CT protocol optimisation in PET/CT: a systematic review

Recent Breakthroughs in PET-CT Multimodality Imaging: Innovations and Clinical Impact

This review presents a detailed examination of the most recent advancements in positron emission tomography-computed tomography (PET-CT) multimodal imaging over the past five years. The fusion of PET and CT technologies has revolutionized medical imaging, offering unprecedented insights into both anatomical structure and functional processes. The analysis delves into key technological innovations, including advancements in image reconstruction, data-driven gating, and time-of-flight capabilities, highlighting their impact on enhancing diagnostic accuracy and clinical outcomes. Illustrative case studies underscore the transformative role of PET-CT in lesion detection, disease characterization, and treatment response evaluation. Additionally, the review explores future prospects and challenges in PET-CT, advocating for the integration and evaluation of emerging technologies to improve patient care. This comprehensive synthesis aims to equip healthcare professionals, researchers, and industry stakeholders with the knowledge and tools necessary to navigate the evolving landscape of PET-CT multimodal imaging.

Role of Novel Quantitative Imaging Techniques in Hematological Malignancies

Hematological malignancies exhibit a widespread distribution, necessitating evaluation of disease activity over the entire body. In clinical practice, visual analysis and semiquantitative parameters are used to assess 18F-FDGPET/CT imaging, which solely represents measurements of disease activity from limited area and may not adequately reflect global disease assessment. An efficient method for assessing the global disease burden of hematological malignancies is to employ PET/computed tomography based novel quantitative parameters. In this article, we explored novel quantitative parameters on PET/CT imaging for assessing global disease burden and the potential role of artificial intelligence (AI) to determine these parameters in evaluation of hematological malignancies.

Probabilistic U-Net model observer for the DDC method in CT scan protocol optimization

Optimizing complex imaging procedures within Computed Tomography, considering both dose and image quality, presents significant challenges amidst rapid technological advancements and the adoption of machine learning (ML) methods. A crucial metric in this context is the Difference-Detailed Curve, which relies on human observer studies. However, these studies are labor-intensive and prone to both inter- and intra-observer variability. To tackle these issues, a ML-based model observer utilizing the U-Net architecture and a Bayesian methodology is proposed. In order to train a model observer unaffected by the spatial arrangement of low-contrast objects, the image preprocessing incorporates a Gaussian Process-based noise model. Additionally, gradient-weighted class activation mapping is utilized to gain insights into the model observer's decision-making process. By training on data from a diverse group of observers, well-calibrated probabilistic predictions that quantify observer variability are achieved. Leveraging the principles of Beta regression, the Bayesian methodology is used to derive a model observer performance metric, effectively gauging the model observer's strength in terms of an 'effective number of observers'. Ultimately, this framework enables to predict the DDC distribution by applying thresholds to the inferred probabilities (Part of this work has been presented at: Stocker D, Sommer C, Gueng S, Stäuble J, Özden I, Griessinger J, Weyland M S, Lutters G, Scheidegger S (2023). Probabilistic U-Net Model Observer for the DDC Method in CT Scan Protocol Optimization. The 56th SSRMP Annual Meeting 2023, November 30. - December 1., 2023, Luzern, Switzerland).

Role of whole body MRI in paraneoplastic/autoimmune syndromes: An MRPET study to standardize protocols, pattern interpretation, and establish yield of MRI

Imaging a case of autoimmune encephalitis (AIE) can be challenging as the underlying tumor may be occult. The aim of this retrospective case-based study is to evaluate role of whole-body MRI/Positron emission tomography (PET) in workup of AIE. Standardizing the whole-body MRI/PET protocol, Cross modality yield with serology and magnetic resonance/PET (MR/PET) and finally highlight the advantage of hybrid MR/PET. We present the retrospective review data from January 2016 to December 2019 referred for whole body MR/PET with suspected AIE/Paraneoplastic syndrome, per consensus criteria, treated at a single tertiary center. Analysis is done group wise based on referral being for oncological, immunological or neuropsychiatric condition. Detailed results with sensitivity and specificity are presented in tabular format with case-based review in our series for protocols and advantages of MR/PET. Among total of 600 MR/PET cases, 227 were suspected of AIE/paraneoplastic syndrome and were referred for whole body imaging. Distribution of Group 1 Known oncology group (n = 10), Group 2 Non oncological systemic illness group (n = 174) and group 3 the primary neuropsychiatric illness (n = 43) with Group 2 being largest. The gender distribution was similar and mean age was 42 years. Seronegative cases (n = 130) were greater than seropositive cases (n = 97). Seropositivity was in the following order Autoimmune > Paraneoplastic > Myositis panel. Whole body MRPET yielded occult malignancy in 9% and imaging abnormality in 88% of cases. Whole body MR/PET has an important role in workup of AIE. Selection of the appropriate protocol is important, especially when history and physical examination are nonspecific.

Revising and exploring the variations in methodologies for establishing the diagnostic reference levels for paediatric PET/CT imaging

PET-computed tomography (PET/CT) is a hybrid imaging technique that combines anatomical and functional information; to investigate primary cancers, stage tumours, and track treatment response in paediatric oncology patients. However, there is debate in the literature about whether PET/CT could increase the risk of cancer in children, as the machine is utilizing two types of radiation, and paediatric patients have faster cell division and longer life expectancy. Therefore, it is essential to minimize radiation exposure by justifying and optimizing PET/CT examinations and ensure an acceptable image quality. Establishing diagnostic reference levels (DRLs) is a crucial quantitative indicator and effective tool to optimize paediatric imaging procedures. This review aimed to distinguish and acknowledge variations among published DRLs for paediatric patients in PET/CT procedures. A search of relevant articles was conducted using databases, that is, Embase, Scopus, Web of Science, and Medline, using the keywords: PET-computed tomography, computed tomography, PET, radiopharmaceutical, DRL, and their synonyms. Only English and full-text articles were included, with no limitations on the publication year. After the screening, four articles were selected, and the review reveals different DRL approaches for paediatric patients undergoing PET/CT, with primary variations observed in patient selection criteria, reporting of radiation dose values, and PET/CT equipment. The study suggests that future DRL methods for paediatric patients should prioritize data collection in accordance with international guidelines to better understand PET/CT dose discrepancies while also striving to optimize radiation doses without compromising the quality of PET/CT images.

Positron Emission Tomography-Computed Tomography Imaging of Selective Lobar Delivery of Stem Cells in Ex Vivo Lung Model of Mechanical Ventilation

Introduction: The delivery of cell therapies may be an important frontier to treat different respiratory diseases in the near future. However, the cell size, delivery conditions, cell viability, and effect in the pulmonary function are critical factors. We performed a proof-of-concept experiment using ex vivo lungs and novel subglottic airway device that allows for selective lobar isolation and administration of drugs and biologics in liquid solution deep into the lung tissues, while simultaneously ventilating the rest of the lung lobes. Methods: We used radiolabeled cells and positron emission tomography-computed tomography (PET-CT) imaging to demonstrate the feasibility of high-yield cell delivery to a specifically targeted lobe. This study proposes an alternative delivery method of live cells labeled with radioactive isotope into the lung parenchyma and tracks the cell delivery using PET-CT imaging. The technique combines selective lobar isolation and lobar infusion to carry large particles distal to the trachea, subtending bronchial segments and reaching alveoli in targeted regions. Results: The solution with cells and carrier achieved a complete and homogeneous lobar distribution. An increase in tissue density was shown on the computed tomography (CT) scan, and the PET-CT imaging demonstrated retention of the activity at central, peripheral lung parenchyma, and pleural surface. The increase in CT density and metabolic activity of the isotope was restricted to the desired lobe only without leak to other lobes. Conclusion: The selective lobe delivery is targeted and imaging-guided by bronchoscopy and CT to a specific diseased lobe during mechanical ventilation. The feasibility of high-yield cell delivery demonstrated in this study will lead to the development of potential novel therapies that contribute to lung health.

Ultra-low-dose CT reconstructed with the artificial intelligence iterative reconstruction algorithm (AIIR) in 18F-FDG total-body PET/CT examination: a preliminary study

PURPOSE

To investigate the feasibility of ultra-low-dose CT (ULDCT) reconstructed with the artificial intelligence iterative reconstruction (AIIR) algorithm in total-body PET/CT imaging.

METHODS

The study included both the phantom and clinical parts. An anthropomorphic phantom underwent CT imaging with ULDCT (10mAs) and standard-dose CT (SDCT) (120mAs), respectively. ULDCT was reconstructed with AIIR and hybrid iterative reconstruction (HIR) (expressed as ULDCT-AIIR_phantom and ULDCT-HIR_phantom), respectively, and SDCT was reconstructed with HIR (SDCT-HIR_phantom) as control. In the clinical part, 52 patients with malignant tumors underwent the total-body PET/CT scan. ULDCT with AIIR (ULDCT-AIIR) and HIR (ULDCT-HIR), respectively, was reconstructed for PET attenuation correction, followed by the SDCT reconstructed with HIR (SDCT-HIR) for anatomical location. PET/CT images' quality was qualitatively assessed by two readers. The CT_mean, as well as the CT standard deviation (CT_sd), SUV_max, SUV_mean, and the SUV standard deviation (SUV_sd), was recorded. The signal-to-noise ratio (SNR) and contrast-to-noise ratio (CNR) were calculated and compared.

RESULTS

The image quality of ULDCT-HIR_phantom was inferior to the SDCT-HIR_phantom, but no significant difference was found between the ULDCT-AIIR_phantom and SDCT-HIR_phantom. The subjective score of ULDCT-AIIR in the neck, chest and lower limb was equivalent to that of SDCT-HIR. Besides the brain and lower limb, the change rates of CT_mean in thyroid, neck muscle, lung, mediastinum, back muscle, liver, lumbar muscle, first lumbar spine and sigmoid colon were -2.15, -1.52, 0.66, 2.97, 0.23, 8.91, 0.06, -4.29 and 8.78%, respectively, while all CT_sd of ULDCT-AIIR was lower than that of SDCT-HIR. Except for the brain, the CNR of ULDCT-AIIR was the same as the SDCT-HIR, but the SNR was higher. The change rates of SUV_max, SUV_mean and SUV_sd were within [Formula: see text] 3% in all ROIs. For the lesions, the SUV_max, SUV_sd and TBR showed no significant difference between PET-AIIR and PET-HIR.

CONCLUSION

The SDCT-HIR could not be replaced by the ULDCT-AIIR at date, but the AIIR algorithm decreased the image noise and increased the SNR, which can be implemented under special circumstances in PET/CT examination.

PET-CT in Clinical Adult Oncology: I. Hematologic Malignancies

PET-CT is an advanced imaging modality with many oncologic applications, including staging, assessment of response to therapy, restaging and evaluation of suspected recurrence. The goal of this 6-part series of review articles is to provide practical information to providers and imaging professionals regarding the best use of PET-CT for the more common adult malignancies. In the first article of this series, hematologic malignancies are addressed. The classification of these malignancies will be outlined, with the disclaimer that the classification of lymphomas is constantly evolving. Critical applications, potential pitfalls, and nuances of PET-CT imaging in hematologic malignancies and imaging features of the major categories of these tumors are addressed. Issues of clinical importance that must be reported by the imaging professionals are outlined. The focus of this article is on [¹⁸F] fluorodeoxyglucose (FDG), rather that research tracers or those requiring a local cyclotron. This information will serve as a resource for the appropriate role and limitations of PET-CT in the clinical management of patients with hematological malignancy for health care professionals caring for adult patients with hematologic malignancies. It also serves as a practical guide for imaging providers, including radiologists, nuclear medicine physicians and their trainees.

Progresses of animal robots: A historical review and perspectiveness

Animal robots have remarkable advantages over traditional mechatronic ones in terms of energy supply, self-orientation, and natural concealment and can provide remarkable theoretical and practical values for scientific investigation, community service, military detection and other fields. Given these features, animal robots have become high-profile research objects and have recently attracted extensive attention. Herein, we have defined animal robots, reviewed the main types of animal robots, and discussed the potential developing directions. We have also detailed the mechanisms underlying the regulation of animal robots and introduced key methods for manipulating them. We have further proposed several application prospects for different types of animal robots. Finally, we have presented research directions for their further improvement.

Optimisation of CT protocols in PET-CT across different scanner models using different automatic exposure control methods and iterative reconstruction algorithms

Background

A significant proportion of the radiation dose from a PET-CT examination is dependent on the CT protocol, which should be optimised for clinical purposes. Matching protocols on different scanners within an imaging centre is important for the consistency of image quality and dose. This paper describes our experience translating low-dose CT protocols between scanner models utilising different automatic exposure control (AEC) methods and reconstruction algorithms.

Methods

The scanners investigated were a newly installed Siemens Biograph mCT PET with 64-slice SOMATOM Definition AS CT using sinogram affirmed iterative reconstruction (SAFIRE) and two GE Discovery 710 PET scanners with 128-slice Optima 660 CT using adaptive statistical reconstruction (ASiR). Following exploratory phantom work, 33 adult patients of various sizes were scanned using the Siemens scanner and matched to patients scanned using our established GE protocol to give 33 patient pairs. A comparison of volumetric CT dose index (CTDI_vol) and image noise within these patient pairs informed optimisation, specifically for obese patients. Another matched patient study containing 27 patient pairs was used to confirm protocol matching. Size-specific dose estimates (SSDEs) were calculated for patients in the second cohort. With the acquisition protocol for the Siemens scanner determined, clinicians visually graded the images to identify optimal reconstruction parameters.

Results

In the first matched patient study, the mean percentage difference in CTDI_vol for Siemens compared to GE was − 10.7% (range − 41.7 to 50.1%), and the mean percentage difference in noise measured in the patients’ liver was 7.6% (range − 31.0 to 76.8%). In the second matched patient study, the mean percentage difference in CTDI_vol for Siemens compared to GE was − 20.5% (range − 43.1 to 1.9%), and the mean percentage difference in noise was 19.8% (range − 27.0 to 146.8%). For these patients, the mean SSDEs for patients scanned on the Siemens and GE scanners were 3.27 (range 2.83 to 4.22) mGy and 4.09 (range 2.81 to 4.82) mGy, respectively. The analysis of the visual grading study indicated no preference for any of the SAFIRE strengths.

Conclusions

Given the different implementations of acquisition parameters and reconstruction algorithms between vendors, careful consideration is required to ensure optimisation and standardisation of protocols.

Ultra-low dose whole-body CT for attenuation correction in a dual tracer PET/CT protocol for multiple myeloma

PURPOSE

To investigate within phantoms the minimum CT dose allowed for accurate attenuation correction of PET data and to quantify the effective dose reduction when a CT for this purpose is incorporated in the clinical setting.

METHODS

The NEMA image quality phantom was scanned within a large parallelepiped container. Twenty-one different CT images were acquired to correct attenuation of PET raw data. Radiation dose and image quality were evaluated. Thirty-one patients with proven multiple myeloma who underwent a dual tracer PET/CT scan were retrospectively reviewed. ¹⁸F-fluorodeoxyglucose PET/CT included a diagnostic whole-body low dose CT (WBLDCT: 120 kV-80mAs) and ¹¹C-Methionine PET/CT included a whole-body ultra-low dose CT (WBULDCT) for attenuation correction (100 kV-40mAs). Effective dose and image quality were analysed.

RESULTS

Only the two lowest radiation dose conditions (80 kV-20mAs and 80 kV-10mAs) produced artifacts in CT images that degraded corrected PET images. For all the other conditions (CTDI_vol ≥ 0.43 mGy), PET contrast recovery coefficients varied less than ± 1.2%. Patients received a median dose of 6.4 mSv from diagnostic CT and 2.1 mSv from the attenuation correction CT. Despite the worse image quality of this CT, 94.8% of bone lesions were identifiable.

CONCLUSION

Phantom experiments showed that an ultra-low dose CT can be implemented in PET/CT procedures without any noticeable degradation in the attenuation corrected PET scan. The replacement of the standard CT for this ultra-low dose CT in clinical PET/CT scans involves a significant radiation dose reduction.

Usefulness of 18f-FDG PET-CT in Staging, Restaging, and Response Assessment in Pediatric Rhabdomyosarcoma

Rhabdomyosarcoma is the most common soft-tissue sarcoma of childhood. Despite clinical advances, subsets of these patients continue to suffer high morbidity and mortality rates associated with their disease. Following the European guidelines for ¹⁸F-FDG PET and PET-CT imaging in pediatric oncology, the routine use of ¹⁸F-FDG PET-CT may be useful for patients affected by rhabdomyosarcoma, in staging, in the evaluation of response to therapy, and for restaging/detection of relapse. The European Pediatric Protocols are very old, and for staging and restaging, they recommend only radionuclide bone scan. The ¹⁸F-FDG PET-CT exam is listed as an optional investigation prescribed according to local availability and local protocols in the investigations panel required at the end of the treatment. We present two cases highlighting the usefulness of ¹⁸F-FDG PET-CT in managing pediatric patients affected by rhabdomyosarcoma, providing some bibliographic references.

Influence of X-ray computed tomography (CT) exposure and reconstruction parameters on positron emission tomography (PET) quantitation

Background

The CT of PET CT provides diagnostic information, anatomic localisation and attenuation correction (AC). When only AC is required, very lose dose CT is desirable. CT iterative reconstruction (IR) improves image quality with lower exposures however there is little data on very low dose IR CT for AC of PET. This work assesses the impact of CT exposure and reconstruction algorithm on PET voxel values.

Method

An anthropomorphic torso phantom was filled with physiologically typical [18]F concentrations in heart, liver and background compartments. A 17-mm-diameter right lung “tumour” filled with [18]F was included (surrounding lung contained no 18[F]). PET was acquired followed by 24 CT acquisitions with varying CT exposures (15–50 mAs, 80–120 kVp, pitch 0.671 or 0.828). Each CT was reconstructed twice using filtered back projection (FBP) or IR and these used for AC of PET. The reference PET reconstruction (RR) used CT acquired at 50 mAs, 120 kVp, pitch 0.828, IR, all others were test PET reconstructions (TR). Regions of interest (ROIs) were drawn in the liver, soft tissue and over “tumour” on each TR and compared with the RR. Voxel values in each TR were compared to the RR using a paired t test and by calculating which and what proportion of voxels in each TR differed by a quantitatively significant difference (QSD) from the RR.

Results

TRs reconstructed using lower dose CTs underestimated mean and maximum ROI activity relative to the RR; greater with IR than FBP. Once CT dose index (CTDI) increased to 1 mGy, differences were less than QSD. On voxel analysis, all TRs were significantly different to the RR (p < 0.0001). TRs reconstructed at the lowest CT exposure with IR had 6% of voxels that differed by greater than QSD. Differences were reduced with increasing CTDI and FBP reconstruction. Voxels which exceeded the QSD were spatially localised to regions of high activity, interfaces between different attenuation and areas of CT beam hardening.

Conclusions

Very low dose CT exposures are feasible for accurate PET AC. Scanner- and reconstruction-specific validation should be employed prior very low dose CT AC for PET.