The American College of Radiology, with more than 30,000 members, is the principal organization of radiologists, radiation oncologists,

and clinical medical

physicists in the United States. The College is a nonprofit professional society whose primary purposes are to advance the science of radiology, improve
radiologic services to the patient, study the socioeconomic aspects of the practice of radiology, and encourage continuing education for radiologists,
radiation oncologists, medical physicists, and persons practicing in allied professional fields.
The American College of Radiology will periodically define new practice parameters and technical standards for radiologic practice to help advance the science
of radiology and to improve the quality of service to patients throughout the United States. Existing practice parameters and technical standards will be reviewed
for revision or renewal, as appropriate, on their fifth anniversary or sooner, if indicated.
Each practice parameter and technical standard, representing a policy statement by the College, has undergone a thorough consensus process in which it has
been subjected to extensive review and approval. The practice parameters and technical standards recognize that the safe and effective use of diagnostic
and therapeutic radiology requires specific training, skills, and techniques, as described in each document. Reproduction or modification of the published practice
parameter and technical standard by those entities not providing these services is not authorized.

Revised 2023 (CSC/BOC)*

ACR–AAPM TECHNICAL STANDARD FOR MEDICAL PHYSICS

PERFORMANCE MONITORING OF PET/CT IMAGING EQUIPMENT

PREAMBLE

This document is an educational tool designed to assist practitioners in providing appropriate radiologic care for
patients. Practice Parameters and Technical Standards are not inflexible rules or requirements of practice and are
not intended, nor should they be used, to establish a legal standard of care1. For these reasons and those set forth
below, the American College of Radiology and our collaborating medical specialty societies caution against the use
of these documents in litigation in which the clinical decisions of a practitioner are called into question.

The ultimate judgment regarding the propriety of any specific procedure or course of action must be made by the
practitioner considering all the circumstances presented. Thus, an approach that differs from the guidance in this
document, standing alone, does not necessarily imply that the approach was below the standard of care. To the
contrary, a conscientious practitioner may responsibly adopt a course of action different from that set forth in this
document when, in the reasonable judgment of the practitioner, such course of action is indicated by variables such
as the condition of the patient, limitations of available resources, or advances in knowledge or technology after
publication of this document. However, a practitioner who employs an approach substantially different from the
guidance in this document may consider documenting in the patient record information sufficient to explain the
approach taken.

The practice of medicine involves the science, and the art of dealing with the prevention, diagnosis, alleviation, and
treatment of disease. The variety and complexity of human conditions make it impossible to always reach the most
appropriate diagnosis or to predict with certainty a particular response to treatment. Therefore, it should be
recognized that adherence to the guidance in this document will not assure an accurate diagnosis or a successful
outcome. All that should be expected is that the practitioner will follow a reasonable course of action based on
current knowledge, available resources, and the needs of the patient to deliver effective and safe medical care. The
purpose of this document is to assist practitioners in achieving this objective.

1
Iowa Medical Society and Iowa Society of Anesthesiologists v. Iowa Board of Nursing 831 N.W.2d 826 (Iowa 2013) Iowa Supreme Court refuses to find
that the ACR Technical Standard for Management of the Use of Radiation in Fluoroscopic Procedures (Revised 2008) sets a national standard for who may
perform fluoroscopic procedures in light of the standard’s stated purpose that ACR standards are educational tools and not intended to establish a legal
standard of care. See also, Stanley v. McCarver, 63 P.3d 1076 (Ariz. App. 2003) where in a concurring opinion the Court stated that “published standards or
guidelines of specialty medical organizations are useful in determining the duty owed or the standard of care applicable in a given situation” even though ACR
standards themselves do not establish the standard of care.

TECHNICAL STANDARD 1 PET-CT Equipment

I. INTRODUCTION

This technical standard was revised collaboratively by the American College of Radiology (ACR) and the American
Association of Physicists in Medicine (AAPM).

Positron emission tomography/computed tomography (PET/CT) systems can be operated to acquire only PET images
or CT images as well as PET/CT images, combining two medical imaging modalities: CT for both anatomical
imaging and attenuation correction and PET for functional imaging. This brings the advantages and complexities
of both systems while providing anatomical and functional aspects through fused images. All new PET/CT equipment
must be tested on installation and must be monitored at least annually by a Qualified Medical Physicist to ensure
proper functioning within the manufacturer’s specifications and accepted performance standards. Additional or more
frequent performance monitoring may be necessary in certain situations (eg, after major equipment maintenance).

Although it is not possible to consider all variations of equipment performance to be monitored, adherence to this
technical standard will optimize image quality and ensure the accuracy of quantitative clinical results . Key points
to consider are system performance characteristics, patient radiation dose, qualifications of personnel, radiation
shielding, and follow-up procedures.

The primary goal of PET/CT imaging is to produce quantifiably accurate and spatially coregistered PET and CT
images on the same platform. An additional goal is to produce images with the lowest radiation dose consistent with
the clinical use of the equipment and the information requirements of the examination. The purpose of this document
is to provide technical standards for medical physics oversight of PET/CT imaging equipment. The scope of these
technical standards is limited to the PET subsystem of PET/CT systems used for diagnostic imaging. Technical
standards for the CT subsystem are published in a separate document [1]. PET/CT systems used for specialized tasks,
such as radiotherapy dosimetry calculations, may require additional quality management (QM) beyond that described
in this document.

II. QUALIFICATIONS AND RESPONSIBILITIES OF PERSONNEL

A Qualified Medical Physicist must carry out acceptance testing and monitoring of PET/CT equipment.

A Qualified Medical Physicist is an individual who is competent to practice independently in one or more of the
subfields in medical physics. The American College of Radiology (ACR) considers certification, continuing
education, and experience in the appropriate subfield(s) to demonstrate that an individual is competent to practice
one or more of the subfields in medical physics and to be a Qualified Medical Physicist. The ACR strongly
recommends that the individual be certified in the appropriate subfield(s) by the American Board of Radiology
(ABR), the Canadian College of Physicists in Medicine, the American Board of Science in Nuclear Medicine
(ABSNM), or the American Board of Medical Physics (ABMP).

A Qualified Medical Physicist should meet the ACR Practice Parameter for Continuing Medical Education (CME)
[2].

The appropriate subfield of medical physics for this technical standard is Nuclear Medical Physics (including
medical physics certification categories of Radiological Physics and Medical Nuclear Physics and Nuclear Medicine
Physics) with continuing medical education in CT physics.
or
Diagnostic Medical Physics (including medical physics certification categories of Radiological Physics, Diagnostic
Radiological Physics, and Diagnostic Imaging Physics) with continuing education in PET imaging physics. (ACR
Resolution 17, adopted in 1996 – revised in 2008, 2012, 2022, Resolution 41f)

The Qualified Medical Physicist must be familiar with the principles of imaging physics and radiation protection; the
guidelines of the National Council on Radiation Protection and Measurements (NCRP); the laws and regulations
pertaining to the use of the equipment being tested; the function, clinical uses, and performance specifications of the

TECHNICAL STANDARD 2 PET-CT Equipment

imaging equipment; and the calibration processes and limitations of the instruments and the techniques used for
testing performance.

The Qualified Medical Physicist may be assisted by properly trained individuals in obtaining data. These individuals
must be approved by the Qualified Medical Physicist and be trained in the techniques of performing tests, the function
and limitations of the imaging equipment and test instruments, the reasons for the tests, and the importance of the test
results. The Qualified Medical Physicist is responsible for and must review, interpret, and approve all data and must
provide a signed report with conclusions [3].

III. PERFORMANCE CHARACTERISTICS TO BE MONITORED

A. Acceptance Testing

Initial performance testing of newly installed imaging equipment must be performed by a Qualified Medical
Physicist and should be completed before clinical use. This testing should be more comprehensive than periodic
performance testing and must be consistent with current acceptance testing practices [4,5]. Electrical safety of the
equipment must also be tested by appropriate personnel prior to its initial clinical use.

If a major component is replaced or repaired, a Qualified Medical Physicist should, in a timely manner, evaluate the
need for performance testing of the PET/CT scanner. The scope of the evaluation should be determined by the
Qualified Medical Physicist based on the type of component that was replaced or repaired.

B. Performance Evaluation

1. The Qualified Medical Physicist must design a QM program that includes regular quality control
(QC)/quality assurance (QA) procedures to ensure proper daily operation. The procedures should include
daily QC tests as well as quarterly scanner testing to evaluate image uniformity, image spatial resolution,
standardized uptake value (SUV) or activity concentration in becquerel (Bq/cc) accuracy, and image
contrast.

The following characteristics should be evaluated on at least an annual basis as applicable to the design of
the scanner:

a. Count rate performance (count rate versus activity), including corrections for count losses and random
coincidences
a. Sensitivity
b. Image uniformity and artifact assessment
c. Image spatial resolution
d. Image contrast
e. Accuracy of CT-based attenuation and scatter correction, and SUV or activity concentration
g. Image coregistration between PET and CT
h. Safety evaluation
i. Mechanical
ii. Electrical

Guidance in performing these tests is available from several sources [4-6]. The Qualified Medical Physicist
should decide how the tests should be performed for each system they survey.

2. Overall PET/CT imaging performance is affected by the individual and the joint performance of the PET
and CT subsystems. Performance evaluations should test each subsystem individually and together.

TECHNICAL STANDARD 3 PET-CT Equipment

C. Quality Management Program

A QM program must be established for all PET/CT systems with the assistance of a Qualified Medical Physicist
consistent with the recommendations of this document, the ACR–ACNM–SNMMI–SPR Practice Parameter for the
Use of Radiopharmaceuticals in Diagnostic Procedures [7], and the ACR–AAPM Technical Standard for Diagnostic
Medical Physics Performance Monitoring of Computed Tomography (CT) Equipment [1]. The Qualified Medical
Physicist should determine tolerances, the frequency of each QC/QA procedure and who should perform each
QC/QA procedure based on the facility, PET/CT usage, and the equipment manufacturer’s requirements and
recommendations. An on-site technologist should be identified to be responsible for conducting routine QC/QA
[1,7].

The results of the QM program must be monitored at least annually by the Qualified Medical Physicist. If measured
values of QC/QA parameters fall outside the established tolerances, the QC/QA technologist should consult with the
Qualified Medical Physicist. The Qualified Medical Physicist should recommend or, when appropriate, initiate
investigative or corrective actions. A Qualified Medical Physicist should be available to assist in prescribing
corrective actions for unresolved problems.

D. Written Survey Reports and Follow-Up Procedures

The Qualified Medical Physicist must provide a written report of the findings of acceptance testing and a performance
evaluation to the professional(s) in charge of obtaining or providing necessary service to the equipment and, if
appropriate, to the responsible physician(s). Written reports must be provided in a timely manner consistent with the
importance of any adverse findings.

If appropriate, the Qualified Medical Physicist should notify the facility to initiate the required service. The facility
must complete corrective actions in a timely manner consistent with the importance of any adverse findings. The
facility should retain service reports from competent service personnel as verification that the issue(s) were
appropriately resolved. The reports may be reviewed by a Qualified Medical Physicist to confirm that the equipment
is performing in a safe and acceptable fashion after the required service is performed or as required by federal, state,
or local regulations.

If use of the equipment would pose a danger to life or health or potentially result in erroneous clinical findings, the
Qualified Medical Physicist in collaboration with the facility’s Radiation Safety Officer and interpreting physician
must take immediate action to either prevent equipment use or to indicate in writing what limited studies can be
performed safely using the equipment until the hazard is addressed.

IV. RADIATION SAFETY IN IMAGING

Radiologists, medical physicists, non-physician radiology providers, radiologic technologists, and all supervising
physicians have a responsibility for safety in the workplace by keeping radiation exposure to staff, and to society as
a whole, "as low as reasonably achievable” (ALARA) and to assure that radiation doses to individual patients are
appropriate, taking into account the possible risk from radiation exposure and the diagnostic image quality
necessary to achieve the clinical objective. All personnel who work with ionizing radiation must understand the key
principles of occupational and public radiation protection (justification, optimization of protection, application of
dose constraints and limits) and the principles of proper management of radiation dose to patients (justification,
optimization including the use of dose reference levels). https://www-
pub.iaea.org/MTCD/Publications/PDF/PUB1775_web.pdf

Facilities and their responsible staff should consult with the radiation safety officer to ensure that there are policies
and procedures for the safe handling and administration of radiopharmaceuticals in accordance with ALARA
principles. These policies and procedures must comply with all applicable radiation safety regulations and
conditions of licensure imposed by the Nuclear Regulatory Commission (NRC) and by applicable state, local, or
other relevant regulatory agencies and accrediting bodies, as appropriate. Quantities of radiopharmaceuticals should

TECHNICAL STANDARD 4 PET-CT Equipment

be tailored to the individual patient by prescription or protocol, using body habitus or other customized method
when such guidance is available.

Nationally developed guidelines, such as the ACR’s Appropriateness Criteria®, should be used to help choose the
most appropriate imaging procedures to prevent unnecessary radiation exposure.

Additional information regarding patient radiation safety in imaging is available from the following websites –
Image Gently® for children (www.imagegently.org) and Image Wisely® for adults (www.imagewisely.org). These
advocacy and awareness campaigns provide free educational materials for all stakeholders involved in imaging
(patients, technologists, referring providers, medical physicists, and radiologists).

Radiation exposures or other dose indices should be periodically measured by a Qualified Medical Physicist in
accordance with the applicable ACR Technical Standards. Monitoring or regular review of dose indices from
patient imaging should be performed by comparing the facility’s dose information with national benchmarks, such
as the ACR Dose Index Registry and relevant publications relying on its data, applicable ACR Practice Parameters,
NCRP Report No. 172, Reference Levels and Achievable Doses in Medical and Dental Imaging: Recommendations
for the United States or the Conference of Radiation Control Program Director’s National Evaluation of X-ray
Trends; 2006, 2009, amended 2013, revised 2023 (Res. 2d).

Information on typical organ doses from radiopharmaceuticals should be available for all procedures. This
information must be reviewed by the Qualified Medical Physicist at least annually and updated when any of the
following occur: addition of new procedures and/or pharmaceuticals, changes in dosage schedules, change in route
of administration, and availability of more accurate dosimetry data [8-12]. For facilities performing pediatric
imaging, the radiopharmaceutical administered activities should be adjusted to be appropriate for the mass of the
patient. It is recommended that the administered activities follow those in the North American Consensus Guidelines
for Administered Radiopharmaceutical Activities in Children and Adolescents [13-16].

For performance evaluation and radiation dose assessment for CT, see the ACR–AAPM Technical Standard for
Diagnostic Medical Physics Performance Monitoring of Computed Tomography (CT) Equipment [1].

V. RADIATION SHIELDING CONSIDERATIONS

Special care must be exercised regarding radiation shielding requirements for PET/CT facility design. Appropriate
shielding must be provided for patient injection/uptake rooms, PET/CT imaging suites, hot labs, and any other areas
where PET radiopharmaceuticals are produced, prepared, used, disposed, or stored. Due to the high energy of
annihilation radiation used in PET, the amount and type of shielding materials needed to protect adjacent areas is
typically different from that of X-ray or conventional nuclear medicine. A Qualified Medical Physicist should be
consulted early in facility design planning stages so that shielding requirements can be determined and structural
design issues, created from using the larger amounts of shielding, can be assessed. The AAPM Task Group 108 report
“PET and PET/CT Shielding Requirements,” [17] in conjunction with the National Council on Radiation Protection
Report 147, should be used as a reference in determining PET/CT shielding requirements.

ACKNOWLEDGEMENTS

This technical standard was revised according to the process described under the heading The Process for Developing
ACR Practice Parameters and Technical Standards on the ACR website (https://www.acr.org/Clinical-
Resources/Practice-Parameters-and-Technical-Standards) by the Committee on Practice Parameters and Technical
Standards – Medical Physics of the ACR Commission on Medical Physics in collaboration with the AAPM.

Writing Committee – members represent their societies in the initial and final revision of this technical standard

ACR AAPM
Samuel A. Einstein, PhD, Chair David W. Jordan, PhD
Kenneth G. Lewis, II, MS, PhD

TECHNICAL STANDARD 5 PET-CT Equipment

 Osama Mawlawi, PhD, FACR
Keisha C. McCall, PhD
Alok Shankar, PhD

Committee on Practice Parameters and Technical Standards – Medical Physics

(ACR Committee responsible for sponsoring the draft through the process)

Mary Ann Keenan, DMP, Chair Samuel A. Einstein, PhD

Katherine P Andriole, PhD, FACR Ralph P. Lieto, MSE, FACR
Eric A. Berns, Ph.D, FACR Osama Mawlawi, PhD, FACR
Courtney R. Buckey, PhD Matthew A. Pacella, MS, FACR
Diana E. Carver, PhD Ashley E. Rubinstein, PhD
Heidi A. Edmonson, PhD Russell B. Tarver, MS

Mahadevappa Mahesh, MS, PhD, FACR, Chair, Commission on Medical Physics

David B. Larson, MD, MBA, FACR, Chair, Commission on Quality and Safety
Mary S. Newell, MD, FACR, Chair, Committee on Practice Parameters and Technical Standards

Comments Reconciliation Committee

Andrew K. Moriarity, MD, Chair David B. Larson, MD, MBA, FACR
Maxwell R. Amurao, PhD, MBA, Co-Chair Paul A. Larson, MD, FACR
Bradley Beattie, MS Kenneth G. Lewis, II, MS, PhD
Timothy A. Crummy, MD, MHA, FACR Mahadevappa Mahesh, MS, PhD, FACR
Samuel A. Einstein, PhD Osama Mawlawi, PhD, FACR
William Erwin, MS Keisha C. McCall, PhD
Mary Ellen Jafari, MD, FACR Mary S. Newell, MD, FACR
David W. Jordan, PhD Charles Schmidtlein, PhD
Mary Ann Keenan, DMP Alok Shankar, PhD
Amy L. Kotsenas, MD, FACR Roland Wong, ScM

REFERENCES

1. American College of Radiology. ACR–AAPM technical standard for diagnostic medical physics performance
monitoring of computed tomography (CT) equipment. Available at: https://www.acr.org/-
/media/ACR/Files/Practice-Parameters/CT-Equip.pdf. Accessed February 1, 2022.
2. American College of Radiology. ACR practice parameter for continuing medical education (CME). Available
at: https://www.acr.org/-/media/ACR/Files/Practice-Parameters/CME.pdf. Accessed January 20, 2022.
3. American Association of Physicists in Medicine. AAPM medical physics practice guideline 7.a.: supervision of
medical physicist assistants. Available at: https://aapm.onlinelibrary.wiley.com/doi/full/10.1002/acm2.12774.
Accessed April 1, 2022.
4. American Association of Physicists in Medicine. PET/CT acceptance testing and quality assurance: the report of
AAPM task group 126. Available at: https://www.aapm.org/pubs/reports/RPT_126.pdf. Accessed April 1, 2022.
5. National Electrical Manufacturers Assocation. Performance Measurements of Positron Emission Tomographs.
NEMA Standards Publication NU 2 [Available at: https://www.nema.org/Standards/Pages/Performance-
Measurements-of-Positron-Emission-Tomographs.aspx. Accessed April 1, 2022.
6. International Atomic Energy Agency. Quality Assurance for PET and PET/CT Systems. IAEA Human Health
Series, No. 1 [http://www-pub.iaea.org/MTCD/publications/PDF/Pub1393_web.pdf. Accessed June 15, 2012.
7. American College of Radiology. ACR–ACNM–SNMMI–SPR practice parameter for the use of
radiopharmaceuticals in diagnostic procedures. Available at: https://www.acr.org/-/media/ACR/Files/Practice-
Parameters/Radiopharmaceuticals.pdf. Accessed February 1, 2022.
8. American College of Radiology. ACR–AAPM–ACNM–SNMMI practice parameter for reference levels and
achievable administered activity for nuclear medicine and molecular imaging. Available at:
https://www.acr.org/-/media/ACR/Files/Practice-Parameters/RefLevels-NucMed.pdf. Accessed April 1, 2022.
9. International Commission on Radiological Protection. Publication 53 - radiation dose to patients from

TECHNICAL STANDARD 6 PET-CT Equipment

 radiopharmaceuticals. Available at: https://journals.sagepub.com/doi/pdf/10.1177/ANIB_18_1-4. Accessed
April 1, 2022.
10. International Commission on Radiological Protection. Publication 80 - radiation dose to patients from
radiopharmaceuticals addendum to ICRP 53; also includes addendum 1 to ICRP publication 72. Available at:
https://journals.sagepub.com/doi/pdf/10.1177/ANIB_28_3. Accessed April 1, 2022.
11. International Commission on Radiological Protection. Publication 106 - radiation dose to patients from
radiopharmaceuticals (a third amendment to ICRP Publication 53; also includes: radiation exposure of hands in
radiopharmacies) Available at: https://journals.sagepub.com/doi/pdf/10.1177/ANIB_38_1-2. Accessed April 1,
2022.
12. International Commission on Radiological Protection. Publication 128 - radiation dose to patients from
radiopharmaceuticals: a compendium of current information related to frequently used substances. Available at:
https://journals.sagepub.com/doi/pdf/10.1177/0146645314558019. Accessed April 1, 2022.
13. Lassmann M, Treves ST. Pediatric Radiopharmaceutical Administration: harmonization of the 2007 EANM
Paediatric Dosage Card (Version 1.5.2008) and the 2010 North American Consensus guideline. Eur J Nucl Med
Mol Imaging 2014;41:1636.
14. Oak Ridge Institute for Science and Education. Dose estimates and other compendia. Available at:
https://orise.orau.gov/resources/reacts/dose-estimation-resources.html. Accessed October 26, 2022.
15. Society of Nuclear Medicine and Molecular Imaging. Dosimetry. Available at:
http://www.snmmi.org/ClinicalPractice/content.aspx?ItemNumber=5325&navItemNumber=10792. Accessed
October 26, 2022.
16. Treves ST, Gelfand MJ, Fahey FH, Parisi MT. 2016 Update of the North American Consensus Guidelines for
Pediatric Administered Radiopharmaceutical Activities. Journal of nuclear medicine : official publication,
Society of Nuclear Medicine 2016;57:15N-18N.
17. Madsen MT, Anderson JA, Halama JR, et al. AAPM Task Group 108: PET and PET/CT shielding requirements.
Medical physics 2006;33:4-15.

*As of May 2015, all practice parameters and technical standards that are collaborative with only the American
Association of Physics in Medicine are approved by the ACR Council Steering Committee and the ACR Board of
Chancellors and will not go through the ACR Council (ACR Resolution 54, 2015). The effective date is the first day of
the month following a 60-day period that begins on the date the document was approved.

Development Chronology for this Technical Standard

2006 (Resolution 27, 16g, 17)
Revised 2008 (Resolution 4)
Amended 2009 (Resolution 11)
Amended 2012 (Resolution 42)
Revised 2013 (Resolution 45)
Revised 2018 (CSC/BOC)
Amended 2022 (Resolution 41f)
Revised 2023 (CSC/BOC) - Effective January 1st, 2024

TECHNICAL STANDARD 7 PET-CT Equipment