Introduction To PET/CT: Jon A. Anderson

Introduction to PET/CT
Jon A. Anderson
Department of Radiology
The University of Texas Southwestern Medical Center at Dallas
CRCPD Winter 2004 Meeting

J. A. Anderson 2/18/04
Acknowledgements
• Tammy Pritchett, RT, CNMT (UTSW)
• Michael Viguet, CNMT, (UTSW)
• Dana Mathews, MD (UTSW)
• Thomas Lane, PhD (UTSW)
• Jonathan Frey (Siemens)
• Jim McCann (Siemens)
• James Bland (CPS)
• Charles Watson (CPS)
• Alex Ganin, PhD (General Electric)
• Jeff Simer (General Electric)
• Ken Halliday (CTI)
• Johann Fernando, PhD (Philips)
PET Fundamentals: Ideal Case
Annihilation
Positron-emitting Event
Nucleus
γ2
Detector Ring e+
γ1
Two Events ( ) in Detector

at the Same Time* Define
Line of Response (LOR)
*Same Time = within 6-12 ns (typ)
Used in Reconstruction
How is the Data Arranged?
Sinogram
Angle (θ)
θ
Position (t)
Count on an LOR gets mapped to corresponding place in sinogram
PET Fundamentals: Real Case
RANDOMS
with false
γ2
LOR γ2
suppress
with small
coincidence
γ1 time and
collimation γ1
TRUES
with correct
LOR SCATTERS
γ2
γ1 ’ with misplaced
scatter
γ1 LOR
LOR = line of response suppress with energy
resolution and collimation
What Influences These
Contributions?
Trues
↑ as radio-nuclide concentration ↑ (the good stuff)
↓ as patient size ↑ (absorption and scatter effects)
Randoms
↑↑ as count rate ↑ (varies as square of count rate)
Effects dominate image noise at high injected activities
Reduce by faster electronics, faster crystals
Scatters
↓ with collimation
(about 15% for 2D PET and 50% for 3D PET)
Reduce with collimation
(energy selection not efficient in PET)
2D and 3D Flavors of PET (Similar
to single-row vs multi-detector CT)
2D 3D
collimators
2D
Sensitivity
3D - Collimators, restricted - No collimators, larger span

span between rings between rings
- Lower sensitivity, - Higher sensitivity, higher
reduced scatter scatter; ‘missing’ projections
Plane and nonuniform sensitivity
Corrections for Quantitative
Studies (All PET is Quantitative*)
Raw Sinogram Data (T +S+ R)
(*but how
Remove Randoms quantitative
depends on
Normalize Detector Responses
how hard you
Correct for Deadtime want to work)
Correct for Scatter

It’s not exactly like
this, and it’s not Correct for Attenuation
necessarily as linear as
this! T Sinogram
Ready for Reconstruction
Attenuation Correction Factors (ACFs)
Big issue for PET/CT The probability of
both annihilation
photons reaching the
γ1 detector ring depends
γ2 on the attenuation
along the total path
length (s1 + s2) of the
LOR inside the body.
s1
s2
ACF is inverse of this
probability. Multiply
PET/CT Note: measuring the photon activity in a LOR by ACF
attenuation along a line in the body is
exactly what a CT scanner does!
to get correct value.
small prob →large ACF
How Big is the Attenuation
Correction Factor (ACF)?
Attenuation Correction Factor in Soft Tissue d = 23 cm
140
→ ACF ≈ 9
120
Attenuation Correction Factor
100
80
60
40
20 d = 35 cm
0 → ACF ≈ 28
0 10 20 30 40 50 60
Path Length [cm]
One Last Concept: Specific
Uptake Value
Measured Activity Concentration [Bq/ml]
SUV =
Injected Activity (Bq)
Pt. Mass/ (1 g/ml)
concentration if activity
uniformly distributed in
the body
SUV is used as an index to determine if a hotspot is significant
Its use depends on
STANDARDIZED UPTAKE TIMES
CALIBRATED SCANNER
J. A. Anderson 2/18/04 NO ARTIFACTS THAT CHANGE COUNTS
PET and PET/CT Imaging
- uses rotating isotopic sources for
acquiring transmission image
- 70 % E/30% T time split
- typically, 15 cm axial FOV
- 2D or 3D acquisitions
- newer crystals allow lower noise,
shorter acquisition times
Conventional PET
- uses coupled x-ray CT scanner

to acquire transmission image
for attenuation correction
- provides auto registration of
anatomic CT and functional PET
- faster scans through reduced
transmission image time PET/CT
In A Sense, We Have Had PET/CT
For A Long Time, but ….
Attenuation (and possibly scatter)
corrections for PET require an
attenuation map (µ-map, AKA CT
image) at 511 keV
- measured transmission of 511
or 662 keV photons from
isotopic sources.
- obtained sequentially to
emission scan
- acquired on same time scale PET µ-map images are CT scans that
(requires about 1/3 of - are made at 511 keV
- have low spatial resolution
total imaging time, say 3 - visualize bone, tissue, and contrast
out of 8 minutes in scan) differently than x-ray CT
Why Are We Excited About
PET/CT with X-rays?
• Use of x-ray CT and PET in the same scanner
to obtain detailed anatomical and functional
images yields
– “automatic” and reliable co-registration of
images,
– reduced acquisition time for PET study,
– lower noise in the attenuation correction
– “knock your socks off” images that referring
physicians can readily appreciate and use.
PET Alone
Pneumonia, based on Where is it?

CT findings Lung, bone, mediastinum?
PET/CT
Esophageal CA
constricting the esophagus
Current Implementations
CPS
(marketed by CTI and Siemens)
Reveal RT/Reveal XVI
Biograph LSO/Biograph Sensation 16
GE
Discovery LS
Discovery ST
apologies to any vendor

that was inadvertently
omitted! Philips GEMINI
Available Technology
Manufacturer Product CT PET Detectors

CPS Reveal Siemens ACCEL LSO
Somatom (up to 16
(CTI and slices)
Siemens) Biograph
GE Discovery LS GE Lightspeed Advance NXI BGO

(4, 8, 16 slice)
Discovery ST Discovery ST
Philips GEMINI Philips MX8000 Allegro GSO

(2 slice)
PET Detector Crystal Performance
Compared to NaI(Tl)
Detector Performance
160% Decay Time

140%
Comparison to
Attenuation Length
120%
* Light Output
NaI(Tl)
100%
80% Energy Resolution
60% *
40% * = a winner
20% *
0% *
BGO LSO GSO
Detector Material
Decay Time, Attenuation Length, and Energy Resolution: Less is Better

Light Output: More is Better
Typical Configuration and
Performance for PET, PET/CT
# of Crystals 9000 - 18,000
Axial Field of View 15-18 cm
Transverse Field of View 55-70 cm
# Image Planes in FOV 35-90
Spatial Resolution 5-7 mm (worse in clinical
practice)
Issues Specific to PET/CT
• Proper mapping of attenuation coefficients
from 70 keV to 511 keV
• Recognition of PET artifacts due to
– Attenuation correction model failures
– Patient motion
– CT artifacts
– CT truncation (mismatch between PET,CT
FOV
• QA and test procedures
Converting µ70keV →µ511keV
Mass Attenuation Coefficients for Principal Tissue Types
10.00
Soft Tissue Total
Soft Tissue PE
Adipose Tissue Total
Adipose Tissue PE
1.00 CT Energy
70 keV Bone Total
µ/ρ [cm /g]
Bone PE
2
PET Energy
511 keV
0.10
Photoelectric
Component
Compton Component Accounts
of Attenuation
for Almost All of Attenuation
Coefficient
Coefficient
0.01
10 100 1000
Energy [keV]
Conclusions Regarding the
Relation of µ70keV to µ511keV
1) The attenuation coefficient at 511 keV can
be obtained from that at 70 keV by simple
multiplication by a constant, independent
of tissue type, for all tissues having
attenuation dominated by Compton scatter
at CT energies (≈ 70 keV).
2) For materials having substantial 70 keV

contribution from photoelectric absorption,
the scaling factor will be dependent on the
nature of the material.
Initial Scheme for Converting
µ70keV →µ511keV
1) Adjust resolution in CT to agree
with resolution of PET
2) Convert CT numbers to µ70 keV,
µ = ((CT/1000)+1)*µH2O,70 keV
3) Scale all µ values corresponding to
CT values below ≈ 200 − 300 by a
factor of µH2O,511 keV/µH2O,70 keV
CT + 1024
4) Scale all µ values corresponding to
CT values above ≈ 200 − 300 by a Histogram of CT image, showing
factor of µbone,511 keV/µbone,70 keV separation of tissue types [Kinahan
et al.]
Used in Siemens/CTI Scanners

“hybrid segmentation”
Kinahan et al.,Med Phys 25, 2046-2053 (1998)
Comparison of Attenuation
Correction Methods
0.20
Exact forms depend
0.18 Hybrid Segmentation Approach on choice of
Mixture Approach parameters; for this
Attenuation Coefficient at 511 keV
0.16
plot
0.14
0.12 Hybrid
Segmentation
0.10 threshold=200 HU
0.08
PET/CT<200 = 0.5
PET/CT>200 = 0.41
0.06
Mixture
0.04
threshold = 0 HU
0.02 µH2O,80 keV = 0.184 cm-1
µbone,80 keV = 0.428 cm-1
0.00 µH2O,511 = 0.096 cm-1
-1000 -500 0 500 1000 µbone,511 keV = 0.172 cm-1
CT Number (HU)
Principal Artifacts Specific to
PET/CT
• Artifacts due to fundamental failure of the
attenuation correction model
• Artifacts due to patient motion between the
CT and PET scans
• Truncation artifacts due to patient extending
outside the CT field of view
Failure of the Attenuation
Correction Model
• There is no perfect way to tell from CT number
what material we’ve got or how much, but
only what the total attenuation is at CT energies
• Materials not in the model (metal, iodine, barium)
can scale differently (CT → PET) and give the
wrong attenuation correction
• Incorrect PET attenuation values →
wrong corrections →
incorrect activities, too high or too low
The size of the ACF (factors of 20, 50, more) means an error
here can cause a big artifact!
The Origin of Contrast and Metal
Artifacts in PET/CT
Mass Attenuation Coefficients for Tissue and Contrast Materials
10.00
CT Energy Soft Tissue
70 keV Bone
Barium Sulfate
Sodium Iodide
1.00
µ/ρ [cm /g]
2
PET Energy
511 keV
0.10
The mass attenuation coefficients for contrast materials

are significantly larger than those for tissues (including
bone) due to the large photoelectric component; the
scaling to 511 keV is different and the attenuation
correction will be overestimated!
0.01
10 100 1000
Energy [keV]
Artifacts from Oral Contrast
CT AC
Non-
AC
Bolus of contrast in bowel

generates apparent area of Non-attenuation-
high uptake on attenuation- corrected image
corrected image reveals little
contrast wrt
surrounding tissues
Artifacts from Hardware:
Mediports
AC AC w PET Non-
AC
Hot spot on PET Correlates to Mediport No anomalous

placement uptake in non-
attenuation corrected
image
Artifacts from Metal: Orthopedic
Hardware
Intense activity shown on
PET/CT (SUV = 6) is associated
with metallic hardware having
CT# > 3000HU
Artifacts from Metal: Orthopedic
Hardware, continued
Attenuation Corrected PET Non-attenuation Corrected PET
Note: Non-attenuation-corrected image has typical bright rim
Artifacts from Patient Motion
Artifacts arise because the CT and PET scans are taken

- at different times (i.e. sequentially)
- on different time scales (seconds for CT, minutes for PET)
Voluntary movements: Patient shifts position between CT scan

and PET scan; principally movements of head and arms
Involuntary movements: CT catches snapshot of patient

position, but PET averages over minutes
- CT is not normally done with breath hold (contrary to
normal CT practice), but with shallow breathing
- PET artifact not seen on conventional PET because both
emission and transmission averaged over similar periods
Breathing Artifact
Breathing during
helical CT
acquisition can lead
to “floating liver”
artifact (variously
called banana or
mushroom artifact)
which can then be
reflected in PET
scan.
Truncation Artifacts
Arise when objects extend outside the field
of view of the CT, but are in the PET field of
view
Rim artifact due CT FOV
to out-of-field
object on CT
will generate rim
artifact on PET;
no attenuation
correction for
out-of-field
PET FOV
anatomy.
Quality Assurance Program:
• QA for PET --
– Daily check per mfg with line or volume source to assure
that system performance is not drifting
– Calibration check to assure proper SUV reports
– Periodic Physics check per standard PET practice
• QA for CT --
– Daily air cals and image quality check per mfg
– Period Physics check per standard CT practice
• Registration check -- check for proper registration of
PET and CT images on periodic basis
Examples: QA Procedures
CPS (Siemens-CTI):
Obtained with volume
phantom (1.5 mCi
68Ge); summary report
presented and logged;
sinogram viewer for
details.
GE: Obtained with rotating line source in

gantry. Report generated with fan-sum
views and comparisons to previous trends.
Gantry Offset Correction/Check:
Phantom Geometry
Registration Test
CT FUSION PET
In our case, Siemens/CT Gantry Offset Procedure could be used to

numerically evaluate x (horizontal) y(vertical) and z(axial)
registration without modifying machine calibration. Results can
also be evaluated visually or with other programs
Stability of Registration: An
Example The reproducibility of the
acquisition process was
Registration Stability better than σ = 0.1 mm
(registration repeated
1 without removing the
dual line phantom)
0.5
0 The reproducibility of the

registration procedure
Correction [mm]
-0.5
(multiple replacement of
-1 Z-900 mm the phantom) was better
than σ = 0.4 mm.
-1.5 X
-2 Y The stability of the
system over the first 45
-2.5
days was characterized by
-3 σ = 0.5 mm or better for
2/23 3/5 3/15 3/25 4/4 4/14 4/24 all 3 axes.
Date
J. A. Anderson 2/18/04 note: not errors, but correction factors!

Examples of PET Testing Tools
Provided for PET/CT Machines
• CPS (Siemens, CTI)
– Uniformity and Sensitivity test software shipped with
machine, based on volume 68Ge source used for daily
QC
• GE
– Will provide physicist with testing software (NEMA
NU-2 2001)
• Philips
– Will ship NEMA NU-2 2001 software with machine
What Tests are Important?
(You may get different answers from different folks!)
NEMA NU-2 1994 NEMA NU-2 2001
Spatial resolution (xverse,axial) Spatial resolution
Scatter fraction Scatter fraction, count losses, randoms
Sensitivity Sensitivity
Deadtime,count-rate losses {now part of scatter fraction}
Uniformity Uniformity
Scatter correction accuracy {now part of image quality test}
Count-rate correction accuracy Count rate correction accuracy
Attenuation correction accuracy {now part of image quality test}
Image quality (scatter, AC accuracy)
94 Scatter fraction test
94 Count rate tests
These tests were developed to compare classes of machines rather than to
provide practical acceptance test or QA procedures. NU2-94 may be more
appropriate for brain scanners and NU2-01 for WB oncology scans.
Workflow at the PET Center
(FDG Whole Body Scans)
Arrival of patient Receive doses
Pt instruction and prep Injection of Pt

* Assay of dose
30-60 min Uptake of pharmaceutical
Have Pt empty bladder
Transport Pt to scanner *
10 min Position Pt *
* steps with highest
5-30 min Scan technologist exposure
Release Pt QA Check of Scan
Read study
Print for file and referring; distribute to PACS

What Are the Differences from
Conventional Nuclear Medicine?
1) Requirements for patient handling during
injection and uptake phase
2) 511 keV energy

increases exposure rate from doses, patients
greatly increases thickness of shielding,
if required (hence, use time and distance
when possible)
3) Combined modality scanners (PET/CT) require

consideration of both gamma-ray and x-ray hazard
Workload Estimation
PET Facility Throughput Example:
1 Hour Uptake, 30 Minute Scan
15
Patient Number
13
11
9
7 Phase
5 Uptake
3
Scanning
8:00 9:00 10:00 11:00 12:00 13:00 14:00 15:00 16:00 17:00
Time of Day
#pts/day = (Twork - Tuptake)/Tscan_rm # uptake rooms = Tuptake/Tscan_rm

Hot Lab Details: Dose Storage
Area
Notes:
1) Floor
protection
(containers
weigh 66 lbs)
2) Space needed
depends on how
often deliveries
are made; may
have >100 mCi
here at a time,
even for one
scanner
3) Extra
shielding may
be required
Hot Lab Details: Dose Assay
and Preparation Area Notes:
1) Calibrator
convenient to
dose storage
2) L Block
close to
calibrator
3) Note use of
carrier for
syringe
4) Note L
Block: thick
window, 2"
lead, 2" lead
wrap-around
Hot Lab Details
Notes:
1) All this lead requires solid support -- have a heart-to-
heart talk with the cabinet maker
2) Counter mount of calibrator decreases tech exposure
3) Extra shielding required on well counter to shield
from sources in scanner, calibration sources, patient in
scanner, etc.
4) Use tungsten syringe shields for dose reduction to
fingers.
Injection Room Details
Notes:
1) Injection room
Hot lab
PET/CT bay
are most likely to need
shielding
2) To minimize
anomalous uptake
-minimize external
stimuli
-keep patient quiet and
still on gurney or in
injection chair
The minimum number of injection areas required
3) Need adjacent hot
per scanner at a full patient load is given by
toilet for patients to use
(uptake time)/(scan room time)
after uptake period.
Shielding and the PET Center
Common Viewpoint: Nuclear medicine departments
don't need shielding
Under older regulatory limits of 5 mSv/yr for members

of the public, little or no additional shielding would be
needed in many cases. This is ususally not true under
new 1 mSv/yr limits. (5 times less dose allowed)
Another way of putting this: much of the shielding

required in practice is on the order of 2 to 3 half-value
layers (factor of 4-8). Each half value layer is about
1/8” of lead!
Magnitude of Technologist
Exposure Consistent with conventional nuclear medicine
practice, most of technologist dose comes from
positioning, transport, and injection.
Technologist Doses average dose/procedure

about 10 µSv (1 mrem)
Dose/Activity Handled
0.100
(mrem/mCi)
0.080
µ Sv/MBq
0.060
0.040
0.020
0.000
Benetar Chisea Chisea McElroy UTSW Average
SI Units 0.018 0.012 0.023 0.019 0.019 0.018

Conventional Units 0.067 0.044 0.085 0.069 0.069 0.067
Reference
Miscellaneous Operating
Suggestions to Reduce Tech Dose
Complete patient instruction, interaction before
injection. Minimize time near patient after injection.
Use unit doses.
Lay out hot lab to minimize handling time.
Establish IV access with butterfly infusion set before

injection.
Use syringe shields, syringe carriers, carts, etc. to

reduce exposure
during dose transport, injection.
Release of Radioactive Patients
10CFR35.75 and Regulatory Guide 8.39
Release allowed: unlikely others receive > 5 mSv
Instructions needed: likely to expose others to > 1 mSv
Short half-life allows release of patient with normal (10-

15 mCi) amounts of administered FDG activity, even
under conservative assumptions.
Breast-feeding mothers may expose infants through

proximity rather than through milk until activity has
died away; instruction may be needed (Hicks, J. Nucl.
Med. 42(8), 1238-1242 (2001))
Effective Dose Comparison:
Conventional PET vs PET/CT
Whole Body Scan, HR+ in 2D mode
12 mCi 18F FDG 1.3 rem

transmission scan (average exposure of
56 mR on axis, free air,
6 bed scan, 8 min/bed,)
Whole Body Scan, Biograph
10 mCi 18F FDG 1.1 rem

WB CT scan 1.3 rem
(130 kVp, 120 mAs, 5 mm, p = 1.5)
Total 2.4 rem
The
J. A. Anderson 2/18/04 End

Introduction To PET/CT: Jon A. Anderson

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Introduction to PET/CT

CRCPD Winter 2004 Meeting

Two Events ( ) in Detector

3D - Collimators, restricted - No collimators, larger span

Correct for Scatter

- uses coupled x-ray CT scanner

Pneumonia, based on Where is it?

apologies to any vendor

Manufacturer Product CT PET Detectors

GE Discovery LS GE Lightspeed Advance NXI BGO

Philips GEMINI Philips MX8000 Allegro GSO

160% Decay Time

Decay Time, Attenuation Length, and Energy Resolution: Less is Better

Mass Attenuation Coefficients for Principal Tissue Types

2) For materials having substantial 70 keV

Used in Siemens/CTI Scanners

The mass attenuation coefficients for contrast materials

Bolus of contrast in bowel

Hot spot on PET Correlates to Mediport No anomalous

Attenuation Corrected PET Non-attenuation Corrected PET

Note: Non-attenuation-corrected image has typical bright rim

Artifacts arise because the CT and PET scans are taken

Voluntary movements: Patient shifts position between CT scan

Involuntary movements: CT catches snapshot of patient

GE: Obtained with rotating line source in

In our case, Siemens/CT Gantry Offset Procedure could be used to

0 The reproducibility of the

J. A. Anderson 2/18/04 note: not errors, but correction factors!

Pt instruction and prep Injection of Pt

30-60 min Uptake of pharmaceutical

Have Pt empty bladder

Release Pt QA Check of Scan

Print for file and referring; distribute to PACS

2) 511 keV energy

3) Combined modality scanners (PET/CT) require

#pts/day = (Twork - Tuptake)/Tscan_rm # uptake rooms = Tuptake/Tscan_rm

Under older regulatory limits of 5 mSv/yr for members

Another way of putting this: much of the shielding

Technologist Doses average dose/procedure

SI Units 0.018 0.012 0.023 0.019 0.019 0.018

Use unit doses.

Lay out hot lab to minimize handling time.

Establish IV access with butterfly infusion set before

Use syringe shields, syringe carriers, carts, etc. to

Short half-life allows release of patient with normal (10-

Breast-feeding mothers may expose infants through

12 mCi 18F FDG 1.3 rem

Whole Body Scan, Biograph

10 mCi 18F FDG 1.1 rem

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