Ralph Bundschuh

Tissue Classification as a Potential Approach for Attenuation Correction in Whole-Body PET/MRI: Evaluation with PET/CT Data

Attenuation correction (AC) of whole-body PET data in combined PET/MRI tomographs is expected to be a technical challenge. In this study, a potential solution based on a segmented attenuation map is proposed and evaluated in clinical PET/CT cases. Methods: Segmentation of the attenuation map into 4 classes (background, lungs, fat, and soft tissue) was hypothesized to be sufficient for AC purposes. The segmentation was applied to CT-based attenuation maps from 18F-FDG PET/CT oncologic examinations of 35 patients with 52 18F-FDG–avid lesions in the lungs (n = 15), bones (n = 21), and neck (n = 16). The standardized uptake values (SUVs) of the lesions were determined from PET images reconstructed with nonsegmented and segmented attenuation maps, and an experienced observer interpreted both PET images with no knowledge of the attenuation map status. The feasibility of the method was also evaluated with 2 patients who underwent both PET/CT and MRI. Results: The use of a segmented attenuation map resulted in average SUV changes of 8% ± 3% (mean ± SD) for bone lesions, 4% ± 2% for neck lesions, and 2% ± 3% for lung lesions. The largest SUV change was 13.1%, for a lesion in the pelvic bone. There were no differences in the clinical interpretations made by the experienced observer with both types of attenuation maps. Conclusion: A segmented attenuation map with 4 classes derived from CT data had only a small effect on the SUVs of 18F-FDG–avid lesions and did not change the interpretation for any patient. This approach appears to be practical and valid for MRI-based AC.

Evaluation of the attenuation properties of MR equipment for its use in a whole-body PET/MR scanner

The combination of magnetic resonance imaging (MR) and positron emission tomography (PET) scanners can provide a powerful tool for clinical diagnosis and investigation. Among the challenges of developing a combined scanner, obtaining attenuation maps for PET reconstruction is of critical importance. This requires accounting for the presence of MR hardware in the field of view. The attenuation introduced by this hardware cannot be obtained from MR data. We propose the creation of attenuation models of MR hardware, to be registered into the MR-based attenuation map prior to PET reconstruction. Two steps were followed to assess the viability of this method. First, transmission and emission measurements were performed on MR components (RF coils and medical probes). The severity of the artifacts in the reconstructed PET images was evaluated. Secondly, a high-exposure computed tomography (CT) scan was used to obtain a model of a head coil. This model was registered into the attenuation map of PET/CT scans of a uniform phantom fitted with the coil. The resulting PET images were compared to the PET/CT reconstruction in the absence of coils. The artifacts introduced by misregistration of the model were studied. The transmission scans revealed 17% count loss due to the presence of head and neck coils in the field of view. Important sources of attenuation were found in the lock, signal cables and connectors. However, the worst source of attenuation was the casing between both coils. None of the measured medical probes introduced a significant amount of attenuation. Concerning the attenuation model of the head coil, reconstructed PET images with model-based correction were comparable to the reference PET/CT reconstruction. However, inaccuracies greater than 1-2 mm in the axial positioning of the model led to important artifacts. In conclusion, the results show that model-based attenuation correction is possible. Using a high-exposure scan to create an attenuation model of the coils has been proved feasible. However, adequate registration of the model is mandatory.

The effect of limited MR field of view in MR/PET attenuation correction

PURPOSE A critical question in the development of combined MR/PET scanners is whether MR can provide the tissue attenuation data required for PET reconstruction. Unfortunately, MR images are often unable to encompass the entire patient. The resulting truncation in the transverse plane leads to incomplete attenuation maps, causing artifacts in the reconstructed PET image. This article describes the experiments performed to quantify these artifacts. A method to compensate the missing data was evaluated to determine whether software correction is possible or whether additional transmission hardware has to be included in the scanner. METHODS Three studies were made. First, simulated PET data were used to quantify the bias due to an incomplete attenuation map. A set of spherical lesions was simulated in the lungs and mediastinum of a patient. The data were reconstructed with complete and partial attenuation maps and the uptake differences were evaluated. Second, clinical data from PET/CT oncology patients were used. To reproduce the expected conditions in an MR/PET scanner, only patients scanned with the arms resting along the body were considered. These scans were then used to create maps of the reconstruction bias due to field of view (FOV) limitations. Lastly, a PET reconstruction with incomplete attenuation data was evaluated as a means to obtain attenuation information beyond the MR FOV. The patient outline was automatically segmented with a three-dimensional snake algorithm and used to fill the truncated data in the attenuation map. RESULTS Average bias up to 15% and local biases up to 50% were estimated when PET data were reconstructed with incomplete attenuation information. Completing the attenuation map with data extracted from a PET prereconstruction globally reduced these biases to below 10%. This correction proved to be tolerant to inaccuracies in positioning and attenuation values. However, local artifacts up to 20% could still be found near the edges of the MR FOV. CONCLUSIONS MR FOV restrictions can indeed make the reconstructed PET data unacceptable for diagnostic purposes. Biases can be globally compensated by automatic preprocessing of the attenuation map. However, inaccuracies in the correction will result in small artifacts near the periphery of the image that could lead to false-positive findings.

The sensitivity of [11C]choline PET/CT to localize prostate cancer depends on the tumor configuration.

Purpose: To evaluate the dependency of the sensitivity of [11C]choline positron emission tomography/computed tomography (PET/CT) for detecting and localizing primary prostate cancer (PCa) on tumor configuration in the histologic specimen. Experimental Design: Forty-three patients with biopsy-proven PCa were included. They underwent radical prostatectomy within 31 days after [11C]choline PET/CT. The transaxial image slices and the histologic specimens were analyzed by comparing the respective slices. Maximum standardized uptake values (SUVmax) were calculated in each segment and correlated with histopathology. The tumor configuration in the histologic specimen was grouped as: I, unifocal; II, multifocal; III, rind-like shaped; IV, size <5 mm. Data analysis included the investigation of detection of PCa by SUVmax, the assessment of the influence of potential contributing factors on tumor prediction, and the evaluation of whether SUV could discriminate cancer tissue from benign prostate hyperplasia (BPH), prostatitis, HGPIN (high-grade prostate intraepithelial neoplasm), or normal prostate tissue. General estimation equation models were used for statistical analysis. Results: Tumor configuration in histology was classified as I in 21 patients, as II in 9, as III in 5, and as IV in 8. The prostate segment involved by cancer is identified in 79% of the patients. SUVmax was located in the same side of the prostate in 95% of patients. Tumor configuration was the only factor significantly negatively influencing tumor prediction (P < 0.001). PCa-SUVmax (median SUVmax = 4.9) was not significantly different from BPH-SUV (median SUVmax = 4.5) and prostatitis-SUV (median SUVmax = 3.9), P = 0.102 and P = 0.054, respectively. Conclusions: The detection and localization of PCa in the prostate with [11C]choline PET/CT is impaired by tumor configuration. Additionally, in our patient population, PCa tissue could not be distinguished from benign pathologies in the prostate. Clin Cancer Res; 17(11); 3751–9. ©2011 AACR.

Postacquisition Detection of Tumor Motion in the Lung and Upper Abdomen Using List-Mode PET Data: A Feasibility Study

One of the main degrading factors in the quality of oncologic PET images of the thorax and upper abdomen is respiratory motion of tumors. One method to reduce this effect is the acquisition of PET data in gated mode. A second method is the correction of studies for motion. Motion registration is essential in both cases. We report a method using list-mode data to detect the craniocaudal (z) movement of thoracic and abdominal lesions without using any external gating device. The aim of this study was to show the feasibility of applying this method to patient data. Methods: For 10 patients with lesions in the lung or upper abdominal organs, images for short time bins of 250, 500, and 750 ms were reconstructed. A volume of interest, which was manually defined in a summed image around the structure of interest, was projected to each time bin. The center of mass of the activity distribution in this volume of interest was determined for each case. The curves of the z-coordinate of the center of mass (zCOM) over the time were analyzed and compared with respiration curves obtained by a pressure-sensitive belt. Results: In 7 of the 10 patients, movement of the lesion was registered in good accordance with the pressure belt. In the 3 remaining patients, no changes in the center of mass due to respiration could be detected, most likely because of minimal respiratory motion. The maximal difference in zCOM for a lesion that was detected within the 10-min acquisition was 18.5 mm. For 7 of the 10 patients, the mean value for each respiration amplitude was between 11.0 and 2.0 mm. Conclusion: We have shown the feasibility of registering movement of high-uptake lesions without the use of any external device that may restrain the patient. Furthermore, unlike external sensors, this method quantifies internal motion and, thus, is a promising base for correction methods.

Textural Parameters of Tumor Heterogeneity in 18F-FDG PET/CT for Therapy Response Assessment and Prognosis in Patients with Locally Advanced Rectal Cancer

18F-FDG PET/CT is effective in the assessment of therapy response. Changes in glucose uptake or tumor size are used as a measure. Tumor heterogeneity was found to be a promising predictive and prognostic factor. We investigated textural parameters for their predictive and prognostic capability in patients with rectal cancer using histopathology as the gold standard. In addition, a comparison to clinical outcome was performed. Methods: Twenty-seven patients with rectal cancer underwent 18F-FDG PET/CT before, 2 wk after the start, and 4 wk after the completion of neoadjuvant chemoradiotherapy. In all PET/CT scans, conventional parameters (tumor volume, diameter, maximum and mean standardized uptake values, and total lesion glycolysis [TLG]) and textural parameters (coefficient of variation [COV], skewness, and kurtosis) were determined to assess tumor heterogeneity. Values on pretherapeutic PET/CT as well as changes early in the course of therapy and after therapy were compared with histopathologic response. In addition, the prognostic value was assessed by correlation with time to progression and survival time. Results: The COV showed a statistically significant capability to assess histopathologic response early in therapy (sensitivity, 68%; specificity, 88%) and after therapy (79% and 88%, respectively). Thereby, the COV had a higher area under the curve in receiver-operating-characteristic analysis than did any analyzed conventional parameter for early and late response assessment. The COV showed a statistically significant capability to evaluate disease progression and to predict survival, although the latter was not statistically significant. Conclusion: Tumor heterogeneity assessed by the COV, being superior to the investigated conventional parameters, is an important predictive factor in patients with rectal cancer. Furthermore, it can provide prognostic information. Therefore, its application is an important step for personalized treatment of rectal cancer.

Imaging of Acute and Chronic Aortic Dissection by 18F-FDG PET/CT

By conventional imaging modalities, the discrimination between acute and chronic aortic dissection (AD) for surgical risk evaluation is not possible. However, acute and chronic stable AD potentially may be distinguished by detection of reparatory hypermetabolism in the lacerated aortic wall of acute AD using 18F-FDG PET/CT. In this study, we analyzed the 18F-FDG uptake in the aortic wall of acute and chronic stable AD. Methods: Eighteen patients with acute (n = 9), symptomatic progressive (n = 2), or known chronic stable (n = 7) type B AD underwent 18F-FDG PET/CT. Images were analyzed qualitatively and quantitatively considering 18F-FDG uptake patterns and the standardized uptake values (SUVs) of the aortic wall, dissection membrane, and luminal 18F-FDG activity. The SUV ratio (maximum SUV in the aorta divided by mean SUV in the blood pool) was calculated to relativize individual luminal 18F-FDG spillover effects. Results: In contrast to chronic stable AD, all acute or acute progressive AD showed accentuated 18F-FDG uptake at the injured aortic wall or dissection membrane. The maximum SUV of the dissection membrane or aortic wall was significantly higher (P = 0.02) in acute AD than in chronic stable AD. Thereby, SUV varied from 3.03 to 4.64 (average maximum SUV, 3.84 ± 0.51) for the dissection membrane and from 2.22 to 4.60 (average maximum SUV, 2.94 ± 0.81) for the aortic wall, with false-negative and false-positive outliers. The discrimination between acute and stable AD was improved significantly (P < 0.001), and false-positive or -negative outliers were eliminated, using the SUV ratio method. Conclusion: Our results indicate that 18F-FDG PET/CT might be useful in differentiation of acute from chronic AD in clinically unclear cases. However, larger studies are needed to confirm our preliminary results.

Respiratory Gated PET Derived in a Fully Automated Manner From Raw PET Data

Respiratory motion in PET degrades image quality and limits detectability of small or low-contrast lesions. Although image quality can be improved using respiratory-gating, this adds to the complexity and expense of acquiring PET data. We aimed to develop a data-driven method, based on individual voxel signal fluctuations, for accomplishing electronic respiratory gating of clinical PET data, requiring no additional hardware or end-user input. We tested our methods using both simulated PET scans and actual human PET acquisitions. For the simulations, our methods correctly identified the start frame of each respiratory cycle defined for the phantom. Resultant gated images demonstrated improved effective resolution and increased measured uptake for lesions located in the thorax. For human PET data, we were able to recover respiratory phase information with a high signal-to-noise ratio. We report here a method to achieve fully automated voxel-based respiratory gating of PET images, without the need for gating hardware or additional user input, capable of improving effective resolution and increasing lesion detectability.

Monitoring response to therapeutic interventions in patients with cancer.

Positron emission tomography (PET) and PET/computed tomography (CT) with the glucose analog (18)F-fluorodeoxyglucose (FDG) are increasingly used to assess response to therapy in patients, and there is converging evidence that changes in glucose utilization during therapy can be used to predict clinical outcome. Today, integrated PET/CT systems have mainly replaced stand-alone PET devices, providing the opportunity to integrate morphologic information and functional information. However, the use of PET/CT systems also gives rise to methodological challenges for the quantitative analysis of PET scans for treatment monitoring. Recently published single-center studies demonstrate that FDG-PET and FDG-PET/CT have been successfully used for monitoring of tumor response to cytotoxic therapy in a variety of tumor entities. The potential early identification of nonresponding tumors provides an opportunity to alter treatment regimens according to the individual chemosensitivity of the tumor tissue. In this article, we review the methodological background to monitoring of cancer treatment with PET/CT, the diagnostic and prognostic performance of PET/CT for predicting tumor response with the glucose analog FDG in various tumor entities, and the clinical potential of new imaging probes. In addition, the future direction of research and clinical applications is discussed.

Somatostatin receptor based PET/CT in patients with the suspicion of cardiac sarcoidosis: an initial comparison to cardiac MRI.

Diagnosis of cardiac sarcoidosis is often challenging. Whereas cardiac magnetic resonance imaging (CMR) and positron emission tomography/computed tomography (PET/CT) with 18F-fluorodeoxyglucose (FDG) are most commonly used to evaluate patients, PET/CT using radiolabeled somatostatin receptor (SSTR) ligands for visualization of inflammation might represent a more specific alternative. This study aimed to investigate the feasibility of SSTR–PET/CT for detecting cardiac sarcoidosis in comparison to CMR. 15 patients (6 males, 9 females) with sarcoidosis and suspicion on cardiac involvement underwent SSTR-PET/CT imaging and CMR. Images were visually scored. The AHA 17-segment model of the left myocardium was used for localization and comparison of inflamed myocardium for both imaging modalities. In semi-quantitative analysis, mean (SUVmean) and maximum standardized uptake values (SUVmax) of affected myocardium were calculated and compared with both remote myocardium and left ventricular (LV) cavity. SSTR-PET was positive in 7/15, CMR in 10/15 patients. Of the 3 CMR+/PET− subjects, one patient with minor involvement (<25% of wall thickness in CMR) was missed by PET. The remaining two CMR+/PET− patients displayed no adverse cardiac events during follow-up. In the 17-segment model, PET/CT yielded 27 and CMR 29 positive segments. Overall concordance of the 2 modalities was 96.1% (245/255 segments analyzed). SUVmean and SUVmax in inflamed areas were 2.0±1.2 and 2.6±1.2, respectively. The lesion-to-remote myocardium and lesion-to-LV cavity ratios were 1.8±0.2 and 1.9±0.2 for SUVmean and 2.0±0.3 and 1.7±0.3 for SUVmax, respectively. Detection of cardiac sarcoidosis by SSTR-PET/CT is feasible. Our data warrant further analysis in larger prospective series.