Exploration of the total-body PET/CT reconstruction protocol with ultra-low 18F-FDG activity over a wide range of patient body mass indices

[64Cu]Cu-FAP-NOX, a N-oxalyl modified cyclic peptide for FAP PET imaging with a flexible imaging time window

BACKGROUND

The aim of the present study was to develop a novel 64Cu-labeled cyclic peptide ([64Cu]Cu-FAP-NOX) that targets fibroblast activation protein (FAP) and may offer advantages in terms of image contrast, imaging time window, and low uptake in normal tissues.

METHODS

The novel cyclic peptide featuring with a N-oxalyl modified tail was constructed and conjugated to NOTA for 64Cu labeling. Biochemical and cellular assays were performed with A549.hFAP cells. The performance of [64Cu]Cu-FAP-NOX was compared to that of two established tracers ([64Cu]Cu-FAPI-04 and [68Ga]Ga-FAP-2286) and three different NOTA-conjugates in HEK-293T.hFAP xenograft mice using micro-PET imaging. Ex vivo biodistribution studies were performed to confirm the FAP specificity and to validate the PET data. Furthermore, a first-in-human study of this novel tracer was conducted on one patient with lung cancer.

RESULTS

Compared to [64Cu]Cu-FAPI-04, [64Cu]Cu-FAP-NOX demonstrated faster and higher rates of cellular uptake and internalization in A549.hFAP cells, but lower rates of cellular efflux. All six radiotracers were rapidly taken up by the tumor within the first 4 h post-injection. However, [64Cu]Cu-FAP-NOX had more intense tumor accumulation and slower washout from the target. The ratios of the tumor to normal tissue (including kidneys and muscles) increased significantly over time, with [64Cu]Cu-FAP-NOX reaching the highest ratio among all tracers. In the patient, [64Cu]Cu-FAP-NOX PET showed a comparable result to FDG PET in the primary malignant lesion while exhibiting higher uptake in pleural metastases, consistent with elevated FAP expression as confirmed by immunohistochemistry.

CONCLUSION

[64Cu]Cu-FAP-NOX is a promising FAP-targeted tracer with a highly flexible imaging time window, as evidenced by preclinical evaluation encompassing biodistribution and micro-PET studies, along with a successful patient application. Furthermore, [64Cu]Cu-FAP-NOX showed enhanced image contrast and favorable pharmacokinetic properties for FAP PET imaging, warranting translation into large cohort studies.

Total-Body PET/CT: Pros and Cons

PET/CT devices with an axial field-of-view (FOV) of 1 m allow simultaneous imaging from the head to the upper thighs, the typical axial extent of many "whole-body" oncological studies acquired by moving a patient sequentially through a conventional FOV device, or rapid total-body imaging using the same approach. Increasing the FOV to around 2 m provides true simultaneous total-body imaging. Either approach dramatically increases the sensitivity for detection of annihilation events arising within the body. For the purposes of this review, both configurations are considered to represent "total-body" PET/CT devices because they share both advantages and disadvantages. These pros and cons are discussed in the context of both clinical and research applications from a patient and institutional perspective.

Stability of radiomic features from positron emission tomography images: a phantom study comparing advanced reconstruction algorithms and ordered subset expectation maximization

In this study, we compared the repeatability and reproducibility of radiomic features obtained from positron emission tomography (PET) images according to the reconstruction algorithm used-advanced reconstruction algorithms, such as HYPER iterative (IT), HYPER deep learning reconstruction (DLR), and HYPER deep progressive reconstruction (DPR), or traditional Ordered Subset Expectation Maximization (OSEM)-to understand the potential variations and implications of using advanced reconstruction techniques in PET-based radiomics. We used a heterogeneous phantom with acrylic spherical beads (4- or 8-mm diameter) filled with 18F. PET images were acquired and reconstructed using OSEM, IT, DLR, and DPR. Original and wavelet radiomic features were calculated using SlicerRadiomics. Radiomic feature repeatability was assessed using the Coefficient of Variance (COV) and intraclass correlation coefficient (ICC), and inter-acquisition time reproducibility was assessed using the concordance correlation coefficient (CCC). For the 4- and 8-mm diameter beads phantom, the proportion of radiomic features with a COV < 10% was equivocal or higher for the advanced reconstruction algorithm than for OSEM. ICC indicated that advanced methods generally outperformed OSEM in repeatability, except for the original features of the 8-mm beads phantom. In the inter-acquisition time reproducibility analysis, the combinations of 3 and 5 min exhibited the highest reproducibility in both phantoms, with IT and DPR showing the highest proportion of radiomic features with CCC > 0.8. Advanced reconstruction methods provided enhanced stability of radiomic features compared with OSEM, suggesting their potential for optimal image reconstruction in PET-based radiomics, offering potential benefits in clinical diagnostics and prognostics.

Phantom study and clinical application of total-body 18F-FDG PET/CT imaging: How to use small voxel imaging better?

BACKGROUND

Conventional PET/CT imaging reconstruction is typically performed using voxel size of 3.0-4.0 mm in three axes. It is hypothesized that a smaller voxel sizes could improve the accuracy of small lesion detection. This study aims to explore the advantages and conditions of small voxel imaging on clinical application.

METHODS

Both NEMA IQ phantom and 30 patients with an injected dose of 3.7 MBq/kg were scanned using a total-body PET/CT (uEXPLORER). Images were reconstructed using matrices of 192 × 192, 512 × 512, and 1024 × 1024 with scanning duration of 3 min, 5 min, 8 min, and 10 min, respectively.

RESULTS

In the phantom study, the contrast recovery coefficient reached the maximum in matrix group of 512 × 512, and background variability increased as voxel size decreased. In the clinical study, SUVmax, SD, and TLR increased, while SNR decreased as the voxel size decreased. When the scanning duration increased, SNR increased, while SUVmax, SD, and TLR decreased. The SUVmean was more reluctant to the changes in imaging matrix and scanning duration. The mean subjective scores for all 512 × 512 groups and 1024 × 1024 groups (scanning duration ≥ 8 min) were over three points. One false-positive lesion was found in groups of 512 × 512 with scanning duration of 3 min, 1024 × 1024 with 3 min and 5 min, respectively. Meanwhile, the false-negative lesions found in group of 192 × 192 with duration of 3 min and 5 min, 512 × 512 with 3 min and 1024 × 1024 with 3 min and 5 min were 5, 4, 1, 4, and 1, respectively. The reconstruction time and storage space occupation were significantly increased as the imaging matrix increased.

CONCLUSIONS

PET/CT imaging with smaller voxel can improve SUVmax and TLR of lesions, which is advantageous for the diagnosis of small or hypometabolic lesions if with sufficient counts. With an 18F-FDG injection dose of 3.7 MBq/kg, uEXPLORER PET/CT imaging using matrix of 512 × 512 with 5 min or 1024 × 1024 with 8 min can meet the image requirements for clinical use.

One-tenth-activity total-body positron emission tomography versus full-activity imaging in patients with a complex of hepatic malignant tumors: a retrospective study

Background

The value of ultra-low-activity 2-[18F]-fluoro-2-deoxy-D-glucose (18F-FDG) positron emission tomography (PET) imaging in patients with hepatic malignancies remains unclear.

Methods

A cross-sectional study was conducted from April 2019 to May 2021 in Zhongshan Hospital, Fudan University. A total of 49 patients with hepatic malignancies, including hepatocellular carcinoma (HCC) (n=13) or intrahepatic cholangiocarcinoma (ICC) (n=36), underwent 60-min dynamic PET imaging, with 15 undergoing full-activity 18F-FDG and 34 undergoing ultra-low-activity 18F-FDG. The kinetic metrics (K1-k3, and Ki) of tumors were calculated and compared between the activity groups. Another 54 patients (27 each group) with hepatic malignancies, including HCC (n=9), ICC (n=34), and metastases (n=11), underwent static imaging. Image qualities were compared between the groups in terms of 5-point Likert scores (with a score ≥3 fulfilling the clinical requirement), the mean standardized uptake value (SUVmean), the standard deviation of standardized uptake value (SUVSD), and the signal-to-noise ratio (SNR) of the liver; the SUVmean of blood pool and muscle; and the tumor-to-liver ratio (TLR), tumor-to-blood ratio (TBR), and tumor-to-muscle ratio (TMR) of lesions. Intergroup comparisons were performed using Chi-squared test for categorical variables and the Student's t-test or the Mann-Whitney test for continuous variables depending on the normality of variables.

Results

There was a nonsignificant difference in the kinetic metrics (K1-k3 and Ki) of tumors between the activity groups. In static imaging, 1-min full-activity (F1) and 8-min ultra-low-activity (L8) images obtained image-quality scores >3 and were thus selected for intergroup comparisons. Nonsignificant differences in SUVmean of liver, blood pool, and muscle were identified between F1 and L8 images (P=0.641, P=0.542, and P=0.073, respectively) although the liver SNR was slightly higher in F1 (13.10 vs. 11.31; P=0.003). Lesion detectability was 98.5% and 100% for F1 and L8 images, respectively, but there were no significant differences in TLR, TBR, or TMR between the groups.

Conclusions

The results of this single-center study indicate that the performance of ultra-low-activity PET imaging is comparable to that of full-activity imaging in patients with hepatic malignancies.

Current and Future Use of Long Axial Field-of-View Positron Emission Tomography/Computed Tomography Scanners in Clinical Oncology

The latest technical development in the field of positron emission tomography/computed tomography (PET/CT) imaging has been the extension of the PET axial field-of-view. As a result of the increased number of detectors, the long axial field-of-view (LAFOV) PET systems are not only characterized by a larger anatomical coverage but also by a substantially improved sensitivity, compared with conventional short axial field-of-view PET systems. In clinical practice, this innovation has led to the following optimization: (1) improved overall image quality, (2) decreased duration of PET examinations, (3) decreased amount of radioactivity administered to the patient, or (4) a combination of any of the above. In this review, novel applications of LAFOV PET in oncology are highlighted and future directions are discussed.

A proper protocol for routine 18F-FDG uEXPLORER total-body PET/CT scans

BACKGROUND

Conventional clinical PET scanners typically have an axial field of view (AFOV) of 15-30 cm, resulting in limited coverage and relatively low photon detection efficiency. Taking advantage of the development of long-axial PET/CT, the uEXPLORER PET/CT scanner with an axial coverage of 194 cm increases the effective count rate by approximately 40 times compared to that of conventional PET scanners. Ordered subset expectation maximization (OSEM) is the most widely used iterative algorithm in PET. The major drawback of OSEM is that the iteration process must be stopped before convergence to avoid image degradation due to excessive noise. A new Bayesian penalized-likelihood iterative PET reconstruction, named HYPER iterative, was developed and is now available on the uEXPLORER total-body PET/CT, which incorporates a noise control component by using a penalty function in each iteration and finds the maximum likelihood solution through repeated iterations. To date, its impact on lesion visibility in patients with a full injected dose or half injected dose is unclear. The goal of this study was to determine a proper protocol for routine 18F-FDG uEXPLORER total-body PET/CT scans.

RESULTS

The uEXPLORER total-body PET/CT images reconstructed using both OSEM and HYPER iterative algorithms of 20 tumour patients were retrospectively reviewed. The quality of the 5 min PET image was excellent (score 5) for all of the dose and reconstruction methods. Using the HYPER iterative method, the PET images reached excellent quality at 1 min with full-dose PET and at 2 min with half-dose PET. The PET image reached a similar excellent quality at 2 min with a full dose and at 3 min with a half dose using OSEM. The noise in the OSEM reconstruction was higher than that in the HYPER iterative. Compared to OSEM, the HYPER iterative had a slightly higher SUVmax and TBR of the lesions for large positive lesions (≥ 2 cm) (SUVmax: up to 9.03% higher in full dose and up to 12.52% higher in half dose; TBR: up to 8.69% higher in full dose and up to 23.39% higher in half dose). For small positive lesions (≤ 10 mm), the HYPER iterative had an obviously higher SUVmax and TBR of the lesions (SUVmax: up to 45.21% higher in full dose and up to 74.96% higher in half dose; TBR: up to 44.91% higher in full dose and up to 93.73% higher in half dose).

CONCLUSIONS

A 1 min scan with a full dose and a 2 min scan with a half dose are optimal for clinical diagnosis using the HYPER iterative and 2 min and 3 min for OSEM. For quantification of the small lesions, HYPER iterative reconstruction is preferred.

So, you want to get into "total-body" PET/CT scanning? An installation guide for beginners!

"Total-body" and ultra-extended field-of-view PET/CT scanners are now available commercially with great enthusiasm for their potential in both streamlining clinical practice and providing unique research opportunities. Accordingly, many groups are rushing to implement this technology. For early adopters, the challenges of these systems compared with more standard PET/CT systems have been significant. In this guide, aspects that need to be considered in planning installation of one of these scanners are discussed. These include financing, space, structural engineering, power supply, chilled water and environmental controls to manage heat loads, IT infrastructure and data storage, radiation safety and radiopharmaceutical procurement, staffing levels, patient handling logistics and imaging protocol redesign to leverage the superior sensitivity of these scanners, and marketing. It is a daunting but worthwhile endeavor in the author's opinion but needs a great team and the ability to bring in the appropriate expertise at the appropriate time.

An artificial intelligence-driven image quality assessment system for whole-body [18F]FDG PET/CT

PURPOSE

Image quality control is a prerequisite for applying PET/CT. This study aimed to develop an artificial intelligence-driven real-time and accurate whole-body [¹⁸F]FDG PET/CT image quality assessment system.

METHODS

This study included 173 patients (age, 59 ± 12 years; 66.3% males) with whole-body [¹⁸F]FDG PET/CT imaging. Images of ten patients were used as an educational set. Images of the rest 163 patients were reconstructed to 952 images by simulating several scanning times and randomly split into training (60%, 98 patients, 578 images), validation (20%, 33 patients, 192 images), and test (20%, 32 patients,182 images) sets. Two experienced physicians (R1 and R2) independently assessed the image quality of thorax, abdomen, and pelvis region twice (R1a and b; R2a and b), 1 month apart, using a 5-point Likert scale. Objective image quality metrics were extracted from the mediastinal blood pool, three liver levels, and the bilateral gluteus maximus. The developed convolutional neural networks for image quality assessment (IQA-CNNs) generated the subjective quality scores and objective image metrics. The IQA-CNNs and physicians' performances were compared for localization accuracy, score agreement, and process time.

RESULTS

The physicians demonstrated good inter- and intra-rater subjective assessment agreement, with kappa coefficients (R1a vs. R2a, R1a vs. R1b, R2a vs. R2b, and R1a vs. R2b) of 0.78, 0.77, 0.76, and 0.80. The IQA-CNNs and R1 or R2 agreed in the subjective assessments, with kappa coefficients of 0.79 and 0.78. IQA-CNNs and R1 or R2 also agreed in their objective image quality assessment (ICC > 0.60). The IQA-CNNs evaluation speed was 200 times faster than the manual assessment.

CONCLUSION

An automated system for rapid assessment of [¹⁸F]FDG PET/CT image quality was developed, showing comparable performance to senior physicians. The system generates a comprehensive and detailed image quality assessment report, including subjective visual scores and objective image metrics for various anatomical regions.

Ultralow-dose [18F]FDG PET/CT imaging: demonstration of feasibility in dynamic and static images

OBJECTIVES

Validation of [¹⁸F]FDG PET/CT at ultralow-dose (0.37 MBq/kg) and compared to imaging at half-dose (1.85 MBq/kg).

METHODS

This prospective head-to-head intraindividual study compared dynamic and static parameters of ultralow-dose with half-dose [¹⁸F]FDG total-body PET/CT. In static imaging, the ultralow-dose groups of PET images were denoted ULD5, 60-65 min; ULD8, 60-68 min; ULD10, 60-70 min; and ULD15, 60-75 min. The half-dose group images were reconstructed to 60-61, 60-62, 60-63, and 60-75 min, defined as LD1, LD2, LD3, and LD15, respectively. A 5-point Likert scale was used to subjectively evaluate the quality of static PET images, with a score greater than 3 considered to meet the requirements for clinical diagnosis.

RESULTS

Thirty participants were included in this study, and in terms of kinetic indicators, no special differences were found between the two groups of normal organs and lesions. In static images, those in groups ULD8 and LD2 achieved scores of [Formula: see text] 3.0, meeting the requirements for clinical diagnosis. In static imaging, four lesions were missed in the LD1 group with a lesion detectability of 89.7% (35/39). In the meantime, lesions were not missed in the whole ultra-low dose group (ULD5, ULD8, ULD10, and ULD15) and half-dose groups (LD2 and LD3).

CONCLUSIONS

Compared with half-dose imaging, ultralow-dose [¹⁸F]FDG total-body PET/CT imaging is clinically feasible, and there was no meaningful difference between the two groups of quantitative and qualitative analysis either dynamic or static images. Total-body PET/CT with ultralow-dose activity, the corresponding acquisition time of 8 min provides acceptable image quality and lesion detection.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: ChiCTR2000036487 KEY POINTS: • A prospective single-center study showed that the total-body PET scanner allows ultralow-dose [¹⁸F]FDG imaging with acceptable image quality and lesion detectability. • For the participant, radiation exposure can be reduced with ultralow-dose [¹⁸F]FDG total-body PET/CT imaging.

Phantom and clinical evaluation of the effect of a new Bayesian penalized likelihood reconstruction algorithm (HYPER Iterative) on 68Ga-DOTA-NOC PET/CT image quality

BACKGROUND

Bayesian penalized likelihood (BPL) algorithm is an effective way to suppress noise in the process of positron emission tomography (PET) image reconstruction by incorporating a smooth penalty. The strength of the smooth penalty is controlled by the penalization factor. The aim was to investigate the impact of different penalization factors and acquisition times in a new BPL algorithm, HYPER Iterative, on the quality of ⁶⁸Ga-DOTA-NOC PET/CT images. A phantom and 25 patients with neuroendocrine neoplasms who underwent ⁶⁸Ga-DOTA-NOC PET/CT were included. The PET data were acquired in a list-mode with a digital PET/CT scanner and reconstructed by ordered subset expectation maximization (OSEM) and the HYPER Iterative algorithm with seven penalization factors between 0.03 and 0.5 for acquisitions of 2 and 3 min per bed position (m/b), both including time-of-flight and point of spread function recovery. The contrast recovery (CR), background variability (BV) and radioactivity concentration ratio (RCR) of the phantom; The SUV_mean and coefficient of variation (CV) of the liver; and the SUV_max of the lesions were measured. Image quality was rated by two radiologists using a five-point Likert scale.

RESULTS

The CR, BV, and RCR decreased with increasing penalization factors for four "hot" spheres, and the HYPER Iterative 2 m/b groups with penalization factors of 0.07 to 0.2 had equivalent CR and superior BV performance compared to the OSEM 3 m/b group. The liver SUV_mean values were approximately equal in all reconstruction groups (range 5.95-5.97), and the liver CVs of the HYPER Iterative 2 m/b and 3 m/b groups with the penalization factors of 0.1 to 0.2 were equivalent to those of the OSEM 3 m/b group (p = 0.113-0.711 and p = 0.079-0.287, respectively), while the lesion SUV_max significantly increased by 19-22% and 25%, respectively (all p < 0.001). The highest qualitative score was attained at a penalization factor of 0.2 for the HYPER Iterative 2 m/b group (3.20 ± 0.52) and 3 m/b group (3.70 ± 0.36); those scores were comparable to or greater than that of the OSEM 3 m/b group (3.09 ± 0.36, p = 0.388 and p < 0.001, respectively).

CONCLUSIONS

The HYPER Iterative algorithm with a penalization factor of 0.2 resulted in higher lesion contrast and lower image noise than OSEM for ⁶⁸Ga-DOTA-NOC PET/CT, allowing the same image quality to be achieved with less injected radioactivity and a shorter acquisition time.