Integration of FDG-PET/CT into external beam radiation therapy planning Technical aspects and recommendations on methodological approaches

This work addresses the clinical adoption of FDG-PET/CT for image-guided radiation therapy planning (RIP). As such, important technical and methodological aspects of PET/CT-based RIP are reviewed and practical recommendations are given for routine patient management and clinical studies. First, recent developments in PET/CT hardware that are relevant to RIP are reviewed in the context of quality control and system calibration procedures that are mandatory for a reproducible adoption of PET/CT in RTP. Second, recommendations are provided on image acquisition and reconstruction to support the standardization of imaging protocols. A major prerequisite for routine RTP is a complete and secure data transfer to the actual planning system. Third, state-of-the-art tools for image fusion and co-registration are discussed briefly in the context of PET/CT imaging pre- and post-RIP. This includes a brief review of state-of-the-art image contouring algorithms relevant to PET/CT-guided RIP. Finally, practical aspects of clinical workflow and patient management, such as patient setup and requirements for staff training are emphasized. PET/CT-guided RIP mandates attention to logistical aspects, patient set-up and acquisition parameters as well as an in-depth appreciation of quality control and protocol standardization. Conclusion: Upon fulfilling the requirements to perform PET/CT for RIP, a new dimension of molecular imaging can be added to traditional morphological imaging. As a consequence, PET/CT imaging will support improved RIP and better patient care. This document serves as a guidance on practical and clinically validated instructions that are deemed useful to the staff involved in PET/CT-guided RIP.