Estimation of activity of administered ^{18}F-fluorodeoxyglucose by measurement of the dose equivalent rate on the right temporal region of the head
- Kenta Sakaguchi^{1},
- Makoto Hosono^{1, 2}Email author,
- Tomomi Imamura^{3},
- Naomi Takahara^{3},
- Misa Hayashi^{3},
- Yuko Yakushiji^{3},
- Kazunari Ishii^{1, 2},
- Tatsuro Uto^{2} and
- Takamichi Murakami^{1, 2}
Received: 6 July 2016
Accepted: 1 November 2016
Published: 14 November 2016
Abstract
Background
Positron emission tomography (PET) with ^{18}F-fluorodeoxyglucose (FDG) is now a routine procedure for the management of cancer patients. Intravenous administration of FDG is sometimes halted due to troubles. In such cases, estimations of the FDG dosage injected prior to halting administration may be helpful. We have established a method of estimating the activity of FDG to patients on the basis of the dose equivalent rate on the surface of the right temporal region of the head. The correlation of actual administered dosage with independent variables, such as the dose equivalent rate on the right temporal region of the head, age, sex, and body weight, was analyzed using multiple regression analysis to obtain linear, quadratic, and cubic regression equations.
Results
When entering independent variables, the cubic regression equation could be used to estimate an administered dosage with an accuracy of ±10 % for 62 % of all patients and ±20 % for 90 % of all patients.
Conclusions
We conclude that this method is useful for estimating the administered dosage from the dose equivalent rate on the temporal region of the head.
Background
Exploiting the enhanced glucose uptake by tumor cells as compared with normal cells, positron emission tomography (PET) with ^{18}F-fluorodeoxyglucose (FDG) is a routine procedure for the management of cancer patients [1–3]. Intravenous administration of FDG is sometimes halted due to extravasation of FDG, pain, or malfunction of injection devices. In such cases, estimations of the FDG dosage injected prior to halting administration may be helpful in making a decision on how to proceed, whether to perform venipuncture at a different site to inject additional FDG or to estimate the eventual influence of underdosing on standardized uptake values (SUVs) and image quality [4–6]. Thus, the activity remaining in the line and syringe may be estimated by using a radionuclide calibrator. This, however, may increase unnecessary radiation exposure to staffers because they have to handle the line and syringe and sometimes the injection device which may contain a large amount of radioactivity. To date, few studies have attempted to establish methods for estimating the administered dosage against such incomplete dosages immediately after administration was halted [7]. In this study, the dose equivalent rate on the head of patients was assumed to give accurate estimates of administered dosages. The aim of this study was to establish a method for estimating the administered dosage based on variables including, dose equivalent rate on the right temporal region of the head, age, sex, body weight (weight), height, elapsed time from administration, and blood sugar using multiple regression analysis.
Methods
Patients and data collection
Seven hundred six patients underwent PET examination in our site during the period between the 9th of March 2015 and the 23rd of May 2015. Of these, 520 patients were prospectively enrolled in this study with Institutional Review Board approval. The requirement to obtain informed consent was waived. The remaining 180 patients were not included in this study because of refusal to be involved, unfavorable physical condition, or incomplete records.
where Int() is the function of “round down to the nearest decimal.” For example, for a 69-kg patient, 180 MBq is administered using an FDG automated injector (M130, SUMITOMO Heavy Industries, Tokyo, Japan). After FDG administration, using an FDG automated injector, the dose equivalent rate on the right temporal lobe (DER) was measured with the patient sitting upright using an ionization chamber type survey meter (ICS-323, HITACHI ALOKA). No patients voided their bladders between injection and dose-rate measurement. The right temporal lobe was chosen based on patient comfort and the ability to conduct stable measurements. DER, administered dosage, and elapsed time following FDG administration were recorded, as well as age, sex, height, weight, and blood sugar. There are two reasons for having adopted the elapsed time following FDG administration as a dependent variable, the first is to reflect the physical decay and the second is to follow time-dependent uptake of the tracer in the brain. All data were recorded by six nurses working in our PET institution.
Multiple regression analysis
This study was performed on a presupposition that DER should be in proportion to AD. However, DER/AD (i.e., DER per unit dosage) is not completely a constant value. DER/AD is influenced by patients’ characteristics, such as sex, elapsed time following administration, patient age, height, weight, and blood sugar. Therefore, to achieve the presuppositions, DER had to be converted to corrected DER (CDER), which was unaffected by the influence of patients’ characteristics. The process of obtaining CDER is demonstrated as follows. IBM SPSS statistics (International Business Machines Corporation) was employed for analysis and calculation of multiple regression analysis.
Here, it should be noted that weight, height, and BMI exhibit multicollinearity. Therefore, the most appropriate variable, of the three, was determined using the Pearson test. The variable with the highest Pearson correlation coefficient was determined to be the most important independent variable.
where L(1), Q(1), Q(2), C(1), C(2), and C(3) are regression coefficients, and the intercept is zero.
Results
Test of normality
Variables and statistics
Variables | Mean ± SD | Range | Skewness | Kurtosis |
---|---|---|---|---|
Administered dose [MBq] | 152.7 ± 35.9 | 73.8–281.2 | 0.458 | 0.181 |
Elapsed time [s] | 217.0 ± 95.1 | 36.0–620.0 | 0.001 | −0.720 |
Dose equivalent rate [μSv/h] | 210.6 ± 41.0 | 104.0–374.0 | 0.220 | 0.191 |
Height [cm] | 160.7 ± 9.4 | 129.0–185.0 | 0.035 | −0.376 |
Weight [kg] | 58.12 ± 11.6 | 31.4–99.6 | 0.382 | −0.185 |
Blood sugar [mg/dl] | 112.6 ± 24.6 | 60.0–274.0 | 2.599 | 10.431 |
Age [years] | 66.1 ± 12.2 | 18.0–91.0 | −0.863 | 0.873 |
DER/AD [(μSv/h)/MBq] | 1.41 ± 0.26 | 0.76–2.14 | 0.226 | −0.103 |
Shapiro-Wilk test of variables
Shapiro-Wilk test | ||
---|---|---|
W | P value | |
Administered dose [MBq] | 0.980 | 0.000 |
Elapsed Time [s] | 0.878 | 0.000 |
Dose equivalent rate [μSv/h] | 0.995 | 0.096 |
Height [cm] | 0.993 | 0.020 |
Weight [kg] | 0.987 | 0.000 |
Blood sugar [mg/dl] | 0.780 | 0.000 |
Age [years] | 0.955 | 0.000 |
DER/AD [(μSv/h)/MBq] | 0.995 | 0.062 |
Calculation of CDER with stepwise multiple regression analysis
DER/AD and height, weight, and BMI
Height | Weight | BMI | ||
---|---|---|---|---|
DER/AD | Pearson correlation | −0.452 | −0.590 | −0.414 |
p value (2-tailed) | 0.000^{a} | 0.000^{a} | 0.000^{a} |
Stepwise multiple regression analysis models
Model | Adjusted R-square | Unstandardized coefficients | Standardized coefficients | t value | Sig. | Collinearity statistics | |||
---|---|---|---|---|---|---|---|---|---|
Regression coefficient | Std. error | Beta | Tolerance | VIF | |||||
1 | (Constant) | 0.346 | 2.181021 | 0.047049 | 46.356 | 0.000 | |||
Weight [kg] | −0.013178 | 0.000793 | −0.590 | −16.614 | 0.000 | 1.000 | 1.000 | ||
2 | (Constant) | 0.414 | 2.022751 | 0.048944 | 41.327 | 0.000 | |||
Weight [kg] | −0.013117 | 0.000751 | −0.587 | −17.465 | 0.000 | 1.000 | 1.000 | ||
Elapsed time [s] | 0.000713 | 0.000091 | 0.262 | 7.804 | 0.000 | 1.000 | 1.000 | ||
3 | (Constant) | 0.451 | 2.237429 | 0.059558 | 37.567 | 0.000 | |||
Weight [kg] | −0.012969 | 0.000728 | −0.580 | −17.823 | 0.000 | 0.999 | 1.001 | ||
Elapsed Time [s] | 0.000743 | 0.000089 | 0.273 | 8.385 | 0.000 | 0.997 | 1.003 | ||
Blood sugar [mg/dl] | −0.002040 | 0.000343 | −0.194 | −5.951 | 0.000 | 0.996 | 1.004 | ||
4 | (Constant) | 0.458 | 2.197180 | 0.060822 | 36.124 | 0.000 | |||
Weight [kg] | −0.011904 | 0.000814 | −0.533 | −14.626 | 0.000 | 0.787 | 1.270 | ||
Elapsed time [s] | 0.000752 | 0.000088 | 0.277 | 8.542 | 0.000 | 0.995 | 1.005 | ||
Blood Sugar [mg/dl] | −0.001987 | 0.000341 | −0.189 | −5.829 | 0.000 | 0.993 | 1.007 | ||
Sex | −0.053893 | 0.018947 | −0.104 | −2.844 | 0.005 | 0.784 | 1.275 |
Estimation of administered dosage with linear and nonlinear regression analysis
Parameter estimates
Parameter | Estimate | Standard error | 95% confidence interval | |
---|---|---|---|---|
Lower bound | Upper bound | |||
L1 | 9.832E−001 | 5.747E−003 | 9.719E−001 | 9.945E−001 |
Q1 | −1.328E−003 | 0.000E+000 | −1.328E−003 | −1.328E−003 |
Q2 | 1.216E+000 | 1.081E−004 | 1.216E+000 | 1.217E+000 |
C1 | 3.422E−006 | 1.491E−006 | 4.926E−007 | 6.352E−006 |
C2 | −2.654E−003 | 5.878E−004 | −3.809E−003 | −1.499E−003 |
C3 | 1.336E+000 | 5.578E−002 | 1.227E+000 | 1.446E+000 |
Discussion
We have described a method to estimate the actual dosage of FDG administered using corrected DER and four independent variables of sex, weight, blood sugar, and elapsed time following administration in a cubic regression equation obtained by analyzing 520 patients. The ratio of DER over actual administered dosage becomes practically constant when we correct DER using the independent variables, as indicated, by stepwise multiple regression analysis. This method is useful for calculating the radioactivity of FDG administered to patients when administration must be halted for any reason. However, it does not necessarily give a precise value of administered dosage but just an estimate. Care should be taken when an administered dosage is estimated by our method and it may affect the diagnostic interpretation or quantification of FDG accumulation. Of the four independent variables, the influence of blood sugar was less than weight and elapsed time following administration in stepwise multiple regression analysis. This is interesting because usually blood sugar affects brain uptake of FDG [8, 9]. One proposed reason for the decreased influence, of blood sugar on FDG uptake in the brain, might be that DER was measured shortly after administration of FDG. Thus, the effect of blood sugar on brain uptake was not large [10].
Because the proposed estimation method makes use of dose equivalent rates on the surface of the right temporal lobe, other factors, that may affect brain uptake of FDG and, consequently, the accuracy of the method, should be considered. Diversion of FDG to large tumors, leading to decreased brain uptake, has already been reported in malignancies including lymphoma [11]. In this study, FDG uptake into tumors was not included as a variable because routinely tumor uptake is unknown at the very time of administration of FDG; thus, it cannot be incorporated in the estimation of the administered dosage.
One limitation of this study is that incomplete injection of FDG, in patients, was not examined, which means that the in vivo predictive power of this estimation method has not been verified. Of particular concern is the case of extravasation, where measurement of the actual radioactivity of FDG injected into the circulation is difficult to determine because FDG could be absorbed by subcutaneous tissue or vascular tissue. DER is most likely associated with radioactivity injected into the circulation. In time, the accuracy of our proposed estimation method can be verified using data accumulated from cases in which DER, the independent variables, and quantitative image data are all known. Another limitation is that this study was conducted at only one facility. To establish such regression approaches, including populations from multiple sites may be crucial to enhance generic applicability and wide clinical adoption. Further, multi-center studies are needed to determine the viability of our estimation method in PET facilities with various clinical circumstances.
Conclusions
The actual administered dosage of FDG in patients was successfully estimated on the basis of dose the equivalent rate using multiple regression analysis with four independent variables of sex, weight, blood sugar, and elapsed time following administration. We propose using this method to determine the radioactivity of FDG administered to patients in cases of incomplete injection.
Declarations
Acknowledgements
The authors thank Hideo Morimoto, Kaeko Matano, Hiroshi Takada, Toshiaki Kurokawa, Shuhei Yoshida, and Shota Watanabe for their assistance with data collection.
Authors’ contributions
KS is the main author. KS, MH, and TI conceived the study, collected the data, and derived the multiple regression equation for estimation of the injected dosage. NT, MH, and YY collected the data and established data collection method. KI, TU, and TM participated in the comprehensive design of the study, evaluated the multiple regression equation, and revised the manuscript. All authors read and approved the final manuscript.
Competing interests
This work was supported by JSPS KAKENHI Grant Number 25461854 and 26670568.
Ethics approval and consent to participate
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
This article does not contain any studies with animals performed by any of the authors.
Five hundred twenty patients undergoing PET examination following a single administration of FDG were prospectively enrolled in this study with Institutional Review Board approval. The requirement to obtain informed consent was waived.
Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.
Authors’ Affiliations
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