CR: Upper limb, Humerus Clavicle Trans-Thoracic Lateral

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PA Projection in Ulnar Deviation Position (Scaphoid)

– Perpendicular to the scaphoid

 

PA Axial Scaphoid (Stecher Method)

– Perpendicular to table and enters at scaphoid. Note: If proper support for IR is unavailable, CR may be angled 20 degrees toward the elbow.

 

AP Forearm

– Perpendicular to IR. Enters patient at midpoint of forearm

 

Lateral Forearm

– Directed perpendicular to the IR. Enters patient at midpoint of forearm

 

AP Elbow

– Perpendicular to elbow joint

 

Lateral Elbow

– Perpendicular to elbow joint

 

AP Oblique Elbow Medial Rotation Position

– Perpendicular to elbow joint

 

AP Oblique Elbow Lateral Rotation Position

– Perpendicular to elbow joint

 

AP Shoulder in External Rotation

–Perpendicular, Enters patient 2.5 cm inferior to coracoid process

•Respiration is suspended

 

Inferosuperior Axial Projection (Lawrence Method)

–Horizontal. Medial angulation of 15 to 30 degrees. Enters axilla; passes through AC joint . Angle depends on abduction of humerus. More abduction = greater angle

•Respiration is suspended.

AP Scapula

–Perpendicular to 5 cm inferior to coracoid process

•Respiration: Slow breathing

 

Lateral Scapula

–Perpendicular to mid medial border of scapula

 

Transthoracic Lateral Projection

–Perpendicular.Enters midcoronal plane at surgical neck. If shoulders are in same plane, CR angled 10 to 15 degrees cephalad

•Respiration: On full inspiration OR shallow breathing method.

 

AP Clavicle

–Perpendicular to midshaft of clavicle

•Respiration: Suspend at end of expiration

 

AP Axial Clavicle

–Lordotic position – 0 to 15 degrees cephalic. Supine position – 15 to 30 degrees cephalic. Enters midshaft of clavicle

• Respiration: Suspend respiration at end of full inspiration

 

AP Humerus

–Perpendicular to midportion of humerus and centered to IR

 

Humerus: Lateral Projection

–Perpendicular to midportion of humerus and centered to IR

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    18F-FDG PET and Combined 18F-FDG–Contrast CT Parameters as Predictors of Tumor Control for Hepatocellular Carcinoma After Stereotactic Ablative Radiotherapy
    1Department of Radiation Oncology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan

    2Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan

    3Institute of Clinical Medicine Science and School of Medicine, College of Medicine, China Medical University, Taichung, Taiwan

    4Department of Nuclear Medicine and PET Center, China Medical University Hospital, Taichung, Taiwan

    5Departments of Medical Research and Nuclear Medicine, Changhua Christian Hospital, Changhua, Taiwan

    6Department of Radiation Oncology, Cardinal Tien Hospital, Taipei, Taiwan

    7School of Public Health, National Defense Medical Center, Taipei, Taiwan

    8Department of Nuclear Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan; and

    9Institute of Medical Science, National Defense Medical Center, Taipei, Taiwan

    For correspondence or reprints contact: Yee-Min Jen, Department of Radiation Oncology, Tri-Service General Hospital, National Defense Medical Center, No. 325, Sec. 2, Cheng-Kong Rd., Nei-Hu 11490, Taipei, Taiwan. E-mail: yeeminjen@yahoo.com.tw

    Abstract

    The application of stereotactic ablative radiotherapy (SABR) to hepatocellular carcinoma (HCC) is emerging. To identify pretreatment prognostic indicators is crucial for patient selection and optimal individual therapy. The aim of this study was to determine whether 18F-FDG PET and a combined 18F-FDG–contrast CT parameter could be useful tools to predict tumor control for patients with HCC treated by SABR. Methods: We retrospectively identified 31 patients (41 tumors) who underwent 18F-FDG PET before SABR between November 2007 and September 2011. 18F-FDG PET parameters were collected as prognostic indicators, including visual PET scale (+/−), maximal standardized uptake value (SUV) of the tumor (TSUVmax), ratio of TSUVmax to maximal normal-liver SUV, ratio of TSUVmax to mean normal-liver SUV, and score combining tumor volume and TSUVmax (CT/18F-FDG PET score). They underwent SABR with a median dose of 42 Gy (ranging from 30 to 50 Gy) in 4–5 fractions. 18F-FDG PET parameters and clinical factors were tested as predictors of tumor control and patient survival. Results: The median follow-up time was 18 mo. Among the parameters examined, TSUVmax and CT/18F-FDG PET score were significantly correlated with tumor control. TSUVmax with a cutoff value of 3.2 was the most significant prognostic indicator. The 4-y control rate was 86.2% in tumors with a TSUVmax of 3.2 or less but only 37.5% in those with a TSUVmax of more than 3.2 (adjusted hazard ratio, 9.40; 95% confidence interval, 1.18–74.76; P = 0.034). CT/18F-FDG PET score (≤4 vs. >4) was also a significant predictor of tumor control after SABR. Tumors with a CT/18F-FDG PET score of more than 4 had a 5.23-fold risk of tumor failure. After adjustment for factors of sex, American Joint Committee on Cancer stage, Cancer of the Liver Italian Program score, and Child–Pugh classification, tumors with a score of more than 4 had a 4.96-fold risk of failure after SABR, compared with tumors with a score of 4 or less. For overall survival, none was statistically significant. Conclusion: The use of 18F FDG PET to predict tumor control is feasible. TSUVmax with a cutoff value of 3.2 is the best prognostic indicator. We suggest that 18F-FDG PET may be a reference for prognostic prediction, patient selection, and radiation dose adjustment for HCC patients treated with SABR.

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