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Positron emissiontomography
A strategy for provision in the UK
A report of the
Intercollegiate Standing Committee on Nuclear Medicine
Representing the Royal College of Physicians of London, the Royal
College of Physicians and Surgeons of Glasgow, the Royal College of
Physicians of Edinburgh, the Royal College of Pathologists, the Royal
College of Radiologists and the British Nuclear Medicine Society
January 2003
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ROYAL COLLEGE OF PHYSICIANS OF LONDON11 St Andrews Place, London NW1 4LE
Registered Charity No 210508
ROYAL COLLEGE OF RADIOLOGISTS38 Portland Place, London W1N 4JQ
Copyright © 2003 Royal College of Physicians of London
ISBN 1 86016 170 7
Cover design by Merriton Sharp
Typeset by Dan-Set Graphics, Telford, Shropshire
Printed in Great Britain by Sarum ColourView Group, Salisbury, Wiltshire
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Contents
Foreword v
Executive summary and recommendations vii
PART 1: A STRATEGY FOR THE PROVISION OF POSITRON EMISSION
TOMOGRAPHY IN THE UK
1 Introduction 3
Background 3
2 Clinical PET: areas of use 5
The role of PET in oncology 5
The role of PET in cardiology and cardiac surgery 7
The role of PET in neurology and neuropsychiatry 7
Cost effectiveness 7
3 The requirements of a national PET service 9
Equipment and personnel 10
4 Current problems and their solutions 11
Problems with service provision 11
Problems with establishing PET in the UK 12
5 Suggested strategy for the provision of a PET service 13
6 Conclusion 16
PART 2: CLINICAL INDICATIONS FOR POSITRON EMISSION TOMOGRAPHY
IMAGING: CURRENT ICSCNM SUGGESTIONS
Introduction 19Radiation hazards 19Breast feeding 20Pregnancy and protection of the foetus 20The clinical indications table 20
Clinical indications for positron emission tomography 21
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APPENDICES
1: Imaging with a distant supply of tracer: the minimum establishment 292: Imaging with full production of tracer: the minimum establishment 323: Training issues 38
References 39
Bibliography 41
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Foreword
The Intercollegiate Standing Committee on Nuclear Medicine (ICSCNM) is committed to the
maintenance of standards in, and the development of, nuclear medicine and radionuclide
radiology in a way which contributes to the care of patients.
Nuclear medicine technologies are developing at a great pace and, in keeping with the molecular
developments in medicine, positron emission tomography (PET) is now capable of providing
molecular imaging. Clinical PET’s contribution to the management of patients with cancer is
growing in terms of diagnosis, staging, restaging and the monitoring of response to therapy. The
new combination technology of PET-CT scanners will impact on radiotherapy planning as well
as on assessing gene therapy and early tumour response. Although oncology is the major area
of PET usage, applications in neurology and cardiology are apparent and will develop in the
future.
As with all new technologies, setting up a service can be difficult both in terms of capital cost
and staff training. Currently the access to PET services for UK patients is extremely limited and
inequitable in geographical location. For PET to be developed and used appropriately and to a
high standard, the constituent bodies of the ICSCNM felt that a strategic view should be available
to allow decisions to be made for a rational implementation of a service.
This document is therefore intended to provide a clear indication of the potential value and
practical implications of the development of a PET service. It should also act as a stimulus to
those in relevant patient care to press for the provision of such a service.
A working party of the ICSCNM (consisting of Dr MJ O’Doherty (Chairman), Prof I McCall
and Dr TO Nunan) produced this document, which has since been reviewed and modified by
all members of the committee. It has therefore been endorsed by the Royal College of Physicians
of London, the Royal College of Physicians and Surgeons of Glasgow, the Royal College of
Physicians of Edinburgh, the Royal College of Pathologists, the Royal College of Radiologists
and the British Nuclear Medicine Society. The document will be available on the websites of the
Royal College of Physicians, the Royal College of Radiologists and the British Nuclear Medicine
Society.
Special thanks are extended to Ms M Dakin (of Guy’s and St Thomas’ Clinical PET Centre) for
the financial information.
January 2003 PROFESSOR IAIN MCCALL
Chairman, ICSCNM
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Executive summary and recommendations
SUMMARY
Positron emission tomography (PET) has been in use for over 20 years as a research tool, and
over the last decade in a clinical role. The major clinical applications of PET are in the areas of
oncology, cardiology and neurology, with over 85–90% of the workload in oncology. There have
been around 15,000 publications related to PET, and although the majority of these have been
small retrospective studies, all major studies have had similar findings. The literature lacks
randomised controlled trials (with the exception of lung cancer1) and large prospective series
or cost-effectiveness analyses (other than modelling studies). Despite this, PET scanning has
been adopted throughout the USA and Europe, gaining Centers for Medicare and Medicaid
Services (CMS, previously known as the Health Care Financing Administration or HCFA)
approval for reimbursement in patients with certain cancers and cardiac conditions in the US.
There are over 160 sites in the USA and over 120 sites in Europe (80 of these are in Germany).
PET is a technology that uses short-lived radionuclides (with half-lives currently ranging from
2 to 110 minutes) attached to tracers to examine metabolic processes associated with health and
disease. These functions are often altered by disease and precede changes that can be visualised
by cross-sectional imaging (eg computed tomography (CT) or magnetic resonance imaging
(MRI)). PET radionuclides are produced in cyclotrons which are available in a variety of sizes
and energies. The most commonly produced radionuclide is fluorine-18 (F-18), but others
include nitrogen-13 (N-13), carbon-11 (C-11) and oxygen-15 (O-15). F-18 has the advantage
of having a longer half-life (110 minutes) and can be attached to a molecule that mimics glucose
metabolism, fluorodeoxyglucose, to produce 18F-FDG. Cancer cells have altered glucose
metabolism and therefore FDG is a major tracer used in the assessment of cancer.
Evidence of the diagnostic accuracy of PET scanning is based on traditional full-ring dedicated
PET, with very few publications using gamma camera coincidence imaging (GCI). The technology
for GCI is currently inferior to dedicated PET scanners and is unlikely to have the same versatility.
Health technology assessment is notoriously difficult to undertake since the technology is
advancing so rapidly. The studies that have been performed demonstrate that PET is more
accurate in detecting malignant disease than conventional imaging, but is often best used in
combination with conventional cross-sectional imaging in the assessment of cancer patients.
Modelling studies in pulmonary nodules and lung cancer have been carried out using published
sensitivities and specificities. The points of interest are that the predications of these studies
appear to support the findings from recent prospective research and a recent randomised
controlled trial of lung cancer and PET. There are a number of studies in different cancer groups
demonstrating change in management as a result of PET scanning. In one study, 62 out of 102
patients with lung cancer being assessed for surgery had their management changed, having
been staged by conventional means.2
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PET in the UK has been severely restricted by the lack of availability of scanners and cyclotrons.
Clinical PET was introduced into the UK at Guy’s and St Thomas’ Hospitals in 1992; the unit
now has two scanners and has rapidly become inundated with work, such that 2,000 patient
studies are being performed per annum on patients travelling from Scotland, Wales and all corners
of England. Since 1992 only three other dedicated clinical PET facilities have developed, all of
which are in London. Research scanners have been established in London, Manchester, Cambridge
and Aberdeen. All of these have access to a cyclotron and radiotracer production facilities.
PET scanning has been limited by the lack of positron-emitting tracers caused by the small
number of cyclotrons. The present cyclotrons can supply 18F-FDG to hospitals within an
approximate two-hour travel-time radius. However, radionuclides currently used for vascular
flow measurements all have a very short half-life and can only be used in scanners immediately
adjacent to the cyclotron. The key to delivering a service lies in deciding how many centres and
which studies are required.
PET should be available to all cancer centres for early diagnosis, staging and the identification of
tumour recurrences. These tasks will constitute approximately 85–90% of a PET centre’s work. It
should also be available to tertiary referral centres where there is substantial work being undertaken
on neuropsychiatric conditions (eg epilepsy), and possibly dementing illnesses (eg Alzheimer’s
disease) and also the evaluation of cardiac muscle viability prior to coronary artery surgery (see
Part 2). These latter uses will only make up the remaining 10–15% of the workload.
A dedicated PET camera could perform between 1,000 and 1,600 patient studies per year,
depending on the complexity and type of study. With new technologies, such as PET-CT cameras,
their number may increase. Therefore a knowledge of the population base which is likely to
provide at least that number is required. It is estimated that a population of approximately
1–1.5 million people would have 700–750 patients per annum falling in to the cancer types which
from the body of evidence available would benefit from PET scanning, ie lung cancer, metastatic
or recurrent colorectal cancer and lymphoma. In addition to these groups the evidence for the
role of PET in a larger range of cancers is becoming established (see Part 2). Most cancer centres
in the UK subserve this population of patients. The establishment of a PET centre in each cancer
network would be a useful start to the process.
PET centre optionsThere would need to be two types of PET centre developed in the UK: dedicated full-ring PET
scanners in conjunction with a cyclotron and radiochemistry production facility, and stand-
alone PET scanners. The staffing of these centres is outlined in Part 1 of this document and in
the appendix. The delivery of a PET service is expensive; however, the calculated incremental
cost-effectiveness ratios (ICERs) are low. The location of each type of centre would need to be
carefully considered to give optimum access for the patient population. The likely capital cost
of a PET scanner facility is £1,285,050 and the cyclotron/radiochemistry facility is an additional
£1,469,700. Revenue consequences will vary depending on the service offered, but for the scanner
alone the estimate based on 1,000 patients is £585,900 (see the appendices for a more detailed
analysis of costs).
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Staffing issuesThe staffing requirements of a PET centre will vary depending on the type of centre (scanner
and cyclotron, or scanner alone) and also on whether the centre is predominantly clinical, or
both research and clinical. Whatever the service offered, there are issues relating to training for
all staff members. There are few trained clinicians, radiochemists, cyclotron engineers, physicists
and radiographers/medical technologists. Staff training in the UK needs to be addressed with
funding and the establishment of formal training courses. The funding may come partly from
the industry and partly from the government. A curriculum for medical training has been
established within the nuclear medicine training programme.
Findingsi The committee accepts that the accumulating evidence indicates that with regard to
patients with lung cancer, solitary pulmonary nodules and colorectal cancer and
lymphoma, the addition of PET is likely to be cost effective in their management.
i Evidence suggesting that PET will be beneficial in the management of patients with
other tumour types is accumulating.
i Currently PET is used in addition to other imaging techniques and in most cancers
FDG PET has a higher sensitivity than other forms of imaging.
i FDG PET is safe to perform.
i The method of imaging should be dedicated full-ring PET. The crystal type remains
to be evaluated and depends on recent developments with germanium
oxyorthosilicate (GSO) and lutetium oxyorthosilicate (LSO) rings. Most available data
uses bismuth germanate (BGO) systems.
i PET services performed using GCI should be discouraged. This should only be
reviewed:
– when these systems can demonstrate performance that is equivalent to or better
than the full-ring PET systems; or
– if their clinical utility can be demonstrated by adequate clinical studies to indicate
an incremental value to patient management compared with other imaging
methods.
i The establishment of clinical PET in the UK should be centrally controlled and
financed to allow the optimum provision of service throughout the UK whilst
maintaining a high clinical standard. A public-private partnership may be appropriate
for the provision of cyclotron facilities and tracer supply.
i The established cancer networks, cancer centres and appropriate tertiary referral
centres should provide the structure upon which the introduction of PET centres is
based. The exact siting of such centres will depend on the availability of tracer in the
short term, and the development of cyclotrons either by using or upgrading existing
facilities. There will be a need to develop new facilities particularly in those areas
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without access. These include the North East and South West of England, the central
corridor of Scotland and Northern Ireland.
RECOMMENDATIONS1 A national policy for the development of PET facilities should be established as soon
as possible.
2 State-of-the-art dedicated PET camera facilities should be established in at least
15 sites within the UK in the next 3–5 years, and in at least 40–60 sites in the next
10 years.
3 The majority of the initial sites should include cyclotron and radiotracer production
facilities or be sited where there are existing production facilities within two hours’
journey time.
4 Each cancer network should have access to a dedicated PET facility attached to a
radiotracer production facility. This is to enable the full range of PET tracers to be
available on at least one site within the network.
5 Cyclotron provision may be government funded, privately funded or a combination
of both. The cyclotrons should either be 10–13 or 13–18 MeV, depending on the
proposed size of the unit and the research potential.
6 PET scanners should be funded by the government, or a combination of private and
government funding. Operating costs should be included in the budgets of the cancer
networks and the cardiac and neurology services as appropriate.
7 Government funding is required in training programmes for PET radiochemists and
cyclotron engineers.
8 The number of trained personnel and the expense may be reduced by siting several
cameras on one site, providing patients have ready access to the facility.
PET imaging is developing rapidly elsewhere in the world. Health technology reviews performed
one or two years ago are already dated. The time is ripe to press on with providing an organised
national service for PET. This technology development should be regarded as a necessary part
of the NHS Plan and the NHS Cancer Plan.
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PART 1A strategy for the provisionof positron emissiontomography in the UK
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1 Introduction
1.1 Clinical positron emission tomography (PET) is now a reality. The transition from the
research environment, where it has been in use for over 25 years, to the clinical environment
has been made successfully over the last ten years. The major problem is that the UK has fallen
behind the rest of Europe and the USA in the provision of this service.3,4 The need for the service
will increase over the next five to ten years, particularly in relation to the management of patients
with malignancy such that a PET service is likely to be regarded as a mandatory part of staging
and restaging disease as well as monitoring therapy. It is therefore essential that the issue of the
provision of PET services is addressed. The NHS Plan has identified cancer, heart disease and
mental health as current clinical priorities.5 The NHS Cancer Plan outlines a series of objectives
aimed at reducing times from referral to diagnosis and appropriate treatment.6 PET has a role
in selecting patients for appropriate treatment, in diagnosis and in monitoring the patient’s
response to treatment. Decades of underinvestment in people and equipment have taken their
toll and it is possible this mistake will continue if the opportunity to develop clinical PET is not
taken.
Background1.2 PET is a nuclear medicine technology that uses short-lived radionuclides (carbon-11,
oxygen-15, nitrogen-13 and fluorine-18) attached to biological molecules to allow the
visualisation of metabolic processes in the body by producing an image of the distribution. Using
these tracers to visualise the biochemistry of a human, it is possible to view perturbations of the
system caused by disease processes such as cancer, coronary artery disease and neurological
disease. Biochemical or functional changes in the body often occur before any structural change,
so these functional images can show disease before anatomical images (computed tomography
(CT), magnetic resonance imaging (MRI) or ultra-sound scans (USS)) in some circumstances.
1.3 The most commonly used tracer is F-18 fluorodeoxyglucose (FDG) which allows the
examination of alterations in glucose metabolism which are known to occur in cancer cells. It
can also demonstrate abnormalities in areas of the body that use glucose preferentially as their
energy source, for example the brain and the myocardium. Other molecules which have a role
in evaluating disease (eg aminoacids, purines and pyrimidines as well as tracers that show blood
flow, hypoxia etc) can also be labelled. These short-lived radionuclides are made using cyclotrons
and then attached to the biological molecules using rapid chemistry techniques.
1.4 Clinical PET was introduced in the UK in 1992 through a self-funding unit based at Guy’s
and St Thomas’ Hospital. This unit has two dedicated PET cameras and is currently working at
capacity, accepting patients from around the UK. The use of PET, however, is now established
and its role becoming known to a wide variety of clinicians. There are three other clinical PET
imaging centres in the UK, two based in London, at University College London and Harley
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Street, and a further one at the Paul Strickland Scanner Centre at Mount Vernon Hospital in
Middlesex. There are also two research units in London, based at Imaging Research Solutions
Limited (IRSL, formerly the Medical Research Council Cyclotron Unit) at the Hammersmith
Hospital and the Functional Imaging Laboratory at Queen Square. Outside of London there are
the Wolfson Brain Imaging Centre at Addenbrooke’s Hospital in Cambridge, the Manchester
PET Centre at Christie Hospital and the PET Imaging Research Group at the University of
Aberdeen. These research units do not offer a comprehensive clinical scanning service, but some
do produce and distribute PET radiotracers. The above centres all have dedicated PET scanners.
There are also a number of other trusts that have acquired gamma camera coincidence imaging
(GCI), and these provide a limited PET service. The capabilities of such cameras are in their
infancy; whether they will mature remains to be seen, and their role is not established.3,4 The
technology is unlikely to have the same capabilities as dedicated PET and there may be other
drawbacks to providing a quality service. In line with clinical governance and evidence-based
practice this document considers the establishment of dedicated PET centres.
1.5 There are also private initiatives including mobile PET scanners, which may have a role in
the establishment of PET scanning in other regions of the country. Careful supervision would
be required to establish a quality service and the provision for adequate training of the reporting
clinicians. The costs of such an initiative would need to be explored with the private sector.
Similarly there are already commercial companies with expertise gained in the USA and Europe
who are establishing radiotracer production facilities in the UK.
1 Introduction
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2 Clinical PET: areas of use
2.1 There are three areas of use in the clinical arena. The largest area is within the field of
oncology, with cardiology and neuropsychiatry as the other predominant areas. A list of the
committee’s views on the current indications for PET are identified in Part 2 of this document.
The role of PET in oncology2.2 The principal role of PET in oncology can be thought of either in generic terms or in terms
of the systems affected by cancer.
Generic indications
2.3 The generic use of PET in the assessment of malignant disease can be summarised as:
i distinguishing benign from malignant disease, eg lung nodules, brain lesions etc;
i establishing the grade of malignancy, eg brain tumours, soft tissue masses;
i establishing the stage of disease, eg lung cancer, lymphoma;
i establishing whether there is recurrent or residual disease, eg lymphoma, teratoma,
seminoma;
i establishing the site of disease in the face of rising tumour markers, eg colorectal,
germ cell tumours;
i establishing the response to therapy before, during and after therapy imaging; and
i identifying the primary site of a tumour for biopsy either when site is unknown but
clinical indications are strongly pointing to a tumour (eg paraneoplastic syndrome)
or for therapeutic purposes.
Tumour-specific indications
2.4 PET is changing the way in which cancer is managed and is forcing a reassessment of
conventional staging with CT and MRI in certain cancer groups. It can be used to plan the
delivery of, and rapidly assess response to, therapy, allowing the treatment regimens to be
modified without delay if the response is inadequate. The largest influence of PET has been in
the management of lung tumours, colorectal tumours and lymphoma (see the appropriate
sections in the bibliography). The management of many other tumours is also affected. This is
evidenced by an increasing number of publications (particularly head and neck cancer
recurrence, testicular tumours, oesophageal cancer and melanoma (see bibliography)). These
roles although less well evaluated have been shown with anecdotal evidence to be beneficial to
patients.
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2 Clinical PET: areas of use
2.5 FDG PET has been shown to be cost effective in the assessment of pulmonary nodules and
in the staging of lung cancer. In the assessment of pulmonary nodules FDG PET has a reported
sensitivity of 82–100% and a specificity of 60–100%, with the majority of studies suggesting a
sensitivity of approximately 90% and a specificity of approximately 85%.7 The use of PET, either
in combination with CT or on its own, has been shown through the use of decision-tree modelling
to be cost effective. Ghambir et al demonstrated that a CT and PET strategy produced savings of
$1,154 per patient without loss of life expectancy.8 Dietlein et al showed that compared to a watch-
and-wait strategy the PET incremental cost-effectiveness ratio (ICER) was e3,218 per life year
saved, whereas if exploratory surgery were the norm then PET would be e6,912 per life year
saved.9 In lung cancer staging the sensitivity in the detection of metastatic disease has varied
between 66% and 100% with the majority of the literature suggesting 75% and the specificity
ranging between 80% and 100% with the majority in the region of 95%. Ghambir et al have
shown cost savings of between $91 and $2,200 per patient using both CT and PET to stage patients
with lung cancer.10 Dietlein et al showed that FDG PET was most cost effective in those patients
with normal sized mediastinal nodes on CT, with the ICER per life year saved costing only e143.11
Recently a prospective study has demonstrated the superiority of PET over CT in the assessment
of patients with lung cancer referred for surgery.1,2 Management changes have been observed in
20–60% of patients in various studies.2,12 These changes have been in both up- and down-staging
of patients; either promoting patients to surgery or preventing ineffective surgical intervention.
A recent randomised controlled study demonstrated that conventional workup and FDG PET
resulted in a 51% relative reduction in futile thoracotomy compared to conventional workup
alone.1 The use of FDG PET in radiotherapy treatment planning and for down-staging assessment
after chemotherapy is still to be evaluated. If PET is found to be valuable in these areas as well as
in surgical assessment then its role will expand within lung cancer.
2.6 Patients with recurrent colorectal carcinoma present a number of problems to the clinician.
Conventional imaging assessments have a poor record, with only 25% of patients with apparently
limited disease curable at surgery. With hepatic recurrence, over 50% are found to be unresectable
at surgery. A meta-analysis of the literature available on recurrent colorectal cancer demon-
strates an overall sensitivity of 97% (95% confidence levels 95–99%) and specificity of 76%
(95% confidence levels, 64–88%) for detecting disease sites, with management changes in 29%
(95% confidence levels of 25–34%) when FDG PET is used.13
2.7 CT is normally the modality used to stage lymphoma. FDG PET has been shown to change
management in anything up to 40% of patients who have already been staged with CT.
Furthermore, FDG PET appears to be useful in the assessment of residual masses found on CT.
The other potential area of use is in early assessment of disease response to chemotherapy, since
change of treatment regimes may be instigated earlier than normal if no response or a limited
response is observed following two cycles of therapy. This may have long-term benefits in the
reduction of second malignancies following initial chemotherapy.
2.8 The role of PET in other tumours cannot be underestimated. Significant evidence of utility
has been demonstrated, for example in the management of oesophageal cancer, soft tissue
sarcomas, testicular tumour recurrence (in residual masses or patients with rising markers),
metastatic melanoma and many other tumours. As of January 2001, health insurers in the USA
are funding FDG PET studies for solitary pulmonary nodules, staging of non-small cell lung
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2 Clinical PET: areas of use
cancer, lymphoma staging and restaging as well as recurrent colorectal tumours and recurrent
or metastatic melanoma. This list has expanded from its introduction in 1998, and in the USA
Centers for Medicare and Medicaid Services (CMS, previously known as the Health Care
Financing Administration or HCFA) proposed that ‘this science-based coverage decision provides
important expanded coverage of dedicated full-circular ring PET scanners and some partial-
ring systems for any clinically appropriate use for six types of cancer – lung, colorectal, lymphoma,
melanoma, oesophageal, and head and neck (but not brain or thyroid) cancer – and new coverage
of the neurologic and cardiac applications’. This list was further updated in November 2001 to
stipulate that most of these indications were for full-ring or partial-ring PET cameras.
The role of PET in cardiology and cardiac surgery2.9 The major role for PET imaging in this area is to establish whether there is sufficient viable
myocardium in a patient with poor ventricular function to justify attempts at revascularisation.
The predictive ability for contractile recovery is approximately 80% positive predictive value of
mismatched perfusion and FDG uptake, and 85% negative predictive value for matched reduction
in perfusion and FDG uptake. The other potential use is in patients with severe ischaemic
cardiomyopathy who are being considered for cardiac transplantation. A survival benefit has
been shown to be present in those that had mismatched perfusion and FDG, and underwent
revascularisation, compared with those that had no mismatch and underwent medical treatment.
Those patients who had no mismatch and underwent cardiac transplantation also had improved
survival. Furthermore, the accuracy of PET for the detection of coronary artery disease is highly
sensitive and specific of the order 82–100%. The indications would appear to be:
i diagnosis of hibernating myocardium in patients with poor left ventricular function
prior to revascularisation procedure;
i distinguishing ischaemic from non-ischaemic cardiomyopathy;
i identifying patients with a fixed single photon emission computed tomography
(SPECT) deficit who might benefit from revascularisation; and
i use prior to referral for cardiac transplantation.
The role of PET in neurology and neuropsychiatry2.10 The principal applications for PET in neurology are for the pre-surgical workup of patients
with partial epilepsy, assessment of dementias, and diagnosis and detection of recurrent primary
brain tumours. The sensitivity and specificity for unilateral hypometabolism in temporal lobe
epilepsy are approximately 70–85% and 86% respectively. The role in dementia imaging is at
present limited, since although it has a high sensitivity and diagnostic accuracy is not a great
deal better than single photon emission tomography (SPET) imaging techniques.
Cost effectiveness2.11 There have been a number of reports by a variety of health technology assessments including,
most recently, the Commonwealth report on PET,14 the United States Veterans Affairs Management
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8
2 Clinical PET: areas of use
Decision and Research Center (MDRC) Technology Assessment Program in 1996 and 1998,15,16
and the United Kingdom National Coordinating Centre for Health Technology Assessment
(NCCHTA).17 These reports all have their problems, not least the fact that they are now out of
date and using literature that is at least two years old, and in some cases six or seven years old.
The NCCHTA report had a number of other problems, particularly the Delphi study in which
questions were asked of researchers or specialists who were hoping to generate funding for
equipment and research. The areas of assessment of the technology raised in the report by Roberts
and Milne are likely to be superseded since there is broad agreement that the GCI technology is
inferior to dedicated PET cameras. Similarly, prospective studies have been performed in real
clinical situations demonstrating the added value of dedicated PET over conventional CT imaging
in lung cancer. Peter Valk has eloquently argued that randomised controlled trials are not
appropriate for assessing imaging methods, and the use of modelling sensitivity and specificity
data to assess the likely cost effectiveness is a more rapid way of providing such information, and
one which does so in a way that can be applied to each country’s health circumstances.18 It is also
of interest that the most recent review of PET in the Commonwealth document still used these
dated HTA reports, and despite reaching the conclusion that there is little cost-effectiveness data
available the report suggested that PET has a role in:
i differentiation of malignant from benign lesions in patients with a solitary
pulmonary nodule;
i primary staging in patients with non-small cell lung cancer (NSCLC);
i primary staging in patients with suspected primary brain tumour;
i evaluation of residual structural lesions after definitive therapy for colorectal cancer
(CRC);
i evaluation of residual structural lesions after definitive therapy for recurrent glioma;
i pre-operative assessment of metastatic disease in CRC;
i pre-operative assessment of apparently limited metastatic disease in malignant
melanoma;
i localisation of epilepsy; and
i assessment of ischaemic heart disease.
2.12 The economic modelling has been performed in different health care settings and suggests
that PET is cost effective, or even cost saving, based on the assumptions made. Whether PET affects
long-term outcome remains to be fully tested in malignant conditions, however it is clear that it
can affect the short-term management of patients with cancer. Outcome effects may take up to
20 years to evaluate; for example, whether changes in chemotherapy or radiotherapy regimens early
in the course of disease treatment will reduce the occurrence of second cancers. If an imaging
modality is superior to another imaging modality and provides different information allowing
management changes, we should not wait a further 5–10 years to show long-term outcome effects;
these changes have been modelled and prospective studies are showing these models to be true.
Furthermore, the human costs of delay in the introduction of this modality may be large, since the
management changes demonstrated suggest that unnecessary surgery can be avoided and necessary
surgery expedited. There is consequently the potential to enable the appropriate treatment pathway.
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9
3 The requirements of a national PET service
3.1 The major use of clinical PET is in oncology as discussed above. The recent publication of
health statistics shows the number of cases of cancer in England and Wales.19 If the major cases
of cancer are considered and compared with the current identified role of PET then the potential
patient base can be identified. The number of new cases of cancer identified in 1994 was 224,320.
The major cancers in men were lung, colorectal and prostate and in women they were lung,
colorectal and breast. These tumour types constituted over half the registrations. For lung cancer
and colorectal cancer there is meta-analysis evidence of the utility of PET. There is emerging
evidence of probable use in breast cancer. Furthermore the cancer statistics for 1997 show over
6,000 new cases of oesophageal cancer, 1,400 cases of testicular cancer, 3,500 cases of brain
tumour and 7,200 cases of non-Hodgkin’s lymphoma, 5,500 cases of lip, mouth and larynx
cancer and 4,600 cases of melanoma in 1997.19 All of these tumour groups would benefit from
PET examinations for staging and treatment response assessments. The prevalence of patients
with cancer on the 1 January 1993 was almost 650,000. The patients who are still alive and have
had cancer will be under surveillance and so may also contribute to the demand for PET (since
a large portion of these will have colorectal cancer where the evidence for the role of PET scanning
in the detection of recurrent disease is robust). The registration of new cancers for 1995–7 is
very similar to the numbers for 1994 with 219,700 noted.
3.2 The statistics quoted can also be portrayed as new cases per million of the population.
These figures show an overall cancer incidence of 8,690 p.a. per million with over half of these
falling into groups where there is robust evidence of the benefits of clinical PET with the currently
available tracer, FDG. Assuming the role of PET is confined to the tumour groups with either
meta-analysis evidence or robust clinical data supporting its use, the new lung cancer cases are
presently 1,390 p.a. per million, colorectal disease 1,120 p.a. per million and lymphoma cases
280 p.a. per million. Assuming that 15% of lung cancers are considered operable and a further
10% may be downstaged by chemotherapy, then PET has a potential role in approximately 25%
of lung cancers, that is 208–347 p.a. per million of the population. Similarly for the colorectal
cancers with this sort of incidence the prevalence of cases for assessment of residual or recurrent
disease is likely to be 250 p.a. per million of the population. All lymphomas would benefit from
staging with PET scanning in addition to either interim assessment during chemotherapy or
post chemotherapy. Therefore within a population of a million a conservative estimate of the
number of patients who would directly benefit from PET scans each year is 730. Other tumour
types will also benefit under a variety of circumstances. Perhaps a more realistic estimate can be
obtained by projecting that about 15–20% of the 8,000 patients p.a. per million of the population
with cancer would benefit from PET imaging; this would amount to approximately 1,600 patients
each year.
3.3 A dedicated clinical PET centre could be justified serving a population of 1–1.5 million
people. This is approximately the number of people subserved by the current cancer centres.
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Some of these PET centres would enable investigation of the other conditions for which PET
can contribute to the treatment within cardiology and neurology. This would be particularly
true if the PET facility was in a tertiary referral centre with a high workload in these areas.
Equipment and personnel3.4 An editorial in Lancet has addressed the issue with regard to the equipment currently
available and becoming available.4 The staffing issues will ultimately depend on the mix of clinical
service provision and research and development undertaken by a centre. The presence of an on-
site cyclotron would generally need a larger than normal scanning staff in addition to the
production staff, due to the ability of the centre to perform more complex studies using a variety
of shorter half-life radiotracers. Staffing of a clinical PET centre depends on the number of PET
cameras and the variety and volume of work undertaken. A model can be established for a
scanning facility supplied with fluorine-based radiotracers from a distant production facility.
The work is likely to be less complex and may start later in the day.
3.5 For each of these models, costs for providing a service can be divided into fixed and variable
costs. The costs for a centre which provides an imaging service with a distant supply of tracer
are:
Capital costs: £1,285,050
Operating costs: £585,900 p.a.
The costs for a centre which undertakes imaging and full production are:
Capital costs: £2,761,750
Operating costs: £670,850 p.a.
These figures are discussed in more detail in the appendices.
10
3 The requirements of a national PET service
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11
4 Current problems and their solutions
Problems with service provision
Staffing
4.1 The problem with staffing PET units is that there is at present a shortage of suitably trained
and experienced staff at all levels. Providing a full scanning service with radiotracer production
requires a multidisciplinary team of scientific, medical, technical and support staff. The pressure
of dealing with short half-life radiotracers can at times be challenging and requires flexibility,
precision, commitment and the ability to work to stringent time pressures. Staff at a scanning
site which is remote from the production facility can be subject to delays and the occasional
production failure; this can be frustrating and disruptive to the working day.
Training issues
4.2 There are training issues associated with all the disciplines involved in PET scanning. There
is a need to establish a comprehensive training programme. There are few trained PET
radiochemists or cyclotron engineers/technicians in the world, let alone the UK. Training may
be undertaken by private companies with experience in providing radiotracer production
facilities. However it may also be provided through MSc courses, or vocational training on an
approved university course which is sponsored by industry or the government. This needs to be
established as a matter of urgency. Similarly there are few trained cyclotron engineers/technicians,
but other disciplines such as radiotherapy workshop technologists do have some of the skills,
which, with the appropriate training, could provide necessary trouble-shooting and first-line
maintenance. Formal training and on-the-job experience is required for these key members of
the production team. The current difficulties in recruiting nuclear medicine technologists and
radiographers for general departments are exacerbated when attempting to recruit for PET
centres. Experienced, trained staff are not readily available in the UK and training needs to be
given on site. BSc courses now include some PET lectures and an annual course is now offered
by Guy’s and St Thomas’ PET Centre, but on-the-job training is required. Arranging rotations
or split posts with other cross-sectional imaging departments (such as CT or MRI) may make
these positions more attractive to radiographers who have not trained in nuclear medicine. There
are few trained PET clinicians. Training for clinicians is being addressed by including PET as
part of the Certificate of Completion of Specialist Training (CCST) in nuclear medicine, but
post-CCST experience is also required. Post-CCST modular training would also be appropriate
for radionuclide radiologists but there is no mechanism to validate such training. There are few
centres in the UK where this experience can be gained and consequently it has been necessary
for clinicians to gain on-the-job experience or to spend short periods in non-UK centres. This
will be a significant issue in the clinical staffing of PET centres.
4.3 The delivery and maintenance of the service needs to be consistent with the Ionising
Radiation (Medical Exposure) Regulations 200020 and the relevant aspects of Ionising Radiations
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12
4 Current problems and their solutions
Regulations 1999,21 and the Administration of Radioactive Substances Advisory Committee
(ARSAC).22 It also needs to comply with necessary standards of delivery of a high quality service
as well as issues related to clinical governance.
Problems with establishing PET in the UK4.4 Currently there are few centres in the UK with PET scanning, and even fewer radiotracer
production sites. There needs to be a large capital investment programme covering all regions
of the UK to establish the technique and provide a service, especially for cancer patients. There
is a golden opportunity at this time for the government to identify strategic geographical sites
for the establishment of radiotracer production facilities and a subsequent positioning of
scanning units. There are currently cyclotrons at St Thomas’ Hospital, Imaging Research
Solutions Limited (IRSL) at the Hammersmith Hospital, the Wolfson Brain Imaging Centre at
Addenbrooke’s Hospital Cambridge, Mount Vernon Hospital, and the PET Imaging Research
Group at the University of Aberdeen. The cyclotron at Clatterbridge produces F-18 for FDG
production at the Manchester PET Centre at the Christie Hospital. There is also a large cyclotron
in Birmingham which could possibly be adapted to produce radiotracers for PET scanning.
These centres could provide the starting point for a network of PET radiotracer production
facilities, with PET scanning units being established within two to four hours’ travel from those
sited in cancer centres. This has the advantage that the major capital outlay on cyclotrons and
radiotracer production facilities could be deferred whilst ensuring access for a larger number of
patients to PET scanning. Consideration should be given to funding for a cyclotron and
production facilities associated with cancer centres and nuclear medicine facilities in the north
east and south west of England and the central corridor of Scotland. This would establish a unit
in regions of the country where access would otherwise be difficult and would involve travelling
to London.
4.5 While these developments are occurring, staff could be trained in existing clinical PET
institutions providing funding can be found.
i The training of staff needs to be addressed with government support for training programmes,
especially for the scientific staff.
i For medical trainees the training has been addressed in the new curriculum of the RCP for the
CCST in nuclear medicine.
i Radiographers should be encouraged to embrace PET scanning as an additional skill, perhaps linking
it with CT and MRI training to provide combined jobs in the future.
BOX 1 Action on staffing
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13
5 Suggested strategy for the provision of a PET service
5.1 There is a proposal to develop approximately 37 cancer networks in England and Wales.
These could form the basis for the provision of a high quality PET service. If Scotland and
Northern Ireland follow the same model, it could be developed to cover the whole of the UK.
There are currently around 60 cancer centres in the UK and even more cancer units. All cancer
centres should have access to the full range of nuclear medicine services, and therefore have the
services of one or more specialists in nuclear medicine.23
5.2 The case has been made in this document for a PET service to supply a population of about
one million people. This number of people will allow a single camera facility to be utilised full-
time, providing enough patients to maintain the throughput necessary to ensure the need for a
high quality service and maintenance of clinical skills. Larger cancer centres which deal with a
greater variety of tumours and provide advances in therapy would almost certainly need an
additional camera to allow research and development alongside the monitoring of therapy. The
introduction of PET can be phased in around the country, but individual trusts would need
financial support to introduce a service and maintain it. An initial investment to provide a service
in 15 areas of the country should be considered, along with the establishment of a PET radiotracer
production facility in the North East and South West of England, the central corridor of Scotland,
and Northern Ireland. There should then be a second phase introducing further scanners, either
at new or established sites.
5.3 The expenditure on dual coincidence imaging should be curtailed. Even if the dual
coincidence GCI has a limited role it will not compete with dedicated PET, and the previously
quoted statement from the HCFA in the USA suggests that full-ring systems are the method they
are willing to finance. Both technologies are advancing and the likelihood is that dedicated PET
systems will have a high patient throughput in the next few years because of the advances in
crystal design and nature, and the electronics of the cameras, which will allow larger numbers
of patients to be scanned. The clinical utility is proven with dedicated PET and has yet to be
proven with GCI. The UK has a history of not funding the optimum methods of imaging until
much later than is necessary. There should be no delay in funding this imaging method with the
optimum equipment.
5.4 The resource of PET has to be embraced as a national strategy to give patients the full
benefit of the technology. Therefore a controlled introduction, judiciously positioned, needs to
be considered. It will need to be funded either separately by the Government (both the capital
outlay and the running of the service), or by private investment. This latter strategy is beyond
the scope of this paper.
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5.5 Macintyre et al recently discussed the use of evidence to inform health policy.24 The criteria
suggested for use in the evaluation of policy recommendations have been applied to PET as
follows:
1 Support by systematic evidence, empirical evidence. There is a wealth of data
establishing the role of dedicated PET in oncology, and other data to support its role
in specific areas of cardiology and neuropsychiatry (see bibliography). Accompanying
these publications have been meta-analyses of the available data supporting the use in
colorectal recurrence, lung malignancies and so on, and cost-effectiveness analyses
supporting the use of PET in solitary pulmonary nodules and the staging of
pulmonary malignancies.
2 Support by cogent argument. The case for development of a PET network
throughout the UK is presented above.
3 Scale of likely health benefits. The cost-effectiveness data for lung cancer points the
way to further cost-effectiveness studies which need to be performed. There is,
however, substantial published evidence which demonstrates the effect on
management of patients such that the US health insurers have accepted the role of
PET in areas outlined above.
4 Likelihood that policy would bring benefits other than health benefits. Benefits
would be in terms of employment of skilled personnel and contribution to research.
5 Compatibility with existing or proposed government strategy. The proposed
introduction of PET facilities coincides with the government strategy on improving
the management of patients with cancer and cardiac disorders.
6 Possibility that the policy might do harm. The introduction of a number of PET
centres is unlikely to do harm. It is important to avoid the introduction of a system
where the centres are not run by trained personnel and where misdiagnosis is
therefore a potential problem.
7 Ease of implementation. The strategy would be possible to implement if the
distribution of centres was determined by a central government edict. The siting of
cyclotrons could be evaluated, depending on the populations to be subserved,
transport links and the skills available. PET scanners could be installed through a
rolling programme, initially in centres with access to existing cyclotrons and then
14
5 Suggested strategy for the provision of a PET service
i The currently available clinical cyclotrons should be invested in to ensure they are capable of
producing tracer for other units.
i The sites for clinical PET centres should be identified as a first phase for new scanners.
i PET should be associated with cancer centres, or at the least cancer networks.
i Private sector funding should be assessed.
BOX 2 Action on the provision of a national PET service
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rolled out when further cyclotrons are installed. Over this period funding for training
individuals (as outlined above) would need to be started and trainees encouraged to
take up posts.
8 Cost of implementation. PET is an expensive technology and therefore needs to be
implemented in several phases and over many years. If an initial 10–15 centres were
established around the UK an assessment could be made over one or two years as to
the ultimate requirement. This is likely to be between 40 and 60 centres with between
one and three scanners per centre.
15
5 Suggested strategy for the provision of a PET service
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6 Conclusion
6.1 The establishment of clinical PET in the UK should be controlled and financed centrally
to allow the optimum provision of service throughout the UK whilst maintaining a high clinical
standard.
6.2 The established cancer networks and cancer centres should provide the structure upon
which the introduction of PET centres is based. The exact siting of the centres will depend on
the availability of tracer in the short term, and the development of radiotracer production
facilities around the country. These facilities already exist in certain areas and the feasibility of
them providing tracer or being upgraded to increase tracer production needs to be investigated.
The areas of the country which are without access include the North East and South West of
England, the central corridor of Scotland and Northern Ireland, and investment in cyclotrons
may need to be provided to establish these areas.
16
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PART 2Clinical indications forpositron emissiontomography imaging:current ICSCNMsuggestions
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Introduction
Positron emission tomography (PET) scanning is now available in the UK as a diagnostic imaging
modality. This rapidly developing technique has been shown to be clinically useful in a range of
specialties, and further assessment of its role in patient management is under way in a number
of clinical studies worldwide. Although PET scanning is sometimes thought of as a separate and
unique imaging specialty (like MRI) it should be regarded as an extension of nuclear medicine
using specific radiopharmaceuticals (positron-labelled tracers) and a specialised detecting system
optimised for the detection of the 511 KeV coincidence photons.
It is not possible at the current time to be dogmatic about the role of PET imaging in clinical
medicine, partly because of the limited facility for PET imaging in the UK. However, based on
clinical experience, coupled with the published data, there are now many clinical situations where
it is the imaging method of choice. There will always be situations when more than one diagnostic
technique can be used to provide similar although less accurate information and the choice will
often depend on factors such as availability, cost, skills etc.
The common radiotracers used are FDG (F-18 Fluorodeoxyglucose), methionine (C-11
methionine), ammonia (N-13 ammonia), water (O-15 water) and flumazenil (C-11 flumazenil).
Radiation hazardsThe radiation dose to the patient, associated with PET investigations, will depend on the tracer
used and the activity administered (Table 1).
Radiation doses received by accompanying persons are low because of the short half-lives of the
tracers currently used. The doses to adults are below the current European recommended levels.
19
Table 1 Typical radiation doses for current practice. The administration of activity for paediatricstudies are scaled down by the body weight as a proportion of a 70kg adult dose.
Radionuclide Radiopharmaceutical Injected Target organ Whole body activity (MBq) dose (mSv)
Carbon-11 Methionine 370–740 Pancreas 1.7–3.4
Flumazenil 370 Small intestine 1.32
Fluorine Fluorodeoxyglucose 250–400 Bladder 6.8–10
Fluoride 222 Bladder 6.0
Nitrogen-13 Ammonia 550 Bladder 1.5
Oxygen-15 Water 2,300 Ovaries (female) 2.7Large intestine (male)
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Children should not accompany parents who are having a PET scan, since close contact
immediately following tracer administration will result in higher received radiation doses. The
radiation dose rates are low when contact is resumed two hours after the injection.25
Breast feedingThe patient is encouraged to express the next feed after the scan but does not need to reduce
contact with children given the current injected activity of 350–400 MBq of FDG. Breast feeding
may then be restarted normally. Whilst this advice applies to one-off exposures, patients who
are likely to receive a number of PET or nuclear medicine scans may be advised to reduce close
contact with small children for a longer period.
Pregnancy and protection of the foetusIrradiation of a foetus is to be avoided whenever possible. If the scan is judged clinically essential
then discussion with the patient with regard to the radiation dose and the risks associated with
not performing the investigation should be undertaken.
The clinical indications tableThe following table is divided into the four clinical sections which cover the main areas of PET
imaging: oncology, cardiology, neuropsychiatry and miscellaneous applications. For each of
these sections the indications will be classified into ‘indicated’, ‘not routinely indicated (but may
be helpful)’, and ‘not indicated’.
The strength of the evidence for the various indications is identified using the NHS Executive
clinical guidelines.26 This system of definitions is used in the Making the best use of a department
of clinical radiology booklet published by the Royal College of Radiologists.
The strength of evidence is classified as:
A. Randomised controlled clinical trials, meta-analyses, systematic reviews.
B. Robust experimental or observational studies.
C. Other evidence where the advice relies on expert opinion and has the endorsement of
respected authorities.
Note about oncology applications
Applications in oncology can be considered under a number of headings, which have different
importance in different tumours. Areas of use may be considered by generic guidance or by the
pathological system affected. The generic guidance considers the management issues for oncology
patients. The list in paragraph 2.3 of Part 1 relates generally to all malignancies and forms a basis
for which PET examinations may be useful. Indications organised by the pathological system
affected are given in the table below.
20
Clinical indications
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21
Clinical indications
Brai
n an
d sp
inal
cor
di
Susp
ecte
d tu
mou
r re
curr
ence
whe
n i
Seco
ndar
y tu
mou
rs in
the
bra
in. (
C)
anat
omic
al im
agin
g is
diff
icul
t or
equ
ivoc
al a
nd
iA
sses
s tu
mou
r re
spon
se t
o th
erap
y. (
C)
man
agem
ent
will
be
affe
cted
. Oft
en a
com
bina
tion
of m
ethi
onin
e an
d FD
G P
ET s
cans
will
nee
d to
be
per
form
ed. (
B)i
Beni
gn v
ersu
s m
alig
nant
lesi
ons,
whe
re t
here
is
unce
rtai
nty
on a
nato
mic
al im
agin
g an
d a
rela
tive
cont
rain
dica
tion
to b
iops
y. (
B)i
Inve
stig
atio
n of
the
ext
ent
of t
umou
r w
ithin
th
e br
ain
or s
pina
l cor
d. (
C)
Paro
tidi
Iden
tific
atio
n of
met
asta
tic d
isea
se in
the
nec
k i
Diff
eren
tiatio
n of
Sjo
gren
s Sy
ndro
me
from
fr
om a
dia
gnos
ed m
alig
nanc
y. (
C)
mal
igna
ncy
in t
he s
aliv
ary
glan
ds. (
C)
iPr
imar
y tu
mou
r of
the
par
otid
to
dist
ingu
ish
beni
gn fr
om m
alig
nant
dis
ease
. (C
)
Mal
igna
ncie
s of
the
i
Iden
tify
exte
nt o
f the
pri
mar
y di
seas
e w
ith o
r i
Preo
pera
tive
stag
ing
of k
now
n or
opha
ryng
eal
orop
hary
nxw
ithou
t im
age
regi
stra
tion.
(C
)tu
mou
rs. (
C)
iId
entif
y tu
mou
r re
curr
ence
in p
revi
ousl
y tr
eate
d i
Sear
ch fo
r pr
imar
y w
ith n
odal
met
asta
ses.
(C
)ca
rcin
oma.
(C
)
Lary
nxi
Iden
tify
tum
our
recu
rren
ce in
pre
viou
sly
iSt
agin
g kn
own
lary
ngea
l tum
ours
. (C
)tr
eate
d ca
rcin
oma.
(C
)i
Iden
tific
atio
n of
met
asta
tic d
isea
se in
the
nec
k fr
om a
di
agno
sed
mal
igna
ncy.
(C
)
Thy
roid
iA
sses
smen
t of
pat
ient
s w
ith e
leva
ted
iA
sses
smen
t of
tum
our
recu
rren
ce in
med
ulla
ry
iR
outin
e as
sess
men
t of
thy
rogl
obul
in p
ositi
ve
thyr
oglo
bulin
and
neg
ativ
e io
dine
sca
ns fo
r ca
rcin
oma
of t
he t
hyro
id. (
C)
recu
rren
ce w
ith r
adio
iodi
ne u
ptak
e. (
C)
recu
rren
t di
seas
e. (
B)
Indi
cate
dN
ot
indi
cate
d ro
utin
ely
(but
may
be
help
ful)
No
t in
dica
ted
Onc
olo
gy a
pplic
atio
ns
Clin
ical
indi
catio
ns fo
r po
sitro
n em
issio
n to
mog
raph
y
cont
inue
d
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22
Clinical indications
Para
thyr
oid
iLo
calis
atio
n of
par
athy
roid
ade
nom
as w
ith m
ethi
onin
e w
hen
othe
r in
vest
igat
ions
are
neg
ativ
e. (
C)
Lung
iD
iffer
entia
tion
of b
enig
n ve
rsus
mal
igna
nt
iA
sses
smen
t of
res
pons
e to
tre
atm
ent.
(C)
lesi
ons
whe
re a
nato
mic
al im
agin
g or
bio
psy
are
inco
nclu
sive
or
ther
e is
a r
elat
ive
cont
rain
dica
tion
to b
iops
y. (
A)
iPr
eope
rativ
e st
agin
g of
non
sm
all c
ell p
rim
ary
lung
tum
ours
. (A
)i
Ass
essm
ent
of r
ecur
rent
dis
ease
in p
revi
ousl
y tr
eate
d ar
eas
whe
re a
nato
mic
al im
agin
g is
un
help
ful.
(C)
Oes
opha
gus
iSt
agin
g of
pri
mar
y ca
ncer
. (B)
iA
sses
smen
t of
neo
adju
vant
che
mot
hera
py. (
C)
iA
sses
smen
t of
dis
ease
rec
urre
nce
in
prev
ious
ly t
reat
ed c
ance
rs. (
C)
Stom
ach
iN
o ro
utin
e in
dica
tion.
(C
)i
Ass
essm
ent
of g
astr
o-oe
soph
agea
l mal
igna
ncy
and
loca
l m
etas
tase
s. (
C)
Smal
l bow
eli
No
rout
ine
indi
catio
n. (
C)
iPr
oven
sm
all b
owel
lym
phom
a to
ass
ess
exte
nt o
f di
seas
e. (
C)
Brea
st c
ance
ri
Ass
essm
ent
and
loca
lisat
ion
of b
rach
ial p
lexu
s i
Axi
llary
nod
e st
atus
whe
re t
here
is a
rel
ativ
e i
Rou
tine
asse
ssm
ent
of p
rim
ary
brea
st c
ance
r. (
C)
lesi
ons
in b
reas
t ca
ncer
. (R
adia
tion
effe
cts
vers
us
cont
rain
dica
tion
to a
xilla
ry d
isse
ctio
n. (
C)
mal
igna
nt in
filtr
atio
n.)
(C)
iA
sses
smen
t of
mul
tifoc
al d
isea
se w
ithin
the
diff
icul
t i
Ass
essm
ent
of t
he e
xten
t of
dis
sem
inat
ed
brea
st (
dens
e br
east
or
equi
voca
l rad
iolo
gy).
(C)
brea
st c
ance
r. (
C)
iSu
spec
ted
loca
l rec
urre
nce.
(C
)i
Ass
essm
ent
of c
hem
othe
rapy
res
pons
e. (
C)
Live
r: p
rim
ary
lesi
oni
Rou
tine
asse
ssm
ent
of h
epat
oma.
(C
)
Indi
cate
dN
ot
indi
cate
d ro
utin
ely
(but
may
be
help
ful)
No
t in
dica
ted
cont
inue
d
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23
Clinical indications
Live
r: s
econ
dary
lesi
oni
Equi
voca
l dia
gnos
tic im
agin
g (C
T, M
RI,
ultr
asou
nd).
(C)
iA
sses
smen
t pr
e an
d po
st t
hera
py in
terv
entio
n. (
C)
iEx
clud
e ot
her
met
asta
tic d
isea
se p
rior
to
met
aste
ctom
y. (
C)
Panc
reas
iSt
agin
g a
know
n pr
imar
y. (
C)
iD
iffer
entia
tion
of c
hron
ic p
ancr
eatit
is fr
om p
ancr
eatic
ca
rcin
oma.
(C
)i
Ass
essm
ent
of p
ancr
eatic
mas
ses
to d
eter
min
e be
nign
or
mal
igna
nt s
tatu
s. (
C)
Col
on a
nd r
ectu
mi
Ass
essm
ent
of r
ecur
rent
dis
ease
. (A
)i
Ass
essm
ent
of t
umou
r re
spon
se. (
C)
iA
sses
smen
t of
pol
yps.
(C
)i
Prio
r to
met
aste
ctom
y fo
r co
lore
ctal
can
cer.
(C
)i
Ass
essm
ent
of a
mas
s th
at is
diff
icul
t to
bio
psy.
(C
)i
Stag
ing
a kn
own
prim
ary.
(C
)
Ren
al a
nd a
dren
ali
Ass
essm
ent
of p
ossi
ble
adre
nal m
etas
tase
s. (
C)
iPa
raga
nglio
nom
as o
r m
etas
tatic
pha
eoch
rom
ocyt
oma
iA
sses
smen
t of
ren
al c
arci
nom
a. (
C)
to id
entif
y si
tes
of d
isea
se. (
C)
iPh
aeoc
hrom
ocyt
oma
– M
IBG
sca
nnin
g is
usu
ally
su
peri
or. (
C)
Blad
der
iN
o ro
utin
e in
dica
tion.
(C
)i
Stag
ing
a kn
own
prim
ary
in s
elec
ted
case
s. (
C)
iR
ecur
renc
e w
ith e
quiv
ocal
imag
ing.
(C
)
Pros
tate
iFD
G in
pro
stat
e ca
ncer
ass
essm
ent.
(C)
Tes
ticle
iA
sses
smen
t of
rec
urre
nt d
isea
se fr
om
iA
sses
smen
t of
pri
mar
y tu
mou
r st
agin
g. (
C)
sem
inom
as a
nd t
erat
omas
. (B)
iA
sses
smen
t of
res
idua
l mas
ses.
(B)
Ova
ryi
In d
iffic
ult
man
agem
ent
situ
atio
ns t
o as
sess
loca
l an
d di
stan
t sp
read
(C
)
Ute
rus:
cer
vix
iN
o ro
utin
e in
dica
tion.
(C
)i
In d
iffic
ult
situ
atio
ns t
o de
fine
the
exte
nt o
f dis
ease
w
ith a
ccom
pany
ing
imag
e re
gist
ratio
n. (
C)
Indi
cate
dN
ot
indi
cate
d ro
utin
ely
(but
may
be
help
ful)
No
t in
dica
ted
cont
inue
d
![Page 31: Positron emission tomography - NCRI PET · Positron emission tomography (PET) has been in use for over 20 years as a research tool, and over the last decade in a clinical role. The](https://reader035.vdocuments.us/reader035/viewer/2022062606/5fe027a3c02c1061967b0ee5/html5/thumbnails/31.jpg)
24
Clinical indications
Ute
rus:
bod
yi
No
rout
ine
indi
catio
n. (
C)
Lym
phom
ai
Stag
ing
of H
odgk
in’s
lym
phom
a. (
B)i
Ass
essm
ent
of b
owel
lym
phom
a. (
C)
iSt
agin
g of
non
-Hod
gkin
’s ly
mph
oma.
(B)
iA
sses
smen
t of
bon
e m
arro
w t
o gu
ide
biop
sy. (
C)
iA
sses
smen
t of
res
idua
l mas
ses
for
activ
e i
Ass
essm
ent
of r
emis
sion
from
lym
phom
a. (
C)
dise
ase.
(B)
iId
entif
icat
ion
of d
isea
se s
ites
whe
n th
ere
is
susp
icio
n of
rel
apse
from
clin
ical
ass
essm
ent.
(C)
iR
espo
nse
to c
hem
othe
rapy
. (C
)
Mus
culo
skel
etal
tum
ours
iSo
ft t
issu
e pr
imar
y m
ass
asse
ssm
ent
to
iIm
age
regi
stra
tion
of t
he p
rim
ary
mas
s to
iden
tify
dist
ingu
ish
high
gra
de m
alig
nanc
y fr
om lo
w o
r op
timum
bio
psy
site
. (C
)be
nign
dis
ease
. (B)
iSt
agin
g of
pri
mar
y so
ft t
issu
e m
alig
nanc
y to
as
sess
non
skel
etal
met
asta
ses.
(B)
iA
sses
smen
t of
rec
urre
nt a
bnor
mal
ities
in
oper
ativ
e si
tes.
(B)
iA
sses
smen
t of
ost
eoge
nic
sarc
omas
for
met
asta
tic d
isea
se. (
C)
iFo
llow
up
to d
etec
t re
curr
ence
or
met
asta
ses.
(B)
Skin
tum
ours
iM
alig
nant
mel
anom
a w
ith k
now
n di
ssem
inat
ion
iSt
agin
g of
ski
n ly
mph
omas
. (C
)i
Mal
igna
nt m
elan
oma
with
neg
ativ
e se
ntin
el n
ode
to a
sses
s ex
tent
of d
isea
se. (
B)bi
opsy
. (B)
iM
alig
nant
mel
anom
a in
who
m a
sen
tinel
nod
e bi
opsy
was
not
or
can
not
be p
erfo
rmed
in s
tage
II.
(AJC
C u
pdat
ed c
lass
ifica
tion)
. (C
)
Met
asta
ses
from
i
Det
erm
inin
g th
e si
te o
f an
unkn
own
prim
ary
iW
ides
prea
d m
etas
tatic
dis
ease
whe
n th
e un
know
n pr
imar
yw
hen
this
influ
ence
s m
anag
emen
t. (C
)de
term
inat
ion
of t
he s
ite is
onl
y of
inte
rest
. (C
)
Indi
cate
dN
ot
indi
cate
d ro
utin
ely
(but
may
be
help
ful)
No
t in
dica
ted
cont
inue
d
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25
Clinical indications
iD
iagn
osis
of h
iber
natin
g m
yoca
rdiu
m in
i
Dia
gnos
is o
f cor
onar
y ar
tery
dis
ease
or
asse
ssm
ent
of
iPa
tient
s w
ith c
onfir
med
cor
onar
y ar
tery
dis
ease
pa
tient
s w
ith p
oor
left
ven
tric
ular
func
tion
prio
r kn
own
coro
nary
ste
nosi
s w
here
oth
er in
vest
igat
ions
. in
who
m r
evas
cula
risa
tion
is n
ot c
onte
mpl
ated
or
to r
evas
cula
risa
tion
proc
edur
e. (
A)
(SPE
CT
, EC
G e
tc)
rem
ain
equi
voca
l. (B
)in
dica
ted.
(C
)i
Patie
nts
with
a fi
xed
SPET
def
icit
who
mig
ht
iD
iffer
entia
l dia
gnos
is o
f car
diom
yopa
thy
(isch
aem
ic
iR
outin
e sc
reen
ing
for
coro
nary
art
ery
dise
ase.
be
nefit
from
rev
ascu
lari
satio
n. (
B)ve
rsus
oth
er t
ypes
of d
ilate
d ca
rdio
myo
path
y). (
C)
(C)
iPr
ior
to r
efer
ral f
or c
ardi
ac t
rans
plan
tatio
n. (
B)i
Med
ical
tre
atm
ent
of is
chae
mic
hea
rt d
isea
se in
hig
h ri
sk h
yper
lipid
emic
pat
ient
s. (
C)
Neu
rops
ychi
atry
app
licat
ions
iPr
esur
gica
l eva
luat
ion
of e
pile
psy.
(B)
iT
he g
radi
ng o
f pri
mar
y br
ain
tum
our.
(B)
iD
iagn
osis
of d
emen
tia w
here
MR
I is
clea
rly
iSu
spec
ted
recu
rren
ce o
r fa
iled
prim
ary
iLo
calis
atio
n of
opt
imal
bio
psy
site
(ei
ther
pri
mar
y or
ab
norm
al. (
C)
trea
tmen
t of
pri
mar
y m
alig
nant
bra
in t
umou
rs.
recu
rren
t br
ain
tum
our)
. (C
)i
Mos
t in
stan
ces
of s
trok
e. (
C)
(Mos
t of
the
se p
atie
nts
will
hav
e ha
d M
RI a
nd C
T
iD
iffer
entia
ting
mal
igna
ncy
from
infe
ctio
n in
HIV
sub
ject
s i
Mos
t ps
ychi
atri
c di
sord
ers
othe
r th
an e
arly
w
ith e
quiv
ocal
res
ults
). (B
)w
here
MR
I is
equi
voca
l. (C
)de
men
tia. (
C)
iEa
rly
diag
nosi
s of
dem
entia
(es
peci
ally
you
nger
i
Pre-
sym
ptom
atic
or
at r
isk
Hun
tingd
on’s
pa
tient
s an
d A
lzhe
imer
’s d
isea
se)
whe
n M
RI o
r C
T
dise
ase.
(C
)is
eith
er n
orm
al, m
argi
nally
abn
orm
al o
r i
Dia
gnos
is o
f epi
leps
y. (
C)
equi
voca
lly a
bnor
mal
. (B)
Mis
cella
neo
us a
pplic
atio
ns
Dis
ease
ass
essm
ent
in
iId
entif
icat
ion
of s
ites
to b
iops
y in
pat
ient
s w
ith
iR
outin
e as
sess
men
t of
wei
ght
loss
whe
re m
alig
nanc
y is
H
IV a
nd o
ther
py
rexi
a. (
C)
susp
ecte
d. (
C)
imm
unos
uppr
esse
d i
Diff
eren
tiatin
g be
nign
from
mal
igna
nt c
ereb
ral
patie
nts
path
olog
y. (
B)
Ass
essm
ent
of b
one
iA
sses
smen
t of
bon
e in
fect
ion
asso
ciat
ed w
ith
infe
ctio
npr
osth
eses
. (C
)i
Ass
essm
ent
of s
pina
l inf
ectio
n or
pro
blem
atic
cas
es o
f in
fect
ion.
(C
)
Indi
cate
dN
ot
indi
cate
d ro
utin
ely
(but
may
be
help
ful)
No
t in
dica
ted
Car
diac
app
licat
ions
cont
inue
d
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26
Clinical indications
Ass
essm
ent
of b
one
iW
hen
bone
sca
n or
oth
er im
agin
g is
equ
ivoc
al. (
C)
met
asta
ses
Ass
essm
ent
of t
umou
r i
Iden
tifyi
ng r
ecur
rent
func
tiona
l pitu
itary
tum
ours
whe
n re
curr
ence
in t
he
anat
omic
al im
agin
g ha
s no
t be
en s
ucce
ssfu
l. (C
)pi
tuita
ry
Feve
r of
unk
now
n i
Iden
tifyi
ng s
ourc
e of
the
feve
r of
unk
now
n or
igin
. (C
)or
igin
Indi
cate
dN
ot
indi
cate
d ro
utin
ely
(but
may
be
help
ful)
No
t in
dica
ted
![Page 34: Positron emission tomography - NCRI PET · Positron emission tomography (PET) has been in use for over 20 years as a research tool, and over the last decade in a clinical role. The](https://reader035.vdocuments.us/reader035/viewer/2022062606/5fe027a3c02c1061967b0ee5/html5/thumbnails/34.jpg)
APPENDICES
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APPENDIX 1Imaging with a distant supply of tracer : theminimum establishment*
Capital costsCapital costs include the PET scanner, associated computer workstations and network equipment
in addition to data storage media. A full resuscitation trolley, a pulse oximeter and blood glucose
monitoring equipment for the scan room are included, as well as radiation protection and
monitoring equipment. An allocation for basic office equipment and furniture is also listed.
Building and space renovation costs have not been included.
Operating costsIt has been assumed that this facility would scan in the region of 1,000 patients per year. This
assumes an average throughput of four patients per day if scanning is said to be five days per
week for 48 weeks of the year with allowance made for maintenance, breakdown and bank
holidays. London weighting and on-costs are included. It is assumed that the facility will be
managed from an associated nuclear medicine or radiology department.
Staff costs
Two to three radiographers/nuclear medicine technologists would be required to perform
radiotracer administration, patient scanning and image processing. The support of one WTE
medical physicist would be necessary to provide cover for data processing, scanner quality control
and the on-going development of image acquisition and processing protocols and radiation
protection. The receptionist/secretary is required to book scans, send out appointments, type
29
Capital costs: £1,285,050
Operating costs: £585,900
Staff costs: £198,050
Fixed costs: £72,850
Variable costs: £315,000
Summary of costs
* The figures in this appendix are based on the experience of the Guy’s and St Thomas’ Clinical PET Centre in 2001.
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reports and provide general administrative support. In addition, two 0.5 WTE clinical appoint-
ments would provide scan reporting and medical support. This assumes that basic FDG imaging
is being performed.
30
Appendix 1
Table 1 Capital costs for imaging with a distant supply of tracer. VAT is not included.
Item Quantity Costs (£)
PET scanner 1 1,200,000
Capintec 1 5,000
Protected bench 1 16,000
Lead safe 1 5,000
Protected injection devices 3 600
Hand/area radiation monitors 2 3,000
Emergency trolley 1 6,000
Pulse oximeter 1 2,000
Blood glucose monitor 1 500
Patient trolleys 2 1,850
Transportation pot 1 4,500
Workstations 2 10,000
Hard disks (36Gby) 2 1,000
Tape drives 2 1,000
Image printer 1 12,000
PCs (general use) 6 6,000
Text printer 1 600
Furniture – 10,000
Total 1,285,050
Table 2 Staff costs per annum for imaging with a distant supply of tracer. These figures assume athroughput of 1,000 patients each year, and include London weighting and on-costs.
Grade WTEs Total salary costs (£)
Radiographer (senior 1/MTO 3) 1 29,200
Radiographer (senior II/MTO 2) 2 50,000
Clinical scientist (physicist) 1 30,800
Consultant physician 1 (0.5 + 0.5) 65,700
Receptionist/secretary (grade 4) 1 19,850
Training/uniforms etc – 2,500
Total 198,050
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Fixed costs
Fixed costs are itemised in Table 3 and include the cost of a fully comprehensive maintenance
contract for the scanner and associated workstations. The cost of space allocation has not been
included but contract cleaning is listed. Germanium rod sources need to be replaced yearly and
are therefore included. Costs associated with the initial marketing of the service and educational
sessions for potential referrers have also been included.
Variable costs
Variable costs are identified at £315 per patient scan. This includes the delivery of tracer doses
at £300 per patient dose (assuming that a dose is defined as 350MBq) of FDG. VAT has not been
included. The cost of radiotracer supply will vary depending on the distance between the scanner
and the production facility. For the purposes of this paper it has been assumed that there is a
maximum time of one half-life between dispatch from the production site to the first patient
administration. Doses for subsequent patients will need to be decay-corrected appropriately for
timed administrations. It is usually possible for 3–4 patient doses to be included in one delivery
but this will depend on activity available from each production run. Radiotracer and delivery
costs will inevitably increase with distance from the production facility. The market for
radiotracers is increasing rapidly and costs are likely to be subject to variations as commercial
suppliers enter the market. Basic consumable costs per patient scan have also been included.
31
Appendix 1
Table 3 Fixed costs per annum for imaging with a distant supply of tracer.
Item Costs (£)
Scanner maintenance 50,000
Computer maintenance 750
Housekeeping contract 4,500
Marketing/education 5,000
Rod sources 6,000
Building maintenance 6,600
Total 72,850
Table 4 Variable costs per annum for imaging with a distant supply of tracer. These figures assume athroughput of 1,000 patients per year.
Item Costs (£)
350MBq FDG and transport 300,000
Scanning supplies (needles, syringes, linen etc) 10,000
Data storage 1,000
Hard copy and stationery 4,000
Total 315,000
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APPENDIX 2Imaging with full production of tracer : theminimum establishment*
Capital costsScanning costs are as per the remote site, but with the addition of a syringe pump and ECG
monitoring to enable stress heart studies to be performed. If quantitative research studies are
to be performed a gamma counter, fluid analyser and associated equipment for handling blood
sampling would be required.
Imaging
32
Capital costs: £2,761,750
Imaging facility: £1,292,050
Radiotracer production: £1,469,700
Operating costs: £670,850
Staff costs:
Scanning: £301,300
Radiotracer production: £140,700
Fixed costs:
Scanning: £72,850
Radiotracer production: £74,000
Variable costs:
Scanning: £18,000
Radiotracer production: £64,000
Summary of costs
Table 5 Total capital scanning costs for imaging and radiotracer production facility.
Item Quantity Costs (£)
Scanning room (as per Table 1) 1,285,050
Syringe pump 1 2,000
12 lead ECG machine 1 5,000
Total 1,292,050
* The figures in this appendix are based on the experience of the Guy’s and St Thomas’ Clinical PET Centre in 2001.
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Equipment to enable production of the main clinical tracers has been itemised. It is assumed
that FDG will be produced for use internally and for distribution. Quality control equipment
has therefore been included to enable the centre to perform rigorous analysis of FDG in particular
in order to comply with present Medicines Control Agency (MCA) regulations and the European
Pharmacopea entry.
Commercial chemistry modules for the production of FDG and C-11 Methionine have been
included. It should be noted that the commercial market for these units is developing rapidly
and pricing is competitive. As with the previous model, building costs or renovation of existing
space have not been included.
Operating costsThis model assumes that the scanning and radiotracer production facility operates as an
integrated unit within areas of shared expertise and resources. Internal cross-charging for FDG
tracer doses has not therefore been itemised. The costs associated with FDG production are
included in the operating costs of the cyclotron and radiotracer production.
It has been assumed that this facility would scan in the region of 1,200+ patients per year, giving
an average throughput of five patients per day. Scanning is said to be five days per week for 48 weeks
of the year, allowance being made for maintenance, breakdown and bank holidays. This level of
throughput has been based on the experience of one centre performing oncological, cardiological
and neurological scans as well as some research studies. This may be considered to be a fairly
conservative estimate which will be affected by variations in patient mix and protocol design. Faster
scanners coming on to the market should also improve the throughput of patients.
Staff costs
This model would require a staffing complement similar to the previous model. However with an
on-site cyclotron and production facility it is likely that more complex clinical imaging and some
research would be undertaken during a longer working day. The staff costs for the scanning facility
therefore reflect this and anticipate some shift work to accommodate the longer scanning times
and increased patient throughput. There is a requirement for two WTE physics and computing
personnel to provide support for data processing and storage, scanner quality control, trouble-
shooting and the development of image processing protocols for clinical and basic research studies.
If complex quantitative research protocols are envisaged then additional physics and computing
staff will be required. Secretarial/reception support of one WTE is listed. An additional 0.5–1 WTE
SpR will be required for medical support, training and scan reporting. The complexity of the total
operation requires a person in the position of manager/administrator who is able to co-ordinate
the activities of the centre as a whole. This would include strategic planning, the setting and
monitoring of budgets, marketing and arranging contracts for FDG supply and distribution, and
day-to-day operational management. If the centre is under the management of nuclear medicine
or radiology, some of these activities may be undertaken by personnel or departments already in
existence. However it is likely that, having invested in a radiochemistry production facility, there
will be a significant commercial component to the operation which will require careful planning
and on-going management if the full potential is to be realised.
Imaging
Radiotracerproduction
33
Appendix 2
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34
Appendix 2
Table 6 Capital costs for full production of radiotracer within an imaging and full production oftracer facility.
Item Quantity Costs (£)
Cyclotron and laboratory infrastructure
Cyclotron 1 1,000,000
Isolator cabinet 1 40,000
Dispenser 1 15,000
Dose meters (Mini-Inst) 2 2,000
Surface/hand monitors 2 4,500
Area monitors (Lab Impex) 6 9,000
Personal radiation monitors 6 1,200
Fume cupboards 2 6,000
Total 1,077,700
FDG production
FDG box 1 50,000
Mini hot cell 1 30,000
Lead castles – 15,000
Total 95,000
C-11 production
C-11 chemistry module 1 60,000
Hot cell 1 50,000
Gradient pump 1 13,000
UV detector 1 6,000
Rad detector 1 8,000
Total 137,000
QC equipment
Dionex PED detector 1 20,000
Isocractic pump 1 5,000
Rad detector 1 6,000
PC, software and printer 1 7,000
TLC scanner 1 25,000
Suppressor 1 2,000
Injector 1 750
Gradient pump 1 12,000
UV detector 1 6,000
Rad detector 1 8,000
Injector 1 750
PC, software and printer 1 7,500
Gas chromotograph 1 16,000
Chart recorders 2 3,000
Oven 1 1,500
Total 120,500continued
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35
Appendix 2
Table 6 continued.
General laboratory equipment
Refrigerator 1 400
Freezer 1 200
Assorted glassware 400
Assorted tweezers and tongs 500
Lead safe 1 3,000
Lead pots 20 1,000
Balances 2 5,000
Pipettes 3 400
Solvent cupboards 2 400
Internal transport trolley 1 2,000
Capintecs 2 10,000
Crimping tool 1 200
Decrimping tool 1 200
Rad detector (GM tube) 1 1,000
Lead syringe shields 8 1,000
Osmolality kit 1 2,000
Shielded delivery boxes 2 5,000
Ultrasonic bath 1 400
LAL test kit 1 400
Laboratory/office furniture 6,000
Total 39,500
Total capital costs 1,469,700
Table 7 Staff costs per annum for imaging within an imaging and full production of tracer facility. Thesefigures assume a throughput of 1,200+ patients per year, and include London weighting and on-costs.
Grade WTE’s Total salary costs (£)
Radiographer (supt III/MTO 4) 1 31,800
Radiographer (senior I/MTO 3) 1 29,200
Radiographer (senior II/MTO 2) 1.5 37,500
Clinical scientist (physicist) 1 30,800
Systems administrator 1 26,500
Consultant physician 1 (0.5 + 0.5) 65,700
SpR 0.5 17,950
Receptionist/secretary (grade 4) 1 19,850
Manager/administrator 1 38,000
Training, uniforms etc 4,000
Total 301,300
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To maintain a reliable daily production of 18F-fluoride based radiotracers for internal and
external distribution, in addition to a variety of shorter half-life tracers, a minimum complement
of two radiochemists and a laboratory technician working a flexible rota would be required. A
minimum of two WTE cyclotron technicians with the experience and capability to trouble-shoot
and provide first line maintenance is also necessary. It may be possible to cross-train cyclotron
and chemistry staff to perform routine functions in the laboratory to increase flexibility, but
this would not reduce the need for experienced and competent technicians and chemists.
Staffing for the cyclotron and radiotracer production facility has assumed that the following
routine clinical radiotracers are available: 18FDG, N13H3, C11 Methionine and H2O15.
State-of-the-art FDG chemistry processing units are providing increasing yields and reduced
turnaround times. This enables one production site to support a number of imaging units.
Capital investment in additional imaging equipment will be required as patient numbers increase;
however, placing these facilities strategically with respect to the production facility remains the
most cost effective means of providing a comprehensive service for PET scanning. Extra staff
would be required for extra production runs, to operate additional cameras and to perform
more complex research studies, but optimum equipment usage can be achieved by flexible
staffing and extended hours of operation. The configuration of the imaging sites in relation to
the production facility is crucial to the optimum use of this expensive resource.
Fixed costs
The scanning component would not differ significantly from the remote site (£72,850 – see table 3).
Fixed costs for the production facility include contract maintenance for the cyclotron and items
of laboratory equipment. It should however be noted that maintenance expertise from supplying
companies may not be well developed in the UK. Trouble-shooting expertise and first-line
maintenance provided on-site is invaluable and could be deemed essential if a reliable service
of daily radiotracer production is to be supported (see section of staff training). General plant
maintenance costs, power usage and housekeeping are also included.
Radiotracerproduction
Imaging
Radiotracerproduction
36
Appendix 2
Table 8 Staff costs for the cyclotron and radiochemistry within an imaging and full production of tracerunit. These figures assume a throughput of 1,200 patients each year, and include London weighting andon-costs.
Grade WTEs Total salary costs (£)
Senior radiochemist RA1A/MTO4 1 33,250
Radiochemist RA1A/MTO3 1 28,600
Chemistry technician MTO2 1 18,250
Cyclotron technologists 2 58,600
Training, uniforms etc – 2,000
Total 140,700
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Variable costs
Assuming that the cyclotron production facility supplies radiotracers to the scanning unit, costs
associated with medical/injection supplies, data storage, stationery and hard copy production
are included (assuming a throughput of 1,200 patients per annum).
Laboratory supplies and cyclotron gases are included in this sum in addition to the production
chemicals and target materials. It should be noted that the target material for 18F-, O18 water
is an expensive commodity which is presently in short supply worldwide.
When pricing scans and radiotracer doses the cost of replacement equipment must be considered.
A PET scanner can be used for 8–10 yrs whilst computing equipment will generally need to be
replaced in 2–3 yrs.
The cyclotron will be operational over a longer period, around 20 years, but provision will need
to be made for replacement of some major parts depending on how the maintenance programme
is structured.
Replace-ment
programme
Radiotracerproduction
Imaging
37
Appendix 2
Table 9 Fixed radiotracer production costs.
Item Cost (£)
Cyclotron maintenance 50,000
Laboratory equipment maintenance 5,000
Power/building maintenance 15,000
Housekeeping contract 4,000
Total 74,000
Table 10 Variable scanning costs.
Item Cost (£)
Scanning supplies (needles, syringes, linen etc) 12,000
Data storage 1,200
Hard copy and stationery 4,800
Total 18,000
Table 11 Radiotracer production variable costs.
Item Cost (£)
Laboratory supplies 25,000
Chemicals/target materials 30,000
Gases 9,000
Total 64,000
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APPENDIX 3Training issues
There are training issues associated with all the disciplines involved in PET scanning. There are
few trained PET radiochemists in the world let alone the UK. Consequently there is a need to
establish a comprehensive training programme which could be organised either through MSc
courses or vocational training by an approved university course. This needs to be established as
a matter of urgency. Similarly there are few trained cyclotron engineers/technicians, and whilst
other disciplines (ie radiotherapy workshop technologists) do have some of the skills, there is a
need for experience in trouble shooting and first-line maintenance skills. Formal training and
on the job experience is required for these key members of the production team. The current
difficulties in recruiting nuclear medicine technologists and radiographers for general
departments are exacerbated when attempting to recruit for PET centres. Experienced, trained
staff are not readily available in the UK and training needs to be given on site. BSc courses now
include some PET lectures and an annual course is now offered by Guy’s & St Thomas’ PET
Centre but on the job training is required. Arranging rotations or split posts with other cross-
sectional imaging departments such as CT or MRI may make these positions more attractive to
radiographers who have not trained in nuclear medicine. There are few trained PET clinicians.
Training for clinicians is being addressed by including PET as part of the CCST training in
nuclear medicine but post-CCST experience is also required. There are few centres in the UK
where this experience can be gained and consequently it has been necessary for clinicians to gain
on the job experience or to spend short periods in overseas centres. This will be a significant
issue in the clinical staffing of PET centres.
The delivery and maintenance of the service needs to be consistent with the Ionising Radiation
(Medical Exposure) Regulations 20004 and the relevant aspects of IRR 199921 and ARSAC. It
also needs to comply with necessary standards of delivery of a high quality service as well as
issues related to clinical governance.
38
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J Nucl Med 2000;27:1598–1609.
Gambhir SS, Hoh CK, Phelps ME et al. Decision tree sensitivity analysis for cost effectiveness of FDG-
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J Nucl Med 2000;27:1598–1609.
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