Added Value of Respiratory Gating in Positron Emission Tomography for the Clinical Management of Lung Cancer Patients

Positron emission tomography (PET) is an important imaging modality for personalizing clinical management of patients with lung cancer. In this regard, PET imaging is essential for adequate clinical staging and monitoring of treatment response in patients with lung cancer. The key advantage of PET over other radiological imaging modalities is its high sensitivity for the detection of pulmonary lesions, normal-sized metastatic hilar and/or mediastinal lymph nodes, and distant metastases. Furthermore, with increasing clinical evidence, the role of PET imaging for treatment selection, adaptation, early response mon-itoring and follow up in patients with lung cancer is being increasingly recognized. At the heart of PET imaging lies the ability to visualize and quantify numerous biological parame-ters that are responsible for treatment resistance. In order to ensure accurate and repro-ducible image quantification, harmonization of patient preparation and imaging protocols is essential. Additionally, there are several technical factors during PET scanning that have to be taken care of to safeguard image quality and quantitative accuracy. One of these factors is the occurrence of respiratory motion artifacts, which is a well-known fac-tor that can significantly influence image quality and quantitative accuracy of PET images. If left uncorrected, respiratory motion artifacts can introduce uncertainties in diagnosis and staging, inaccuracies in definition of target volumes for radiation treatment planning, and hinder adequate monitoring of therapy response. Although many different respiratory gating techniques have been developed to correct PET images for respiratory motion arti-facts, respiratory gating has traditionally not been widely adopted in clinical practice. This is due to the fact that these methods tend to be disruptive for the clinical workflow due the lengthening of image acquisition times, higher amounts of activity being administered to the patient, and the requirement to synchronize additional hardware with the scanner. Developments in respiratory gating techniques over the last years have resulted in considerable technical improvements. These newer respiratory gating techniques can operate directly on the acquired PET data without the use of additional hardware to trace respiratory motion and can be seamlessly applied into clinical routine. Furthermore, instead of only using a fraction of the acquired PET data newer methods have the ability to use all of the acquired PET data for image reconstruction, thereby improving image quality. The clinically added value of respiratory gating lies in improving image quality by reducing the amount of respiration-induced image blurring. This considerably improves the detection and characterization of small lesions, potentially improving early diagnosis and staging of patients with lung cancer. Furthermore, the incorpo-ration of (4D) respiratory gated PET for radiotherapy purposes has shown to improve target vol-ume definition through more accurate tracking of tumor motion. In addition, the effect of respiratory motion artifacts on widely used volumetric and uptake parameters in PET have been described. Although respiratory gating improves quantitative accuracy of PET images, the exact impact of these corrections on clinical management of patients with lung cancer often still needs to be determined.