An extended bore length solid-state digital-BGO PET/CT system: design, preliminary experience, and performance characteristics.

PURPOSE: A solid-state PET/CT system uses bismuth germanium oxide (BGO) scintillating crystals coupled to silicon photomultipliers over an extended 32 cm axial field-of-view (FOV) to provide high spatial resolution and very high sensitivity. Performance characteristics were determined for this digital-BGO system, including NEMA and EARL standards. METHODS: Spatial resolution, scatter fraction (SF), noise equivalent count rate (NECR), sensitivity, count rate accuracy, and image quality (IQ) were evaluated for the digital-BGO system as per NEMA NU 2-2018, at 2 sites of first clinical install. System energy resolution was measured. Bayesian penalized-likelihood reconstruction (BPL) was used for IQ. EARL Standards 2 studies were reconstructed by BPL combined with a contrast-enhancing deep learning algorithm. An Esser PET phantom was evaluated. Three patient examples were obtained with low-dose radiotracer activity: 2 MBq/kg of [18F]FDG ([18F]-2-fluoro-2-deoxy-D-glucose), 2.3 MBq/kg [68Ga]Ga-DOTA-TATE ([dodecane tetra-acetic acid,Tyr3]-octreotate), and 14.5 MBq/kg [82Rb]RbCl ([82Rb]-rubidium-chloride). Total scan times were ≤ 8 min. RESULTS: NEMA sensitivity was 47.6 cps/kBq at the axial center. Spatial resolution at 1 cm from the center axis was ≤4.5 mm (filtered back projection) and ≤3.8 mm (ordered subset expectation maximization). SF was 35.6%, count rate accuracy was 2.16%, and peak NECR was 485.2 kcps at 16.9 kBq/mL. Contrast for IQ was 61.1 to 90.7% (smallest to largest sphere) with background variations from 7.6 to 2.1%, and a "lung" error of 4.7%. The average detector energy resolution was 9.67%. Image quality for patient scans was good. EARL Standards 2 criteria were robustly met and Esser phantom features ≥4.8 mm were resolved at 2 min per bed position. CONCLUSION: A solid-state 32 cm axial FOV digital-BGO PET/CT system provides good spatial and energy resolution, high count rates, and superior NEMA sensitivity in its class, enabling fast clinical acquisitions with low-dose radiotracer activity.

The effect of CT-based attenuation correction on the automatic perfusion score of myocardial perfusion imaging using a dedicated cardiac solid-state CZT SPECT/CT.

BACKGROUND: Data regarding cardiac cadmium-zinc-telluride (CZT)-specific augmented databases and their impact on CT-based attenuation correction (AC) perfusion scores in myocardial perfusion imaging (MPI) were obtained on a multiple-pinhole CZT SPECT/CT. METHODS AND RESULTS: Summed stress (SSS) and rest scores (SRS) were measured using automated software in three independent patient groups: group 1 (n = 80) underwent MPI on both CZT and conventional sodium iodide (NaI) devices, group 2 (n = 80) with low coronary artery disease likelihood and normal MPI provided reference CZT databases; and group 3 (n = 152) served to compare AC and non-AC (NAC) scores on CZT. Group 1 CZT and NaI scores gave a significant 1:1 linear correlation for CZT scores referenced to the custom database vs NaI scores referenced to the default database, but these were not concordant when CZT scores were referenced to the default database. AC significantly decreased average SSS and SRS in men vs NAC, 4.29 ± 6.30 vs 5.37 ± 7.26 (P < 0.001) and 2.37 ± 4.72 vs 3.13 ± 5.85 (P < 0.001), but not in women, 2.28 ± 3.42 vs 2.28 ± 3.08 (p NS) and 0.46 ± 1.51 vs 0.61 ± 1.86, (p NS), respectively. CONCLUSIONS: Specifically designed databases for solid-state CZT cardiac SPECT provide accurate quantitation of perfusion scores concordant with those previously validated for conventional SPECT. AC and NAC CZT scores differed significantly, especially in men.

Strategies for Minimizing Occupational Radiation Exposure in Cardiac Imaging.

PURPOSE OF REVIEW: Radiation safety has been at the center of interest of both researchers and healthcare institutions. This review will summarize and shed light on the various techniques adapted to reduce staff exposure to ionizing radiation (IR) in the field of cardiac imaging. RECENT FINDINGS: In the last years, with the advance of awareness and the development of new technologies, there have been several tools and techniques adapted. The breakthrough of several technologies to lower radiation dose and shorten the duration of diagnostic tests associated with IR, the use of protection devices by staff members, and mostly the awareness of exposure to IR are the hallmark of these advances. Using all these measures has led to a significant decrease in staff exposure to IR. Reducing staff exposure to meet the "As Low As Reasonably Achievable" principle is feasible. This review introduces the most important strategies applied in cardiac imaging.

3D iteratively reconstructed spatial resolution map and sensitivity characterization of a dedicated cardiac SPECT camera.

BACKGROUND: A solid-state cadmium zinc telluride (CZT) SPECT device provides ultrafast myocardial perfusion imaging (MPI) with a spherical field-of-view (FOV). This study aims at determining the spatial resolution and sensitivity throughout this FOV as a guide for patient positioning. METHODS AND RESULTS: For this CZT camera (Discovery 570c, GE Healthcare), the iteratively reconstructed spatial resolution along 3 Cartesian axes was compared (average resolution 6.9 ± 1.0 mm full-width at half-maximum) using a 2 dimensional array of point sources in air which was aligned with a transverse plane shifted throughout the FOV. Sensitivity was plotted in the central transverse slice and axially in locations comparable to the placement of the heart in 266 rest/stress cardiac studies (M 78, age 63 ± 13 years). The average sensitivity was 0.46 ± 0.19 kc/s/MBq with a transverse gradient of 0.039 ± 0.001 kc/s/MBq/cm (8.9% of the sensitivity per cm). Reconstructed relative activity was uniform (uniformity <9%) and count rate was linear (R = 0.999) over 3 orders of magnitude. CONCLUSIONS: The CZT SPECT camera offers good resolution, sensitivity, and uniformity, and provides linearity in count rate. A gradient of >8%/cm in sensitivity justifies the crucial role of patient positioning with the heart closest to the detector.

Digital Solid-State SPECT/CT Quantitation of Absolute 177Lu Radiotracer Concentration: In Vivo and In Vitro Validation.

The accuracy of 177Lu radiotracer concentration measurements using quantitative clinical software was determined by comparing in vivo results for a digital solid-state cadmium-zinc-telluride SPECT/CT system with in vitro sampling. Methods: First, image acquisition parameters were assessed for an International Electrotechnical Commission body phantom emulating clinical count rates loaded with a lung insert and 6 hot spheres with a 12:1 target-to-background ratio of 177Lu solution. Then, the data of 28 whole-body SPECT/CT scans of 7 patients who underwent 177Lu prostate-specific membrane antigen radioligand therapy were retrospectively analyzed. Three users analyzed SPECT/CT images for in vivo urinary bladder radiotracer uptake using quantitative software. In vitro radiopharmaceutical concentrations were calculated using urine sampling obtained immediately after each scan, scaled to SUVs. Any in vivo or in vitro identity relations were determined by linear regression (ideally, slope = 1 and intercept = 0), within a 95% confidence interval. Results: Phantom results demonstrated lower quantitative error for acquisitions using the 113-keV 177Lu energy peak rather than including the 208-keV peak, given that only low-energy collimation was available in this camera configuration. In the clinical study, 24 in vivo-in vitro pairs were eligible for further analysis, with 4 having been rejected as outliers (via Cook distance calculations). All linear regressions (R2 ≥ 0.82, P < 0.0001) provided identity in vivo-in vitro relations (95% confidence interval), with SUV averages from all users giving a slope of 0.96 ± 0.13, an intercept of -0.07 ± 0.46 g/mL, and an average residual difference of 19.5%. In acquisitions with the lower-energy 177Lu energy peak, solid-state SPECT/CT imaging provided an accuracy to within approximately 20% of in vivo urinary bladder radiotracer concentrations. Conclusion: This noninvasive in vivo quantitation method can potentially improve diagnosis, patient management, and treatment response assessment and provide data essential to 177Lu dosimetry.

SPECT/CT: Standing on the Shoulders of Giants, It Is Time to Reach for the Sky!

Twenty years ago, SPECT/CT became commercially available, combining the strengths of both techniques: the diagnostic sensitivity of SPECT and the anatomic detail of CT. Other benefits initially included attenuation correction of SPECT reconstructions, ultimately evolving to correction techniques that would enable absolute tracer uptake quantification. Recent developments in SPECT hardware include solid-state digital systems with higher sensitivity and resolution, using novel collimator designs based on tungsten. Similar advances in CT technology have been introduced in hybrid SPECT/CT systems, replacing low-end x-ray tubes with high-end multislice CT scanners equipped with iterative reconstruction, metal artifact reduction algorithms, and dual-energy capabilities. More recently, the design of whole-body SPECT/CT systems has taken another major leap with the introduction of a ring-shaped gantry equipped with multiple movable detectors surrounding the patient. These exciting developments have fueled efforts to develop novel SPECT radiopharmaceuticals, creating new chelators and prosthetic groups for radiolabeling. Innovative SPECT radionuclide pairs have now become available for radiolabeling with the potential for use as theranostic agents. The growth of precision medicine and the associated need for accurate radionuclide treatment dosimetry will likely drive the use of SPECT/CT in the near future. In addition, expanding clinical applications of SPECT/CT in other areas such as orthopedics offer exciting opportunities. Although it is true that the SPECT/CT ecosystem has seen several challenges during its development over the past 2 decades, it is now a feature-rich and mature tool ready for clinical prime time.

Directions and magnitudes of misregistration of CT attenuation-corrected myocardial perfusion studies: incidence, impact on image quality, and guidance for reregistration.

UNLABELLED: CT-based attenuation-corrected (AC) myocardial perfusion imaging (MPI) studies may show significant artifacts caused by misregistration between SPECT and CT data. The present study aimed at identifying the directions and magnitudes of misregistration with greatest impact on AC myocardial perfusion image quality. METHODS: The incidence, magnitude, and direction of misregistration were assessed in 248 consecutive stress-rest MPI studies in 124 patients. In addition, cardiac SPECT/CT registration was artificially modified in 40 studies, shifting CT data by +/-1, +/-2, and +/-3 pixels along the cephalad/caudal, dorsal/ventral, and left/right axes. Percentage of change in 5-wall AC-MPI polar map scoring was calculated for each region, and the direction of the shift along each axis was analyzed statistically (Student t test, P < 0.05) and compared to determine the region most significantly affected by each shift (Newman-Keuls test, P < 0.05). Changes in the normal and abnormal summed stress score (SSS) due to artificial misregistration were assessed (kappa-statistics, McNemar differences). RESULTS: SPECT/CT misregistration of more than 1 pixel was found in 73% (181/248) of studies and more than 2 pixels in 23% of studies (57/248). A 3-pixel ventral shift most significantly affected polar map scoring (-15.4% +/- 6.1% change in lateral wall; -7.5% +/- 5.5% change in inferior wall). A 3-pixel dorsal shift resulted in a -9.5% +/- 5.3% apical and -8.8% +/- 5.8% septal change. Polar map scoring was least affected by the cephalad/caudal shift (<5% average change in all regions except for the anterior wall; -9.9% +/- 7.4% change for 3-pixel caudal shift). The most significant changes occurred in the lateral and anterior walls when the myocardium on SPECT overlapped lung tissue on CT, encountered in 16% of studies (40/248). Clinically significant changes (in SSS) occurred for the 3-pixel caudal, dorsal, and right shifts. CONCLUSION: A misregistration of significant magnitude occurred in 23% of studies and in the direction of the most severe artifacts in 16% of studies. Severe misregistration along the dorsal/ventral axis most significantly affected AC-MPI. Quality control of SPECT and CT registration and manual realignment should be performed routinely, with the highest priority in AC studies showing an overlay of the myocardium on SPECT with lung tissue on the CT component of AC-MPI.

Brain mapping of patients with lung cancer and controls: inquiry into tumor-to-brain communication.

UNLABELLED: Recent converging evidence suggests that the brain may receive stimuli and possibly modulate tumor progression via the vagus nerve. The present study aimed to compare brain metabolism in patients with and without lung cancer and to assess if significant differences exist in regions associated with the vagus nerve. METHODS: Eighteen patients with lung malignancy and 19 controls underwent (18)F-FDG PET of the brain. Brain metabolism was compared using statistical parametric mapping. RESULTS: Patients with lung malignancy showed a statistically significantly higher right cerebellar metabolism. CONCLUSION: This finding may be related to the role of the cerebellum in immune regulation, because of its proximity to the nucleus tractus solitarius innervated by the vagus and its connections with the hypothalamus. This higher metabolism in the right cerebellum may reflect an attempt to reinstate homeostasis in functions such as respiration and immunity pertinent to lung malignancy.

Absolute radiotracer concentration measurement using whole-body solid-state SPECT/CT technology: in vivo/in vitro validation.

The accuracy of recently approved quantitative clinical software was determined by comparing in vivo/in vitro measurements for a solid-state cadmium-zinc-telluride SPECT/CT (single photon emission computed tomography/x-ray computed tomography) camera. Bone SPECT/CT, including the pelvic region in the field of view, was performed on 16 patients using technetium-99m methylene diphosphonic acid as a radiotracer. After imaging, urine samples from each patient provided for the measurement of in vitro radiopharmaceutical concentrations. From the SPECT/CT images, three users measured in vivo radiotracer concentration and standardized uptake value (SUV) for the bladder using quantitative software (Q.Metrix, GE Healthcare). Linear regression was used to validate any in vivo/in vitro identity relations (ideally slope = 1, intercept = 0), within a 95% confidence interval (CI). Thirteen in vivo/in vitro pairs were available for further analysis, after rejecting two as clinically irrelevant (SUVs > 100 g/mL) and one as an outlier (via Cook's distance calculations). All linear regressions (R2 ≥ 0.85, P < 0.0001) provided identity in vivo/in vitro relations (95% CI), with SUV averages from all users giving a slope of 0.99 ± 0.25 and intercept of 0.14 ± 5.15 g/mL. The average in vivo/in vitro residual difference was < 20%. Solid-state SPECT/CT imaging can reliably provide in vivo urinary bladder radiotracer concentrations within approximately 20% accuracy. This practical, non-invasive, in vivo quantitation method can potentially improve diagnosis and assessment of response to treatment. Graphical abstract.

Centrifugation and decontamination procedures selectively impair recovery of important populations in Mycobacterium smegmatis.

Diagnosis and treatment monitoring of patients with tuberculosis (TB) requires detection of all viable mycobacteria in clinical samples. Quantitation of Mycobacterium tuberculosis (Mtb) in sputum is commonly performed by culture after sample decontamination to prevent overgrowth by contaminant organisms. Exponentially growing cultures have cells that predominately lack non-polar lipid bodies whereas stationary cultures have a predominance of cells with non-polar lipid bodies. This may reflect rapidly growing 'active' and non-replicating 'persister' sub-populations respectively in sputum from TB patients. We investigated the effect of decontamination on culture-based quantitation of exponential and stationary phase cultures of Mycobacterium smegmatis in an artificial sputum model. Exponentially growing populations were between 89 and 50 times more susceptible to decontamination than stationary phase cultures when quantified by most probable number and colony forming units. These findings suggest that decontamination selectively eliminates the 'active' population. This may impair diagnostic sensitivity, treatment monitoring, and compromise clinical trials designed to identify new antibiotic combinations with activity against all mycobacterial cell states.

Evaluation of Staff Radiation Exposure during Transthoracic Echocardiography Close to Myocardial Perfusion Imaging.

BACKGROUND: Transthoracic echocardiography (TTE) and myocardial perfusion imaging (MPI) are used in cardiac patients. In this study the radiation exposure of sonographers performing TTE following MPI was evaluated. METHODS: Of 40 study patients, 30 underwent same-day 99mTc sestamibi MPI and TTE, while another 10 underwent only TTE. Patients who underwent both studies were divided into three groups: right-handed TTE performed by an echocardiographer and right- and left-handed TTE performed by a cardiac sonographer. Seven thermoluminescent radiation dosimeter badges monitored the forehead, wrists, anterolateral right and left chest, sternal notch, and umbilical region of each examiner. Group characteristics were compared. Radiation exposures were deemed positive if >0.1 mSv. RESULTS: There were no statistical differences in patient weight and body mass index. The left-handed approach group had higher residual radioactivity (979 ± 73 vs 884 ± 73 MBq [P < .01] and 906 ± 81 MBq [P < .04]), but no statistical difference in duration of TTE, compared with the other two MPI groups. Radiation exposure was positive in the right anterolateral chest and hand (0.45 and 1 mSv, respectively) for the echocardiographer, the right anterolateral chest and wrist and umbilical region (0.59, 1.06, and 0.15 mSv, respectively) for the right-handed sonographer, and the left chest and hand (0.12 and 0.34 mSv, respectively) for the left-handed sonographer. Dosimeters indicated no radiation exposure in the TTE-only group. CONCLUSIONS: Staff members performing TTE after MPI are exposed to radiation that might warrant monitoring. Altering study sequence, adopting a left-handed approach, and using other radiation-reducing techniques can minimize the degree of exposure.

The reduction of artifacts due to metal hip implants in CT-attenuation corrected PET images from hybrid PET/CT scanners.

CT beam hardening artifacts near metal hip implants may erroneously enhance or diminish radiotracer uptake following CT attenuation correction (AC) of PET images. An artifact reduction algorithm (ARA) was developed to reduce metal artifacts in CT-based AC-PET. The algorithm employed a Bayes classifier to identify beam-hardening artifacts, followed by a partial correction of the attenuation map. ARA was implemented on phantom and patient 18F-FDG studies using a clinical PET/CT scanner. In phantom studies ARA successfully removed two artifacts of erroneously elevated uptake near a stainless steel hip prosthesis which were depicted in the standard CT-AC PET. ARA has also identified two targets absent on the scanner PET images. Target-to-background ratios were 1.5-3 times higher for ARA-PET than scanner images. In a patient study, metal artifacts were of lower intensity in ARA-PET as compared to standard images. Potentially, ARA may improve detectability of small lesions located near metal hip implants.

Motion detection and amelioration in a dedicated cardiac solid-state CZT SPECT device.

A solid-state cadmium zinc tellurium (CZT) dedicated multipinhole cardiac camera which acquires all views simultaneously has been introduced for myocardial SPECT acquisition. We report a method to detect and ameliorate patient motion artifacts in myocardial perfusion imaging (MPI) studies recorded with this device. To detect motion, a myocardial phantom study was recorded, and at mid-scan, the phantom was moved stepwise along each of 6 orthogonal directions, causing MPI artifacts. Using QPS software (Cedars-Sinai) and an in-house normal database, displacements giving artifactual perfusion defects (total perfusion deficit score, TPD, >5 %) were all 1.5 cm or greater (11.2 ± 1.3 % for 1.5 cm). List mode data were reframed into 10-s steps, and the norm of the changes in center of mass among the 19 projections (32 × 32 matrix, pixel size 2.46 mm) was used as a motion index. Rejection of misregistered data gave artifact-free reconstructions (TPD = 1.0 ± 0.8 %) in phantom scans and reduced blur in a rest/stress clinical study. Blur on the patient's stress scan was consistent with increased motion compared to rest (motion index of 4.4 vs. 3.0 pixels, respectively). For CZT cameras that acquire data from multiple views simultaneously, motion during MPI can cause clinically significant artifacts. Reframing acquisitions into discrete time intervals enables the detection of motion and its amelioration, improving diagnostic accuracy.

Super-resolution in PET imaging.

This paper demonstrates a super-resolution method for improving the resolution in clinical positron emission tomography (PET) scanners. Super-resolution images were obtained by combining four data sets with spatial shifts between consecutive acquisitions and applying an iterative algorithm. Super-resolution attenuation corrected PET scans of a phantom were obtained using the two-dimensional and three-dimensional (3-D) acquisition modes of a clinical PET/computed tomography (CT) scanner (Discovery LS, GEMS). In a patient study, following a standard 18F-FDG PET/CT scan, a super-resolution scan around one small lesion was performed using axial shifts without increasing the patient radiation exposure. In the phantom study, smaller features (3 mm) could be resolved axially with the super-resolution method than without (6 mm). The super-resolution images had better resolution than the original images and provided higher contrast ratios in coronal images and in 3-D acquisition transaxial images. The coronal super-resolution images had superior resolution and contrast ratios compared to images reconstructed by merely interleaving the data to the proper axial location. In the patient study, super-resolution reconstructions displayed a more localized 18F-FDG uptake. A new approach for improving the resolution of PET images using a super-resolution method has been developed and experimentally confirmed, employing a clinical scanner. The improvement in axial resolution requires no changes in hardware.

A hybrid algorithm for PET/CT image merger in hybrid scanners.

PURPOSE: To improve the PET image quality of a hybrid PET/CT scanner by merging CT borders with PET texture. PET/CT scanners provide both high-resolution CT images showing anatomical details and PET images of low-resolution physiological information about radiopharmaceutical uptake. Standard smoothing of noisy PET images may further impair PET resolution, reducing small lesion detectability. METHODS: The CT edge data and the PET texture data were merged using a modified form of an algorithm called HCT (hybrid computed tomography). In merged PET/CT images, each PET pixel value was estimated by iteratively applying a corrected 2D Taylor expansion to each of its eight neighbors. The spatial derivative term was used only near anatomical edges provided by the CT. This counts-preserving algorithm was tested on a special resolution phantom and patient data sets obtained by PET/CT acquisitions. RESULTS: The HCT algorithm provided phantom PET images with sharp borders and improved resolution (< or = 3 mm as compared to > or = 4 mm). HCT increased the signal to background contrast ratios by an average of 61% (40-89%) while maintaining noise reduction similar to the Gaussian filtering standard in PET. In the clinical PET images, HCT allowed for an improved delineation of pulmonary and pelvic lesions and an improved visualization of the brain. CONCLUSION: A new reconstruction algorithm for merging CT anatomical edge data with functional PET data has been introduced. The algorithm smooths noisy PET images while retaining sharper edges at corresponding anatomical borders, resulting in an improvement in resolution and contrast ratio.

Improved image fusion in PET/CT using hybrid image reconstruction and super-resolution.

PURPOSE: To provide PET/CT image fusion with an improved PET resolution and better contrast ratios than standard reconstructions. METHOD: Using a super-resolution algorithm, several PET acquisitions were combined to improve the resolution. In addition, functional PET data was smoothed with a hybrid computed tomography algorithm (HCT), in which anatomical edge information taken from the CT was employed to retain sharper edges. The combined HCT and super-resolution technique were evaluated in phantom and patient studies using a clinical PET scanner. RESULTS: In the phantom studies, 3 mm(18)F-FDG sources were resolved. PET contrast ratios improved (average: 54%, range: 45%-69%) relative to the standard reconstructions. In the patient study, target-to-background ratios also improved (average: 34%, range: 17%-47%). Given corresponding anatomical borders, sharper edges were depicted. CONCLUSION: A new method incorporating super-resolution and HCT for fusing PET and CT images has been developed and shown to provide higher-resolution metabolic images.