Current generation time-of-flight 18F-FDG PET/CT provides higher SUVs for normal adrenal glands, while maintaining an accurate characterization of benign and malignant glands

OBJECTIVE: Modern PET/CT scanners have significantly improved detectors and fast time-of-flight (TOF) performance and this may improve clinical performance. The aim of this study was to analyze the impact of a current generation TOF PET/CT scanner on standardized uptake values (SUV), lesion-background contrast and characterization of the adrenal glands in patients with suspected lung cancer, in comparison with literature data and commonly used SUV cut-off levels. METHODS: We included 149 adrenal glands from 88 patients with suspected lung cancer, who underwent (18)F-FDG PET/CT. We measured the SUV(max) in the adrenal gland and compared this with liver SUV(mean) to calculate the adrenal-to-liver ratio (AL ratio). Results were compared with literature derived with older scanners, with SUV(max) values of 1.0 and 1.8 for normal glands [1, 2]. Final diagnosis was based on histological proof or follow-up imaging. We proposed cut-off values for optimal separation of benign from malignant glands. RESULTS: In 127 benign and 22 malignant adrenal glands, SUV(max) values were 2.3 ± 0.7 (mean ± SD) and 7.8 ± 3.2 respectively (p < 0.01). Corresponding AL ratios were 1.0 ± 0.3 and 3.5 ± 1.4 respectively (p < 0.01). With a SUV(max) cut-off value of 3.7, 96 % sensitivity and 96 % specificity was reached. An AL ratio cut-off value of 1.8 resulted in 91 % sensitivity and 97 % specificity. The ability of both SUV(max) and AL ratio to separate benign from malignant glands was similar (AUC 0.989 vs. 0.993, p = 0.22). CONCLUSIONS: Compared with literature based on the previous generation of PET scanners, current generation TOF (18)F-FDG PET/CT imaging provides higher SUVs for benign adrenal glands, while it maintains a highly accurate distinction between benign and malignant glands. Clinical implementation of current generation TOF PET/CT requires not only the use of higher cut-off levels but also visual adaptation by PET readers

Multicentre quantitative Ga-68 PET/CT performance harmonisation

Purpose Performance standards for quantitative F-18-FDG PET/CT studies are provided by the EANM Research Ltd. (EARL) to enable comparability of quantitative PET in multicentre studies. Yet, such specifications are not available for Ga-68. Therefore, our aim was to evaluate Ga-68-PET/CT quantification variability in a multicentre setting. Methods A survey across Dutch hospitals was performed to evaluate differences in clinical Ga-68 PET/CT study protocols. Ga-68 and F-18 phantom acquisitions were performed by 8 centres with 13 different PET/CT systems according to EARL protocol. The cylindrical phantom and NEMA image quality (IQ) phantom were used to assess image noise and to identify recovery coefficients (RCs) for quantitative analysis. Both phantoms were used to evaluate cross-calibration between the PET/CT system and local dose calibrator. Results The survey across Dutch hospitals showed a large variation in clinical Ga-68 PET/CT acquisition and reconstruction protocols. Ga-68 PET/CT image noise was below 10%. Cross-calibration was within 10% deviation, except for one system to overestimate F-18 and two systems to underestimate the Ga-68 activity concentration. RC-curves for F-18 and Ga-68 were within and on the lower limit of current EARL standards, respectively. After correction for local Ga-68/F-18 cross-calibration, mean Ga-68 performance was 5% below mean EARL performance specifications. Conclusions Ga-68 PET/CT quantification performs on the lower limits of the current EARL RC standards for F-18. Correction for local Ga-68/F-18 cross-calibration mismatch is advised, while maintaining the EARL reconstruction protocol thereby avoiding multiple EARL protocols

Optimized dose regimen for whole-body FDG-PET imaging

BACKGROUND: The European Association of Nuclear Medicine procedure guidelines for whole-body fluorodeoxyglucose positron-emission tomography (FDG-PET) scanning prescribe a dose proportional to the patient’s body mass. However, clinical practice shows degraded image quality in obese patients indicating that using an FDG dose proportional to body mass does not overcome size-related degradation of the image quality. The aim of this study was to optimize the administered FDG dose as a function of the patient’s body mass or a different patient-dependent parameter, providing whole-body FDG-PET images of a more constant quality. METHODS: Using a linear relation between administered dose and body mass, FDG-PET imaging was performed on two PET/computed tomography scanners (Biograph TruePoint and Biograph mCT, Siemens). Image quality was assessed by the signal-to-noise ratio (SNR) in the liver in 102 patients with a body mass of 46 to 130 kg. Moreover, the best correlating patient-dependent parameter was derived, and an optimized FDG dose regimen was determined. This optimized dose regimen was validated on the Biograph TruePoint system in 42 new patients. Furthermore, this relation was verified by a simulation study, in which patients with different body masses were simulated with cylindrical phantoms. RESULTS: As expected, both PET systems showed a significant decrease in SNR with increasing patient’s body mass when using a linear dosage. When image quality was fitted to the patient-dependent parameters, the fit with the patient’s body mass had the highest R(2). The optimized dose regimen was found to be A(new)= c/t × m(2), where m is the body mass, t is the acquisition time per bed position and c is a constant (depending on scanner type). Using this relation, SNR no longer varied with the patient’s body mass. This quadratic relation between dose and body mass was confirmed by the simulation study. CONCLUSION: A quadratic relation between FDG dose and the patient’s body mass is recommended. Both simulations and clinical observations confirm that image quality remains constant across patients when this quadratic dose regimen is used

Bose-Einstein correlations in W+ W- events at LEP2

Analyses of Bose-Einstein Correlations in w+w- events at LEP2 by the four LEP collaborations are presented. In particular, Bose-Einstein correlations in w+w- overlap are investigated and the possible existence of these correlations between particles coming from different W's, which may influence the W mass measurements in the fully-hadronic channel e+e- --+ w+w- --+ qiihq3ij<. No evidence for such an inter-W Bose-Einstein correlation is found by L3 and ALEPH. Possible indication of these correlations by DELPHI is mentioned

Multi-modality nuclear medicine imaging: artefacts, pitfalls and recommendations

Multi-modality imaging is rapidly becoming an essential tool in oncology. Clinically, the best example of multimodality imaging is seen in the rapid evolution of hybrid positron emission tomography (PET)/computed tomography (CT) and single positron emission computed tomography (SPECT)/CT scanners. However, use of multi-modality imaging is prone to artefacts and pitfalls. Important artefacts that may lead to clinical misinterpretation result from the use of CT data to correct for attenuation and the existence of mismatches between the fused images, for example due to respiratory movement. Furthermore, for institutions who proceed from a standalone PET to a hybrid PET-CT, there is an issue of interchangeability between these systems, especially for quantitative studies. Another issue is visualisation: hospital PACS is not sufficiently capable of adequately viewing integrated images. This article reviews and illustrates the most common artefacts and pitfalls that can be encountered in multi-modality nuclear medicine imaging. For correct management of oncological patients it is essential to be able to detect and correctly interpret these artefacts and pitfalls. Therefore, solutions and recommendations to these problems are provided

SUV variability in EARL-accredited conventional and digital PET

Background: A high SUV-reproducibility is crucial when different PET scanners are in use. We evaluated the SUV variability in whole-body FDG-PET scans of patients with suspected or proven cancer using an EARL-accredited conventional and digital PET scanner. In a head-to-head comparison we studied images of 50 patients acquired on a conventional scanner (cPET, Ingenuity TF PET/CT, Philips) and compared them with images acquired on a digital scanner (dPET, Vereos PET/CT, Philips). The PET scanning order was randomised and EARL-compatible reconstructions were applied. We measured SUVmean, SUVpeak, SUVmax and lesion diameter in up to 5 FDG-positive lesions per patient. The relative difference ΔSUV between cPET and dPET was calculated for each SUV-parameter. Furthermore, we calculated repeatability coefficients, reflecting the 95% confidence interval of ΔSUV. Results: We included 128 lesions with an average size of 19 ± 14 mm. Average ΔSUVs were 6-8% with dPET values being higher for all three SUV-parameters (p < 0.001). ΔSUVmax was significantly higher than ΔSUVmean (8% vs. 6%, p = 0.002) and than ΔSUVpeak (8% vs. 7%, p = 0.03). Repeatability coefficients across individual lesions were 27% (ΔSUVmean and ΔSUVpeak) and 33% (ΔSUVmax) (p < 0.001). Conclusions: With EARL-accredited conventional and digital PET, we found a limited SUV variability with average differences up to 8%. Furthermore, only a limited number of lesions showed a SUV difference of more than 30%. These findings indicate that EARL standardisation works. Trial registration: This prospective study was registered on the 31th of October 2017 at ClinicalTrials.cov. URL: https://clinicaltrials.gov/ct2/show/NCT03457506?id=03457506&rank=1

Minimal starting time of data reconstruction for qualitative myocardial perfusion rubidium-82 positron emission tomography imaging

Objective Qualitative positron emission tomography (PET) myocardial perfusion imaging (MPI) scans are reconstructed with a delay after an injection of rubidium-82 (82 Rb) to ensure blood pool clearance and sufficient left ventricle to myocardium contrast. Our aim was to derive the minimal starting time of data reconstruction (STDR) after an injection of 82 Rb for which the diagnostic value and image quality remained unaffected. Materials and methods We retrospectively included 23 patients who underwent rest-stress 82 Rb PET MPI using 740 MBq. Patients fulfilling one of the two criteria indicating a slow blood pool clearance (ejection fraction <50% and/or cardiac output <3 l/min) were included in a consecutive manner. PET images using five different STDRs (1:15-2:15 min) were reconstructed and compared with reference images (STDR of 2:30 min). Differences in the summed rest score greater than or equal to 3 and total perfusion deficit greater than 3% were considered to significantly influence the diagnostic value. In addition, image quality was scored by two experts as not interpretable, inferior, adequate, or excellent. Results The summed rest score differed greater than or equal to 3 from the reference in seven or more patients (≥30%) using STDR less than or equal to 2:00 min (P<0.02). STDR less than or equal to 1:30 min resulted in six or more patients (≥26%) with a total perfusion deficit difference greater than 3% (P<0.03). In addition, STDR less than or equal to 2:00 min resulted in a lower image quality (P<0.002) and STDR less than or equal to 2:15 min resulted in greater than or equal to two scans with noninterpretable image quality. Conclusion STDR less than or equal to 2:15 min resulted in lower diagnostic value or insufficient image quality for qualitative PET MPI using 740 MBq 82 Rb. An STDR of 2:30 min can be considered for clinical adoption

Performance of Digital PET Compared with High-Resolution Conventional PET in Patients with Cancer

Recently introduced PET systems using silicon photomultipliers with digital readout (dPET) have an improved timing and spatial resolution, aiming at a better image quality than conventional PET (cPET) systems. We prospectively evaluated the performance of a dPET system in patients with cancer, as compared with high-resolution (HR) cPET imaging. Methods: After a single 18F-FDG injection, 66 patients underwent dPET and cPET imaging in randomized order. We used HR reconstructions (2 × 2 × 2 mm voxels) for both scanners and determined SUVmax, SUVmean, lesion-to-background ratio (LBR), metabolic tumor volume (MTV), and lesion diameter in up to 5 18F-FDG-positive lesions per patient. Furthermore, we counted the number of visible and measurable lesions on each PET scan. Two nuclear medicine specialists determined, in a masked manner, the TNM score from both image sets in 30 patients referred for initial staging. For all 66 patients, these specialists separately evaluated image quality (4-point scale) and determined the scan preference. Results: We included 238 lesions that were visible and measurable on both PET scans. For 27 patients, we found 37 additional lesions on dPET (41%) that were unmeasurable (n = 14) or invisible (n = 23) on cPET. Mean (±SD) SUVmean, SUVmax, LBR, and MTV on cPET were 5.2 ± 3.9, 6.9 ± 5.6, 5.0 ± 3.6, and 2,991 ± 13,251 mm3, respectively. On dPET, SUVmean, SUVmax, and LBR increased by 24%, 23%, and 27%, respectively (P < 0.001) whereas MTV decreased by 13% (P < 0.001), compared with cPET. Visual analysis showed TNM upstaging with dPET in 13% of the patients (4/30). dPET images also had higher scores for quality (P = 0.003) and were visually preferred in most cases (65%). Conclusion: dPET improved the detection of small lesions, upstaged the disease, and produced images that were visually preferred to those from HR cPET. More studies are necessary to confirm the superior diagnostic performance of dPET.Keywords: digital PET; conventional PET; FDG PET; lesion detection; cancer imaging

Diagnostic value of regional myocardial flow reserve measurements using Rubidium-82 PET: Disclosures none

Purpose: Visual assessment of Rubidium (Rb-82) PET myocardial perfusion images is usually combined with global myocardial flow reserve (MFR) measurements. However, small regional blood flow deficits may go unnoticed. Our aim was to compare the diagnostic value of regional with global MFR in the detection of obstructive coronary artery disease (oCAD). Methods: We retrospectively included 1519 patients referred for rest and regadenoson-induced stress Rb-82 PET/CT without prior history of oCAD. MFR was determined globally, per vessel territory and per myocardial segment and compared using receiver-operating characteristic analysis. Vessel MFR was defined as the lowest MFR of the coronary territories and segmental MFR as the lowest MFR of the 17-segments. The primary endpoint was oCAD on invasive coronary angiography. Results: The 148 patients classified as having oCAD had a lower global MFR (median 1.9, interquartile range [1.5–2.4] vs. 2.4 [2.0–2.9]), lower vessel MFR (1.6 [1.2–2.1] vs. 2.2 [1.9–2.6]) and lower segmental MFR (1.3 [0.9–1.6] vs. 1.8 [1.5–2.2]) as compared to the non-oCAD patients (p < 0.001). The area under the curve for segmental MFR (0.81) was larger (p ≤ 0.005) than of global MFR (0.74) and vessel MFR (0.78). Conclusions: The use of regional MFR instead of global MFR is recommended as it improves the diagnostic value of Rb-82 PET in the detection of oCAD

Technical note: how to determine the FDG activity for tumour PET imaging that satisfies European guidelines

Background: For tumour imaging with PET, the literature proposes to administer a patient-specific FDG activity that depends quadratically on a patient’s body weight. However, a practical approach on how to implement such a protocol in clinical practice is currently lacking. We aimed to provide a practical method to determine a FDG activity formula for whole-body PET examinations that satisfies both the EANM guidelines and this quadratic relation. Results: We have developed a methodology that results in a formula describing the patient-specific FDG activity to administer. A PET study using the NEMA NU-2001 image quality phantom forms the basis of our method. This phantom needs to be filled with 2.0 and 20.0 kBq FDG/mL in the background and spheres, respectively. After a PET acquisition of 10 min, a reconstruction has to be performed that results in sphere recovery coefficients (RCs) that are within the specifications as defined by the EANM Research Ltd (EARL). By performing reconstructions based on shorter scan durations, the minimal scan time per bed position (Tmin) needs to be extracted using an image coefficient of variation (COV) of 15 %. At Tmin, the RCs should be within EARL specifications as well. Finally, the FDG activity (in MBq) to administer can be described by A ¼ c ⋅w2⋅ Tmin t with c a constant that is typically 0.0533 (MBq/kg2), w the patient’s body weight (in kg), and t the scan time per bed position that is chosen in a clinical setting (in seconds). We successfully demonstrated this methodology using a state-of-the-art PET/CT scanner. Conclusions: We provide a practical method that results in a formula describing the FDG activity to administer to individual patients for whole-body PET examinations, taking into account both the EANM guidelines and a quadratic relation between FDG activity and patient’s body weight. This formula is generally applicable to any PET system, using a specified image reconstruction and scan time per bed position