Influences of point-spread function and time-of-flight reconstructions on standardized uptake value of lymph node metastases in FDG-PET

Purpose

The purpose of this study was to investigate the effects of point-spread function (PSF) and time-of-flight (TOF) on the standardized uptake value (SUV) of lymph node metastasis in FDG-PET/CT.

Materials and methods

This study evaluated 41 lymph node metastases in 15 patients who had undergone ¹⁸F-FDG PET/CT. The lesion diameters were 2.5 cm or less. The mean short-axis diameter of the lymph nodes was 10.5 ± 3.7 mm (range 4.6–22.8 mm). The PET data were reconstructed with baseline OSEM algorithm, with OSEM + PSF, with OSEM + TOF and with OSEM + PSF + TOF. A semi-quantitative analysis was performed using the maximum and mean SUV of lymph node metastases (SUV_max and SUV_mean) and mean SUV of normal lung tissue (SUV_lung). We also evaluated image quality using the signal-to-noise ratio in the liver (SNR_liver).

Results

Both PSF and TOF increased the SUV of lymph node metastases. The combination of PSF and TOF increased the SUV_max by 43.3% and the SUV_mean by 31.6% compared with conventional OSEM. By contrast, the SUV_lung was not influenced by PSF and TOF. TOF significantly improved the SNR_liver.

Conclusion

PSF and TOF both increased the SUV of lymph node metastases. Although PSF and TOF are considered to improve small-lesion detectability, it is important to be aware that PSF and TOF influence the accuracy of quantitative measurements.     

Influence of PET reconstruction technique and matrix size on qualitative and quantitative assessment of lung lesions on [18F]-FDG-PET: A prospective study in 37 cancer patients

PurposeTo evaluate the influence of point spread function (PSF)-based reconstruction and matrix size for PET on (1) lung lesion detection and (2) standardized uptake values (SUV).MethodsThis prospective study included oncological patients who underwent [18F]-FDG-PET/CT for staging. PET data were reconstructed with a 2D ordered subset expectation maximization (OSEM) algorithm, and a 2D PSF-based algorithm (TrueX), separately with two matrix sizes (168 × 168 and 336 × 336). The four PET reconstructions (TrueX-168; OSEM-168; TrueX-336; and OSEM-336) were read independently by two raters, and PET-positive lung lesions were recorded. Blinded to the PET findings, a third independent rater assessed lung lesions with diameters of >4 mm on CT. Subsequently, PET and CT were reviewed side-by side in consensus. Multi-factorial logistic regression analyses and two-way repeated measures analyses of variance (ANOVA) were performed.ResultsThirty-seven patients with 206 lung lesions were included. Lesion-based PET sensitivities differed significantly between reconstruction algorithms (P < 0.001) and between reconstruction matrices (P = 0.022). Sensitivities were 94.2% and 88.3% for TrueX-336; 88.3% and 85.9% for TrueX-168; 67.8% and 66.3% for OSEM-336; and 67.0% and 67.9% for OSEM-168; for rater 1 and rater 2, respectively. SUV_max and SUV_mean were significantly higher for images reconstructed with 336 × 336 matrices than for those reconstructed with 168 × 168 matrices (P < 0.001).ConclusionOur results demonstrate that PSF-based PET reconstruction, and, to a lesser degree, higher matrix size, improve detection of metabolically active lung lesions. However, PSF-based PET reconstructions and larger matrix sizes lead to higher SUVs, which may be a concern when PET data from different institutions are compared.     

Quantification accuracy of neuro-oncology PET data as a function of emission scan duration in PET/MR compared to PET/CT

ObjectivesTo evaluate and compare the effect of reduced acquisition time, as a surrogate of injected activity, on the PET quantification accuracy in PET/CT and PET/MR imaging.MethodsTwenty min ¹⁸F-FDG phantom measurements and 10 min ¹⁸F-FET brain scans were acquired in a Biograph-True-Point-True-View PET/CT (n = 8) and a Biograph mMR PET/MR (n = 16). Listmode data were repeatedly split into frames of 1 min to 10 min length and reconstructed using two different reconstruction settings of a 3D-OSEM algorithm: with post-filtering (“OSEM”), and without post-filtering but with resolution recovery (“PSF”). Recovery coefficients (RC_max, RC_A50) and standard uptake values (SUV_max, SUV_A50) were evaluated.ResultsRC_max (phantom) and SUV_max (patients) increased significantly when reducing the frame duration. Significantly lower deviations were observed for RC_A50 and SUV_A50, respectively, making them more appropriate to compare PET studies at different number of counts. No statistical significant differences were observed when using post-filtering and reducing the frame time to 4 min (RC_A50, reference 20 min, phantom) and to 3 min (SUV_A50, reference 10 min, patients).ConclusionsFor hybrid aminoacid brain imaging, frame duration (or injected activity) can potentially be reduced to 30% of the standard used in clinical routine without significant changes on the quantification accuracy of the PET images if adequate reconstruction settings and quantitative measures are used. Frame times below 4 min in the NEMA phantom are not advisable to obtain quantitative and reproducible measures.     

Improved clinical workflow for simultaneous whole-body PET/MRI using high-resolution CAIPIRINHA-accelerated MR-based attenuation correction

PurposeTo explore the value and reproducibility of a novel magnetic resonance based attenuation correction (MRAC) using a CAIPIRINHA-accelerated T1-weighted Dixon 3D-VIBE sequence for whole-body PET/MRI compared to the clinical standard.MethodsThe PET raw data of 19 patients from clinical routine were reconstructed with standard MRAC (MRAC_std) and the novel MRAC (MRAC_caipi), a prototype CAIPIRINHA accelerated Dixon 3D-VIBE sequence, both acquired in 19 s/bed position. Volume of interests (VOIs) for liver, lung and all voxels of the total image stack were created to calculate standardized uptake values (SUV_mean) followed by inter-method agreement (Passing-Bablok regression, Bland-Altman analysis). A voxel-wise SUV comparison per patient was performed for intra-individual correlation between MRAC_std and MRAC_caipi. Difference images (MRAC_std-MRAC_caipi) of attenuation maps and SUV images were calculated. The image quality of in/opposed-phase water and fat images obtained from MRAC_caipi was assessed by two readers on a 5-point Likert-scale including intra-class coefficients for inter-reader agreement.ResultsSUV_mean correlations of VOIs demonstrated high linearity (0.95 < Spearman’s rho < 1, p < 0.0001, respectively), substantiated by voxel-wise SUV scatter-plots (1.79 × 10⁸ pixels). Outliers could be explained by different physiological conditions between the scans such as different segmentation of air-containing tissue, lungs, kidneys, metal implants, diaphragm edge or small air bubbles in the gastrointestinal tracts that moved between MRAC acquisitions. Nasal sinuses and the trachea were better segmented in MRAC_caipi. High-resolution T1w Dixon 3D VIBE images were acquired in all cases and could be used for PET/MRI fusion. MRAC_caipi images were of high diagnostic quality (4.2 ± 0.8) with 0.92-0.96 intra-class correlation.ConclusionsThe novel prototype MRAC_caipi extends the value for attenuation correction by providing a high spatial resolution DIXON-based dataset suited for diagnostic assessment towards time-efficient whole-body PET/MRI.     

Application of image-derived and venous input functions in major depression using [carbonyl-11C]WAY-100635

IntroductionImage-derived input functions (IDIFs) represent a promising non-invasive alternative to arterial blood sampling for quantification in positron emission tomography (PET) studies. However, routine applications in patients and longitudinal designs are largely missing despite widespread attempts in healthy subjects. The aim of this study was to apply a previously validated approach to a clinical sample of patients with major depressive disorder (MDD) before and after electroconvulsive therapy (ECT).MethodsEleven scans from 5 patients with venous blood sampling were obtained with the radioligand [carbonyl-¹¹C]WAY-100635 at baseline, before and after 11.0 ± 1.2 ECT sessions. IDIFs were defined by two different image reconstruction algorithms 1) OSEM with subsequent partial volume correction (OSEM + PVC) and 2) reconstruction based modelling of the point spread function (TrueX). Serotonin-1A receptor (5-HT_1A) binding potentials (BP_P, BP_ND) were quantified with a two-tissue compartment (2TCM) and reference region model (MRTM2).ResultsCompared to MRTM2, good agreement in 5-HT_1A BP_ND was found when using input functions from OSEM + PVC (R² = 0.82) but not TrueX (R² = 0.57, p < 0.001), which is further reflected by lower IDIF peaks for TrueX (p < 0.001). Following ECT, decreased 5-HT_1A BP_ND and BP_P were found with the 2TCM using OSEM + PVC (23%–35%), except for one patient showing only subtle changes. In contrast, MRTM2 and IDIFs from TrueX gave unstable results for this patient, most probably due to a 2.4-fold underestimation of non-specific binding.ConclusionsUsing image-derived and venous input functions defined by OSEM with subsequent PVC we confirm previously reported decreases in 5-HT_1A binding in MDD patients after ECT. In contrast to reference region modeling, quantification with image-derived input functions showed consistent results in a clinical setting due to accurate modeling of non-specific binding with OSEM + PVC.     

PET quantification with a histogram derived total activity metric: Superior quantitative consistency compared to total lesion glycolysis with absolute or relative SUV thresholds in phantoms and lung cancer patients

IntroductionThe increasing use of molecular imaging probes as biomarkers in oncology emphasizes the need for robust and stable methods for quantifying tracer uptake in PET imaging. The primary motivation for this research was to find an accurate method to quantify the total tumor uptake. Therefore we developed a histogram-based method to calculate the background subtracted lesion (BSL) activity and validated BSL by comparing the quantitative consistency with the total lesion glycolysis (TLG) in phantom and patient studies.MethodsA thorax phantom and a PET-ACR quality assurance phantom were scanned with increasing FDG concentrations. Volumes of interest (VOIs) were placed over each chamber. TLG was calculated with a fixed threshold at SUV 2.5 (TLG_2.5) and a relative threshold at 42% of SUV_max (TLG_42%). The histogram for each VOI was built and BSL was calculated. Comparison with the total injected FDG activity (TIA) was performed using concordance correlation coefficients (CCC) and the slope (a). Fifty consecutive patients with FDG-avid lung tumors were selected under an IRB waiver. TLG_42%, TLG_2.5 and BSL were compared to the reference standard calculating CCC and the slope.ResultsIn both phantoms, the CCC for lesions with a TIA ≤ 50 ml*SUV between TIA and BSL was higher and the slope closer to 1 (CCC = 0.933, a = 1.189), than for TLG_42% (CCC = 0.350, a = 0.731) or TLG_2.5 (CCC = 0.761, a = 0.727). In 50 lung lesions BSL had a slope closer to 1 compared to the reference activity than TLG_42% (a = 1.084 vs 0.618 – for high activity lesions) and also closer to 1 than TLG_2.5 (a = 1.117 vs 0.548 – for low activity lesions).ConclusionThe histogram based BSL correlated better with TIA in both phantom studies than TLG_2.5 or TLG_42%. Also in lung tumors, the BSL activity is overall more accurate in quantifying the lesion activity compared to the two most commonly applied TLG quantification methods.     

Dynamic contrast-enhanced perfusion area-detector CT assessed with various mathematical models: Its capability for therapeutic outcome prediction for non-small cell lung cancer patients with chemoradiotherapy as compared with that of FDG-PET/CT

PurposeTo directly compare the capability of dynamic first-pass contrast-enhanced (CE-) perfusion area-detector CT (ADCT) and PET/CT for early prediction of treatment response, disease progression and overall survival of non-small cell carcinoma (NSCLC) patients treated with chemoradiotherapy.Materials and methodsFifty-three consecutive Stage IIIB NSCLC patients who had undergone PET/CT, dynamic first-pass CE-perfusion ADCT, chemoradiotherapy, and follow-up examination were enrolled in this study. They were divided into two groups: 1) complete or partial response (CR + PR) and 2) stable or progressive disease (SD + PD). Pulmonary arterial and systemic arterial perfusions and total perfusion were assessed at targeted lesions with the dual-input maximum slope method, permeability surface and distribution volume with the Patlak plot method, tumor perfusion with the single-input maximum slope method, and SUV_max, and results were averaged to determine final values for each patient. Next, step-wise regression analysis was used to determine which indices were the most useful for predicting therapeutic effect. Finally, overall survival of responders and non-responders assessed by using the indices that had a significant effect on prediction of therapeutic outcome was statistically compared.ResultsThe step-wise regression test showed that therapeutic effect (r² = 0.63, p = 0.01) was significantly affected by the following three factors in order of magnitude of impact: systemic arterial perfusion, total perfusion, and SUV_max. Mean overall survival showed a significant difference for total perfusion (p = 0.003) and systemic arterial perfusion (p = 0.04).ConclusionDynamic first-pass CE-perfusion ADCT as well as PET/CT are useful for treatment response prediction in NSCLC patients treated with chemoradiotherapy.     

Evaluation of PET and MR datasets in integrated 18F-FDG PET/MRI: A comparison of different MR sequences for whole-body restaging of breast cancer patients

ObjectivesTo investigate the diagnostic value of different MR sequences and 18F-FDG PET data for whole-body restaging of breast cancer patients utilizing PET/MRI.MethodsA total of 36 patients with suspected tumor recurrence of breast cancer based on clinical follow-up or abnormal findings in follow-up examinations (e.g. CT, MRI) were prospectively enrolled in this study. All patients underwent a PET/CT and subsequently an additional PET/MR scan. Two readers were instructed to identify the occurrence of a tumor relapse in subsequent MR and PET/MR readings, utilizing different MR sequence constellations for each session. The diagnostic confidence for the determination of a malignant or benign lesion was qualitatively rated (3-point ordinal scale) for each lesion in the different reading sessions and the lesion conspicuity (4-point ordinal scale) for the three different MR sequences was additionally evaluated.ResultsTumor recurrence was present in 25/36 (69%) patients. All three PET/MRI readings showed a significantly higher accuracy as well as higher confidence levels for the detection of recurrent breast cancer lesions when compared to MRI alone (p < 0.05). Furthermore, all three PET/MR sequence constellations showed comparable diagnostic accuracy for the identification of a breast cancer recurrence (p > 0.05), yet the highest confidence levels were obtained, when all three MR sequences were used for image interpretation. Moreover, contrast-enhanced T1-weighted VIBE imaging showed significantly higher values for the delineation of malignant and benign lesions when compared to T2 w HASTE and diffusion-weighted imaging.ConclusionIntegrated PET/MRI provides superior restaging of breast cancer patients over MRI alone. Facing the need for appropriate and efficient whole-body PET/MR protocols, our results show the feasibility of fast and morphologically adequate PET/MR protocols. However, considering an equivalent accuracy for the detection of breast cancer recurrences in the three PET/MR readings, the application of contrast-agent and the inclusion of DWI in the study protocol seems to be debatable.     

Detection and quantification of focal uptake in head and neck tumours: 18F-FDG PET/MR versus PET/CT

Purpose

Our objectives were to assess the quality of PET images and coregistered anatomic images obtained with PET/MR, to evaluate the detection of focal uptake and SUV, and to compare these findings with those of PET/CT in patients with head and neck tumours.

Methods

The study group comprised 32 consecutive patients with malignant head and neck tumours who underwent whole-body ¹⁸F-FDG PET/MR and PET/CT. PET images were reconstructed using the attenuation correction sequence for PET/MR and CT for PET/CT. Two experienced observers evaluated the anonymized data. They evaluated image and fusion quality, lesion conspicuity, anatomic location, number and size of categorized (benign versus assumed malignant) lesions with focal uptake. Region of interest (ROI) analysis was performed to determine SUVs of lesions and organs for both modalities. Statistical analysis considered data clustering due to multiple lesions per patient.

Results

PET/MR coregistration and image fusion was feasible in all patients. The analysis included 66 malignant lesions (tumours, metastatic lymph nodes and distant metastases), 136 benign lesions and 470 organ ROIs. There was no statistically significant difference between PET/MR and PET/CT regarding rating scores for image quality, fusion quality, lesion conspicuity or anatomic location, number of detected lesions and number of patients with and without malignant lesions. A high correlation was observed for SUV_mean and SUV_max measured on PET/MR and PET/CT for malignant lesions, benign lesions and organs (ρ?=?0.787 to 0.877, p?<?0.001). SUV_mean and SUV_max measured on PET/MR were significantly lower than on PET/CT for malignant tumours, metastatic neck nodes, benign lesions, bone marrow, and liver (p?<?0.05). The main factor affecting the difference between SUVs in malignant lesions was tumour size (p?<?0.01).

Conclusion

In patients with head and neck tumours, PET/MR showed equivalent performance to PET/CT in terms of qualitative results. Comparison of SUVs revealed an excellent correlation for measurements on both modalities, but underestimation of SUVs measured on PET/MR as compared to PET/CT.     

Synthesis and evaluation of 2-amino-5-(4-[18F]fluorophenyl)pent-4-ynoic acid ([18F]FPhPA): A novel 18F-labeled amino acid for oncologic PET imaging

Introduction¹⁸ F-labeled amino acids are important PET radiotracers for molecular imaging of cancer. This study describes synthesis and radiopharmacological evaluation of 2-amino-5-(4-[¹⁸ F]fluorophenyl)pent-4-ynoic acid ([¹⁸ F]FPhPA) as a novel amino acid radiotracer for oncologic imaging.Methods¹⁸ F]FPhPA was prepared using Pd-mediated Sonogashira cross-coupling reaction between 4-[¹⁸ F]fluoroiodobenzene ([¹⁸ F]FIB) and propargylglycine. The radiopharmacological profile of [¹⁸ F]FPhPA was evaluated in comparison with O-(2-[¹⁸ F]fluoroethyl)-L-tyrosine ([¹⁸ F]FET) using the murine breast cancer cell line EMT6 involving cellular uptake studies, radiotracer uptake competitive inhibition experiments and small animal PET imaging.Results¹⁸ F]FPhPA was prepared in 42 ± 10% decay-corrected radiochemical yield with high radiochemical purity >95% after semi-preparative HPLC purification. Cellular uptake of L-[¹⁸ F]FPhPA reached a maximum of 58 ± 14 % radioactivity/mg protein at 90 min. Lower uptake was observed for racemic and D-[¹⁸ F]FPhPA.Radiotracer uptake inhibition studies by synthetic and naturally occurring amino acids suggested that Na⁺-dependent system ASC, especially ASCT2, and Na⁺-independent system L are important amino acid transporters for [¹⁸ F]FPhPA uptake into EMT6 cells. Small animal PET studies demonstrated similar high tumor uptake of [¹⁸ F]FPhPA in EMT6 tumor-bearing mice compared to [¹⁸ F]FET reaching a maximum standardized uptake value (SUV) of 1.35 after 60 min p.i.. Muscle uptake of [¹⁸ F]FPhPA was higher (SUV_30min = 0.65) compared to [¹⁸ F]FET (SUV_30min = 0.40), whereas [¹⁸ F]FPhPA showed a more rapid uptake and clearance from the brain compared to [¹⁸ F]FET.ConclusionL-[¹⁸ F]FPhPA is the first ¹⁸ F-labeled amino acid prepared through Pd-mediated cross-coupling reaction.Advances in Knowledge and Implications for patient CareL-[¹⁸ F]FPhPA displayed promising properties as a novel amino acid radiotracer for molecular imaging of system ASC and system L amino acid transporters in cancer.     

Correlation of apparent diffusion coefficients measured by 3T diffusion-weighted MRI and SUV from FDG PET/CT in primary cervical cancer

Purpose  Diffusion-weighted magnetic resonance imaging (DWI) and fluorodeoxyglucose positron emission tomography/computed tomography (FDG PET/CT) are oncological feasible techniques. Currently, apparent diffusion coefficient (ADC) measured by DWI and standard uptake value (SUV) from FDG PET/CT have similar applications in clinical oncology. The aim of this study was to assess the correlation between ADC and SUV in primary cervical cancer. Materials and methods  Patients with documented primary cervical cancer were recruited. All participants underwent abdominopelvic DWI at 3T and FDG PET/CT within 2 weeks. For the primary tumor, ADC was measured as minimum ADC (ADC_min) and mean ADC (ADC_mean) within the whole tumor by DWI. Maximum SUV (SUV_max) and mean SUV (SUV_mean) were measured by FDG PET/CT. Results  A total of 33 patients were included. There was no significant correlation either between ADC_min and SUV_max or between ADC_mean and SUV_mean. The relative ADC_min (rADC_min) defined as ADC_min/ADC_mean ratio was significantly inversely correlated with the relative SUV_max (rSUV_max) defined as SUV_max/SUV_mean ratio (r = –0.526, P = 0.0017) in all study patients. A significantly inverse correlation between rADC_min and rSUV_max was observed in patients with adenocarcinoma/adenosquamous carcinoma (r = –0.685, P = 0.0012) and those with well-to-moderate differentiated tumor (r = –0.631, P = 0.0050). No significant correlation was demonstrated in patients with squamous cell carcinoma or poorly differentiated tumor. Conclusions  The significantly inverse correlation between rADC_min and rSUV_max in primary cervical tumor suggests that DWI and FDG PET/CT might play a complementary role for the clinical assessment of this cancer type.     

Adrenergic pathway activation enhances brown adipose tissue metabolism: A [18 F]FDG PET/CT study in mice

ObjectivePharmacologic approaches to study brown adipocyte activation in vivo with a potential of being translational to humans are desired. The aim of this study was to examine pre- and postsynaptic targeting of adrenergic system for enhancing brown adipose tissue (BAT) metabolism quantifiable by [¹⁸ F]fluoro-2-deoxyglucose ([¹⁸ F]FDG) positron emission tomography (PET)/computed tomography (CT) in mice.MethodsA β₃-adrenoreceptor selective agonist (CL 316243), an adenylyl cyclase enzyme activator (forskolin) and a potent blocker of presynaptic norepinephrine transporter (atomoxetine), were injected through the tail vein of Swiss Webster mice 30 minutes before intravenous (iv) administration of [¹⁸ F]FDG. The mice were placed on the PET/CT bed for 30 min PET acquisition followed by 10 min CT acquisition for attenuation correction and anatomical delineation of PET images.ResultsActivated interscapular (IBAT), cervical, periaortic and intercostal BAT were observed in 3-dimentional analysis of [¹⁸ F]FDG PET images. CL 316243 increased the total [¹⁸ F]FDG standard uptake value (SUV) of IBAT 5-fold greater compared to that in placebo-treated mice. It also increased the [¹⁸ F]FDG SUV of white adipose tissue (2.4-fold), and muscle (2.7-fold), as compared to the control. There was no significant difference in heart, brain, spleen and liver uptakes between groups. Forskolin increased [¹⁸ F]FDG SUV of IBAT 1.9-fold greater than that in placebo-treated mice. It also increased the [¹⁸ F]FDG SUV of white adipose tissue (2.2-fold) and heart (5.4-fold) compared to control. There was no significant difference in muscle, brain, spleen, and liver uptakes between groups. Atomoxetine increased [¹⁸ F]FDG SUV of IBAT 1.7-fold greater than that in placebo-treated mice. There were no significant differences in all other organs compared to placebo-treated mice except liver (1.6 fold increase). A positive correlation between SUV levels of IBAT and CT Hounsfield unit (HU) (R² = 0.55, p < 0.001) and between CT HU levels of IBAT and liver (R² = 0.69, p < 0.006) was observed.ConclusionsThe three pharmacologic approaches reported here enhanced BAT metabolism by targeting different sites in adrenergic system as measured by [¹⁸ F]FDG PET/CT.     

Optimized Bayes variational regularization prior for 3D PET images

A new prior for variational Maximum a Posteriori regularization is proposed to be used in a 3D One-Step-Late (OSL) reconstruction algorithm accounting also for the Point Spread Function (PSF) of the PET system.The new regularization prior strongly smoothes background regions, while preserving transitions. A detectability index is proposed to optimize the prior.The new algorithm has been compared with different reconstruction algorithms such as 3D-OSEM + PSF, 3D-OSEM + PSF + post-filtering and 3D-OSL with a Gauss-Total Variation (GTV) prior.The proposed regularization allows controlling noise, while maintaining good signal recovery; compared to the other algorithms it demonstrates a very good compromise between an improved quantitation and good image quality.     

Influence of region-of-interest determination on measurement of signal-to-noise ratio in liver on PET images

Objective

On ¹⁸F-fluoro-2-deoxy-d-glucose (¹⁸F-FDG) positron emission tomography (PET), signal-to-noise ratio in the liver (SNR_liver) is used as a metric to assess image quality. However, some regions-of-interest (ROIs) are used when measuring the SNR_liver. The purpose of this study is to examine the different ROIs and volumes of interest (VOIs) to obtain a reproducible SNR_liver.

Methods

This study included 108 patients who underwent ¹⁸F-FDG-PET/CT scans for the purpose of cancer screening. We examined four different ROIs and VOIs; a 3-cm-diameter and a 4-cm-diameter circular ROI and a 3-cm-diameter and a 4-cm-diameter spherical VOI on the right lobe of the patients’ livers. The average of SUV (SUV_mean), standard deviation (SD) of SUV (SUV_SD), SNR_liver and SD of the SNR_liver obtained using ROIs and VOIs were then compared.

Results

Although the SUV_mean was not different among the ROIs and VOIs, the SUV_SD was small with a 3-cm-diameter ROI. The largest SUV_SD was obtained with a 4-cm-diameter spherical VOI. The SNR_liver and the SD of the SNR_liver with a 4-cm-diameter spherical VOI were the smallest, while those with a 3-cm-diameter circular ROI were the largest. These results suggest that a small ROI may be placed on a relatively homogeneous region not representing whole liver unintentionally.

Conclusion

The SNR_liver varied according to the shape and size of ROIs or VOIs. A 4-cm-diameter spherical VOI is recommended to obtain stable and reproducible SNR_liver.

     

Association of pharmacokinetic and metabolic parameters derived using simultaneous PET/MRI: Initial findings and impact on response evaluation in breast cancer

PurposeTo study relationships among pharmacokinetic and ¹⁸F-fluorodeoxyglucose (¹⁸F-FDG) PET parameters obtained through simultaneous PET/MRI in breast cancer patients and evaluate their combined potential for response evaluation.MethodsThe study included 41 breast cancer patients for correlation study and 9 patients (pre and post therapy) for response evaluation. All patients underwent simultaneous PET/MRI with dedicated breast imaging. Pharmacokinetic parameters and PET parameters for tumor were derived using an in- house developed and vendor provided softwares respectively. Relationships between SUV and pharmacokinetic parameters and clinical as well as histopathologic parameters were evaluated using Spearman correlation analysis. Response to chemotherapy was derived as percentage reduction in size and in parameters post therapy.ResultsSignificant correlations were observed between SUVmean, max, peak, TLG with K^trans (ρ = 0.446, 0.417, 0.491, 0.430; p ≤ 0.01); with Kep(ρ = 0.303, ρ = 0.315, ρ = 0.319; p ≤ 0.05); and with iAUC(ρ = 0.401, ρ = 0.410, ρ = 0.379; p ≤ 0.05, p ≤ 0.01). The ratio of ve/iAUC showed significant negative correlation to SUVmean, max, peak and TLG (ρ = 0.420, 0.446, 0.443, 0.426; p ≤ 0.01). Ability of SUV as well as pharmacokinetic parameters to predict response to therapy matched the RECIST criteria in 9 out of 11 lesions in 9 patients. Maximum post therapy quantitative reduction was observed in SUVpeak, TLG and K^trans.ConclusionSimultaneous PET/MRI enables illustration of close interactions between glucose metabolism and pharmacokinetic parameters in breast cancer patients and potential of their simultaneity in response assessment to therapy.     

Pulmonary MRI at 3T: Non-enhanced pulmonary magnetic resonance Imaging Characterization Quotients for differentiation of infectious and malignant lesions

ObjectiveTo investigate 3T pulmonary magnetic resonance imaging (MRI) for characterization of solid pulmonary lesions in immunocompromised patients and to differentiate infectious from malignant lesions.Materials and methodsThirty-eight pulmonary lesions in 29 patients were evaluated. Seventeen patients were immunocompromised (11 infections and 6 lymphomas) and 12 served as controls (4 bacterial pneumonias, 8 solid tumors). Ten of the 15 infections were acute. Signal intensities (SI) were measured in the lesion, chest wall muscle, and subcutaneous fat. Scaled SIs as Non-enhanced Imaging Characterization Quotients ((SI_Lesion − SI_Muscle)/(SI_Fat − SI_Muscle)*100) were calculated from the T2-weighted images using the mean SI (T2-NICQ_mean) or the 90th percentile of SI (T2-NICQ_90th) of the lesion. Simple quotients were calculated by dividing the SI of the lesion by the SI of chest wall muscle (e.g. T1-Q_mean: SI_Lesion/SI_Muscle).ResultsInfectious pulmonary lesions showed a higher T2-NICQ_mean (40.1 [14.6–56.0] vs. 20.9 [2.4–30.1], p < 0.05) and T2-NICQ_90th (74.3 [43.8–91.6] vs. 38.5 [15.8–48.1], p < 0.01) than malignant lesions. T1-Q_mean was higher in malignant lesions (0.85 [0.68–0.94] vs. 0.93 [0.87–1.09], p < 0.05). Considering infections only, T2-NICQ_90th was lower when anti-infectious treatment was administered >24 h prior to MRI (81.8 [71.8–97.6] vs. 41.4 [26.6–51.1], p < 0.01). Using Youden’s index (YI), the optimal cutoff to differentiate infectious from malignant lesions was 43.1 for T2-NICQ_mean (YI = 0.42, 0.47 sensitivity, 0.95 specificity) and 55.5 for T2-NICQ_90th (YI = 0.61, 0.71 sensitivity, 0.91 specificity). Combining T2-NICQ_90th and T1-Q_mean increased diagnostic performance (YI = 0.72, 0.77 sensitivity, 0.95 specificity).ConclusionConsidering each quotient alone, T2-NICQ_90th showed the best diagnostic performance and could allow differentiation of acute infectious from malignant pulmonary lesions with high specificity. Combining T2-NICQ_90th with T1-Q_mean increased overall performance, especially regarding sensitivity.     

Harmonizing SUVs in multicentre trials when using different generation PET systems: prospective validation in non-small cell lung cancer patients

Purpose

We prospectively evaluated whether a strategy using point spread function (PSF) reconstruction for both diagnostic and quantitative analysis in non-small cell lung cancer (NSCLC) patients meets the European Association of Nuclear Medicine (EANM) guidelines for harmonization of quantitative values.

Methods

The NEMA NU-2 phantom was used to determine the optimal filter to apply to PSF-reconstructed images in order to obtain recovery coefficients (RCs) fulfilling the EANM guidelines for tumour positron emission tomography (PET) imaging (PSF_EANM). PET data of 52 consecutive NSCLC patients were reconstructed with unfiltered PSF reconstruction (PSF_allpass), PSF_EANM and with a conventional ordered subset expectation maximization (OSEM) algorithm known to meet EANM guidelines. To mimic a situation in which a patient would undergo pre- and post-therapy PET scans on different generation PET systems, standardized uptake values (SUVs) for OSEM reconstruction were compared to SUVs for PSF_EANM and PSF_allpass reconstruction.

Results

Overall, in 195 lesions, Bland-Altman analysis demonstrated that the mean ratio between PSF_EANM and OSEM data was 1.03 [95 % confidence interval (CI) 0.94–1.12] and 1.02 (95 % CI 0.90–1.14) for SUV_max and SUV_mean, respectively. No difference was noticed when analysing lesions based on their size and location or on patient body habitus and image noise. Ten patients (84 lesions) underwent two PET scans for response monitoring. Using the European Organization for Research and Treatment of Cancer (EORTC) criteria, there was an almost perfect agreement between OSEM_PET1/OSEM_PET2 (current standard) and OSEM_PET1/PSF_EANM-PET2 or PSF_EANM-PET1/OSEM_PET2 with kappa values of 0.95 (95 % CI 0.91–1.00) and 0.99 (95 % CI 0.96–1.00), respectively. The use of PSF_allpass either for pre- or post-treatment (i.e. OSEM_PET1/PSF_allpass-PET2 or PSF_allpass-PET1/OSEM_PET2) showed considerably less agreement with kappa values of 0.75 (95 % CI 0.67–0.83) and 0.86 (95 % CI 0.78–0.94), respectively.

Conclusion

Protocol-optimized images and compliance with EANM guidelines allowed for a reliable pre- and post-therapy evaluation when using different generation PET systems. These data obtained in NSCLC patients could be extrapolated to other solid tumours.     

18F-FDG PET/CT and contrast-enhanced CT findings of pulmonary cryptococcosis

PurposePulmonary cryptococcosis is an uncommon cause of pulmonary nodules in non-AIDS patients. This study reports the ¹⁸F-fluorodeoxyglucose-positron emission tomography (¹⁸F-FDG PET/CT) and contrast-enhanced CT (CE-CT) findings of 42 patients with pulmonary cryptococcosis.Materials and methodsA retrospective review of the ¹⁸F-FDG PET/CT and CE-CT findings of 42 patients with histologically proven pulmonary cryptococcosis was conducted. All patients underwent PET/CT and CE-CT in the same session. The CT diagnosis was based on the location, morphological features, and enhancement of lesions. The PET/CT findings were recorded, and clinical data and surgical and histopathological findings were collected.ResultsThe results of the PET scans revealed that 37 (88%) of 42 patients showed higher FDG uptake, and 5 (12%) patients demonstrated lower FDG uptake than the mediastinal blood pool. The maximum standardized uptake value (SUV) of pulmonary cryptococcosis ranged from 1.4 to 13.0 (average: 5.7 ± 3.3, median 4.9). A single nodular pattern was the most prevalent pattern observed and was found in 29 (69%) patients. This pattern was followed by scattered nodular (n = 4, 10%), clustered nodular (n = 3, 7%), mass-like (n = 3, 7%), and bronchopneumonic (n = 3, 7%) patterns. The most frequent pattern of immunocompetent patients was the single nodular pattern (29 of 33, 88%). Immunocompromised patients most frequently pattern exhibited mass-like (3 of 9, 33%) and bronchopneumonic (3 of 9, 33%) patterns.ConclusionPulmonary cryptococcosis most commonly appears as single nodules in immunocompetent patients. Mass-like and bronchopneumonic patterns were common in immunocompromised patients. In 88% of patients, lung lesions showed high FDG uptake, thus mimicking a possible malignant condition.     

Clinical evaluation of PET image reconstruction using a spatial resolution model

Purpose

PET image resolution is variable across the measured field-of-view and described by the point spread function (PSF). When accounting for the PSF during PET image reconstruction image resolution is improved and partial volume effects are reduced. Here, we evaluate the effect of PSF-based reconstruction on lesion quantification in routine clinical whole-body (WB) PET/CT imaging.

Materials and methods

41 oncology patients were referred for a WB-PET/CT examination (Biograph 40 TruePoint). Emission data were acquired at 2.5 min/bed at 1 h pi of 400 MBq [18F]-FDG. Attenuation-corrected PET images were reconstructed on 336 × 336-matrices using: (R1) standard AW-OSEM (4 iter, 8 subsets, 4 mm Gaussian) and (R2) AW-OSEM with PSF (3 iter, 21 subsets, 2 mm). Blinded and randomised reading of R1- and R2-PET images was performed. Individual lesions were located and counted independently on both sets of images. The relative change in PET quantification (SUV_max, SUV_mean, volume) of lesions seen on R1 and R2 is reported as (R2 − R1)/R1. Furthermore, SUV_max and SUV_mean was measured for a 3 cm spherical norm region in the right lobe of the healthy liver for R1 and R2.

Results

Clinical reading revealed 91 and 103 positive lesions for R1 and R2, respectively. For all lesions SUV_max (R2) was higher than SUV_max (R1). Regression analysis indicated that the relative increase in SUV_max (and SUV_mean) decreased with lesion size, whilst it increased with increasing radial distance from the centre of the field of view (FOV). There was no significant difference in SUV_mean in homogenous liver tissue between R1 and R2.

Conclusion

In whole-body FDG-PET/CT using routine clinical protocols, PSF-based PET reconstruction increases lesion detection and affects SUV_max measurements compared to standard AW-OSEM PET reconstruction.     

Hepatic steatosis is associated with increased hepatic FDG uptake

ObjectiveThe use of liver as a reference tissue for semi-quantification of tumour FDG uptake may not be valid in hepatic steatosis (HS). Previous studies on the relation between liver FDG uptake and HS have been contradictory probably because they ignored blood glucose (BG). Because hepatocyte and blood FDG concentrations equalize, liver FDG uptake parallels BG, which must therefore be considered when studying hepatic FDG uptake. We therefore re-examined the relation between HS and liver uptake taking BG into account.MethodsThis was a retrospective study of 304 patients undergoing routine PET/CT with imaging 60 min post-FDG. Average standard uptake value (SUV_ave), maximum SUV (SUV_max) and CT density (index of HS) were measured in a liver ROI. Blood pool SUV was based on the left ventricular cavity (SUV_LV). Correlations were assessed using least squares fitting of continuous data. Patients were also divided into BG subgroups (<4, 4–5, 5–6, 6–8, 8–10 and 10+ mmol/l).ResultsSUV_ave, SUV_max and SUV_LV displayed similar relations with BG. SUV_max/SUV_LV, but not SUV_ave/SUV_LV, correlated significantly with BG. SUV_max, but not SUV_ave, correlated inversely with CT density before and after adjusting for BG. SUV_max/SUV_ave correlated more strongly with CT density than SUV_max. CT density correlated inversely with SUV_max/SUV_LV but positively with SUV_ave/SUV_LV.ConclusionsHepatic SUV is more influenced by BG than by HS. Its relation with BG renders it unsuitable as a reference tissue. Nevertheless, hepatic fat does correlate positively with liver SUV, although this is seen only with SUV_max because SUV_ave is ‘diluted’ by hepatic fat.