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Alves VDPV, Ata NA, MacLean J, Sharp SE, Li Y, Brady S, Trout AT. Reduced count pediatric whole-body 18F-FDG PET imaging reconstruction with a Bayesian penalized likelihood algorithm. Pediatr Radiol 2024; 54:170-180. [PMID: 37962603 DOI: 10.1007/s00247-023-05801-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Revised: 10/24/2023] [Accepted: 10/26/2023] [Indexed: 11/15/2023]
Abstract
BACKGROUND Advanced positron emission tomography (PET) image reconstruction methods promise to allow optimized PET/CT protocols with improved image quality, decreased administered activity and/or acquisition times. OBJECTIVE To evaluate the impact of reducing counts (simulating reduced acquisition time) in block sequential regularized expectation maximization (BSREM) reconstructed pediatric whole-body 18F-fluorodeoxyglucose (FDG) PET images, and to compare BSERM with ordered-subset expectation maximization (OSEM) reconstructed reduced-count images. MATERIALS AND METHODS Twenty children (16 male) underwent clinical whole-body 18F-FDG PET/CT examinations using a 25-cm axial field-of-view (FOV) digital PET/CT system at 90 s per bed (s/bed) with BSREM reconstruction (β=700). Reduced count simulations with varied BSREM β levels were generated from list-mode data: 60 s/bed, β=800; 50 s/bed, β=900; 40 s/bed, β=1000; and 30 s/bed, β=1300. In addition, a single OSEM reconstruction was created at 60 s/bed based on prior literature. Qualitative (Likert scores) and quantitative (standardized uptake value [SUV]) analyses were performed to evaluate image quality and quantitation across simulated reconstructions. RESULTS The mean patient age was 9.0 ± 5.5 (SD) years, mean weight was 38.5 ± 24.5 kg, and mean administered 18F-FDG activity was 4.5 ± 0.7 (SD) MBq/kg. Between BSREM reconstructions, no qualitative measure showed a significant difference versus the 90 s/bed β=700 standard (all P>0.05). SUVmax values for lesions were significantly lower from 90 s/bed, β=700 only at a simulated acquisition time of 30 s/bed, β=1300 (P=0.001). In a side-by-side comparison of BSREM versus OSEM reconstructions, 40 s/bed, β=1000 images were generally preferred over 60 s/bed TOF OSEM images. CONCLUSION In children who undergo whole-body 18F-FDG PET/CT on a 25-cm FOV digital PET/CT scanner, reductions in acquisition time or, by corollary, administered radiopharmaceutical activity of >50% from a clinical standard of 90 s/bed may be possible while maintaining diagnostic quality when a BSREM reconstruction algorithm is used.
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Affiliation(s)
- Vinicius de Padua V Alves
- Department of Radiology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Kasota Building MLC 5031, Cincinnati, OH, 45226, USA
| | - Nadeen Abu Ata
- Department of Radiology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Kasota Building MLC 5031, Cincinnati, OH, 45226, USA
- Department of Radiology, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Joseph MacLean
- Department of Radiology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Kasota Building MLC 5031, Cincinnati, OH, 45226, USA
| | - Susan E Sharp
- Department of Radiology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Kasota Building MLC 5031, Cincinnati, OH, 45226, USA
- Department of Radiology, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Yinan Li
- Department of Radiology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Kasota Building MLC 5031, Cincinnati, OH, 45226, USA
- Department of Radiology, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Samuel Brady
- Department of Radiology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Kasota Building MLC 5031, Cincinnati, OH, 45226, USA
- Department of Radiology, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Andrew T Trout
- Department of Radiology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Kasota Building MLC 5031, Cincinnati, OH, 45226, USA.
- Department of Radiology, University of Cincinnati College of Medicine, Cincinnati, OH, USA.
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA.
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Giraudo C, Carraro S, Zucchetta P, Cecchin D. Pediatric Imaging Using PET/MR Imaging. Magn Reson Imaging Clin N Am 2023; 31:625-636. [PMID: 37741646 DOI: 10.1016/j.mric.2023.06.001] [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] [Indexed: 09/25/2023]
Abstract
PET/MR imaging is a one-stop shop technique for pediatric diseases allowing not only an accurate clinical assessment of tumors at staging and restaging but also the diagnosis of neurologic, inflammatory, and infectious diseases in complex cases. Moreover, applying PET kinetic analyses and sequences such as diffusion-weighted imaging as well as quantitative analysis investigating the relationship between disease metabolic activity and cellularity can be applied. Complex radiomics analysis can also be performed.
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Affiliation(s)
- Chiara Giraudo
- Complex Unit of Nuclear Medicine, Department of Medicine (DIMED), University Hospital of Padova, Via Nicolo' Giustiniani 2, 35128, Padova, Italy
| | - Silvia Carraro
- Unit of Pediatric Allergy and Respiratory Medicine, Women's and Children's Health Department, University Hospital of Padova, Via Nicolo' Giustiniani 2, 35128, Padova, Italy
| | - Pietro Zucchetta
- Complex Unit of Nuclear Medicine, Department of Medicine (DIMED), University Hospital of Padova, Via Nicolo' Giustiniani 2, 35128, Padova, Italy
| | - Diego Cecchin
- Complex Unit of Nuclear Medicine, Department of Medicine (DIMED), University Hospital of Padova, Via Nicolo' Giustiniani 2, 35128, Padova, Italy.
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Pace E, Johnson TS, Kao SC, Parikh AK, Qi J, Rajderkar DA, Reid JR, Towbin AJ, States LJ. Imaging of pediatric extragonadal pelvic soft tissue tumors: A COG Diagnostic Imaging Committee/SPR Oncology Committee White Paper. Pediatr Blood Cancer 2023; 70 Suppl 4:e29966. [PMID: 36482882 PMCID: PMC10710207 DOI: 10.1002/pbc.29966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Accepted: 08/16/2022] [Indexed: 12/13/2022]
Abstract
The most common pediatric extragonadal pelvic cancers include germ cell tumors, sacrococcygeal teratomas, and rhabdomyosarcomas (arising from the urinary bladder, prostate, paratesticular tissues, vagina, uterus, and perineum). This paper describes the radiological and nuclear medicine features of these entities and provides consensus-based recommendations for the assessment at diagnosis, during, and after treatment.
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Affiliation(s)
- Erika Pace
- Department of Radiology, The Royal Marsden NHS Foundation Trust, London, England, United Kingdom
| | - Tatum S. Johnson
- Department of Radiology, Brenner Children’s Wake Forest Baptist Health, Winston-Salem, North Carolina, USA
| | - Simon C. Kao
- Department of Radiology, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Ashish K. Parikh
- Department of Radiology, Emory University Children’s Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Jing Qi
- Department of Radiology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Dhanashree A. Rajderkar
- Department of Radiology, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Janet R. Reid
- Department of Radiology, Children’s Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Alexander J. Towbin
- Department of Radiology, Cincinnati Children’s Hospital, Cincinnati, Ohio, USA
| | - Lisa J. States
- Department of Radiology, Children’s Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Acord MR, Pace E, El-Ali A, Chaturvedi A, Iyer RS, Navarro OM, Pandit-Taskar N, K Parikh A, Schechter A, Shaikh R, McCarville MB. Imaging of pediatric extremity soft tissue tumors: A COG Diagnostic Imaging Committee/SPR Oncology Committee White Paper. Pediatr Blood Cancer 2023; 70 Suppl 4:e29944. [PMID: 36070194 PMCID: PMC10641877 DOI: 10.1002/pbc.29944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Accepted: 08/08/2022] [Indexed: 11/05/2022]
Abstract
Pediatric soft tissue tumors of the extremity include rhabdomyosarcoma and nonrhabdomyosarcoma neoplasms. This manuscript provides consensus-based imaging recommendations for imaging evaluation at diagnosis, during treatment, and following completion of therapy for patients with a soft tissue tumor of the extremity.
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Affiliation(s)
- Michael Richard Acord
- Department of Radiology, The Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Erika Pace
- Cancer Research UK Cancer Imaging Centre, Division of Radiation Therapy and Imaging, The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Alexander El-Ali
- Division of Pediatric Radiology, Department of Radiology, NYU Grossman School of Medicine, New York, New York, USA
| | - Apeksha Chaturvedi
- Department of Imaging Science, University of Rochester Medical Center, Rochester, New York, USA
| | - Ramesh S Iyer
- Department of Radiology, Seattle Children's Hospital, University of Washington, Seattle, Washington, USA
| | - Oscar M Navarro
- Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Neeta Pandit-Taskar
- Molecular Imaging and Therapy Service, Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Ashishkumar K Parikh
- Department of Radiology, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Ann Schechter
- Department of Diagnostic Imaging, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Raja Shaikh
- Division of Interventional Radiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - M Beth McCarville
- Department of Diagnostic Imaging, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
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Fragoso Costa P, Jentzen W, SÜßELBECK F, Fendler WP, Rischpler C, Herrmann K, Conti M, Kersting D, Weber M. Reduction of emission time for [68Ga]Ga-PSMA PET/CT using the digital biograph vision: a phantom study. THE QUARTERLY JOURNAL OF NUCLEAR MEDICINE AND MOLECULAR IMAGING : OFFICIAL PUBLICATION OF THE ITALIAN ASSOCIATION OF NUCLEAR MEDICINE (AIMN) [AND] THE INTERNATIONAL ASSOCIATION OF RADIOPHARMACOLOGY (IAR), [AND] SECTION OF THE SOCIETY OF... 2023; 67:57-68. [PMID: 34309334 DOI: 10.23736/s1824-4785.21.03300-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND The aim of this phantom study was to optimize the [68Ga]Ga-PSMA PET/CT examination in terms of scan time duration and image reconstruction parameters, in combination with PSF and TOF modelling, in a digital Biograph Vision PET/CT scanner. METHODS Three types of phantoms were used: 1) soft-tissue tumor phantom consisting of six spheres mounted in a torso phantom; 2) bone-lung tumor phantom; 3) resolution phantom. Phantom inserts were filled with activity concentrations (ACs) that were derived from clinical data. Phantom data were acquired in list-mode at one bed position. Images with emission data ranging from 30 to 210 s in 30-s increments were reconstructed from a reference image acquired with 3.5-min emission. Iterative image reconstruction (OSEM), point-spread-function (PSF) and time-of-flight (TOF) options were applied using different iterations, Gaussian filters, and voxel sizes. The criteria for image quality was lesion detectability and lesion quantification, evaluated as contrast-to-noise ratio (CNR) and maximum AC (peak AC), respectively. A threshold value of CNR above 6 and percentage maximum AC (peak AC) deviation range of ±20% of the reference image were considered acceptable. The proposed single-bed scan time reduction was projected to a whole-body examination (patient validation scan) using the continuous-bed-motion mode. RESULTS Sphere and background ACs of 20 kBq/mL and 1 kBq/mL were selected, respectively. The optimized single-bed scan time was approximately 60 s using OSEM-TOF or OSEM-TOF+PSF (four iterations, 4.0-mm Gaussian filter and almost isotropic voxel size of 3.0-mm side length), resulting in a PET spatial resolution of 6.3 mm for OSEM-TOF and 5.5 mm for OSEM-TOF+PSF. In the patient validation, the maximum percentage difference in lesion quantification between standard and optimized protocol (whole-body scan time of 15 vs. 5 min) was below 19%. CONCLUSIONS A reduction of single-bed and whole-body scan time for [68Ga]Ga-PSMA PET/CT compared to current recommended clinical acquisition protocols is postulated. Clinical studies are warranted to validate the applicability of this protocol.
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Affiliation(s)
- Pedro Fragoso Costa
- Department of Nuclear Medicine, Essen University Hospital, Duisburg-Essen University, Essen, Germany -
| | - Walter Jentzen
- Department of Nuclear Medicine, Essen University Hospital, Duisburg-Essen University, Essen, Germany
| | - Finja SÜßELBECK
- Department of Nuclear Medicine, Essen University Hospital, Duisburg-Essen University, Essen, Germany
| | - Wolfgang P Fendler
- Department of Nuclear Medicine, Essen University Hospital, Duisburg-Essen University, Essen, Germany
| | - Christoph Rischpler
- Department of Nuclear Medicine, Essen University Hospital, Duisburg-Essen University, Essen, Germany
| | - Ken Herrmann
- Department of Nuclear Medicine, Essen University Hospital, Duisburg-Essen University, Essen, Germany
| | | | - David Kersting
- Department of Nuclear Medicine, Essen University Hospital, Duisburg-Essen University, Essen, Germany
| | - Manuel Weber
- Department of Nuclear Medicine, Essen University Hospital, Duisburg-Essen University, Essen, Germany
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Aydos U, Balcı E, Ateş SG, Akdemir ÜÖ, Karadeniz C, Atay LÖ. Quantitative and visual analyses of the effect of activity reduction on image metrics and quality in 18F-FDG PET/MRI in pediatric oncology. Turk J Med Sci 2023; 53:289-302. [PMID: 36945939 PMCID: PMC10387842 DOI: 10.55730/1300-0144.5584] [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: 07/18/2022] [Accepted: 11/30/2022] [Indexed: 03/23/2023] Open
Abstract
BACKGROUND : The aim of our study was to evaluate the effect of reduced injected tracer activities on the quantitative image metrics and the visual image quality in whole-body 18F-FDG PET/MRI with TOF capability in pediatric oncology. METHODS Seventy-seven PET/MRI examinations of 54 patients were analyzed (standard injected activity: 1.9 MBq/kg, standard PET scan duration: 5 min per bed position). Lower activity PET images (1.2 MBq/kg and 0.9 MBq/kg) were retrospectively simulated from the originally acquired list-mode data sets. Quantitative parameters were assessed by measuring the SUV metrics, signal-to-noise ratio (SNR), contrast-to-noise ratios (CNR), and textural features in each PET data set. PET images were also evaluated visually for image quality by using a scoring system. RESULTS SNRs were found as significantly different among PET data sets (p < 0.001) and showed increasing image noise with decreasing activities. CNR values did not show significant differences among PET data sets. The mean relative percentage changes in SUV metrics were found to be lower in 1.2 MBq/kg data set compared to 0.9 MBq/kg data set. Lesion SUVmax, SUVmean, SULpeak, and textural features were significantly different in 0.9 MBq/kg data set compared to the original data set (p < 0.05 for all). However, SUV metrics and textural features did not show a significant difference between the original and 1.2 MBq/kg data sets. While, the mean visual scores in 0.9 MBq/kg data set were significantly different compared to the original data set (p < 0.001), there was no significant difference between the original and 1.2 MBq/kg data sets in terms of general image quality and image sharpness. DISCUSSION Our analyses showed that the reduction of injected activity to 1.2 MBq/kg may be feasible in pediatric oncological PET/ MRI, with a smaller relative percentage change in quantitative parameters and with similar image quality to the original data set.
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Affiliation(s)
- Uğuray Aydos
- Department of Nuclear Medicine, Faculty of Medicine, Gazi University, Ankara, Turkey
| | - Erdem Balcı
- Department of Nuclear Medicine, Faculty of Medicine, Gazi University, Ankara, Turkey
| | - Seda Gülbahar Ateş
- Department of Nuclear Medicine, Faculty of Medicine, Gazi University, Ankara, Turkey
| | - Ümit Özgür Akdemir
- Department of Nuclear Medicine, Faculty of Medicine, Gazi University, Ankara, Turkey
| | - Ceyda Karadeniz
- Department of Pediatric Oncology, Faculty of Medicine, Gazi University, Ankara, Turkey
| | - Lütfiye Özlem Atay
- Department of Nuclear Medicine, Faculty of Medicine, Gazi University, Ankara, Turkey
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Simulated Reduced-Count Whole-Body FDG PET: Evaluation in Children and Young Adults Imaged on a Digital PET Scanner. AJR Am J Roentgenol 2022; 219:952-961. [PMID: 35731102 DOI: 10.2214/ajr.22.27894] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND. Digital PET scanners with increased sensitivity may allow shorter scan acquisition times or reductions in administered radiopharmaceutical activities. OBJECTIVE. The purpose of this study was to evaluate in children and young adults the impact of shorter simulated acquisition times on the quality of whole-body FDG PET images obtained using a digital PET/CT system. METHODS. This retrospective study included 27 children and young adults (nine male and 18 female patients) who underwent clinically indicated whole-body FDG PET/CT examinations performed using a 25-cm axial FOV PET/CT system at 90 s per bed position (expressed hereafter as seconds per bed). Raw list-mode data were reprocessed to simulate acquisition times of 60, 55, 50, 45, 40, and 30 s/bed. Three radiologists independently reviewed reconstructed images and assigned Likert scores for lesion conspicuity, normal structure conspicuity, image quality, and image noise. A separate observer recorded the SUVmax, SUVmean, and SD of the SUV (SUVSD) for liver, thigh, and the most FDG-avid lesion. The SUVSD/SUVmean (the SUVSD divided by the SUVmean) was calculated as a surrogate of image noise. ANOVA, the Friedman test, and the Dunn test were used to compare qualitative measures (combining reader scores) and SUV measurements. RESULTS. The mean patient age was 10.8 ± 8.3 (SD) years, mean BMI was 18.7 ± 2.9, and mean administered FDG activity was 4.44 ± 0.37 MBq/kg (0.12 ± 0.01 mCi/kg). No qualitative measure showed a significant difference versus 90 s/bed for the simulated acquisition at 60 s/bed (all p > .05). Significant differences (all p < .05) versus 90 s/bed were observed for lesion conspicuity at at most 40 s/bed, conspicuity of normal structures and overall image quality at at most 45 s/bed, and image noise at at most 55 s/bed. SUVmean was not significantly different from 90 s/bed for any site for any reduced-count simulation (all p > .05). SUVSD/SUVmean and SUVmax showed gradual increases with decreasing acquisition times and were significantly different from 90 s/bed only for liver at 60 s/bed (for SUVmax: 1.00 ± 0.00 vs 1.05 ± 0.03, p = .02; for SUVSD/SUVmean: 0.09 ± 0.02 vs 0.11 ± 0.02, p = .04). CONCLUSION. Favorable findings for the simulated acquisition at 60 s/bed suggest that, in children and young adults who undergo imaging performed using a 25-cm FOV digital PET scanner, acquisition time or administered FDG activity may be decreased by approximately 33% from the clinical standard without significantly impacting image quality. CLINICAL IMPACT. A 25-cm axial FOV digital scanner may allow FDG PET/CT examinations to be performed with reduced radiation exposure or faster scan acquisition times.
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Piccardo A, Albert NL, Borgwardt L, Fahey FH, Hargrave D, Galldiks N, Jehanno N, Kurch L, Law I, Lim R, Lopci E, Marner L, Morana G, Young Poussaint T, Seghers VJ, Shulkin BL, Warren KE, Traub-Weidinger T, Zucchetta P. Joint EANM/SIOPE/RAPNO practice guidelines/SNMMI procedure standards for imaging of paediatric gliomas using PET with radiolabelled amino acids and [ 18F]FDG: version 1.0. Eur J Nucl Med Mol Imaging 2022; 49:3852-3869. [PMID: 35536420 PMCID: PMC9399211 DOI: 10.1007/s00259-022-05817-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 04/23/2022] [Indexed: 01/18/2023]
Abstract
Positron emission tomography (PET) has been widely used in paediatric oncology. 2-Deoxy-2-[18F]fluoro-D-glucose ([18F]FDG) is the most commonly used radiopharmaceutical for PET imaging. For oncological brain imaging, different amino acid PET radiopharmaceuticals have been introduced in the last years. The purpose of this document is to provide imaging specialists and clinicians guidelines for indication, acquisition, and interpretation of [18F]FDG and radiolabelled amino acid PET in paediatric patients affected by brain gliomas. There is no high level of evidence for all recommendations suggested in this paper. These recommendations represent instead the consensus opinion of experienced leaders in the field. Further studies are needed to reach evidence-based recommendations for the applications of [18F]FDG and radiolabelled amino acid PET in paediatric neuro-oncology. These recommendations are not intended to be a substitute for national and international legal or regulatory provisions and should be considered in the context of good practice in nuclear medicine. The present guidelines/standards were developed collaboratively by the EANM and SNMMI with the European Society for Paediatric Oncology (SIOPE) Brain Tumour Group and the Response Assessment in Paediatric Neuro-Oncology (RAPNO) working group. They summarize also the views of the Neuroimaging and Oncology and Theranostics Committees of the EANM and reflect recommendations for which the EANM and other societies cannot be held responsible.
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Affiliation(s)
- Arnoldo Piccardo
- Department of Nuclear Medicine, E.O. "Ospedali Galliera", Genoa, Italy
| | - Nathalie L Albert
- Department of Nuclear Medicine, University Hospital of LMU Munich, Munich, Germany
| | - Lise Borgwardt
- Department of Clinical Physiology, Nuclear Medicine and PET, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Frederic H Fahey
- Department of Radiology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Darren Hargrave
- Department of Paediatric Oncology, Great Ormond Street Hospital NHS Trust, London, UK
| | - Norbert Galldiks
- Department of Neurology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
- Institute of Neuroscience and Medicine (INM-3), Research Center Juelich, Juelich, Germany
| | - Nina Jehanno
- Department of Nuclear Medicine, Institut Curie Paris, Paris, France
| | - Lars Kurch
- Department of Nuclear Medicine, University Hospital Leipzig, Leipzig, Germany.
| | - Ian Law
- Department of Clinical Physiology, Nuclear Medicine and PET, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Ruth Lim
- Department of Radiology, Massachusetts General Hospital, Boston, MA, USA
| | - Egesta Lopci
- Nuclear Medicine Unit, IRCCS-Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano, Milano, Italy
| | - Lisbeth Marner
- Department of Clinical Physiology and Nuclear Medicine, Copenhagen University Hospital Bispebjerg, Copenhagen, Denmark
| | - Giovanni Morana
- Department of Neurosciences, University of Turin, Turin, Italy
| | - Tina Young Poussaint
- Department of Radiology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Victor J Seghers
- Singleton Department of Pediatric Radiology, Texas Children's Hospital, Houston, TX, USA
- Department of Radiology, Baylor College of Medicine, Houston, TX, USA
| | - Barry L Shulkin
- Nuclear Medicine Department of Diagnostic Imaging St. Jude Children's Research Hospital, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Katherine E Warren
- Department of Pediatric Oncology, Dana Farber Cancer Institute, Boston, MA, USA
| | - Tatjana Traub-Weidinger
- Division of Nuclear Medicine, Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Pietro Zucchetta
- Nuclear Medicine Unit, Department of Medicine - DIMED, University Hospital of Padova, Padua, Italy
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Dickson J, Eberlein U, Lassmann M. The effect of modern PET technology and techniques on the EANM paediatric dosage card. Eur J Nucl Med Mol Imaging 2022; 49:1964-1969. [PMID: 34910233 PMCID: PMC9016049 DOI: 10.1007/s00259-021-05635-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 11/24/2021] [Indexed: 11/08/2022]
Abstract
AIM Recent advancements in PET technology have brought with it significant improvements in PET performance and image quality. In particular, the extension of the axial field of view of PET systems, and the introduction of semiconductor technology into the PET detector, initially for PET/MR, and more recently available long-field-of-view PET/CT systems (≥ 25 cm) have brought a step change improvement in the sensitivity of PET scanners. Given the requirement to limit paediatric doses, this increase in sensitivity is extremely welcome for the imaging of children and young people. This is even more relevant with PET/MR, where the lack of CT exposures brings further dose reduction benefits to this population. In this short article, we give some details around the benefits around new PET technology including PET/MR and its implications on the EANM paediatric dosage card. MATERIAL AND METHODS : Reflecting on EANM adult guidance on injected activities, and making reference to bed overlap and the concept of MBq.min bed-1 kg-1, we use published data on image quality from PET/MR systems to update the paediatric dosage card for PET/MR and extended axial field of view (≥ 25 cm) PET/CT systems. However, this communication does not cover the expansion of paediatric dosing for the half-body and total-body scanners that have recently come to market. RESULTS In analogy to the existing EANM dosage card, new parameters for the EANM paediatric dosage card were developed (class B, baseline value: 10.7 MBq, minimum recommended activity 10 MBq). The recommended administered activities for the systems considered in this communication range from 11 MBq [18F]FDG for a child with a weight of 3 kg to 149 MBq [18F]FDG for a paediatric patient weight of 68 kg, assuming a scan of 3 min per bed position. The mean effective dose over all ages (1 year and older) is 2.85 mSv. CONCLUSION With this, recommendations for paediatric dosing are given for systems that have not been considered previously.
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Affiliation(s)
- John Dickson
- Institute of Nuclear Medicine, University College London Hospitals, London, UK
| | - Uta Eberlein
- Department of Nuclear Medicine, University Hospital Würzburg, Würzburg, Germany.
| | - Michael Lassmann
- Department of Nuclear Medicine, University Hospital Würzburg, Würzburg, Germany
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Menendez MI, Moore RR, Abdel-Rasoul M, Wright CL, Fernandez S, Jackson RD, Knopp MV. [ 18F] Sodium Fluoride Dose Reduction Enabled by Digital Photon Counting PET/CT for Evaluation of Osteoblastic Activity. Front Med (Lausanne) 2022; 8:725118. [PMID: 35096851 PMCID: PMC8789749 DOI: 10.3389/fmed.2021.725118] [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: 06/14/2021] [Accepted: 12/17/2021] [Indexed: 11/24/2022] Open
Abstract
The aim of the study was to assess the quality and reproducibility of reducing the injected [18F] sodium fluoride ([18F]NaF) dose while maintaining diagnostic imaging quality in bone imaging in a preclinical skeletal model using digital photon counting PET (dPET) detector technology. Beagles (n = 9) were administered three different [18F]NaF doses: 111 MBq (n = 5), 20 MBq (n = 5), and 1.9 MBq (n = 9). Imaging started ≃45 min post-injection for ≃30 min total acquisition time. Images were reconstructed using Time-of-Flight, ultra-high definition (voxel size of 1 × 1 × 1 mm3), with 3 iterations and 3 subsets. Point spread function was modeled and Gaussian filtering was applied. Skeleton qualitative and quantitative molecular image assessment was performed. The overall diagnostic quality of all images scored excellent (61%) and acceptable (39%) by all the reviewers. [18F]NaF SUVmean showed no statistically significant differences among the three doses in any of the region of interest assessed. This study demonstrated that a 60-fold [18F]NaF dose reduction was not significantly different from the highest dose, and it had not significant effect on overall image quality and quantitative accuracy. In the future, ultra-low dose [18F]NaF dPET/CT imaging may significantly decrease PET radiation exposure to preclinical subjects and personnel.
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Affiliation(s)
- Maria I Menendez
- Department of Radiology, The Wright Center of Innovation in Biomedical Imaging, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Richard R Moore
- Department of Radiology, The Wright Center of Innovation in Biomedical Imaging, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Mahmoud Abdel-Rasoul
- Center for Biostatistics, College of Medicine, The Ohio State University, Columbus, OH, United States
| | - Chadwick L Wright
- Department of Radiology, The Wright Center of Innovation in Biomedical Imaging, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Soledad Fernandez
- Center for Biostatistics, College of Medicine, The Ohio State University, Columbus, OH, United States
| | - Rebecca D Jackson
- Department of Internal Medicine, Endocrinology, Diabetes and Metabolism, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Michael V Knopp
- Department of Radiology, The Wright Center of Innovation in Biomedical Imaging, The Ohio State University Wexner Medical Center, Columbus, OH, United States
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11
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Theruvath AJ, Siedek F, Yerneni K, Muehe AM, Spunt SL, Pribnow A, Moseley M, Lu Y, Zhao Q, Gulaka P, Chaudhari A, Daldrup-Link HE. Validation of Deep Learning-based Augmentation for Reduced 18F-FDG Dose for PET/MRI in Children and Young Adults with Lymphoma. Radiol Artif Intell 2021; 3:e200232. [PMID: 34870211 DOI: 10.1148/ryai.2021200232] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Revised: 08/30/2021] [Accepted: 09/17/2021] [Indexed: 11/11/2022]
Abstract
Purpose To investigate if a deep learning convolutional neural network (CNN) could enable low-dose fluorine 18 (18F) fluorodeoxyglucose (FDG) PET/MRI for correct treatment response assessment of children and young adults with lymphoma. Materials and Methods In this secondary analysis of prospectively collected data (ClinicalTrials.gov identifier: NCT01542879), 20 patients with lymphoma (mean age, 16.4 years ± 6.4 [standard deviation]) underwent 18F-FDG PET/MRI between July 2015 and August 2019 at baseline and after induction chemotherapy. Full-dose 18F-FDG PET data (3 MBq/kg) were simulated to lower 18F-FDG doses based on the percentage of coincidence events (representing simulated 75%, 50%, 25%, 12.5%, and 6.25% 18F-FDG dose [hereafter referred to as 75%Sim, 50%Sim, 25%Sim, 12.5%Sim, and 6.25%Sim, respectively]). A U.S. Food and Drug Administration-approved CNN was used to augment input simulated low-dose scans to full-dose scans. For each follow-up scan after induction chemotherapy, the standardized uptake value (SUV) response score was calculated as the maximum SUV (SUVmax) of the tumor normalized to the mean liver SUV; tumor response was classified as adequate or inadequate. Sensitivity and specificity in the detection of correct response status were computed using full-dose PET as the reference standard. Results With decreasing simulated radiotracer doses, tumor SUVmax increased. A dose below 75%Sim of the full dose led to erroneous upstaging of adequate responders to inadequate responders (43% [six of 14 patients] for 75%Sim; 93% [13 of 14 patients] for 50%Sim; and 100% [14 of 14 patients] below 50%Sim; P < .05 for all). CNN-enhanced low-dose PET/MRI scans at 75%Sim and 50%Sim enabled correct response assessments for all patients. Use of the CNN augmentation for assessing adequate and inadequate responses resulted in identical sensitivities (100%) and specificities (100%) between the assessment of 100% full-dose PET, augmented 75%Sim, and augmented 50%Sim images. Conclusion CNN enhancement of PET/MRI scans may enable 50% 18F-FDG dose reduction with correct treatment response assessment of children and young adults with lymphoma.Keywords: Pediatrics, PET/MRI, Computer Applications Detection/Diagnosis, Lymphoma, Tumor Response, Whole-Body Imaging, Technology AssessmentClinical trial registration no: NCT01542879 Supplemental material is available for this article. © RSNA, 2021.
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Affiliation(s)
- Ashok J Theruvath
- Department of Radiology, Molecular Imaging Program at Stanford (A.J.T., F.S., K.Y., A.M.M., M.M., A.C., H.E.D.L.), Department of Pediatrics, Division of Hematology/Oncology, Lucile Packard Children's Hospital (S.L.S., A.P., H.E.D.L.), and Department of Biomedical Data Science (Y.L., Q.Z.), Stanford University, 725 Welch Rd, Stanford, CA 94304; and Subtle Medical, Menlo Park, Calif (P.G.)
| | - Florian Siedek
- Department of Radiology, Molecular Imaging Program at Stanford (A.J.T., F.S., K.Y., A.M.M., M.M., A.C., H.E.D.L.), Department of Pediatrics, Division of Hematology/Oncology, Lucile Packard Children's Hospital (S.L.S., A.P., H.E.D.L.), and Department of Biomedical Data Science (Y.L., Q.Z.), Stanford University, 725 Welch Rd, Stanford, CA 94304; and Subtle Medical, Menlo Park, Calif (P.G.)
| | - Ketan Yerneni
- Department of Radiology, Molecular Imaging Program at Stanford (A.J.T., F.S., K.Y., A.M.M., M.M., A.C., H.E.D.L.), Department of Pediatrics, Division of Hematology/Oncology, Lucile Packard Children's Hospital (S.L.S., A.P., H.E.D.L.), and Department of Biomedical Data Science (Y.L., Q.Z.), Stanford University, 725 Welch Rd, Stanford, CA 94304; and Subtle Medical, Menlo Park, Calif (P.G.)
| | - Anne M Muehe
- Department of Radiology, Molecular Imaging Program at Stanford (A.J.T., F.S., K.Y., A.M.M., M.M., A.C., H.E.D.L.), Department of Pediatrics, Division of Hematology/Oncology, Lucile Packard Children's Hospital (S.L.S., A.P., H.E.D.L.), and Department of Biomedical Data Science (Y.L., Q.Z.), Stanford University, 725 Welch Rd, Stanford, CA 94304; and Subtle Medical, Menlo Park, Calif (P.G.)
| | - Sheri L Spunt
- Department of Radiology, Molecular Imaging Program at Stanford (A.J.T., F.S., K.Y., A.M.M., M.M., A.C., H.E.D.L.), Department of Pediatrics, Division of Hematology/Oncology, Lucile Packard Children's Hospital (S.L.S., A.P., H.E.D.L.), and Department of Biomedical Data Science (Y.L., Q.Z.), Stanford University, 725 Welch Rd, Stanford, CA 94304; and Subtle Medical, Menlo Park, Calif (P.G.)
| | - Allison Pribnow
- Department of Radiology, Molecular Imaging Program at Stanford (A.J.T., F.S., K.Y., A.M.M., M.M., A.C., H.E.D.L.), Department of Pediatrics, Division of Hematology/Oncology, Lucile Packard Children's Hospital (S.L.S., A.P., H.E.D.L.), and Department of Biomedical Data Science (Y.L., Q.Z.), Stanford University, 725 Welch Rd, Stanford, CA 94304; and Subtle Medical, Menlo Park, Calif (P.G.)
| | - Michael Moseley
- Department of Radiology, Molecular Imaging Program at Stanford (A.J.T., F.S., K.Y., A.M.M., M.M., A.C., H.E.D.L.), Department of Pediatrics, Division of Hematology/Oncology, Lucile Packard Children's Hospital (S.L.S., A.P., H.E.D.L.), and Department of Biomedical Data Science (Y.L., Q.Z.), Stanford University, 725 Welch Rd, Stanford, CA 94304; and Subtle Medical, Menlo Park, Calif (P.G.)
| | - Ying Lu
- Department of Radiology, Molecular Imaging Program at Stanford (A.J.T., F.S., K.Y., A.M.M., M.M., A.C., H.E.D.L.), Department of Pediatrics, Division of Hematology/Oncology, Lucile Packard Children's Hospital (S.L.S., A.P., H.E.D.L.), and Department of Biomedical Data Science (Y.L., Q.Z.), Stanford University, 725 Welch Rd, Stanford, CA 94304; and Subtle Medical, Menlo Park, Calif (P.G.)
| | - Qian Zhao
- Department of Radiology, Molecular Imaging Program at Stanford (A.J.T., F.S., K.Y., A.M.M., M.M., A.C., H.E.D.L.), Department of Pediatrics, Division of Hematology/Oncology, Lucile Packard Children's Hospital (S.L.S., A.P., H.E.D.L.), and Department of Biomedical Data Science (Y.L., Q.Z.), Stanford University, 725 Welch Rd, Stanford, CA 94304; and Subtle Medical, Menlo Park, Calif (P.G.)
| | - Praveen Gulaka
- Department of Radiology, Molecular Imaging Program at Stanford (A.J.T., F.S., K.Y., A.M.M., M.M., A.C., H.E.D.L.), Department of Pediatrics, Division of Hematology/Oncology, Lucile Packard Children's Hospital (S.L.S., A.P., H.E.D.L.), and Department of Biomedical Data Science (Y.L., Q.Z.), Stanford University, 725 Welch Rd, Stanford, CA 94304; and Subtle Medical, Menlo Park, Calif (P.G.)
| | - Akshay Chaudhari
- Department of Radiology, Molecular Imaging Program at Stanford (A.J.T., F.S., K.Y., A.M.M., M.M., A.C., H.E.D.L.), Department of Pediatrics, Division of Hematology/Oncology, Lucile Packard Children's Hospital (S.L.S., A.P., H.E.D.L.), and Department of Biomedical Data Science (Y.L., Q.Z.), Stanford University, 725 Welch Rd, Stanford, CA 94304; and Subtle Medical, Menlo Park, Calif (P.G.)
| | - Heike E Daldrup-Link
- Department of Radiology, Molecular Imaging Program at Stanford (A.J.T., F.S., K.Y., A.M.M., M.M., A.C., H.E.D.L.), Department of Pediatrics, Division of Hematology/Oncology, Lucile Packard Children's Hospital (S.L.S., A.P., H.E.D.L.), and Department of Biomedical Data Science (Y.L., Q.Z.), Stanford University, 725 Welch Rd, Stanford, CA 94304; and Subtle Medical, Menlo Park, Calif (P.G.)
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12
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Hu X, Li D, Hu G, Huang Q, Wang P, Cai J. Diagnostic performance of 18F-FDG PET/CT in pediatric lymphoma infiltrating bone marrow: a meta-analysis. Clin Transl Imaging 2021. [DOI: 10.1007/s40336-021-00452-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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13
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Cox CPW, van Assema DME, Verburg FA, Brabander T, Konijnenberg M, Segbers M. A dedicated paediatric [ 18F]FDG PET/CT dosage regimen. EJNMMI Res 2021; 11:65. [PMID: 34279735 PMCID: PMC8289942 DOI: 10.1186/s13550-021-00812-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 07/09/2021] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND The role of 2-[18F]fluoro-2-deoxy-D-glucose ([18F]FDG) positron emission tomography/computed tomography (PET/CT) in children is still expanding. Dedicated paediatric dosage regimens are needed to keep the radiation dose as low as reasonably achievable and reduce the risk of radiation-induced carcinogenesis. The aim of this study is to investigate the relation between patient-dependent parameters and [18F]FDG PET image quality in order to propose a dedicated paediatric dose regimen. METHODS In this retrospective analysis, 102 children and 85 adults were included that underwent a diagnostic [18F]FDG PET/CT scan. The image quality of the PET scans was measured by the signal-to-noise ratio (SNR) in the liver. The SNR liver was normalized (SNRnorm) for administered activity and acquisition time to apply curve fitting with body weight, body length, body mass index, body weight/body length and body surface area. Curve fitting was performed with two power fits, a nonlinear two-parameter model α p-d and a linear single-parameter model α p-0.5. The fit parameters of the preferred model were combined with a user preferred SNR to obtain at least moderate or good image quality for the dosage regimen proposal. RESULTS Body weight demonstrated the highest coefficient of determination for the nonlinear (R2 = 0.81) and linear (R2 = 0.80) models. The nonlinear model was preferred by the Akaike's corrected information criterion. We decided to use a SNR of 6.5, based on the expert opinion of three nuclear medicine physicians. Comparison with the quadratic adult protocol confirmed the need for different dosage regimens for both patient groups. In this study, the amount of administered activity can be considerably reduced in comparison with the current paediatric guidelines. CONCLUSION Body weight has the strongest relation with [18F]FDG PET image quality in children. The proposed nonlinear dosage regimen based on body mass will provide a constant and clinical sufficient image quality with a significant reduction of the effective dose compared to the current guidelines. A dedicated paediatric dosage regimen is necessary, as a universal dosing regimen for paediatric and adult is not feasible.
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Affiliation(s)
- Christina P W Cox
- Department of Radiology & Nuclear Medicine, Erasmus Medical Center, Postbus, 2040 3000 CA, Rotterdam, The Netherlands.
| | - Daniëlle M E van Assema
- Department of Radiology & Nuclear Medicine, Erasmus Medical Center, Postbus, 2040 3000 CA, Rotterdam, The Netherlands
| | - Frederik A Verburg
- Department of Radiology & Nuclear Medicine, Erasmus Medical Center, Postbus, 2040 3000 CA, Rotterdam, The Netherlands
| | - Tessa Brabander
- Department of Radiology & Nuclear Medicine, Erasmus Medical Center, Postbus, 2040 3000 CA, Rotterdam, The Netherlands
| | - Mark Konijnenberg
- Department of Radiology & Nuclear Medicine, Erasmus Medical Center, Postbus, 2040 3000 CA, Rotterdam, The Netherlands
| | - Marcel Segbers
- Department of Radiology & Nuclear Medicine, Erasmus Medical Center, Postbus, 2040 3000 CA, Rotterdam, The Netherlands
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14
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Branchini M, Zorz A, Zucchetta P, Bettinelli A, De Monte F, Cecchin D, Paiusco M. Impact of acquisition count statistics reduction and SUV discretization on PET radiomic features in pediatric 18F-FDG-PET/MRI examinations. Phys Med 2019; 59:117-126. [PMID: 30928060 DOI: 10.1016/j.ejmp.2019.03.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2018] [Revised: 03/02/2019] [Accepted: 03/07/2019] [Indexed: 01/09/2023] Open
Abstract
PURPOSE The evaluation of features robustness with respect to acquisition and post-processing parameter changes is fundamental for the reliability of radiomics studies. The aim of this study was to investigate the sensitivity of PET radiomic features to acquisition statistics reduction and standardized-uptake-volume (SUV) discretization in PET/MRI pediatric examinations. METHODS Twenty-seven lesions were detected from the analysis of twenty-one 18F-FDG-PET/MRI pediatric examinations. By decreasing the count-statistics of the original list-mode data (3 MBq/kg), injected activity reduction was simulated. Two SUV discretization approaches were applied: 1) resampling lesion SUV range into fixed bins numbers (FBN); 2) rounding lesion SUV into fixed bin size (FBS). One hundred and six radiomic features were extracted. Intraclass Correlation Coefficient (ICC), Spearman correlation coefficient and coefficient-of-variation (COV) were calculated to assess feature reproducibility between low tracer activities and full tracer activity feature values. RESULTS More than 70% of Shape and first order features, and around 70% and 40% of textural features, when using FBS and FBN methods respectively, resulted robust till 1.2 MBk/kg. Differences in median features reproducibility (ICC) between FBS and FBN datasets were statistically significant for every activity level independently from bin number/size, with higher values for FBS. Differences in median Spearman coefficient (i.e. patient ranking according to feature values) were not statistically significant, varying the intensity resolution (i.e. bin number/size) for either FBS and FBN methods. CONCLUSIONS For each simulated count-statistic level, robust PET radiomic features were determined for pediatric PET/MRI examinations. A larger number of robust features were detected when using FBS methods.
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Affiliation(s)
- Marco Branchini
- Medical Physics Department, Veneto Institute of Oncology IOV - IRCCS, Padova, Italy.
| | - Alessandra Zorz
- Medical Physics Department, Veneto Institute of Oncology IOV - IRCCS, Padova, Italy
| | - Pietro Zucchetta
- Nuclear Medicine Unit, Department of Medicine DIMED, University Hospital of Padua, Padova, Italy
| | - Andrea Bettinelli
- Medical Physics Department, Veneto Institute of Oncology IOV - IRCCS, Padova, Italy
| | - Francesca De Monte
- Medical Physics Department, Veneto Institute of Oncology IOV - IRCCS, Padova, Italy
| | - Diego Cecchin
- Nuclear Medicine Unit, Department of Medicine DIMED, University Hospital of Padua, Padova, Italy
| | - Marta Paiusco
- Medical Physics Department, Veneto Institute of Oncology IOV - IRCCS, Padova, Italy
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