An international survey on hybrid imaging: do technology advances preempt our training and education efforts?

The utility of pharmacological and radiological interventions to optimize diagnostic information from PET/CT

Background

Positron Emission Tomography with Computed Tomography (PET/CT) is widely used in the assessment of many diseases, particularly including cancer. However, many factors can affect image quality and diagnostic performance of PET scans using FDG or other PET probes.

Main body

The aim of this pictorial essay is to review PET/CT protocols that can be useful to overcome these confounding factors in routine clinical situations, with a particular focus on pharmacological interventions and problem-oriented CT acquisition protocols.

Conclusion

Imaging protocols and representative cases will be discussed, in addition to potential contraindications and precautions to be taken.

Best practice for the nuclear medicine technologist in CT-based attenuation correction and calcium score for nuclear cardiology

The use of hybrid systems is increasingly growing in Europe and this is progressively important for the final result of diagnostic tests. As an integral part of the hybrid imaging system, computed tomography (CT) plays a crucial role in myocardial perfusion imaging diagnostics. Throughout Europe, a variety of equipment is available and also different university curricula of the nuclear medicine technologist are observed. Hence, the Technologist Committee of the European Association of Nuclear Medicine proposes to identify, through a bibliographic review, the recommendations for best practice in computed tomography applied to attenuation correction and calcium score in myocardial perfusion imaging, which courses in the set of knowledge, skills, and competencies for nuclear medicine technologists. This document aims at providing recommendations for CT acquisition protocols and CT image optimization in nuclear cardiology.

[Structured reporting in oncologic hybrid imaging: a consensus recommendation]

Since the clinical introduction of PET/CT in the year of 2001 and PET/MRI in the year of 2010, hybrid imaging-guided precision medicine has become an important component of diagnostic algorithms in oncology. The written report represents the primary mode of communication between the referring physician and both the nuclear medicine physician and the radiologist. Reports have considerable impact on patient management and patient outcome, and serve as a legal documentation of the services provided and the expert impression of the interpreting physician. A high-quality hybrid imaging study should result in a likewise high-quality, structured written report which satisfactorily answers the clinical question of the referring physician. In this manuscript, consensus recommendations for structure and content of oncologic hybrid imaging reports and conclusive impressions are provided. Moreover, exemplary structured reports are provided. The recommendations for structured reporting provided in this document should foster further standardization and harmonization of oncologic reports in the context of hybrid imaging. They should also simplify communication with referring physicians and support both acceptance and appreciation of the clinical value of oncologic hybrid imaging. CITATION FORMAT: · Derlin T, Gatidis S, Krause BJ et al. Konsensusempfehlung zur strukturierten Befunderstellung onkologischer PET-Hybridbildgebung. Nuklearmedizin 2020; 59: DOI:10.1055/a-1176-0275.

What scans we will read: imaging instrumentation trends in clinical oncology

Oncological diseases account for a significant portion of the burden on public healthcare systems with associated costs driven primarily by complex and long-lasting therapies. Through the visualization of patient-specific morphology and functional-molecular pathways, cancerous tissue can be detected and characterized non-invasively, so as to provide referring oncologists with essential information to support therapy management decisions. Following the onset of stand-alone anatomical and functional imaging, we witness a push towards integrating molecular image information through various methods, including anato-metabolic imaging (e.g., PET/CT), advanced MRI, optical or ultrasound imaging.

This perspective paper highlights a number of key technological and methodological advances in imaging instrumentation related to anatomical, functional, molecular medicine and hybrid imaging, that is understood as the hardware-based combination of complementary anatomical and molecular imaging. These include novel detector technologies for ionizing radiation used in CT and nuclear medicine imaging, and novel system developments in MRI and optical as well as opto-acoustic imaging. We will also highlight new data processing methods for improved non-invasive tissue characterization. Following a general introduction to the role of imaging in oncology patient management we introduce imaging methods with well-defined clinical applications and potential for clinical translation. For each modality, we report first on the status quo and, then point to perceived technological and methodological advances in a subsequent status go section. Considering the breadth and dynamics of these developments, this perspective ends with a critical reflection on where the authors, with the majority of them being imaging experts with a background in physics and engineering, believe imaging methods will be in a few years from now.

Overall, methodological and technological medical imaging advances are geared towards increased image contrast, the derivation of reproducible quantitative parameters, an increase in volume sensitivity and a reduction in overall examination time. To ensure full translation to the clinic, this progress in technologies and instrumentation is complemented by advances in relevant acquisition and image-processing protocols and improved data analysis. To this end, we should accept diagnostic images as “data”, and – through the wider adoption of advanced analysis, including machine learning approaches and a “big data” concept – move to the next stage of non-invasive tumour phenotyping. The scans we will be reading in 10 years from now will likely be composed of highly diverse multi-dimensional data from multiple sources, which mandate the use of advanced and interactive visualization and analysis platforms powered by Artificial Intelligence (AI) for real-time data handling by cross-specialty clinical experts with a domain knowledge that will need to go beyond that of plain imaging.

Competencies and training of radiographers and technologists for PET/MR imaging - a study from the UK MR-PET network

Background

After the success of PET/CT as a clinical diagnostic tool, the introduction of PET/MRI is a natural development aimed at further improving combined diagnostic imaging and reduced ionising radiation dose for half-body imaging. As with PET and CT, the combination of PET and MRI presents a series of issues that need to be addressed regarding workforce training and education. At present, there is a lack of agreement over the competencies, training requirements and educational pathways needed for PET/MRI operation. In the UK, following the establishment of the MR-PET imaging network, a task force was created to investigate the status of the workforce training, identify gaps and make recommendations regarding staff training. To do this, we ran a national survey on the status of the workforce training and the local practices across the UK’s seven PET/MRI sites, reviewed the literature, and convened a panel of experts, to assess all the evidence and make recommendations regarding PET/MRI competencies and training of nuclear medicine technologists and radiographers.

Results

There is limited literature available specifically on competencies and training for technologists and radiographers. The recommendations on the topic needed revisiting and adapting to the UK MR-PET network. The online survey confirmed the need for developing PET/MRI competencies and training pathways. Local organisational structures and practices were shared across the seven sites, based on models derived from experience outside the UK. The panel of experts agreed on the need for PET/MRI competencies and training strategies. Professional organisations started collaborative discussions with partners from both Nuclear Medicine and Radiography to set training priorities. Multidisciplinary collaboration and partnership were suggested as a key to a successful implementation of competencies and training.

Conclusions

The report identified the need for establishing competencies for the PET/MRI workforce, particularly for technologists and radiographers. It also helped defining these competencies as well as identifying the demand for bespoke training and the development of local and national courses to be implemented to fulfil this new training need.

State of affairs of hybrid imaging in Europe: two multi-national surveys from 2017

OBJECTIVES

To assess the current state of hybrid imaging in Europe with respect to operations, reading and reporting, as well as qualification and training.

METHODS

The first survey (LOCAL) was sent to the heads of the departments of radiology and nuclear medicine in Europe in 2017, including 15 questions regarding the organisation of hybrid imaging operations, reporting strategies for PET/CT and the existence of relevant training programmes. The second survey (NATIONAL) consisted of 10 questions and was directed to the national ministries of health of 37 European countries addressing combined training options in radiology and nuclear medicine.

RESULTS

In the LOCAL survey, 61 valid responses from 26 European countries were received. In almost half of the institutions, hybrid imaging was performed within a single department, mainly in nuclear medicine departments (31%). In half of the centres (51%), PET/CT reports were performed jointly, while in 20% of the centres, reporting was performed by nuclear medicine physicians. Radiologists were responsible for presenting hybrid imaging results in clinical boards in 34% of responding sites. Integrated hybrid imaging training was available in 41% sites. In the NATIONAL survey, responses from 34 countries were received and demonstrated a heterogeneous landscape of official training possibilities in radiology and nuclear medicine with limited opportunities for additional qualifications in hybrid imaging.

CONCLUSIONS

The results of these surveys demonstrate a notable heterogeneity in the current practice of hybrid imaging throughout Europe. This heterogeneity exists despite the general consensus that strong professional cooperation is required in order to ensure high clinical quality and to strengthen the clinical role of hybrid imaging.

An International Survey on Clinical Reporting of PET/CT Examinations: A Starting Point for Cross-Specialty Engagement

Combined PET/CT imaging has become an integral part of patient management, particularly in oncology. After the imaging examination, a report of the findings is created by expert readers and sent to the referrers as a basis for subsequent decisions. In view of the known wide variation in operational models for PET/CT imaging, we surveyed PET/CT users on their approaches toward PET/CT reporting. Methods: The electronic survey comprised 28 questions on the demographics and professional background of the responders, as well as questions on the structure and quality of PET/CT reports, including the type of reported information, the use of reporting standards, and the mix of reporting standards and expert opinions. The survey was active for 6 wk in early 2018. In total, 242 responses were collected worldwide. Results: The responders were mainly from Europe (78%), with 22% being nuclear medicine specialists, 42% radiologists, 22% dual board-certified, 10% residents in either nuclear medicine or radiology, and 5% medical physicists, radiographers, or oncologists. A slim majority (55%) of responses indicated reports being done according to the European Association of Nuclear Medicine 2015 guidelines for ¹⁸F-FDG PET/CT imaging, but 30% of responders were unaware of these guidelines. Report structures varied across sites, with most sites (38%) reporting the PET findings with supplementary localization information from CT, whereas 27% of sites reported along the lines of a CT report with supplementary PET information. One third of the sites included information on the TNM stage of the oncology patient in all reports, whereas 34% and 12% of sites included this information occasionally or only for selected tumors, respectively. For therapy response assessment, various well-established criteria were used. The number of sites utilizing these criteria ranged from 15% (European Organisation for Research and Treatment of Cancer criteria) to 57% (Deauville criteria). Conclusion: Broad variation in the PET/CT reporting strategies adopted for oncology studies and widespread lack of awareness of existing guidelines for PET/CT reporting are evident from responses to this survey, raising concerns as to whether reporting clinicians are optimally using the complementary information from each modality. Greater efforts are needed to ensure harmonization of reporting practices.