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Radiology-Nuclear Medicine Diagnostic
Imaging: A Correlative Approach
Radiology-Nuclear Medicine Diagnostic
Imaging: A Correlative Approach
Edited by
Ali Gholamrezanezhad, MD
Associate Professor of Clinical Radiology, Keck School of Medicine
Universityof Southern California
Los Angeles, CA, USA
All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means,
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from this title is available at http://www.wiley.com/go/permissions.
The right of Ali Gholamrezanezhad, Majid Assadi, and Hossein Jadvar to be identified as the authors of the editorial material in this work has
been asserted in accordance with law.
Registered Offices
John Wiley & Sons, Inc., 111 River Street, Hoboken, NJ 07030, USA
John Wiley & Sons Ltd, The Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, UK
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Trademarks: Wiley and the Wiley logo are trademarks or registered trademarks of John Wiley & Sons, Inc. and/or its affiliates in the United
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John Wiley & Sons, Inc. is not associated with any product or vendor mentioned in this book.
To my family especially my mother, Maryam, my wife, Moloud, my sons, Arian and Aiden. For their endless sacrifices they
have made to make my life most rewarding
Majid Assadi
To those contributed to my education and excellence, especially my mother (the best teacher I have ever had), Fatemeh, my
brother, Hadi, my wife, Farzaneh, and my son, Adrian
and
To my patients, those who I served with the deepest gratitude and appreciation.
Ali Gholamrezanezhad
vii
Contents
List of Contributors x
Preface xvii
1 Introduction to Correlative Imaging: What Radiologists and Nuclear Medicine Physicians Should
Know on Hybrid Imaging 1
Prathamesh V. Joshi, Alok Pawaskar, and Sandip Basu
4 Radiopharmaceuticals 133
Ferdinando Calabria, Mario Leporace, Rosanna Tavolaro, and Antonio Bagnato
6 PET Imaging in Gliomas: Clinical Principles and Synergies with MRI 194
Riccardo Laudicella, C. Mantarro, B. Catalfamo, P. Alongi, M. Gaeta, F. Minutoli, S. Baldari, and Sotirios Bisdas
23 Osteoporosis: Diagnostic Imaging and Value of Multimodality Approach in Differentiating Benign Versus
Pathologic Compression Fractures 659
Daniela Garcia, Shambo Guha Roy, and Reza Hayeri
68
30 Ga-FAPI, a Twin Tracer for 18F-FDG in the Era of Evolving PET Imaging 814
Reyhaneh Manafi-Farid, GhasemAli Divband, HamidReza Amini, Thomas G. Clifford, Ali Gholamrezanezhad,
Mykol Larvie, and Majid Assadi
Index 871
x
List of Contributors
Akram Al-Ibraheem
Sarah L. Averill
Department of Nuclear Medicine, King Hussein Cancer
University of Iowa, Carver College of Medicine,
Center, Amman, Jordan
Iowa City, IA, USA
Iowa City Veterans Administration Healthcare System,
Ahmed Aljizeeri
Iowa City, IA, USA
King Abdulaziz Cardiac Center, Riyadh, Saudi Arabia
King Saud bin Abdulaziz University for Health Sciences,
Riyadh, Saudi Arabia Antonio Bagnato
King Abdullah International Medical Research Center, Department of Nuclear Medicine and Theranostics,
Riyadh, Saudi Arabia “Mariano Santo” Hospital, Cosenza, Italy
S. Baldari B. Catalfamo
Department of Biomedical Sciences and Morphological Department of Biomedical Sciences and Morphological
and Functional Imaging, Nuclear Medicine Unit, and Functional Imaging, Nuclear Medicine Unit,
University of Messina, Messina, Italy University of Messina, Messina, Italy
Saum Ghodoussipour
Murat Fani Bozkurt
Rutgers Robert Wood Johnson Medical School, New
Department of Nuclear Medicine, Hacettepe University
Brunswick, NJ, USA
Faculty of Medicine, Ankara, Turkey
Section of Urologic Oncology, Rutgers Cancer Institute of
New Jersey, New Brunswick, NJ, USA
P. Ferrari
Department of Medical Physics, Central Hospital of
Ali Gholamrezanezhad
Bolzano, Bolzano, Italy
Department of Radiology, Keck School of Medicine,
University of Southern California, Los Angeles, CA, USA
Brandon K. K. Fields
Keck School of Medicine, University of Southern
Edoardo Giacomello
California, Los Angeles, CA, USA
Dipartimento di Elettronica, Informazione e
Bioingegneria, Politecnico di Milano, Milano, Italy
Russell Flato
Department of Radiology, Keck School of Medicine, Jordan S. Gross
University of Southern California, Los Angeles, CA, USA Department of Radiology, University of California, Los
Angeles, Los Angeles, CA, USA
A. Fracchetti
Department of Medical Physics, Central Hospital of Mariano Grosso
Bolzano, Bolzano, Italy Regional Center of Nuclear Medicine, Department of
Translational Research and Advanced Technologies in
Marco Frigo Medicine and Surgery, University of Pisa, Pisa, Italy
Nuclear Medicine Unit, Department of Medicine,
University of Padua, Padua, Italy Amit Gupta
Radiology, Medicine and Biomedical Engineering,
Jerry W. Froelich Case Western Reserve University School of Medicine,
Radiology, University of Minnesota, Minneapolis, MN, USA Cleveland, OH, USA
Cancer Imaging Program, Case Comprehensive Cancer
Hiroyuki Fujii Center, Cleveland, OH, USA
Department of Radiology, National Center of Neurology Diagnostic Radiography, University Hospital Cleveland
and Psychiatry, Kodaira, Japan Medical Center, Cleveland, OH, USA
List of Contributors xiii
Giuseppe Visconti
Plastic Surgery, Lymphedema Center, A. Gemelli Hospital,
Sacro Cuore Catholic University, Rome, Italy
xvii
Preface
Medical imaging has come a long way since the discovery diagnostic radiology and nuclear medicine, addressing all
of X-rays by Wilhelm Rontgen, for which he received the major organ systems and major diseases (cardiovascular,
Nobel Prize in 1901. For over a century, medical imaging neurologic, oncologic, infection, and inflammation, in
has evolved remarkably with discoveries and the develop- both adults and children). In all chapters, there is emphasis
ment of innovative technologies which in combination on correlative imaging and how one imaging modality
with major strides in understanding the biology of health complements another in a synergistic way. As appropriate,
and disease have contributed significantly to the concept of the reader is introduced to the relevant anatomy and physi-
precision health and precision medicine. These milestones ology. Modern topics of radiomics, AI/DL, and theranos-
include, but are not limited to, the discovery of radioactiv- tics are discussed. This image-rich book will appeal to
ity and positron and technical developments of the radi- physicians, allied healthcare professionals, and trainees
otracer concept, cyclotron, computed tomography (CT), (medical students, residents, fellows). The editors regret
ultrasonography (US), magnetic resonance imaging (MRI), any potential errors and omissions and commit to remedy
single photon computed tomography (SPECT), and posi- any shortcomings in any future editions.
tron emission tomography (PET). Advances in computer We dedicate this book to the memory of Sanjiv “Sam”
technology have also provided opportunities for sophisti- Gambhir, MD, PhD, Chair of Radiology at Stanford
cated incorporation of radiomics, artificial intelligence, University. Sam was our mentor, friend, and colleague. He
and deep learning (AI/DL) algorithms in medical imaging. was larger than life with deep intellect, contagious gener-
Over the past decade, it has become clear that hybrid imag- osity, and remarkable humility. The entire scientific com-
ing (e.g. PET/CT, PET/MRI, SPECT/CT) provides a broader munity and indeed humanity itself lost a glorious soul
view of disease that was unavailable previously. For exam- from his untimely passing in July 2020.
ple, it is now recognized that a small lymph node may har-
bor a tumor while a large lymph node may be benign. Ali Gholamrezanezhad
Another example is visualization of tumor infiltration in Clinical Radiology, University of Southern California,
marrow space without concordant structural abnormali- Los Angeles, CA, USA
ties. Such comprehensive information provides opportuni-
Majid Assadi
ties for enhanced imaging assessment of the patient, which
Nuclear Medicine, Bushehr University of Medical
has been demonstrated to impact clinical management and
Sciences, Bushehr, Iran
improve patient outcome.
The editors of this book have assembled an international Hossein Jadvar
team of expert imaging specialists to compile comprehen- Radiology, Urology, and Biomedical Engineering,
sive coverage of correlative imaging in the domains of University of Southern California, Los Angeles, CA, USA
1
Radiology-Nuclear Medicine Diagnostic Imaging: A Correlative Approach, First Edition. Edited by Ali Gholamrezanezhad,
Majid Assadi, and Hossein Jadvar.
© 2023 John Wiley & Sons Ltd. Published 2023 by John Wiley & Sons Ltd.
2 Radiology-Nuclear Medicine Diagnostic Imaging: A Correlative Approach
Table 1.1 Overview of the salient attributes of important tomographic imaging modalities.
Principle Three-dimensional Computer-generated image of local Combined X-ray Strong magnetic field
distribution of radioactive tracer distribution in transmission source and radio waves to
positron-emitting tissues produced through the detection and detector system create detailed
labeled radiotracers of single-photon emissions from rotating around the images of the organs
radionuclides introduced into the body subject to generate and tissues within
in the form of SPECT radiotracers tomographic images the body
The tracer/ Positron-emitting Gamma-ray-emitting Iodine-containing Gadolinium-based
contrast used radio-pharmaceuticals radio-pharmaceuticals contrast medium contrast agents
Resolution ++ + +++ +++
Functional +++ ++ + ++
assessment
Radiation ++ + +++ None
exposure
Allergy/acute No No Yes Yes
side effects
Measurable PET tracer − Attenuation value/ Apparent diffusion
parameter/ uptake/standardized Hounsfield unit coefficient/mm2/s
quantification uptake value
unit
CT, computed tomography; MRI, magnetic resonance imaging; PET, positron emission tomography; SPECT, single-photon emission
tomography.
Correlative imaging has been in practice in the form of used tracer at present is the 18F-labeled glucose analogue
comparative imaging for many years, a typical example of fluorodeoxyglucose (FDG), and it is the workhorse of
this being the “hot spot” observed in bone scans interpreted PET-CT imaging at present.
as metastatic or degenerative based on comparing it with Though most commonly utilized in oncological imaging,
MRI or CT of the same bone. However, now fusion imaging FDG-PET has many other nononcological applications
techniques such as SPECT-CT, PET-CT, and PET-MRI have now: dementia, myocardial viability, and infection imaging
emerged as most widely accepted form of correlative imag- to name a few. Hence FDG is utilized here as example to
ing. Conventionally, SPECT and PET had been domains of demonstrate PET tracer characteristics to radiologists.
nuclear physicians while CT and MR had been the radiolo-
● Principle of FDG PET imaging
gist’s forte. With the advent and rapid success of fusion
Enhanced glucose metabolism of cancer cells (primarily
imaging there is a need for combined knowledge of both
dependent on anaerobic glycolysis or the Warburg effect)
nuclear medicine and radiology for accurate interpretation
forms the fundamental basis of FDG PET/CT imaging of
of fusion imaging findings. In the next section, we aim to
malignancies. The increased glucose utilization by the
familiarize nuclear physicians and radiologists with the
malignant cells is characterized by high expression of glu-
basic principles of tomographic techniques utilized in
cose transporters (GLUTs, namely GLUT1 and GLUT3)
correlative/fusion imaging.
and upregulation of hexokinase activity [4].
Glucose is taken up by tumor cells by facilitated transport
Positron Emission Tomography–Computed (via GLUT) and then undergoes glycolysis with the forma-
tion of pyruvate under aerobic conditions. However, under
Tomography
hypoxic conditions (such as in a necrotic tumor), glucose is
metabolized under anaerobic conditions with resultant
PET-CT: What a Radiologist Should Know about PET
increased tumor lactate levels. FDG is a radiopharmaceuti-
Basics of PET-CT cal (RP) analog of glucose that is taken up by metabolically
Positron Emission Tomography active tumor cells using facilitated transport similar to that
PET is a tomographic technique that measures the three- used by glucose (Figure 1.1). Despite the chemical differ-
dimensional distribution of positron-emitter labeled radi- ences, cellular uptake of FDG is similar to that for glucose.
otracers. PET allows noninvasive quantitative assessment of FDG passes the cellular membrane through facilitated
biochemical and functional processes. The most commonly transport mediated by the GLUTs, of which more than 14
Introduction to Correlative Imaging 3
CELL
CYTOPLASM
hexokinase
GLUCOSE GLUCOSE GLUCOSE-6-PO4
GLUT Glusose-6-
receptors glycolysis
phosphatase
CELL
CYTOPLASM
hexokinase
F-18 FLUORODEOXYGLUCOSE FDG FDG-6-PO4
(FDG)
GLUT Glusose-6-
receptors glycolysis
phosphatase
Figure 1.1 Mechanism of FDG uptake and metabolic trapping inside the cell.
different isoforms have been identified in humans, differing urine, lymphoid tissue, bone marrow, salivary glands,
in their tissue distribution and affinity for glucose. GLUT1 and testes (Figure 1.2). Breast, uterus, ovary, and thymus
is the most common glucose transporter in humans and is, can show variable FDG uptake.
together with GLUT3, overexpressed in many tumors [5–7].
Like glucose, it undergoes phosphorylation to form FDG-6- Causes of Physiological FDG Uptake and Normal
phosphate; however, unlike glucose, it does not undergo Variants Mimicking Pathology
further metabolism. At the same time, expression of the As increased FDG uptake is not limited to malignant tis-
enzyme glucose-6-phosphatase is usually significantly sues alone, for the appropriate interpretation of FDG
decreased in the malignant cells, and FDG-6-phosphate PET-CT imaging the interpreting radiologist needs to be
thus undergoes only minimal dephosphorylation, hence aware of the physiological causes of FDG uptake as well as
becoming “metabolically trapped” in cancer cells [8]. The commonly encountered physiological variants [10–15].
distribution of FDG in normal organs and pathological Table 1.2 summarizes and enumerates the different
lesions is detected by PET scanners. physiological causes and sites of FDG uptake that can
mimic disease and the suggested interventions to reduce
● Preparation for FDG-PET and scan acquisition
them.
Patients are advised to fast and not consume beverages,
except for water, for at least 4–6 hours before the admin- ● Quantification of FDG uptake and SUV
istration of FDG to decrease physiologic glucose levels While interpreting a PET-CT scan, it is the relative tissue
and to reduce serum insulin levels to near basal levels. uptake of FDG (or any other PET RP) that is of interest to
Oral hydration with water is encouraged. Intravenous the reporting physician. Visual analysis is sufficient in
fluids containing dextrose or parenteral feedings also most cases, but the standardized uptake value (SUV) is a
should be withheld for 4–6 hours [9]. FDG is injected commonly used measure of FDG uptake and it is routinely
intravenously and the PET scan is typically acquired mentioned in PET-CT reports. The basic expression for
50–90 minutes after FDG injection. SUV is [16]
● Normal biodistribution and physiological variants
r
Physiological FDG uptake is seen in the brain, myocar- SUV
a w
dium, liver, spleen, stomach, intestines, kidneys and
4 Radiology-Nuclear Medicine Diagnostic Imaging: A Correlative Approach
(a) (b)
Brain
Heart
Liver Spleen
Kidney
Bone marrow
Urinary
bladder
Testes
Figure 1.2 A typical example of the physiological distribution of FDG uptake in a conventional vertex-to-mid thigh whole-body PET
study. (a) Maximum intensity projection (MIP) image of a PET scan. (b) Three columns depicting (left to right) trans-axial PET only,
trans-axial CT only, and trans-axial fused PET-CT images of physiological distribution.
where r is the radioactivity activity concentration (kBq/ml) utilized as a marker of change in the metabolic activity of
measured by the PET scanner within a region of interest pathology and hence it is important to reproduce the scan
(ROI), a is the decay-corrected amount of injected radiola- conditions during the follow-up PET-CT scan performed
beled FDG (kBq), and w is the weight of the patient (g), for response evaluation.
which is used as a surrogate for distribution volume of
tracer. If all the injected FDG is retained and uniformly dis-
What Nuclear Medicine Physicians Need
tributed throughout the body, the SUV everywhere will be
to Know about CT
1 g/ml regardless of the amount of FDG injected or patient
size [17, 18]. Commonly SUVmax of lesions (maximum PET alone is limited by poor anatomic detail, and correla-
SUV) is provided in reports, which is the SUV of most avid tion with some other form of imaging, such as CT, is desir-
voxel in ROI. able for differentiating normal from abnormal radiotracer
The reproducibility of SUV measurements depends on uptake [8]. Hence PET-CT morpho-metabolic imaging
the reproducibility of clinical protocols, for example dose emerged as an ideal single investigation for oncology prac-
infiltration, time of imaging after 18F-FDG administration, tice. However, this also mandates the nuclear physician to
type of reconstruction algorithms, type of attenuation have adequate knowledge of the CT component of imaging
maps, size of the ROI, and changes in uptake by organs as well as the various interventions employed in CT
other than the tumor [9]. SUV or SUVmax values are often acquisition.
Introduction to Correlative Imaging 5
Table 1.2 Characteristics and causes of physiological uptake of FDG and methods to circumvent them.
Causes/sites of
FDG uptake Physiology behind FDG uptake PET-CT appearance Interventions to reduce uptake
Brown adipose Nonshivering thermogenesis FDG uptake in fat density Making patients wear warm
tissue (BAT) requires glucose for glycolysis as a (−150 to −50 HU) in neck, clothing and providing a
source of adenosine triphosphate, shoulder, and paraspinal regions blanket in the waiting suite
which in turn is utilized in fatty (Figure 1.3) to avoid cold-induced BAT
acid oxidation activation.
Less common in perirenal,
BAT is innervated by the perigastric regions Premedication with
sympathetic nervous system and beta-blockers or diazepam
expresses beta-adrenergic receptors, FDG uptake in BAT is more
which are stimulated by cold common in younger patients,
females > males
Vocal cords Phonation-related laryngeal muscle Symmetrically increased FDG If the region of interest is the
contraction uptake in both vocal cords larynx, the patient should be
(Figure 1.4) instructed to avoid talking
after FDG injection
Myocardium Glucose as substrate for energy Variable, focal or diffuse without Fasting before FDG PET-CT
(GLUT1 and insulin-sensitive corresponding morphologic (4–12 hours)
GLUT4) abnormality on CT High-fat, low-carbohydrate
diet before scan
Premedication with
unfractionated heparin
before FDG injection
Thymus Physiological uptake in pediatric Inverted V-shaped/butterfly pattern The uptake has a diffuse
patients (especially in of anterior mediastinal uptake on characteristic pattern: no
postchemotherapy setting, known the transaxial view and absence of specific intervention
as “thymic rebound”) lesion on corresponding CT
(Figure 1.5)
Lactating Due to secretory hyperplasia and Bilateral breast reveal diffuse FDG The uptake has a diffuse
breasts the increased expression of GLUT-1 uptake, but if infant is suckling characteristic pattern: no
unilateral breast only that side can specific intervention
show diffuse FDG uptake
(Figure 1.6)
Urinary system FDG excretion in urine Usually does not affect scan Dual point/delayed postvoid
interpretation imaging with or without
Focal retention in kidneys/ureter/ diuretic intervention
urinary bladder can mimic
pathology
Ovary FDG uptake in corpus luteal cyst Ovoid FDG uptake with smooth Correlation with menstrual
margins or a rim of FDG uptake history
with a photopenic center
(Figure 1.7)
Endometrium FDG in menstrual flow FDG uptake in endometrium in a If being evaluated for
diffuse uniform pattern gynecological pathology,
(Figure 1.8) PET-CT scan should be
scheduled in the
postmenstrual phase
Colon Related to bowel motility Typically heterogeneous and can Uptake pattern: no
The uptake in cecum and right vary in distribution from mild focal interventions
colon could be result of higher to diffuse uptake
lymphocytes in these regions Often, there is higher uptake
within the cecum and right colon
(Continued)
6 Radiology-Nuclear Medicine Diagnostic Imaging: A Correlative Approach
Causes/sites of
FDG uptake Physiology behind FDG uptake PET-CT appearance Interventions to reduce uptake
Spinal cord Inadequate clearance of FDG from The physiological FDG uptake is
the artery of Adamkiewicz, which visualized in the cervical spinal
originates on the left side of the cord peaking at C4 level, and in the
aorta between the T9 and T11 lower thoracic spinal cord peaking
vertebral segments at the T11–T12 segments
Increased cross-sectional area of (Figure 1.9)
the spinal cord
Skeletal Exercise induces glucose uptake in If related to exercise, usually Patients should avoid
muscles skeletal muscles symmetrical FDG uptake in strenuous exercise for
Labored breathing can increase muscles with no abnormal 48–72 hours before
FDG uptake in intercostal muscles enhancement or lesion on CT scheduled scan
and diaphragm If related to meal/insulin diffuse Fasting status should be
In postmeal state, insulin increases FDG uptake in skeletal muscles confirmed before FDG
GLUT (GLUT-4) mediated skeletal (usually also accompanied with injection
muscle glucose uptake cardiac FDG uptake)
If related to labored breathing,
intercostal muscles and diaphragm
reveal symmetrical increased FDG
uptake (Figure 1.10)
BAT, brown adipose tissue; FDG, fluorodeoxyglucose; GLUT1, glucose transporter 1; GLUT4, glucose transporter 4; PET-CT, positron emission
tomography/computed tomography.
(a) (b)
(c)
(d)
Figure 1.3 (a) FDG uptake in brown adipose tissue in bilateral cervical (red arrows), paraspinal, and perirenal regions as shown in
MIP image, (b) transaxial PET-only image of the neck region, (c) transaxial CT-only image, and (d) fused PET-CT image.
Introduction to Correlative Imaging 7
(a) (b)
Figure 1.4 (a) Transaxial CT-only image of vocal cords. (b) The fused PET-CT image of the same region shows symmetrical increased
FDG uptake in bilateral vocal cords (arrows). This patient was groaning due to painful skeletal secondaries, resulting in
hypermetabolism in the vocal cords.
Principle of CT
The CT scanner creates cross-sectional images by project-
ing a beam of X-rays through one plane of an object
(patient) from defined angle positions performing one rev-
olution. These X-rays are generated by a rotating X-ray tube
(Figure 1.11). As the X-rays pass through the patient‚ some
of them are absorbed, while some are scattered and others
are transmitted. The process of X-ray attenuation refers to
the intensity reduction involving those X-rays which are
scattered or absorbed. X-rays which are attenuated due to
the interactions with the object do not reach the X-ray
detector. Photons transmitted through the object at each
angle are collected on the detector and visualized by com-
puter, creating a complete reconstruction of the patient.
The three-dimensional (3D) gray value data structure
gained in this way represents the electron density distribu-
tion in the area of interest [19].
Figure 1.5 (a) MIP image of PET-CT of a 10-year-old boy The ability of matter to attenuate X-rays is measured in
showing physiological FDG uptake in the thymus (black arrows). Hounsfield units (HU). By definition, water is assigned a
(b) Hypermetabolism in the soft tissue neoplasm in the occipital
density value of 0 HU and air a value of −1000 HU.
region (red arrow).
Attenuation values for most soft tissues fall within
30–100 HU. Notable exceptions are lungs, with attenuation
Computed Tomography
values approaching −1000 HU (due to high air content),
Although the potential applications of X-rays in medical and mineralized tissues such as bone, with attenuation val-
imaging diagnosis were clear from the beginning, the ues of approximately 1000 HU [21].
implementation of the first X-ray CT system was made in
1972 by Godfrey Newbold Hounsfield (Nobel prize winner
Intravenous and Oral Contrast in CT Scanning
in 1979 for Physiology and Medicine), who constructed the
prototype of the first medical CT scanner and is considered Intravenous Contrast
the father of CT. After this, CT was immediately welcomed Differences in the CT attenuation of healthy tissue
by the medical community and has often been referred to and pathology can improve the quality of the images
8 Radiology-Nuclear Medicine Diagnostic Imaging: A Correlative Approach
(a) (b)
(c)
(d)
Figure 1.6 (a) MIP image of PET-CT showing FDG uptake in bilateral breasts of a nursing mother (red arrows), (b) transaxial FDG PET
of breast region, (c) CT of breast region and (d) fused PET-CT of breast region.
(a) (b)
Figure 1.7 (a) CT image of pelvic region and (b) fused PET-CT of same region showing increased FDG uptake in a corpus luteal cyst in
the left adnexal region (arrow).
Introduction to Correlative Imaging 9
(a) (b)
Figure 1.8 FDG PET-CT of a 27-year-old female. (a) Transaxial CT of pelvic region and (b) fused PET-CT image of pelvic region
revealing FDG uptake in fluid in the endometrial cavity (arrow) corresponding to menstruation.
Figure 1.9 (a) Sagital CT, (b) PET, and (c) fused PET-CT images revealing physiological FDG uptake in the cervical spinal cord (arrows).
(d) Transaxial CT, (e) PET, and (f) fused PET-CT images showing focal FDG uptake at the T11-T12 level in the spinal cord (arrows).
10 Radiology-Nuclear Medicine Diagnostic Imaging: A Correlative Approach
(a) (b)
(c)
Figure 1.10 (a) In a carcinoma larynx patient, the MIP image of FDG PET-CT reveals a hypermetabolic lesion in the neck
corresponding to the site of primary malignancy (black arrow). (b) Fused PET-CT image shows increased FDG uptake in the intercostal
muscles and diaphragmatic crura (white arrows). (c) Transaxial CT of the same region. The augmented FDG uptake in these muscles of
respiration was the result of labored breathing due to narrowing of the airway caused by the laryngeal malignancy.
CT Protocols in PET-CT
Protocol1: When CT is used for attenuation correction and localization only (not
intended as a clinically diagnostic CT scan)
A whole-
body
diagnostic CT
Deep
(with shallow
inspiration
breathing),
thoracic CT,
with 45 seconds
CT with 20 seconds PET
delay after
topogram delay from acquisition
thoracic CT
beginning of
(in
IV contrast
equilibrium
infusion
or venous
phase of
contrast)
Figure 1.14 Staging FDG PET-CT of a 53-year-old female diagnosed with locally advanced carcinoma of the left breast (blue arrow)
with metastatic lesion in body of D7 vertebra (red arrow). The following components of PET-CT are seen: (a) maximum intensity
projection (MIP) image, (b) trans-axial PET only image, (c) coronal PET only image, (d) sagittal PET only image, (e) trans-axial CT only
image, (f) coronal CT only image, (g) sagittal CT only image, (h) trans-axial PET-CT fusion image, (i) coronal PET-CT fusion image,
(j) sagittal PET-CT fusion image
Artifacts in PET-CT Fusion Efforts have been made to minimize such image degra-
dation by the generation of a respiratory motion cor-
Recent PET-CT scanners allow excellent fusion of the PET rected or four-dimensional PET-CT during which the
and CT images and thus improve lesion localization and PET data are acquired in synchronization with respira-
interpretation accuracy. Moreover, the employment of the tory motion [30].
CT data for attenuation correction has led to high patient 2) Attenuation correction artifacts: The presence of high-
throughput [29]. Although PET-CT imaging offers many density material in the patient’s body either in the form
advantages, this dual-modality imaging also poses some of high-density material like bone cement or venous
technical challenges due to a few artifacts. The reader inter- pooling of intravenous contrast/barium from previous
preting PET-CT scans needs to be aware of these limitations. studies in bowel loops can result in artifactual FDG
The artifacts can be broadly divided into following uptake due to exaggerated attenuation correction at
categories: these sites. A clinical example is shown in Figure 1.16.
3) Beam hardening artifact: This artifact appears as multiple
1) Motion artifacts (respiratory or patient related): Although linear bands of abnormal attenuation traversing a body
the CT and PET acquisitions are performed without part adjacent to high-attenuation objects, such as metal
changing the patient position, voluntary or involuntary prosthesis, dental fillings, chemo ports, and pacemakers.
movements of patient can result in misregistration of Patients need to be instructed to remove metallic objects
PET and CT images. Most commonly such misregistra- before scan acquisition and a note should be made of
tion artifacts are observed in lesions of the lungs and fixed/in situ metallic prosthesis/implants. An example is
liver. An example is shown in Figure 1.15. shown Figure 1.17. Some implants/prosthesis can result
(a) (b) (c)
Figure 1.15 50-year-old male, known smoker, referred for characterization of a solitary pulmonary nodule in the basal region of the
lower lobe of the right lung. (a) A focus of increased FDG uptake is noted (red arrow), which does not correspond to any morphological
abnormality in fused PET-CT (b) and CT only (c). The acquisitions were repeated with shallow breathing to minimize the lung motion
and the second set of images (d)–(f) reveal focal FDG uptake in a 14 × 14 mm sized nodule in the basal region of the lower lobe of the
right lung (blue arrow), suspicious of neoplastic pathology.
(a) (b)
(c)
(d)
Figure 1.16 MIP image of FDG PET-CT of a 36-year-old female for staging lymphoma. The focal uptake observed in the right axillary
region (black arrows in (a) and (b), and white arrow in (c)) was artifactual due to pooling of intravenous contrast material in the right
subclavian vein. The high density of contrast (red arrow in (d)) resulted in high attenuation correction and resultant artifactual FDG
uptake in the PET image.
14 Radiology-Nuclear Medicine Diagnostic Imaging: A Correlative Approach
in false-positive PET findings due to changes in attenua- with arms down, such as in the case of head and neck
tion correction factors. malignancy. When a patient extends beyond the CT FOV,
A similar artifact can be seen when the PET-CT scan is the extended part of the anatomy is truncated and conse-
acquired with the hands on the sides of the trunk and quently is not represented in the reconstructed CT image.
hence the easiest way to prevent this artifact is to per- Truncation also produces streaking artifacts at the edge
form the scan with arms up or down, depending on of the CT image, resulting in an overestimation of the
clinical indication. attenuation coefficients used to correct the PET data.
4) Truncation artifact: Truncation artifacts in PET-CT are This increase in attenuation coefficients creates a rim of
due to the difference in size of the FOV between the CT high activity at the truncation edge (see the example in
(50 cm) and PET (70 cm) tomographs [31]. These artifacts Figure 1.18), potentially resulting in misinterpretation of
are frequently seen in large patients or patients scanned the PET scan [32]. Therefore, in PET-CT imaging, it is
(a) (b)
(c) (d)
Figure 1.17 Beam hardening artifact caused by a metallic implant in the right femur, seen as linear bands of abnormal attenuation
(arrows in (a)–(c)). No artifact is noted in the PET-only image (d).
Figure 1.18 Truncation artifact in a large patient resulting in the rim of FDG uptake in PET image (a, arrow), loss of information in CT
only image (b), and FDG uptake without morphological data in fused PET-CT (c, arrow).
Introduction to Correlative Imaging 15
crucial that technologists carefully position the patient at chyma (see the example in Figure 1.19). Such uptake
the center of the FOV and with arms above the head to can be the result of iatrogenic FDG micro-embolus at
reduce truncation artifacts [29]. the time of injection [33] and when such a finding can
5) Radiopharmaceutical related: Although relatively rare, affect management of a patient, a follow-up scan can
focal FDG uptake (or other PET radiotracer uptake) be performed to avoid false-positive interpretation. In
without any CT demonstrable lesion needs to be the next section, few clinical case examples present
interpreted with caution, especially in lung paren- (Figures 1.20–1.22).
Figure 1.19 Focal FDG uptake seen in the PET image (a, arrow) and fused PET-CT (b) does not correspond to any nodule/lesion in the
corresponding CT trans-axial slice of the right lung (c). Such a pattern can be the result of an iatrogenic micro-embolus of FDG caused
during injection.
(d) (e)
Figure 1.20 A 28-year-old male recently diagnosed with non-Hodgkin’s lymphoma for staging FDG PET-CT evaluation. The supra-
diaphragmatic and infra-diaphragmatic lymphadenopathy was apparent on CT and was suggestive of stage III NHL. However, the
hypermetabolism in spleen (a and c, arrow) and left iliac bone (e, arrow) could be appreciated in PET and fused PET-CT images and
hence indicated splenic as well as bone marrow involvement, upstaging disease to stage IV. Note that in the CT-only images (b) and
(d) the spleen and left iliac bone appear unremarkable.
16 Radiology-Nuclear Medicine Diagnostic Imaging: A Correlative Approach
Table 1.3 PET beyond FDG: the important contemporary tracers and their clinical applications.
(a) (b)
Pancreatic duct
Figure 1.21 A 56-year-old male complained of chronic, intermittent abdominal pain and recent onset jaundice, nausea. Ultrasonography
revealed an overdistended gall bladder without any calculus. FDG PET-CT was performed with suspicion of pancreatico-biliary neoplastic
pathology. (a) The contrast-enhanced CT revealed a dilated pancreatic duct and common bile duct, the “double duct sign” (white arrow),
indicating pathology in ampullary region. However, on contrast-enhanced CT alone no obvious morphological lesion could be identified
in the ampullary/duodenal region. However, in the FDG PET images, focal hypermetabolism is seen in the right lumbar region of the
abdomen. When the PET and CT images are fused (b), the hypermetabolism corresponds to the ampullary region of the duodenum (green
arrow) and indicates an ampullary lesion obstructing the pancreatic and common bile ducts. On endoscopy, an ulcerated lesion was found
in the second part of the duodenum, which revealed ampullary carcinoma on histopathology.
Introduction to Correlative Imaging 17
(e) (f)
Figure 1.22 Pre- and postchemotherapy FDG PET-CTs of a metastatic carcinoma rectum. The pretherapy PET-CT MIP (a), fused PET-CT
(c), and CT-only (d) images reveal FDG avid hepatic metastasis. Posttreatment images (b), (e), and (f) reveal complete metabolic
response, as seen by resolution of FDG uptake and partial morphological regression, as seen by the reduction in the size of the lesion.
Figure 1.23 MIP image of 68Ga-PSMA-11 PET-CT for evaluation of biochemical recurrence of prostate carcinoma in a 61-year-old
male. Increased PSMA expression seen in pelvic region (a, black arrow). (b) CT and fused PET-CT reveal increased PSMA expression in
perirectal lymph nodes (white arrows). (d) Scan pattern suggests metastatic lymphadenopathy as a cause of rising PSA levels.
(d) (e)
Figure 1.24 MIP image of 68Ga DOTA-Nal3-octreotide PET-CT images of a 51-year-old male patient with clinical suspicion of
neuroendocrine tumor. He complained of recurrent vomiting and abdominal pain, and was found to have substantially elevated serum
chromogranin A levels. (b) Transaxial CT image and (c) fused PET-CT revealed increased somatostatin receptor expression in a small
nodular lesion in the second part of the duodenum (white arrow). (d) Transaxial CT revealed enlarged perilesional lymph node.
(e) Increased somatostatin expression was seen in the enlarged perilesional lymph node (blue arrow). Biopsy of the duodenal lesion
revealed grade 1 neuroendocrine tumor.
(a) (b)
(c) (d)
Figure 1.25 (a) and (b) MIP images of 18F-fluoro-DOPA PET-CT of a 1-month-old baby with recurrent severe hypoglycemia due to
congenital hyperinsulinism. This rare and grave condition is the result of islet cell hyperplasia, which can be either focal or diffuse.
(c) and (d) Transaxial fused PET-CT images reveal diffuse radioactive dopamine uptake was noted in the pancreas, marked with arrows,
suggestive of diffuse islet cell hyperplasia. In the focal type only partial pancreatectomy of the hyperfunctioning focus is performed,
while in the diffuse type a near-total pancreatectomy may be required.
Introduction to Correlative Imaging 19
Source of radioactivity
(Patient)
the target organ may be collected about a particular patho- i) Combined SPECT-CT images have the best of both
physiological process. However, at the same time, what- worlds. They have all the anatomical information lack-
ever little morphological information is obtained by ing in SPECT images and functional information lack-
background tracer activity diminishes significantly. Hence ing in CT images. CT also helps in proper localization
nuclear medicine techniques often lack anatomical land- of tracer uptake to ultimately help in correct diagnosis
marks. Also, there is definite loss of data in the planar and treatment.
imaging due to the attenuation of gamma rays coming ii) Not only this, CT attenuation maps are used for
from organs deep inside the body. attenuation correction and this improves the quality
SPECT entails 3D reconstruction of tracer distribution of SPECT images. There are many applications of
within the patient body with the help of data collected by SPECT-CT that are well established clinically. As
rotating detectors around the patient body. This helps to new advanced systems are becoming widely available,
achieve better anatomical information, for example in further improving the accuracy of image fusion and
the case of bone scan or myocardial perfusion imaging. shortening acquisition times, the newer applications
CT scanning, on the other hand, is a 3D reconstruction of are becoming more evident. Apart from applications
X-ray attenuation value maps providing morphological in oncology, interesting uses of SPECT-CT are seen
details like size, shape, and location. Use of contrast in the areas of minimally invasive surgery and cardi-
agent in CT primarily provides information about perfu- ology. We shall start our treatise with some technical
sion and the changes in perfusion pattern occurring in information about these systems before going into
various disease processes. However, CT often does not the clinical applications.
provide any information on the functional or metabolic
status of organs in the body. Many disease processes
show pathophysiological changes much before morpho- SPECT–CT System Information
logical changes are manifested. Also, in presence of ana-
tomical distortions secondary to various treatments, Combining SPECT and CT images acquired from differ-
anatomical imaging interpretations are difficult and ent standalone machines has often been challenging. This
often uncertain because of changes in symmetry and per- is because usually the studies are acquired on different
fusion pattern. dates, on different machines by different operators using
Hence it is of vital importance to understand that different protocols. This creates differences in the posi-
nuclear medicine (SPECT) and anatomical imaging (CT) tion of the patient body, extremities as well as spinal cur-
are not competitive to each other, but in fact complimen- vatures, as table positions may differ with different
tary in nature. The fundamental advantages of this are as systems. Furthermore, it is not possible to match respira-
follows: tory, cardiac motion, and position of stomach, intestines,
20 Radiology-Nuclear Medicine Diagnostic Imaging: A Correlative Approach
and urinary system at different time frames. Software form at the very beginning of emission and transmission
fusion techniques have been developed which can regis- CT, most notably the work by Kuhl, Hale, and Eaton, who
ter and fuse images from multiple sources [39, 40], but obtained the first trans-axial transmission CT scan of a
they are best suited for correlating images from rigid struc- patient’s thorax using their Mark II brain SPECT scanner
tures such as the brain [41] and skeleton [42, 43]. However, in the mid-1960s [50]. However, use of transmission imag-
for thorax and abdomen, due to inherent movement of ing with an external radionuclide transmission source was
internal organs, software fusion has remained challeng- introduced for attenuation correction in SPECT [51, 52]
ing. Data sets from two fundamentally different imaging and PET [53, 54] only in the 1980s. In this system, external
modalities with different spatial resolution and with few transmission scanning was used with SPECT to perform
common landmarks make it further complicated. A sys- both attenuation correction and anatomical localization.
tem offering same geometry for acquisition of SPECT and However, a transmission scan provides poor quality
CT images almost simultaneously, such as SPECT-CT anatomical details and contrast resolution, hence these
scanning, offers much better data sets for fusion. Here the systems never grew into routine applications. Over the last
patient remains on the same table and in the same posi- decade or so, combined SPECT-CT scanners have become
tion while undergoing SPECT and CT acquisitions sepa- commercially available which acquire data from SPECT
rated by a few minutes. and CT on the same gantry. The patient remains in same
The practical advantages of SPECT-CT fusion imaging position and on the same table, which is then sequentially
are multifold: moved from one modality to another. The final data
acquired is then transferred to a single computer which
i) These systems are able to superimpose functional
does data correction, image reconstruction, integration,
information from nuclear medicine data sets onto ana-
and display and allows analysis for better diagnosis.
tomical information from CT scans, greatly improving
The early SPECT-CT systems tried simultaneous acqui-
the confidence of the reporting diagnostician.
sition of SPECT and CT data [55, 56], but the problem
ii) These systems are able to facilitate attenuation correc-
with a simultaneous SPECT-CT acquisition system was in
tion of SPECT data with patient-specific attenuation
designing a common detector with sufficient temporal
maps acquired from CT [44, 45]. Because of this, there
and energy resolution to discriminate the primary radio-
is improvement in the spatial resolution, contrast, and
nuclide photons from both the X-ray signal and the scat-
signal-to-noise ratio of the image.
ter of the radionuclide photons. This problem remains
iii) There is improvement in the functional data quality
unsolved. The “modern” SPECT-CT system was originally
aided by CT, which shows great promise in quantifica-
developed by Hasegawa et al. at the University of
tion of RP uptake [46, 47]. This is very useful for (i)
California, San Francisco in the mid-1990s [45]. These
better radiation dosimetry [48, 49] and (ii) monitoring
systems have SPECT and CT gantries in tandem (in-line)
response to therapy.
which can acquire patient data sequentially and send it to
The concept of combining structural and functional the same computer for further fusion and processing
information was conceived and implemented in prototype (Figure 1.27).
SPECT-CT gantry
General SPECT–CT Protocols between 3/8 and 3/4 in. (9.5 and 19 mm) depending on the
intended usage for radionuclides emitting lower energy pho-
The first commercial SPECT-CT combination that was tons (e.g. 99mTc) and/or higher energy photons (e.g. 131I).
designed as a single unit was the GE Millenium™ hybrid Thicker crystals improve the photo-peak efficiency but
SPECT/PET/CT camera equipped with a HawkEye™ degrade the intrinsic spatial resolution.
single-slice CT (GE Healthcare, Haifa, Israel). The CT Acquisition on SPECT-CT systems is performed in a
produced images with a slice thickness of 1 cm and a sequential mode. The SPECT-CT systems using a diagnostic
256 × 256 matrix size with a spatial resolution of about CT component have higher spatial resolution and faster
3.5 mm. Because of its coarse resolution, the CT was not scanning time. However, diagnostic CT delivers higher
regarded as a diagnostic CT. Reconstruction was per- radiation doses. The SPECT component is acquired by a
formed using filtered back projection. The system was rotating, dual-head, variable angle sodium-iodide scintilla-
also offered with a 1-in. crystal and a coincidence unit for tion camera. SPECT acquisition currently requires a routine
PET imaging. This system was the commercial implemen- scanning time of approximately 20–30 minutes, depending
tation of the very successful research by the late Hasegawa on the radiotracer and the axial length of the body area
et al. [57]. scanned. CT is usually acquired in matrices of 512 × 512 with
Almost all current SPECT-CT systems offer high- the newest CT scanners or 256 × 256 in older scanners, and
resolution diagnostic CT units as part of their SPECT-CT has to be resized into slices with the same pixel format and
systems. One of the manufacturers (Mediso) even offers a slice width as SPECT. SPECT is reconstructed using itera-
complete SPECT/CT/PET with high-resolution lute- tive methods incorporating photon attenuation correction
tium-yttrium oxyorthosilicate (LYSO) detector technology based on the X-ray transmission map and scatter correction.
as part of their AnyScan family of systems. The CT scan in Since X-ray and radionuclide data are not acquired simulta-
these devices is a diagnostic CT scan which is used for neously, the SPECT images are not contaminated by scatter
attenuation correction based on individual patient-based radiation generated during the X-ray image acquisition.
tissue density data. The SPECT-CT workstations allow Also, since the patient is not removed from the table, both
image reconstruction, and three-plane (transaxial, coronal, imaging components are acquired with a consistent and
sagittal) and 3D display, including MIP and surface volume identical patient position, allowing accurate image registra-
rendering. SPECT, CT, and fused images are shown on the tion if we assume that the patient has not moved during the
same screen, and an interconnected pointer is available to entire duration of the SPECT-CT study.
exactly colocalize the morphological and functional areas The current SPECT systems are equipped with detection
of interest identified in either one of the two study devices or sensors to automatically calculate noncircular
components. orbits: the detection methods can be based on optical detec-
The cost of SPECT-CT systems is considerably higher tion using light-emitting diodes. Aside from the safety
than that of a conventional gamma camera, especially for aspect, noncircular orbits ensure closer distances to the
devices including a full diagnostic capability CT. Higher patient for each of the SPECT projections as well as easy
cost has constrained the availability of this technology to setup procedures, which together reduce the overall time
places with limited financial resources. New SPECT that the patient spends on the imaging table. Companies
devices have recently been developed using CdTe/CdZnTe now offer advanced and integrated diagnostic SPECT-CT
semiconductors instead of the classic NaI (Tl) scintillation solutions with 2-, 6-, or 16-slice diagnostic CTs. Basically,
crystals. Such newer systems are smaller, and have higher the SPECT-CT is a hybrid or a combination of each of the
sensitivity and intrinsic resolution than conventional two systems that have the same characteristics as the
cameras. respective standalone devices.
Most clinical SPECT systems still rely on the Anger camera Most of the newer SPECT systems use statistical iterative
principle discussed earlier, where the location of a photon reconstruction for creating images [59, 60]. An iterative
interaction (i.e. scintillation) site in the body is calculated as procedure includes some kind of model of how the images
the center of gravity of the position-dependent energy sig- are formed by the acquisition system. For a SPECT system,
nals from a two-dimensional (2D) array of photomultiplier an image is formed by the collimation of emitted photons
tubes (PMTs) attached to the back of the scintillation crys- such that only those photons parallel to the collimator hole
tal [58]. The available NaI (Tl) crystal thicknesses vary will interact with the crystal and produce scintillation
22 Radiology-Nuclear Medicine Diagnostic Imaging: A Correlative Approach
events. Hence, these so-called projections are created as 2D attenuation correction, there is a possibility that artifacts
representations of all photons detected along the projec- may appear at boundaries between different attenuating
tion lines and this gives rise to a distance-dependent reso- tissues because of the spill-out of events. Often this effect is
lution. The greater the distance of the camera head from reduced by smoothing the CT images with a Gaussian ker-
the radioactive source, the poorer the resolution. There is nel that results in a spatial resolution of the CT images
no information about source depth in the 2D projections. comparable with the spatial resolution of the SPECT
The purpose of the reconstruction algorithm is therefore to images. Also, depending on the acquisition parameters
create an estimate of the source distribution in 3D. From (voltage and mAs), the CT image may not be optimal for
the CT in SPECT-CT systems, attenuation maps are gener- attenuation correction and the scaling from the X-ray
ated and incorporated in the image formation model. bremsstrahlung spectra to the specific photon energy used
In an iterative reconstruction algorithm, one starts with in SPECT may not be optimal. Hence, when using CT only
an initial estimate of the internal and unknown radionu- for attenuation correction, so-called low-dose protocols
clide distribution. This estimate is usually an image set can be used which are optimized, such as a longer scan-
with equal and constant voxel values. SPECT projections ning time to average the respiratory movements and
are then calculated from the initial estimate using a com- matched spatial resolutions [62].
puter model of the imaging system. The underlying The problem of scatter correction has been taken care of
assumption is that if the calculated projections match the by various methods. Siemens and GE have implemented
measured projections, then the internal unknown activity some form of the dual-energy window method based on the
distribution in the patient matches the estimate. Initially, estimation of scatter from additional energy windows for
these are most likely nonagreeing, so the initial estimate subtraction from projection data or used within iterative
needs to be modified. Therefore, updates are made in the reconstruction methods as an additive term [63]. However,
estimate based on a comparison between calculated projec- it is generally known that the distribution of scatter in addi-
tions of the estimate using the physics of the imaging pro- tional lower scatter windows does not reproduce the scatter
cess and the measured projections. By back projection, the distribution in the main photo-peak energy window.
deviations between these two projection sets finally form Alternatively, model-based scatter compensation has been
an error image of weighting factors that is used to update used that does not rely on additional energy window data
the initial image estimate. This procedure is placed in an collection. Instead, it models the scatter in the main photo-
iterative loop in which the calculated and measured projec- peak energy window by using pre-calculated scatter kernels
tions are compared until the deviation is smaller than a or in real-time calculates the scatter based on theoretical
selected criterion (convergence has been reached). Hence, cross-sections of first-order scattering. Philips has imple-
when this happens, the reconstruction loop is stopped. mented a version of the effective scatter source estimator
However, in actual practice, as projection data is noisy, the method, originally developed by Frey and Tsui [64].
iterative reconstruction procedures are stopped after only a There is also a need for some compensation for the lim-
small number of iterations because the noise in the final ited spatial resolution due to the collimator design. This is
image goes on increasing for a large number of iterations. generally implemented in the iterative reconstruction algo-
The most popular iterative reconstruction algorithm imple- rithm, modeling the depth-dependent blurring caused by
mented is ordered subset expectation maximization (OS- photons that reach the detectors. The effect of partial vol-
EM) [61] due to the speed with which it reaches a good ume is an apparent reduction of the radioactive count
estimate of the activity distribution. density/X-ray density that occurs when an organ/tumor/
However, there are many other factors, such as nonho- defect only partially resides within the “sensitive volume of
mogeneous photon attenuation, contribution from scat- the imaging instrument (in space or time)” [65–68]. From
tered photons, and blurring due to the collimator response, the review of Erlandsson et al. [68] it is clear that an exten-
which need to be accounted for during reconstruction of sive body of work exists in an effort to minimize the partial
the image. The compensation for these factors is relatively volume effect. The main aim of partial volume correction
easy in iterative reconstruction, but there are still some (as well as resolution correction) is to improve the quanti-
issues when combining these two systems. It should be tative accuracy of the structure under investigation. CT can
remembered that a SPECT acquisition is averaged over be used for correction of partial volume in SPECT images
many respiratory cycles, which blurs the image, while rap- owing to its high sampling frequency.
idly acquired CT images are instantaneous images and may Patient body movement can occur during both the SPECT
not match with the averaged SPECT image. The spatial and CT portions of the study. The acquisition times for con-
resolution of the SPECT system is also far lower than that ventional SPECT–CT systems can vary from 10 minutes to
of CT. Hence, if high-resolution CT images are used for more than 30 minutes depending on area scanned and
Introduction to Correlative Imaging 23
count rate. During acquisition, SPECT typically takes much Table 1.4 The major contrasting points between conventional
more time than CT. All manufacturers offer registration (NaI-based) gamma cameras and a cadmium–zinc–telluride
(CZT)-based SPECT-CT system.
tools to manually or automatically register SPECT and CT
in case movement occurs between those two scans. The
Conventional gamma CZT-based
motion during the CT portion of the acquisition is usually Attributes camera (NaI) gamma camera
minimized owing to short scan times as well as breadth-
holding by the patient for diagnostic CT scan. All manufac- Type of crystal Scintillation Semiconductor
turers have some form of motion correction for SPECT itself Interaction of Produces light Produces
using the consistency of the projections. These algorithms gamma rays electron–hole
usually work best for small and simple motions. However, pair
for excessive and complex motions, the SPECT-CT acquisi- Photomultiplier Necessary to convert Not required
tion needs to be repeated. tube light signal to electrical
signal and amplify it
Detector Bulky Sleek
assembly
New SPECT–CT Scanners with Solid-state
Sensitivity + +++
Detectors
Spatial + +++
resolution
The most common scintillation material used in gamma
camera is NaI(Tl). It is readily available and cost-effective. Energy + +++
resolution
If we review the principal characteristic of gamma cam-
Image contrast + +++
eras, then the absorbed photon energy is converted to visi-
ble light in proportion to the deposited energy and this Image quality + +++
light is then detected by PMTs. PMTs convert this light to Acquisition +++ +
time
electrons at the cathode surface of the PMTs and the signal
is amplified using a sequence of dynodes to create an elec- Radiation +++ +
exposure
trical signal. This signal is then processed to get informa-
tion about the energy and position of the original gamma Available field ++ +++
of view
rays. Because there are many steps involved, the uncer-
Cost + +++
tainty in the measured energy signal is quite large, result-
ing in an energy resolution in the order of 10% full width at
half maximum at 140 keV. Furthermore, a large number of
CZT based SPECT–CT system (Discovery NM/CT 870
PMTs are required to determine the location of the interac-
CZT) provides up to 75% reduction in injected dose or scan
tion. That is why the size of the scintillation camera head is
time, improved system spatial resolution, from 4.3 to
quite large and requires sophisticated tuning methods so
2.8 mm, and exceptional energy resolution, 6.3% compared
that all PMTs provide similar amplitude signals for the
to 9.5%, according to data provided by them. They also
same imparted energy.
claim greater than 40% improvement in SPECT contrast-to-
Recently, commercial SPECT systems based on cad-
noise ratio, 67% reduction in detector frame size, from 7.5
mium–zinc–telluride (CdZnTe or simply CZT) have been
to 2.5 cm, and 25% greater optimal FOV than Nal [69].
introduced. CZT is a solid-state detector material that gen-
There are newer CZT systems, such as the VERITON CZT
erates signals from the collection of induced charge created
camera (Spectrum Dynamics, Caesarea, Israel), which are
by the ionizations from photoelectric interactions or
similar to PET-CT cameras in architecture with detectors
Compton scattering. Here each photon is directly con-
arranged in a ring configuration around the patient [70].
verted into an electrical signal. The major advantages of
these new CZT modules are their small size and the
absence of PMTs, which allows for a compact camera. It Clinical Examples of SPECT–CT
also increases the overall system sensitivity significantly.
The improvement in sensitivity can either be used to As there are chapters dedicated to the clinical applications
reduce the acquisition time of a given administered activity of SPECT-CT system later in the book, we restrict ourselves
or reduce the radioactivity administered for the same to a few clinical examples. The selected clinical examples
acquisition time. The major contrasting points between a of SPECT-CT acquisitions shown in Figures 1.28–1.32 are
conventional gamma camera and the CZT-based SPECT-CT such that, if not for combined imaging, the diagnosis might
system are given in Table 1.4. The GE Healthcare full-size have been missed or delayed.
(a) (b)
(c)
ANTERIOR POSTERIOR
Figure 1.28 A 51-year-old female with a presenting complaint of left hip joint pain. (a) The bone scan showed increased tracer
uptake in the upper part of the left hip joint. (b) and (c) The SPECT-CT scan of the pelvis showed subchondral cysts in the head of the
left femur, suggestive of osteoarthritis. In this case the bone scan helped to find the active osteoblastic reaction in the left hip joint
region as cause of pain and the CT component helped to localize abnormal tracer uptake. The morphological findings of osteoarthritis
on CT added specificity to bone SPECT findings.
(a) (b)
SPECT
CT
SPECT-CT
fused
image
ANTERIOR POSTERIOR
Figure 1.29 A 70-year-old male with diagnosed carcinoma of prostate. His serum PSA level was 34 ng/ml. (a) The whole-body bone
scan shows focal increased tracer uptake in the upper dorsal vertebra. (b) The SPECT-CT scan of the thorax shows increased tracer
uptake corresponding to sclerotic lesion involving the D2 vertebral body consistent with solitary skeletal metastasis. In this case, the
bone scan detected a solitary osteoblastic lesion in the upper dorsal vertebra and CT localized it to the D2 vertebra showing sclerosis,
hence confirming metastatic disease.
(a)
(b)
Figure 1.30 A 35-year-old male with recurrent pancreatitis. He was found to have elevated serum parathyroid hormone levels during
evaluation and was referred for a 99mTc-MIBI parathyroid scan. (a) Dual phase parathyroid scintigraphy in anterior static images
showing focal abnormal tracer uptake near the lower pole of the left lobe of the thyroid gland (blue arrow) with focal tracer retention
seen in the delayed image. (b) SPECT-CT of the neck showing abnormal tracer uptake corresponding to a 14 × 14 mm nodule in the left
upper paratracheal region inferior to the lower pole of the left lobe of the thyroid gland suggestive of parathyroid adenoma.
The SPECT-CT scan helped in the exact localization of the parathyroid lesion and aided with better surgical planning.
(d) (f)
(b)
Figure 1.31 A 70-year-old male with chronic kidney disease and suspected pulmonary thromboembolism. The 99mTc-
macroaggregated albumin lung perfusion scan (a, b) showed a perfusion defect in the right middle lobe. The SPECT-CT scan (e, f)
showed a large perfusion defect in the middle lobe of the right lung with no morphological abnormality, such as a space-occupying
lesion, consolidation or fluid accumulation on the CT scan. The CT scan (c, d) showed well-aerated lung parenchyma in the region of
the perfusion defect, potentially eliminating the need for a ventilation scan to diagnose pulmonary thromboembolism.
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