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Mihailović J. Pre-Treatment and Post-Treatment I-131 Imaging in Differentiated Thyroid Carcinoma. J Clin Med 2024; 13:1984. [PMID: 38610749 PMCID: PMC11012677 DOI: 10.3390/jcm13071984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Revised: 03/25/2024] [Accepted: 03/27/2024] [Indexed: 04/14/2024] Open
Abstract
Radioiodine imaging in initial perioperative settings, after the total thyroidectomy, includes pre-treatment and post-treatment radioiodine imaging. While the benefit of post-treatment whole-body imaging (PT-WBI) is well established, the role of diagnostic whole-body imaging (dx WBI), prior to radioiodine (I-131) ablative or therapeutic doses, is controversial. Dx WBI has been abandoned in most nuclear medicine centers long ago. Planar low-dose dxWBI provides the volume of postoperative thyroid remnants, but it cannot detect occult metastatic foci in the neck. The modern integrated multimodality, i.e., SPECT/CT imaging, provides three dimensional images and accurate anatomic/metabolic data. This hybrid technology offers better spatial resolution but not better sensitivity. Dx WBI has low theranostic power because of the radioiodine indifference and low detection sensitivity for small-volume nodal disease in the neck. Since dx WBI cannot clarify the paratracheal cervical uptake, thyroid remnants may be easily misinterpreted as nodal disease, leading to a false N upstaging (from N0 stage to N1 stage) in DTC patients. Post-ablation I-131 imaging has a significant role in the initial staging of radioiodine-avid DTC and in the identification of non-radioiodine avid tumors. Additionally, SPECT/CT in the post-treatment setting provides more accurate initial TNM staging and better risk stratification of DTC patients. Post-treatment I-131 imaging is obligatory and must be performed in all DTC patients who receive radioiodine treatment.
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Affiliation(s)
- Jasna Mihailović
- Department of Nuclear Medicine, Faculty of Medicine, University of Novi Sad, Hajduk Veljkova 3, 21000 Novi Sad, Serbia; ; Tel.: +381-63-526835
- Division of Nuclear Medicine, Oncology Institute of Vojvodine, Put dr Goldmana 4, 21204 Sremska Kamenica, Serbia
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Holoubek SA, Sippel RS. Lymph node imaging for thyroid cancer. Clin Endocrinol (Oxf) 2024; 100:96-101. [PMID: 38009335 DOI: 10.1111/cen.14993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 09/25/2023] [Accepted: 11/09/2023] [Indexed: 11/28/2023]
Abstract
Cervical lymph nodes (LNs) in the central (level VI) and lateral (levels II-V) compartments of the neck are the most common sites of locoregional metastases associated with thyroid cancer. Prophylactic nodal dissections are uncommon in modern thyroid surgery and are not routinely performed due to concern for increased morbidity and do not offer improved survival. Therefore, a selective approach for LN dissections is increasingly important. Preoperatively, this is most frequently assessed with cervical ultrasound (US). Contrast-enhanced computed tomography (CT) of the neck can also be used for preoperative assessment. Both US and CT imaging can be used to characterise LNs in levels II-VI and their risk of malignancy based on size, morphology, and growth. US-guided fine-needle aspiration of equivocal LN with thyroglobulin (Tg) washout can also determine if a LN harbours malignancy. For postoperative surveillance after total thyroidectomy, both US and CT continue to play an important role at 6-12 months intervals. These patients may also benefit from additional biochemical data such as Tg levels in addition to LN and thyroid bed imaging. Thyroid uptake scans may also play a role in LN surveillance postoperatively for well-differentiated thyroid carcinoma in certain clinical contexts. Less commonly, positron emitted tomography may play a role, but is typically reserved for patients with aggressive or radioactive iodine refractory disease.
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Affiliation(s)
- Simon A Holoubek
- Endocrine Surgery Division, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Rebecca S Sippel
- Endocrine Surgery Division, University of Wisconsin-Madison, Madison, Wisconsin, USA
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Brown AK, Carapellucci J, Oshrine B, Gomez A, Meoded A, Asante-Korang A. Diagnostic and management roles of FDG PET/CT imaging in post-transplant lympho-proliferation in pediatric heart transplantation. Clin Transplant 2023; 37:e15015. [PMID: 37237443 DOI: 10.1111/ctr.15015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 04/28/2023] [Indexed: 05/28/2023]
Abstract
BACKGROUND Post-transplant lymphoproliferative disorder (PTLD) is a serious complication of pediatric heart transplant (PHTx). 18F-FDG PET/CT has been used to differentiate early lympho-proliferation from more advanced PTLD. We report our experience with PET/CT in the management of PTLD following PHTx. METHODS This was a retrospective study of 100 consecutive PHTx recipients at our institution between 2004 and 2018. Patients who underwent PET/CT or conventional CT scans to evaluate for PTLD or high Epstein-Barr viral load were included. RESULTS Males, eight females. Median age at transplant was 3.5 months (IQR = 1.5-27.5). Median age at PTLD diagnosis was 13.3 years (IQR = 9.2-16.1). Median time between transplant and PTLD diagnosis was 9.5 (IQR = 4.5-15) years. Induction agents were used in 12 patients (50%): Thymoglobulin (N = 9), anti-IL2 (N = 2), and Rituximab (N = 1). Eighteen patients (75%) had PET/CT, of whom 14 had 18FDG-avid PTLD. Six had conventional CT. Nineteen patients (79.2%) had diagnostic biopsy confirmation of PTLD, and 5 (20.8%) had excisional biopsies. Two patients had Hodgkin's lymphoma; nine had monomorphic PTLD; eight had polymorphic PTLD; five were classified as other. Nine patients had monomorphic PTLD, including seven with diffuse large cell lymphoma (DLBC) and one with T cell lymphoma. The majority (16/24) had multi-site involvement at PTLD diagnosis, and PET/CT showed that 31.3% (5/16) had easily accessible subcutaneous nodes. Seventeen patients (overall survival 71%) underwent successful treatment without recurrence of PTLD. Of seven deaths (7/24, 29%), five had DLBC lymphoma, one had polymorphic PTLD and one had T-cell lymphoma. CONCLUSION PET-CT allowed simultaneous anatomical and functional assessment of PTLD lesions, while guiding biopsy. In patients with multiple lesions, PET/CT revealed the most prominent and active lesions, improving diagnostic accuracy.
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Affiliation(s)
| | - Jennifer Carapellucci
- Division of Pediatric Cardiology, Johns Hopkins All Children's Hospital, Saint Petersburg, Florida, USA
| | - Benjamin Oshrine
- Division of Oncology, Johns Hopkins All Children's Hospital, Saint Petersburg, Florida, USA
| | - Anthony Gomez
- Division of Pediatric Cardiology, Johns Hopkins All Children's Hospital, Saint Petersburg, Florida, USA
| | - Avner Meoded
- Edward B. Singleton Department of Radiology, Texas Children's Hospital, Baylor college of Medicine, Houston, Texas, USA
| | - Alfred Asante-Korang
- Division of Pediatric Cardiology, Johns Hopkins All Children's Hospital, Saint Petersburg, Florida, USA
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Sun J, Du Y, Li C, Wu TH, Yang B, Mok GSP. Pix2Pix generative adversarial network for low dose myocardial perfusion SPECT denoising. Quant Imaging Med Surg 2022; 12:3539-3555. [PMID: 35782241 PMCID: PMC9246746 DOI: 10.21037/qims-21-1042] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Accepted: 02/18/2022] [Indexed: 11/12/2023]
Abstract
BACKGROUND Myocardial perfusion (MP) SPECT is a well-established method for diagnosing cardiac disease, yet its radiation risk poses safety concern. This study aims to apply and evaluate the use of Pix2Pix generative adversarial network (Pix2Pix GAN) in denoising low dose MP SPECT images. METHODS One hundred male and female patients with different 99mTc-sestamibi activity distributions, organ and body sizes were simulated by a population of digital 4D Extended Cardiac Torso (XCAT) phantoms. Realistic noisy SPECT projections of full dose of 987 MBq injection and 16 min acquisition, and low dose ranged from 1/20 to 1/2 of the full dose, were generated by an analytical projector from the right anterior oblique (RAO) to the left posterior oblique (LPO) positions. Additionally, twenty patients underwent ~1,184 MBq 99mTc-sestamibi stress SPECT/CT scan were also retrospectively recruited for the study. For each patient, low dose SPECT images (7/10 to 1/10 of full dose) were generated from the full dose list mode data. Our Pix2Pix GAN model was trained with full dose and low dose reconstructed SPECT image pairs. Normalized mean square error (NMSE), structural similarity index (SSIM), coefficient of variation (CV), full-width-at-half-maximum (FWHM) and relative defect size differences (RSD) of Pix2Pix GAN processed images were evaluated along with a reference convolutional auto encoder (CAE) network and post-reconstruction filters. RESULTS NMSE values of 0.0233±0.004 vs. 0.0249±0.004 and 0.0313±0.007 vs. 0.0579±0.016 were obtained on 1/2 and 1/20 dose level for Pix2Pix GAN and CAE in the simulation study, while they were 0.0376±0.010 vs. 0.0433±0.010 and 0.0907±0.020 vs. 0.1186±0.025 on 7/10 and 1/10 dose level in the clinical study. Similar results were also obtained from the SSIM, CV, FWHM and RSD values. Overall, the use of Pix2Pix GAN was superior to other denoising methods in all physical indices, particular in the lower dose levels in the simulation and clinical study. CONCLUSIONS The Pix2Pix GAN method is effective to reduce the noise level of low dose MP SPECT. Further studies on clinical performance are warranted to demonstrate its full clinical effectiveness.
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Affiliation(s)
- Jingzhang Sun
- Biomedical Imaging Laboratory (BIG), Department of Electrical and Computer Engineering, Faculty of Science and Technology, University of Macau, Macau, China
| | - Yu Du
- Biomedical Imaging Laboratory (BIG), Department of Electrical and Computer Engineering, Faculty of Science and Technology, University of Macau, Macau, China
- Center for Cognitive and Brain Sciences, Institute of Collaborative Innovation, University of Macau, Macau, China
| | - ChienYing Li
- Department of Biomedical Imaging and Radiological Sciences, National Yang Ming Chiao Tung University, Taipei
- Department of Nuclear Medicine, Taipei Veterans General Hospital, Taipei
| | - Tung-Hsin Wu
- Department of Biomedical Imaging and Radiological Sciences, National Yang Ming Chiao Tung University, Taipei
| | - BangHung Yang
- Department of Biomedical Imaging and Radiological Sciences, National Yang Ming Chiao Tung University, Taipei
- Department of Nuclear Medicine, Taipei Veterans General Hospital, Taipei
| | - Greta S. P. Mok
- Biomedical Imaging Laboratory (BIG), Department of Electrical and Computer Engineering, Faculty of Science and Technology, University of Macau, Macau, China
- Center for Cognitive and Brain Sciences, Institute of Collaborative Innovation, University of Macau, Macau, China
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Ben-Rejeb N, Ben-Sellem D. Estimation of additional dosimetry from low-dose CT scan to 99mTc-HMDP SPECT/CT. J Med Imaging Radiat Sci 2021; 53:87-92. [PMID: 34836833 DOI: 10.1016/j.jmir.2021.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 10/11/2021] [Accepted: 10/28/2021] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Currently, the addition of computed tomography (CT) to a gamma-camera has revolutionized nuclear medicine. Indeed the CT, because of its good spatial resolution, of the attenuation correction of the single photon emission computed tomography (SPECT) images and of a better anatomical localization of lesions, improves the sensitivity, specificity and accuracy of the examination. Despite the fact that the hybrid camera uses a low-dose non-diagnostic scanner, increases the overall delivered dose of radiation. METHODS The aim of this study was to evaluate the contribution of CT to the total effective dose of 99mTc-HMDP (hydroxymethylenediphosphonate labelled with technetium 99 metastable) SPECT/CT for an adult oncologic population. This prospective study included 103 patients (75 women and 28 men) aged 28 to 79 years. RESULTS The mean effective doses of SPECT, CT and SPECT/CT were respectively 3.8 mSv, 3.3 mSv and 7.1 mSv, respectively. The average contribution of CT scans to the total effective dose for SPECT/CT examination was 45 ± 9.7%, and ranged from 10 to 67.4%. The lowest value was for the thorax area. CONCLUSION This radiation dose is not negligible. But, taking into account the benefit of hybrid imaging, this additional radiation remains justifiable. Nevertheless, the "As Low as Reasonably Achievable (ALARA)'' principle must be respected to ensure that the patient is not subjected to unnecessarily high levels of radiation.
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Affiliation(s)
- Naima Ben-Rejeb
- Université de Tunis El Manar, Laboratoire de recherche en Biophysique et Technologies Médicales (LRBTM), Institut Supérieur des Technologies Médicales de Tunis (ISTMT), 1006, Tunis, Tunisia.
| | - Dorra Ben-Sellem
- Université de Tunis El Manar, Faculté de Médecine de Tunis, Laboratoire de recherche en Biophysique et Technologies Médicales (LRBTM) ISTMT, Institut Salah AZAIEZ: Service de Médecine Nucléaire, 1006, Tunis, Tunisia
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Biassoni L, Privitera L. 123I-Meta-Iodobenzylguanidine Single-Photon Emission Computerized Tomography/Computerized Tomography Scintigraphy in the Management of Neuroblastoma. Indian J Nucl Med 2021; 36:293-299. [PMID: 34658554 PMCID: PMC8481844 DOI: 10.4103/ijnm.ijnm_10_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Accepted: 01/28/2021] [Indexed: 11/04/2022] Open
Abstract
Neuroblastoma is the most common pediatric extracranial solid tumor. High-risk neuroblastoma is the most frequent presentation with an overall survival of approximately 50%. 123I-meta-iodobenzylguanidine (123I-mIBG) scintigraphy in the assessment of the primary tumor and its metastases at diagnosis and after chemotherapy is a cornerstone imaging modality. In particular, the bulk of skeletal metastatic disease evaluated with 123I-mIBG at diagnosis and the following chemotherapy has a prognostic value. Currently, single-photon emission computerized tomography/computerised tomography (SPECT/CT) is considered a fundamental part of 123I-mIBG scintigraphy. 123I-mIBG SPECT/CT is a highly specific and sensitive imaging biomarker and it has been the basis of all existing neuroblastoma trials requiring molecular imaging. The introduction of SPECT/CT has shown not only the heterogeneity of the mIBG uptake within the primary tumor but also the presence of completely mIBG nonavid metastatic lesions with mIBG-avid primary neuroblastomas. It is currently possible to semi-quantitatively assess tracer uptake with standardized uptake value, which allows a more precise evaluation of the tracer avidity and can help monitor chemotherapy response. The patchy mIBG uptake has consequences from a theranostic perspective and may partly explain the failure of some neuroblastomas to respond to 131I-mIBG molecular radiotherapy. Various positron emission tomography tracers, targeting different aspects of neuroblastoma cell biology, are being tested as possible alternatives to 123I-mIBG.
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Affiliation(s)
- Lorenzo Biassoni
- Department of Radiology, Great Ormond Street Hospital for Children, London, UK
| | - Laura Privitera
- Department of Developmental Biology and Cancer Research, UCL GOS Institute of Child Health, London, UK
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Tagiling N, Tee VWS, Lee YY, Che Jalil NA, Mat Nawi N. Practical advantage of SPECT/CT image co-registration for accurate bleeding Meckel’s diverticulum localization in pediatrics: A case report. PROCEEDINGS OF SINGAPORE HEALTHCARE 2021. [DOI: 10.1177/20101058211031036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Planar scintigraphy with 99mTc-pertechnetate or Meckel scan is the gold standard in the diagnosis of a bleeding Meckel’s diverticulum (MD) for pediatrics. However, several setbacks may occur during the interpretation of a scintigram, especially in cases of an atypical MD presentation. In this report, we highlight the importance of functional and anatomical image co-registration using a hybrid SPECT/CT scanner to precisely localize a MD lesion. An 18-month-old boy presented with severe hematochezia over 4 days with declining hemoglobin levels. He underwent a conventional 60-min dynamic planar imaging of the Meckel scan. Upon review of the Meckel scan, a suspicious increase in the 99mTc-pertechnetate uptake was observed at the right upper quadrant of the abdomen. Due to its atypical location at the right kidney, we could not differentiate between a physiological uptake of the right kidney or an ectopic gastric mucosa. The patient was imaged again using single-photon emission computed tomography (SPECT) and low-dose CT protocol with a hybrid SPECT/CT scanner, and the co-registration of both SPECT and CT images was able to confirm the MD, which was located anterior to the right kidney at the right hepatic flexure region. An exploratory laparotomy was then ensued to remove the bleeding MD. The patient was discharged after 3 days with no complications. In summary, this case illustrates that hybrid imaging modality and co-registration allow for a more definitive diagnosis, as well as a more precise localization of MD.
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Affiliation(s)
- Nashrulhaq Tagiling
- Department of Nuclear Medicine, Radiotherapy and Oncology, School of Medical Sciences, Universiti Sains Malaysia, Kelantan, Malaysia
| | - Vincent Wei Shen Tee
- Department of Medicine, School of Medical Sciences, Universiti Sains Malaysia, Kelantan, Malaysia
| | - Yeong Yeh Lee
- Department of Medicine, School of Medical Sciences, Universiti Sains Malaysia, Kelantan, Malaysia
- Hospital USM, Universiti Sains Malaysia, Kelantan, Malaysia
| | - Nur Asyilla Che Jalil
- Hospital USM, Universiti Sains Malaysia, Kelantan, Malaysia
- Department of Pathology, School of Medical Sciences, Universiti Sains Malaysia, Kelantan, Malaysia
| | - Norazlina Mat Nawi
- Department of Nuclear Medicine, Radiotherapy and Oncology, School of Medical Sciences, Universiti Sains Malaysia, Kelantan, Malaysia
- Hospital USM, Universiti Sains Malaysia, Kelantan, Malaysia
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Salman K, Wagieh S, Bakhsh A, Al-Monshy T, Talaat O, Al-Malki M, Al-Ezzi M, Fouda A, Hamid G. Measurement of cumulative radiation exposure to children and adolescents in contact with outpatients treated with low dose radioactive iodine ( 131I). J Egypt Natl Canc Inst 2020; 32:2. [PMID: 32372394 DOI: 10.1186/s43046-019-0013-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Accepted: 12/19/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Radiation exposure from patients treated with radioactive iodine (131I) represents a radiation hazard to children and adolescents, representing the most vulnerable group of household contacts. Our aim was to calculate the cumulative radiation exposure (CRE) figures to children and adolescents sharing the same home with outpatients treated with low-dose 131I. The secondary aim was to study the demographic and educational factors that may significantly affect radiation exposure to them. RESULTS The whole number of household contacts less than 18 years was 99, out of them 49 ≤ 12 years. CRE level to children and adolescents ranged from 79 to 934 uSv. The mean, median, and 75th percentile figures were 284 ± 178 uSv, 215 uSv, and 334 uSv, respectively. The compliance of this group of contacts to radiation exposure constraint (1 mSv) was 100%. All CRE values were below this figure with 75% of them below half of this constraint. Thirteen adolescents from 12 to 18 years and 17 mothers of 23 household contacts ≤ 12 years got radiation safety instructions (RSI) directly from a radiation safety officer (RSO). This group had a significantly lower mean CRE value (184 ± 93 uSv) compared to those who got RSI from the patient or from other family members (298 ± 185 uSv) with a significant p value. CONCLUSION The compliance of adolescents and children to the 1-mSv radiation exposure constraint is 100%. It is advised for adolescents and mothers of children in contact with 131I-treated patients to get direct RSI from the RSO, which is the only factor associated with significantly lower radiation exposure figures.
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Affiliation(s)
- Khaled Salman
- King Abdullah Medical City (KAMC), Makkah, Saudi Arabia
| | - Shereen Wagieh
- King Abdullah Medical City (KAMC), Jeddah Oncology Centre, Jeddah, Saudi Arabia.
| | - Aquib Bakhsh
- King Abdullah Medical City (KAMC), Makkah, Saudi Arabia
| | | | | | | | - Manal Al-Ezzi
- King Abdullah Medical City (KAMC), Makkah, Saudi Arabia
| | - Ashraf Fouda
- King Abdullah Medical City (KAMC), Jeddah Oncology Centre, Jeddah, Saudi Arabia
| | - Gihad Hamid
- King Abdullah Medical City (KAMC), Jeddah Oncology Centre, Jeddah, Saudi Arabia
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Israel O, Pellet O, Biassoni L, De Palma D, Estrada-Lobato E, Gnanasegaran G, Kuwert T, la Fougère C, Mariani G, Massalha S, Paez D, Giammarile F. Two decades of SPECT/CT - the coming of age of a technology: An updated review of literature evidence. Eur J Nucl Med Mol Imaging 2019; 46:1990-2012. [PMID: 31273437 PMCID: PMC6667427 DOI: 10.1007/s00259-019-04404-6] [Citation(s) in RCA: 92] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Accepted: 06/14/2019] [Indexed: 02/08/2023]
Abstract
PURPOSE Single-photon emission computed tomography (SPECT) combined with computed tomography (CT) was introduced as a hybrid SPECT/CT imaging modality two decades ago. The main advantage of SPECT/CT is the increased specificity achieved through a more precise localization and characterization of functional findings. The improved diagnostic accuracy is also associated with greater diagnostic confidence and better inter-specialty communication. METHODS This review presents a critical assessment of the relevant literature published so far on the role of SPECT/CT in a variety of clinical conditions. It also includes an update on the established evidence demonstrating both the advantages and limitations of this modality. CONCLUSIONS For the majority of applications, SPECT/CT should be a routine imaging technique, fully integrated into the clinical decision-making process, including oncology, endocrinology, orthopaedics, paediatrics, and cardiology. Large-scale prospective studies are lacking, however, on the use of SPECT/CT in certain clinical domains such as neurology and lung disorders. The review also presents data on the complementary role of SPECT/CT with other imaging modalities and a comparative analysis, where available.
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Affiliation(s)
- Ora Israel
- Rappaport School of Medicine, Israel Institute of Technology, Haifa, Israel.
| | - O Pellet
- Nuclear Medicine and Diagnostic Imaging Section International Atomic Energy Agency, Vienna, Austria
| | - L Biassoni
- Department of Radiology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - D De Palma
- Nuclear Medicine Unit, Circolo Hospital, ASST-Settelaghi, Varese, Italy
| | - E Estrada-Lobato
- Nuclear Medicine and Diagnostic Imaging Section International Atomic Energy Agency, Vienna, Austria
| | - G Gnanasegaran
- Department of Nuclear Medicine, Royal Free NHS Foundation Trust, London, UK
| | - T Kuwert
- Clinic of Nuclear Medicine, University Hospital, Erlangen, Germany
| | - C la Fougère
- Division of Nuclear Medicine and Clinical Molecular Imaging, Department of Radiology, University Hospital, Tubingen, Germany
| | - G Mariani
- Regional Center of Nuclear Medicine, University of Pisa, Pisa, Italy
| | - S Massalha
- Department of Medicine, University of Ottawa Heart Institute, Ottawa, Canada
- Department of Nuclear Medicine, Rambam Healthcare Campus, Haifa, Israel
| | - D Paez
- Nuclear Medicine and Diagnostic Imaging Section International Atomic Energy Agency, Vienna, Austria
| | - F Giammarile
- Nuclear Medicine and Diagnostic Imaging Section International Atomic Energy Agency, Vienna, Austria
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Abstract
Nuclear medicine has a central role in the diagnosis, staging, response assessment and long-term follow-up of neuroblastoma, the most common solid extracranial tumour in children. These EANM guidelines include updated information on 123I-mIBG, the most common study in nuclear medicine for the evaluation of neuroblastoma, and on PET/CT imaging with 18F-FDG, 18F-DOPA and 68Ga-DOTA peptides. These PET/CT studies are increasingly employed in clinical practice. Indications, advantages and limitations are presented along with recommendations on study protocols, interpretation of findings and reporting results.
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Khalatbari H, Parisi MT, Kwatra N, Harrison DJ, Shulkin BL. Pediatric Musculoskeletal Imaging: The Indications for and Applications of PET/Computed Tomography. PET Clin 2018; 14:145-174. [PMID: 30420216 DOI: 10.1016/j.cpet.2018.08.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The use of PET/computed tomography (CT) for the evaluation and management of children, adolescents, and young adults continues to expand. The principal tracer used is 18F-fluorodeoxyglucose and the principal indication is oncology, particularly musculoskeletal neoplasms. The purpose of this article is to review the common applications of PET/CT for imaging of musculoskeletal issues in pediatrics and to introduce the use of PET/CT for nononcologic issues, such as infectious/inflammatory disorders, and review the use of 18F-sodium fluoride in trauma and sports-related injuries.
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Affiliation(s)
- Hedieh Khalatbari
- Department of Radiology, University of Washington School of Medicine, Seattle Children's Hospital, 4800 Sandpoint Way NE, Seattle, WA 98105, USA.
| | - Marguerite T Parisi
- Department of Radiology, University of Washington School of Medicine, Seattle Children's Hospital, 4800 Sandpoint Way NE, Seattle, WA 98105, USA; Department of Pediatrics, University of Washington School of Medicine, Seattle Children's Hospital, 4800 Sandpoint Way NE, Seattle, WA 98105, USA
| | - Neha Kwatra
- Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA
| | - Douglas J Harrison
- Department of Pediatrics, MD Anderson Cancer Center, 7600 Beechnut Street, Houston, TX 77074, USA
| | - Barry L Shulkin
- Department of Diagnostic Imaging, St Jude Children's Research Hospital, 262 Danny Thomas Place, Memphis, TN 38105, USA
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Iravani A, Hofman MS, Mulcahy T, Williams S, Murphy D, Parameswaran BK, Hicks RJ. 68Ga PSMA-11 PET with CT urography protocol in the initial staging and biochemical relapse of prostate cancer. Cancer Imaging 2017; 17:31. [PMID: 29268784 PMCID: PMC5740783 DOI: 10.1186/s40644-017-0133-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Accepted: 12/08/2017] [Indexed: 12/20/2022] Open
Abstract
Background 68Ga-labelled prostate specific membrane antigen (PSMA) ligand PET/CT is a promising modality in primary staging (PS) and biochemical relapse (BCR) of prostate cancer (PC). However, pelvic nodes or local recurrences can be difficult to differentiate from radioactive urine. CT urography (CT-U) is an established method, which allows assessment of urological malignancies. The study presents a novel protocol of 68Ga-PSMA-11 PET/CT-U in PS and BCR of PC. Methods A retrospective review of PSMA PET/CT-U preformed on 57 consecutive patients with prostate cancer. Fifty mL of IV contrast was administered 10 min (range 8–15) before the CT component of a combined PET/CT study, acquired approximately 60 min (range 40–85) after administration of 166 MBq (range 91–246) of 68Ga-PSMA-11. PET and PET/CT-U were reviewed by two nuclear medicine physicians and CT-U by a radiologist. First, PET images were reviewed independently followed by PET/CT-U images. Foci of activity which could not unequivocally be assessed as disease or urinary activity were recorded. PET/CT-U was considered of potential benefit in final interpretation when the equivocal focal activity in PET images corresponded to opacified ureter, bladder, prostate bed, seminal vesicles, or urethra. Student’s T test and Pearson’s correlation coefficient was used for assessment of variables including lymph node size and standardized uptake value. Results Overall 50 PSMA PET/CT-U studies were performed for BCR and 7 for PS. Median PSA with BCR and PS were 2.0 ± 11.4 ng/ml (0.06–57.3 ng/ml) and 18 ± 35.3 ng/ml (6.8–100 ng/ml), respectively. The median Gleason-score for both groups was 7 (range 6–10). In BCR group, PSMA PET was reported positive in 36 (72%) patients, CT-U in 11(22%) patients and PET/CT-U in 33 (66%) patients. In PS group, PSMA PET detected the primary site in all seven patients, of which one patient with metastatic nodal disease had negative CT finding. Of 40 equivocal foci (27/57 patients) on PET, 11 foci (10/57 patients, 17.5%) were localized to enhanced urine on PET/CT-U, hence considered of potential benefit in interpretation. Of those, 3 foci (3 patients) were solitary sites of activity on PSMA imaging including two local and one nodal site and 4 foci (3 patients) were in different nodal fields. Conclusions PET/CT-U protocol is a practical approach and may assist in interpretation of 68Ga-PSMA-11 imaging by delineation of the contrast opacified genitourinary system and matching focal PSMA activity with urinary contrast. Electronic supplementary material The online version of this article (10.1186/s40644-017-0133-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Amir Iravani
- Centre for Molecular Imaging, Department of Cancer Imaging, Peter MacCallum Cancer Centre, 305 Grattan Street, Melbourne, Australia.
| | - Michael S Hofman
- Centre for Molecular Imaging, Department of Cancer Imaging, Peter MacCallum Cancer Centre, 305 Grattan Street, Melbourne, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne, 305 Grattan Street, Melbourne, Australia
| | - Tony Mulcahy
- Centre for Molecular Imaging, Department of Cancer Imaging, Peter MacCallum Cancer Centre, 305 Grattan Street, Melbourne, Australia
| | - Scott Williams
- Sir Peter MacCallum Department of Radiation Oncology, University of Melbourne, 305 Grattan Street, Melbourne, Australia
| | - Declan Murphy
- Sir Peter MacCallum Department of Surgical Oncology, University of Melbourne, 305 Grattan Street, Melbourne, Australia
| | - Bimal K Parameswaran
- Centre for Molecular Imaging, Department of Cancer Imaging, Peter MacCallum Cancer Centre, 305 Grattan Street, Melbourne, Australia
| | - Rodney J Hicks
- Centre for Molecular Imaging, Department of Cancer Imaging, Peter MacCallum Cancer Centre, 305 Grattan Street, Melbourne, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne, 305 Grattan Street, Melbourne, Australia
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Pelletier-Galarneau M, Martineau P, Zuckier LS, Pham X, Lambert R, Turpin S. 18 F-FDG-PET/CT Imaging of Thoracic and Extrathoracic Tuberculosis in Children. Semin Nucl Med 2017; 47:304-318. [DOI: 10.1053/j.semnuclmed.2016.12.003] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Application of advanced preclinical models and methods in anesthetic neurotoxicity research. Neurotoxicol Teratol 2017; 61:1-6. [DOI: 10.1016/j.ntt.2017.04.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Revised: 04/14/2017] [Accepted: 04/17/2017] [Indexed: 01/12/2023]
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Low-dose computed tomography scans with automatic exposure control for patients of different ages undergoing cardiac PET/CT and SPECT/CT. Nucl Med Commun 2017; 38:546-555. [PMID: 28430740 DOI: 10.1097/mnm.0000000000000679] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE This study aimed to evaluate the efficacy of automatic exposure control (AEC) in order to optimize low-dose computed tomography (CT) protocols for patients of different ages undergoing cardiac PET/CT and single-photon emission computed tomography/computed tomography (SPECT/CT). METHODS One PET/CT and one SPECT/CT were used to acquire CT images for four anthropomorphic phantoms representative of 1-year-old, 5-year-old and 10-year-old children and an adult. For the hybrid systems investigated in this study, the radiation dose and image quality of cardiac CT scans performed with AEC activated depend mainly on the selection of a predefined image quality index. Multiple linear regression methods were used to analyse image data from anthropomorphic phantom studies to investigate the effects of body size and predefined image quality index on CT radiation dose in cardiac PET/CT and SPECT/CT scans. RESULTS The regression relationships have a coefficient of determination larger than 0.9, indicating a good fit to the data. According to the regression models, low-dose protocols using the AEC technique were optimized for patients of different ages. In comparison with the standard protocol with AEC activated for adult cardiac examinations used in our clinical routine practice, the optimized paediatric protocols in PET/CT allow 32.2, 63.7 and 79.2% CT dose reductions for anthropomorphic phantoms simulating 10-year-old, 5-year-old and 1-year-old children, respectively. The corresponding results for cardiac SPECT/CT are 8.4, 51.5 and 72.7%. CONCLUSION AEC is a practical way to reduce CT radiation dose in cardiac PET/CT and SPECT/CT, but the AEC settings should be determined properly for optimal effect. Our results show that AEC does not eliminate the need for paediatric protocols and CT examinations using the AEC technique should be optimized for paediatric patients to reduce the radiation dose as low as reasonably achievable.
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Parisi MT, Bermo MS, Alessio AM, Sharp SE, Gelfand MJ, Shulkin BL. Optimization of Pediatric PET/CT. Semin Nucl Med 2017; 47:258-274. [PMID: 28417855 DOI: 10.1053/j.semnuclmed.2017.01.002] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
PET/CT, the most common form of hybrid imaging, has transformed oncologic imaging and is increasingly being used for nononcologic applications as well. Performing PET/CT in children poses unique challenges. Not only are children more sensitive to the effects of radiation than adults but, following radiation exposure, children have a longer postexposure life expectancy in which to exhibit adverse radiation effects. Both the PET and CT components of the study contribute to the total patient radiation dose, which is one of the most important risks of the study in this population. Another risk in children, not typically encountered in adults, is potential neurotoxicity related to the frequent need for general anesthesia in this patient population. Optimizing pediatric PET/CT requires making improvements to both the PET and the CT components of the procedure while decreasing the potential for risk. This can be accomplished through judicious performance of imaging, the use of recommended pediatric 18fluorine-2-fluoro-2-deoxy-d-glucose (18F-FDG) administered activities, thoughtful selection of pediatric-specific CT imaging parameters, careful patient preparation, and use of appropriate patient immobilization. In this article, we will review a variety of strategies for radiation dose optimization in pediatric 18F-FDG-PET/CT focusing on these processes. Awareness of and careful selection of pediatric-specific CT imaging parameters designed for appropriate diagnostic, localization, or attenuation correction only CT, in conjunction with the use of recommended radiotracer administered activities, will help to ensure image quality while limiting patient radiation exposure. Patient preparation, an important determinant of image quality, is another focus of this review. Appropriate preparative measures are even more crucial in children in whom there is a higher incidence of brown fat, which can interfere with study interpretation. Finally, we will discuss measures to improve the patient experience, the resource use, the departmental workflow, and the diagnostic performance of the study through the use of appropriate technology, all in the context of minimizing procedure-related risks.
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Affiliation(s)
- Marguerite T Parisi
- Departments of Radiology, University of Washington School of Medicine, Seattle Children's Hospital, Seattle, WA; Departments of Pediatrics, University of Washington School of Medicine and Seattle Children's Hospital, Seattle, WA.
| | - Mohammed S Bermo
- Department of Nuclear Medicine, University of Washington School of Medicine, Seattle, WA
| | - Adam M Alessio
- Departments of Radiology, University of Washington School of Medicine, Seattle Children's Hospital, Seattle, WA
| | - Susan E Sharp
- Departments of Radiology, University of Cincinnati College of Medicine and Cincinnati Children's Hospital Medical Center, Cincinatti, OH
| | - Michael J Gelfand
- Departments of Radiology, University of Cincinnati College of Medicine and Cincinnati Children's Hospital Medical Center, Cincinatti, OH
| | - Barry L Shulkin
- Department of Diagnostic Imaging, St. Jude Children's Research Hospital, Memphis, TN
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Dehesa A, Zugazaga A, De Miguel M, Biassoni L. Evaluation of a crossed fused renal ectopia in a paediatric patient using 99mTc-DMSA SPECT/CT. Rev Esp Med Nucl Imagen Mol 2016. [DOI: 10.1016/j.remnie.2016.01.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Dehesa A, Zugazaga A, De Miguel M, Biassoni L. Evaluation of a crossed fused renal ectopia in a paediatric patient using 99mTc-DMSA SPECT/CT. Rev Esp Med Nucl Imagen Mol 2016; 35:406-408. [DOI: 10.1016/j.remn.2016.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2015] [Revised: 12/22/2015] [Accepted: 01/02/2016] [Indexed: 10/22/2022]
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Zhang X, Liu F, Slikker W, Wang C, Paule MG. Minimally invasive biomarkers of general anesthetic-induced developmental neurotoxicity. Neurotoxicol Teratol 2016; 60:95-101. [PMID: 27784630 DOI: 10.1016/j.ntt.2016.10.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2016] [Revised: 08/29/2016] [Accepted: 10/21/2016] [Indexed: 12/22/2022]
Abstract
The association of general anesthesia with developmental neurotoxicity, while nearly impossible to study in pediatric populations, is clearly demonstrable in a variety of animal models from rodents to nonhuman primates. Nearly all general anesthetics tested have been shown to cause abnormal brain cell death in animals when administered during periods of rapid brain growth. The ability to repeatedly assess in the same subjects adverse effects induced by general anesthetics provides significant power to address the time course of important events associated with exposures. Minimally-invasive procedures provide the opportunity to bridge the preclinical/clinical gap by providing the means to more easily translate findings from the animal laboratory to the human clinic. Positron Emission Tomography or PET is a tool with great promise for realizing this goal. PET for small animals (microPET) is providing valuable data on the life cycle of general anesthetic induced neurotoxicity. PET radioligands (annexin V and DFNSH) targeting apoptotic processes have demonstrated that a single bout of general anesthesia effected during a vulnerable period of CNS development can result in prolonged apoptotic signals lasting for several weeks in the rat. A marker of cellular proliferation (FLT) has demonstrated in rodents that general anesthesia-induced inhibition of neural progenitor cell proliferation is evident when assessed a full 2weeks after exposure. Activated glia express Translocator Protein (TSPO) which can be used as a marker of presumed neuroinflammatory processes and a PET ligand for the TSPO (FEPPA) has been used to track this process in both rat and nonhuman primate models. It has been shown that single bouts of general anesthesia can result in elevated TSPO expression lasting for over a week. These examples demonstrate the utility of specific PET tracers to inform, in a minimally-invasive fashion, processes associated with general anesthesia-induced developmental neurotoxicity. The fact that PET procedures are also used clinically suggests an opportunity to confirm in humans what has been repeatedly observed in animals.
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Software-based PET-MR image coregistration: combined PET-MRI for the rest of us! Pediatr Radiol 2016; 46:1552-61. [PMID: 27380195 PMCID: PMC5039099 DOI: 10.1007/s00247-016-3641-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2015] [Revised: 03/07/2016] [Accepted: 05/12/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND With the introduction of hybrid positron emission tomography/magnetic resonance imaging (PET/MRI), a new imaging option to acquire multimodality images with complementary anatomical and functional information has become available. Compared with hybrid PET/computed tomography (CT), hybrid PET/MRI is capable of providing superior anatomical detail while removing the radiation exposure associated with CT. The early adoption of hybrid PET/MRI, however, has been limited. OBJECTIVE To provide a viable alternative to the hybrid PET/MRI hardware by validating a software-based solution for PET-MR image coregistration. MATERIALS AND METHODS A fully automated, graphics processing unit-accelerated 3-D deformable image registration technique was used to align PET (acquired as PET/CT) and MR image pairs of 17 patients (age range: 10 months-21 years, mean: 10 years) who underwent PET/CT and body MRI (chest, abdomen or pelvis), which were performed within a 28-day (mean: 10.5 days) interval. MRI data for most of these cases included single-station post-contrast axial T1-weighted images. Following registration, maximum standardized uptake value (SUVmax) values observed in coregistered PET (cPET) and the original PET were compared for 82 volumes of interest. In addition, we calculated the target registration error as a measure of the quality of image coregistration, and evaluated the algorithm's performance in the context of interexpert variability. RESULTS The coregistration execution time averaged 97±45 s. The overall relative SUVmax difference was 7% between cPET-MRI and PET/CT. The average target registration error was 10.7±6.6 mm, which compared favorably with the typical voxel size (diagonal distance) of 8.0 mm (typical resolution: 0.66 mm × 0.66 mm × 8 mm) for MRI and 6.1 mm (typical resolution: 3.65 mm × 3.65 mm × 3.27 mm) for PET. The variability in landmark identification did not show statistically significant differences between the algorithm and a typical expert. CONCLUSION We have presented a software-based solution that achieves the many benefits of hybrid PET/MRI scanners without actually needing one. The method proved to be accurate and potentially clinically useful.
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Xie Q, Ma Q, Ji B, Gao S, Wen Q. Incremental value of SPECT/CT in detection of Meckel's diverticulum in a 10-year-old child. SPRINGERPLUS 2016; 5:1270. [PMID: 27540503 PMCID: PMC4975725 DOI: 10.1186/s40064-016-2928-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/09/2015] [Accepted: 07/27/2016] [Indexed: 11/15/2022]
Abstract
Introduction Meckel’s diverticulum is a common congenital abnormality of gastrointestinal tract in children. Planar scintigraphy using Technetium-99m pertechnetate is widely used in the diagnosis of Meckel’s diverticulum. Single photon emission computed tomography/computed tomography (SPECT/CT) fusion imaging may help to locate the Meckel’s diverticulum lesion. We now present a Meckel’s diverticulum case which tends to be missed. Case description The patient was diagnosed with Mecke’s diverticulum by planar scintigraphy in 2007. After seven years, a recurrence of hematochezia made the patient undergo planar scintigraphy again. However, the concentration on planar image was located at the right kidney level, we could not determine whether it was caused by physiological uptake of the right kidney or by an ectopic gastric mucosa. Using SPECT/CT technique, we confirmed that the lower part of the concentration was from a Meckel’s diverticulum from the small intestine based on the functional and anatomical information together. Discussion and Evaluation For concentrations about the kidney level, planar scintigraphy is not enough to be diagnostic of Meckel’s diverticulum. SPECT/CT imaging may be beneficial for a definitive diagnosis. Also, fusion images may provide precise localization of the lesion. To make sure that patients obtain optimal benefit from a SPECT/CT examination, we have to balance the priority between information of anatomic location and avoiding redundant radiation to the patients. Conclusions Our case study suggest that for cases with ambiguous planar scintigraphy images, SPECT/CT imaging should be performed to obtain a definitive diagnosis. Electronic supplementary material The online version of this article (doi:10.1186/s40064-016-2928-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Qian Xie
- Department of Nuclear Medicine, China-Japan Union Hospital, Jilin University, 126 Xiantai Avenue, Changchun, 130033 China
| | - Qingjie Ma
- Department of Nuclear Medicine, China-Japan Union Hospital, Jilin University, 126 Xiantai Avenue, Changchun, 130033 China
| | - Bin Ji
- Department of Nuclear Medicine, China-Japan Union Hospital, Jilin University, 126 Xiantai Avenue, Changchun, 130033 China
| | - Shi Gao
- Department of Nuclear Medicine, China-Japan Union Hospital, Jilin University, 126 Xiantai Avenue, Changchun, 130033 China
| | - Qiang Wen
- Department of Nuclear Medicine, China-Japan Union Hospital, Jilin University, 126 Xiantai Avenue, Changchun, 130033 China
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De Palma D, Nadel HR, Bar-Sever Z. Skeletal scintigraphy with SPECT/CT in benign pediatric bone conditions. Clin Transl Imaging 2016. [DOI: 10.1007/s40336-016-0169-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Mhiri A. Dosimetry estimation of SPECT/CT for iodine 123-labeled metaiodobenzylguanidine in children. INTERNATIONAL JOURNAL OF CANCER THERAPY AND ONCOLOGY 2015. [DOI: 10.14319/ijcto.33.3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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Abstract
18F-fluoride PET/CT has been used for a wide variety of indications in children and young adults. Nearly all pediatric 18F-fluoride PET/CTs are performed to evaluate benign conditions. The most common indication is the evaluation of back pain in a wide variety of circumstances, including patients with sports injuries, scoliosis, trauma, and back pain after surgery. The high image quality of 18F-fluoride PET/CT can make it particularly useful for evaluating benign skeletal lesions such as osteoid osteoma and Langerhans cell histiocytosis. Quantitative assessment of bone turnover with 18F-fluoride PET/CT may make it useful for assessing the skeleton in patients with metabolic bone diseases, eating disorders, and avascular necrosis. There is little pediatric experience using 18F-fluoride PET/CT for evaluation of skeletal or soft tissue disease in childhood cancers.
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Affiliation(s)
- Frederick D Grant
- Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, Boston Children's Hospital, and The Joint Program in Nuclear Medicine, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA.
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Freebody J, Wegner EA, Rossleigh MA. 2-deoxy-2-( 18F)fluoro-D-glucose positron emission tomography/computed tomography imaging in paediatric oncology. World J Radiol 2014; 6:741-755. [PMID: 25349660 PMCID: PMC4209422 DOI: 10.4329/wjr.v6.i10.741] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2013] [Revised: 03/05/2014] [Accepted: 09/17/2014] [Indexed: 02/06/2023] Open
Abstract
Positron emission tomography (PET) is a minimally invasive technique which has been well validated for the diagnosis, staging, monitoring of response to therapy, and disease surveillance of adult oncology patients. Traditionally the value of PET and PET/computed tomography (CT) hybrid imaging has been less clearly defined for paediatric oncology. However recent evidence has emerged regarding the diagnostic utility of these modalities, and they are becoming increasingly important tools in the evaluation and monitoring of children with known or suspected malignant disease. Important indications for 2-deoxy-2-(18F)fluoro-D-glucose (FDG) PET in paediatric oncology include lymphoma, brain tumours, sarcoma, neuroblastoma, Langerhans cell histiocytosis, urogenital tumours and neurofibromatosis type I. This article aims to review current evidence for the use of FDG PET and PET/CT in these indications. Attention will also be given to technical and logistical issues, the description of common imaging pitfalls, and dosimetric concerns as they relate to paediatric oncology.
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Rojas Y, Guillerman RP, Zhang W, Vasudevan SA, Nuchtern JG, Thompson PA. Relapse surveillance in AFP-positive hepatoblastoma: re-evaluating the role of imaging. Pediatr Radiol 2014; 44:1275-80. [PMID: 24839140 DOI: 10.1007/s00247-014-3000-6] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2013] [Revised: 02/17/2014] [Accepted: 04/08/2014] [Indexed: 12/15/2022]
Abstract
BACKGROUND Children with hepatoblastoma routinely undergo repetitive surveillance imaging, with CT scans for several years after therapy, increasing the risk of radiation-induced cancer. OBJECTIVE The purpose of this study was to determine the utility of surveillance CT scans compared to serum alpha-fetoprotein (AFP) levels for the detection of hepatoblastoma relapse. MATERIALS AND METHODS This was a retrospective study of all children diagnosed with AFP-positive hepatoblastoma from 2001 to 2011 at a single institution. RESULTS Twenty-six children with hepatoblastoma were identified, with a mean age at diagnosis of 2 years 4 months (range 3 months to 11 years). Mean AFP level at diagnosis was 132,732 ng/ml (range 172.8-572,613 ng/ml). Five of the 26 children had hepatoblastoma relapse. A total of 105 imaging exams were performed following completion of therapy; 88 (84%) CT, 8 (8%) MRI, 5 (5%) US and 4 (4%) FDG PET/CT exams. A total of 288 alpha-fetoprotein levels were drawn, with a mean of 11 per child. The AFP level was elevated in all recurrences and no relapses were detected by imaging before AFP elevation. Two false-positive AFP levels and 15 false-positive imaging exams were detected. AFP elevation was found to be significantly more specific than PET/CT and CT imaging at detecting relapse. CONCLUSION We recommend using serial serum AFP levels as the preferred method of surveillance in children with AFP-positive hepatoblastoma, reserving imaging for the early postoperative period, for children at high risk of relapse, and for determination of the anatomical site of clinically suspected recurrence. Given the small size of this preliminary study, validation in a larger patient population is warranted.
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Affiliation(s)
- Yesenia Rojas
- Pediatric Surgery Division, Michael E. DeBakey Department of Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
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Yang CC, Liu SH, Mok GSP, Wu TH. Evaluation of radiation dose and image quality of CT scan for whole-body pediatric PET/CT: A phantom study. Med Phys 2014; 41:092505. [DOI: 10.1118/1.4893273] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
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Nogueira SA, Dimenstein R, Cunha ML, Wagner J, Funari MBG, Lederman HM. Low-dose radiation protocol using 3D mode in a BGO PET/CT. Radiol Med 2014; 120:251-5. [DOI: 10.1007/s11547-014-0422-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2013] [Accepted: 02/17/2014] [Indexed: 11/30/2022]
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Cordasco G, Portelli M, Militi A, Nucera R, Lo Giudice A, Gatto E, Lucchese A. Low-dose protocol of the spiral CT in orthodontics: comparative evaluation of entrance skin dose with traditional X-ray techniques. Prog Orthod 2013; 14:24. [PMID: 24325970 PMCID: PMC4384968 DOI: 10.1186/2196-1042-14-24] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2012] [Accepted: 07/31/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The aim of this study was to evaluate the amount of radiation doses absorbed by soft tissues (entrance skin dose) with a low-dose spiral computed tomography (CT) protocol compared to conventional X-ray techniques commonly used in orthodontics. METHODS The amount of skin dose has been evaluated using a tissue-equivalent head-neck radiotherapy humanoid phantom with thermoluminescent dosimeters placed at the level of eye lens, parotid glands, and thyroid glands. CT images have been taken using a Sensation 16 Siemens CT scan and a low-dose protocol (15 mAs, 1 pitch, 2.5 mGy (CTDIvol), 80 kV, 1-mm slice thickness). RESULTS The difference in image quality between traditional X-ray techniques and low-dose spiral CT was statistically significant (P<0.05). The difference in mean absorbed dose instead was not statistically significant. CONCLUSIONS Our protocol allows a more accurate orthodontic diagnosis without an increase of radiological risk for the patients in comparison to traditional X-ray techniques.
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Affiliation(s)
- Giancarlo Cordasco
- Department of Orthodontics, University of Messina, Via Consolare Valeria, Messina 98100, Italy.
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Fahey FH, Treves ST, Adelstein SJ. Minimizing and communicating radiation risk in pediatric nuclear medicine. J Nucl Med Technol 2012; 40:13-24. [PMID: 22393223 DOI: 10.2967/jnumed.109.069609] [Citation(s) in RCA: 108] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
The value of pediatric nuclear medicine is well established. Pediatric patients are referred to nuclear medicine from nearly all pediatric specialties including urology, oncology, cardiology, gastroenterology, and orthopedics. Radiation exposure is associated with a potential, small, risk of inducing cancer in the patient later in life and is higher in younger patients. Recently, there has been enhanced interest in exposure to radiation from medical imaging. Thus, it is incumbent on practitioners of pediatric nuclear medicine to have an understanding of dosimetry and radiation risk to communicate effectively with their patients and their families. This article reviews radiation dosimetry for radiopharmaceuticals and also CT given the recent proliferation of PET/CT and SPECT/CT. It also describes the scientific basis for radiation risk estimation in the context of pediatric nuclear medicine. Approaches for effective communication of risk to patients' families are discussed. Lastly, radiation dose reduction in pediatric nuclear medicine is explicated.
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Affiliation(s)
- Frederic H Fahey
- Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, Children's Hospital Boston, Boston, Massachusetts 02115, USA.
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Avram AM. Radioiodine scintigraphy with SPECT/CT: an important diagnostic tool for thyroid cancer staging and risk stratification. J Nucl Med 2012; 42:170-80. [PMID: 22550280 DOI: 10.2967/jnumed.111.104133] [Citation(s) in RCA: 72] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Staging and risk stratification predicate the postoperative management of thyroid cancer patients, determining not only the need for (131)I therapy or alternative options (conservative management without ablation, surgical reintervention, or external-beam radiation therapy) but also the long-term follow-up strategy. This paper presents the progress made in the field of thyroid cancer imaging by application of SPECT/CT technology to radioiodine scintigraphy in both diagnostic and post-therapy settings and reviews the impact of fusion radioiodine imaging on staging, risk stratification, and clinical management of patients with thyroid cancer. In addition, this paper addresses the role of preablation radioiodine imaging and provides nuclear medicine physicians with the background knowledge required for integrating information from fusion imaging into the clinical and histopathologic risk stratification for developing an individualized treatment plan for patients with thyroid cancer.
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Affiliation(s)
- Anca M Avram
- Division of Nuclear Medicine/Radiology, University of Michigan Medical Center, Ann Arbor, Michigan 48109-5028, USA.
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Sgouros G, Frey EC, Bolch WE, Wayson MB, Abadia AF, Treves ST. An approach for balancing diagnostic image quality with cancer risk: application to pediatric diagnostic imaging of 99mTc-dimercaptosuccinic acid. J Nucl Med 2012; 52:1923-9. [PMID: 22144506 DOI: 10.2967/jnumed.111.092221] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
UNLABELLED A recent survey of pediatric hospitals showed a large variability in the activity administered for diagnostic nuclear medicine imaging of children. Imaging guidelines, especially for pediatric patients, must balance the risks associated with radiation exposure with the need to obtain the high-quality images necessary to derive the benefits of an accurate clinical diagnosis. METHODS Pharmacokinetic modeling and a pediatric series of nonuniform rational B-spline-based phantoms have been used to simulate (99m)Tc-dimercaptosuccinic acid SPECT images. Images were generated for several different administered activities and for several lesions with different target-to-background activity concentration ratios; the phantoms were also used to calculate organ S values for (99m)Tc. Channelized Hotelling observer methodology was used in a receiver-operating-characteristic analysis of the diagnostic quality of images with different modeled administered activities (i.e., count densities) for anthropomorphic reference phantoms representing two 10-y-old girls with equal weights but different body morphometry. S value-based dosimetry was used to calculate the mean organ-absorbed doses to the 2 pediatric patients. Using BEIR VII age- and sex-specific risk factors, we converted absorbed doses to excess risk of cancer incidence and used them to directly assess the risk of the procedure. RESULTS Combined, these data provided information about the tradeoff between cancer risk and diagnostic image quality for 2 phantoms having the same weight but different body morphometry. The tradeoff was different for the 2 phantoms, illustrating that weight alone may not be sufficient for optimally scaling administered activity in pediatric patients. CONCLUSION The study illustrates implementation of a rigorous approach for balancing the benefits of adequate image quality against the radiation risks and also demonstrates that weight-based adjustment to the administered activity is suboptimal. Extension of this methodology to other radiopharmaceuticals would yield the data required to generate objective and well-founded administered activity guidelines for pediatric and other patients.
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Affiliation(s)
- George Sgouros
- Russell H Morgan Department of Radiology and Radiological Science, Johns Hopkins University, School of Medicine, Baltimore, Maryland 21231, USA
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Abstract
The use of PET/PET-CT is a rapidly growing area of imaging and research in the care of children. Until recently, diagnostic imaging methods have provided either anatomical or functional assessment. The development of fused imaging modalities, such as PET-CT or PET-MRI, now provides the opportunity for simultaneously providing both anatomical and functional or physiological assessment. This review will discuss current established uses of PET-CT, possible uses and potential research investigations in the use of this modality in the pediatric population. The focus of this paper will be its use in children being treated for non-central nervous system and non-cardiac disorders.
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Portwine C, Marriott C, Barr RD. PET imaging for pediatric oncology: an assessment of the evidence. Pediatr Blood Cancer 2010; 55:1048-61. [PMID: 20979168 DOI: 10.1002/pbc.22747] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Positron emission tomography (PET) has shown potential benefits when used in therapeutic clinical trials for children with cancer. However, existing trials are limited in scope with small numbers of patients and varied observations, making accurate conclusions about the usefulness of PET scanning impossible. This review examines PET and its applications in pediatric oncology. While evidence is limited, there appears to be a basis for rigorous evaluation of this imaging modality before widespread application without validation from clinical trials.
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Affiliation(s)
- Carol Portwine
- Division of Pediatric Hematology/Oncology, McMaster University, Hamilton, Ontario, Canada.
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Moharir M, London K, Howman-Giles R, North K. Utility of positron emission tomography for tumour surveillance in children with neurofibromatosis type 1. Eur J Nucl Med Mol Imaging 2010; 37:1309-17. [PMID: 20179923 DOI: 10.1007/s00259-010-1386-4] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2009] [Accepted: 01/05/2010] [Indexed: 01/08/2023]
Abstract
PURPOSE There is little consensus regarding optimal surveillance of optic pathway glioma (OPG) and plexiform neurofibroma (PNF) in childhood neurofibromatosis type 1 (NF1). (18)F-2-Fluoro-2-deoxy-D: -glucose (FDG) positron emission tomography and computed tomography (PET/CT) is employed in the surveillance of adult PNFs; but its utility has neither been specifically studied in children with PNFs nor in children with OPG. METHODS Review of PET/CT studies was performed in NF1 children with OPG or PNF. FDG-avidity of tumours was semi-quantitatively analysed and graded by calculating the maximum standardised uptake value (SUV(max)) [grade 1: <3 (low), grade 2: >3-<4 (intermediate), grade 3: >4 (intense)]. RESULTS Eighteen children (ten girls; median age: 8.5-years) had PET/CT. Nineteen OPGs were imaged. The SUV(max) could be measured in 16. Ten were grade 1 and three each were grade 2 and grade 3. FDG-avidity reduced from grade 3 to grade 1 in two symptomatic OPGs following chemotherapy and this was associated with clinical improvement. PET/CT diagnosed symptomatic OPGs with a sensitivity of 0.625 [95% confidence interval (CI): 0.259-0.897] and specificity of 0.875 (95% CI: 0.466-0.993). Sixteen PNFs were imaged. Twelve were grade 1 and two each were grade 2 and grade 3. The two grade 3 PNFs were confirmed malignant peripheral nerve sheath tumours. PET/CT diagnosed malignant transformation with a sensitivity of 1.0 (95% CI: 0.197-1.0) and specificity of 0.857 (95% CI: 0.561-0.974). CONCLUSION PET/CT may contribute useful information to the surveillance of OPG in childhood NF1-particularly to identify progressive, symptomatic tumours. As in adults, PET/CT is useful for the detection of malignant transformation in PNFs in children with NF1.
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Affiliation(s)
- Mahendranath Moharir
- Division of Neurology, The Hospital for Sick Children, 555 University Avenue, Toronto, Ontario, M5G 1X8, Canada.
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Devine CE, Mawlawi O. Radiation Safety With Positron Emission Tomography and Computed Tomography. Semin Ultrasound CT MR 2010; 31:39-45. [DOI: 10.1053/j.sult.2009.09.005] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Alessio AM, Kinahan PE, Manchanda V, Ghioni V, Aldape L, Parisi MT. Weight-Based, Low-Dose Pediatric Whole-Body PET/CT Protocols. J Nucl Med 2009; 50:1570-7. [DOI: 10.2967/jnumed.109.065912] [Citation(s) in RCA: 97] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Dillman JR, Wong KK, Brown RKJ, Frey KA, Strouse PJ. Utility of SPECT/CT with Meckel's scintigraphy. Ann Nucl Med 2009; 23:813-5. [PMID: 19784878 DOI: 10.1007/s12149-009-0301-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2009] [Accepted: 08/28/2009] [Indexed: 12/21/2022]
Abstract
Meckel's diverticulum is a relatively common source of gastrointestinal tract morbidity in children. Individuals may present with symptoms of lower gastrointestinal tract bleeding, bowel obstruction or diverticulitis. Technetium-99 m pertechnetate scintigraphy is used to demonstrate those Meckel's diverticula that contain heterotopic gastric mucosa. We present a case of an adolescent male patient with rectal bleeding and suspected Meckel's diverticulum where the use of SPECT/CT fusion imaging provided valuable diagnostic information and prevented a false-negative study.
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Affiliation(s)
- Jonathan R Dillman
- Department of Radiology, C S Mott Children's Hospital, University of Michigan Health System, Ann Arbor, MI 48109, USA
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Nichols KJ, Van Tosh A, Palestro CJ. Prospects for advancing nuclear cardiology by means of new detector designs. J Nucl Cardiol 2009; 16:691-6. [PMID: 19629610 DOI: 10.1007/s12350-009-9123-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2009] [Accepted: 07/06/2009] [Indexed: 10/20/2022]
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Abstract
Appropriate patient preparation is necessary for high-quality PET and PET/CT imaging in children and adolescents. Standard adult protocols and techniques will sometimes give suboptimal results, so attention to specific pediatric protocols is important. Additionally, attempts should be made to limit radiation doses, as pediatric patients are more sensitive to the effects of radiation. Administered [F-18]2-fluoro-2-deoxyglucose activities may be reduced using weight based protocols, and CT parameters should be reduced to appropriate pediatric levels, with low-dose localization settings used when diagnostic-quality CT images are not needed. Complicating factors, such as patient motion and brown adipose-tissue uptake, are more commonly encountered in pediatric patients, and appropriate measures should be taken to limit their impact on imaging.
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Affiliation(s)
- Michael J Gelfand
- Nuclear Medicine Section, Department of Radiology, Cincinnati Children's Hospital Medical Center, MLC 5031, 3333 Burnet Avenue, Cincinnati, OH 45229-3039, USA; Department of Radiology, University of Cincinnati, 231 Albert Sabin Way, Cincinnati, OH 45267-0761, USA.
| | - Susan E Sharp
- Nuclear Medicine Section, Department of Radiology, Cincinnati Children's Hospital Medical Center, MLC 5031, 3333 Burnet Avenue, Cincinnati, OH 45229-3039, USA; Department of Radiology, University of Cincinnati, 231 Albert Sabin Way, Cincinnati, OH 45267-0761, USA
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Gelfand MJ. Dosimetry of FDG PET/CT and other molecular imaging applications in pediatric patients. Pediatr Radiol 2009; 39 Suppl 1:S46-56. [PMID: 19083225 DOI: 10.1007/s00247-008-1023-6] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2008] [Accepted: 09/10/2008] [Indexed: 10/24/2022]
Abstract
Effective doses for PET and SPECT imaging of molecular imaging agents depend on the radiopharmaceutical, administered activity and the weight of the patient. Effective doses for the accompanying CT scan depend on the CT protocol being used. CT protocols can be designed to produce diagnostic quality images, localization images or attenuation correction data without imaging. In each case, the co-registered molecular imaging examination (PET or SPECT) and the CT study must be acquired without patient movement. For PET/CT, attention to the respiratory phase during the CT study is also of critical importance. In addition to the molecular imaging agents (18)F-FDG and (123)I-MIBG that are frequently used in children, additional PET and SPECT imaging agents may have promise for molecular imaging in children.
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Affiliation(s)
- Michael J Gelfand
- Department of Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229-3039, USA.
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Papathanassiou D, Liehn JC. The growing development of multimodality imaging in oncology. Crit Rev Oncol Hematol 2008; 68:60-5. [PMID: 18765183 DOI: 10.1016/j.critrevonc.2008.04.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2008] [Accepted: 04/16/2008] [Indexed: 11/16/2022] Open
Abstract
The first decade of the century has been the beginning of an era of new practice in daily medical imaging, that is the multimodality involving functional or metabolic imaging brought by nuclear medicine techniques directly associated with anatomical information brought by CT (Computed X-Ray Tomography) devices combined with nuclear medicine detectors. PET (Positron Emission Tomography)/CT and SPECT (Single Photon Emission Computed Tomography)/CT are now established to further increase the interest of PET and SPECT, thanks to improved localization of the pathologic processes, and in many instances thanks to a gain in specificity. An even better use of the combined information will necessitate redefining some protocols and indications, and the future will probably see the continued development of multimodality imaging in practice. Besides the combination with CT, another modality is expected in the future: PET/MRI (Magnetic Resonance Imaging).
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The Role of PET/CT in the Monitoring and Diagnosis of Pediatric Inflammatory Bowel Disease. PET Clin 2008; 3:597-603. [DOI: 10.1016/j.cpet.2009.04.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Wong KK, Avram AM. Posttherapy I-131 thymic uptake demonstrated with SPECT/CT in a young girl with papillary thyroid carcinoma. Thyroid 2008; 18:919-20. [PMID: 18690800 DOI: 10.1089/thy.2007.0394] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
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Chamroonrat W, Houseni M, Li G, Alavi A, Zhuang H. PET and PET/CT in Pediatric Gastrointestinal Tract Oncology. PET Clin 2008; 3:227-38. [DOI: 10.1016/j.cpet.2008.10.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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