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51
48
9
5
10
5
Ho
dg
kin
's L
ym
ph
om
a -
sta
gin
g
Ho
dg
kin
's L
ym
ph
om
a -
re
sta
gin
g
No
n-H
od
gkin
's L
ym
ph
om
a
Ha
em
ato
log
ica
l M
alig
na
nc
y
Rh
ab
do
myo
sarc
om
a
Ne
uro
bla
sto
ma
Oth
er
Tum
ou
rs
Ne
uro
fib
rom
ato
sis
Typ
e 1
Do
se c
on
sid
era
tio
nT
he E
uro
pean A
ssocia
tion o
f N
ucle
ar
Medic
ine (
EA
NM
) pro
vid
e a
paedia
tric
dose c
alc
ula
tor
for
PE
T im
agin
g in c
hild
ren. A
n e
xam
ple
of
the e
xpecte
d d
oses is d
em
onstr
ate
d in T
able
2.
Doses a
re h
igher
than C
T o
r P
ET
alo
ne,
but th
e a
dditio
nal
info
rmation c
an h
ave s
ignific
ant
impact
on p
atient
managem
ent.
The
dose r
isk-u
tilit
y b
enefit
should
be c
onsid
ere
d o
n a
case
-to-c
ase b
asis
.
CT
dose w
ill r
ely
on local scanner,
scannin
g p
roto
col and p
atient
siz
e.
Paed
iatr
icP
ET
-CT:
a 1
0-y
ear
serv
ice r
evie
w
Dis
cu
ssio
n
Intr
od
ucti
on
The
use o
f F
18
-FD
G P
ET
-CT
is w
ide
ly e
sta
blis
hed in a
dult im
agin
g.
In c
ontr
ast, th
e e
xperi
ence o
f its u
se in th
e p
aed
iatr
ic p
op
ula
tion is
rela
tively
lim
ited
. In
20
14,
a d
edic
ate
d p
aedia
tric
PE
T-C
T g
uid
elin
e
was p
roduced b
y t
he
RC
R.
Prio
r to
this
, vario
us c
linic
al guid
elin
es
exis
ted
at
the
natio
nal and
Euro
pean
le
vel fo
r ad
ults, w
hic
h w
ere
used b
y e
xtr
apo
latio
n in
child
ren
. T
his
le
d to
un
ce
rtain
ty a
nd
a
hete
rogen
eou
s u
se o
f P
ET
-CT
in
this
patient
pop
ula
tion.
We p
rovid
e a
n in
sig
ht in
to t
he s
cope
of
pae
dia
tric
FD
G P
ET
-CT
scans p
erf
orm
ed a
t a
la
rge
tea
ch
ing h
ospital over
a 1
0 y
ear
peri
od.
We a
im t
o h
ighlig
ht curr
ent
RC
R a
nd
Euro
pea
n g
uid
elin
es,
co
nsid
era
tio
ns o
f scan a
cq
uis
itio
n,
inte
rpre
tatio
n p
itfa
lls a
nd
rad
iatio
n d
ose.
Re
fere
nc
es
Sy
ste
mD
iag
no
sis
Gu
ide
lin
es
On
co
log
yH
od
gk
in’s
an
d n
on
-Ho
dg
kin
’s ly
mp
ho
ma
,
eq
uiv
oc
al st
ag
e 4
dis
ea
se o
n o
the
r im
ag
ing
,
extr
a-m
ed
ulla
ry le
uka
em
ia, m
alig
na
nc
y o
f
un
kn
ow
n p
rim
ary
, so
fttiss
ue
sa
rco
ma
, M
IBG
-ve
ne
uro
bla
sto
ma
, g
erm
ce
ll tu
mo
urs
, La
ng
erh
an
s’
ce
ll h
isto
cyto
sis,
re
lap
sed
FD
G +
ve
dis
ea
se.
RC
R 2
016
1
RC
R P
ae
ds
2014
2
EA
NM
2008
3
Ne
uro
log
yFo
ca
l e
pile
psy
. M
alig
na
nt
tra
nsf
orm
atio
n o
f a
ple
xifo
rm o
r su
bc
uta
ne
ou
s n
eu
rofib
rom
a in
ne
uro
fib
rom
ato
sis
1
RC
R 2
016
1
RC
R P
ae
ds
2014
2
EA
NM
2008
3
Infe
ctio
n a
nd
infla
mm
atio
n
Py
rexia
of u
nk
no
wn
orig
in,v
asc
ulit
is, fo
ca
l
infe
ctio
n in
imm
un
oc
om
pro
mis
ed
pa
tie
nts
RC
R 2
016
1
EA
NM
/SN
MM
I
2013
4
Tab
le 1
: S
ele
cte
d i
nd
icati
on
s f
or
the u
se o
f F
DG
PE
T-C
T in
th
e p
aed
iatr
ic p
op
ula
tio
n a
s p
er
gu
idelin
e.
Ind
icati
on
s
in b
old
are
so
me o
f th
e m
ost
freq
uen
tly r
eq
ueste
d a
t o
ur
insti
tuti
on
. F
ull g
uid
elin
es a
vailab
le i
n r
efe
ren
ces.
Me
tho
ds
Retr
osp
ective r
evie
w o
f a
pro
sp
ectively
main
tain
ed
in
stitu
tio
nal P
ET
-
CT
data
ba
se
for
all
sca
ns p
erf
orm
ed in
patie
nts
un
der
the
ag
e o
f 17 a
t
a s
ingle
in
stitu
tio
n. P
atient
de
mogra
phic
s,
clin
ical in
dic
atio
n, acqu
isitio
n
pro
tocol, s
ca
n fin
din
gs, fo
llow
-up a
nd
fin
al outc
om
e w
ere
record
ed.
84
patie
nts
un
derw
ent
15
2 P
ET
-CT
scans o
ver
a 1
0 y
ear
peri
od.
Clin
ica
l dem
and a
pp
ears
to b
e o
n th
e in
cre
ase (
Fig
1).
132
(87%
)
scans w
ere
perf
orm
ed f
or
oncolo
gic
al in
dic
atio
ns. N
on
-oncolo
gic
al
scans w
ere
perf
orm
ed f
or
a v
ari
ety
of in
dic
atio
ns in
clu
din
g infe
ctio
n
and
in
fla
mm
ation,
pyre
xia
of u
nknow
n o
rigin
and e
pile
psy (
Fig
2).
Resu
lts
Use o
f F
DG
PE
T-C
T in p
aedia
tric
s h
as b
een s
low
er
than in a
dults. T
his
may b
e in p
art
be d
ue t
o lack o
f early e
vid
ence
-based g
uid
ance
and c
oncern
over
dose.
Paedia
tric
PE
T-C
T is n
ow
routinely
esta
blis
hed in H
odgkin
’s lym
phom
a w
here
baselin
eand p
ost-
treatm
ent
scans h
ave a
n e
vid
ence-b
ase f
or
PE
T-a
daptive t
hera
py
5.
When t
here
is u
ncert
ain
ty a
bout
dis
tant
dis
ease o
r re
curr
ence o
n
conventional im
agin
g,
PE
T-C
T c
an b
e u
sed t
o c
larify
and p
ote
ntially
alter
patient
treatm
ent options.
Patient
dose r
isk s
hould
be
consid
ere
d o
n a
case-b
y-c
ase b
asis
, as c
an b
e b
ala
nced b
y t
he b
enefit
of
more
accura
te a
ssessm
ent
and p
ote
ntial im
pact
on
managem
ent.
In o
rder
to a
chie
ve h
igh
-qualit
y im
agin
g,
a d
edic
ate
d p
aedia
tric
pro
tocol should
be d
evelo
ped locally
by a
multi-
dis
cip
linary
team
inclu
din
g r
adio
logis
ts,
radio
gra
phers
/technic
ians,
medic
al physic
s,
paedia
tric
oncolo
gy a
nd a
naesth
etics.
Nu
mb
er
of
stu
die
s p
er
ye
ar
20
08
-2017
Cu
rren
t in
dic
ati
on
s f
or
paed
iatr
ic F
DG
PE
T-C
TIn
dic
ati
on
s f
or
PE
T-
CT
perf
orm
ed
at
ou
r
insti
tuti
on
betw
een
2008-2
017
Fig
1: B
rea
kd
ow
n o
f n
um
be
r o
f P
ET-
CT
stu
die
s p
erf
orm
ed
pe
r ye
ar
fro
m 2
00
8-2
017
. *
Va
lue
s u
p
to J
uly
20
17
-p
roje
cte
d n
um
be
r o
f sc
an
s fo
r 2
01
7 in
ye
llow
. Th
e g
en
era
l tr
en
d s
inc
e 2
01
3 h
as
be
en
a s
tea
dy in
cre
ase
in
PET-
CT
de
ma
nd
. † N
o p
ae
dia
tric
sc
an
s w
ere
pe
rfo
rme
d in
Le
ed
s in
20
08
/09
as
a f
ixe
d P
ET-
CT
sca
nn
er
wa
s n
ot
in p
lac
e u
ntil 2
01
0. P
atie
nts
re
ferr
ed
to
Lo
nd
on
.
6
6
8
Pyre
xia
of
Un
kn
ow
n O
rig
in
Ep
ilep
sy
Syst
em
ic/I
nfe
ctive
No
n -
On
co
log
ica
l
On
co
log
ica
l
Inte
rpre
tati
on
pit
falls
Th
e u
tili
ty o
f P
ET
-CT
Fig
3:
CE
CT
neck s
ho
wed
a left
-sid
ed
necro
tic
lym
ph
no
de i
n s
usp
ecte
d l
ym
ph
om
a
recu
rren
ce.
PE
T-C
T (
axia
l fu
sed
at
the s
am
e
level
as C
T)
an
d P
ET
MIP
co
nfi
rm l
eft
sid
ed
recu
rren
ce a
s w
ell a
s o
ccu
lt c
on
trala
tera
l n
od
al
dis
ease.
Th
is f
ind
ing
alt
ere
d p
lan
ned
pati
en
t
man
ag
em
en
t.
Fig
4:
5 y
ear
old
ch
ild
wit
h p
ers
iste
ntl
y r
ais
ed
infl
am
mato
ry m
ark
ers
an
d s
yste
mic
sym
pto
ms
. P
ET
MIP
(left
) an
d f
used
axia
l P
ET
-CT
(ri
gh
t –
top
) d
em
on
str
ate
d
ab
no
rmal
FD
G u
pta
ke i
n t
he r
igh
t th
igh
mass s
usp
icio
us
for
malig
nan
cy.
MR
I o
f ri
gh
t th
igh
(ri
gh
t -
mid
dle
an
d
bo
tto
m)
an
d b
iop
sy c
on
firm
ed
rh
ab
do
myo
sa
rco
ma
.
PE
T-C
T is t
ypic
ally
reserv
ed f
or
prim
ary
sta
gin
g o
f m
alig
nancy a
nd
pro
ble
m s
olv
ing.
Due t
o
hig
h F
DG
upta
ke in a
variety
of
tum
our
types
and b
ein
g a
whole
body
imagin
g t
echniq
ue,
PE
T-
CT
can d
ete
ct
local and
dis
tant
dis
ease. T
his
makes it
ideal fo
r sta
gin
g,
response a
ssessm
ent
and
recurr
ence d
ete
ction
(Fig
3).
It c
an a
lso d
ete
ction o
ccult
inflam
mato
ry o
r m
alig
nant
path
olo
gy w
hen c
linic
al
assessm
ent,
blo
od t
ests
and c
onventional im
agin
g
have n
ot fo
und a
n
underlyin
g c
ause
(Fig
4).
Pitfa
lls in a
dult P
ET
-CT
are
well
docum
ente
d b
ut
there
are
som
e s
pecific
findin
g m
ore
com
monly
encounte
red in
paedia
tric
patients
. P
hysio
logic
al bro
wn
fat activity c
an s
imula
te d
isease o
r
pote
ntially
mask d
isease in n
eck a
nd
media
stinum
(F
ig 5
).
In p
ost-
chem
oth
era
py p
atients
, th
ym
ic
enla
rgem
ent
and incre
ased F
DG
activity
can m
ake r
esponse a
ssessm
ent
difficult,
especia
lly in lym
phom
a p
atients
. T
his
is
term
ed ‘th
ym
ic r
ebound h
yperp
lasia
’ and
can p
ers
ist
up t
o 2
years
follo
win
g
treatm
ent.
It should
not be m
ista
ken f
or
active d
isease a
nd c
an b
e r
ecognis
ed b
y
the t
ypic
al ‘in
vert
ed V
shape’ on c
oro
nal
imagin
g (
Fig
6).
G C
ham
bers
, R
Fro
od, H
Neja
dham
zeeig
ilani, C
Pate
l
Depart
ment
of
Radio
logy
St Jam
es H
ospital, L
eeds T
eachin
g H
ospital T
rust,
UK
We
igh
t(K
g)
10
19
32
55
70
Ap
pro
xim
ate
Ag
e
(ye
ars
)
15
10
15
Ad
ult
FD
G a
dm
inis
tere
d
ac
tiv
ity (
MB
q)
38
65
102
163
196
Eff
ec
tiv
e d
ose
(m
Sv
)3.6
3.3
3.8
4.0
3.7
Tab
le 2
: In
jecte
d a
cti
vit
y a
nd
eff
ecti
ve d
ose f
or
dif
fere
nt
weig
hts
of
paed
iatr
ic p
ati
en
ts a
s d
efi
ned
by
the E
AN
M
05
10
15
20
25
30
35
Number of studies
Ye
ar
In o
rder
to o
ptim
ise s
can a
cquis
itio
n in p
aedia
tric
patients
, som
e m
odific
ation o
f scannin
g
pro
tocol is
required.
Belo
w a
re k
ey c
onsid
era
tions in o
ur
local paedia
tric
pro
tocol:
Gen
era
l an
aesth
eti
c:
<5 y
ears
–m
ost patients
; 6
-9 y
ears
–case b
y c
ase b
asis
; 10+
years
–not ro
utinely
required. T
his
will
require a
ssis
tance f
rom
a r
egula
r paedia
tric
anaesth
etist.
Pro
pan
olo
l u
se:
Patients
10+
years
of
age s
hould
ideally
have p
ropanolo
l pre
medic
ation
(in t
he a
bsence o
f contr
ain
dic
ations)
prior
to the s
tudy t
o s
uppre
ss b
row
n f
at activity.
Local
pro
tocol should
be a
gre
ed w
ith p
aedia
tric
oncolo
gis
ts.
Inje
cte
d a
cti
vit
y:
Based o
n b
odyw
eig
ht
(see d
ose c
onsid
era
tions b
ox)
and a
dju
sting b
ed
positio
n t
imin
g t
o e
nsure
the p
atient
can t
ole
rate
the e
ntire
scan
Oth
er:
The s
can r
oom
can b
e a
n intim
idating p
lace f
or
young c
hild
ren a
nd t
he u
se o
f a p
lay
thera
pis
t should
be c
onsid
ere
d. A
pre
-scan v
isit t
o t
he d
epart
ment
and s
canner
room
can
reduce a
nxie
ty f
or
the c
hild
and p
are
nts
. T
he inje
ction a
nd s
can r
oom
s s
hould
be k
ept
warm
, especia
lly in w
inte
r, in o
rder
to m
inim
ise b
row
n f
at activity.
Op
tim
isin
g s
can
acq
uis
itio
n a
nd
qu
ality
*
1 –
Ro
ya
l Co
lleg
e o
f P
hysi
cia
ns
of
Lon
do
n, R
oya
l Co
lleg
e o
f P
hysi
cia
ns
an
d S
urg
eo
ns
of
Gla
sgo
w, R
oya
l Co
lleg
e o
f P
hysi
cia
ns
of
Ed
inb
urg
h, R
oya
l Co
lleg
e o
f R
ad
iolo
gis
ts,
British
Nu
cle
ar
Me
dic
ine
So
cie
ty, A
dm
inis
tra
tio
n o
f R
ad
ioa
ctiv
e S
ub
sta
nc
es
Ad
vis
ory
Co
mm
itte
e.
Ev
ide
nc
e-b
ase
d in
dic
atio
ns
for
the
use
of
PET-
CT
in t
he
Un
ite
d K
ing
do
m
20
16
. Lo
nd
on
: Th
e R
oya
l Co
lleg
e o
f R
ad
iolo
gis
ts, 2
01
6.
2 –
The
Ro
ya
l Co
lleg
e o
f R
ad
iolo
gis
ts. G
uid
elin
es
for
the
use
of
PET-
CT
in c
hild
ren
. Se
co
nd
Ed
. Lo
nd
on
: Th
e R
oya
l Co
lleg
e o
f R
ad
iolo
gis
ts, 2
01
4.
3 –
Str
au
ss J
, Fra
nzi
us
C,
Plu
ge
r T,
et
al.
Gu
ide
line
s fo
r 1
8f-
FD
G P
ET
an
d P
ET-
CT
ima
gin
g in
pa
ed
iatr
ic o
nc
olo
gy. Eu
r J
Nu
cl M
ed
Mo
l Im
ag
ing
. 2
00
8; 3
5(8
):1
58
1-8
8.
4 –
Jam
ar
F, B
usc
om
be
J,
Ch
iti A
, e
t a
l. EA
NM
/SN
MM
I g
uid
elin
e f
or
18
F-F
DG
use
in
infla
mm
atio
n a
nd
in
fec
tio
n. J
Nu
cl M
ed
. 2
01
3; 5
4(4
):6
47
-58
.5
–C
he
son
B, Fis
he
r R
, B
arr
ing
ton
S, e
t a
l. R
ec
om
me
nd
atio
ns
for
initia
l ev
alu
atio
n, st
ag
ing
, a
nd
re
spo
nse
ass
ess
me
nt
of
Ho
dg
kin
an
d N
on
-ho
dg
kin
Lym
ph
om
a: Th
e L
ug
an
o
Cla
ssific
atio
n. J
Clin
On
c2
01
4; 3
2(2
7):
30
59
-67
.
n 40
51 4 8 9 5 10 5
Fig
6:
Po
st-
ch
em
oth
era
py P
ET
-CT
in
a H
od
gkin
’s
lym
ph
om
a p
ati
en
t d
em
on
str
ati
ng
in
cre
ased
up
take i
n t
he a
nte
rio
r m
ed
iasti
nu
m,
wh
ich
localises t
o a
n e
nla
rged
th
ym
us.
Th
is i
s i
n
keep
ing
wit
h t
hym
ic r
eb
ou
nd
hyp
erp
lasia
an
d
sh
ou
ld n
ot
be c
on
fused
wit
h a
cti
ve d
isease.
Fig
5:
Po
st-
ch
em
oth
era
py P
ET
-CT
im
ag
ing
fo
r
lym
ph
om
a d
em
on
str
ate
s m
ult
ifo
cal
up
take i
n t
he
neck a
nd
axilla
e,
wh
ich
lo
calises t
o t
he n
orm
al
ap
peari
ng
fat
on
CT.
Th
is i
s i
n k
eep
ing
wit
h
ph
ysio
log
ical
bro
wn
fat
acti
vit
y a
nd
sh
ou
ld n
ot
be
co
nfu
sed
wit
h n
od
al
dis
ease.
†
