocols for Imaging in Clinical Trials response assessment criteria. The average quality score over all hospitals was 69%. Scans with a non-compliant uptake time had a larger standard deviation of the mean standardized uptake value (SUVmean) of the liver than scans with compliant uptake times.\nConclusions: Although a standardization protocol was agreed on, there was a large variability in imaging parameters. For future, multicenter studies including PET imaging a prospective central quality review during patient inclusion is needed to improve compliance with image standardization protocols as defined by EANM.","DOI":"10.1080/0284186X.2017.1346824","ISSN":"0284-186X, 1651-226X","title-short":"Quality assessment of positron emission tomography scans","language":"en","author":[{"family":"Jong","given":"Evelyn E. C.","non-dropping-particle":"de"},{"family":"Elmpt","given":"Wouter","non-dropping-particle":"van"},{"family":"Hoekstra","given":"Otto S."},{"family":"Groen","given":"Harry J. M."},{"family":"Smit","given":"Egbert F."},{"family":"Boellaard","given":"Ronald"},{"family":"Lambin","given":"Philippe"},{"family":"Dingemans","given":"Anne-Marie C."}],"issued":{"date-parts":[["2017",11,2]]}}}],"schema":""} (40). Likewise, for studies with baseline and follow-up scans, it is pertinent to ensure that both scans are acquired under similar, pre-defined conditions. Special considerations must be given if images originate from two different PET/CT systems, as harmonization across devices, especially by different vendor/models, may not be achievable. Pre-study qualifying scans ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"FtxaXbiN","properties":{"formattedCitation":"({\\i{}41})","plainCitation":"(41)","noteIndex":0},"citationItems":[{"id":2010,"uris":[""],"uri":[""],"itemData":{"id":2010,"type":"article-journal","title":"Standardization of image quality across multiple centers by optimization of acquisition and reconstruction parameters with interim FDG-PET/CT for evaluating diffuse large B cell lymphoma","container-title":"Annals of Nuclear Medicine","page":"225-232","volume":"27","issue":"3","source":"PubMed","abstract":"OBJECTIVE: A multicenter trial is currently underway using FDG-PET/CT to evaluate diffuse large B cell lymphoma in Japan (JSCT NHL10). Standardization of the image quality between the participating centers is a fundamental aspect of the study. Within the framework of JSCT NHL10, standardization of the image quality was attempted by optimizing the acquisition and reconstruction conditions using mid-therapy FDG-PET/CT for diffuse large B cell lymphoma. This report describes the procedures and results of this attempt.\nMETHODS: The acquisition protocols and imaging quality were initially determined at each center and again after modification. The image quality was based on performance with an (18)F-filled National Electrical Manufacturers Association standards body phantom. We determined that the acquisition duration and reconstruction parameters of each scanner evaluated were in compliance with the Japanese guideline for the oncology FDG-PET/CT data acquisition protocol: synopsis of Version 1.0 (the Guideline) based on the results of the phantom experiments performed by the Core Laboratory.\nRESULTS: A total of 18 centers (19 scanners) participated in this trial. The center's default protocol was unchanged for 9 scanners (47.4%) and changed for 10 scanners (52.6%). Both acquisition duration and reconstruction parameters were changed in 3 (15.8%) of 10 scanners and the acquisition duration alone was changed in 7 (36.8%) scanners. Also, the accuracy of the standardized uptake value (SUV) was evaluated with the acceptable level 1.0 ± 0.1, resulting in readjustment and recalibration in 2 scanners (10.5%), which were confirmed to attain the acceptable accuracy after the required readjustment. As of August 2012, 21 patients have undergone an FDG-PET/CT examination under the acquisition protocols determined by the Core Laboratory. Evaluation of the image quality using several physical parameters confirmed that the accumulated data were of sufficient quality.\nCONCLUSIONS: Optimization of the acquisition protocol, in compliance with the guideline, was successfully achieved by the Core Laboratory in the framework of JSCT NHL10 to accumulate equivalent quality data across multiple centers. The progress of the trial was greatly facilitated by support from the Japan Society of Nuclear Medicine Working Group for Investigation of Response Evaluation Criteria in Malignant Tumors Using Standardized PET/CT (Principal Investigator: Ukihide Tateishi, MD., PhD).","DOI":"10.1007/s12149-012-0676-2","ISSN":"1864-6433","note":"PMID: 23264065","journalAbbreviation":"Ann Nucl Med","language":"eng","author":[{"family":"Daisaki","given":"Hiromitsu"},{"family":"Tateishi","given":"Ukihide"},{"family":"Terauchi","given":"Takashi"},{"family":"Tatsumi","given":"Mitsuaki"},{"family":"Suzuki","given":"Kazufumi"},{"family":"Shimada","given":"Naoki"},{"family":"Nishida","given":"Hiroyuki"},{"family":"Numata","given":"Akihiko"},{"family":"Kato","given":"Koji"},{"family":"Akashi","given":"Koichi"},{"family":"Harada","given":"Mine"}],"issued":{"date-parts":[["2013",4]]}}}],"schema":""} (41) and routine quality control over the course of a research study are pertinent to ensuring high quality data. Much of the required data (e.g. image acquisition and reconstruction parameters, tracer uptake times, blood glucose level) may be available from the image DICOM header, but care should be taken to ensure that this data is not stripped during data anonymization, transfer, and conversion. Other data should be captured in clinical report forms (CRF) and checked for quality. Rapid feedback and guidance of imaging sites by the core lab is essential to achieving and maintaining optimal data quality throughout the course of the study.Multicenter trials may especially benefit from the use of a standardized phantom which facilitate qualitative and quantitative validation of image quality against known activity distributions and enables objective comparison between sites and equipment. Such initiatives have been well demonstrated by professional groups including the Society of Nuclear Medicine and Molecular Imaging (SNMMI) Clinical Trials Network ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"dYr3T2aZ","properties":{"formattedCitation":"({\\i{}42})","plainCitation":"(42)","noteIndex":0},"citationItems":[{"id":2046,"uris":[""],"uri":[""],"itemData":{"id":2046,"type":"article-journal","title":"Quantitative PET/CT Scanner Performance Characterization Based Upon the Society of Nuclear Medicine and Molecular Imaging Clinical Trials Network Oncology Clinical Simulator Phantom","container-title":"Journal of Nuclear Medicine","page":"145-152","volume":"56","issue":"1","source":"Crossref","DOI":"10.2967/jnumed.114.148056","ISSN":"0161-5505","language":"en","author":[{"family":"Sunderland","given":"J. J."},{"family":"Christian","given":"P. E."}],"issued":{"date-parts":[["2015",1,1]]}}}],"schema":""} (42), American College of Radiology Nuclear Medicine Accreditation Program ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"0By7hAH2","properties":{"formattedCitation":"({\\i{}43})","plainCitation":"(43)","noteIndex":0},"citationItems":[{"id":2050,"uris":[""],"uri":[""],"itemData":{"id":2050,"type":"report","title":"PET phantom instructions for evaluation of PET image quality","collection-title":"ACR Nuclear Medicine Accreditation Program","publisher":"American College of Radiology","page":"15","URL":"","language":"English","issued":{"date-parts":[["2010",2,22]]},"accessed":{"date-parts":[["2018",4,5]]}}}],"schema":""} (43), EANM Research Ltd (EARL) ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"Q5F4637r","properties":{"formattedCitation":"({\\i{}44})","plainCitation":"(44)","noteIndex":0},"citationItems":[{"id":2688,"uris":[""],"uri":[""],"itemData":{"id":2688,"type":"webpage","title":"EARL Homepage","URL":"","accessed":{"date-parts":[["2019",7,15]]}}}],"schema":""} (44) and Ontario Clinical Oncology Group (OCOG) ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"Hd6YCVTC","properties":{"formattedCitation":"({\\i{}45})","plainCitation":"(45)","noteIndex":0},"citationItems":[{"id":2051,"uris":[""],"uri":[""],"itemData":{"id":2051,"type":"article-journal","title":"PET imaging standards and quality assurance for the multi-center trials of the Ontario Clinical Oncology Group (OCOG)","container-title":"Journal of Nuclear Medicine","page":"365P-365P","volume":"47","issue":"suppl 1","source":"jnm.","abstract":"1414\nObjectives: The Ontario Clinical Oncology Group (OCOG) is currently conducting 5 multi-center FDG PET/CT imaging trials in lung (2), breast, head&neck, and colorectal cancers. Scans are performed at one of 5 PET centers using 2D and 3D, full-ring and partial-ring, PET and PET/CT imaging equipment from the 3 major vendors. There is a need to ensure consistent PET image quality and interpretation across sites.\nMethods: Initial scans of lesion SUV maximum value and contrast recovery were performed using the NEMA NU2-2001 image quality phantom, to 1) verify SUV calibration inaccuracy < 5%, 2) verify reconstructed image resolution < 10 mm FWHM, and 3) qualify iterative reconstruction methods used at each site. Patient noise equivalent counts (PNEC) > 30 Mcounts/meter (±10%) were recommended for whole-body PET scans. Injected FDG activity, scan-time, and imaging protocols (e.g. 2D/3D, arms in/out) were adjusted on-site to meet the minimum PNEC. Image signal-to-noise ratio (SNR) was measured as SUV mean/sd using a lesion-free region-of-interest in the liver. These QA statistics and sample patient scans (n=43) were reviewed monthly over an 18-month period ending Nov 2005.\nResults: The initial qualifying scans indicated a median SUV inaccuracy of 1.6%, with 4 of the 5 centers < 5%. All 5 sites were able to meet the minimum 10 mm FWHM resolution standard. The mean whole-body scan PNEC was 37 ± 13 Mcounts/meter, and 80% of patient scans were above the recommended minimum. Image SNR was correlated with scan PNEC (r=0.64, p<0.001), and an image SNR = 6.5 was found to correspond to the recommended minimum PNEC. The mean image SNR was 9.5 ± 3.1, and 90% of the patients were above a recommended value of 6.5. 93% of the patient scans reviewed were above the minimum scan PNEC or image SNR.\nConclusions: Quality assurance data were shown to meet the imaging criteria recommended to produce a mimumum standard of image quality across different scanners and patients in the OCOG PET trials. Similar standards may be useful for other multi-center clinical trials in oncology PET.","ISSN":"0161-5505, 2159-662X","journalAbbreviation":"J Nucl Med","language":"en","author":[{"family":"deKemp","given":"Robert"},{"family":"Caldwell","given":"Curtis"},{"family":"Farncombe","given":"Troy"},{"family":"McKee","given":"Barry"},{"family":"Wassenaar","given":"Richard"},{"family":"Wells","given":"R."},{"family":"Wilson","given":"David"},{"family":"Gulenchyn","given":"Karen"}],"issued":{"date-parts":[["2006",5,1]]}}}],"schema":""} (45), and therefore phantom data may be readily available at active research and/or accredited sites. Traditionally, these phantoms focus on PET uptake quantification and image quality, but for RTP an emphasis should also be placed on aspects of target volume delineation including location and size. ................
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