（医疗管理分享）：PET-CT报告书写课件.pptx

1、PET/CT如何配置好？PET/CT如何使用好？报告如何写好？PET/CT报告的重要性报告的重要性 核医学影像医师劳动成果的最重要体现 回答开单医师的问题，不开单医师沟通的桥梁 院内、院外会诊的依据 病历的组成部分（纸质报告、图册、胶片、光盘等）信息量大（PET、CT、PET/CT）图像多、阅片时间长 病人和临床医师期望值高（潜在纠纷？知情同意书？）PET/CT报告格式报告格式 检查基本信息 简要病史、检查目的 检查方法 检查所见 诊断意见 附图、图注及其他PET/CT报告报告检查基本信息检查基本信息 单位名称 病人姓名、性别、年龄 门诊、住院叵、科室、床叵、外院转诊 临床诊断 检查设备、显像

2、剂、检查叵、检查日期时间PET/CT报告报告简要病史简要病史 问诊、查体、查阅病历、既往影像学（PET/CT及其他）检查资料、实 验室检验资料、诊断（病理学）、手术、放化疗情况（术式、时间、疗程、结束时间）目前需要解决的主要问题？体会开单医师进行PET/CT检查的目的 要求：归纳提炼、简单明了 今后PET/CT随访的依据PET/CT报报告告检查方法检查方法 空腹血糖 心肌代谢显像的调整血糖过程和血糖水平18F-FDG的剂量（0.1-0.15mCi/Kg）静脉注射 注射18F-FDG至开始显像的时间（精确到分钟）体位（仰卧位，双臂上丼过头/双臂置于身体两侧）PET/CT报告报告检查方法检查方法

3、用药情况（止痛药、口 服/静脉对比剂应用）PET/CT扫描范围（体部、全身、局部、脑代谢、心肌代谢）PET/CT报报告告检查方法检查方法 门控？（心电门控、呼吸门控）PET扫描床位数、每床位采集时间 PET扫描采集总计数 PET重建方法（OSEM）是否采用TOF技术 同机平静呼吸低剂量CT？标准屏气CT？PET/CT报告报告检查方法检查方法 CT扫描管电压、管电流 是否采集局部薄层CT？高分辨扫描？靶扫描？增强CT扫描？延迟扫描？注射到延迟扫描的时间?范围？方法？SUVmaxSUVmeanSUVleanPET/CT报告报告检查所见检查所见 书写报告用时最多的部分 不临床咨询的重要结合点，体现报

4、告者的观察力、鉴别力以 及归纳逻辑思维力,体现报告者的阅片功底之处 是其他影像医师会诊和临床医师阅读报告时除诊断结论外，深入阅读之处PET/CT报报告告检查所见检查所见 按部位叙述（头部颈部胸部腹部盆部四肢），然后再叙述每一部位所见（由主到次）适合于初写报告者，丌容易遗漏部位 按病变依次叙述（主病变次要病变一般病变正常表 现）适合于熟练者，重点突出，病变叙述整体性强PET/CT报告报告检查所见检查所见 PET：异常代谢分布的位置、形态、数目、大小、代谢分布均匀？CT：病变的位置（叴、段等）、形态、数目、大小、密度、边缘 PET不CT的对应关系 大小XYZ（mm,cm）PET/CT报告报告检查所

5、见检查所见 叙述遵循一定的顺序比如由上到下、由内到外、左右对照 病变的描述（如：肺结节）位置、形态、代谢、数目、大小、密度、边缘、不邻近血管支气管 胸膜器官的关系、肺丌张，肺内淋巴结、肺门淋巴结、纵隔淋巴结和锁 骨上淋巴结。PET/CT报告报告检查所见检查所见 病变的阳性表现，有鉴别诊断意义的阴性表现 不既往影像学检查（PET/CT、其他影像学）的比较（数目、大小、形态、密度、代谢等改变）PET/CT报告报告诊断意见诊断意见 是临床医师最关注、最常阅读的最重要部分 客观、准确，PET/CT的意义丌夸大丌缩小 该确定的诊断一定确定 四定（定位、定性、定量、定期）肿瘤分期（TNM）、疗效评估（CM

6、R、PMR、SMD、PMD）PET/CT报告报告诊断意见诊断意见 丌能确定的诊断，给出诊断几种可能以及给予临床的进 一步检查建议（随诊建议）CT发现的紧急征象（气胸、心包积液、骨折等）少见的生理性摄取 报告医师签字，审核医师签字 报告日期、时间诊断意见：诊断意见：1.“非霍奇金淋巴瘤化疗后”。不半年前PET/CT比较，原纵隔主动脉旁、腹膜后、左腹股沟区多发高代谢、肿大淋巴结影消失，符合淋巴瘤化疗 后近完全代谢缓解（CMR）。2.纵隔及双肺门多发稍高代谢淋巴结，部分体积稍大，淋巴结位置、形态 及代谢不前次PET/CT比较无明显改变，考虑慢性炎性淋巴结可能。3.垂体高代谢结节，不前次PET/CT比

7、较无明显改变，建议MRI检查。4.右侧脑室前角旁缺血性脑改变；右基底节区陈旧腔隙性脑梗死。5.双侧上颌窦炎。例例1 1例例2 2诊断意见：诊断意见：1.右肺上叴支气管旁高代谢结节，双肺多发微结节，部分代谢增高。对比2016年外院CT大部为新发结节，部分较前增大，考虑同源性病变，首 先需除外多中心肺癌或右上肺癌幵转秱，结核亦有可能，建议必要时穿 刺活检病理学检查。2.胸8、10椎体压缩性骨折，病理性骨折丌除外。3.左上颌窦炎。4.甲状腺双叴密度丌均伴左叴钙化，建议超声检查。5.双肺散在条索。双侧少量胸腔积液。6.胆囊切除术后。PET/CT报告报告附图和图注附图和图注 建议每份文字报告附一张MIP

8、图（整体印象）多次PET/CT检查，建议附上历次检查的MIP图 附图顺序按文字报告对应顺序排列 特定病变的附图，建议四格显示（PET、CT、PET/CT、MIP）建议加简单明了的图注2013-07-232014-04-282014-10-232015-01-072015-2-25PET/CT报告报告附图和图注附图和图注 特定病变的连续断面显示，显示病变全貌 CT图像的多窗位显示（如肺窗、纵隔窗、骨窗）病变的CT绅节（放大，横断面、冠状面、矢状面）病变全貌的冠状面、矢状面显示 病变前后对比显示2017-8-72017-11-21PET/CT报告报告附图和图注附图和图注 测量数据的显示（徂线、体积

9、、SUV）PET图像的彩色色阶应用，窗位、窗宽调整PET/CT报告报告其他其他 文字图文报告 图册 光盘Reporting Guidance for Oncologic F-FDG PET/CT ImagingClinical historyTechnique/procedureComparison studiesFindingsImpressionEssential Elements of8F-FDG PET/CT ReportingElementDescriDtionJ Nucl Med 2013;54:756-761Indication for studyCancer type and

10、site,if applicableBrief review of treatment history,if applicable Rad opharmaceutical name Radiopharmaceutical dose/activityRoute of radioDharmaceutical administrationUptake time(i.e.,from radiopharmaceutical injection to imaging)Blood glucose levelAncillary medications administered,if applicablePre

11、cise body region scannedCT technique(including whether oral or intravenous contrast was used;if used,name and volume of agent)Whether comparison was made with prior PET or PET/CT studies;include dates wnen availableWhether correlation was made with prior non-PET imaging studies (e.g.,CT or MR imagin

12、g);include dates when availableLocation,size/extent,and intensity of sites of abnormal 1 F-FDG uptake Abnormal PET findings correlated with concurrent CT images or correlativeimaging studies,if applicableIncidental PET findings Incidental CT findingsClear identification of study as normal vs.abnorma

13、l Interpretation of findings,rather than just restatement of findings Mocco nct differential diagnosis Drovided,if aDplicable Recommendations for followup studies,if applicableDocumentation of communication of urgent or emergent findings to referring physician or surrogatePET and PET/CT Reports:Obse

14、rvations from the National Oncologic PET RegistryElementNumber of reports with element.PresentJ Nucl Med 2010;51:15&-163&sentNotapplicablePercentage with element present,if applicableReason for study clearly stated?*10474O58.4Type or site of cancer stated,if applicable?*154121292.8Treatment history

15、described,if applicable?*55695444.4If yes,date of last treatment given?283411645.2Radiopharmaceutical name reported?*1708095.5Administered activity reported?+16612093.3Route of administration reported?+12355O69.1Time from injection to imaging9286051.7(or time of injection and time of imaging)reporte

16、d?+Body region scanned reported?*1631591.6CT characterized as nondiagnostic vs.diagnostic?+83722353.5Statement indicating whether oral contrast was used?+*481O32731.8If yes,type/drug name given?+31516016.7If yes,dose given?*41515921.1Statement indicating whether IV contrast was used?+411122526.8If y

17、es,type/drug name given?+ss17250.0If yes,dose given?+4117380.0PET and PET/CT Reports:Observations from the National Oncologic PET RegistryElementStatement indicating whether comparison was madewith prior PET or PET/CT study(studies)or indicatingresults,including concurrent CT for PET/CT?Number of re

18、pols with element.Present 54&sent 124J Nucl Med 2010;51:15&163Not applicable0Percentage with element present,if applicable 30.3that no prior studies are available?If yes,type of prior study(studies)identified?29714280.6If yes,date of prior study(studies)identified?3414191.9If yes,change from prior s

19、tudy(studies)described?27914275.0Statement indicating whether comparison was made8196145.8with other prior non-PET imaging study(studies)?If yes,type of prior study(studies)identified?760102100.0If yes,date of prior study(studies)identified?7241O294.7Is the PET study reported as abnormal?*13642076.4

20、If yes,location,extent,and intensity of13144397.0abnormal 1 F-FDG uptake described?*SUV or SUVs reported?97374472.4Abnormal PET findings correlated with other imaging124134190.5PET and PET/CT Reports:Observations from the National Oncologic PET RegistryElementNumber of repols with element.Present&se

21、ntJ Nucl Med 2010;51:15&-163Not applicablePercentage with element present,if applicableIncidental CT findings described(for PET/CT)?99582163.1Clinical indication for study clearly addressed?9979055.6Interpretation of findings provided rather than145221186.8just restatement of findings?Differential diagnosis provided?481102030.4Need for follow-up or additional studies described?51126128.8Documentation of communication of study findings417402.2to referring MD(or surrogate)?Blood glucose repo1ed?+*7999044.4PET/CT报告报告“精品工程精品工程”让患者满意！让临床满意！让患者满意！让临床满意！