Pe d i a t r i c I m a g i n g • O r i g i n a l R e s e a r c h

Sammer et al.
PET/CT in Pediatric Lymphoma

Pediatric Imaging
Original Research
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FOCUS ON:

Role of Limited Whole-Body

JOURNAL CLUB PET/CT in Pediatric Lymphoma
Marla B. K. Sammer 1,2 OBJECTIVE. Performing true whole-body FDG PET/CT is standard practice in pediatric
Barry L. Shulkin 3 lymphoma staging and follow-up. In adults, imaging is typically limited whole-body PET/
Adam Alessio1 CT, which has advantages over true whole-body PET/CT, primarily decreased scanning time
Marguerite T. Parisi1 and decreased radiation. We hypothesize that in pediatric lymphoma, limited whole-body
PET/CT is sufficient for routine follow-up when disease on the true whole-body staging study
Sammer MBK, Shulkin BL, Alessio A, Parisi MT is confined to the limited whole-body field of view (FOV).
MATERIALS AND METHODS. True whole-body PET/CT studies performed for
staging and follow-up of pediatric lymphoma patients between November 2004 and July 2009
at two tertiary pediatric referral hospitals were retrospectively reviewed. Abnormalities on
the limited whole-body and additional true whole-body FOV were documented.
RESULTS. One hundred seventy patients met the inclusion criteria (752 examinations).
At staging, disease involved the limited whole-body FOV without involving the additional
true whole-body FOV in 150. Of the 150, 145 had routine follow-up (508 examinations). In
these patients, no new 18F-FDG-avid disease was identified outside of the limited whole-body
FOV on routine follow-up (positive predictive value, 0%, 95% CI, 0–0.02).
CONCLUSION. The limited whole-body PET/CT for routine follow-up when disease
is confined to the limited whole-body FOV at staging is appropriate. Given its definite
advantages over true whole-body PET/CT, it is preferred.

Keywords: limited whole-body imaging, lymphoma,
pediatrics, PET/CT, true whole-body imaging
DOI:10.2214/AJR.10.6074
Received October 30, 2010; accepted after revision
February 13, 2011.
A. Alessio is a coinvestigator on a research grant from
GE Healthcare for the development of PET
instrumentation technology. The aims of this grant do not
overlap with this study.
1
Department of Radiology, University of Washington and
Seattle Children’s Hospital, 4800 Sand Point Way, R-5417,
Seattle, WA 98105. Address correspondence to
M. T. Parisi (meg.parisi@seattlechildrens.org).
2
Present address: Department of Radiology, T. C.
Thompson Children’s Hospital, Chattanooga, TN.
3
Department of Radiological Sciences, Division of
Diagnostic Imaging, St. Jude Children’s Research
Hospital, Memphis, TN.
AJR 2011; 196:1047–1055
0361–803X/11/1965–1047
© American Roentgen Ray Society
E
stablished pediatric indications for
18F-FDG PET include lymphoma
[1–3], sarcoma [4, 5], and some
cases of neuroblastoma [6]. Cur-
rently, the literature on pediatric oncologic
PET and PET/CT advocates performance of
true whole body examinations [7], which im-
age the head, neck, chest, abdomen, pelvis, and
upper and lower extremities. In adults, exami-
nations are routinely limited to the neck, chest,
abdomen, and pelvis (limited whole body),
which provides significant advantages. Excep-
tions are made for some sarcomas, melanomas,
or cases of primary or suspected extremity in-
volvement [8]. Some articles suggest that lim-
ited whole body PET or PET/CT may be indi-
cated in some cases of pediatric lymphoma,
although the authors acknowledge that this has
not yet been validated in the literature [1, 7, 9].
Limited whole-body PET/CT provides
significant advantages for patients: primar-
ily, decreased patient radiation exposure and
shorter scanning time. Although the overall
FDG dose is not altered with limited whole-
body PET/CT, radiation exposure related to
attenuation correction CT in the addition-
al fields of view (FOVs) is eliminated. De-
creased scanning time is advantageous for
increased patient comfort and potentially for
improved image quality. A decrease in imag-
ing time may encourage more patient coop-
eration leading to decreased patient motion.
Additionally, decreased imaging time will
improve patient throughput and general ease
of the examination. Finally, although less
likely, in those pediatric patients in whom
sedation is necessary, the need for and lev-
el of sedation may be reduced if imaging
time can be sufficiently decreased in limited
whole-body PET/CT. Consequently, clinical
advantages will be achieved if specific indi-
cations for limited whole-body PET/CT are
identified in the pediatric population.
In this article, we evaluate the use of lim-
ited whole-body PET/CT in patients with
lymphoma, both Hodgkin lymphoma (HL)
and non-Hodgkin lymphoma (NHL). HL has
a relatively predictable progression of metasta-
ses, with rare extremity involvement in the ab-
sence of disseminated disease, or bone marrow

AJR:196, May 2011 1047

 Sammer et al.

involvement within the chest, abdomen, and
pelvis (which are examined on limited whole-
body PET/CT) [10, 11]. Indications for FDG
PET and PET/CT have also been established
in certain types of NHL [12–14]. However, its
utility varies depending on histology [15, 16]
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graphics of the 170 patients who met the inclusion
criteria are as follows. Institution 1: nine females,
10 males; mean age, 14.0 years; age range, 8–17
years, and institution 2: 58 females, 93 males;
mean age, 13.5 years; age range, 3–21 years. The
relatively larger proportion of males at institution
Examinations in which relapse was clinical-
ly suspected were not included in the analysis of
routine follow-up examinations (groups B and C).
All of these patients had follow-up examinations
in which clinical relapse was not suspected before
and after their clinically suspected relapse exam-

because FDG avidity is variable and does not 2 is not thought to be of clinical significance be- inations, and these examinations were treated as
always reflect the clinical stage [17]. In this cause disease biology is not changed with sex. routine follow-up examinations.
study, we hypothesize that given its advantag- Of the 170 patients who met the inclusion crite-
es, limited whole-body PET/CT is preferred ria for staging true whole-body PET/CT, 165 un- Acquisition Protocol
in routine follow-up examinations when dis- derwent follow-up examinations. In 10 of these All examinations were performed as true
ease on the patient’s staging true whole-body patients, clinical relapse was suspected on at least whole-body PET/CT (from the top of the skull
PET/CT is limited to the limited whole-body one examination. The examinations were parti- through the toes). The majority of examinations at
FOV (see group B). We secondarily evaluate tioned into four groups: group A, staging exami- both institutions were performed with the arms at
the role of limited whole-body PET/CT in nations (n = 170); group B, routine follow-up ex- the side, which typically facilitated examination
three additional scenarios: initial staging, aminations of patients with disease limited to the of the arms in their entirety.
routine follow-up of patients with disease in- limited whole-body FOV on staging (n = 145); At institution 1, all data were acquired with a
volving both limited whole-body and true group C, routine follow-up examinations of pa- combined 64-MDCT PET/CT system (Discovery
whole-body FOV on the staging study, and tients with disease involving both limited whole- VCT, GE Healthcare) [18]. Patients fasted for at
follow-up examinations performed for clini- body and true whole-body FOV on staging (n = least 6 hours and were imaged approximately 60
cally suspected relapse. 20); and group D, follow-up examinations in minutes after injection of a standard FDG dose of
which relapse was suspected clinically (n = 10, 5.3 MBq/kg, with a 37-MBq minimum and a 370-
Materials and Methods 5 each from groups B and C). Disease type and MBq maximum. Shorter patients (height ≤ 120
Patients stage are summarized in Table 1. cm) without known pelvic pathology were scanned
Institutional review board (IRB) approval was
obtained at both institutions for retrospective re- TABLE 1:  Disease Distribution
view of consecutive pediatric patients who un- Disease Group A Group B Group C Group D
derwent PET/CT for staging and follow-up of
Hodgkin 115 100 12 8
lymphoma. At institution 1 (a tertiary regional
pediatric referral center), examinations between Stage I 13 13 0 1
September 2007 and October 2008 were includ- Stage II 61 59 0
ed, and at institution 2 (a national pediatric can-
Stage III 9 9 0
cer referral center), examinations between No-
vember 2004 and July 2009 were included. The Stage IV 32 19 12 7
included examinations at institution 1 were from Non-Hodgkin 55 45 8 2
installation of the PET/CT scanner through the Lymphoblastic 14 11 3
date of IRB approval. At institution 2, included
Burkitt 11 10 1 1
examinations were from the date of initiation of
true whole-body PET/CT for all pediatric patients Diffuse large B-cell 12 10 1 1
through the date of IRB approval. Anaplastic 5 4 1
Database searches at each institution identi- Lymphoproliferative disease 1 1
fied all PET/CT examinations performed between
Mature B-cell
these periods in patients with lymphoma. The da-
tabase search at institution 1 initially identified 31 Aggressive 1
patients and at institution 2 identified 197 patients Nodular marginal zone 1 1
for a total of 228 patients. Of these, 58 patients Follicular 2 2
were excluded, resulting in a total of 170 eligible
Peripheral T-cell
patients who underwent staging true whole-body
PET/CT. Excluded patients were 36 whose exam- Mature T-cell 4 4
ination was performed after treatment had been NK T-cell 1 1
initiated and 22 whose initial examination was Subcutaneous panniculitis- 1 1
limited whole-body (18 performed at outside in- like
stitutions and four at institution 1 or 2). Review Hepatosplenic T-cell 1 1
of the medical records was used to document sex,
Primary cutaneous 1 1
age, and disease histology for all patients. Addi-
tionally, the provided clinical history was used Note—Group A = all patients (staging true whole-body PET/CT before treatment, group B = routine follow-up
when additional true whole-body fields of view (FOVs) were negative at staging, group C = routine follow-up
to identify patients in whom relapse was clinical- when disease on staging involved both limited whole-body and additional true whole-body FOVs, group D =
ly suspected at the time of examination. Demo- relapse suspected (subset of groups B and C).

1048 AJR:196, May 2011

 PET/CT in Pediatric Lymphoma

from head to toe; patients taller than 120 cm and
those with known pelvic pathology were scanned
with the bladder field of view first and proceed-
ing cephalad to the head. Then for larger patients,
the patient was removed from the scanner, repo-
sitioned, and the legs were examined. The entire
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a 440-MBq maximum. Patients were examined
proceeding caudad from the head. Then, for larger
patients (greater than 165 cm in length), the patient
was removed from the scanner, repositioned, and
the legs were examined. The whole body of smaller
patients could be examined without repositioning.
relate or known physiologic cause), the stage of dis-
ease based on the limited whole-body findings was
recorded according to the Ann Arbor Classification
[21, 22]. Findings on the additional true whole-body
FOV were documented as either negative, no abnor-
mal FDG-avid foci; benign, FDG-avid lesion with

body of smaller patients could be examined with-
out repositioning.
PET data were acquired in the 3D mode with
acquisition time of 3 minutes per FOV for those
under 22.4 kg and 5 minutes per FOV for those
22.5 kg or greater. For the legs of those patients
greater than 120 cm, acquisition time was 2 min-
utes. Between five and 12 scanning bed positions
were used depending on patient height.
CT was then acquired with the technique deter-
mined from an established pediatric weight-based
protocol [19]. All patients were scanned with a pitch
of 0.98:1, rotation speed of 0.5 second, body bow-tie
filter, and reconstructed slice thickness of 2.5 mm.
CT was performed during quiet breathing and cov-
ered the region from the top of the skull through the
feet. IV contrast material was not administered.
At institution 2, all data were acquired with a
combined 4-MDCT PET/CT system (LS Discovery
PET/CT, GE Healthcare) [20]. Patients fasted for
at least 4 hours and were imaged approximately
60 minutes after injection of a standard FDG dose
of 5.3 MBq/kg, with a 74-MBq minimum and
PET data were acquired in the 2D mode with an
acquisition time of 5 minutes per FOV.
CT was performed with a slice thickness of 0.5
cm, 0.8-second tube rotation, table speed of 1.5
cm/rotation, pitch of 1.5:1, 120 kV, and 90 mA
with dose modulation. CT was performed during
quiet breathing and covered the region from the
top of the skull through the feet. IV contrast mate-
rial was not administered.
Imaging Review and Analysis
Initial and follow-up examinations were ana-
lyzed by one reviewer who is trained in both nucle-
ar medicine and pediatric radiology. The findings
were compared with reports in the patient’s medical
record. No significant discrepancies were identified.
At the time of evaluation, the reviewer was blind-
ed to the disease type and clinical stage. The limit-
ed whole-body FOV and the additional true whole-
body FOV were scored separately. Within the
limited whole-body FOV, findings were recorded as
either negative or positive. When the examination
was positive (FDG avid lesions without benign cor-
benign CT correlate or known physiologic cause;
indeterminate, site of FDG activity in an atypical
location or with an atypical appearance for metas-
tasis and without definite benign imaging or physi-
ologic correlate; or positive, FDG avid lesion with
appearance and location typical for metastasis and
without benign CT correlate or known physiologic
cause. Typical lesions classified as benign were dif-
fuse muscular uptake (Fig. 1), injection site activi-
ty, and fibroxanthomata. Abnormalities classified as
indeterminate included focal muscular uptake (Fig.
1) and focal bone uptake without definite CT find-
ings. Abnormalities classified as positive included
focal lesions within the marrow, soft tissue (Figs.
2A and 2B), and brain. For all patients with inde-
terminate findings, the patient’s electronic medi-
cal record was searched to determine if the finding
changed the patient’s staging or disease manage-
ment. Indeterminate findings were not treated as
identifying a positive abnormality on the additional
true whole-body FOV because confidence for actu-
al lymphoma involvement was insufficient to assign
tumor to this region.

A C D
Fig. 1—15-year-old girl with lymphoblastic lymphoma.
A–C, On follow-up examination, true whole-body PET/CT coronal maximum-intensity-projection image (A) and axial transverse image (B) of lower extremity field of view
show indeterminate focal 18F-FDG activity within right upper leg musculature. No corresponding abnormality is present on CT (C). Additionally, note diffuse physiologic
muscular activity of lower leg musculature that would be classified as benign.
D, Subsequent follow-up FDG true whole-body PET/CT image (only lower extremities provided) shows resolution of previous abnormal focal muscular activity.

AJR:196, May 2011 1049


The data were entered into a spreadsheet (Mi-
crosoft Excel 2007) for statistical analysis. Ex-
aminations were analyzed using standard two-
by-two tables and the chi-square test. Dosimetry
was estimated for CT acquisition using simulated
dose computations of an adult from the U.K. Na-
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tional Radiologic Protection Board [23] and the
ImPACT CT Dosimetry Calculator [24]. Organ
weighting factors for the relative contribution of
each organ-specific dose to effective dose were
from the International Commission on Radiologi-
cal Protection publication 103 [25].
Results
We have summarized the results for each
group as well as by disease type (HL vs
NHL) in Table 2.
A B
E F
1050 AJR:196, May 2011
Sammer et al.
Group A: Staging Evaluation
Of the 170 patients with staging exami-
nations, there were no patients whose dis-
ease involved the additional true whole-body
FOV without involving the limited whole-
body FOV: 67 females, 103 males; mean age,
13.4 years; age range, 3–21 years. One hun-
dred forty-two (83%) had disease limited to
the limited whole-body FOV, with negative
(n = 94), benign (n = 43), and indetermi-
nate (n = 5) findings on the additional true
whole-body FOV. Twenty (12%) patients
had positive findings on limited whole-body
FOV and also on the additional true whole-
body FOV (positive predictive value [PPV],
12%; 95% CI, 0.075–0.172). Nineteen of the
170 patients were stage IV on the basis of
the limited whole-body FOV, and the addi-
tional findings on the additional true whole-
body FOV did not change their clinical stage.
However, in one patient with lymphoblastic
NHL, the imaging stage was altered with
the additional true whole-body FOV (PPV,
1%; 95% CI, 0.0003–0.0276). Clinical stage
was changed in no patients (PPV 0%; 95%
CI 0–0.02). In the single patient whose im-
aging stage changed based on additional
true whole-body findings, disease on lim-
ited whole-body FOV (Fig. 3) was limited to
the right axilla (stage I); on the additional true
whole-body FOV, findings were suggestive of
marrow involvement (stage IV based on PET/
CT). Bilateral bone marrow biopsy and aspi-
rates performed on this patient were positive
C D
Fig. 2—15-year-old boy with large cell lymphoma.
A and B, Maximum-intensity-projection (MIP)
images from 18F-FDG staging examination show
extensive multifocal abnormal uptake throughout
limited whole-body and true whole-body fields of
view, indicating widely metastatic disease—positive
findings.
C and D, On follow-up examination performed for
suspected clinical relapse, attenuation-corrected
coronal MIP images show unsuspected brain
metastasis (arrow, C). Faint focal uptake in soft
tissues of distal left thigh is also suggestive of
metastasis in this patient with prior multifocal soft-
tissue disease. Near absence of uptake in central
mediastinum–thoracic spine is related to intervening
radiation therapy. Relatively diffuse and more focal
pulmonary uptake is also noted.
E and F, Axial PET image (E) with subsequent T1-
weighted contrast-enhanced MRI (F) correlation
show enhancing brain mass, typical for metastasis.
 PET/CT in Pediatric Lymphoma

TABLE 2:  Results Summary

Group A Group B Group C Group D
Findings All HL NHL All HL NHL All HL NHL All HL NHL
Limited whole-body 20 12 8 0 0 0 6 2 4 3 1 2
and true whole-
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body findingsa
Limited whole-body 150 103 47 145 100 45 14 10 4 7 7 0
only findingsb
Limited whole-body 12 10 15 0 0 0 30 17 25 30 13 100
PPV (%)
95% CI 0.075–0.172 0.057–0.168 0.070–0.253 0–0.020 0–0.063 0–0.063 0.136–0.509 0.032–0.421 0.054–0.567 0.093–0.588 0.009–0.433 0.368–1.000
Note—Group A = all patients (staging true whole-body PET/CT before treatment), group B = routine follow-up when additional true whole-body fields of view (FOVs) were
negative at staging, group C = routine follow-up when disease on staging involved both limited whole-body and additional true whole-body FOVs, group D = relapse
suspected (subset of groups B and C), HL = Hodgkin lymphoma, NHL = non-Hodgkin lymphoma, PPV = positive predictive value.
aNumber of patients with positive findings on both the limited whole-body FOVs and additional true whole-body FOVs.
bNumber of patients with positive findings limited to the limited whole-body FOV.

for lymphoma. Consequently, the marrow in-
volvement that was identified only on the
additional true whole-body FOV may not
have changed clinical management. Finally,
eight patients (5%) were negative on limit-
ed whole-body and negative [7], or benign
[1] on the additional true whole-body FOV
(Burkitt lymphoma [4], stage I HL [2], and
mature B-cell lymphoma [2]).
In an analysis by subtype (HL vs NHL),
of the 115 patients with HL, 12 had find-
ings at staging involving both limited whole-
body and true whole-body FOV (PPV, 10%;
95% CI, 0.057–0.168). On the basis of limit-
ed whole-body FOV alone, the patients were
stage IV, and additional findings on the true
whole-body FOV did not change the stage
(PPV, 0%; 95% CI, 0–0.025). Eight of the 55
NHL patients had disease involving the lim-
ited whole-body and true whole-body FOV
at staging (PPV, 15%; 95% CI, 0.070–0.253).

Fig. 3—10-year-old boy with lymphoblastic lymphoma.

A, Coronal maximum-intensity-projection (MIP) image from true whole-body
PET/CT staging examination shows focal uptake at nodal mass in right axilla in
addition to extensive brown fat uptake.
B–D, Lower extremity coronal MIP image (B) and axial image (C) and CT (D) from
same examination show focal uptake within right femur, classified as positive; no
correlative benign finding was identified on CT.
A B

C D

AJR:196, May 2011 1051


As before, staging on the basis of PET/CT
was changed in only one (PPV, 2%; 95% CI,
0.001–0.082), and clinical staging changed
in none (PPV, 0%; 95% CI, 0–0.052).
Group B: Routine Follow-Up When Additional
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True Whole-Body FOV Was Negative at Staging
At staging, 150 patients had no disease or
disease limited to the limited whole-body
FOV. Of these, 145 had follow-up; 58 fe-
males, 87 males; mean age, 13.4 years; age
range, 3–21 years. In these patients, a total
of 518 routine follow-up examinations were
performed. Ten of these examinations were
excluded: eight limited whole-body PET/
CT and two nondiagnostic because of al-
tered biodistribution. Of the remaining 508
true whole-body follow-up examinations,
each patient averaged 3.5 follow-up stud-
ies (range, 1–17). Mean length of follow-
up was 516 days (range, 14–1599 days). On
these 508 follow-up examinations, no posi-
tive FDG-avid lesion was identified on the
additional true whole-body FOV (0 of 145;
PPV, 0%; 95% CI, 0–0.020). Further evalua-
tion by disease type was as follows: HL (0 of
100; PPV, 0%; 95% CI, 0–0.029) and NHL
(0 of 45; PPV, 0%; 95% CI, 0–0.063).
Group C: Routine Follow-Up When Disease on
Staging Involved Both Limited Whole-Body and
Additional True Whole-Body FOV
In the 20 patients whose disease on the
staging examination involved both the lim-
ited whole-body FOV and true whole-body
FOV, all had follow-up: eight females, 12
males; mean age, 13.4 years; age range,
5–19 years. A total of 66 routine follow-up
examinations were performed. Four exami-
nations were excluded (three limited whole-
body only and one nondiagnostic because
of altered biodistribution). Of the 62 includ-
ed follow-up examinations, each patient av-
eraged 3.4 follow-up examinations (range,
1–11). Mean length of follow-up was 381
days (37–1708 days). In six of the 20 pa-
tients, follow-up examinations showed find-
ings on the additional true whole-body FOV
that could reflect clinically important dis-
ease (PPV, 30%; 95% CI, 0.136–0.509). In
three patients, positive true whole-body FOV
findings were seen in the setting of continued
stage IV disease on limited whole-body FOV
(15-year-old boy with large cell lymphoma,
15-year-old boy with Burkitt lymphoma,
and 17-year-old girl with HL). In the other
three, there were positive findings on true
whole-body FOV when disease on the lim-
1052 AJR:196, May 2011
Sammer et al.
ited whole-body FOV was no longer stage IV
(considered definitely important). In two pat-
ents (12-year-old boy with HL and 9-year-old
girl with lymphoblastic lymphoma), findings
on the true whole-body FOV were present
with a negative limited whole-body FOV. In
the third, a 17-year-old boy with lymphoblas-
tic lymphoma, findings remained on the true
whole-body FOV whereas limited whole-
body FOV showed only stage I disease.
When evaluated by disease type, two
of the 12 with HL had findings on the true
whole-body FOV at follow-up (PPV, 17%;
95% CI, 0.032–0.421), whereas one of 12
was considered definitely important (PPV,
8%; 95% CI, 0.005–0.319). In those with
NHL, four of eight had findings on the ad-
ditional true whole-body FOV at follow-up
(PPV, 50%; 95% CI, 0.212–0.788), whereas
two of eight were considered definitely im-
portant (PPV, 25%; 95% CI, 0.054–0.567).
Group D: Clinically Suspected Relapse
Relapse was suspected clinically in 10 pa-
tients (five from group B and five from group
C): three females, seven males; mean age,
14.9 years; age range, 6–21 years. In two
of these patients, relapse was clinically sus-
pected on two separate occasions (total 12
examinations performed for clinically sus-
pected relapse). On these examinations per-
formed for clinically suspected relapse, three
patients (PPV, 30%; 95% CI, 0.093–0.588)
showed additional disease outside of the lim-
ited whole-body FOV; in HL, one of eight
was positive (PPV, 13%; 95% CI, 0.009–
0.433); and in NHL, two of two were posi-
tive (PPV, 100%; 95% CI, 0.368–1.000). In
a 15-year-old boy with diffuse large B-cell
NHL, an unsuspected new brain metasta-
sis was identified (Fig. 2). In a 13-year-old
boy with HL, disease on initial examina-
tion was confined to the limited whole-body
FOV, without marrow involvement or oth-
er findings to suggest stage IV disease (by
imaging stage III). Bone marrow biopsy
at staging was positive (clinical stage IV).
When relapse was suspected clinically, posi-
tive findings were seen throughout the mar-
row spaces, including new disease outside
of the limited whole-body FOV (imaging
stage IV). In the final patient, a 15-year-old
boy with Burkitt NHL, new bone marrow
involvement was identified outside the lim-
ited whole-body FOV, whereas on the stag-
ing examination, disease was confined to the
limited whole-body FOV and did not involve
bone marrow (imaging stage III). However,
with a positive bone marrow biopsy at this
time, the patient was clinically stage IV.
Indeterminate and Benign Findings
As described in the Imaging Review and
Analysis section, findings were also classified
as indeterminate and benign. The results for
patients from all groups will be discussed here.
At staging, five patients had indeterminate
findings on the additional true whole-body
FOV, all focal soft-tissue uptake (usually
muscular lower extremity). All had follow-up
examinations (average follow-up, 5.6 months,
range, 2–11 months; mean length of follow-
up, 37.0 months), and abnormalities were no
longer present. Additionally, the clinical stage
was not changed in these patients on the basis
of these indeterminate findings.
On follow-up examinations, 12 patients
(7.3%) had new indeterminate findings on the
additional true whole-body FOV. Of these,
nine were focal soft-tissue uptake (mostly
muscular) and three were focal bone uptake.
Foci of bone uptake were as follows: focal dis-
tal femoral epiphyseal (n = 2) and focal proxi-
mal tibial metaphyseal uptake (n = 1). None of
these new indeterminate findings were treat-
ed as clinically significant, and original stage
and treatment were not altered. Three of these
patients had no follow-up PET/CT after these
new indeterminate findings were discovered.
In the remaining nine, the findings resolved on
follow-up examination. The average number of
follow-up examinations was 1.8 (range, 1–4),
with mean length of follow-up 12.9 months
(range, 1–24 months). Benign findings outside
of the limited whole-body FOV were identified
at staging in 44 patients (26%) and on follow-
up examinations in 104 patients (63%).
Discussion
Although current guidelines for pediat-
ric oncologic PET and PET/CT suggest use
of true whole-body examinations [7], these
guidelines and other articles [1, 9] acknowl-
edge that limited whole-body PET/CT is like-
ly to be sufficient for some cases of pediatric
lymphoma. We have provided evidence that
limited whole-body PET/CT is sufficient in
pediatric lymphoma follow-up when disease
on the patient’s staging examination is con-
fined to the limited whole-body FOV and
there is no clinical suspicion of relapse. Lim-
ited whole-body PET/CT has the clear ad-
vantages of decreased radiation (related to
elimination of the CT performed for atten-
uation correction), decreased imaging time,
decreased length of sedation, and potentially

decreased need for or depth of sedation. Con-
sequently, on the basis of our data we conclude
that in this population, limited whole-body
PET/CT is preferred over true whole-body
PET/CT for routine follow-up examinations.
However, true whole-body PET/CT is
Downloaded from www.ajronline.org by 180.242.15.129 on 05/27/18 from IP address 180.242.15.129. Copyright ARRS. For personal use only; all rights reserved
sometimes preferred over limited whole-
body examination because potentially clini-
cally relevant additional information may be
missed in limited whole-body imaging. For
example, a recent article in the adult onco-
logic literature detailed several unexpected
metastatic lesions identified in the extremi-
ties that would have been missed on limited
whole-body PET/CT [26]. Although this ar-
gument for true whole-body PET/CT includ-
ed two cases of potentially missed soft-tissue
metastases on true whole-body FOV in pa-
tients with NHL, the study did not system-
atically and specifically address follow-up
as we have here (dividing the patient popula-
tion into those with both limited whole-body
and true whole-body FOV involvement on
staging examination vs those with only lim-
ited whole-body FOV involvement). Conse-
quently, although our data support limited
whole-body PET/CT for routine pediatric
lymphoma follow-up when disease on the
staging examination is confined to the limit-
ed whole-body FOV, our data do not support
its routine use in staging, clinically suspect-
ed relapse, or follow-up when disease in-
volves both the limited whole-body and true
whole-body FOV on the staging examina-
tion. Rather, our data show added informa-
tion from true whole-body in some patients
in these scenarios. However, the clinical sig-
nificance of such findings is uncertain. Spe-
cifically, the clinical stage was not changed
in any patient from the additional informa-
tion obtained on the additional true whole-
body FOV (although bone marrow biopsy is
TABLE 3:  Acquisition Duration Estimates
Torso FOV × Legs FOV × Torso Time Legs Time TWB PET
Hospital Age (y) Height (m) FOV
Institution 1 3 0.92 7.49
13 1.5 12.21
20 1.7 13.83
Institution 2 3 0.92 6.77
13 1.5 11.04
20 1.7 12.52
Note—FOV = field of view, TWB = true whole-body, LWB = limited whole-body.
aTime torso + Time legs + 10 minutes for repositioning.
bEstimated two additional FOV for brain and lower extremities (TWB time minus two FOV).
cTime torso minus one FOV for brain.
AJR:196, May 2011 1053
PET/CT in Pediatric Lymphoma
sometimes only performed in the presence of
positive bone marrow findings on PET/CT).
Knowledge of these additional disease sites,
however, is probably still clinically helpful.
Finally, on the basis of the small number
of patients, our data do not support limited
whole-body PET/CT for clinically suspect-
ed relapse or routine follow-up when dis-
ease involved both FOVs at staging. Perfor-
mance of true whole-body PET/CT in these
situations is even more important in patients
with NHL. In those with HL, the advantag-
es of limited whole-body PET/CT will need
to be weighed with the added information
obtained from true whole-body PET/CT. A
more dedicated study specifically aimed at
justifying the continued use of true whole-
body PET/CT may be helpful to develop a
clinical prediction rule to determine its use.
As discussed previously, there are definite
advantages of limited whole-body PET/CT
over true whole-body PET/CT. Especially in
the pediatric population, the decreased radia-
tion of limited whole-body PET/CT is prefer-
able. Low-level ionizing radiation has been im-
plicated in conferring a latent increased risk of
malignancy [27, 28]. This is especially impor-
tant in pediatric patients who, given their age,
have longer to manifest these adverse effects
[29, 30]. In pediatric oncology, recent reports
have also shown a significant cumulative ra-
diation dose in lymphoma patients [31, 32]. In
all examinations involving radiation, the radi-
ology and nuclear medicine communities have
adapted the as low as reasonably achievable
principle (ALARA) [33], which in PET/CT
applies to both the FDG dose and the acquisi-
tion parameters for attenuation correction CT
[34]. With respect to PET/CT, one method for
decreasing dose is eliminating the attenuation
correction CT dose to the extremities and brain
if limited whole-body PET/CT is performed
Time (min) Time (min) (min) (min) Time (min)
7×3 0 21 0 21
8×5 5×2 40 10 50
8×5 6×2 40 12 52
6×5 0 30 0 30
8×5 5×2 40 8 50
8×5 6×2 40 10 52
rather than true whole-body PET/CT. Using
published pediatric PET/CT acquisition pro-
tocols [19], the limited whole-body FOV CT
acquisition (eyes to thighs) imparts a whole-
body effective dose of, at most, 5.5 mSv. The
whole-body acquisition imparts 5.7 mSv. The
limited FOV acquisition results in a 4% reduc-
tion in whole-body effective dose; this small
reduction in effective dose is expected consid-
ering that the additional scanned region con-
tains relatively radio-insensitive organs (brain
and legs) that contribute little to the calculation
of total whole-body effective dose. In terms of
organ-specific doses, compared with the true
whole-body examination, the limited FOV ac-
quisition reduces the CT dose to the brain by
70%, to the skin by 15%, and to the remaining
organs (primarily oral mucosa) by 7%. Despite
the arguably small reduction in whole-body ef-
fective dose (4%), the ALARA principle moti-
vates the use of limited whole-body for radia-
tion dose reduction in appropriate cases.
Another advantage of limited whole-body
PET/CT over true whole-body examination
is a shorter scanning time. Table 3 presents
a summary of scanning durations for differ-
ent size patients. Using the average height of
our mean patient, eliminating the additional
true whole-body FOV under current imaging
protocols would decrease scanning time by
approximately 15 minutes (Table 3). Reposi-
tioning the patient to scan the legs also adds ap-
proximately 10 minutes, with a total decrease
in scanning time of limited whole-body versus
true whole-body PET/CT of 25 minutes. In pa-
tients whose height is less than 120 cm, the
time differential is less (Table 3). For scan-
ners that do not use 3D acquisitions, the time
benefits from eliminating the true whole-
body FOV would be greater. Conversely, im-
aging centers with different PET/CT systems
or a higher tolerance for noise in images may
Total
TWB PET Time (min) LWB PET Time (min)
21 15b
60a 35c
62a 35c
30 20b
60a 35c
62a 35c

scan patients with shorter acquisition dura-
tions, leading to less benefit from eliminating
the true whole-body FOV. In any case, a short-
er imaging time can improve patient comfort,
thereby potentially improving image quali-
ty through increased patient cooperation and
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potentially less motion artifact. A shorter im-
aging time may also increase accessibility of
PET/CT examinations in centers where high
demand on facility resources is present.
A decrease in imaging time will result in a
similarly decreased length of anesthesia time
for those patients requiring sedation. The
need for shorter sedation could allow use of
a more desirable anesthetic, which would be
determined according to pediatric sedation
guidelines [35]. Depth of sedation may also
potentially be reduced, which could result in
similar advantages. However, it is unlikely
that the shorter imaging time will entirely
eliminate the need for sedation, and the ad-
vantages are less, given the smaller patients
are typically those requiring sedation.
Finally, our findings suggest potential disad-
vantages to performing true whole-body PET/
CT, particularly when benign or indeterminate
abnormalities are identified on the addition-
al views. Although the benign findings would
typically not pose a diagnostic dilemma, some
difficulties may arise if the interpreting physi-
cian is not thoroughly versed in the common
benign findings often seen in the extremities of
pediatric patients. For this, additional educa-
tion and training may be helpful. On the other
hand, there is always the potential for the pur-
suit of indeterminate findings (which we de-
fined as an FDG-avid lesion that is atypical for
metastasis but without a benign CT correlate
or known physiologic cause) to adversely affect
patient outcome by resulting in complications
from unnecessary studies. Similarly, false up-
staging of patients may lead to toxicities from
unneeded therapy. Further study would be re-
quired to quantify the effect.
This study has limitations. A prospective
multicenter study with pathologic correla-
tion of all PET/CT findings would be ide-
al. However, we have a large diverse patient
population with excellent PET/CT follow-
up and clinical correlation when necessary.
Although pathologic confirmation of the le-
sions identified on PET/CT is the reference
standard, it is neither practical nor would the
invasive means be justified. Especially in the
pediatric population, prudent use of invasive
diagnostic methods is standard procedure,
both to avoid unnecessary adverse outcomes
and patient discomfort and also to subject the
1054 AJR:196, May 2011
Sammer et al.
patient sparingly to potentially neuro­toxic
effects of sedatives and anesthetics [36].
In the absence of a reference standard, we
assumed that the PET/CT performed for this
work provided adequate lesion detection to
support our claims. There are numerous pa-
rameters (including injected dose, acquisi-
tion duration, image reconstruction settings,
and so on) to optimize in pediatric PET/CT,
and these vary widely based on local experi-
ence and preference [37]. Both of the PET/
CT systems used in this study were operated
in an optimal fashion on the basis of years of
pediatric imaging experience, with acquisi-
tion durations that are arguably longer than
most imaging centers. With these relatively
long-duration acquisitions, the image quality
is generally very high and supports our as-
sumption of adequate lesion performance on
both PET/CT systems.
Additionally, although a prospective mul-
ticenter trial would be optimal, we have com-
bined data from two distinct institutions.
Each institution had different acquisition
protocols (for example 2D vs 3D mode) and
used systems with different effective sensi-
tivity. Although this combination has the po-
tential to be a confounder, we believe it adds
strength, increasing both power and general-
izability of the results.
An additional limitation of our study is our
relatively small number of patients with the
different subtypes of NHL. Whereas HL be-
haves in a relatively predictable fashion with
well-defined staging methodology, NHL en-
compasses a relatively heterogeneous group
of histologies, many with different morpholo-
gies, presentations, and natural histories [38].
Consequently, although our study did not show
differences in the patients with NHL com-
pared with those in HL with respect to limited
whole-body PET/CT follow-up, given our rela-
tively small numbers in this population, further
studies dedicated to NHL or specific types of
NHL may be helpful to more precisely define
the role of limited whole-body PET/CT fol-
low-up in these patients. In the eventuality that
rare cases of disease outside the limited whole-
body FOV are identified on follow-up when
disease on the staging examination is limited
to the limited whole-body FOV, a clinical pre-
diction rule may be developed to help identify
those patients who would benefit from contin-
ued true whole-body follow-up.
Conclusion
In this study, we provide evidence that rou-
tine follow-up with limited whole-body PET/
CT is justified in those lymphoma patients in
whom disease on the staging examination
is confined to the limited whole-body FOV.
However, in staging, clinically suspected re-
lapse, and those patients in whom disease on
the staging examination involves both the
limited whole-body and true whole-body
FOV, our data do not support the routine use
of limited whole-body PET/CT. Moreover,
our data suggest that, especially for NHL,
the use of true whole-body PET/CT provides
additional information; however, the clini-
cal utility of these additional findings is not
clearly addressed in this article. Specifical-
ly, although additional findings were found
in staging (which changed imaging stage in
one patient), none of the additional findings
changed the clinical stage. Consequently, a
dedicated multiinstitutional study to address
these situations may be helpful.
Our study highlights the potential advan-
tages of limited whole-body PET/CT over true
whole-body PET/CT but stresses the impor-
tance of true whole-body PET/CT when indi-
cated. In pediatric oncology, where true whole-
body examination is the standard of care in all,
our discovery of a subgroup in which limited
whole-body PET/CT examination is preferred
is significant. There will be direct benefits of
improved patient comfort, decreased imag-
ing time, and decreased radiation exposure in
those pediatric lymphoma patients in whom
limited whole-body PET/CT is justified. In ad-
dition, our findings serve to remind pediatric
radiologists and nuclear medicine physicians
not only of the ALARA principle but also that
continued evidence-based investigation of true
whole-body PET/CT is warranted.
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