FDG PET in preoperative assessment of colorectal liver metastases combining "evidence-based practice" and "technology assessment" methods to develop departmental imaging protocols: should FDG PET be routinely used in the preoperative assessment of patients with colorectal liver metastases?

In today's environment of progressively evolving and expensive imaging modalities, radiologists are asked to justify the use of resources to patients, referring physicians, hospital management, and third party payers. With this aim, the radiologist may use "top-down" or "bottom-up" "evidence-based practice" (EBP) techniques. "Top-down" suggests that the practitioner should wait until a higher authority, external to their practice, generates a solution to practice dilemmas (e.g., National Institute for Health and Clinical Excellence [NICE] guidelines). "Bottom-up" however, is based on the theory that the ordinary practitioner is best served by a decentralized approach to problem solving that is internal to their practice. The technology assessment framework modeled by Mackenzie and Dixon comprehensively assesses the effects of imaging using levels of efficacy including diagnostic performance, diagnostic impact, and therapeutic impact, impact on health and cost effectiveness. In this article, we describe how issues regarding new imaging modalities in ordinary radiology practice can be addressed by using stepwise "bottom-up" EBP techniques combined with the technology assessment framework. We also detail how EBP techniques form an integral part of practice-based learning among radiology residents as part of noninterpretive residency training. The following clinical scenario is used: your hospital's chief hepatobiliary surgeon writes to your department regarding the lack of access to 18-fluoro-2-deoxy-D-glucose positron emission tomography in the preoperative assessment of patients with colorectal cancer liver metastases under consideration for hepatic resection. How would you approach this problem? Here is how we would do it.

Early repeated 18F-FDG PET scans during neoadjuvant chemoradiation fail to predict histopathologic response or survival benefit in adenocarcinoma of the esophagus.

UNLABELLED: This study evaluated the role of (18)F-FDG PET as an early predictor of histopathologic response to neoadjuvant chemoradiotherapy and overall survival in patients with adenocarcinoma of the esophagus undergoing multimodal therapy. METHODS: Thirty-seven patients with locally advanced adenocarcinoma of the esophagus underwent pretreatment and an intratreatment (18)F-FDG PET scan in the second week of a 6-wk regimen of neoadjuvant chemoradiotherapy. Histopathologic response and overall survival were correlated with percentage change in (18)F-FDG uptake (%Δmaximum standardized uptake value [%ΔSUVmax]). RESULTS: In 16 patients (43%), treatment induced a histopathologic response (<10% viable tumor cells), which was associated with a significant (P < 0.05) survival benefit. The optimal reduction in (18)F-FDG uptake, which separated histopathologic responders and nonresponders, was a -26.4% ΔSUVmax (receiver-operating-characteristic curve analysis). At this separation, sensitivity, specificity, positive predictive value, negative predictive value, and accuracy (area under the receiver operating characteristic curve) were 62.5%, 71.4%, 62.5%, 71.4%, and 67.4%, respectively, for intratreatment (18)F-FDG PET scans. Kaplan-Meier survival analysis of (18)F-FDG PET responders (>26.4% reduction in SUVmax), compared with (18)F-FDG PET nonresponders (<26.4% reduction in SUVmax), revealed no survival benefit for responders (P = 0.6812). CONCLUSION: The %ΔSUVmax during the second week of induction chemoradiation did not correlate either with histopathologic response or with survival. Our results show that, in contrast to published reports on neoadjuvant chemotherapy, combined chemoradiotherapy in patients with adenocarcinoma of the esophagus lowers the predictive accuracy of early repeated (18)F-FDG PET in identifying histopathologic responders and those with chances for increased survival below clinically applicable levels.

Radionuclide impurities in proton-irradiated [18O]H2O for the production of 18F-: activities and distribution in the [18F]FDG synthesis process.

Proton- and neutron-induced activation products in the components of a high-pressure [(18)O]H(2)O target vessel used for the production of (18)F(-) in a medical cyclotron have been identified using high resolution gamma spectrometry. The activities leached from the target vessel into the [(18)O]H(2)O during irradiation, and the distribution of the identified radionuclide impurities in the various cartridges and solutions used in the [(18)F]FDG synthesis process have been measured and are discussed from the perspective of waste disposal. The results indicate that, at the energies and beam currents employed, only a few, relatively short-lived radionuclides are present in the irradiated [(18)O]H(2)O, and that the activities involved (<10 kBq in each case) are well below typical exemption limits. Activities of beta-emitting (3)H in irradiated [(18)O]H(2)O, produced via the (18)O(p,(3)H)(16)O reaction, have also been determined using liquid scintillation spectrometry. Measured activity concentrations, in the range 150-180 kBq g(-1), are consistent with those reported by other workers. Analyses of the synthesised [(18)F]FDG confirm the radiochemical purity of the product, both for (3)H and for gamma-emitting radionuclides in the energy range 25-1650 keV.