PHP152 How are topics selected and prioritized by the national institute of health and care excellence (nice) and what might be the options if a technology is not selected?

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Comparison of CT ventilation imaging and hyperpolarised gas MRI: effects of breathing manoeuvre.

Image registration of lung CT images acquired at different inflation levels has been proposed as a surrogate method to map lung 'ventilation'. Prior to clinical use, it is important to understand how this technique compares with direct ventilation imaging modalities such as hyperpolarised gas MRI. However, variations in lung inflation level have been shown to affect regional ventilation distributions. Therefore, the aim of this study was to evaluate the impact of lung inflation levels when comparing CT ventilation imaging to ventilation from 3He-MRI.
 
 7 asthma patients underwent breath-hold CT at total lung capacity (TLC) and functional residual capacity (FRC). 3He-MRI and a same-breath 1H-MRI were acquired at FRC+1L and TLC. Percentage ventilated volumes (%VVs) were calculated for FRC+1L and TLC 3He-MRI. TLC-CT and registered FRC-CT were used to compute a surrogate ventilation map from voxel-wise intensity differences in Hounsfield unit values, which was thresholded at the 10th and 20th percentiles. For direct comparison of CT and 3He-MRI ventilation, FRC+1L and TLC 3He-MRI were registered to TLC-CT indirectly via the corresponding same-breath 1H-MRI data. For 3He-MRI and CT ventilation comparison, Dice similarity coefficients (DSCs) between the binary segmentations were computed.
 
 The median (range) of %VVs for FRC+1L and TLC 3He-MRI were 90.5 (54.9-93.6) and 91.8 (67.8-96.2), respectively (p=0.018). For MRI versus CT ventilation comparison, statistically significant improvements in DSCs were observed for TLC 3He MRI when compared with FRC+1L, with median (range) values of 0.93 (0.86-0.93) and 0.86 (0.68-0.92), respectively (p=0.017), for the 10-100th percentile and 0.87 (0.83-0.88) and 0.81 (0.66-0.87), respectively (p=0.027), for the 20-100th percentile.
 
 Correlation of CT ventilation imaging and hyperpolarised gas MRI is sensitive to lung inflation level. For ventilation maps derived from CT acquired at FRC and TLC, a higher correlation with gas ventilation MRI can be achieved if the MRI is acquired at TLC. &#13

Regional ventilation changes in the lung: Treatment response mapping by using hyperpolarized gas MR imaging as a quantitative biomarker

Purpose: To assess the magnitude of regional response to respiratory therapeutics in the lungs using Treatment Response Mapping (TRM) with hyperpolarized gas MRI. TRM is used to quantify regional physiological response in asthmatic adults using a bronchodilator challenge. Methods: The study was approved by the national research ethics committee and performed with informed consent. Imaging was performed in 20 adult asthmatic patients using hyperpolarized 3He ventilation MRI. Two sets of baseline images were acquired before inhalation of a bronchodilator (Inhaled Salbutamol 400 mcg) and one set was acquired after. All images were registered for voxelwise comparison. Regional treatment response, ΔR(r), is calculated as the difference in regional gas distribution (R(r) = ratio of inhaled gas to total volume of a voxel when normalized for lung inflation volume) before and after intervention. A voxelwise activation threshold from the variability of the baseline images was applied to ΔR(r) maps. The summed global TRM (ΔRnet) was then used as global lung index for comparison with metrics of bronchodilator response measured using spirometry and the global imaging metric, percentage ventilated volume (%VV). Results: ΔRnet showed significant correlation (p<0.01) with changes in FEV1 (r=0.70), FVC (r=0.84) and %VV (r=0.56). A significant (p<0.01) positive treatment effect was detected by all metrics, however ΔRnet showed a lower inter-subject coefficient of variation (CV=64%) than all of the other tests (CV≥99%). Conclusions: TRM provides regional quantitative information on changes in inhaled gas ventilation in response to therapy. This method could be used as sensitive regional outcome metric of novel respiratory interventions. Online supplemental material is available for this article

A method for quantitative analysis of regional lung ventilation using deformable image registration of CT and hybrid hyperpolarized gas/H-1 MRI

Hyperpolarized gas magnetic resonance imaging (MRI) generates highly detailed maps of lung ventilation and physiological function while CT provides corresponding anatomical and structural information. Fusion of such complementary images enables quantitative analysis of pulmonary structure-function. However, direct image registration of hyperpolarized gas MRI to CT is problematic, particularly in lungs whose boundaries are difficult to delineate due to ventilation heterogeneity. This study presents a novel indirect method of registering hyperpolarized gas MRI to CT utilizing 1H-structural MR images that are acquired in the same breath-hold as the gas MRI. The feasibility of using this technique for regional quantification of ventilation of specific pulmonary structures is demonstrated for the lobes. The direct and indirect methods of hyperpolarized gas MRI to CT image registration were compared using lung images from 15 asthma patients. Both affine and diffeomorphic image transformations were implemented. Registration accuracy was evaluated using the target registration error (TRE) of anatomical landmarks identified on 1H MRI and CT. The Wilcoxon signed-rank test was used to test statistical significance. For the affine transformation, the indirect method of image registration was significantly more accurate than the direct method (TRE = 14.7  ±  3.2 versus 19.6  ±  12.7 mm, p = 0.036). Using a deformable transformation, the indirect method was also more accurate than the direct method (TRE = 13.5  ±  3.3 versus 20.4  ±  12.8 mm, p = 0.006). Accurate image registration is critical for quantification of regional lung ventilation with hyperpolarized gas MRI within the anatomy delineated by CT. Automatic deformable image registration of hyperpolarized gas MRI to CT via same breath-hold 1H MRI is more accurate than direct registration. Potential applications include improved multi-modality image fusion, functionally weighted radiotherapy planning, and quantification of lobar ventilation in obstructive airways disease