Quantification: there is more to worry about than good scanner hardware and reliable calibration

Positron emission tomography (PET) is "an analytical imaging technology developed to use compounds labelled with positron-emitting radioisotopes as molecular probes to image and measure biochemical processes of mammalian biology in vivo" [1]. One outstanding feature of the PET technology is the ability to perform absolute quantification of regional perfusion, metabolism, and function [2]. There are clinical demands for quantification regarding description of biodistribution, dosimetry, intra- and inter-individual comparisons, and setup of age- and gender-specific (normal) databases. Notably, FDG PET allows diagnosis, differential diagnosis, assessment of prognosis, and patient stratification in malignant disease. Moreover, image guided therapy has been proven to improve tumour delineation and irradiation field definition regarding protection of normal tissue and dose escalation on tumour tissue [3]. After initial assessment, follow-up investigations describe the effect of therapy and influence therapeutic management regarding continuation or change of modality and intensification or de-escalation of therapy. In addition to qualitative description and quantification of tracer uptake or uptake changes during follow-up, more sophisticated kinetic modelling and analysis may be applied. However, reliability and significance of all derived numbers is influenced by technical factors and biological processes.