EANM procedural recommendations for managing the paediatric patient in diagnostic nuclear medicine

Imaging insights of FDG-PET from neonates to infants

In pediatric oncology, 18F-fluorodeoxyglucose (FDG)-positron emission tomography (PET)/computed tomography (CT) is valuable as a tool for noninvasive imaging and monitoring. While many reports have reviewed the use of PET and PET/CT in pediatrics, considerable variations in age, body size, and metabolism are seen during different stages of childhood development. Neonates (from birth to one month old) and infants (from 1 month to 1 year) present unique challenges for FDG-PET/CT examination due to their small body size, the immaturity of organs, the need for specialized patient preparation, and support requirements during scanning. In addition, differences in metabolic activity can lead to distinct differences in patterns of physiological FDG uptake on PET/CT imaging between neonates and infants. These factors differ significantly from those encountered in older children, who may be treated similarly to adults during imaging procedures. This review, based on both the literature and clinical experience, explores the specific characteristics, challenges, and considerations for FDG-PET/CT imaging from neonates to infants, with a focus on optimizing imaging protocols and interpreting physiological variations in this growth period.

Expert consensus on workflow of PET/CT with long axial field-of-view

PURPOSE

Positron emission tomography/computed tomography (PET/CT) imaging has been widely used in clinical practice. Long axial field-of-view (LAFOV) systems have enhanced clinical practice by leveraging their technological advantages and have emerged as the new state-of-the-art PET imaging modalities. A consensus was conducted to explore expert views in this emerging field to comprehensively elucidate the proposed workflow in LAFOV PET/CT examinations and highlight the potential challenges inherent in the workflow.

METHODS

A multidisciplinary task group formed by 28 experts from six countries over the world discussed and approved the consensus based on the published guidelines, peer-reviewed articles of LAFOV PET/CT, and the collective experience from clinical practice. This consensus focuses on the workflow that allows for a broader range of imaging protocols of LAFOV PET/CT, catering to diverse patient needs and in line with precision medicine principles.

RESULTS

This consensus describes the workflows and imaging protocols of LAFOV PET/CT for various imaging scenarios including routine static imaging, dynamic imaging, low-activity imaging, fast imaging, prolonged imaging, delayed imaging, and dual-tracer imaging. In addition, imaging reconstruction and reviewing specific to LAFOV PET/CT imaging, as well as the main challenges facing installation and application of LAFOV PET/CT scanner were also summarized.

CONCLUSION

This consensus summarized the various imaging workflow, imaging protocol, and challenges of LAFOV PET/CT imaging, aiming to enhance the clinical and research applications of these scanners.

Long Axial Field-of-View PET/CT: New Opportunities for Pediatric Imaging

The combined use of Positron Emission Tomography (PET) and Computed Tomography (CT) has become increasingly vital for diagnosing and managing oncological and infectious diseases in pediatric patients. The introduction of long axial field-of-view (LAFOV) PET/CT scanners, also known as "Total Body PET/CT," marks a significant advancement in nuclear medicine. This new technology enables faster pediatric imaging with substantially reduced radiation exposure and essentially eliminates the need for sedation, addressing previous critical concerns in pediatric imaging. This review will explore the applications and challenges of LAFOV PET/CT in pediatric imaging, highlight the benefits observed at two Danish hospitals, and evaluate its potential to transform the management of pediatric patients.

Diagnostic radiographers' experiences with paediatric patients during radiography examinations in Malawi - A qualitative study

INTRODUCTION

Performing radiography examinations on paediatric patients is challenging and requires expertise from diagnostic radiographers. The patient needs to remain still in radiography to acquire a diagnostic image. In Malawi, diagnostic radiographers continue to experience challenges when imaging paediatric patients. Therefore, this study explored diagnostic radiographers' experiences with paediatric patients during radiography examinations in Malawi.

METHODS

The study used a qualitative, exploratory, and descriptive design. Twelve diagnostic radiographers working in five selected health facilities and registered with the Medical Council of Malawi (MCM) participated in this study. Data was collected by the main researcher using face-to-face semi-structured interviews and field notes. Qualitative thematic analysis was used to analyse the transcribed data.

RESULTS

Three themes were developed from thematic analysis: 1) to foster an effective patient-practitioner relationship, 2) partnering with guardians during paediatric radiography and 3) application of paediatric-centred imaging techniques.

CONCLUSION

Findings from the study highlight how various approaches can lead to a successful radiography process with paediatric patients during examinations. Making a child cooperate for an examination was crucial for a smooth diagnostic process.

IMPLICATION FOR PRACTICE

Diagnostic radiographers should build strong patient-practitioner relationships and actively engage guardians to improve paediatric patients' cooperation during radiography examinations. Implementing paediatric-centred imaging techniques can significantly enhance the quality of diagnostic images and the overall efficiency of the radiography process in paediatric patients.

QUALIPAED-A retrospective quality control study evaluating pediatric long axial field-of-view low-dose FDG-PET/CT

Introduction

Pediatric patients have an increased risk of radiation-induced malignancies due to their ongoing development and long remaining life span. Thus, optimization of PET protocols is an important task in pediatric nuclear medicine. Long axial field-of-view (LAFOV) PET/CT has shown a significant increase in sensitivity, which provides an ideal opportunity for reduction of injected tracer activity in the pediatric population. In this study we aim to evaluate the clinical performance of a 2-[18F]FDG-tracer reduction from 3 MBq/kg to 1.5 MBq/kg on the Biograph Vision Quadra LAFOV PET/CT.

Materials and methods

The first 50 pediatric patients referred for clinical whole-body PET/CT with 1.5 MBq/kg 2-[18F]FDG, were included. A standard pediatric protocol was applied. Five reconstructions were created with various time, filter and iteration settings. Image noise was computed as coefficient-of-variance (COV = SD/mean standardized-uptake-value) calculated from a spherical 20-50 mm (diameter) liver volume-of-interest. Sets of reconstructions were reviewed by one nuclear medicine physicians, who reported image lesions on a pre-defined list of sites. Paired comparison analysis was performed with significance at PB < 0.05 (Bonferroni corrected).

Results

All reconstructions, except one, achieved a COVmean (0.08-0.15) equal to or lower than current clinical acceptable values (COVref ≤ 0.15). Image noise significantly improved with increasing acquisition time, lowering iterations (i) from 6i to 4i (both with five subsets) and when applying a 2 mm Gauss filter (PB < 0.001). Significant difference in lesion detection was seen from 150s to 300s and from 150s to 600s (PB = 0.006-0.007). 99% of all lesions rated as malignant could be found on the 150s reconstruction, while 100% was found on the 300s, when compared to the 600s reconstruction.

Conclusion

Injected activity and scan time can be reduced to 1.5 MBq/kg 2-[18F]FDG with 5 min acquisition time on LAFOV PET/CT, while maintaining clinical performance in the pediatric population. These results can help limit radiation exposure to patients and personnel as well as shorten total scan time, which can help increase patient comfort, lessen the need for sedation and provide individually tailored scans.

Nuclear medicine and pediatric nephro-urology: a long-lasting successful partnership

Congenital anomalies of the kidney and urinary tract, as well as urinary infections, are very frequent in children. After the clinical and laboratory evaluation, the first imaging procedure to be done is a renal and bladder ultrasound, but afterwards, a main contribution comes from nuclear medicine. Through minimally invasive and sedation-free procedures, nuclear medicine allows the evaluation of the functional anatomy of the urinary tract, and the quantification of renal function and drainage. If pediatric dosage cards provided by scientific societies are used, radiation exposure can also be low. In the pediatric conditions previously mentioned, nuclear medicine is used both for initial diagnosis and follow-up, mostly in cases of suspicion of ureteropelvic or ureterovesical junction syndromes, as well as vesicoureteral reflux or renal scars of febrile infectious episodes. Pediatric nephro-urology constitutes a significant workload of pediatric nuclear medicine departments. The following paragraphs are a revision of the renal radiopharmaceuticals, as well as the nuclear nephro-urology procedures - dynamic and static renal scintigraphy, and direct and indirect radionuclide cystography. A summary of the techniques, main indications, interpretation criteria and pitfalls will be provided. Some future directions for the field are also pointed out, among which the most relevant is the need for nuclear medicine professionals to use standardized protocols and integrate multidisciplinary teams with other pediatric and adult health professionals that manage these life-long pediatric pathologies, which are recognized as an important cause of adult chronic kidney disease.