BACKGROUND:Pulmonary hypertension (PH) is a rare but progressive disorder characterized by elevated pressure in the pulmonary arteries. Early diagnosis is essential for effective treatment; however, its nonspecific symptoms often lead to delayed diagnosis. METHODS:In this retrospective cross-sectional study, a total of 648 patients who underwent myocardial perfusion scintigraphy (MPS) were analyzed. The patients were divided into two groups: those suspected of having PH and a control group without such suspicion. Ratios of right ventricular uptake to septal and lateral wall uptake on MPS were compared with pulmonary artery pressures (PAP) measured by transthoracic echocardiography. Correlation analyses focused particularly on changes following exercise. RESULTS:Among patients suspected of having PH, significant positive correlations were observed between right ventricular uptake ratios and PAPs. The p-values for rest right/septum, rest right/lateral, stress right/septum, and stress right/lateral were 0.001, 0.002, 0.001, and 0.001, respectively. This relationship was more pronounced after exercise. In contrast no significant correlation was detected in the control group. These findings indicate that increased right ventricular activity on MPS may reflect early hemodynamic changes associated with PH. CONCLUSIONS:MPS may be considered a non-invasive adjunctive modality that can provide supportive information for the early diagnosis of PH. Nevertheless, due to the retrospective design and absence of invasive confirmation, further prospective studies with larger cohorts are warranted.
BACKGROUND:This review aims to summarize and critically evaluate published clinical trials investigating the role of [18F]FDG PET in bladder cancer (BC) management, and to provide an overview of ongoing trials in this field. METHODS:A literature search was conducted in PubMed up to 31 August 2025 and on ClinicalTrials.gov to identify clinical trials assessing the role of [18F]FDG PET/CT in patients with BC. The search strategy used the terms "FDG PET," "bladder cancer," "PET/CT," "clinical trials," and "PET/MRI." Review articles, editorials, letters, comments, and case reports were excluded. Two investigators independently screened the literature, and additional trial information was retrieved from ClinicalTrials.gov. RESULTS:Five eligible full-text publications and eight registered clinical trials were identified. Among the publications, two reported study protocols, two were pilot studies, and one was an ancillary analysis from a larger trial. In addition, eight ongoing clinical trials were retrieved from ClinicalTrials.gov. Available data suggest that [18F]FDG PET/MRI may be more suitable than PET/CT for evaluating primary bladder lesions, while PET/CT is particularly effective in detecting distant metastases. Several ongoing studies are also investigating delayed acquisition protocols to improve detection of nodal metastases. CONCLUSIONS:[18F]FDG PET/CT and PET/MRI show promise for enhancing local and distant staging in muscle-invasive bladder cancer, although their role in nodal evaluation remains uncertain. Current evidence is limited by heterogeneous study designs, small patient cohorts, and the lack of standardized imaging protocols.
Lung scintigraphy has served as a cornerstone in the evaluation of pulmonary embolism for over 5 decades and currently retains an important role in the evaluation of both acute and chronic disease. This article elucidates the basic physiologic principles, choice of radiopharmaceuticals, imaging methods, and interpretation criteria used in lung scintigraphy and includes a lexicon of lung scintigraphy and nuclear medicine terminology which will be helpful to the yet uninitiated.
BACKGROUND:To summarize the more robust evidence about the performance of 18 fluorine-fluorodeoxyglucose positron emission tomography/computed tomography ([18F]FDG PET/CT) for diagnosis of cardiovascular infections, particularly endocarditis, cardiac implantable electronic device (CIED) infections, left ventricular assist device (LVAD) and vascular graft infection (VGI). METHODS:This systematic review of systematic reviews was carried out according to a predefined protocol. A search string was created. A comprehensive search of literature was performed until October 2025. RESULTS:Quality assessment of eligible systematic reviews was performed and main findings were described. CONCLUSIONS:[18F]FDG PET/CT has good diagnostic accuracy in detecting prosthetic valve endocarditis, cardiac devices infections (both CIED and LVAD) and VGI, while the accuracy seems to be sub optimal in patients with native valve endocarditis.
BACKGROUND:Sarcoidosis is a multisystem granulomatous disorder characterized by diverse clinical presentations and imaging findings, usually affecting the lungs and lymph nodes and skin and less commonly the heart and other organs. Positron emission tomography (PET), especially with [18F]FDG, has increasingly been used to improve the detection, risk stratification, and therapeutic monitoring of both cardiac sarcoidosis (CS) and systemic sarcoidosis (SS). METHODS:This umbrella review systematically examined published systematic reviews and meta-analyses reporting the evidence-based performance and clinical utility of PET, particularly hybrid techniques such as PET/CT for the evaluation of cardiac and systemic sarcoidosis. Multiple biomedical databases, including PubMed/MEDLINE and the Cochrane Library, were systematically searched using defined keywords related to PET imaging and sarcoidosis. RESULTS:A qualitative synthesis of the included systematic reviews and meta-analyses revealed consistent evidence supporting the application of [18F]FDG PET/CT in both cardiac and systemic sarcoidosis. Selected reviews highlighted [18F]FDG PET/CT's value for diagnosing active disease, guiding immunosuppressive therapy, and risk stratification, especially in cardiac involvement. [18F]FDG PET/CT emerged as a valuable adjunct in evaluating suspected sarcoidosis when conventional diagnostic methods were inconclusive or insufficient. CONCLUSIONS:Evidence-based reviews consistently support the integration of [18F]FDG PET/CT for clinical decision-making in cardiac and systemic sarcoidosis, particularly for patients with unclear presentations or complex disease, for diagnosing, risk stratification and monitoring sarcoidosis. Advancing this field will require focused efforts on standardizing imaging protocols, fostering multicenter collaboration, and incorporating PET-based analyses into treatment strategies to enhance patient care and promote precision medicine in inflammatory cardiomyopathies.
BACKGROUND:Papillary thyroid carcinoma (PTC) with a BRAFV600E mutation is linked to more aggressive tumor characteristics, as well as a higher likelihood of recurrence and disease-specific mortality. This study aimed to investigate the association between BRAFV600E mutation status in patients with recurrent PTC post radioiodine (RAI) therapy and its relationship with clinicopathological characteristics and [18F]FDG-uptake patterns on PET/CT. METHODS:The multi-step selection process resulted in a final cohort of 38 patients out of 851 patients with thyroid carcinoma. The final cohort had confirmed papillary thyroid carcinoma, underwent thyroidectomy with subsequent RAI treatment, documented BRAFV600E status and elevated thyroglobulin (Tg) levels, and a [18F]FDG-PET/CT scan post-biopsy. Collected clinicopathological data encompassed among others tumor size and number of metastases. Furthermore, the lesions' SUVmax, peak, mean, MTV, and TLG were assessed, and associated with the respective BRAF-Status and the clinicopathological data. RESULTS:The statistical analyses showed a significant association between SUVmax, SUVpeak, SUVmean, and BRAFV600E mutation status, with P=0.009, P=0.0088, P=0.0092, respectively. There was also an independent correlation between tumor size and SUVmax. No significant difference in tumor size was observed between the BRAF+ and BRAF- groups. There was no significant association between TLG, MTV, Tg levels with SUVs. CONCLUSIONS:The BRAFV600E mutation and larger tumor size are linked to increased maximum, mean, and peak FDG uptake values on [18F]FDG-PET/CT in patients with recurrent PTC. These findings improve understanding of mutation-associated metabolic behavior in recurrent PTC; however, they do not support changes in clinical management or risk stratification based solely on FDG PET/CT metrics or BRAFV600E status. Further research should investigate the potential of [18F]FDG-PET/CT metrics as biomarkers for guiding individualized treatment strategies in BRAFV600E-positive PTC.
INTRODUCTION:Fever or inflammation of unknown origin (FUO/IUO), bacteremia, and sepsis represent challenging diagnostic scenarios in clinical practice. Over the past decade, multiple systematic reviews and meta-analyses have reported quantitative data regarding the diagnostic accuracy, clinical impact, and cost-effectiveness of fluorine-18 fluorodeoxyglucose positron emission tomography combined with computed tomography ([18F]FDG PET/CT) in these complex infectious and inflammatory conditions. We performed an umbrella review of published systematic reviews and meta-analyses to provide a comprehensive evidence-based summary of the diagnostic performance, clinical utility, and cost-effectiveness of [18F]FDG PET/CT across different patient populations and clinical scenarios. EVIDENCE ACQUISITION:A comprehensive literature search of PubMed/MEDLINE and Cochrane Library databases was conducted to identify published evidence-based articles evaluating [18F]FDG PET/CT in adult FUO/IUO, pediatric FUO, bacteremia, sepsis, febrile neutropenia, and chronic Q fever. Quality assessment of included reviews was performed using the critical appraisal framework of the Oxford Centre for Evidence-Based Medicine (OCEBM). EVIDENCE SYNTHESIS:A total of 14 published systematic reviews met the inclusion criteria. [18F]FDG PET/CT demonstrated high diagnostic sensitivity (81-94%) in adult FUO/IUO with diagnostic yield ranging from 56-75%. In pediatric FUO, sensitivity was 83% with specificity of 77.6% and area under the curve of 0.83. In bacteremia and sepsis, particularly in critically ill patients, [18F]FDG PET/CT achieved sensitivity of 94%. The imaging modality showed diagnostic utility in specialized populations including chronic Q fever (focus detection rate 79.5%), febrile neutropenia (83% added clinical value), and ICU patients (mean sensitivity 94.6%). Management modifications were observed in 20-48% of patients based on [18F]FDG PET/CT findings. Cost-effectiveness analysis supports selective use in high-risk patient populations, with numbers-needed-to-scan ranging from 3-6 in complex bacteremia. CONCLUSIONS:Evidence from systematic reviews demonstrates that [18F]FDG PET/CT is a valuable diagnostic tool in FUO/IUO, bacteremia, sepsis, and related infectious/inflammatory conditions, with clinically significant impact on patient management. Strategic patient selection based on clinical risk factors optimizes cost-effectiveness. Future standardization of imaging protocols and prospective comparative studies are needed to define optimal clinical indications across different populations.
177Lu-PSMA-targeted radioligand therapy (TRT) represents a major advance in managing metastatic castration-resistant prostate cancer (mCRPC), exploiting PSMA overexpression to deliver β-particle radiation precisely to tumor cells while sparing healthy tissue. Following demonstration of survival and quality-of-life benefits in the Phase III VISION trial, it has been approved by the FDA and incorporated into international guidelines as a standard-of-care option. As clinical use expands, patient-specific internal dosimetry is increasingly recognized as essential for optimizing efficacy, minimizing toxicity, and enabling personalized treatment planning. This review provides a practical, step-by-step framework for performing 177Lu-PSMA dosimetry, from administration and quantitative imaging to time-activity-curve generation and absorbed-dose estimation. Evidence supports a strong correlation between tumor absorbed dose and therapeutic response, while established thresholds for organs at risk, particularly kidneys, salivary glands, and bone marrow, help guide safe administration. Although logistical barriers have limited routine implementation, innovations such as reduced-field-of-view imaging, deep-learning-assisted reconstruction, simplified single- or dual-time-point schemes, and automated pipelines are streamlining workflows. Machine-learning dose-prediction models and ongoing prospective trials, such as PRODIGY-1, are advancing individualized dosing strategies. Personalized dosimetry is thus emerging as a cornerstone for maximizing the safety and effectiveness of 177Lu-PSMA therapy and integrating it seamlessly into routine clinical practice.
BACKGROUND:Molecular imaging of bladder cancer (BC) remains challenging, mainly due to the limitations of [18F]FDG PET/CT in assessing the primary tumor site and differentiating malignant from physiological urinary activity. Consequently, the development of novel PET radiopharmaceuticals is crucial to enhance diagnostic accuracy and optimize patient management. Emerging radiopharmaceuticals have shown potential advantages in this context. Therefore, the aim of this narrative review was to summarize available evidence on the role of alternative PET radiopharmaceuticals for the evaluation of BC. METHODS:Fourteen studies involving 158 patients from six countries met the inclusion criteria. Investigated radiopharmaceuticals included [18F]/[68Ga]-FAPI, [18F]Fluciclovine, [68Ga]Ga-N188 (nectin-4-targeted), and 64CuCl2. In four studies, [18F]FDG PET/CT was used as an imaging comparator. The quality was good in 6 original articles including more than 10 patients. [18F]Fluciclovine demonstrated high specificity and a favorable biodistribution for muscle invasive BC staging; PSMA-targeted imaging showed diagnostic and theranostic promise despite variable expression. FAPI radiopharmaceuticals offered a superior lesion detection, image contrast, and potential therapeutic applications, while 64CuCl2 and [68Ga]Ga-N188 underscored a shift toward personalized molecular imaging. RESULTS:Fourteen studies evaluated emerging radiopharmaceuticals for BC imaging. FAPI agents showed the highest lesion detectability, while fluciclovine demonstrated high specificity for muscle-invasive disease. PSMA tracers, 64CuCl2 and [68Ga]Ga-N188 underscored a growing move toward personalised, theranostic molecular imaging. CONCLUSIONS:[18F]FDG remains the reference PET agent in BC; however, novel agents show encouraging results for improving staging and therapy monitoring. Broader clinical implementation requires multicentric validation and standardized imaging protocols.
BACKGROUND:Fibroblast activation protein (FAP) is highly expressed in the stroma of various cancers, making it a promising target for positron emission tomography (PET) imaging. This study aimed to evaluate the clinical performance of 68Ga-labeled fibroblast activation protein inhibitor (FAPI)-46 PET/CT across multiple cancer types. METHODS:In this single-center, retrospective study, we included 22 patients (mean age 43 years, range 10-69) with histopathologically confirmed primary or metastatic cancers in whom 18F-FDG PET/CT or conventional imaging yielded inconclusive results. All patients underwent 68Ga-FAPI-46 PET/CT. Scan positivity was determined by two experienced nuclear medicine physicians based on non-physiologic tracer uptake. Malignancy was confirmed by histopathology (the reference standard) or correlative imaging follow-up. Analysis was performed on both a per-patient and per-lesion basis. Tumor uptake was quantified using maximum standardized uptake value (SUVmax) and tumor-to-background ratio (TBR). Statistical comparisons of SUVmax and TBR between different groups were performed using Student's t-tests. RESULTS:A total of 115 lesions were identified and evaluated across 12 different cancer types. The highest 68Ga-FAPI-46 avidity (SUVmax>12) was observed in sarcoma, breast cancer, and cholangiocarcinoma, while the lowest uptake (SUVmax<6) was found in renal cell, differentiated thyroid, and gastric cancers. Intermediate uptake (SUVmax 6-12) was seen in hepatocellular, colorectal, and ovarian cancers. Due to minimal background activity (muscle and blood pool SUVmax<2), TBRs were high, exceeding 3-fold for intermediate and 6-fold for high-uptake tumors. CONCLUSIONS:68Ga-FAPI-46 PET/CT provides high-contrast imaging across a wide spectrum of malignancies, demonstrating particularly strong potential for visualizing tumors with prominent stromal components. These findings suggest a significant clinical role for this modality in improving tumor staging, restaging, and therapy assessment, especially in cases where 18F-FDG PET/CT is suboptimal.
The long-term management of patients after pulmonary embolism (PE) remains a major challenge, owing to the risk of persistent symptoms, complications, and recurrence. Residual pulmonary vascular obstruction (RPVO) is common, affecting up to 50% of patients after six months of anticoagulation. Ventilation-perfusion (V/Q) scintigraphy is the imaging modality of choice for detecting RPVO, which typically presents as mismatched perfusion defects, as it offers a sensitivity superior to that of computed tomography pulmonary angiography (CTPA), together with lower radiation exposure and the absence of iodinated contrast agents. V/Q scintigraphy plays a pivotal role in the screening of chronic thromboembolic pulmonary hypertension (CTEPH) and chronic thromboembolic pulmonary disease (CTEPD). Furthermore, follow-up V/Q scintigraphy may aid in the diagnosis of recurrent PE and in predicting recurrence risk.
Pulmonary embolism (PE) remains a major diagnostic challenge due to its potentially life-threatening nature and the clinical burden associated with anticoagulation therapy. While computed tomography pulmonary angiography (CTPA) has become the dominant imaging modality for suspected PE, limitations including radiation exposure - particularly to breast tissue-iodinated contrast administration, and concerns about overdiagnosis have prompted renewed interest in alternative strategies. Ventilation-perfusion (V/Q) scintigraphy, grounded in physiological assessment of pulmonary ventilation and perfusion, offers a non-invasive approach with substantially lower radiation and an excellent safety profile. However, planar V/Q imaging is limited by a high proportion of nondiagnostic studies. Recent advances in single-photon emission computed tomography (SPECT) and hybrid SPECT/CT have significantly improved diagnostic accuracy, reduced inconclusive results, and enhanced the ability to distinguish embolic from non-embolic causes of perfusion defects. Despite widespread adoption, formal outcome validation of SPECT-based diagnostic algorithms has been lacking until the recent completion of the international SPECTACULAR randomized controlled trial, designed to compare planar V/Q, CTPA, and SPECT V/Q strategies using three-month thromboembolic recurrence as the reference for clinical safety. Results will be available shortly following presentation at SNMMI annual meeting 2025. Lung scintigraphy plays an essential role in specific populations, including pregnancy or contrast use is restricted. Moreover, ongoing developments in V/Q PET imaging and artificial intelligence-driven post-processing promise improved spatial resolution, quantification, and workflow efficiency, while advanced molecular tracers may enable characterization of thrombus biology. In summary, V/Q scintigraphy - particularly SPECT and SPECT/CT - remains a robust and clinically valuable modality for diagnosing acute PE, offering a radiation-sparing alternative to CTPA. Technological innovation and high-quality outcome evidence are likely to support its broader integration into future diagnostic pathways.
Lung scintigraphy is a common nuclear medicine procedure for evaluating pulmonary perfusion and ventilation, particularly in the diagnosis of pulmonary embolism (PE) and preoperative lung function assessment. With the advent of artificial intelligence (AI), this modality is undergoing a transformative evolution. This review explores the multifaceted integration of AI across the lung scintigraphy workflow - from patient positioning and image acquisition to reconstruction, interpretation, and reporting. We review clinically available, published, and possible future applications of AI. We begin with AI for PE detection, segmentation, and classification, and highlight emerging opportunities in diagnosing chronic obstructive pulmonary disease (COPD), chronic thromboembolic pulmonary hypertension (CTEPH), and pneumonia. The paper also discusses AI-driven image enhancement, cross-modality image synthesis, and automated lung lobe segmentation. Throughout, we emphasize the importance of representative datasets and internal validation. We touch on clinical integration of AI and the potential for AI to revitalize lung scintigraphy amidst competing imaging modalities. Through this overview, we aim to inform clinicians and researchers of the current landscape and future directions of AI in lung scintigraphy, to caution against common pitfalls, and remind of the continued responsibility of clinicians to prevent medical errors.
Pulmonary ventilation scintigraphy is a key examination for assessing regional lung function, with important implications for the management of numerous pulmonary diseases. Several radiopharmaceuticals are available for ventilation imaging, such as gases tracers (133Xe and 81mKr) or aerosol-based radiopharmaceuticals ([99mTc]Tc-DTPA; Technegas, Cyclopharm Limited, Kingsgrove, Australia), each with specific physical and technical characteristics that influence image quality, practical implementation, and clinical interpretation. The choice of tracer therefore has direct consequences for diagnostic accuracy and workflow in routine practice. This review summarizes the main agents currently used for ventilation scintigraphy and outlines their respective properties, advantages, and limitations.
Lung scintigraphy has withstood the test of time having been in use for over 60 years. It has evolved today to a tomographic modality with optimal radiopharmaceuticals for both ventilation (V) and perfusion (Q) imaging using technetium-99m radiolabeled agents. In addition to the SPECT imaging of V and Q, today's multimodality imaging devices can add low-dose CT to provide anatomical correlation further improving the sensitivity and, in particular, specificity of lung scanning for pulmonary embolism (PE). Lung scanning has moved beyond just imaging for PE now to assessing regional lung function and the matching between ventilation and perfusion for optimal gas exchange. This helps guide decisions regarding surgical and similar interventions. The enhanced capability afforded by SPECT/CT imaging of regional ventilation and perfusion also brings some attendant challenges such as apparent artefacts due to ventilation patterns that exceed normal perfusion at the borders of the lungs. However, with appropriate experience, the lung scan can now produce an answer on the diagnosis of PE in better than 95% of cases with few indeterminate reports.
BACKGROUND:The effect of breathing on the [18F]fluorocholine parathyroid uptake profile has not been yet evaluated. The main objective of our study is to assess the technical feasibility of respiratory-gated [18F]fluorocholine PET/CT in patients with hyperparathyroidism. Specifically, we aimed to investigate whether respiratory motion correction has a measurable impact on quantitative PET parameters compared to free-breathing PET in a cohort of patients with clearly identifiable hypermetabolic parathyroid lesions. METHODS:Respiratory-gated [18F]fluorocholine PET/CT was performed using a pressure-sensitive belt placed around the thorax. An elliptic volume of interest was drawn on each hyperfunctioning parathyroid on both respiratory-gated and free-breathing PET scans, and SUVmax and SUVpeak were measured. An image profile was drawn across hypermetabolic targets on the coronal view, and full-width-at-half-maxima (FWHM) of glandular uptake profile was calculated. Wilcoxon signed-rank test and Mann-Whitney U-test were used for intragroup and intergroup comparison, respectively. A P value <0.05 was considered as significant. RESULTS:A total of 143 hyperfunctioning parathyroid glands (61 superior, 79 inferior, three ectopic) were identified in 110 patients. Respiratory-gated PET showed a statistically significant increase in both SUVmax and SUVpeak compared to ungated PET across all glands (P<0.001). The effect was more pronounced for inferior glands, with a mean SUVmax increment of 10.14%, compared to 7.81% for superior glands, although the difference was not statistically significant for the latter. The mean extent of respiratory parathyroid blurring in the axial direction was 13.7 mm. FWHM analysis revealed a significant reduction in respiratory blurring in respiratory-gated PET (P<0.001). CONCLUSIONS:Respiratory gating improves image quality and visual assessment of hyperfunctioning parathyroid glands by reducing image blurring. Further research is necessary to assess the diagnostic impact of these findings in clinical practice, especially in cases with indeterminate ungated [18F]Fluorocholine PET examinations.
BACKGROUND:A non-invasive location of the abnormal parathyroid glands (PT) is recommended, by pairing ultrasonography (US) with a functional imaging modality, the most accurate being 18F-fluorocholine (FCH) PET/CT. Limited evidence is available about optimization of presurgical imaging in renal hyperparathyroidism (rHPT). We performed a head-to-head comparison of the detection of abnormal parathyroid glands pairing those two imaging modalities in this context. We also investigated whether awareness of the results of the examination carried out first improved the sensitivity of the interpretation of the second examination, aiming to determine the most effective sequence for performing those paired examinations (PEs). METHODS:FCH PET/CT has been performed as part of presurgical work-up for rHPT in one single PET center, paired with ultrasonography (US) (PE: paired examinations), without predefined sequence order, in a real-world context. Were selected from our database 159 PEs performed between September 2012 and September 2022. PET/CT was acquired 20-30 min after FCH injection of 3 MBg/kg body mass; US was performed from the angle of the mandible to the mediastinum with a high-frequency linear probe and a microconvex probe for deep structures. The interpretation reports have been carried out-on site after each examination, aware of the elements of the patient's file, including the result of the 1st PE for interpreting the 2nd PE. Each abnormal focus or image was rated as positive or equivocal for an abnormal parathyroid gland (PT), or of another origin. The positivity rate was determined for each imaging modality. We were aware of PT (re)operation after 98 PEs; 227 abnormal PTs were resected, histology being the standard-of-truth to determine the gland-based sensitivity. The Fisher's Test was used to compare the gland-based sensitivity of each imaging modality, according to being performed first or second. RESULTS:The patient-based positivity rate of FCH PET/CT was greater than that of US (P<0.0001), equivocal foci or images being considered either as negative (91% vs. 64% respectively) or as positive (92% vs. 69%). Accordingly, the gland-based sensitivity of FCH PET/CT was also greater than that of US (P<0.0001), equivocal foci or images being considered either as negative (85% vs. 58%, respectively) or as positive (89% vs. 62%, respectively). Interestingly, the diagnostic performance of US was significantly greater if practiced and interpreted aware of FCH PET/CT results (gland-based sensitivity, equivocal images considered as negative: 50% US 1st vs. 74% US 2nd after FCH PET/CT, P<0.0006). For FCH PET/CT, the difference was not significant. CONCLUSIONS:This is currently the largest of published series about preoperative imaging with FCH PET/CT in rHPT. Our results confirmed superior gland-based sensitivity of FCH PET/CT and also substantiated performing US after FCH PET/CT, whose results can guide US practice and interpretation, both PEs contributing for an optimal surgical protocol. We conclude that optimal imaging sequence in rHPT is FCH PET/CT performed first and not just part of the first line imaging examinations.
