Risks and safety aspects related to PET/MR examinations

Predicting cognitive decline: Which is more useful, baseline amyloid levels or longitudinal change?

The use of biomarkers for the early detection of Alzheimer's disease (AD) is crucial for developing potential therapeutic treatments. Positron Emission Tomography (PET) is a well-established tool used to detect β-amyloid (Aβ) plaques in the brain. Previous studies have shown that cross-sectional biomarkers can predict cognitive decline (Schindler et al.,2021). However, it is still unclear whether longitudinal Aβ-PET may have additional value for predicting time to cognitive impairment in AD. The current study aims to evaluate the ability of baseline- versus longitudinal rate of change in-11C-Pittsburgh compound B (PiB) Aβ-PET to predict cognitive decline. A cohort of 153 participants who previously underwent PiB-PET scans and comprehensive clinical assessments were used in this study. Our analyses revealed that baseline Aβ is significantly associated with the rate of change in cognitive composite scores, with cognition declining more rapidly when baseline PiB Aβ levels were higher. In contrast, no signification association was identified between the rate of change in PiB-PET Aβ and cognitive decline. Additionally, the ability of the rate of change in the PiB-PET measures to predict cognitive decline was significantly influenced by APOE ε4 carrier status. These results suggest that a single PiB-PET scan is sufficient to predict cognitive decline and that longitudinal measures of Aβ accumulation do not improve the prediction of cognitive decline once someone is amyloid positive.

An integrated measure of GABA to characterize post-stroke plasticity

Stroke is a major cause of death and chronic neurological disability. Despite the improvements in stroke care, the number of patients affected by stroke keeps increasing and many stroke survivors are left permanently disabled. Current therapies are limited in efficacy. Understanding the neurobiological mechanisms underlying post-stroke recovery is therefore crucial to find new therapeutic options to address this medical burden. Long-lasting and widespread alterations of γ-aminobutyric acid (GABA) neurotransmission seem to play a key role in stroke recovery. In this review we first discuss a possible model of GABAergic modulation of post-stroke plasticity. We then overview the techniques currently available to non-invasively assess GABA in patients and the conclusions drawn from this limited body of work. Finally, we address the remaining open questions to clarify GABAergic changes underlying post-stroke recovery, we briefly review possible ways to modulate GABA post stroke and propose a novel approach to thoroughly quantify GABA in stroke patients, by integrating its concentration, the activity of its receptors and its link with microstructural changes.

Evaluation of frequency magnetic field, static field, and Temozolomide on viability, free radical production and gene expression (p53) in the human glioblastoma cell line (A172)

Thirteen million cancer deaths and 21.7 million new cancer cases are expected in the world by 2030. Glioblastoma is the most common primary malignant tumor of the central nervous system which is the most lethal type of primary brain tumor in adults with the survival time of 12-15 months after the initial diagnosis. Glioblastoma is the most common and most malignant type of brain tumor, and despite surgery, chemotherapy and radiation treatment, the average survival of patients is about 14 months. The current research showed that the frequency magnetic field (FMF) and static magnetic field (SMF) can influence cancer cell proliferation and coupled with anticancer drugs may provide a new strategy for cancer therapy. At the present study, we investigated the effects of FMF (10 Hz, 50 G), SMF (50 G) and Temozolomide (200 μm) on viability, free radical production, and p53 followed by p53 protein expression in the human glioblastoma cell line (A172) by MTT, NBT, RT-PCR and Western blot. Results showed that the effect of Temozolomide (TMZ) with SMF and FMF together increased the cytotoxicity, free radical production, and p53 followed by p53 protein expression in the human glioblastoma cell line (A172).

Double-strand breaks in lymphocyte DNA of humans exposed to [18F]fluorodeoxyglucose and the static magnetic field in PET/MRI

BACKGROUND

Given the increasing clinical use of PET/MRI, potential risks to patients from simultaneous exposure to ionising radiation and (electro)magnetic fields should be thoroughly investigated as a precaution. With this aim, the genotoxic potential of 2-deoxy-2-[18F]fluoro-D-glucose ([18F]FDG) and a strong static magnetic field (SMF) were evaluated both in isolation and in combination using the γH2AX assay detecting double-strand breaks in lymphocyte DNA.

METHODS

Thirty-two healthy young volunteers allocated to three study arms were exposed to [18F]FDG alone, to a 3-T SMF alone or to both combined over 60 min at a PET/CT or a PET/MRI system. Blood samples taken after in vivo exposure were incubated up to 60 min to extend the irradiation of blood by residual [18F]FDG within the samples and the time to monitor the γH2AX response. Absorbed doses to lymphocytes delivered in vivo and in vitro were estimated individually for each volunteer exposed to [18F]FDG. γH2AX foci were scored automatically by immunofluorescence microscopy.

RESULTS

Absorbed doses to lymphocytes exposed over 60 to 120 min to [18F]FDG varied between 1.5 and 3.3 mGy. In this time interval, the radiotracer caused a significant median relative increase of 28% in the rate of lymphocytes with at least one γH2AX focus relative to the background rate (p = 0.01), but not the SMF alone (p = 0.47). Simultaneous application of both agents did not result in a significant synergistic or antagonistic outcome (p = 0.91).

CONCLUSION

There is no evidence of a synergism between [18F]FDG and the SMF that may be of relevance for risk assessment of PET/MRI.

FDG-PET/MRI imaging for the management of alveolar echinococcosis: initial clinical experience at a reference centre in Austria

BACKGROUND

[¹⁸ F]-2-fluoro-2-deoxy-D-glucose (18F-FDG) positron emission tomography/computed tomography (FDG-PET/CT) imaging provides important information about the size and metabolic activity of lesions caused by Echinococcus multilocularis and is therefore recommended for the initial assessment and follow-up of human alveolar echinococcosis (AE). The introduction of positron emission tomography/magnetic resonance imaging (PET/MRI) into clinical practice in affluent health care systems provides an alternative dual imaging modality, which has not yet been evaluated for AE.

OBJECTIVE

Here, we describe the initial clinical experience with comparative PET/CT and PET/MR imaging in four human AE patients at an Austrian reference centre.

RESULTS

PET/MR imaging showed comparable diagnostic capacity for liver lesions attributable to E. multilocularis infection, with a discrepancy only in the assessment of calcifications in one patient. Effective doses of radiation were 30.4-31 mSV for PET/CT, which were reduced in PET/MRI to the exposure of ¹⁸ F-FDG only (4.9-5.5 mSv).

CONCLUSIONS

PET/MRI provides comparable diagnostic information for AE management. The reduction in radiation exposure compared to PET/CT may be of particular importance for children and young patients not amenable for curative surgery requiring repeated long-term follow-up with dual imaging modalities. Further studies are warranted to prospectively evaluate the potential of PET/MRI in the management of AE.

PET/MRI: a frontier in era of complementary hybrid imaging

With primitive approaches, the diagnosis and therapy were operated at the cellular, molecular, or even at the genetic level. As the diagnostic techniques are more concentrated towards molecular level, multi modal imaging becomes specifically essential. Multi-modal imaging has extensive applications in clinical as well as in pre-clinical studies. Positron Emission Tomography (PET) has flourished in the field of nuclear medicine, which has motivated it to fuse with Computed Tomography (CT) and Magnetic Resonance Imaging (MRI) for PET/CT and PET/MRI respectively. However, the challenges in PET/CT are due to the inability of simultaneous acquisition and reduced soft tissue contrast, which has led to the development of PET/MRI. Also, MRI offers the better soft tissue contrast over CT. Hence, fusion of PET and MRI results in combining structural information with functional image from PET. Yet, it has many technical challenges due to the interference between the modalities. Also, it must be resolved with various approaches for addressing the shortcomings of each system and improvise on the image quantification system. This review elaborates on the various challenges in the present PET/MRI system and the future directions of the hybrid modality. Also, the different data acquisition and analysis techniques of PET/MRI system are discussed with enhanced details on the software tools.

Non-invasive imaging modalities to study neurodegenerative diseases of aging brain

The aim of this article is to highlight current approaches for imaging elderly brain, indispensable for cognitive neuroscience research with emphasis on the basic physical principles of various non-invasive neuroimaging techniques. The first part of this article presents a quick overview of the primary non-invasive neuroimaging modalities used by cognitive neuroscientists such as transcranial magnetic stimulation (TMS), transcranial electrical stimulation (tES), electroencephalography (EEG), magnetoencephalography (MEG), single photon emission computed tomography (SPECT), positron emission tomography (PET), magnetic resonance spectroscopic imaging (MRSI), Profusion imaging, functional magnetic resonance imaging (fMRI), near infrared spectroscopy (NIRS) and diffusion tensor imaging (DTI) along with tractography and connectomics. The second part provides a comprehensive overview of different multimodality imaging techniques for various cognitive neuroscience studies of aging brain.

Radiation exposure of patients undergoing whole-body FDG-PET/CT examinations: an update pursuant to the new ICRP recommendations

AIM

Reinvestigation of the radiation exposure of patients undergoing whole-body [18F]FDG-PET/CT examinations pursuant to the revised recommendations of the ICRP.

METHODS

Conversion coefficients for equivalent organ doses were determined for realistic anthropomorphic phantoms of reference persons. Based on these data, conversion coefficients for the effective dose were calculated using the revised tissue-weighting factors that account for the different radiation susceptibilities of organs and tissues, and the redefinition of the group 'remainder tissues'.

RESULTS

Despite the markedly changed values of the equivalent organ doses estimated for FDG and of the tissue-weighting factors, the conversion coefficient for the effective dose resulting from FDG administration decreases only slightly by 10 %. For whole-body CT scans it remains even unchanged.

CONCLUSION

The updated dose coefficients provide a valuable tool to easily assess the generic radiation risk of patients undergoing whole-body PET/CT (or PET/MRI) examinations and can be used, amongst others, for protocol optimization.

Does the novel integrated PET/MRI offer the same diagnostic performance as PET/CT for oncological indications?

BACKGROUND

We compared PET/MRI with PET/CT in terms of lesion detection and quantitative measurement to verify the feasibility of the novel integrated imaging modality for oncological applications.

METHODOLOGY/PRINCIPAL FINDINGS

In total, 285 patients referred to our PET/CT center for oncological indications voluntarily participated in this same-day PET/CT and PET/MRI comparative study. PET/CT images were acquired and reconstructed following routine protocols, and then PET/MRI was performed at a mean time interval of 28±11 min (range 15-45 min). PET/MRI covered the body trunk with a sequence combination of transverse T1WI 3D-volumetric interpolated breath-hold, T2WI turbo spin echo with fat saturation, diffusion-weighted imaging with double b values (50 and 800 s/mm2), and simultaneous PET acquisition over 45 min/5 bed positions. The maximum standardized uptake value (SUVmax) was assessed by manually drawn regions of interest over fluorodeoxyglucose-positive lesions. Among 285 cases, 57 showed no abnormalities, and 368 lesions (278 malignant, 68 benign and 22 undetermined) were detected in 228 patients. When stand-alone modalities were evaluated, PET revealed 31 and 12 lesions missed by CT and MRI, respectively, and CT and MRI revealed 38 and 61 more lesions, respectively, than PET. Compared to CT, MRI detected 40 more lesions and missed 8. In the integrated mode, PET/CT correctly detected 6 lesions misdiagnosed by PET/MRI, but was false-negative in 30 cases that were detected by PET/MRI. The overall diagnosis did not differ between integrated PET/MRI and PET/CT. SUVmax for lesions were slightly higher from PET/MRI than PET/CT but correlated well (ρ = 0.85-0.91).

CONCLUSIONS/SIGNIFICANCE

The novel integrated PET/MRI performed comparatively to PET/CT in lesion detection and quantitative measurements. PET from either scanner modality offered almost the same information despite differences in hardware. Further study is needed to explore features of integrated PET/MRI not addressed in this study.

Competitive advantage of PET/MRI

Multimodality imaging has made great strides in the imaging evaluation of patients with a variety of diseases. Positron emission tomography/computed tomography (PET/CT) is now established as the imaging modality of choice in many clinical conditions, particularly in oncology. While the initial development of combined PET/magnetic resonance imaging (PET/MRI) was in the preclinical arena, hybrid PET/MR scanners are now available for clinical use. PET/MRI combines the unique features of MRI including excellent soft tissue contrast, diffusion-weighted imaging, dynamic contrast-enhanced imaging, fMRI and other specialized sequences as well as MR spectroscopy with the quantitative physiologic information that is provided by PET. Most evidence for the potential clinical utility of PET/MRI is based on studies performed with side-by-side comparison or software-fused MRI and PET images. Data on distinctive utility of hybrid PET/MRI are rapidly emerging. There are potential competitive advantages of PET/MRI over PET/CT. In general, PET/MRI may be preferred over PET/CT where the unique features of MRI provide more robust imaging evaluation in certain clinical settings. The exact role and potential utility of simultaneous data acquisition in specific research and clinical settings will need to be defined. It may be that simultaneous PET/MRI will be best suited for clinical situations that are disease-specific, organ-specific, related to diseases of the children or in those patients undergoing repeated imaging for whom cumulative radiation dose must be kept as low as reasonably achievable. PET/MRI also offers interesting opportunities for use of dual modality probes. Upon clear definition of clinical utility, other important and practical issues related to business operational model, clinical workflow and reimbursement will also be resolved.

PET/MR imaging: technical aspects and potential clinical applications

Instruments that combine positron emission tomography (PET) and magnetic resonance (MR) imaging have recently been assembled for use in humans, and may have diagnostic performance superior to that of PET/computed tomography (CT) for particular clinical and research applications. MR imaging has major strengths compared with CT, including superior soft-tissue contrast resolution, multiplanar image acquisition, and functional imaging capability through specialized techniques such as diffusion-tensor imaging, diffusion-weighted (DW) imaging, functional MR imaging, MR elastography, MR spectroscopy, perfusion-weighted imaging, MR imaging with very short echo times, and the availability of some targeted MR imaging contrast agents. Furthermore, the lack of ionizing radiation from MR imaging is highly appealing, particularly when pediatric, young adult, or pregnant patients are to be imaged, and the safety profile of MR imaging contrast agents compares very favorably with iodinated CT contrast agents. MR imaging also can be used to guide PET image reconstruction, partial volume correction, and motion compensation for more accurate disease quantification and can improve anatomic localization of sites of radiotracer uptake, improve diagnostic performance, and provide for comprehensive regional and global structural, functional, and molecular assessment of various clinical disorders. In this review, we discuss the historical development, software-based registration, instrumentation and design, quantification issues, potential clinical applications, potential clinical roles of image segmentation and global disease assessment, and challenges related to PET/MR imaging.

SUPPLEMENTAL MATERIAL

http://radiology.rsna.org/lookup/suppl/doi:10.1148/radiol.13121038/-/DC1.

PET/MR: a paradigm shift

More than a decade ago, multimodality imaging was introduced into clinical routine with the development of the positron emission tomography (PET)/computed tomography (CT) technique. Since then, PET/CT has been widely accepted in clinical imaging and has emerged as one of the main cancer imaging modalities. With the recent development of combined PET/magnetic resonance (MR) systems for clinical use, a promising new hybrid imaging modality is now becoming increasingly available. The combination of functional information delivered by PET with the morphologic and functional imaging of MR imaging (e.g., diffusion-weighted imaging, dynamic contrast-enhanced MR imaging and MR spectroscopy) offers exciting possibilities for clinical applications as well as basic research. However, the differences between CT and MR imaging are fundamental. This also leads to distinct differences between PET/CT and PET/MR not only regarding image interpretation but also concerning data acquisition, data processing and image reconstruction. This article provides an overview of the principal differences between PET/CT and PET/MR in terms of scanner design and technology, attenuation correction, speed, acquisition protocols, radiation exposure and safety aspects. PET/MR is expected to show advantages over PET/CT in clinical applications in which MR is known to be superior to CT due to its high intrinsic soft tissue contrast. However, as of now, only assumptions can be made about the future clinical role of PET/MR, as data about the performance of PET/MR in the clinical setting are still limited. The possible future clinical use of PET/MR in oncology, neurology and neurooncology, cardiology and imaging of inflammation is discussed.

MR/PET or PET/MRI: does it matter?

After the very successful clinical introduction of combined PET/CT imaging a decade ago, a hardware combination of PET and MR is following suit. Today, three different approaches towards integrated PET/MR have been proposed: (1) a triple-modality system with a 3T MRI and a time-of-flight PET/CT installed in adjacent rooms, (2) a tandem system with a 3T MRI and a time-of-flight PET/CT in a co-planar installation with a joint patient handling system, and (3) a fully-integrated system with a whole-body PET system mounted inside a 3T MRI system. This special issue of MAGMA brings together contributions from key experts in the field of PET/MR, PET/CT and CT. The various papers share the author's perspectives on the state-of-the-art PET/MR imaging with any of the three approaches mentioned above. In addition to several reviews discussing advantages and challenges of combining PET and MRI for clinical diagnostics, first clinical data are also presented. We expect this special issue to nurture future improvements in hardware, clinical protocols, and efficient post-processing strategies to further assess the diagnostic value of combined PET/MR imaging. It remains to be seen whether a so-called "killer application" for PET/MRI will surface. In that case PET/MR is likely to excel in pre-clinical and selected research applications for now. This special issue helps the readers to stay on track of this exciting development.

Subjective perception of radiation risk

Physicians, medical staff, and patients, much like the general population, are becoming increasingly sensitized to the issue of radiation exposure from diagnostic or therapeutic procedures. The attitudes of patients undergoing diagnostic imaging procedures that use ionizing radiation vary widely. Patient perception of radiation dose strongly influences their acceptance of diagnostic examinations or therapies involving radioactivity. Here, we review perceptions and concerns about radiation and radioactivity by laypersons and medical experts. Several studies show that physicians are frequently poorly informed about radiation levels associated with nuclear medicine and radiologic examinations. In addition, patients' decisions against undergoing an imaging procedure are frequently based on partial and sometimes incorrect information. Thus, physicians must take the concerns of their patients seriously. From the literature and our own experience, we conclude that it is extremely important to thoroughly and carefully educate all involved in patient work-up about radiation exposure levels and perceived or actual health risks. Although the choice and timing of imaging examinations should always outweigh the risk that secondary illness will develop, the patients' concerns still must be alleviated.

Clinical significance of creative 3D-image fusion across multimodalities [PET+CT+MR] based on characteristic coregistration

OBJECTIVE

To investigate a registration approach for 2-dimension (2D) based on characteristic localization to achieve 3-dimension (3D) fusion from images of PET, CT and MR one by one.

METHOD

A cubic oriented scheme of"9-point & 3-plane" for co-registration design was verified to be geometrically practical. After acquisiting DICOM data of PET/CT/MR (directed by radiotracer 18F-FDG etc.), through 3D reconstruction and virtual dissection, human internal feature points were sorted to combine with preselected external feature points for matching process. By following the procedure of feature extraction and image mapping, "picking points to form planes" and "picking planes for segmentation" were executed. Eventually, image fusion was implemented at real-time workstation mimics based on auto-fuse techniques so called "information exchange" and "signal overlay".

RESULT

The 2D and 3D images fused across modalities of [CT+MR], [PET+MR], [PET+CT] and [PET+CT+MR] were tested on data of patients suffered from tumors. Complementary 2D/3D images simultaneously presenting metabolic activities and anatomic structures were created with detectable-rate of 70%, 56%, 54% (or 98%) and 44% with no significant difference for each in statistics.

CONCLUSION

Currently, based on the condition that there is no complete hybrid detector integrated of triple-module [PET+CT+MR] internationally, this sort of multiple modality fusion is doubtlessly an essential complement for the existing function of single modality imaging.

A pilot study utilizing whole body 18 F-FDG-PET/CT as a comprehensive screening strategy for occult malignancy in patients with unprovoked venous thromboembolism

BACKGROUND

Approximately 7-10% of patients with unprovoked VTE will be diagnosed with cancer within 12 months. Although cancer screening has been proposed in these patients, the optimal strategy remains unclear. In a pilot study, we prospectively investigated the use of FDG-PET/CT to screen for occult malignancy in 40 patients with unprovoked VTE.

MATERIALS/METHODS

Patients were initially screened for occult malignancy with a focused history, physical, and laboratory evaluation. Patients underwent whole body FDG-PET/CT and were followed for up to two years for a new diagnosis of cancer. The total costs of using FDG-PET/CT as a comprehensive screening strategy were determined using 2010 Medicare reimbursement rates.

RESULTS

Completion of FDG-PET/CT imaging was feasible and identified abnormal findings requiring additional evaluations in 62.5% of patients. Occult malignancy was evident in only one patient (cancer incidence 2.5%) and FDG-PET/CT imaging excluded malignancy in the remainder of patients. No patients with a negative FDG-PET/CT were diagnosed with malignancy during an average (±SD) follow-up of 449 (±311) days. The use of FDG-PET/CT to screen for occult malignancy added $59,151 in total costs ($1,479 per patient). The majority of these costs were due to the cost of the FDG-PET/CT ($1,162 per patient or 78.5% of total per-patient costs).

CONCLUSIONS

FDG-PET/CT may have utility for excluding occult malignancy in patients with unprovoked VTE. The costs of this comprehensive screening strategy were comparable to other screening approaches. Larger studies are needed to further evaluate the utility and cost-effectiveness of FDG-PET/CT as a cancer screening strategy in patients with unprovoked VTE.

The future of hybrid imaging-part 3: PET/MR, small-animal imaging and beyond

Since the 1990s, hybrid imaging by means of software and hardware image fusion alike allows the intrinsic combination of functional and anatomical image information. This review summarises in three parts the state of the art of dual-technique imaging with a focus on clinical applications. We will attempt to highlight selected areas of potential improvement of combined imaging technologies and new applications. In this third part, we discuss briefly the origins of combined positron emission tomography (PET)/magnetic resonance imaging (MRI). Unlike PET/computed tomography (CT), PET/MRI started out from developments in small-animal imaging technology, and, therefore, we add a section on advances in dual- and multi-modality imaging technology for small animals. Finally, we highlight a number of important aspects beyond technology that should be addressed for a sustained future of hybrid imaging. In short, we predict that, within 10 years, we may see all existing multi-modality imaging systems in clinical routine, including PET/MRI. Despite the current lack of clinical evidence, integrated PET/MRI may become particularly important and clinically useful in improved therapy planning for neurodegenerative diseases and subsequent response assessment, as well as in complementary loco-regional oncology imaging. Although desirable, other combinations of imaging systems, such as single-photon emission computed tomography (SPECT)/MRI may be anticipated, but will first need to go through the process of viable clinical prototyping. In the interim, a combination of PET and ultrasound may become available. As exciting as these new possible triple-technique—imaging systems sound, we need to be aware that they have to be technologically feasible, applicable in clinical routine and cost-effective.

Combined PET/MR Imaging — Technology and Applications

The combination of PET and MR in one imaging device has certain advantages over conventional imaging modalities. These include: no additional radiation dose from the MR, superior soft tissue contrast and a multitude of tracers for PET. Certain technical challenges exist when designing a PET/MR system. On the one hand these stem from the presence of the strong MR magnetic field and the addition of PET components to the MR system. Different approaches are presented to overcome these technical obstacles ranging from long optical fibers to systems that use semiconductor light detectors for photon counting. The applications of combined PET/MR are profound in the field of oncology and allow imaging of the four main processes in cancer formation: apoptosis resistance, angiogenesis, proliferation and metastasis. PET/MR has also many clinical and research applications in neurology and cardiology. Alternative techniques such as image fusion, hyperpolarized imaging, 17 O imaging and whole body diffusion are discussed in respect to their relevance regarding PET/MR. Simultaneous multifunctional and anatomical imaging using PET/MR has a great potential to impact biomedical imaging in research and clinic.