Use of the flat panel detector fluoroscope reduces radiation exposure during periacetabular osteotomy.

The Periacetabular Osteotomy is a technically demanding procedure that requires precise intraoperative evaluation of pelvic anatomy. Fluoroscopic images pose a radiation risk to operating room staff, scrubbed personnel, and the patient. Most commonly, a Standard Fluoroscope with an Image Intensifier is used. Our institution recently implemented the novel Fluoroscope with a Flat Panel Detector. The purpose of this study was to compare radiation dosage and accuracy between the two fluoroscopes. A retrospective review of a consecutive series of patients who underwent Periacetabular Osteotomy for symptomatic hip dysplasia was completed. The total radiation exposure dose (mGy) was recorded and compared for each case from the standard fluoroscope (n = 27) and the flat panel detector (n = 26) cohorts. Lateral center edge angle was measured and compared intraoperatively and at the six-week postoperative visit. A total of 53 patients (96% female) with a mean age and BMI of 17.84 (± 6.84) years and 22.66 (± 4.49) kg/m2 (standard fluoroscope) and 18.23 (± 4.21) years and 21.99 (± 4.00) kg/m2 (flat panel detector) were included. The standard fluoroscope averaged total radiation exposure to be 410.61(± 193.02) mGy, while the flat panel detector averaged 91.12 (± 49.64) mGy (p < 0.0001). The average difference (bias) between intraoperative and 6-week postoperative lateral center edge angle measurement was 0.36° (limits of agreement: - 3.19 to 2.47°) for the standard fluoroscope and 0.27° (limits of agreement: - 2.05 to 2.59°) for the flat panel detector cohort. Use of fluoroscopy with flat panel detector technology decreased the total radiation dose exposure intraoperatively and produced an equivalent assessment of intraoperative lateral center edge angle. Decreasing radiation exposure to young patients is imperative to reduce the risk of future comorbidities.

Gel Rolls Increase Percutaneous Nephrolithotomy Radiation Exposure.

Introduction: Despite increasing interest in reducing radiation doses during endoscopic stone surgery, there is conflicting evidence as to whether percutaneous nephrolithotomy (PCNL) positioning (prone or supine) impacts radiation. We observed clinically that a patient placed prone on gel rolls had higher than expected radiation with intraoperative CT imaging and that gel rolls were visible on the coaxial imaging. We hypothesized that gel rolls directly increase radiation doses. Methods: Anthropomorphic experiments to simulate PCNL positions were performed using a robotic multiplanar fluoroscopy system (Artis Zeego Care+Clear, Siemens) and a 5-second coaxial imaging protocol (5s BODY). A fluoroscopy phantom was placed in various positions, including prone on a gel roll; prone on blankets of equal thickness; prone and supine directly on the table; and modified supine (MS) positions using a thin gel roll or rolled blanket. Impacts of C-arm direction and use of a 1 L saline bag were also evaluated. Measured dose area product (DAP) was compared for the groups. Results: Measured DAP was found to increase by 146 µGy*m2 (287%) when prone on gel rolls compared with only 62.29 (23%) when placed on blankets of equal thickness, although the model likely both overstates the relative impact and understates the absolute impact that would be seen clinically. Measured DAP between experimental groups also varied considerably despite fluoroscopy time being held constant. Conclusions: Our experiments support our hypothesis that gel rolls directly increase radiation dose, which has not been previously reported, using an anthropomorphic model. Surgeons should consider radiolucent materials for positioning to limit radiation exposure to patients and the surgical team.

AAPM Medical Physics Practice Guideline 14.a: Yttrium-90 microsphere radioembolization.

Radioembolization using Yttrium-90 (90 Y) microspheres is widely used to treat primary and metastatic liver tumors. The present work provides minimum practice guidelines for establishing and supporting such a program. Medical physicists play a key role in patient and staff safety during these procedures. Products currently available are identified and their properties and suppliers summarized. Appropriateness for use is the domain of the treating physician. Patient work up starts with pre-treatment imaging. First, a mapping study using Technetium-99m (Tc-99m ) is carried out to quantify the lung shunt fraction (LSF) and to characterize the vascular supply of the liver. An MRI, CT, or a PET-CT scan is used to obtain information on the tumor burden. The tumor volume, LSF, tumor histology, and other pertinent patient characteristics are used to decide the type and quantity of 90 Y to be ordered. On the day of treatment, the appropriate dose is assayed using a dose calibrator with a calibration traceable to a national standard. In the treatment suite, the care team led by an interventional radiologist delivers the dose using real-time image guidance. The treatment suite is posted as a radioactive area during the procedure and staff wear radiation dosimeters. The treatment room, patient, and staff are surveyed post-procedure. The dose delivered to the patient is determined from the ratio of pre-treatment and residual waste exposure rate measurements. Establishing such a treatment modality is a major undertaking requiring an institutional radioactive materials license amendment complying with appropriate federal and state radiation regulations and appropriate staff training commensurate with their respective role and function in the planning and delivery of the procedure. Training, documentation, and areas for potential failure modes are identified and guidance is provided to ameliorate them.

Quantitative Accuracy of Penalized-Likelihood Reconstruction for ROI Activity Estimation.

Estimation of the tracer uptake in a region of interest (ROI) is an important task in emission tomography. ROI quantification is essential for measuring clinical factors such as tumor activity, growth rate, and the efficacy of therapeutic interventions. Accuracy of ROI quantification is significantly affected by image reconstruction algorithms. In penalized maximum-likelihood (PML) algorithm, the regularization parameter controls the resolution and noise tradeoff and, hence, affects ROI quantification. To obtain the optimum performance of ROI quantification, it is desirable to use a moderate regularization parameter to effectively suppress noise without introducing excessive bias. However, due to the non-linear and spatial-variant nature of PML reconstruction, choosing a proper regularization parameter is not an easy task. Our previous theoretical study [1] has shown that the bias-variance characteristic for ROI quantification task depends on the size and activity distribution of the ROI. In this work, we design physical phantom experiments to validate these predictions in a realistic situation. We found that the phantom data results match well the theoretical predictions. The good agreement between the phantom results and theoretical predictions shows that the theoretical expressions can be used to predict the accuracy of ROI activity quantification.

Fabrication and characterization of a 0.5-mm lutetium oxyorthosilicate detector array for high-resolution PET applications.

UNLABELLED: With the increasing use of in vivo imaging in mouse models of disease, there are many interesting applications that demand imaging of organs and tissues with submillimeter resolution. Though there are other contributing factors, the spatial resolution in small-animal PET is still largely determined by the detector pixel dimensions. METHODS: In this work, a pair of lutetium oxyorthosilicate (LSO) arrays with 0.5-mm pixels was coupled to multichannel photomultiplier tubes and evaluated for use as high-resolution PET detectors. RESULTS: Flood histograms demonstrated that most crystals were clearly identifiable. Energy resolution varied from 22% to 38%. The coincidence timing resolution was 1.42-ns full width at half maximum (FWHM). The intrinsic spatial resolution was 0.68-mm FWHM as measured with a 30-gauge needle filled with (18)F. The improvement in spatial resolution in a tomographic setting is demonstrated using images of a line source phantom reconstructed with filtered backprojection and compared with images obtained from 2 dedicated small-animal PET scanners. Finally, a projection image of the mouse foot is shown to demonstrate the application of these 0.5-mm LSO detectors to a biologic task. CONCLUSION: A pair of highly pixelated LSO detections has been constructed and characterized for use as high-spatial-resolution PET detectors. It appears that small-animal PET systems capable of a FWHM spatial resolution of 600 microm or less are feasible and should be pursued.

High-resolution PET detector design: modelling components of intrinsic spatial resolution.

The development of dedicated small animal PET (positron emission tomography) scanners has led to significantly higher spatial resolution and comparable sensitivity to clinical scanners. However, it is not clear whether we are approaching the fundamental limit of spatial resolution. This work aims to understand what is currently limiting spatial resolution during data formation and collection and how to apply that knowledge to obtain the best possible resolution for small animal PET without sacrificing sensitivity. Monte Carlo simulations were performed of the interactions of a 511 keV photon in a variety of detector materials to evaluate the modulation transfer function of the materials. Positron range, non-colinearity and pixel size were modelled to determine the contribution of additional components of data formation and collection on the complete modulation transfer function of a PET system. These simulations are shown to predict the intrinsic detector resolution of current high resolution systems very well. They also show that current detectors are not limited by inter-crystal scatter. An intrinsic resolution of 0.5 mm can be achieved, but would require a detector with a pixel size of around 250 microm that can be read out unambiguously. It is shown that a range of different detector materials, both scintillators and semiconductors, can be used in these high-resolution detectors. While this design relies on thin (approximately 3 mm) pieces of material, stacks of the material are shown to simultaneously provide spatial resolution near 0.5 mm and 60% efficiency. This work has shown that detectors with significantly better resolution and sensitivity can be developed for small animal PET applications.

MicroPET II: design, development and initial performance of an improved microPET scanner for small-animal imaging.

MicroPET II is a second-generation animal PET scanner designed for high-resolution imaging of small laboratory rodents. The system consists of 90 scintillation detector modules arranged in three contiguous axial rings with a ring diameter of 16.0 cm and an axial length of 4.9 cm. Each detector module consists of a 14 x 14 array of lutetium oxyorthosilicate (LSO) crystals coupled to a multi-channel photomultiplier tube (MC-PMT) through a coherent optical fibre bundle. Each LSO crystal element measures 0.975 mm x 0.975 mm in cross section by 12.5 mm in length. A barium sulphate reflector material was used between LSO elements leading to a detector pitch of 1.15 mm in both axial and transverse directions. Fused optical fibre bundles were made from 90 microm diameter glass fibres with a numerical aperture of 0.56. Interstitial extramural absorber was added between the fibres to reduce optical cross talk. A charge-division readout circuit was implemented on printed circuit boards to decode the 196 crystals in each array from the outputs of the 64 anode signals of the MC-PMT. Electronics from Concorde Microsystems Inc. (Knoxville, TN) were used for signal amplification, digitization, event qualification, coincidence processing and data capture. Coincidence data were passed to a host PC that recorded events in list mode. Following acquisition, data were sorted into sinograms and reconstructed using Fourier rebinning and filtered hackprojection algorithms. Basic evaluation of the system has been completed. The absolute sensitivity of the microPET II scanner was 2.26% at the centre of the field of view (CFOV) for an energy window of 250-750 keV and a timing window of 10 ns. The intrinsic spatial resolution of the detectors in the system averaged 1.21 mm full width at half maximum (FWHM) when measured with a 22Na point source 0.5 mm in diameter. Reconstructed image resolution ranged from 0.83 mm FWHM at the CFOV to 1.47 mm FWHM in the radial direction, 1.17 mm FWHM in the tangential direction and 1.42 mm FWHM in the axial direction at 1 cm offset from the CFOV. These values represent highly significant improvements over our earlier microPET scanner (approximately fourfold sensitivity increase and 25-35% improvement in linear spatial resolution under equivalent operating conditions) and are expected to be further improved when the system is fully optimized.