Technical aspects of positron emission tomography/computed tomography in radiotherapy treatment planning

The usage of functional data in radiation therapy (RT) treatment planning (RTP) process is currently the focus of significant technical, scientific, and clinical development. Positron emission tomography (PET) using ((18)F) fluorodeoxyglucose is being increasingly used in RT planning in recent years. Fluorodeoxyglucose is the most commonly used radiotracer for diagnosis, staging, recurrent disease detection, and monitoring of tumor response to therapy (Lung Cancer 2012;76:344-349; Lung Cancer 2009;64:301-307; J Nucl Med 2008;49:532-540; J Nucl Med 2007;48:58S-67S). All the efforts to improve both PET and computed tomography (CT) image quality and, consequently, lesion detectability have a common objective to increase the accuracy in functional imaging and thus of coregistration into RT planning systems. In radiotherapy, improvement in target localization permits reduction of tumor margins, consequently reducing volume of normal tissue irradiated. Furthermore, smaller treated target volumes create the possibility of dose escalation, leading to increased chances of tumor cure and control. This article focuses on the technical aspects of PET/CT image acquisition, fusion, usage, and impact on the physics of RTP. The authors review the basic elements of RTP, modern radiation delivery, and the technical parameters of coregistration of PET/CT into RT computerized planning systems.