Noninvasive quantification of the cerebral metabolic rate for glucose using positron emission tomography, 18F-fluoro-2-deoxyglucose, the Patlak method, and an image-derived input function

Assessment of image-derived input functions from small vessels for patlak parametric imaging using total-body PET/CT

PURPOSE

The image-derived input function (IDIF) from the descending aorta has demonstrated performance comparable to arterial blood sampling while avoiding its invasive nature in parametric imaging. However, in conventional PET, large vessels may not always be within the imaging field of view (FOV). This study aims to evaluate the efficacy of dynamic parametric Ki imaging using image-derived input functions (IDIFs) extracted from various arteries, facilitated by total-body PET/CT.

METHOD

Twenty-three participants underwent a 60-minute total-body [18F]FDG PET scan. Data from each subject were used to reconstruct both total-body PET images and short-axis field-of-view PET images at different bed positions, each with a 25 cm axial field-of-view (AFOV). Partial volume correction (PVC) was performed using the blurred Van Cittert iterative deconvolution. IDIFs extracted from the descending aorta, carotid artery, abdominal aorta, and iliac artery were employed for Patlak analysis. The resulting Ki images were compared using quantification indicators and subjective assessment. Linear regression analysis was conducted to examine the correlation of Ki values among IDIFs in normal organ and lesion regions of interest (ROIs).

RESULT

High similarities were observed in Ki images derived from the IDIFs from the descending aorta and other arteries, with a median structural similarity index measure (SSIM) above 0.98 and a median peak signal-to-noise ratio (PSNR) above 37dB. Linear regression analysis revealed strong correlations in Ki values (r² > 0.88) between the descending aorta and the three alternative vessels, with slopes of the linear fits close to 1. No significant difference in lesion detectability among IDIFs was found, as assessed visually and using metrics such as tumor-to-background ratio (TBR) and contrast-to-noise ratio (CNR) (P < 0.05).

CONCLUSION

IDIFs from smaller vessels can reliably reconstruct parametric Ki images without compromising lesion detectability, providing clinically relevant information.

Validation of cardiac image-derived input functions for functional PET quantification

PURPOSE

Functional PET (fPET) is a novel technique for studying dynamic changes in brain metabolism and neurotransmitter signaling. Accurate quantification of fPET relies on measuring the arterial input function (AIF), traditionally achieved through invasive arterial blood sampling. While non-invasive image-derived input functions (IDIF) offer an alternative, they suffer from limited spatial resolution and field of view. To overcome these issues, we developed and validated a scan protocol for brain fPET utilizing cardiac IDIF, aiming to mitigate known IDIF limitations.

METHODS

Twenty healthy individuals underwent fPET/MR scans using [18F]FDG or 6-[18F]FDOPA, utilizing bed motion shuttling to capture cardiac IDIF and brain task-induced changes. Arterial and venous blood sampling was used to validate IDIFs. Participants performed a monetary incentive delay task. IDIFs from various blood pools and composites estimated from a linear fit over all IDIF blood pools (3VOI) and further supplemented with venous blood samples (3VOIVB) were compared to the AIF. Quantitative task-specific images from both tracers were compared to assess the performance of each input function to the gold standard.

RESULTS

For both radiotracer cohorts, moderate to high agreement (r: 0.60-0.89) between IDIFs and AIF for both radiotracer cohorts was observed, with further improvement (r: 0.87-0.93) for composite IDIFs (3VOI and 3VOIVB). Both methods showed equivalent quantitative values and high agreement (r: 0.975-0.998) with AIF-derived measurements.

CONCLUSION

Our proposed protocol enables accurate non-invasive estimation of the input function with full quantification of task-specific changes, addressing the limitations of IDIF for brain imaging by sampling larger blood pools over the thorax. These advancements increase applicability to any PET scanner and clinical research setting by reducing experimental complexity and increasing patient comfort.

Non-Invasive Quantification of the Brain [¹⁸F]FDG-PET Using Inferred Blood Input Function Learned From Total-Body Data With Physical Constraint

Full quantification of brain PET requires the blood input function (IF), which is traditionally achieved through an invasive and time-consuming arterial catheter procedure, making it unfeasible for clinical routine. This study presents a deep learning based method to estimate the input function (DLIF) for a dynamic brain FDG scan. A long short-term memory combined with a fully connected network was used. The dataset for training was generated from 85 total-body dynamic scans obtained on a uEXPLORER scanner. Time-activity curves from 8 brain regions and the carotid served as the input of the model, and labelled IF was generated from the ascending aorta defined on CT image. We emphasize the goodness-of-fitting of kinetic modeling as an additional physical loss to reduce the bias and the need for large training samples. DLIF was evaluated together with existing methods in terms of RMSE, area under the curve, regional and parametric image quantifications. The results revealed that the proposed model can generate IFs that closer to the reference ones in terms of shape and amplitude compared with the IFs generated using existing methods. All regional kinetic parameters calculated using DLIF agreed with reference values, with the correlation coefficient being 0.961 (0.913) and relative bias being 1.68±8.74% (0.37±4.93%) for [Formula: see text] ( [Formula: see text]. In terms of the visual appearance and quantification, parametric images were also highly identical to the reference images. In conclusion, our experiments indicate that a trained model can infer an image-derived IF from dynamic brain PET data, which enables subsequent reliable kinetic modeling.

Can Internal Carotid Arteries Be Used for Noninvasive Quantification of Brain PET Studies?

Because of the limited axial field of view of conventional PET scanners, the internal carotid arteries are commonly used to obtain an image-derived input function (IDIF) in quantitative brain PET. However, time-activity curves extracted from the internal carotids are prone to partial-volume effects due to the limited PET resolution. This study aimed to assess the use of the internal carotids for quantifying brain glucose metabolism before and after partial-volume correction. Methods: Dynamic [18F]FDG images were acquired on a 106-cm-long PET scanner, and quantification was performed with a 2-tissue-compartment model and Patlak analysis using an IDIF extracted from the internal carotids. An IDIF extracted from the ascending aorta was used as ground truth. Results: The internal carotid IDIF underestimated the area under the curve by 37% compared with the ascending aorta IDIF, leading to Ki values approximately 17% higher. After partial-volume correction, the mean relative Ki differences calculated with the ascending aorta and internal carotid IDIFs dropped to 7.5% and 0.05%, when using a 2-tissue-compartment model and Patlak analysis, respectively. However, microparameters (K 1, k 2, k 3) derived from the corrected internal carotid curve differed significantly from those obtained using the ascending aorta. Conclusion: These results suggest that partial-volume-corrected internal carotids may be used to estimate Ki but not kinetic microparameters. Further validation in a larger patient cohort with more variable kinetics is needed for more definitive conclusions.

Kinetic Modeling of Brain [18-F]FDG Positron Emission Tomography Time Activity Curves with Input Function Recovery (IR) Method

Accurate positron emission tomography (PET) data quantification relies on high-quality input plasma curves, but venous blood sampling may yield poor-quality data, jeopardizing modeling outcomes. In this study, we aimed to recover sub-optimal input functions by using information from the tail (5th-100th min) of curves obtained through the frequent sampling protocol and an input recovery (IR) model trained with reference curves of optimal shape. Initially, we included 170 plasma input curves from eight published studies with clamp [18F]-fluorodeoxyglucose PET exams. Model validation involved 78 brain PET studies for which compartmental model (CM) analysis was feasible (reference (ref) + training sets). Recovered curves were compared with original curves using area under curve (AUC), max peak standardized uptake value (maxSUV). CM parameters (ref + training sets) and fractional uptake rate (FUR) (all sets) were computed. Original and recovered curves from the ref set had comparable AUC (d = 0.02, not significant (NS)), maxSUV (d = 0.05, NS) and comparable brain CM results (NS). Recovered curves from the training set were different from the original according to maxSUV (d = 3) and biologically plausible according to the max theoretical K1 (53//56). Brain CM results were different in the training set (p < 0.05 for all CM parameters and brain regions) but not in the ref set. FUR showed reductions similarly in the recovered curves of the training and test sets compared to the original curves (p < 0.05 for all regions for both sets). The IR method successfully recovered the plasma inputs of poor quality, rescuing cases otherwise excluded from the kinetic modeling results. The validation approach proved useful and can be applied to different tracers and metabolic conditions.

Simultaneous estimation of a model-derived input function for quantifying cerebral glucose metabolism with [18F]FDG PET

BACKGROUND

Quantification of the cerebral metabolic rate of glucose (CMRGlu) by dynamic [18F]FDG PET requires invasive arterial sampling. Alternatives to using an arterial input function (AIF) include the simultaneous estimation (SIME) approach, which models the image-derived input function (IDIF) by a series of exponentials with coefficients obtained by fitting time activity curves (TACs) from multiple volumes-of-interest. A limitation of SIME is the assumption that the input function can be modelled accurately by a series of exponentials. Alternatively, we propose a SIME approach based on the two-tissue compartment model to extract a high signal-to-noise ratio (SNR) model-derived input function (MDIF) from the whole-brain TAC. The purpose of this study is to present the MDIF approach and its implementation in the analysis of animal and human data.

METHODS

Simulations were performed to assess the accuracy of the MDIF approach. Animal experiments were conducted to compare derived MDIFs to measured AIFs (n = 5). Using dynamic [18F]FDG PET data from neurologically healthy volunteers (n = 18), the MDIF method was compared to the original SIME-IDIF. Lastly, the feasibility of extracting parametric images was investigated by implementing a variational Bayesian parameter estimation approach.

RESULTS

Simulations demonstrated that the MDIF can be accurately extracted from a whole-brain TAC. Good agreement between MDIFs and measured AIFs was found in the animal experiments. Similarly, the MDIF-to-IDIF area-under-the-curve ratio from the human data was 1.02 ± 0.08, resulting in good agreement in grey matter CMRGlu: 24.5 ± 3.6 and 23.9 ± 3.2 mL/100 g/min for MDIF and IDIF, respectively. The MDIF method proved superior in characterizing the first pass of [18F]FDG. Groupwise parametric images obtained with the MDIF showed the expected spatial patterns.

CONCLUSIONS

A model-driven SIME method was proposed to derive high SNR input functions. Its potential was demonstrated by the good agreement between MDIFs and AIFs in animal experiments. In addition, CMRGlu estimates obtained in the human study agreed to literature values. The MDIF approach requires fewer fitting parameters than the original SIME method and has the advantage that it can model the shape of any input function. In turn, the high SNR of the MDIFs has the potential to facilitate the extraction of voxelwise parameters when combined with robust parameter estimation methods such as the variational Bayesian approach.

The role of dynamic, static, and delayed total-body PET imaging in the detection and differential diagnosis of oncological lesions

OBJECTIVES

Commercialized total-body PET scanners can provide high-quality images due to its ultra-high sensitivity. We compared the dynamic, regular static, and delayed 18F-fluorodeoxyglucose (FDG) scans to detect lesions in oncologic patients on a total-body PET/CT scanner.

MATERIALS & METHODS

In all, 45 patients were scanned continuously for the first 60 min, followed by a delayed acquisition. FDG metabolic rate was calculated from dynamic data using full compartmental modeling, whereas regular static and delayed SUV images were obtained approximately 60- and 145-min post-injection, respectively. The retention index was computed from static and delayed measures for all lesions. Pearson's correlation and Kruskal-Wallis tests were used to compare parameters.

RESULTS

The number of lesions was largely identical between the three protocols, except MRFDG and delayed images on total-body PET only detected 4 and 2 more lesions, respectively (85 total). FDG metabolic rate (MRFDG) image-derived contrast-to-noise ratio and target-to-background ratio were significantly higher than those from static standardized uptake value (SUV) images (P < 0.01), but this is not the case for the delayed images (P > 0.05). Dynamic protocol did not significantly differentiate between benign and malignant lesions just like regular SUV, delayed SUV, and retention index.

CONCLUSION

The potential quantitative advantages of dynamic imaging may not improve lesion detection and differential diagnosis significantly on a total-body PET/CT scanner. The same conclusion applied to delayed imaging. This suggested the added benefits of complex imaging protocols must be weighed against the complex implementation in the future.

CLINICAL RELEVANCE

Total-body PET/CT was known to significantly improve the PET image quality due to its ultra-high sensitivity. However, whether the dynamic and delay imaging on total-body scanner could show additional clinical benefits is largely unknown. Head-to-head comparison between two protocols is relevant to oncological management.

Clinical application of a population-based input function (PBIF) for a shortened dynamic whole-body FDG-PET/CT protocol in patients with metastatic melanoma treated by immunotherapy

BACKGROUND

The aim was to investigate the feasibility of a shortened dynamic whole-body (dWB) FDG-PET/CT protocol and Patlak imaging using a population-based input function (PBIF), instead of an image-derived input function (IDIF) across the 60-min post-injection period, and study its effect on the FDG influx rate (Ki) quantification in patients with metastatic melanoma (MM) undergoing immunotherapy.

METHODS

Thirty-seven patients were enrolled, including a PBIF modeling group (n = 17) and an independent validation cohort (n = 20) of MM from the ongoing prospective IMMUNOPET2 trial. All dWB-PET data were acquired on Vision 600 PET/CT systems. The PBIF was fitted using a Feng's 4-compartments model and scaled to the individual IDIF tail's section within the shortened acquisition time. The area under the curve (AUC) of PBIFs was compared to respective IDIFs AUC within 9 shortened time windows (TW) in terms of linear correlation (R2) and Bland-Altman tests. Ki metrics calculated with PBIF vs IDIF on 8 organs with physiological tracer uptake, 44 tumoral lesions of MM and 11 immune-induced inflammatory sites of pseudo-progression disease were also compared (Mann-Whitney test).

RESULTS

The mean ± SD relative AUC bias was calculated at 0.5 ± 3.8% (R2 = 0.961, AUCPBIF = 1.007 × AUCIDIF). In terms of optimal use in routine practice and statistical results, the 5th-7th pass (R2 = 0.999 for both Ki mean and Ki max) and 5th-8th pass (mean ± SD bias = - 4.9 ± 6.5% for Ki mean and - 4.8% ± 5.6% for Ki max) windows were selected. There was no significant difference in Ki values from PBIF5_7 vs IDIF5_7 for physiological uptakes (p > 0.05) as well as for tumor lesions (mean ± SD Ki IDIF5_7 3.07 ± 3.27 vs Ki PBIF5_7 2.86 ± 2.96 100ml/ml/min, p = 0.586) and for inflammatory sites (mean ± SD Ki IDIF5_7 1.13 ± 0.59 vs Ki PBIF5_7 1.13 ± 0.55 100ml/ml/min, p = 0.98).

CONCLUSION

Our study showed the feasibility of a shortened dWB-PET imaging protocol with a PBIF approach, allowing to reduce acquisition duration from 70 to 20 min with reasonable bias. These findings open perspectives for its clinical use in routine practice such as treatment response assessment in oncology.

Impact of patient characteristic factors on the dynamics of liver glucose metabolism: Evaluation of multiparametric imaging with dynamic whole-body 18 F-fluorodeoxyglucose-positron emission tomography

AIMS

To assess the impact of various patient characteristics on the dynamics of liver glucose metabolism using automated multiparametric imaging with whole-body dynamic 18 F-fluorodeoxyglucose (FDG)-positron emission tomography (PET).

MATERIALS AND METHODS

We retrospectively enrolled 540 patients who underwent whole-body dynamic FDG-PET. Three quantitative indices representing hepatic glucose metabolism [mean standardized uptake value normalized by lean body mass (SULmean), metabolic glucose rate (kinetic index) and distribution volume (DV)] were measured from multiparametric PET images produced automatically based on the Patlak plot model. Patient characteristics including age, sex, body mass index, fasting time, blood glucose level, and the presence of diabetes mellitus (DM) or hepatic steatosis (HS) were collected. We examined the correlations between the characteristic factors and three quantitative indices using multiple regression analysis.

RESULTS

The success rate of kinetic analysis using multiparametric PET imaging was 93.3% (504/540). Hepatic SULmean was significantly correlated with age (p < .001), sex (p < .001) and blood glucose level (p = .002). DV was significantly correlated with age (p = .033), sex (p < .001), body mass index (p = .002), fasting time (p = .043) and the presence of HS (p = .002). The kinetic index was significantly correlated with age (p < .001) and sex (p = .004). In the comparison of the healthy, DM and HS groups, patients with DM had a significantly increased SULmean, whereas patients with HS had a significantly decreased DV.

CONCLUSIONS

Our results showed that liver glucose metabolism was influenced by various patient characteristic factors. Multiparametric FDG-PET imaging can be used to analyse the kinetics of liver glucose metabolism in routine clinical practice.

An update on the use of image-derived input functions for human PET studies: new hopes or old illusions?

BACKGROUND

The need for arterial blood data in quantitative PET research limits the wider usability of this imaging method in clinical research settings. Image-derived input function (IDIF) approaches have been proposed as a cost-effective and non-invasive alternative to gold-standard arterial sampling. However, this approach comes with its own limitations-partial volume effects and radiometabolite correction among the most important-and varying rates of success, and the use of IDIF for brain PET has been particularly troublesome.

MAIN BODY

This paper summarizes the limitations of IDIF methods for quantitative PET imaging and discusses some of the advances that may make IDIF extraction more reliable. The introduction of automated pipelines (both commercial and open-source) for clinical PET scanners is discussed as a way to improve the reliability of IDIF approaches and their utility for quantitative purposes. Survey data gathered from the PET community are then presented to understand whether the field's opinion of the usefulness and validity of IDIF is improving. Finally, as the introduction of next-generation PET scanners with long axial fields of view, ultra-high sensitivity, and improved spatial and temporal resolution, has also brought IDIF methods back into the spotlight, a discussion of the possibilities offered by these state-of-the-art scanners-inclusion of large vessels, less partial volume in small vessels, better description of the full IDIF kinetics, whole-body modeling of radiometabolite production-is included, providing a pathway for future use of IDIF.

CONCLUSION

Improvements in PET scanner technology and software for automated IDIF extraction may allow to solve some of the major limitations associated with IDIF, such as partial volume effects and poor temporal sampling, with the exciting potential for accurate estimation of single kinetic rates. Nevertheless, until individualized radiometabolite correction can be performed effectively, IDIF approaches remain confined at best to a few tracers.

A new framework for metabolic connectivity mapping using bolus [18F]FDG PET and kinetic modeling

Metabolic connectivity (MC) has been previously proposed as the covariation of static [18F]FDG PET images across participants, i.e., across-individual MC (ai-MC). In few cases, MC has been inferred from dynamic [18F]FDG signals, i.e., within-individual MC (wi-MC), as for resting-state fMRI functional connectivity (FC). The validity and interpretability of both approaches is an important open issue. Here we reassess this topic, aiming to 1) develop a novel wi-MC methodology; 2) compare ai-MC maps from standardized uptake value ratio (SUVR) vs. [18F]FDG kinetic parameters fully describing the tracer behavior (i.e., Ki, K1, k3); 3) assess MC interpretability in comparison to structural connectivity and FC. We developed a new approach based on Euclidean distance to calculate wi-MC from PET time-activity curves. The across-individual correlation of SUVR, Ki, K1, k3 produced different networks depending on the chosen [18F]FDG parameter (k3 MC vs. SUVR MC, r = 0.44). We found that wi-MC and ai-MC matrices are dissimilar (maximum r = 0.37), and that the match with FC is higher for wi-MC (Dice similarity: 0.47-0.63) than for ai-MC (0.24-0.39). Our analyses demonstrate that calculating individual-level MC from dynamic PET is feasible and yields interpretable matrices that bear similarity to fMRI FC measures.

Quantitation of dynamic total-body PET imaging: recent developments and future perspectives

BACKGROUND

Positron emission tomography (PET) scanning is an important diagnostic imaging technique used in disease diagnosis, therapy planning, treatment monitoring, and medical research. The standardized uptake value (SUV) obtained at a single time frame has been widely employed in clinical practice. Well beyond this simple static measure, more detailed metabolic information can be recovered from dynamic PET scans, followed by the recovery of arterial input function and application of appropriate tracer kinetic models. Many efforts have been devoted to the development of quantitative techniques over the last couple of decades.

CHALLENGES

The advent of new-generation total-body PET scanners characterized by ultra-high sensitivity and long axial field of view, i.e., uEXPLORER (United Imaging Healthcare), PennPET Explorer (University of Pennsylvania), and Biograph Vision Quadra (Siemens Healthineers), further stimulates valuable inspiration to derive kinetics for multiple organs simultaneously. But some emerging issues also need to be addressed, e.g., the large-scale data size and organ-specific physiology. The direct implementation of classical methods for total-body PET imaging without proper validation may lead to less accurate results.

CONCLUSIONS

In this contribution, the published dynamic total-body PET datasets are outlined, and several challenges/opportunities for quantitation of such types of studies are presented. An overview of the basic equation, calculation of input function (based on blood sampling, image, population or mathematical model), and kinetic analysis encompassing parametric (compartmental model, graphical plot and spectral analysis) and non-parametric (B-spline and piece-wise basis elements) approaches is provided. The discussion mainly focuses on the feasibilities, recent developments, and future perspectives of these methodologies for a diverse-tissue environment.

Generation of Whole-Body FDG Parametric Ki Images from Static PET Images Using Deep Learning

FDG parametric Ki images show great advantage over static SUV images, due to the higher contrast and better accuracy in tracer uptake rate estimation. In this study, we explored the feasibility of generating synthetic Ki images from static SUV ratio (SUVR) images using three configurations of U-Nets with different sets of input and output image patches, which were the U-Nets with single input and single output (SISO), multiple inputs and single output (MISO), and single input and multiple outputs (SIMO). SUVR images were generated by averaging three 5-min dynamic SUV frames starting at 60 minutes post-injection, and then normalized by the mean SUV values in the blood pool. The corresponding ground truth Ki images were derived using Patlak graphical analysis with input functions from measurement of arterial blood samples. Even though the synthetic Ki values were not quantitatively accurate compared with ground truth, the linear regression analysis of joint histograms in the voxels of body regions showed that the mean R2 values were higher between U-Net prediction and ground truth (0.596, 0.580, 0.576 in SISO, MISO and SIMO), than that between SUVR and ground truth Ki (0.571). In terms of similarity metrics, the synthetic Ki images were closer to the ground truth Ki images (mean SSIM = 0.729, 0.704, 0.704 in SISO, MISO and MISO) than the input SUVR images (mean SSIM = 0.691). Therefore, it is feasible to use deep learning networks to estimate surrogate map of parametric Ki images from static SUVR images.

Four-dimensional quantitative analysis using FDG-PET in clinical oncology

Positron emission tomography (PET) with F-18 fluorodeoxyglucose (FDG) has been commonly used in many oncological areas. High-resolution PET permits a three-dimensional analysis of FDG distributions on various lesions in vivo, which can be applied for tissue characterization, risk analysis, and treatment monitoring after chemoradiotherapy and immunotherapy. Metabolic changes can be assessed using the tumor absolute FDG uptake as standardized uptake value (SUV) and metabolic tumor volume (MTV). In addition, tumor heterogeneity assessment can potentially estimate tumor aggressiveness and resistance to chemoradiotherapy. Attempts have been made to quantify intratumoral heterogeneity using radiomics. Recent reports have indicated the clinical feasibility of a dynamic FDG PET-computed tomography (CT) in pilot cohort studies of oncological cases. Dynamic imaging permits the assessment of temporal changes in FDG uptake after administration, which is particularly useful for differentiating pathological from physiological uptakes with high diagnostic accuracy. In addition, several new parameters have been introduced for the in vivo quantitative analysis of FDG metabolic processes. Thus, a four-dimensional FDG PET-CT is available for precise tissue characterization of various lesions. This review introduces various new techniques for the quantitative analysis of FDG distribution and glucose metabolism using a four-dimensional FDG analysis with PET-CT. This elegant study reveals the important role of tissue characterization and treatment strategies in oncology.

A deep neural network for parametric image reconstruction on a large axial field-of-view PET

PURPOSE

The PET scanners with long axial field of view (AFOV) having ~ 20 times higher sensitivity than conventional scanners provide new opportunities for enhanced parametric imaging but suffer from the dramatically increased volume and complexity of dynamic data. This study reconstructed a high-quality direct Patlak Ki image from five-frame sinograms without input function by a deep learning framework based on DeepPET to explore the potential of artificial intelligence reducing the acquisition time and the dependence of input function in parametric imaging.

METHODS

This study was implemented on a large AFOV PET/CT scanner (Biograph Vision Quadra) and twenty patients were recruited with ¹⁸F-fluorodeoxyglucose (¹⁸F-FDG) dynamic scans. During training and testing of the proposed deep learning framework, the last five-frame (25 min, 40-65 min post-injection) sinograms were set as input and the reconstructed Patlak Ki images by a nested EM algorithm on the vendor were set as ground truth. To evaluate the image quality of predicted Ki images, mean square error (MSE), peak signal-to-noise ratio (PSNR), and structural similarity index measure (SSIM) were calculated. Meanwhile, a linear regression process was applied between predicted and true Ki means on avid malignant lesions and tumor volume of interests (VOIs).

RESULTS

In the testing phase, the proposed method achieved excellent MSE of less than 0.03%, high SSIM, and PSNR of ~ 0.98 and ~ 38 dB, respectively. Moreover, there was a high correlation (DeepPET: [Formula: see text]= 0.73, self-attention DeepPET: [Formula: see text]=0.82) between predicted Ki and traditionally reconstructed Patlak Ki means over eleven lesions.

CONCLUSIONS

The results show that the deep learning-based method produced high-quality parametric images from small frames of projection data without input function. It has much potential to address the dilemma of the long scan time and dependency on input function that still hamper the clinical translation of dynamic PET.

Non-invasive kinetic modelling approaches for quantitative analysis of brain PET studies

Pharmacokinetic modelling with arterial sampling is the gold standard for analysing dynamic PET data of the brain. However, the invasive character of arterial sampling prevents its widespread clinical application. Several methods have been developed to avoid arterial sampling, in particular reference region methods. Unfortunately, for some tracers or diseases, no suitable reference region can be defined. For these cases, other potentially non-invasive approaches have been proposed: (1) a population based input function (PBIF), (2) an image derived input function (IDIF), or (3) simultaneous estimation of the input function (SIME). This systematic review aims to assess the correspondence of these non-invasive methods with the gold standard. Studies comparing non-invasive pharmacokinetic modelling methods with the current gold standard methods using an input function derived from arterial blood samples were retrieved from PubMed/MEDLINE (until December 2021). Correlation measurements were extracted from the studies. The search yielded 30 studies that correlated outcome parameters (V_T, DVR, or BP_ND for reversible tracers; K_i or CMR_glu for irreversible tracers) from a potentially non-invasive method with those obtained from modelling using an arterial input function. Some studies provided similar results for PBIF, IDIF, and SIME-based methods as for modelling with an arterial input function (R² = 0.59-1.00, R² = 0.71-1.00, R² = 0.56-0.96, respectively), if the non-invasive input curve was calibrated with arterial blood samples. Even when the non-invasive input curve was calibrated with venous blood samples or when no calibration was applied, moderate to good correlations were reported, especially for the IDIF and SIME (R² = 0.71-1.00 and R² = 0.36-0.96, respectively). Overall, this systematic review illustrates that non-invasive methods to generate an input function are still in their infancy. Yet, IDIF and SIME performed well, not only with arterial blood calibration, but also with venous or no blood calibration, especially for some tracers without plasma metabolites, which would potentially make these methods better suited for clinical application. However, these methods should still be properly validated for each individual tracer and application before implementation.

Patient-Adaptive Population-Based Modeling of Arterial Input Functions

Kinetic modeling of dynamic PET data requires knowledge of tracer concentration in blood plasma, described by the arterial input function (AIF). Arterial blood sampling is the gold standard for AIF measurement, but is invasive and labour intensive. A number of methods have been proposed to accurately estimate the AIF directly from blood sampling and/or imaging data. Here we consider fitting a patient-adaptive mixture of historical population time course profiles to estimate individual AIFs. Travel time of a tracer atom from the injection site to the right ventricle of the heart is modeled as a realization from a Gamma distribution, and the time this atom spends in circulation before being sampled is represented by a subject-specific linear mixture of population profiles. These functions are estimated from independent population data. Individual AIFs are obtained by projection onto this basis of population profile components. The model incorporates knowledge of injection duration into the fit, allowing for varying injection protocols. Analyses of arterial sampling data from 18F-FDG, 15O-H2O and 18F-FLT clinical studies show that the proposed model can outperform reference techniques. The statistically significant gain achieved by using population data to train the basis components, instead of fitting these from the single individual sampling data, is measured on the FDG cohort. Kinetic analyses of simulated data demonstrate the reliability and potential benefit of this approach in estimating physiological parameters. These results are further supported by numerical simulations that demonstrate convergence and stability of the proposed technique under varying training population sizes and noise levels.

Investigation of image-derived input functions for non-invasive quantification of myelin density using [11C]MeDAS PET

Multiple sclerosis (MS) is an inflammatory demyelinating disease. Current treatments are focussed on immune suppression to modulate pathogenic activity that causes myelin damage. New treatment strategies are needed to prevent demyelination and promote remyelination. Development of such myelin repair therapies require a sensitive and specific biomarker for efficacy evaluation. Recently, it has been shown that quantification of myelin density is possible using [¹¹C]MeDAS PET. This method, however, requires arterial blood sampling to generate an arterial input function (AIF). As the invasive nature of arterial sampling will reduce clinical applicability, the purpose of this study was to assess whether an image-derived input function (IDIF) can be used as an alternative way to facilitate its routine clinical use. Six healthy controls and 11 MS patients underwent MRI and [¹¹C]MeDAS PET with arterial blood sampling. The application of both population-based whole blood-to-plasma conversion and metabolite corrections were assessed for the AIF. Next, summed images of the early time frames (0-70 s) and the frame with the highest blood-brain contrast were used to generate IDIFs. IDIFs were created using either the hottest 2, 4, 6 or 12 voxels, or an isocontour of the hottest 10% voxels of the carotid artery. This was followed by blood-to-plasma conversion and metabolite correction of the IDIF. The application of a population-based metabolite correction of the AIF resulted in high correlations of tracer binding (K_i) within subjects, but variable bias across subjects. All IDIFs had a sharper and higher peak in the blood curves than the AIF, most likely due to dispersion during blood sampling. All IDIF methods resulted in similar high correlations within subjects (r = 0.95-0.98), but highly variable bias across subjects (mean slope=0.90-1.09). Therefore, both the use of population based blood-plasma and metabolite corrections and the generation of the image-derived whole-blood curve resulted in substantial bias in [¹¹C]MeDAS PET quantification, due to high inter-subject variability. Consequently, when unbiased quantification of [¹¹C]MeDAS PET data is required, individual AIF needs to be used.

Evaluation of [18F]F-TZ3108 for PET Imaging of Metabolic-Associated Fatty Liver Disease

PURPOSE

Sigma-1 receptor (Sig-1R), a chaperone that resides at the mitochondrion-associated endoplasmic reticulum (ER) membrane, is an ER stress biomarker. It is thought that ER stress plays a critical role in the progression of metabolic-associated fatty liver disease (MAFLD). The aim of this study was to evaluate a positron emission tomography (PET) tracer [¹⁸F]F-TZ3108 targeting Sig-1R for MAFLD.

PROCEDURES

The mouse model of MAFLD was established by feeding high-fat diet (HFD) for 12 weeks. Dynamic (0-60 min) PET/CT scans were performed after intravenous injection of 2-deoxy-2[¹⁸F]fluoro-D-glucose ([¹⁸F]-FDG) and [¹⁸F]F-TZ3108. Tracer kinetic modeling was performed for quantification of the PET/CT imaging of the liver. Post-PET biodistribution, the liver tissue western blotting (WB), and immunofluorescence (IF) were performed to compare the expression of Sig-1R levels in the organs harvested from both MAFLD and age-matched control mice.

RESULTS

The micro PET/CT imaging revealed a significantly decreased uptake of [¹⁸F]F-TZ3108 in the livers of the MAFLD group compared to the healthy controls, while the uptake of [¹⁸F]-FDG in the livers was not significantly different between the two groups. Based on the tracer kinetic modeling, the binding disassociate rate (k₄) for [¹⁸F]F-TZ3108 was significantly increased in MAFLD group compared to healthy controls. The volume distribution (V_T), and the non-displacement binding potential (BP_ND) revealed significantly decrease in MAFLD compared to healthy controls respectively. The post-PET biodistribution (%ID/g) of [¹⁸F]F-TZ3108 in the livers of MAFLD mice was significantly reduced nearly twofold than that in the livers of control mice. WB and IF experiments further confirmed the reduction of Sig-1R expression in the MAFLD group.

CONCLUSIONS

The expression of Sig-1R in the liver, measured by the PET tracer, [¹⁸F]F-TZ3108, was significantly decreased in mouse model of MAFLD. The [¹⁸F]F-TZ3108 PET/CT imaging may provide a novel means of visualization for ER stress in MAFLD or other diseases in vivo.

Population-based input function (PBIF) applied to dynamic whole-body 68Ga-DOTATOC-PET/CT acquisition

Rational

To validate a population-based input function (PBIF) model that alleviates the need for scanning since injection time in dynamic whole-body (WBdyn) PET.

Methods

Thirty-seven patients with suspected/known well-differentiated neuroendocrine tumors were included (GAPETNET trial NTC03576040). All WBdyn 68Ga-DOTATOC-PET/CT acquisitions were performed on a digital PET system (one heart-centered 6 min-step followed by nine WB-passes). The PBIF model was built from 20 image-derived input functions (IDIFs) obtained from a respective number of patients' WBdyn exams using an automated left-ventricle segmentation tool. All IDIF peaks were aligned to the median time-to-peak, normalized to patient weight and administrated activity, and then fitted to an exponential model function. PBIF was then applied to 17 independent patient studies by scaling it to match the respective IDIF section at 20-55 min post-injection time windows corresponding to WB-passes 3-7. The ratio of area under the curves (AUCs) of IDIFs and PBIF3-7 were compared using a Bland-Altman analysis (mean bias ± SD). The Patlak-estimated mean Ki for physiological uptake (Ki-liver and Ki-spleen) and tumor lesions (Ki-tumor) using either IDIF or PBIF were also compared.

Results

The mean AUC ratio (PBIF/IDIF) was 0.98 ± 0.06. The mean Ki bias between PBIF3-7 and IDIF was -2.6 ± 6.2% (confidence interval, CI: -5.8; 0.6). For Ki-spleen and Ki-tumor, low relative bias with low SD were found [4.65 ± 7.59% (CI: 0.26; 9.03) and 3.70 ± 8.29% (CI: -1.09; 8.49) respectively]. For Ki-liver analysis, relative bias and SD were slightly higher [7.43 ± 13.13% (CI: -0.15; 15.01)].

Conclusion

Our study showed that the PBIF approach allows for reduction in WBdyn DOTATOC-PET/CT acquisition times with a minimum gain of 20 min.

Clinical validation of a population-based input function for 20-min dynamic whole-body 18F-FDG multiparametric PET imaging

Purpose

Contemporary PET/CT scanners can use 70-min dynamic whole-body (D-WB) PET to generate more quantitative information about FDG uptake than just the SUV by generating parametric images of FDG metabolic rate (MR_FDG). The analysis requires the late (50–70 min) D-WB tissue data combined with the full (0–70 min) arterial input function (AIF). Our aim was to assess whether the use of a scaled population-based input function (sPBIF) obviates the need for the early D-WB PET acquisition and allows for a clinically feasible 20-min D-WB PET examination.

Methods

A PBIF was calculated based on AIFs from 20 patients that were D-WB PET scanned for 120 min with simultaneous arterial blood sampling. MR_FDG imaging using PBIF requires that the area under the curve (AUC) of the sPBIF is equal to the AUC of the individual patient’s input function because sPBIF AUC bias translates into MR_FDG bias. Special patient characteristics could affect the shape of their AIF. Thus, we validated the use of PBIF in 171 patients that were divided into 12 subgroups according to the following characteristics: diabetes, cardiac ejection fraction, blood pressure, weight, eGFR and age. For each patient, the PBIF was scaled to the aorta image-derived input function (IDIF) to calculate a sPBIF, and the AUC bias was calculated.

Results

We found excellent agreement between the AIF and IDIF at all times. For the clinical validation, the use of sPBIF led to an acceptable AUC bias of 1–5% in most subgroups except for patients with diabetes or patients with low eGFR, where the biases were marginally higher at 7%. Multiparametric MR_FDG images based on a short 20-min D-WB PET and sPBIF were visually indistinguishable from images produced by the full 70-min D-WB PET and individual IDIF.

Conclusions

A short 20-min D-WB PET examination using PBIF can be used for multiparametric imaging without compromising the image quality or precision of MR_FDG. The D-WB PET examination may therefore be used in clinical routine for a wide range of patients, potentially allowing for more precise quantification in e.g. treatment response imaging.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40658-022-00490-y.

Modeling venous plasma samples in [18F] FDG PET studies: a nonlinear mixed-effects approach

The gold-standard approach to quantifying dynamic PET images relies on using invasive measures of the arterial plasma tracer concentration. An attractive alternative is to employ an image-derived input function (IDIF), corrected for spillover effects and rescaled with venous plasma samples. However, venous samples are not always available for every participant. In this work, we used the nonlinear mixed-effects modeling approach to develop a model which infers venous tracer kinetics by using venous samples obtained from a population of healthy individuals and integrating subject-specific covariates. Population parameters (fixed effects), their between-subject variability (random effects), and the effects of covariates were estimated. The selected model will allow to reliably infer venous tracer kinetics in subjects with missing measurements. Clinical relevance - The derived model will be relevant for fully noninvasive dynamic FDG PET quantification using image-derived input functions in both healthy and patient populations when hemodynamics is not impaired.

Image-derived Input Function in brain [18F]FDG PET data: which alternatives to the carotid siphons?

Quantification of brain [¹⁸F] fluorodeoxyglucose ([¹⁸F]FDG) positron emission tomography (PET) data requires an input function. A noninvasive alternative to gold-standard arterial sampling is the image-derived input function (IDIF), typically extracted from the internal carotid arteries (ICAs), which are however difficult to segment and subjected to spillover effects. In this work, we evaluated the feasibility of extracting the IDIF from two different vascular sites, i.e., 1) common carotids (CCA) and 2) superior sagittal sinus (SSS), other than 3) ICA in a large group of glioma patients undergoing a dynamic [¹⁸F]FDG PET acquisition on a hybrid PET/MR scanner. Comparisons are drawn between the different IDIFs in terms of peak amplitude and shape, as well as between the estimates of fractional uptake rate (Kr) obtained from the different extraction sites in terms of a) grey/white matter average absolute values, b) ratio of grey-to-white matter, and c) spatial patterns for the hemisphere contralateral to the lesion. Clinical Relevance - This work points towards new feasible IDIF extraction sites (CCA in particular) which could allow for fully noninvasive absolute PET quantification in clinical populations.

Brain effect of bariatric surgery in people with obesity

BACKGROUND/OBJECTIVES

The link between obesity and brain function is a fascinating but still an enigmatic topic. We evaluated the effect of Roux-en-Y gastric bypass (RYGB) on peripheral glucose metabolism, insulin sensitivity, brain glucose utilization and cognitive abilities in people with obesity.

SUBJECTS/METHODS

Thirteen subjects with obesity (F/M 11/2; age 44.4 ± 9.8 years; BMI 46.1 ± 4.9 kg/m²) underwent 75-g OGTT during a [18F]FDG dynamic brain PET/CT study at baseline and 6 months after RYGB. At the same timepoints, cognitive performance was tested with Mini Mental State Examination (MMSE), Montreal Cognitive Assessment (MoCA), Trail making test (TMT) and Token test (TT). Glucose, insulin, C-peptide, GLP-1, GIP, and VIP levels were measured during OGTT. Leptin and BDNF levels were measured before glucose ingestion.

RESULTS

RYGB resulted in significant weight loss (from 46.1 ± 4.9 to 35.3 ± 5.0 kg/m²; p < 0.01 vs baseline). Insulin sensitivity improved (disposition index: from 1.1 ± 0.2 to 2.9 ± 1.1; p = 0.02) and cerebral glucose metabolic rate (CMRg) declined in various brain areas (all p ≤ 0.01). MMSE and MoCA score significantly improved (p = 0.001 and p = 0.002, respectively). TMT and TT scores showed a slight improvement. A positive correlation was found between CMRg change and HOMA-IR change in the caudate nucleus (ρ = 0.65, p = 0.01). Fasting leptin decreased (from 80.4 ± 13.0 to 16.1 ± 2.4 ng/dl; p = 0.001) and correlated with CMRg change in the hippocampus (ρ = 0.50; p = 0.008). CMRg change was correlated with cognitive scores changes on the TMT and TT (all p = 0.04 or less).

CONCLUSIONS

Bariatric surgery improves CMRg directly related to a better cognitive testing result. This study highlights the potential pleiotropic effects of bariatric surgery.

TRIAL REGISTRY NUMBER

NCT03414333.

Direct inference of Patlak parametric images in whole-body PET/CT imaging using convolutional neural networks

Purpose

This study proposed and investigated the feasibility of estimating Patlak-derived influx rate constant (K_i) from standardized uptake value (SUV) and/or dynamic PET image series.

Methods

Whole-body ¹⁸F-FDG dynamic PET images of 19 subjects consisting of 13 frames or passes were employed for training a residual deep learning model with SUV and/or dynamic series as input and K_i-Patlak (slope) images as output. The training and evaluation were performed using a nine-fold cross-validation scheme. Owing to the availability of SUV images acquired 60 min post-injection (20 min total acquisition time), the data sets used for the training of the models were split into two groups: “With SUV” and “Without SUV.” For “With SUV” group, the model was first trained using only SUV images and then the passes (starting from pass 13, the last pass, to pass 9) were added to the training of the model (one pass each time). For this group, 6 models were developed with input data consisting of SUV, SUV plus pass 13, SUV plus passes 13 and 12, SUV plus passes 13 to 11, SUV plus passes 13 to 10, and SUV plus passes 13 to 9. For the “Without SUV” group, the same trend was followed, but without using the SUV images (5 models were developed with input data of passes 13 to 9). For model performance evaluation, the mean absolute error (MAE), mean error (ME), mean relative absolute error (MRAE%), relative error (RE%), mean squared error (MSE), root mean squared error (RMSE), peak signal-to-noise ratio (PSNR), and structural similarity index (SSIM) were calculated between the predicted K_i-Patlak images by the two groups and the reference K_i-Patlak images generated through Patlak analysis using the whole acquired data sets. For specific evaluation of the method, regions of interest (ROIs) were drawn on representative organs, including the lung, liver, brain, and heart and around the identified malignant lesions.

Results

The MRAE%, RE%, PSNR, and SSIM indices across all patients were estimated as 7.45 ± 0.94%, 4.54 ± 2.93%, 46.89 ± 2.93, and 1.00 ± 6.7 × 10⁻⁷, respectively, for models predicted using SUV plus passes 13 to 9 as input. The predicted parameters using passes 13 to 11 as input exhibited almost similar results compared to the predicted models using SUV plus passes 13 to 9 as input. Yet, the bias was continuously reduced by adding passes until pass 11, after which the magnitude of error reduction was negligible. Hence, the predicted model with SUV plus passes 13 to 9 had the lowest quantification bias. Lesions invisible in one or both of SUV and K_i-Patlak images appeared similarly through visual inspection in the predicted images with tolerable bias.

Conclusion

This study concluded the feasibility of direct deep learning-based approach to estimate K_i-Patlak parametric maps without requiring the input function and with a fewer number of passes. This would lead to shorter acquisition times for WB dynamic imaging with acceptable bias and comparable lesion detectability performance.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00259-022-05867-w.

Improved Clinical Workflow for Whole-Body Patlak Parametric Imaging Using Two Short Dynamic Acquisitions

Objective

We sought to explore the feasibility of shorter acquisition times using two short dynamic scans for a multiparametric PET study and the influence of quantitative performance in shortened dynamic PET.

Methods

Twenty-one patients underwent whole-body dynamic ¹⁸F-FDG PET/CT examinations on a PET/CT (Siemens Biograph Vision) with a total scan time of 75 min using continuous bed motion for Patlak multiparametric imaging. Two sets of Patlak multiparametric images were produced: the standard MR_FDG and DV_FDG images (MR_FDG-_std and DV_FDG-_std) and two short dynamic MR_FDG and DV_FDG images (MR_FDG-_tsd and DV_FDG-_tsd), which were generated by a 0–75 min post injection (p.i.) dynamic PET series and a 0–6 min + 60–75 min p.i. dynamic PET series, respectively. The maximum, mean, and peak values of the standard and two short dynamic multiparametric acquisitions were obtained and compared using Passing–Bablok regression and Bland–Altman analysis.

Results

High correlations were obtained between MR_FDG-_tsd and MR_FDG-_std, and between DV_FDG-_tsd and DV_FDG-_std for both normal organs and all lesions (0.962 ≦ Spearman’s rho ≦ 0.982, p < 0.0001). The maximum, mean, and peak values of the standard and two short dynamic multiparametric acquisitions were also in agreement. For normal organs, the Bland–Altman plot showed that the mean bias of MR_FDG-max, MR_FDG-mean, and MR_FDG-peak was -0.002 (95% CI: -0.032–0.027), -0.002 (95% CI: -0.026–0.023), and -0.002 (95% CI: -0.026–0.022), respectively. The mean bias of DV_FDG-max, DV_FDG-mean, and DV_FDG-peak was -3.3 (95% CI: -24.8–18.2), -1.4 (95% CI: -12.1–9.2), and -2.3 (95% CI: -15–10.4), respectively. For lesions, the Bland–Altman plot showed that the mean bias of MR_FDG-max, MR_FDG-mean, and MR_FDG-peak was -0.009 (95% CI: -0.056–0.038), -0.004 (95% CI: -0.039–0.031), and -0.004 (95% CI: -0.036–0.028), respectively. The mean bias of DV_FDG-max, DV_FDG-mean, and DV_FDG-peak was -8.4 (95% CI: -42.6–25.9), -4.8 (95% CI: -20.2–10.6), and -4.0 (95% CI: -23.7–15.6), respectively.

Conclusions

This study demonstrates the feasibility of using two short dynamic scans that include the first 0–6 min and 60–75 min scans p.i. for Patlak multiparametric images, which can increase patient throughout for parametric analysis.

PET Imaging of Leg Arteries for Determining the Input Function in PET/MRI Brain Studies Using a Compact, MRI-Compatible PET System

In this study, we used a compact, high-resolution, and MRI-compatible PET camera (VersaPET) to assess the feasibility of measuring the image-derived input function (IDIF) from arteries in the leg with the ultimate goal of enabling fully quantitative PET brain imaging without blood sampling. We used this approach in five ¹⁸F-FDG PET/MRI brain studies in which the input function was also acquired using the gold standard of serial arterial blood sampling. After accounting for partial volume, dispersion, and calibration effects, we compared the metabolic rates of glucose (MRglu) quantified from VersaPET IDIFs in 80 brain regions to those using the gold standard and achieved a bias and variability of <5% which is within the range of reported test-retest values for this type of study. We also achieved a strong linear relationship (R² >0.97) against the gold standard across regions. The results of this preliminary study are promising and support further studies to optimize methods, validate in a larger cohort, and extend to the modeling of other radiotracers.

caliPER: A software for blood-free parametric Patlak mapping using PET/MRI input function

Routine clinical use of absolute PET quantification techniques is limited by the need for serial arterial blood sampling for input function and more importantly by the lack of automated pharmacokinetic analysis tools that can be readily implemented in clinic with minimal effort. PET/MRI provides the ability for absolute quantification of PET probes without the need for serial arterial blood sampling using image-derived input functions (IDIFs). Here we introduce caliPER, a modular and scalable software for simplified pharmacokinetic modelling of PET probes with irreversible uptake or binding based on PET/MR IDIFs and Patlak Plot analysis. caliPER generates regional values or parametric maps of net influx rate (K_i) using reconstructed dynamic PET images and anatomical MRI aligned to PET for IDIF vessel delineation. We evaluated the performance of caliPER for blood-free region-based and pixel-wise Patlak analyses of [¹⁸F] FDG by comparing caliPER IDIF to serial arterial blood input functions and its application in imaging brain glucose hypometabolism in Frontotemporal dementia. IDIFs corrected for partial volume errors including spill-out and spill-in effects were similar to arterial blood input functions with a general bias of around 6-8%, even for arteries <5 mm. The K_i and cerebral metabolic rate of glucose estimated using caliPER IDIF were similar to estimates using arterial blood sampling (<2%) and within limits of whole brain values reported in literature. Overall, caliPER is a promising tool for irreversible PET tracer quantification and can simplify the ability to perform parametric analysis in clinical settings without the need for blood sampling.

Phantom Validation of a Conservation of Activity-Based Partial Volume Correction Method for Arterial Input Function in Dynamic PET Imaging

Dynamic PET (dPET) imaging can be utilized to perform kinetic modelling of various physiologic processes, which are exploited by the constantly expanding range of targeted radiopharmaceuticals. To date, dPET remains primarily in the research realm due to a number of technical challenges, not least of which is addressing partial volume effects (PVE) in the input function. We propose a series of equations for the correction of PVE in the input function and present the results of a validation study, based on a purpose built phantom. ¹⁸F-dPET experiments were performed using the phantom on a set of flow tubes representing large arteries, such as the aorta (1" 2.54 cm ID), down to smaller vessels, such as the iliac arteries and veins (1/4" 0.635 cm ID). When applied to the dPET experimental images, the PVE correction equations were able to successfully correct the image-derived input functions by as much as 59 ± 35% in the presence of background, which resulted in image-derived area under the curve (AUC) values within 8 ± 9% of ground truth AUC. The peak heights were similarly well corrected to within 9 ± 10% of the scaled DCE-CT curves. The same equations were then successfully applied to correct patient input functions in the aorta and internal iliac artery/vein. These straightforward algorithms can be applied to dPET images from any PET-CT scanner to restore the input function back to a more clinically representative value, without the need for high-end Time of Flight systems or Point Spread Function correction algorithms.

Measuring brain glucose metabolism in order to predict response to antidepressant or placebo: A randomized clinical trial

There is critical need for a clinically useful tool to predict antidepressant treatment outcome in major depressive disorder (MDD) to reduce suffering and mortality. This analysis sought to build upon previously reported antidepressant treatment efficacy prediction from 2-[¹⁸F]-fluorodeoxyglucose - Positron Emission Tomography (FDG-PET) using metabolic rate of glucose uptake (MRGlu) from dynamic FDG-PET imaging with the goal of translation to clinical utility. This investigation is a randomized, double-blind placebo-controlled trial. All participants were diagnosed with MDD and received an FDG-PET scan before randomization and after treatment. Hamilton Depression Rating Scale (HDRS-17) was completed in participants diagnosed with MDD before and after 8 weeks of escitalopram, or placebo. MRGlu (mg/(min*100 ml)) was estimated within the raphe nuclei, right insula, and left ventral Prefrontal Cortex in 63 individuals. Linear regression was used to examine the association between pretreatment MRGlu and percent decrease in HDRS-17. Additionally, the association between percent decrease in HDRS-17 and percent change in MRGlu between pretreatment scan and post-treatment scan was examined. Covariates were treatment type (SSRI/placebo), handedness, sex, and age. Depression severity decrease (n = 63) was not significantly associated with pretreatment MRGlu in the raphe nuclei (β = -2.61e^-03 [-0.26, 0.25], p = 0.98), right insula (β = 0.05 [-0.23, 0.32], p = 0.72), or ventral prefrontal cortex (β = 0.06 [-0.23, 0.34], p = 0.68) where β is the standardized estimated coefficient, with a 95% confidence interval, or in whole brain voxelwise analysis (family-wise error correction, alpha = 0.05). MRGlu percent change was not significantly associated with depression severity decrease (n = 58) before multiple comparison correction in the RN (β = 0.20 [-0.07, 0.47], p = 0.15), right insula (β = 0.24 [-0.03, 0.51], p = 0.08), or vPFC (β = 0.22 [-0.06, 0.50], p = 0.12). We propose that FDG-PET imaging does not indicate a clinically relevant biomarker of escitalopram or placebo treatment response in heterogeneous major depressive disorder cohorts. Future directions include focusing on potential biologically-based subtypes of major depressive disorder by implementing biomarker stratified designs.

Dynamic whole-body FDG-PET imaging for oncology studies

Introduction

Recent PET/CT systems have improved sensitivity and spatial resolution by smaller PET detectors and improved reconstruction software. In addition, continuous-bed-motion mode is now available in some PET systems for whole-body PET imaging. In this review, we describe the advantages of dynamic whole-body FDG-PET in oncology studies.

Methods

PET–CT imaging was obtained at 60 min after FDG administration. Dynamic whole-body imaging with continuous bed motion in 3 min each with flow motion was obtained over 400 oncology cases. For routine image analysis, these dynamic phases (usually four phases) were summed as early FDG imaging. The image quality of each serial dynamic imaging was visually evaluated. In addition, changes in FDG uptake were analyzed in consecutive dynamic imaging and also in early delayed (90 min after FDG administration) time point imaging (dual-time-point imaging; DTPI). Image interpretation was performed by consensus of two nuclear medicine physicians.

Result

All consecutive dynamic whole-body PET images of 3 min duration had acceptable image quality. Many of the areas with physiologically high FDG uptake had altered uptake on serial images. On the other hand, most of the benign and malignant lesions did not show visual changes on serial images. In the study of 60 patients with suspected colorectal cancer, unchanged uptake was noted in almost all regions with pathologically proved FDG uptake, indicating high sensitivity with high negative predictive value on both serial dynamic imaging and on DTPI. We proposed another application of serial dynamic imaging for minimizing motion artifacts for patients who may be likely to move during PET studies.

Discussion

Dynamic whole-body imaging has several advantages over the static imaging. Serial assessment of changes in FDG uptake over a short period of time is useful for distinguishing pathological from physiological uptake, especially in the abdominal regions. These dynamic PET studies may minimize the need for DPTI. In addition, continuous dynamic imaging has the potential to reduce motion artifacts in patients who are likely to move during PET imaging. Furthermore, kinetic analysis of the FDG distribution in tumor areas has a potential for precise tissue characterization.

Conclusion

Dynamic whole-body FDG-PET imaging permits assessment of serial FDG uptake change which is particularly useful for differentiation of pathological uptake from physiological uptake with high diagnostic accuracy. This imaging can be applied for minimizing motion artifacts. Wide clinical applications of such serial, dynamic whole-body PET imaging is expected in oncological studies in the near future.

Source-to-Target Automatic Rotating Estimation (STARE) - a publicly-available, blood-free quantification approach for PET tracers with irreversible kinetics: Theoretical framework and validation for [18F]FDG

INTRODUCTION

Full quantification of positron emission tomography (PET) data requires an input function. This generally means arterial blood sampling, which is invasive, labor-intensive and burdensome. There is no current, standardized method to fully quantify PET radiotracers with irreversible kinetics in the absence of blood data. Here, we present Source-to-Target Automatic Rotating Estimation (STARE), a novel, data-driven approach to quantify the net influx rate (K_i) of irreversible PET radiotracers, that requires only individual-level PET data and no blood data. We validate STARE with human [¹⁸F]FDG PET scans and assess its performance using simulations.

METHODS

STARE builds upon a source-to-target tissue model, where the tracer time activity curves (TACs) in multiple "target" regions are expressed at once as a function of a "source" region, based on the two-tissue irreversible compartment model, and separates target region K_i from source K_i by fitting the source-to-target model across all target regions simultaneously. To ensure identifiability, data-driven, subject-specific anchoring is used in the STARE minimization, which takes advantage of the PET signal in a vasculature cluster in the field of view (FOV) that is automatically extracted and partial volume-corrected. To avoid the need for any a priori determination of a single source region, each of the considered regions acts in turn as the source, and a final K_i is estimated in each region by averaging the estimates obtained in each source rotation.

RESULTS

In a large dataset of human [¹⁸F]FDG scans (N=69), STARE K_i estimates were correlated with corresponding arterial blood-based K_i estimates (r=0.80), with an overall regression slope of 0.88, and were precisely estimated, as assessed by comparing STARE K_i estimates across several runs of the algorithm (coefficient of variation across runs=6.74 ± 2.48%). In simulations, STARE K_i estimates were largely robust to factors that influence the individualized anchoring used within its algorithm.

CONCLUSION

Through simulations and application to [¹⁸F]FDG PET data, feasibility is demonstrated for STARE blood-free, data-driven quantification of K_i. Future work will include applying STARE to PET data obtained with a portable PET camera and to other irreversible radiotracers.

Whole-body Parametric Imaging of FDG PET using uEXPLORER with Reduced Scan Time

Parametric imaging of the net influx rate (K_i) in ¹⁸F-FDG PET has been shown to provide improved quantification and specificity for cancer detection compared with SUV imaging. Current methods of generating parametric images usually require a long dynamic scanning time. With the recently developed uEXPLORER scanner, a dramatic increase in sensitivity has reduced the noise in dynamic imaging, making it more robust to use a nonlinear estimation method and flexible protocols. In this work, we explored 2 new possible protocols besides the standard 60-min one for the possibility of reducing scanning time for K_i imaging. Methods: The gold standard protocol (protocol 1) was conventional dynamic scanning with a 60-min scanning time. The first proposed protocol (protocol 2) included 2 scanning periods: 0–4 min and 54–60 min after injection. The second proposed protocol (protocol 3) consisted of a single scanning period from 50 to 60 min after injection, with a second injection applied at 56 min. The 2 new protocols were simulated from the 60-min standard scans. A hybrid input function combining the population-based input function and the image-derived input function (IDIF) was used. The results were also compared with the IDIF acquired from protocol 1. A previously developed maximum-likelihood approach was used to estimate the K_i images. In total, 7 cancer patients imaged using the uEXPLORER scanner were enrolled in this study. Lesions were identified from the patient data, and the lesion K_i values were compared among the different protocols. Results: The acquired hybrid input function was comparable in shape to the IDIF for each patient. The average difference in area under the curve was about 3%, suggesting good quantitative accuracy. The visual difference between the K_i images generated using IDIF and those generated using the hybrid input function was also minimal. The acquired K_i images using different protocols were visually comparable. The average K_i difference in the lesions was 2.8% ± 2.1% for protocol 2 and 1% ± 2.2% for protocol 3. Conclusion: The results suggest that it is possible to acquire K_i images using the nonlinear estimation approach with a much-reduced scanning time. Between the 2 new protocols, the protocol with dual injection shows the greatest promise in terms of practicality.

Minimally invasive quantification of cerebral P2X7R occupancy using dynamic [18F]JNJ-64413739 PET and MRA-driven image derived input function

[¹⁸F]JNJ-64413739 has been evaluated as PET-ligand for in vivo quantification of purinergic receptor subtype 7 receptor (P2X7R) using Logan graphical analysis with a metabolite-corrected arterial plasma input function. In the context of a P2X7R PET dose occupancy study, we evaluated a minimally invasive approach by limiting arterial sampling to baseline conditions. Meanwhile, post dose distribution volumes (V_T) under blocking conditions were estimated by combining baseline blood to plasma ratios and metabolite fractions with an MR angiography driven image derived input function (IDIF). Regional postdose V_T,IDIF values were compared with corresponding V_T,AIF estimates using a arterial input function (AIF), in terms of absolute values, test–retest reliability and receptor occupancy. Compared to an invasive AIF approach, postdose V_T,IDIF values and corresponding receptor occupancies showed only limited bias (Bland–Altman analysis: 0.06 ± 0.27 and 3.1% ± 6.4%) while demonstrating a high correlation (Spearman ρ = 0.78 and ρ = 0.98 respectively). In terms of test–retest reliability, regional intraclass correlation coefficients were 0.98 ± 0.02 for V_T,IDIF compared to 0.97 ± 0.01 for V_T,AIF. These results confirmed that a postdose IDIF, guided by MR angiography and using baseline blood and metabolite data, can be considered for accurate [¹⁸F]JNJ-64413739 PET quantification in a repeated PET study design, thus avoiding multiple invasive arterial sampling and increasing dosing flexibility.

Dynamic 18F-FDG PET imaging of liver lesions: evaluation of a two-tissue compartment model with dual blood input function

Background

Dynamic PET with kinetic modeling was reported to be potentially helpful in the assessment of hepatic malignancy. In this study, a kinetic modeling analysis was performed on hepatocellular carcinoma (HCC) and intrahepatic cholangiocarcinoma (ICC) from dynamic FDG positron emission tomography/computer tomography (PET/CT) scans.

Methods

A reversible two-tissue compartment model with dual blood input function, which takes into consideration the blood supply from both hepatic artery and portal vein, was used for accurate kinetic modeling of liver dynamic ¹⁸F-FDG PET imaging. The blood input functions were directly measured as the mean values over the VOIs on descending aorta and portal vein respectively. And the contribution of hepatic artery to the blood input function was optimization-derived in the process of model fitting. The kinetic model was evaluated using dynamic PET data acquired on 24 patients with identified hepatobiliary malignancy. 38 HCC or ICC identified lesions and 24 healthy liver regions were analyzed.

Results

Results showed significant differences in kinetic parameters \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$${K}_{1}-{k}_{4}$$\end{document}K1-k4, blood supplying fraction \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$${f}_{A}$$\end{document}fA, and metabolic rate constant \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$${K}_{i}$$\end{document}Ki between malignant lesions and healthy liver tissue. And significant differences were also observed in \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$${K}_{1}$$\end{document}K1, \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$${k}_{3}$$\end{document}k3, \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$${f}_{A}$$\end{document}fA and \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$${K}_{i}$$\end{document}Ki between HCC and ICC lesions. Further investigations of the effect of SUV measurements on the derived kinetic parameters were conducted. And results showed comparable effectiveness of the kinetic modeling using either SUVmean or SUVmax measurements.

Conclusions

Dynamic 18F-FDG PET imaging with optimization-derived hepatic artery blood supply fraction dual-blood input function kinetic modeling can effectively distinguish malignant lesions from healthy liver tissue, as well as HCC and ICC lesions.

Prospective study of dynamic whole-body 68Ga-DOTATOC-PET/CT acquisition in patients with well-differentiated neuroendocrine tumors

To present the feasibility of a dynamic whole-body (DWB) ⁶⁸Ga-DOTATOC-PET/CT acquisition in patients with well-differentiated neuroendocrine tumors (WD-NETs). Sixty-one patients who underwent a DWB ⁶⁸Ga-DOTATOC-PET/CT for a histologically proven/highly suspected WD-NET were prospectively included. The acquisition consisted in single-bed dynamic acquisition centered on the heart, followed by the DWB and static acquisitions. For liver, spleen and tumor (1–5/patient), Ki values (in ml/min/100 ml) were calculated according to Patlak's analysis and tumor-to-liver (TLR-Ki) and tumor-to-spleen ratios (TSR-Ki) were recorded. Ki-based parameters were compared to static parameters (SUVmax/SUVmean, TLR/TSRmean, according to liver/spleen SUVmean), in the whole-cohort and according to the PET system (analog/digital). A correlation analysis between SUVmean/Ki was performed using linear and non-linear regressions. Ki-liver was not influenced by the PET system used, unlike SUVmax/SUVmean. The regression analysis showed a non-linear relation between Ki/SUVmean (R² = 0.55,0.68 and 0.71 for liver, spleen and tumor uptake, respectively) and a linear relation between TLRmean/TLR-Ki (R² = 0.75). These results were not affected by the PET system, on the contrary of the relation between TSRmean/TSR-Ki (R² = 0.94 and 0.73 using linear and non-linear regressions in digital and analog systems, respectively). Our study is the first showing the feasibility of a DWB ⁶⁸Ga-DOTATOC-PET/CT acquisition in WD-NETs.

Assessment of population-based input functions for Patlak imaging of whole body dynamic 18F-FDG PET

BACKGROUND

Arterial blood sampling is the gold standard method to obtain the arterial input function (AIF) for quantification of whole body (WB) dynamic 18F-FDG PET imaging. However, this procedure is invasive and not typically available in clinical environments. As an alternative, we compared AIFs to population-based input functions (PBIFs) using two normalization methods: area under the curve (AUC) and extrapolated initial plasma concentration (CP*(0)). To scale the PBIFs, we tested two methods: (1) the AUC of the image-derived input function (IDIF) and (2) the estimated CP*(0). The aim of this study was to validate IDIF and PBIF for FDG oncological WB PET studies by comparing to the gold standard arterial blood sampling.

METHODS

The Feng 18F-FDG plasma concentration model was applied to estimate AIF parameters (n = 23). AIF normalization used either AUC(0-60 min) or CP*(0), estimated from an exponential fit. CP*(0) is also described as the ratio of the injected dose (ID) to initial distribution volume (iDV). iDV was modeled using the subject height and weight, with coefficients that were estimated in 23 subjects. In 12 oncological patients, we computed IDIF (from the aorta) and PBIFs with scaling by the AUC of the IDIF from 4 time windows (15-45, 30-60, 45-75, 60-90 min) (PBIFAUC) and estimated CP*(0) (PBIFiDV). The IDIF and PBIFs were compared with the gold standard AIF, using AUC values and Patlak Ki values.

RESULTS

The IDIF underestimated the AIF at early times and overestimated it at later times. Thus, based on the AUC and Ki comparison, 30-60 min was the most accurate time window for PBIFAUC; later time windows for scaling underestimated Ki (- 6 ± 8 to - 13 ± 9%). Correlations of AUC between AIF and IDIF, PBIFAUC(30-60), and PBIFiDV were 0.91, 0.94, and 0.90, respectively. The bias of Ki was - 9 ± 10%, - 1 ± 8%, and 3 ± 9%, respectively.

CONCLUSIONS

Both PBIF scaling methods provided good mean performance with moderate variation. Improved performance can be obtained by refining IDIF methods and by evaluating PBIFs with test-retest data.

Diagnostic performance of a whole-body dynamic 68GA-DOTATOC PET/CT acquisition to differentiate physiological uptake of pancreatic uncinate process from pancreatic neuroendocrine tumor

To evaluate the diagnostic performance of net influx rate (Ki) values from a whole-body dynamic (WBD) Ga-DOTATOC-PET/CT acquisition to differentiate pancreatic neuroendocrine tumors (pNETs) from physiological uptake of pancreatic uncinate process (UP).Patients who were benefited from a WBD acquisition for the assessment of a known well-differentiated neuroendocrine tumor (NET)/suspicion of disease in the prospective GAPET-NET cohort were screened. Only patients with a confirmed pNET/UP as our gold standard were included. The positron emission tomography (PET) procedure consisted in a single-bed dynamic acquisition centered on the heart, followed by a whole-body dynamic acquisition and then a static acquisition. Dynamic (Ki calculated according to Patlak method), static (SUVmax, SUVmean, SUVpeak) parameters, and tumor-to-liver and tumor-to-spleen ratio (TLRKi and TSRKi (according to hepatic/splenic Ki)), tumor SUVmax to liver SUVmax (TM/LM), tumor SUVmax to liver SUVmean (TM/Lm), tumor SUVmax to spleen SUVmax (TM/SM), and tumor SUVmax to spleen SUVmean (TM/Sm) (according to hepatic/splenic SUVmax and SUVmean respectively) were calculated. A Receiver Operating Characteristic (ROC) analysis was performed to evaluate their diagnostic performance to distinguish UP from pNET.One hundred five patients benefited from a WBD between July 2018 and July 2019. Eighteen (17.1%) had an UP and 26 (24.8%) a pNET. For parameters alone, the Ki and SUVpeak had the best sensitivity (88.5%) while the Ki, SUVmax, and SUVmean had the best specificity (94.4%). The best diagnostic accuracy was obtained with Ki (90.9%). For ratios, the TLRKi and the TSRKi had the best sensitivity (95.7%) while the TM/SM and TM/Sm the best specificity (100%). TLRKi had the best diagnostic accuracy (95.1%) and the best area under the curve (AUC) (0.990).Our study is the first one to evaluate the interest of a WBD acquisition to differentiate UP from pNETs and shows excellent diagnostic performances of the Ki approach.

Image-Derived Input Functions for Quantification of A1 Adenosine Receptors Availability in Mice Brains Using PET and [18F]CPFPX

Purpose

In vivo imaging for the A₁ adenosine receptors (A₁ARs) with positron emission tomography (PET) using 8-cyclopentyl-3-(3-[¹⁸F]fluoropropyl)-1-propylxan- thine ([¹⁸F]CPFPX) has become an important tool for studying physiological processes quantitatively in mice. However, the measurement of arterial input functions (AIFs) on mice is a method with restricted applicability because of the small total blood volume and the related difficulties in withdrawing blood. Therefore, the aim of this study was to extract an appropriate [¹⁸F]CPFPX image-derived input function (IDIF) from dynamic PET images of mice.

Procedures

In this study, five mice were scanned with [¹⁸F]CPFPX for 60 min. Arterial blood samples (n = 7 per animal) were collected from the femoral artery and corrected for metabolites. To generate IDIFs, three different approaches were selected: (A) volume of interest (VOI) placed over the heart (cube, 10 mm); (B) VOI set over abdominal vena cava/aorta region with a cuboid (5 × 5 × 15 mm); and (C) with 1 × 1 × 1 mm voxels on five consecutive slices. A calculated scaling factor (α) was used to correct for partial volume effect; the method of obtaining the total metabolite correction of [¹⁸F]CPFPX for IDIFs was developed. Three IDIFs were validated by comparison with AIF. Validation included the following: visual performance; computing area under the curve (AUC) ratios (IDIF/AIF) of whole-blood curves and parent curves; and the mean distribution volume (V_T) ratios (IDIF/AIF) of A₁ARs calculated by Logan plot and two-tissue compartment model.

Results

Compared with the AIF, the IDIF with VOI over heart showed the best performance among the three IDIFs after scaling by 1.77 (α) in terms of visual analysis, AUC ratios (IDIF/AIF; whole-blood AUC ratio, 1.03 ± 0.06; parent curve AUC ratio, 1.01 ± 0.10) and V_T ratios (IDIF/AIF; Logan V_T ratio, 1.00 ± 0.17; two-tissue compartment model V_T ratio, 1.00 ± 0.13) evaluation. The A₁ARs distribution of average parametric images was in good accordance to autoradiography of the mouse brain.

Conclusion

The proposed study provides evidence that IDIF with VOI over heart can replace AIF effectively for quantification of A₁ARs using PET and [¹⁸F]CPFPX in mice brains.

Influx rate constant of 18F-FDG increases in metastatic lymph nodes of non-small cell lung cancer patients

PURPOSE

Primary tumor (PT) and metastatic lymph node (MLN) status have a great influence on diagnosis and treatment of lung cancer. Our main purpose was to investigate the imaging characteristics of PT or MLN by applying the ¹⁸F-FDG PET dynamic modeling approach for non-small cell lung cancer (NSCLC).

METHODS

Dynamic ¹⁸F-FDG PET scans were performed for 76 lung cancer patients, and 62 NSCLC cases were finally included in this study: 37 with newly diagnosed early and locally advanced lung cancer without distant metastases (group M0) and 25 metastatic lung cancer (group M1). Patlak graphic analysis (K_i calculation) based on the dynamic modeling and SUV analysis from conventional static data were performed.

RESULTS

For PT, both K_i^PT (0.050 ± 0.005 vs 0.026 ± 0.004 min^-1, p < 0.001) and SUV^PT (8.41 ± 0.64 vs 5.23 ± 0.73, p < 0.01) showed significant higher values in group M1 than M0. For MLN, K_i^MLN showed significant higher values in M1 than M0 (0.033 ± 0.005 vs 0.016 ± 0.003 min^-1, p < 0.01), while no significant differences were found for SUV^MLN between M0 and M1 (4.22 ± 0.49 vs 5.57 ± 0.59, p > 0.05). Both SUV ^PT and K_i^PT showed significant high values in squamous cell carcinoma than adenocarcinoma, but neither SUV^PT nor K_i^PT showed significant differences between EGFR mutants versus wild types. The overall Spearman analysis for SUV and K_i from different groups showed variable correlation (r = 0.46-0.94).

CONCLUSION

The dynamic modeling for MLN (K_i^MLN) showed more sensitive than the static analysis (SUV) to detect metastatic lymph nodes in NSCLC, although both methods were sensitive for PT. This methodology of non-invasive imaging may become an important tool to evaluate MLN and PT status for patients who cannot undergo histological examination.

CLINICAL TRIAL REGISTRATION

The clinical trial registration number is NCT03679936 (http://www.clinicaltrials.gov/).

A hybrid region growing tumour segmentation method for low contrast and high noise Nuclear Medicine (NM) images by combining a novel non-linear diffusion filter and global gradient measure (HNDF-GGM-RG)

Poor spatial resolution and low signal-to-noise ratio (SNR) along with the finite image sampling constraint make lesion segmentation on Nuclear Medicine (NM) images (e.g., PET-Positron Emission Tomography) a challenging task. Since the size, signal-to-background ratio (SBR) and SNR of lesion vary within and between patients, performance of the conventional segmentation methods are not consistent against statistical fluctuations. To overcome these limitations, a hybrid region growing segmentation method is proposed combining non-linear diffusion filter and global gradient measure (HNDF-GGM-RG). The performance of the algorithm is validated on PET images and compared with the 40%-fixed threshold and a state-of-the-art active contour (AC) methods. Segmented volume, dice similarity coefficient (DSC) and percentage classification error (% CE) were used as the quantitative figures of merit (FOM) using the torso NEMA phantom that contains six different sizes of spheres. A 2:1 SBR was created between the spheres and background and the phantom was scanned with a Siemens TrueV PET-CT scanner. 40T method is SNR dependent and overestimates the volumes ( ≈ 4.5  times ) . AC volumes match with the true volumes only for the largest three spheres. On the other hand, the proposed HNDF-GGM-RG volumes match closely with the true volumes irrespective of the size and SNR. Average DSC of 0.32 and 0.66 and % CE of 700% and 160% were achieved by the 40T and AC methods respectively. Conversely, average DSC and %CE are 0.70 and 60% for HNDF-GGM-RG and less dependent on SNR. Since two-sample t-test indicates that the performance of AC and HNDF-GGM-RG are statistically significant for the smallest three spheres and similar for the rest, HNDF-GGM-RG can be applied where the size, SBR and SNR are subject to change either due to alterations in the radiotracer uptake because of treatment or uptake variability of different radiotracers because of differences in their molecular pathways.

Substitution of venous for arterial blood sampling in the determination of regional rates of cerebral protein synthesis with L-[1-11C]leucine PET: A validation study

We developed and validated a method to estimate input functions for determination of regional rates of cerebral protein synthesis (rCPS) with L-[1-¹¹C]leucine PET without arterial sampling. The method is based on a population-derived input function (PDIF) approach, with venous samples for calibration. Population input functions were constructed from arterial blood data measured in 25 healthy 18-24-year-old males who underwent L-[1-¹¹C]leucine PET scans while awake. To validate the approach, three additional groups of 18-27-year-old males underwent L-[1-¹¹C]leucine PET scans with both arterial and venous blood sampling: 13 awake healthy volunteers, 10 sedated healthy volunteers, and 5 sedated subjects with fragile X syndrome. Rate constants of the L-[1-¹¹C]leucine kinetic model were estimated voxel-wise with measured arterial input functions and with venous-calibrated PDIFs. Venous plasma leucine measurements were used with venous-calibrated PDIFs for rCPS computation. rCPS determined with PDIFs calibrated with 30-60 min venous samples had small errors (RMSE: 4-9%), and no statistically significant differences were found in any group when compared to rCPS determined with arterial input functions. We conclude that in young adult males, PDIFs calibrated with 30-60 min venous samples can be used in place of arterial input functions for determination of rCPS with L-[1-¹¹C]leucine PET.

MRI-Driven PET Image Optimization for Neurological Applications

Positron emission tomography (PET) and magnetic resonance imaging (MRI) are established imaging modalities for the study of neurological disorders, such as epilepsy, dementia, psychiatric disorders and so on. Since these two available modalities vary in imaging principle and physical performance, each technique has its own advantages and disadvantages over the other. To acquire the mutual complementary information and reinforce each other, there is a need for the fusion of PET and MRI. This combined dual-modality (either sequential or simultaneous) could generate preferable soft tissue contrast of brain tissue, flexible acquisition parameters, and minimized exposure to radiation. The most unique superiority of PET/MRI is mainly manifested in MRI-based improvement for the inherent limitations of PET, such as motion artifacts, partial volume effect (PVE) and invasive procedure in quantitative analysis. Head motion during scanning significantly deteriorates the effective resolution of PET image, especially for the dynamic scan with lengthy time. Hybrid PET/MRI device can offer motion correction (MC) for PET data through MRI information acquired simultaneously. Regarding the PVE associated with limited spatial resolution, the process and reconstruction of PET data can be further optimized by using acquired MRI either sequentially or simultaneously. The quantitative analysis of dynamic PET data mainly relies upon an invasive arterial blood sampling procedure to acquire arterial input function (AIF). An image-derived input function (IDIF) method without the need of arterial cannulization, can serve as a potential alternative estimation of AIF. Compared with using PET data only, combining anatomical or functional information from MRI for improving the accuracy in IDIF approach has been demonstrated. Yet, due to the interference and inherent disparity between the two modalities, these methods for optimizing PET image based on MRI still have many technical challenges. This review discussed upon the most recent progress, current challenges and future directions of MRI-driven PET data optimization for neurological applications, with either sequential or simultaneous acquisition approach.

A phantom study to assess the reproducibility, robustness and accuracy of PET image segmentation methods against statistical fluctuations

Background

Automatic and semi-automatic segmentation methods for PET serve as alternatives to manual delineation and eliminate observer variability. The robustness of these segmentation methods against statistical fluctuations arising from variable size, contrast and noise are vital for providing reliable clinical outcomes for diagnosis and treatment response assessment. In this study, the performances of several segmentation methods have been investigated using the torso NEMA phantom against statistical fluctuations.

Methods

The six hot spheres (0.5-27ml) and the background of the phantom were filled with different activities of ¹⁸F to yield 2:1 and 4:1 contrast ratios. The phantom was scanned on a TrueV PET-CT scanner for 120 minutes. The images were reconstructed using OSEM (4iterations-21subsets) for different durations (15, 20, 34 and 67 minutes) to represent different noise levels and smoothed with a 4-mm Gaussian filter. Each sphere with different settings was delineated using a fixed 40% threshold (40T), fuzzy clustering mean (FCM), adaptive threshold and region based variational (C-V) segmentation methods and compared with the gold standard volume, which was estimated from the known diameter and position of each sphere.

Results

The smallest three spheres at the 2:1 contrast level are not evaluable for the 40T method. For the other spheres, the 40T method grossly overestimates the volumes and the segmented volumes are highly dependent on the statistical variations. These volumes are the least reproducible (80%) with a mean Dice Similarity Coefficient (DSC) of 0.67 and 90% classification error (CE). The other three methods reduce the dependency on noise and contrast in a similar manner by providing low bias (<10%) and CE (<25%) as well as a high DSC (0.88) and reproducibility (30%) for objects >17mm in diameter. However, for the smallest three spheres at a 2:1 contrast level, the performances of all three methods were significantly low, with the adaptive method being superior to the FCM and C-V (mean bias 168% and 350%, mean DSC 0.65 and 0.50, mean CE 227% and 454% for the adaptive and other two methods (approximately similar for FCM and C-V), respectively).

Conclusions

The segmentation accuracy of the fixed threshold-based method depends on size, contrast and noise. The intensity thresholds determined by the adaptive threshold methods are less sensitive to noise and therefore, the segmented volumes are more reproducible across different acquisition durations. A similar performance can be achieved with the FCM and C-V methods. Though, for small lesions (< 2cm diameter) with low counts and contrast, the adaptive threshold-based method outperforms the FCM and C-V methods, and the performance of neither of these methods is optimal for volumes <2cm in diameter. These three methods can only reliably be used to delineate tumours for diagnostic and monitoring purposes provided that the contrast between the tumour and background is not below a 2:1 ratio and the size of the tumour does not fall not below 2cm in diameter in response to treatment. They can also be used for different radiotracers with variable uptake. However, the FCM and C-V methods have the advantage of not requiring calibrations for different scanners and settings.

Is Response Assessment of Breast Cancer Bone Metastases Better with Measurement of 18F-Fluoride Metabolic Flux Than with Measurement of 18F-Fluoride PET/CT SUV?

Our purpose was to establish whether noninvasive measurement of changes in 18F-fluoride metabolic flux to bone mineral (Ki) by PET/CT can provide incremental value in response assessment of bone metastases in breast cancer compared with SUVmax and SUVmeanMethods: Twelve breast cancer patients starting endocrine treatment for de novo or progressive bone metastases were included. Static 18F-fluoride PET/CT scans were acquired 60 min after injection, before and 8 wk after commencing treatment. Venous blood samples were taken at 55 and 85 min after injection to measure plasma 18F-fluoride activity concentrations, and Ki in individual bone metastases was calculated using a previously validated method. Percentage changes in Ki, SUVmax, and SUVmean were calculated from the same index lesions (≤5 lesions) from each patient. Clinical response up to 24 wk, assessed in consensus by 2 experienced oncologists masked to PET imaging findings, was used as a reference standard. Results: Of the 4 patients with clinically progressive disease (PD), mean Ki significantly increased (>25%) in all, SUVmax in 3, and SUVmean in 2. Of the 8 non-PD patients, Ki decreased or remained stable in 7, SUVmax in 5, and SUVmean in 6. A significant mean percentage increase from baseline for Ki, compared with SUVmax and SUVmean, occurred in the 4 patients with PD (89.7% vs. 41.8% and 43.5%, respectively; P < 0.001). Conclusion: After 8 wk of endocrine treatment for bone-predominant metastatic breast cancer, Ki more reliably differentiated PD from non-PD than did SUVmax and SUVmean, probably because measurement of SUV underestimates fluoride clearance by not considering changes in input function.

Comparative assessment of linear least-squares, nonlinear least-squares, and Patlak graphical method for regional and local quantitative tracer kinetic modeling in cerebral dynamic 18 F-FDG PET

PURPOSE

Dynamic ¹⁸ F-FDG PET allows quantitative estimation of cerebral glucose metabolism both at the regional and local (voxel) level. Although sensitive to noise and highly computationally expensive, nonlinear least-squares (NLS) optimization stands as the reference approach for the estimation of the kinetic model parameters. Nevertheless, faster techniques, including linear least-squares (LLS) and Patlak graphical method, have been proposed to deal with high resolution noisy data, representing a more adaptable solution for routine clinical implementation. Former research investigating the relative performance of the available algorithms lack precise evaluation of kinetic parameter estimates under realistic acquisition conditions.

METHODS

The present study aims at the systematic comparison of the feasibility and pertinence of kinetic modeling of dynamic cerebral ¹⁸ F-FDG PET using NLS, LLS, and Patlak method, based on numerical simulations and patient data. Numerical simulations were used to study the bias and variance of K₁ and K_i parameters estimation under representative noise levels. Patient data allowed to assess the concordance between the three methods at the regional and voxel scale, and to evaluate the robustness of the estimations with respect to patient head motion.

RESULTS AND CONCLUSIONS

Our findings indicate that at the regional level NLS and LLS provide kinetic parameter estimates (K₁ and K_i ) with similar bias and variance characteristics (K₁ bias ± relative standard deviation [RSD] 0.0 ± 5.1% and 0.1% ± 4.9% for NLS and LLS respectively, K_i bias ± RSD 0.1% ± 4.5% and -0.7% ± 4.4% for NLS and LLS respectively). NLS estimates appear, however, to be slightly less sensitive to patient motion. At the voxel level, provided that patient motion is negligible or corrected, LLS offers an appealing alternative solution for local K₁ mapping. It yields K1 estimates that are highly correlated, with high correlation with NLS values (Pearson's r = 0.95 on actual data) within computations times less than two orders of magnitude lower. Last, Patlak method appears as the most robust and accurate technique for the estimation of K_i values at the regional and voxel scale, with or without head motion. It provides low bias/low variance K_i quantification (bias ± RSD -1.5 ± 9.5% and -4.1 ± 19.7% for Patlak and NLS respectively) as well as smooth parametric images suitable for visual assessment.