Five-year experience of quality control for a 3D LSO-based whole-body PET scanner: Results and considerations

PET scanners require routine monitoring and quality control (QC) to ensure proper scanner performance. QC helps to ensure that PET equipment performs as specified by the manufacturer and that there have not been significant changes in the system response since acceptance. In this work we describe the maintenance history and we report on the results obtained from the PET system QC testing program over 5 years at two centers, both utilizing a Siemens Biograph 16 HiRez PET/CT system. QC testing programs were based on international standards and included the manufacturer’s daily QC, monthly uniformity and sensitivity, quarterly cross-calibration and annual resolution and image quality.For the Winnipeg and Novara sites, two and one PET detector blocks have been replaced, respectively. Neither system has had other significant PET system related hardware replacements. The manufacturer’s suggested daily QC was sensitive to detecting problems in the function of PET detector elements. The same test was not sensitive for detecting long term drifts in the systems: the Novara system observed a significant deterioration over five years of testing in the sensitivity which exhibited a decrease of 16% as compared to its initial value measured at system installation. The measure of the energy spectrum, showed that the 511 keV photopeak had shifted to a position of 468 keV. This shift was corrected by having service personnel perform a complete system calibration and detector block setup.We recommend including tests of system energy response and of sensitivity as part of a QC program since they can provide useful information on the actual performance of the scanner. A modification of the daily QC test by the manufacturer is suggested to monitor the long term stability of the system. Image quality and spatial resolution tests have proven to be of limited value for monitoring the system over time.     

Combined approach of perioperative <Superscript>18</Superscript>F-FDG PET/CT imaging and intraoperative <Superscript>18</Superscript>F-FDG handheld gamma probe detection for tumor localization and verification of complete tumor resection in breast cancer

Background

¹⁸F-fluorodeoxyglucose (¹⁸F-FDG) positron emission tomography/computed tomography (PET/CT) has become an established method for detecting hypermetabolic sites of known and occult disease and is widely used in oncology surgical planning. Intraoperatively, it is often difficult to localize tumors and verify complete resection of tumors that have been previously detected on diagnostic PET/CT at the time of the original evaluation of the cancer patient. Therefore, we propose an innovative approach for intraoperative tumor localization and verification of complete tumor resection utilizing ¹⁸F-FDG for perioperative PET/CT imaging and intraoperative gamma probe detection.

Methods

Two breast cancer patients were evaluated. ¹⁸F-FDG was administered and PET/CT was acquired immediately prior to surgery. Intraoperatively, tumors were localized and resected with the assistance of a handheld gamma probe. Resected tumors were scanned with specimen PET/CT prior to pathologic processing. Shortly after the surgical procedure, patients were re-imaged with PET/CT utilizing the same preoperatively administered ¹⁸F-FDG dose.

Results

One patient had primary carcinoma of breast and a metastatic axillary lymph node. The second patient had a solitary metastatic liver lesion. In both cases, preoperative PET/CT verified these findings and demonstrated no additional suspicious hypermetabolic lesions. Furthermore, intraoperative gamma probe detection, specimen PET/CT, and postoperative PET/CT verified complete resection of the hypermetabolic lesions.

Conclusion

Immediate preoperative and postoperative PET/CT imaging, utilizing the same ¹⁸F-FDG injection dose, is feasible and image quality is acceptable. Such perioperative PET/CT imaging, along with intraoperative gamma probe detection and specimen PET/CT, can be used to verify complete tumor resection. This innovative approach demonstrates promise for assisting the oncologic surgeon in localizing and verifying resection of ¹⁸F-FDG positive tumors and may ultimately positively impact upon long-term patient outcomes.

     

Performance and limitations of positron emission tomography (PET) scanners for imaging very low activity sources

Emerging applications for positron emission tomography (PET) may require the ability to image very low activity source distributions in the body. The performance of clinical PET scanners in the regime where activity in the field of view is <1 MBq has not previously been explored. In this study, we compared the counting rate performance of two clinical PET/CT scanners, the Siemens Biograph Reveal 16 scanner which is based on lutetium oxyorthosilicate (LSO) detectors and the GE Discovery-ST scanner which is based on bismuth germanate (BGO) detectors using a modified National Electrical Manufacturers Association (NEMA) NU 2-2007 protocol. Across the activity range studied (2–100 kBq/mL in a 5.5 mL line source in the NEMA scatter phantom), the BGO-based scanner significantly outperformed the LSO-based scanner. This was largely due to the effect of background counts emanating from naturally occurring but radioactive ¹⁷⁶Lu within the LSO detector material, which dominates the observed counting rate at the lowest activities. Increasing the lower energy threshold from 350 keV to 425 keV in an attempt to reduce this background did not significantly improve the measured NECR performance. The measured singles rate due to ¹⁷⁶Lu emissions within the scanner energy window was also found to be dependent on temperature, and to be affected by the operation of the CT component, making approaches to correct or compensate for the background more challenging. We conclude that for PET studies in a very low activity range, BGO-based scanners are likely to have better performance because of the lack of significant background.     

Machine learning in quantitative PET: A review of attenuation correction and low-count image reconstruction methods

The rapid expansion of machine learning is offering a new wave of opportunities for nuclear medicine. This paper reviews applications of machine learning for the study of attenuation correction (AC) and low-count image reconstruction in quantitative positron emission tomography (PET). Specifically, we present the developments of machine learning methodology, ranging from random forest and dictionary learning to the latest convolutional neural network-based architectures. For application in PET attenuation correction, two general strategies are reviewed: 1) generating synthetic CT from MR or non-AC PET for the purposes of PET AC, and 2) direct conversion from non-AC PET to AC PET. For low-count PET reconstruction, recent deep learning-based studies and the potential advantages over conventional machine learning-based methods are presented and discussed. In each application, the proposed methods, study designs and performance of published studies are listed and compared with a brief discussion. Finally, the overall contributions and remaining challenges are summarized.     

Automated Movement Correction for Dynamic PET/CT Images: Evaluation with Phantom and Patient Data

Head movement during a dynamic brain PET/CT imaging results in mismatch between CT and dynamic PET images. It can cause artifacts in CT-based attenuation corrected PET images, thus affecting both the qualitative and quantitative aspects of the dynamic PET images and the derived parametric images. In this study, we developed an automated retrospective image-based movement correction (MC) procedure. The MC method first registered the CT image to each dynamic PET frames, then re-reconstructed the PET frames with CT-based attenuation correction, and finally re-aligned all the PET frames to the same position. We evaluated the MC method''s performance on the Hoffman phantom and dynamic FDDNP and FDG PET/CT images of patients with neurodegenerative disease or with poor compliance. Dynamic FDDNP PET/CT images (65 min) were obtained from 12 patients and dynamic FDG PET/CT images (60 min) were obtained from 6 patients. Logan analysis with cerebellum as the reference region was used to generate regional distribution volume ratio (DVR) for FDDNP scan before and after MC. For FDG studies, the image derived input function was used to generate parametric image of FDG uptake constant (K_i) before and after MC. Phantom study showed high accuracy of registration between PET and CT and improved PET images after MC. In patient study, head movement was observed in all subjects, especially in late PET frames with an average displacement of 6.92 mm. The z-direction translation (average maximum = 5.32 mm) and x-axis rotation (average maximum = 5.19 degrees) occurred most frequently. Image artifacts were significantly diminished after MC. There were significant differences (P<0.05) in the FDDNP DVR and FDG Ki values in the parietal and temporal regions after MC. In conclusion, MC applied to dynamic brain FDDNP and FDG PET/CT scans could improve the qualitative and quantitative aspects of images of both tracers.     

Intégration des critères métaboliques de la TEP au 18FDG pour le choix des lésions cibles en imagerie onco-hématologique

IntroductionMalignant lymphoma is a heterogeneous and widespread disease. The morphological response assessment is currently based on the choice of target lesions at baseline, defined by size criteria on enhanced CT (eCT). FDG PET/CT is now commonly used at staging and the aim of this study was to evaluate the relevance of using metabolic criteria rather than size criteria to define the target lesions.Patients and methodsFifty-nine patients with aggressive lymphoma were retrospectively included. Target lesions were chosen by two radiologists on eCT and by two nuclear physicians on PET/CT. Response assessment, based on the sum of the products of the greatest diameters of up to six target lesions chosen either by size or metabolic criteria, was computed and compared to a clinical gold standard (GS) for each patient. Interobserver agreement and comparison to the GS were assessed with kappa (κ) and intraclass correlation (ICC) statistics.ResultsThe spatial distribution of target nodal areas was equivalent among eCT and PET/CT readers with a maximum of target lesions in cervical and mediastinal areas. Choosing with PET/CT led to significant heterogeneity in the size of target lesions when compared with eCT alone (P = 0.03). Interobserver agreement for quantifying the response rate was equivalent in both groups. However, there was a greater correlation to the response of the GS when using PET/CT to target the patient (κ = 0.64 vs. 0.47) and an increased rate of complete responses.ConclusionsMetabolic criteria can replace current size criteria to define target lesions on FDG PET/CT. The morphological response rate appears accurate with an increased rate of complete responses after therapy and a better correlation to the haematological standard of reference.     

Early positron emission tomography/computed tomography as a predictor of response after CTL019 chimeric antigen receptor –T-cell therapy in B-cell non-Hodgkin lymphomas

Molecular imaging with ¹⁸F-Fluorodeoxyglucose positron emission tomography/computed tomography (FDG-PET/CT) is an established modality for response assessment in patients with lymphoma undergoing treatment. However, patients treated with novel immunotherapies may have false-positive PET/CT findings due to tumor site and systemic inflammation. In particular, treatment with autologous chimeric antigen receptor modified T-cells redirected at CD19 (CTL019 CAR-T cells) is often complicated by “cytokine release syndrome” (CRS) due to a severe systemic inflammatory reaction. Infiltration of tumors by activated CTL019 cells may impact radiographic and functional imaging findings. The role of PET/CT in patients treated with CTL019 has not previously been described. We performed a pilot, single-arm, prospective study to explore the utility of early PET/CT in patients with diffuse large B-cell lymphoma (DLBCL) and follicular lymphoma (FL) undergoing treatment with CTL019 CAR-T cells. Patients had PET/CT prior to CTL019 infusion and then early PET/CT at 1 month after treatment. The primary outcome was the amount/change in metabolically active tumor volume (MTV) and FDG uptake. We enrolled seven patients (DLBCL, three; FL, four). Six of 7 had baseline PET/CT with active disease. On post-treatment PET/CT, three patients had no residual MTV, two patients had a decrease in MTV and two patients had an increase in MTV. The three patients with no residual MTV all remain in remission >2 years post-treatment. The patients with less than complete response all subsequently relapsed. Development of CRS did not confound PET/CT findings. In patients with DLBCL and FL receiving CTL019 CAR-T cells, early PET/CT may predict response to this novel immunotherapy.     

Role of PET/CT in diagnosis and treatment of breast cancer -- review of present knowledge and perspectives for future research

Positron emission tomography (PET) has revolutionized the diagnostic opportunities of malignances, however, it has still a controversial role at some conditions in the management of breast cancer. The article compares PET alone and PET/CT. We review the latest trends of using PET or PET/CT for diagnosis, staging, evaluation of the primary tumor and regional lymph node status, as well as early detection of recurrence and distant lesions. PET/CT provides new methods of assessment of early chemo/endocrine therapy response of locally advanced breast cancer. We discuss the development of new radiotracers and their value in predicting treatment response, identifying tumor subtypes and finding new therapeutic targets by them.     

Apport de la TEP/TDM au 18F-FDG dans le suivi des endocardites infectieuses sur prothèses valvulaires non opérées

Introduction

Prosthetic valve endocarditis is a diagnostic and therapeutic challenge; ¹⁸F-FDG PET/CT has seen increasing use and has been incorporated in the latest ESC endocarditis guidelines. Follow-up by PET/CT has never been studied. The aim was to study the use of PET/CT to help predicting recurrences after full antibiotic treatment.

Conceptual Design and Simulation Study of an ROI-Focused Panel-PET Scanner

Positron emission tomography (PET) is an important imaging modality for clincial use. Conventionally, the PET scanner is generally built to provide a roomy enough transverse field-of-view (FOV) for imaging most adults’ torsos. However, in many cases, the region-of-interest (ROI) for imaging is usually a small area inside the human body. Therefore, to fulfill a PET system which provides an FOV comparable in size to the target ROI seems appealing and more cost effective. Meanwhile, such a PET system has the potential for portable or bedside application with the reduced system size. In this work, we have investigated the feasibility of using dual-headed panel-detectors to build an ROI-focused PET scanner. A novel windowed list-mode ordered subset expectation maximization method was developed to perform the ROI image reconstruction. With this method, the ROI of the object can be reconstructed from the coincidences whose position determined by time-of-flight (TOF) measurements was inside the ROI. Monte Carlo simulation demonstrates the feasibility of detecting lesions not less than 1 cm in diameter, with a 300 ps full width at half maximum timing resolution. As a critical system performance, the impact of TOF information on image quality has been studied and the required TOF capability was assessed. With enhanced timing resolution, the distortions and artifacts were reduced effectively. The further improved TOF capability also shows a noticeable improvement of detection performance for low uptake lesions, as well as the recovery speed of lesion contrast, which is of practical significance in the lesion detection task.     

Apport de la TEP/TDM au 18FDG dans la stadification initiale et l’évaluation précoce de la réponse thérapeutique des rhabdomyosarcomes pédiatriques

PurposeThe objective of this study was to retrospectively evaluate the impact of positron emission tomography/computed tomography (PET/CT) using fluorine-18-fluorodeoxyglucose (FDG), in comparison with conventional imaging modalities (CIM), for initial staging and early therapy assessment in paediatric rhabdomyosarcoma.Patients and methodsPrior to treatment, 18 patients (age range, 9 months to 18 years) with histologically proven rhabdomyosarcoma underwent FDG PET/CT in addition to CIM (magnetic resonance imaging of primary site, whole body CT and bone scintigraphy). After three courses of chemotherapy, 12 patients underwent FDG PET/CT in addition to CIM. RECIST criteria and visual analysis of FDG uptake were used for assessment of response. The standard of reference was determined by an interdisciplinary tumor board based on imaging material, histopathology and follow-up data (median = 5 years).ResultsPET/CT sensitivity was superior to CIM's concerning lymph node involvement (100% versus 83%, respectively) and metastases detection (100% versus 50%, respectively). PET/CT results changed therapeutic management in 11% of cases. After three courses of chemotherapy, the rate of complete response was 66% with PET/CT versus 8% with CIM. Five percent of patients relapsed during follow-up (median = 5 years).ConclusionThis study confirms that PET/CT depicts important additional information in initial staging of paediatric rhabdomyosarcomas and suggests a superior prognostic value of PET/CT in early response to chemotherapy assessment.     

Impact of high energy resolution detectors on the performance of a PET system dedicated to breast cancer imaging

We are developing a high resolution, high sensitivity PET camera dedicated to breast cancer imaging. We are studying two novel detector technologies for this imaging system: a scintillation detector comprising layers of small lutetium oxyorthosilicate (LSO) crystals coupled to new position sensitive avalanche photodiodes (PSAPDs), and a pure semiconductor detector comprising cadmium zinc telluride (CZT) crystal slabs with thin anode and cathode strips deposited in orthogonal directions on either side of each slab. Both detectors achieve 1 mm spatial resolution with 3–5 mm directly measured photon interaction depth resolution, which promotes uniform reconstructed spatial resolution throughout a compact, breast-size field of view. Both detector types also achieve outstanding energy resolution (<3% and <12%, respectively for LSO-PSAPD and CZT at 511 keV). This paper studies the effects that this excellent energy resolution has on the expected system performance. Results indicate the importance that high energy resolution and narrow energy window settings have in reducing background random as well as scatter coincidences without compromising statistical quality of the dedicated breast PET data. Simulations predict that using either detector type the excellent performance and novel arrangement of these detectors proposed for the system facilitate ∼20% instrument sensitivity at the system center and a peak noise-equivalent count rate of >4 kcps for 200 microCi in a simulated breast phantom.     

Non-rigid registration of serial dedicated breast CT,longitudinal dedicated breast CT and PET/CT images using the diffeomorphic demons method

Rationale and objectivesDedicated breast CT and PET/CT scanners provide detailed 3D anatomical and functional imaging data sets and are currently being investigated for applications in breast cancer management such as diagnosis, monitoring response to therapy and radiation therapy planning. Our objective was to evaluate the performance of the diffeomorphic demons (DD) non-rigid image registration method to spatially align 3D serial (pre- and post-contrast) dedicated breast computed tomography (CT), and longitudinally-acquired dedicated 3D breast CT and positron emission tomography (PET)/CT images.MethodsThe algorithmic parameters of the DD method were optimized for the alignment of dedicated breast CT images using training data and fixed. The performance of the method for image alignment was quantitatively evaluated using three separate data sets; (1) serial breast CT pre- and post-contrast images of 20 women, (2) breast CT images of 20 women acquired before and after repositioning the subject on the scanner, and (3) dedicated breast PET/CT images of 7 women undergoing neo-adjuvant chemotherapy acquired pre-treatment and after 1 cycle of therapy.ResultsThe DD registration method outperformed no registration (p < 0.001) and conventional affine registration (p ≤ 0.002) for serial and longitudinal breast CT and PET/CT image alignment. In spite of the large size of the imaging data, the computational cost of the DD method was found to be reasonable (3–5 min).ConclusionsCo-registration of dedicated breast CT and PET/CT images can be performed rapidly and reliably using the DD method. This is the first study evaluating the DD registration method for the alignment of dedicated breast CT and PET/CT images.     

La fluorocholine(18F) a une utilité clinique dans le cancer de la prostate et le carcinome hépatocellulaire… parfois chez le même malade

Case reportIn order to stage hepatocellular carcinoma (HCC), a patient was referred to PET/CT using fluorodeoxyglucose(18F) (FDG) and, if necessary, fluorocholine(18F) (FCH). HCC was proven by biopsy of a hepatic mass discovered on CT performed for a biological recurrence of prostate cancer.ResultFDG PET/CT did not show any anomaly. FCH PET/CT was thus performed and showed various foci: the hepatic mass, a large abdominal adenopathy and an unexpected subcentimetre lung nodule. The diagnostic uncertainty mostly concerned this lung nodule which was biopsied and consisted of a metastasis of the prostate cancer. Due to the presence of two metastatic cancers, the patient's management was altered, with chemotherapy for the HCC and hormone therapy for the prostate cancer.ConclusionSeveral types of cancer take-up fluorocholine(18F), which is a powerful tool to detect metastases, in particular in case of rising levels of marker with a negative FDG PET/CT. Even when FDG PET/CT is positive, FCH may reveal unexpected foci with other metabolic characteristics, although it is not specific of a given primary cancer, as well as FDG. For staging of HCC, we thus recommend to perform PET/CT with both tracers.     

A New Method of Detecting Pulmonary Nodules with PET/CT Based on an Improved Watershed Algorithm

Background

Integrated ¹⁸F-fluorodeoxyglucose positron emission tomography/computed tomography (¹⁸F-FDG PET/CT) is widely performed for staging solitary pulmonary nodules (SPNs). However, the diagnostic efficacy of SPNs based on PET/CT is not optimal. Here, we propose a method of detection based on PET/CT that can differentiate malignant and benign SPNs with few false-positives.

Method

Our proposed method combines the features of positron-emission tomography (PET) and computed tomography (CT). A dynamic threshold segmentation method was used to identify lung parenchyma in CT images and suspicious areas in PET images. Then, an improved watershed method was used to mark suspicious areas on the CT image. Next, the support vector machine (SVM) method was used to classify SPNs based on textural features of CT images and metabolic features of PET images to validate the proposed method.

Results

Our proposed method was more efficient than traditional methods and methods based on the CT or PET features alone (sensitivity 95.6%; average of 2.9 false positives per scan).     

The use of PET/CT scanning technique for 3D visualization and quantification of real-time soil/plant interactions

Aims

Conventional methodology using destructive sampling, which is laborious and has poor spatial and temporal resolution, has limited our understanding of soil-plant interactions. New non-invasive tomographic techniques have the potential to significantly improve our knowledge. In this study we demonstrated the simultaneous use of PET (positron emission tomography) and CT (X-ray computed tomography) to (a) non-destructively image a whole plant growing in sand, and (b) to link the observed morphology with recently assimilated C. The PET scanner was used to detect and visualize the location of the short-lived radioisotope ¹¹C (with a half-life of 20.4?min) taken up by the plant through ¹¹C-labelled CO₂. This provided information on carbon translocation and the metabolism of photo-assimilates in the plant as well as root structure. The CT scanners yielded data on soil and root structure.

Methods

A medical PET/CT scanner was used to scan a fodder radish plant growing in a pot with test soil composed of homogenous sand. We constructed an air-plant-soil controller system (APS) to control the environmental conditions, such as CO₂, temperature and light during the experiment. The plant was allowed to assimilate ¹¹CO₂ for 90?min before PET scanning was initiated. We carried out PET scanning for 60?min. Subsequently, the aerial parts of the plant was cut off and the pot was rescanned using a micro-CT scanner to obtain more detailed information on structure of the root system and the growth medium structure.

Results

The acquired PET and CT images gave images clearly visualizing the architecture and morphology of root and soil. Using a CT scanner, we were able to detect the main taproot located at 0 to 30?mm depth. With the PET scanner, we were able to measure a signal down to 82?mm below the surface of the sand. We found the highest concentration of ¹¹C at the position of the main root. The PET images, at different time intervals, showed the translocation and metabolisation of photo-assimilates from top to root. Using the micro-CT scanner (voxel size of 90?μm), we were able to detect roots down to 100?mm depth. These findings correlated the PET signals measured down to 82?mm depth.

Conclusions

We conclude that the simultaneous use of PET and CT technologies was successfully applied for soil-plant studies. The combined PET/CT technology has potential to provide new fundamental insight into soil-plant interactions and especially into the effect of abiotic stresses in spite of the limitation due to spatial resolution.     

Accelerating Image Reconstruction in Dual-Head PET System by GPU and Symmetry Properties

Positron emission tomography (PET) is an important imaging modality in both clinical usage and research studies. We have developed a compact high-sensitivity PET system that consisted of two large-area panel PET detector heads, which produce more than 224 million lines of response and thus request dramatic computational demands. In this work, we employed a state-of-the-art graphics processing unit (GPU), NVIDIA Tesla C2070, to yield an efficient reconstruction process. Our approaches ingeniously integrate the distinguished features of the symmetry properties of the imaging system and GPU architectures, including block/warp/thread assignments and effective memory usage, to accelerate the computations for ordered subset expectation maximization (OSEM) image reconstruction. The OSEM reconstruction algorithms were implemented employing both CPU-based and GPU-based codes, and their computational performance was quantitatively analyzed and compared. The results showed that the GPU-accelerated scheme can drastically reduce the reconstruction time and thus can largely expand the applicability of the dual-head PET system.     

Comparaison de la dose efficace en TEP/TDM et en TDM

Hybrid imaging, particularly positron emission tomography (PET) combined with CT has emerged in the field of oncology as a modality of choice. The concomitant realization of a standard CT examination, however, raises the question of the additional dose delivered to the patient. This radiation burden could be avoided by performing a single PET/CT examination with injection of contrast media. To verify the potential dosimetric gain of this strategy, we compared the effective dose associated with each modality in a retrospective cohort of 151 patients, homogeneous in weight and size. The average effective dose for a PET/CT (injection of 5-6 MBq/kg of ¹⁸FDG) was 13.5 mSv, the CT dose representing approximately 80% of the PET dose. In our study, the average effective dose in CT thorax/abdomen/pelvis was 21.4 mSv, 60% higher than the PET/CT effective dose.     

Metabolic and Receptor Imaging in Patients with Neuroendocrine Tumors: Comparison of Fludeoxyglucose-Positron Emission Tomography and Computed Tomography with Indium in 111 Pentetreotide

ObjectiveTo determine whether positron emission tomography/computed tomography (PET/CT) and indium In 111 pentetreotide, individually or collectively, predict the outcome of patients with neuroendocrine tumors (NETs).MethodsBetween July 31, 2002, and May 4, 2007, 29 patients with previously diagnosed NETs underwent both PET/CT and indium In 111 pentetreotide imaging at our institution. The images were evaluated for the presence of abnormalities. Clinical outcomes were classified as survival without major morbidities, survival with severe complications of disease, or death. Time to outcome was measured in months from the imaging date to outcome. Kaplan-Meier survival curves were calculated in which patient outcome was compared with results on PET/CT and indium In 111 pentetreotide imaging.ResultsOf the 29 patients, 9 had abnormalities on both PET/CT and indium In 111 pentetreotide imaging. Two patients had abnormal findings on PET/CT but normal findings on pentetreotide imaging. In 5 patients, findings were normal on PET/CT but abnormal on pentetreotide imaging. In 13 patients, normal findings were noted on both PET/CT and pentetreotide imaging. Kaplan-Meier analysis demonstrated a significant survival advantage for patients who had normal findings on PET/CT in comparison with abnormal PET/CT findings (P = .01). Patients with normal findings on indium In 111 pentetreotide imaging had a higher but insignificant survival advantage over those with abnormal results on pentetreotide imaging (P = .08).ConclusionFor evaluation of NETs, PET/CT and indium In 111 pentetreotide are complementary. Increased metabolic activity in tumor cells is reflected by abnormalities on PET/CT. Patients who had abnormal PET/CT findings had a generally poorer prognosis and a more rapid clinical deterioration than those with normal PET/CT findings. (Endocr Pract. 2009;15:521-527)