School of Health Sciences - Medical Radiation Science

CT and PET Imaging RADY 3032

Student Workbook
Medical Imaging Students

Student Name: RAPHAELA WIGET

2018 Version

1
 CONTENTS

Introduction........................................................................................................................................................
Marking Rubric..................................................................................................................................................
Module 1: Protocols...........................................................................................................................................
Module 2: CT CHEST SCANNING................................................................................................................
Module 3: BRAIN............................................................................................................................................
Module 4: PET CT & Pelvic Anatomy............................................................................................................
References........................................................................................................................................................

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 Introduction
The content and entries to be completed in this booklet form the assignment component
worth 25% of the grade for this course.
Download the booklet and type your answers directly into the spaces provided.

Aims
To complement lectures given throughout the course and extend your knowledge on a range
of topics.
To develop skills in anatomical identification of digital images
To further apply the principles of instrumentation, clinical applications, imaging protocols,
data acquisition and image evaluation of CT and PET/CT systems for current and advanced
procedures.

The Course objectives being assessed are:

CO1. Apply knowledge previously acquired in medical radiation science and demonstrate a
knowledge of the principles, instrumentation, clinical applications, imaging protocols;
data acquisition and image evaluation of CT and PET/CT hybrid systems for current
routine and advanced procedures.
CO2. Interpret and evaluate CT, PET and PET/CT images, in terms of anatomy, physiology
and pathology and linking these findings with the procedural protocol required to
produce such images
CO3. Demonstrate a knowledge of the principles of image co-registration, image fusion,
attenuation correction and the application to diagnosis and treatment
CO4. Demonstrate image manipulation of CT and PET images in applied procedures.

Marking Rubric
Assessment feedback
School of Health Science
CT and PET Imaging RADY 3032
Workbook Assignment Weighting 25% Due date Friday 8th June 2018 NAME: RAPHAELA
WIGET
This assignment is designed to assess the following learning objectives:

CO1. Apply knowledge previously acquired in medical radiation science and demonstrate a knowledge of the principles,
instrumentation, clinical applications, imaging protocols; data acquisition and image evaluation of CT and PET/CT
hybrid systems for current routine and advanced procedures.
CO2. Interpret and evaluate CT, PET and PET/CT images, in terms of anatomy, physiology and pathology and linking
these findings with the procedural protocol required to produce such images
CO3. Demonstrate a knowledge of the principles of image co-registration , image fusion, attenuation correction and
the application to diagnosis and treatment
CO4. Demonstrate image manipulation of CT and PET images in applied procedures.

Component Avail Comments

Marks Competent Below expected achievement
Module 1: Written answers Written answers Written Written Insufficient
The extent to which you displayed displayed answers answers were answers with
demonstrate an understanding of exceptional comprehensive displayed not backed no evidence
20 understanding, understanding, adequate up with from texts or
the topic including the
were extensive, were understanding evidence applied
application of theory to general and backed up appropriate, and and mostly from texts examples.
CT protocols, image viewing and with evidence backed up with backed up with and no Many
image manipulation. from texts with evidence from evidence from applied omissions
Accurate, logical and well many applied texts with some texts – few examples. and /or

3
 applied
examples.
applied
Some
examples
omissions or Quite a few
examples provided.
entries needing omissions or minimal detail
provided. All tasks
expansion with many entries in responses/
Extensively completed with
researched responses to written more detail of that are too tasks not
completed for good detail.
tasks. all tasks. Very High level of
tasks brief or completed.
completed. missed tasks/ Many
high level of accuracy in
Responses detail. Many inaccuracies
accuracy in responses
given are inaccuracies present.
responses.
accurate. present

20-17 16-14 13-11 10-7 7-0

Written
answers
Written answers
displayed
displayed
adequate Written
Written answers comprehensive
understanding answers were Insufficient
displayed understanding,
and mostly not backed answers with
Module 2: exceptional were
backed up with up with no evidence
The extent to which you understanding, appropriate, and
evidence from evidence from texts or
demonstrate an understanding of were extensive, backed up with
texts – few from texts applied
and backed up evidence from
the topic including the applied and no examples.
with evidence texts with some
application of theory to CT chest examples. applied Many
from texts with applied
scanning, windowing, CT image many applied examples Some examples. omissions
reconstruction and sectional omissions or Quite a few and /or
examples provided.
anatomy of the thorax. entries needing omissions or minimal detail
provided. All tasks
Accurate, logical and well expansion with many entries in responses/
Extensively completed with
researched responses to written more detail of that are too tasks not
completed for good detail.
tasks brief or completed.
tasks. all tasks. Very High level of
completed. missed tasks/ Many
high level of accuracy in
Responses detail. Many inaccuracies
accuracy in responses
given are inaccuracies present.
responses.
accurate. present

20 20-17 16-14 13-11 10-7 7-0

Written
answers
displayed
Written answers
Written answers adequate Written
Module 3: displayed
displayed understanding answers were Insufficient
comprehensive
The extent to which you exceptional and mostly not backed answers with
understanding, understanding,
demonstrate an understanding of were backed up with up with no evidence
the topic including the were extensive, evidence from evidence from texts or
appropriate, and
application of theory to CT and backed up texts – few from texts applied
backed up with
brain, image quality and the with evidence applied and no examples.
evidence from
application of contrast media. from texts with examples. applied Many
many applied texts with some
Some examples. omissions
Accurate, logical and well examples applied
omissions or Quite a few and /or
researched responses to practical examples
provided. entries needing omissions or minimal detail
& written tasks. provided.
Extensively expansion with many entries in responses/
All tasks
completed for more detail of that are too tasks not
all tasks. Very completed with
tasks brief or completed.
good detail.
high level of completed. missed tasks/ Many
High level of
accuracy in Responses detail. Many inaccuracies
accuracy in
responses. given are inaccuracies present.
responses
accurate. present

20 20-17 16-14 13-11 10-7 7-0

20 Written answers Written answers Written Written Insufficient
displayed displayed answers answers were answers with
exceptional comprehensive displayed not backed no evidence
understanding, understanding, adequate up with from texts or
were extensive, were understanding evidence applied
Module 4: and backed up appropriate, and and mostly from texts examples.
The extent to which you with evidence backed up with backed up with and no Many
demonstrate an understanding of from texts with evidence from evidence from applied omissions
the topic including the many applied texts with some texts – few examples. and /or
application of theory to fusion examples applied applied Quite a few minimal detail
imaging, PET CT utilisation, provided. examples examples. omissions or in responses/
Extensively provided. Some many entries tasks not
radiopharmaceuticals and pelvic
completed for All tasks omissions or that are too completed.
sectional anatomy. Accurate,
all tasks. Very completed with entries needing brief or Many
logical and well researched high level of good detail. expansion with missed tasks/ inaccuracies
responses to written tasks. accuracy in High level of more detail of detail. Many present.
responses. accuracy in tasks inaccuracies
responses completed. present
Responses 7-0

4
 given are
accurate.

20-17 16-14 13-11 10-7

Syntax,
Very well More spelling or
Writing and format Language used written, Language used prevalent grammatical
•Writing style is clear, appropriate was highly occasional was mostly syntax, problems
and relates to the question appropriate. No informal appropriate. spelling or made the
errors present. language. Few Minor errors grammatical submission
•Grammar and spelling are correct
errors present. present. problems. difficult to
understand.

10 10-9 8-7 6-5.5 5.4-3 2-0

Referencing : Consistent
errors in Errors
 In text References
Minor errors in referencing present in missing or
 Reference list Referencing referencing style style in either both in text poorly
style excellent, in either in text in text or and reference implemented,
all reputable or reference list reference list, list. Low few or low
sources, all all reputable Mainly level sources, level sources
good quality sources, mainly reputable mainly
and quantity good quality and sources, some websites, no
quantity reliance on texts
websites
10 10-9 8-7 6-5.5 5.4-3 2-0
Final Comments
FINAL MARK/ GRADE
100

Module 1: Protocols

Objectives:
 To identify the features of CT imaging protocols and apply related theory

Task:
Work through the questions in this workbook and type your answers in the spaces provided.
Where relevant, answers should refer to reputable sources of information and be referenced
appropriately.

1. What is the purpose of protocols?

Protocols, put basically, are a set of instructions put in place to standardise practice. It
involves radiographers, radiologist, medical physicists and manufacturers (Romans 2011). CT
Scanners come in a variety of brands and generations this can make it confusing to operate
due to the differing terminology for exposure outputs and radiation units (Trattner, 2014).
CT protocols make it easier to achieve dose optimisation and quality assurance by providing
a set of instructions for all procedures and examinations, while also allowing for
personalisation of them to cater for specific needs of the patient (Romans 2011). Ultimately
protocols aim to reduce radiation dose and achieve a standard of practice across different
patients and locations achieving continuality between scans (Trattner, 2014).

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Some of the major components of diagnostic protocols for CT include the following:
mAs (tube current-time product): very important as increasing tube current proportionally
increases radiation dose to patient by increasing quantity of radiation received (Mayles
2007).
mA modulation (tube current modulation): This function greatly reduces dose to
patient(reported up to 40% dose reduction per examination (Trattner, 2014), it modulates
mA during scan to more effectively apply radiation to patient depending on
density/attenuation from topogram (Mayles 2007). For example, for lower attenuating areas
such as a chest mA modulation would tell scanner to produce fewer x-ray photons, then as
scan reaches the shoulders (higher attenuating area) scanner would increase x-ray photons
given to patient (Mayles 2007).
kVp (Tube Voltage): Controls peak energy of each x-ray photon, by increasing from 120kV to
140kV(14% increase) patient dose increases by 30-35% this shows a non-linear relationship
between kVp and dose (Mayles 2007).
kV modification (Tube voltage mod): there is no kVp modulation however correct kV must
be determined specific to patient’s size (Hofer 2010). Big patients may need 120kVp to
adequately penetrate whereas smaller patients who would need significantly less energy to
penetrate, may need to reduce to 80kVp (Siemens 2000). Being aware of this helps better
customize overall exposure to patient reduces risk of unnecessary over exposure of a
smaller than average patient or inadequate penetration of a larger than average patient
(Hofer 2010).
Pitch: defined as table rotation divided by total nominal beam width (Bushong 2013), this is
an important aspect of protocol as dose increases linearly as pitch reduces. If pitch is
manipulated exposure factors must be adjusted accordingly to optimise dose (Romans
2011).
There are many other components of diagnostic protocol including patient position,
contrast use.
but in summery all involved components serve to simplify and standardise the CT imaging
techniques used by radiographers to minimise harm to patient (Trattner, 2014).

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 2. The following image represents a topogram protocol that will run at the beginning
of a CT scan. Note the parameters available and discuss the significance of each
field including the impact of changing the values in these fields.

All parameters available will have some sort of effect on both image quality and patient
dose thus setting them correctly is of vital importance and alterations from set protocol
carefully considered (but sometimes necessary) (Trattner, 2014). Below I discuss the
significance of each field and the impact of changing them, here is the definition of two
terms I refer to in this discussion:
Spatial resolution is the ability of an image to convey fine detail, distinctly see two small
objects close together (Bushong, 2013)
Contrast resolution: this is the difference between two adjacent structures with similar
density(or technically Hu Hounsfield units)(Hofer, 2010), high contrast resolution would
allow finer detail visible on the image versus low contrast resolution, the ability of the
system to differentiate between objects of similar densities (Romans, 2011). CT imaging
systems need to be able to visualise 5mm objects at 0.5% contrast (Bushong, 2013).

mA: This controls the quantity of radiation given to patient (Mayles 2007). Increasing mA
will increase contrast resolution, also decrease noise so bettering the resultant image
quality (Bushong, 2013). If mA is too low image will have a grainy appearance, due to
insufficient photons reaching the detector (Hofer 2010). If mA is too high image will not be
degraded but dose will be increased, this contributes to dose creep in radiography (Hofer
2010).

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kV: Controls peak energy of each x-ray photon, penetrating power or intensity of the beam
(Bushong 2013). For example, increasing from 120kV to 140kV (14% increase) patient dose
increases by 30-35% this shows a non-linear relationship between kVp and dose (Hofer
2010). Contrast resolution is also affected by altering kVp, increasing kVp will increase
Contrast resolution and signal noise ratio but also increase in dose (Bushong, 2013). KV and
mA is more important in actual image acquisition as topogram is usually low does and lower
quality (siemens 2012)

Scan Time: The total duration of image acquisition, longer scan times will increase dose to
patient but yield better image quality (Hofer 2010). Shorter scan times are especially
advantageous in abdominal and chest exams where motion from cardiac and respiratory
functions create image blur and degrade quality (Mayer 2007).

Slice(thickness): technologists can select slice thickness but are limited by what is available
to select on scanner depending on brand and generation (Romans 2011). In general, the
smaller the object being scanned the thinner the slice thickness in order to detect small
pathology and it not be obscured by surrounding anatomy (Romans 2011). Increasing slice
thickness will increase contrast resolution,
thinner slices (decrease in thickness) will increase spatial resolution (Hofer 2010)

Topogram length: allows radiographer to choose length of region to be scanned in mm for

the topogram (siemens 2000). The computer then uses the topogram to ‘plan’ the
examination including dose optimisation, mA modulation (Habibzadeh 2011). Thus, it is
extremely important for the tomogram to be optimal length and centring otherwise
incorrect dose may be given, or target anatomy not in isocentre (Habibzadeh 2011). It
should be noted that changes to topogram length will cause system to determine new
necessary scan times, magnification factors and optimum topogram width (Siemens 2000).
In this particular case topogram will run for 512mm in craniocaudal direction from point
where radiographer positioned.

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Tube Position: Usually automatically selected and not changed, options; top bottom or
lateral. Tube position determines if image is AP, PA or lateral, for example if patient is
supine and tube is at the top the resultant image would be AP (siemens 2012).

Table Position, height and direction: These are the parameters radiographer uses to position
patient in isocentre of gantry (Habibzadeh 2011). Height of table needs to be enough so that
patient can be moved in and out of gantry without obstruction, in this case height of 125mm
was sufficient. Direction is selected dependant on scan, craniocaudal which is head to toe,
or caudocranial toes to head (Siemens 2012). Table position is in relation to its location
along Z axis of available table movement, dependant on patient position on table (Siemens
2012).

3. The following images illustrate an example of a scan protocol utilised for THORAX
imaging. The topogram has loaded at the top of the screen and we are able to
manoeuvre the purple scan box into a suitable position to indicate the area we
wish to scan for the patient. The scan box can be moved and manipulated in size to
cover the area of interest for the scan. Below the topogram we can see the
selected technical factors for the first page of the THORAX protocol. In this first
example the “Routine” tab has been highlighted.

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 The second image demonstrates the selections available under the “Scan” tab.

The third image demonstrates the selections available under the “Recon” tab.

Examine the data fields under each of these protocol tabs and note the set parameters.
Explain the intended use of the parameter selections for each tab.
4. Using the protocol tabs displayed in the previous question for reference discuss
how the parameters selected influence image quality and dose of a CT scan. (I
think I accidently combined 2 questions I think? ..sorry!!)

Routine:
The routine tab is the main protocol tab radiographers will work with for most
examinations, it contains most important settings and shows diagram on right of patient
position and scan mode setting (siemens 2000). In this particular diagram it shows scanning
mode is spiral, with patient supine head first with model of gantry and table top also
displayed above. The Routine tab shows after exam is selected and topogram is performed,
the pink scan box can be moved over area of interest. Multiple data fields are shown:

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Eff mAs = effective tube current seconds, this corresponds to intensity of radiation (Hofer
2010), in CT it is the ratio of mAs to pitch (Bushong 2013). The set parameter is 195mAs for
this patient, this value should have been chosen to provide diagnostic image quality at the
lowest dose (siemens 2000). Sometimes this parameter is used to automatically adjust mA if
pitch is decreased so that dose is not affected, and image quality is kept the same (Romans
2011).
KV = tube voltage, you can improve contrast visualisation of soft tissue by increasing this
value (siemens 2000) always keeping in mind dose to patient (Hofer 2010).
Scan time = duration of radiation of exposure, increasing this will increase dose but improve
image quality (Bushong 2013)
Delay = delay time after radiographer begins acquisition, activating API (discussed in scan
tab) will increase minimum delay time (siemens 2000)
Slice = slice thickness is the width of each image slice, it must be adapted according to size
of anatomical object of interest (Bushong 2013). Adaptation of slice thickness can be done
but must bear in mind that if decreased and range maintains the same, number of images in
acquisition will increase, thus increasing radiation exposure to patient (siemens 2000).
No of images = how many slice images in the examination, more images, higher dose, longer
recon time (Romans 2011).
Range = when scan will begin and end, however radiographer can suspend scan earlier if
they see all anatomy of interest is covered (siemens 2000).
Table position = shows current horizontal table position relative to a selective reference
point (siemens 2000).
Table height = current height of table shown in mm, distance from centre of rotation of tube
detector (siemens 2000), table position can often only be changed using gantry operations
within examination room (siemens 2000).
Direction of scan = shown as craniocaudal but can also be chosen to be caudocranial
Arrows to right of direction of scan drop down menu allow for step-by-step movement of
the gantry (siemens 2000), CT dose indexes are also calculated as an estimate to the right of
exposure controls.

Scan:

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All parameters directly related to scanning are on this tab, it shows you the specifics behind
the particular exam.
CARE kv: this parameter allows technician to choose between continuous radiation and
radiation with pauses (siemens 2000). In the above screen shot it is selected as ‘on’ meaning
scanning is set to reduced radiation one image reconstruction per rotation, if ‘off’ is selected
radiation is continuous and maximum number of images will be reconstructed used for finer
detail (siemens 2000).
Scan time = this parameter indicates the length of image acquisition, how long the patient
will be exposed to radiation (siemens 2000). As this is a thorax protocol it also indicates the
length the patient must hold inspiration for. This parameter can only be changed by
changing topogram length (siemens 2000)
Rotation time = length taken per full rotation of tube (siemens 2000)
Delay = delay time after pressing to begin scan, if API activated delay may be longer
(siemens 2000).
Slice = shows what slice thickness is selected in routine tab.
Pitch = pitch is a parameter that describes table movement through the gantry, defined as
the travel distance of CT table per 360-degree rotation of the tube divided by x-ray beam
collimation width (Romans 2011). When table feed equals beam collimation, pitch will be
one, if feed is less then pitch will equal less than 1 and scan overlap occurs (Romans 2011).
Scan overlap increases dose but betters image quality (Bushong 2013).
Direction = direction table will move horizontally in relation to patient position on bed once
scan is started (siemens 2000). Craniocaudal or caudocranial, direction is usually present
with examination selection but can be changed as long as patient diagram matches actual
patient position.
API = Automatic Patient Instruction system, this gives breathing and movement instructions
to patients automatically when examinations are chosen where it is protocol like in chest CT
(Siemens 2000). This can only be activated if you select an instruction text is chosen from
drop down menu, in this case “None” is selected so API is deactivated.
Language = language of API system
Scan start = How scan radiographer can start the scan (siemens 2000), in this case ‘start
button’ is selected this is usually displayed on table. Foot switch or other options may be
available from drop down menu but this is site/generation dependent (siemens 2000).

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Recon:
Finally, following completion of scan, the recon tab has all parameters computer uses to
calculate images from raw data acquired during scan (siemens 2000). Most scanners will
automatically create axial images of the body part that has been imaged, then radiographers
are required to do further post processing specific to scan and reason for scan (Heffernan
2016).
Recon job: a large amount of raw data is collected for each examination, from this multiple
reconstructions are done. This parameter allows technician to swap between each
reconstruction and change influencing settings for each individual job (siemens 2000).
Algorithm: the drop-down menu has a choice two calculation algorithms, standard(default
setting) and no smooth(deactivates smoothing over time) (siemens 2000).
Window: allows radiographer to select desired window for each reconstruction job suitable
to target tissue.
FoV: field of view applied to topogram is displayed here
Mirroring: This parameter determines in what direction the scans are automatically
mirrored in order to obtain standard viewing of images. Options include: vertical, horizontal,
both vertical and horizontal and none as is selected in the example,
Series description: name and classification of imaging series
Recon job type: just describes the region, choice of axial and 3D
Begin and end position: This shows the reconstruction range, it allows technician to type in
table position to ‘begin’ reconstruction at (where first image is reconstructed) and ‘end’.
Image order: this parameter allows you to select the direction in which you want the
reconstructed images to be sorted; either craniocaudal or caudocranial
Increment: this allows you to create continuous or incremental tomographic images from
raw data obtained in scan controlling level of overlap (siemens 2000). This data field is only
displayed for spiral scans.
Number of images: total number of images for the selected recon job that will be obtained
after reconstruction is complete (siemens 2000). This number is dependent on range, slice
width and pitch (romans 2011).

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 5. Apart from providing a precise set of instructions for how a CT scan will run and
reconstruct, describe the other basic elements that are included in any given CT
protocol.
Patient care: especially important, as technology continues to reduce scan time
radiographers find a large portion of their time is spent specifically on patient care and
preparation (Romans 2011). Patient preparation starts from collection or delivery of patient
to room, radiographer will introduce themselves and talk to the patient ensuring they
understand the procedure, consent and leave feeling valued and cared for (Romans 2011).
Studies have actually shown that increased communication will decrease exam time along
with increasing patient satisfaction (Bradley 1990).
Patient preparation: Before patient gets to facility for imaging steps have already been
taken to prepare the patient (Romans 2011). Medical history, scheduling correct
examination and preparing the CT room all done by radiographers, clerical staff and others
(Romans 2011). The patient arrives, knowing how long fasting was required, roughly the
length of the exam, what they are having done and fill out a consent form. Upon patient
arrival radiographer checks request and consent form, communicates with patient finds out
any contraindications to having the exam or contrast administrations (Romans 2011), then
goes on to select appropriate protocol and preforms exam.
Contrast protocols: Some exams it is vital to use contrast agents in order to visualise
anatomical structures of interest (Hofer 2010). Oral or intravenous contrast agents are
utilised depending on examination, timings of image capture is very important post contrast
administration. Dose is dependent on patient habitus, mainly weight (Romans 2011),
Quality control: General tests that check the working order and quality of CT machine and
associated procedures are done regularly. Contrast resolution should be checked semi-
annually through use of low-contrast test objects with built in analytic schemes (Bushong
2013). Manufactures will also specify how to assess spatial resolution, also semi-annually
(Bushong 2013). Other aspects tested semi-annually or more include; slice thickness
(sensitivity profile), accuracy of table movement, laser localiser and radiation dose (Bushong
2013).

6. List and describe the factors you should consider when choosing a suitable
protocol for any given diagnostic CT scan? Explain your answer with an example.

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To gain accurate and relevant data that best shows desired anatomy in imaging, correct
protocol must be selected and followed. Many factors should come into consideration when
selecting protocol as an incorrect protocol could render exam useless. The request form
from referring doctor will usually state exam required, but it is the radiographers
responsibly to understand different protocols and if it will yield a diagnostic CT image. Below
are some important factors to consider when choosing suitable protocol:

ANATOMY/PATHOLOGY: What is the anatomical area of interest? What pathology is being

looked at? Do you need to include more than just the region of interest in case of secondary
complications for example metastases, vessel obstructions, lymph node enlargement (Hofer
2010)

CONTRAST: Is contrast requited for better visualisation of region(anatomy/pathology) of

interest? If yes, which type; oral or intravenous? Does the patient have any
contraindications for receiving certain types of contrast like reduced kidney function?
Iodinated or non-iodinated? Are vessels looking well enough to receive contrast (some
cancer patients may have “tired” vessels, ensure protocol options for other injection points
are known). Is specific timing needed for image acquisition? Multi-phase scan?

PROTECTION: What radiation protection is appropriate for this patient during this exam?
Eye shields? Breast shields? Lead gowns, all possible requirements ready in the room.

DOSE: How much radiation should be given? If it is a small patient reduce exposure and
volume of contrast given.

PATIENT: age/mental state/size/health: anything that may influence their suitability for the
exam. Are able to stay still and follow breathing instructions for the duration of the exam?
Can the scan time be decreased to minimise effect of image blur from motion? Can the use
of foam pads, pillows and straps help with minimisation of movement? If patient is
immobile ensure you have asked adequate amount of staff to help with PAT slide of patient
to and from CT table.

15
PAEDIATRIC: patient will need their own protocol, sometimes anaesthetics is needed, or
specialist machines.

All these factors combined will ensure best possible protocol is selected specifically to
individual patients. An example would be a middle-aged man presents to radiology
department with suspected prostate cancer. Radiographer would consider all clinical
information/history available and select a portal venous phase abdomen and pelvis
protocol. This protocol will allow assessment of pathology throughout pelvis, specifically
abnormalities involving prostate, bladder, rectum, seminal vesicles and vasculature. This
protocol is best for this pathology as non-ionic intravenous contrast is used to highlight
possible lesions within pelvic region, may also show secondary complications/metastases as
abdomen is also included (siemens 2012). Contrast allows for more accurate diagnosis and
monitoring of tumour growth showing vascular involvement. The patient would have
needed to fast for 4 hours prior, have completed the IV checklist also oral contrast is often
given around 1hour prior. Waiting for an hour after oral contrast will allow time for contrast
to disperse throughout gastrointestinal system and bladder ensuring adequate distention of
gastrointestinal tract allowing for better visualisation of lining of stomach and bowel loops
(Hofer 2010). When patient is fully positioned on table around 100ml of contrast is
administered by power injector there is then a 60 second delay before images are taken.
This delay allows IV contrast to enter external iliac vessels and peripheral prostate vessels,
vascular involvement assessed and better visualisation of lesion if present (Bae 2010).
Contraindications for this protocol would be patients with low kidney function(tested by
obtaining eGFR and creatinine levels), possible allergies or if female, pregnancy (Hofer,
2010)

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17
 Module 2: CT CHEST SCANNING

Objectives:
 Accurate protocol selection for CT Chest scanning
 Apply CT chest image viewing theory
 Recognition of CT Chest anatomy in the axial plane.

Task:
Work through the numbered practical questions in this workbook and type your answers in
the spaces provided. Where relevant, answers should refer to reputable sources of
information and be referenced appropriately.

1. Describe two major challenges associated with CT Chest scanning and give an
indication of how these might be overcome.
Chest comes with unique challenges not present in extremities, two of the major ones
discussed below:
- Respiratory movements: movement from breathing (diaphragm up and down)
especially in patients with shortness of breath will create motion artefacts or burring
of anatomical edges. Effects of this artefact is largest in imaging of thorax, abdomen
and pelvis. The main methods to avoid respiratory movements degrading image
quality is quicker scan times, and controlled breathing (Hofer 2010). Patients need to
be warned of breathing requirements pre scan, then during scan API (automatic
patient instruction) systems are often activated to instruct patient patient to hold
their breath for the entire duration of the scan or multiple small parts of it (Romans
2011). Failure of patient to hold their breath for duration of scan will result in motion
artefact and significant deterioration of image quality (Hofer 2010).
- Cardiac rhythm: poor cardiac output will greatly affect timing of scan, using auto
triggering will help reduce negative effects of this. Normal post contrast
administration delay times may not apply to patients with poor cardiac output this is
where auto triggering which will start scan specific to the individual is advantageous
(Trattner 2014).

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ECG Gating is the main technique used to overcome cardiac motion artefact (Romans 2011),
it is a protocol used in cardiac CT to acquire images during end-diastole. This is the point of
the cardiac cycle where it is thought there is the least cardiac motion, it may vary slightly
from patient to patient (Romans 2011). There are two types of gating methods, the first is
prospective ECG gating where times of least motion are identified by obtaining R wave
signals from the patient’s ECG which then triggers image acquisition (romans 2011). The
second is retrospective ECG gating, where ECG records cardiac rhythm and images are
acquired throughout the cycle then reconstructed post scan into data sets at desired phase
(Romans 2011).

2. Which anatomical structures are best visualised using the lung window? Give an
example of the values associated with this window (a range is acceptable).
As the name suggests the best visualised anatomy is the lung and lung parenchyma
(Heffernan 2016). Lung is a low-density tissue, and windowing correctly will allow for nodule
and low density pulmonary structures to be seen in finer detail and more clearly
differentiated from each other vs a soft tissue window where all lung shows as black
(Romans 2011). An example acceptable range would have to be long scale in order for
increased shades of grey to show air and the very light differentiations between lung
structures. Range is centred much lower usually around -200HU, with window width of
2000HU, meaning scale will be from -1200 to +800 HU (Hofer, 2010).

3. Which anatomical structures are best visualised using the soft tissue window? Give an
example of the values associated with this window (a range is acceptable).

An example of a typical soft tissue window is centred on 50HU with WW(window width) of
350HU (Hofer, 2010), so tissues with HU values from -125HU to +225HU are visualised. Soft
tissue windows are most often used for thoracic imaging, where many tissues of similar
density need more focused contrast to differentiate (Hofer 2010). The anatomical structures
best visualised include thoracic wall, muscles, cardia, connective tissue, vessels and fats
(Heffernan 2016). Contrastingly all tissues with density lower than -125HU will look black,

19
 like the lung. Tissues with densities higher than upper range of +225HU will look very white
with little of their internal structures visible, like bone (Romans 2011).

4. What is the third type of window that can be useful in demonstrating pathology of the
thorax? Give the name, values associated with this window and list the anatomical
structures of the thorax that this would be best suited to.
Bony window is also very useful in demonstrating pathology of the thoracic region,
Hounsfield unit for bone sits usually sits around 1000 (Hofer 2010). Typical values associated
with this type of image is a window width of around 1500, this is large to allow for wide
scale of contrast, and a window level of +300 HU (Hofer 2010). With this scale will be from -
450 to + 1050 meaning all voxels within these values will be demonstrated, all below will be
black, and all above will be white (Hofer 2010). These values allow for visualisation of
cortical outlines and medullary cavities within bone otherwise shown as white in soft tissue
and lung windows (Romans 2011). This window is purely for better visualisation of detail
and possible abnormalities in bony anatomy, vertebral bodies, ribs etc, especially important
when scanning oncology patients to assess for metastases (Heffernan 2016).

5. Review the following request form and from the information provided describe in the
chart below the protocol you would undertake.
Patient Details
Mrs Alvera Brosnon
17.02.38
 NUCLEAR MEDICINE
 RADIOLOGY
Frome University Hospital  ULTRASOUND

 Imaging Request Form 

Consultant: Organ Imaging  : 8648 9676

Ward / Clinic:
URGENT: Organ Imaging Fax: 8646 9667
Phone Pager
Examination requested:  Interpreter required

20
CT Chest Language: ........................

Clinical Notes: L.M.P.: ..............(All females of reproductive age)

Persistent cough and haemoptysis.

Requesting M.O.: Name: ....L. Ung.......................... Date: ....................

Signature: ..............L. Ung..........................

PATIENT POSITION: Feet first, supine, arms above head and supported on pillow

PATIENT PREPARATION A cup of water is given to patient pre-scan

Contrast checklist is confirmed
Breast shields off for topogram and on for scan
Mention breathing instructions will be given just before scan
too take a breath in and hold it
TOPOGRAM: AP
SCAN DIRECTION Craniocaudal
SCAN AREA: Above lung apices down to below costophrenic angles unless
extra anatomy needed.
RECONSTRUCTION: Lung window = 2.5mm/1.25
soft tissue = 2.5mm/1.25
IV CONTRAST: 80 ml at 3.0ml/s with 50ml of saline flush
TIMING: Scan delay for post contrast = 35 seconds

(Siemens 2012)

6. Define the terms Scan FoV and Recon FoV. Include in your answer their relationship to
each other.

Scan FoV = the area within gantry around isocentre from which raw data is acquired
(Romans 2011). The scan field of view can be seen in the routine tab on the topogram as the
purple box, this can be manipulated and moved to be more targeted over anatomy of
interest (Siemens 2000)

21
Recon FoV = often referred to as “display FoV” is the section of data selected to display on
the image (Romans 2011). The recon Field of View is reconstructed data from within scan
field of view post image acquisition (siemens 2000).

7. Define HRCT and describe its application in CT Chest scanning. Include in your answer
how this imaging technique has changed in recent times.
High Resolution Computed Tomography(HRCT) is a technique used when finer detail is
needed to assess lung parenchyma (Padley 1993). HRCT has its own protocols using thinner
slices (0.5-2mm) and faster acquisition times, often non-contrast, this is in order to reduce
effect of image blur from motion and optimise spatial resolution (Romans 2011). Images are
still taken on full inspiration as this intensifies the contrast between low attenuating air and
higher attenuating lung structures (Romans 2011), although when looking for air trapping
sometimes expiration scans will be performed (Padley 1993). A sharp high spatial resolution
lung reconstruction algorithm is applied to the images (Hofer 2010). HRCT is not method of
choice for chest imaging due to increased dose, clinical indications for HRCT chest would be
patients with known or suspected diffuse lung disease such as fibrosis or emphysema also
bronchiectasis (Padley 1993), where normal CT chest would not show the detail required for
radiologists to confidently report on images (Hofer 2010).
Recent changes have been centred around volumetric HRCT slowly replacing HRCT axial
protocols as most sites now have MDCT scanners (Romans 2011). In volumetric HRCT chest
helical mode will be used to scan entire lung rather than representative slices as in older
axial protocols, this allows for a more complete assessment of lungs. No chance of missing
any nodules and increasing post processing capabilities as well (Padley 1993). As the scan is
longer and covers more area most volumetric HRCT protocols will attempt to decrease tube
current in order to minimise radiation dose to patient (Trattner 2014).

8. Identify the anatomy on the following CT image, labels 1-18

22
 1. sternum 10. right bronchus intermedius
2. ascending aorta 11. right lower lobe segmental artery
3. main pulmonary artery 12. rib
4. left superior pulmonary vein 13. right interlobar pulmonary artery
5. left upper lobe bronchus 14. right superior pulmonary vein
6. left lower lobe pulmonary artery 15. superior vena cava
7. descending aorta 16. lung
8. vertebral body 17. let atrium
9. left lower lobe bronchus 18. scapula

Module 3: BRAIN

Objectives:
 Identify the cause and appearance of common artefacts in CT brain imaging.

23
  Identify anatomical structures on axial CT brain images.
 Contrast media identification on normal CT Brain images.
 Demonstrate an understanding of the application of contrast media in CT brain
scanning.
 Correlate clinical information in the selection of an appropriate protocol for a CT
Brain scan.
 Effectively evaluate a CT brain image series for pathology.

Task:
This module requires you to access the Voyager PACS in BJ1-60 computer pool for some
questions.
Work through the practical elements and numbered questions in this workbook in the
spaces provided. Where relevant, answers should refer to reputable sources of information
and be referenced appropriately.
Access the Voyager PACS as per instructions on page 18 of the software applications guide.
Go to the CT worklist and load the following study:
Study name: CT VIEWER COMPARE, Last Name: BR64, First Name: Brain.
There are two image sets for this study. Series 1 is a non-contrast study of the brain. Series 2
is a contrast enhanced study.
Double click in the box containing the non- contrast images to enter single view mode.
Study these images to answer the following questions.
1. The lateral ventricles of the brain can be visualised on image 13 to 17.
2. The right sylvian fissure can be seen on image 11 to 13
3. The cerebellum is covered in this series from image 2 to 8.
4. Comment on the relative radiographic density of white matter as compared to grey
matter

White matter, located centrally, has a slightly higher linear attenuation coefficient (µ) of
0.187 versus that of grey matter 0.184 (Hofer 2010) as it has more myelinated axons. ‘µ’
describes the fraction of x-ray beam that would be absorbed or scattered passing through
the substance, so the higher the number the more a beam will be able to penetrate (Mayles

24
2007). Myelin being a fatty substance makes white matter easier to penetrate resulting in a
darker, hypodense appearance in the image (Romans 2011).

Grey matter, located peripherally, has more cell bodies and water then myelinated axons
meaning it is harder to penetrate, thus appearing lighter on CT images (Romans 2011). This
is reflected in its lower linear attenuation coefficient, meaning anatomy is denser and less
beam will be absorbed or scattered (Mayles 2007) in comparison with white matter. In the
image grey matter appears brighter and hyperdense.

Close the single view window for the non-contrast series by double clicking
anywhere in the screen. Back in the double view mode, scroll through the contrast
enhanced image series.

5. With reference to both image sets, describe the vascular structures that become
visible with the administration of contrast media. To support your answer make
reference to image numbers from the contrast enhanced series.

Vascular structures that come visible with administration of contrast media include:

- Internal carotids seen as two well defined hyperdense vessels anterior to base of
skull bones on images 1-2, symmetrical and normal size.
- Vertebral arteries very clearly seen in image 1 within foramen magnum of occipital
bone, can be visualised in images 2-3 but not as bright.
- Pontine arteries well circumscribed vessel in image 4 anterior to pons.
- Basilar artery best visualised in lower scans, centrally close to base of skull and
brainstem. First seen on image 4 then until 8.
- Superior cerebellar is visualised on image 9 anterior to pons.
- Middle cerebral artery just posterior to basal aspect of frontal lobe, anterior to pons
as a hyperdense vessel going medial to laterally most obvious on image 10.
- Anterior cerebral artery seen anterior to pons and optic chiasm, image 10, and
perhaps slightly on right image 11.
- Posterior cerebral arteries not well visualised, slightly enhanced on image 10 sitting
laterally to pons.

25
 - Pericallosal artery, appears as hyperdense vessel seen end on coming off anterior
cerebral artery in image 11, then seen continuing anteriorly from images 12-15.
- Anterior communicating artery connects middle and anterior cerebral arteries,
enhanced in image 9-10.
- Posterior communicating artery not well visualised, connects middle and posterior
cerebral arteries, image 10.

Other anatomical structures of significance that become enhanced post contrast:

- Choroid plexus shows some calcification, enhanced and located in lateral ventricles
seen throughout images 11-16.
- Sylvian fissure houses branches of middle cerebral artery thus appears slightly
enhanced post contrast administration, image 11-12.
- Falx cerebri is a hyperdense fold of dura mater creating a longitudinal fissure in mid
sagittal region between cerebral hemispheres of the brain, seen images 10-26.

Addition possible artefacts?

- Streak artefact radiating from temporal bones most evident in images 4 and 5 non-
contrast.
- Partial volume artefact shown in image 10 near right middle cerebral artery, artefact
as it shows as bright on both contrast and non-contrast images.

I used Hofer 2010, CT teaching manual to aid my discussion of vascular structures

You can now close the Voyager PACS and research an answer to the next questions.
6. What are the normal densities measured in Hounsfield units of:
a. White matter = 20-30 (Romans 2011)
b. Grey matter = 32-45 (Romans 2011)
c. Cerebrospinal Fluid = ~15 (Heffernan 2016)

7. Describe the cause of the following artefacts and include a description of the likely
image appearance for each.
a. Partial volume artefact.

26
Partial volume artefact occurs when a dense aspect of anatomy does not lie totally within a
slice thickness, protruding only part way into width of x-ray beam (Barrett 2004). This can be
due partially to the divergence of x-ray beams along z axis, where dense object is just within
beam when pointing left to right, but just outside when beam is pointing opposite direction
(Barrett 2004). So, object is picked up by detectors however inconsistencies between sides
causes shading artefacts to appear (Barratt 2004). Partial volume artefact appears as darker
shaded area around object, so borders are not well defined. Effects of this can be reduced
by using thinner slice thicknesses however this would increase dose to patient (Hofer 2010).
It is important for radiographers to be aware of what partial volume artefact looks like, so
they can either point it out to radiologist, attempt to reduce its effect using post processing,
or repeat scan if image is undiagnostic (Romans 2011).
b. Beam hardening artefact.
X-ray beams have a variety of individual photons energies (Mayles 200&), as the beam
passes through an object it is said to become “harder” as more lower energy photons are
absorbed than higher, thus mean energy of beam increases (Mayles 2007). More than one
appearance type of artefact can result from this effect; cupping artefacts and streaks and
bands. Cupping appears as darker in the middle and lighter towards the edges of the object
being penetrated, it occurs when passing though uniform density round anatomy (Barrett
2004). As beam passes through centre of an object it is attenuated, or “hardened”, more
than the edge, thus is more intense towards centre when it reaches detector creating a
attenuation profile that differs from ideal profile without beam hardening (Barrett 2004).
The second possible appearance is broad dark bands or streaks across the image, usually
occurring between two dense objects in very heterogenous cross sections (Barrett 2004).
This occurs as beam is hardened less passing through dense object from one tube position
and more from another (Romans 2011). Artefact can appear when scanning bony regions of
the body, such as petrous ridge appearing as a dark horizontal line though it (Hofer 2010), or
where contrast media is present (Barrett 2004).
c. Ring artefact.
The cause of ring artefacts are defective detectors, for example on a third-generation
scanner if one detector is out of calibration it will consistently give incorrect readings at
each angular position resulting in a circular artefact (Barrett 2004). It is one of the least likely
artefacts to be confused with disease however still significantly degrades diagnostic image

27
quality (Romans 2011), sometimes increase mAs and using a wider window width when
possible can minimise appearance of ring artefacts (Barrett 2004).

8. Explain why CE CT is an effective diagnostic tool for the assessment of intracranial

neoplasms and metastases.

Contrast enhanced CT is an effect diagnostic tool for assessment of intracranial neoplasms

and metastases as these are often isodense to surrounding tissue and almost
indistinguishable on normal non-contrast scans (Fink 2013). Intravenous contrast media
power injected into venous system will increase density of blood (Siemens 2000), thus
allowing for easier differentiation from muscles and organs while also able to cross blood-
brain barrier providing information on rate of contrast uptake in pathologically altered
tissues such as neoplasms and metastases (Hofer 2010). Brain neoplasms and metastases
are often highly vascular meaning lesion will have high uptake of denser contrast media
intensifying signal and appearing bright on images (Hofer 2010). In addition, helical CT and
volume rendering allows for lesions non-superimposed location to be seen (Romans 2011).
Often unenhanced pre-contrast scans are performed then contrast enhances allowing for
images subtraction further aiding in diagnostic information (Hofer 2010). Brain metastases
may be visualised by rind, nodular or solid enhancement with contrast and has been shown
to be more sensitive than non-contrast MRI for detection of metastases (Fink 2013).

9. Review the following request form

Patient Details
Mrs Gilly Moore
17.02.82
 NUCLEAR MEDICINE
 RADIOLOGY
Frome University Hospital  ULTRASOUND

 Imaging Request Form 

Consultant: Organ Imaging  : 8648 9676

Ward / Clinic: Organ Imaging Fax: 8646 9667

28
URGENT:
Phone Pager
Examination requested:  Interpreter required
CT Head Language: ........................
Clinical Notes: L.M.P.: ..............(All females of reproductive age)
Worsening headache over the past week with associated nausea. PMHx Breast Ca

Requesting M.O.: Name: ...Dr.. B. Rain.......................... Date: ....................

Signature: ..............B Rain..........................

From the information provided describe in the chart below the protocol you would
undertake. Reference for all of below: (Siemens 2012)

PATIENT POSITION: - Supine, head first. Head in head holder

- OM baseline as perpendicular to the floor as possible.
- eye shield (off for topogram, on for scan)

PATIENT PREPARATION - Removal of all metal from scan area (hearing aids, air clips
etc)
- Pre-scan checklist completed and approved
- Cannula inserted if IV contrast needed?
TOPOGRAM: LAT 256
SCAN DIRECTION Caudocranial

SCAN AREA: Base of skull  skull vertex, can go a little extra to ensure quality
generation of images
RECONSTRUCTION: 5x5s direct axials – Kernel H31
2x1.6s direct axial (autosend PACS) – Kernel H31

WS4D: Axial 5x5s (utilized to straighten head and achieve correct

baseline)- H31 Sagittal 5x5s (right to left) – H31
Coronal 5x5s (anterior to posterior) – H31
IV CONTRAST: 50 mls, iodinated

29
 TIMING: 5 minutes delay post contrast injection

Module 4: PET CT & Pelvic Anatomy

Objectives: Understand the clinical application of PET CT scanning including;

 18F FDG radiopharmaceutical uptake and appearances
 Patient preparation for PET CT using 18F FDG
 Image fusion
Identify and label anatomy of the male and female pelvis on axial CT scan of the pelvis.
1. Discuss the role of 18F-FDG PET CT as a diagnostic imaging modality in oncology.

Cancer is one of the deadliest diseases in the world with accurate and fast diagnosis and
staging essential for minimising mortality rates. FDG-PET is a highly sensitive technique for
detection of malignant lesions, 18F-FDG is Flurine-18 fluorodeoxyglucose the most
commonly used radiotracer commonly thought of as the major factor in the advancement of
PET imaging (Goerres 2002). The role of 18F-FDG PET CT is especially important in oncology
as one of cancer’s most defining features is its higher metabolism of glucose versus normal
tissues (Buck 2004). Thus, administration of 18F-FDG, an analogue of glucose, will show
higher uptake in malignant lesions showing as “hot spots” on scans (Goerres 2002).
However, this can be problematic in patients that have other pathological processes
occurring simultaneously as infections, inflammatory processes and some benign lesions
may also have significant uptake of the tracer (Romans 2011). In addition, many major
organs have a ‘normal’ FDG uptake and with PET only showing limited anatomical locations
it becomes increasingly difficult to definitively diagnosis a ‘hot spot’ as normal or
pathological (Romans 2011). This is why a combined PET CT machine was developed, PET
gives metabolic information and CT adds benefit of superior anatomical information,
combining the techniques has been shown to significantly improve diagnostic accuracy
(Romans 2011). 18F-FDG PET CT now has a major role not only in cancer detection but also
staging throughout an individual’s treatment plan for response evaluation (Lee 2016). Now,
otherwise small and isodense malignancies be detected and tracked in more confidence
(Buck 2004) with patient scan time decreased and comfort increased.

30
A 59 y.o. gentleman has a medical history of Prostate Ca. treated with external beam
radiation therapy. Monitoring of his condition has revealed rising PSA levels and he has
been referred for a PET CT scan. A sample of his images is shown here.

2. The most likely indication of the blue arrow on this scan is?
a. Normal metabolic uptake of 18F FDG
b. Recurrent prostate disease  not normal uptake looks to be recurrent mass
c. Metastatic disease

Give a rationale for the answer that you have chosen.

The blue arrow points to what looks like an ill-defined mass in right aspect of prostate, quite
large and possibly compressing on adjacent structures. It is not normal uptake of 18F FDG,
the brain bladder and heart show normal uptake (Ahman 2006) but prostate does not
commonly show intense uptake (Romans 2011) such as pointed to by blue arrow. It could
not be metastatic disease either as patient has medical history of primary prostate cancer
and arrow is pointing to prostate, thus if mass is malignant it would be considered recurrent

31
not metastatic. Therefore, I choose recurrent prostate disease, we are also told patient has
rising PSA, prostate specific antigen, levels which also indicates the possibility of recurrent
prostate disease (Jadvar 2009). It is exclusively produced by prostatic epithelial cells and
said to increase with malignant involvement in prostate (Jadvar 2009).
3. The most likely indication of the red arrow on this scan is?
a. Normal metabolic uptake of 18F FDG.
b. Recurrent prostate disease.
c. Metastatic disease  looks to be metastatic bone disease around right pubic
bone

Give a rationale for the answer that you have chosen.

The arrow points to right pubic bone which has an obvious ‘hot spot’ on it, bone marrow
may show a slight heterogenous uptake but not significant like what the red arrow points to.
So, one can conclude that it is not normal anatomy and must be some sort of pathology. For
it to be recurrent prostate disease it would have to be in the prostate, which eliminates that
option and leaves only the possibly of metastatic disease. This would be a logical conclusion
to come to knowing there is medical history of prostate cancer, a visualised recurrent mass
in the prostate also shown on images and high risk of metastases to bone with prostate
cancer (Jadvar 2009).

4. What is the mechanism of uptake for 18F FDG?

Mechanism for uptake is the glycolytic metabolic pathway, being an analogue of glucose
uptake is very similar. FDG is actively transported by glucose transport proteins(GLUT) into
various cells in the body post administration, once in cell normal glucose would undergo
glycolysis pathway to produce energy this is where FDG differs (Jadvar 2009). FDG will not
enter glycolysis rather becomes trapped within cell as FDG-6-phosphate (Goerres 2002).
Malignant tissues have very high mitotic rates (essentially glucose metabolism) than normal
tissue, tumour cells also display increased GLUT these mechanisms cause uptake and
retention of FDG to be significantly higher compared with normal tissues (Goerres 2002). It
must be noted that FDG is not cancer specific, the principle for its uptake is the same for all
tissues with higher metabolic rates and glycolysis thus most sites of normal tissues will show

32
high uptake (Goerres 2002). This is why patients must fast, not move during scan or be
shown a movie that may stimulate brain activity as this would promote hyper activity and
increase uptake of glucose in those areas (Goerres 2002).

5. Using the images provided give a rationale for why we may see normal metabolic
uptake of 18F-FDG. Include in your answer the anatomic areas where this is most
likely to be observed.

Created in a cyclotron by bombarding an 18O target with protons, 18F-FDG is the most
commonly used radiopharmaceutical in PET scanning (Surasi 2014). As previously
mentioned 18F-FDG is an analogue of glucose any cell with high metabolic needs will show
some level of 18F-FDG uptake (Jadvar 2009). Malignant tissues favour glycolytic pathway for
metabolism and are known for increased glucose metabolism, 18F-FDG is taken up but cells
and phosphorylated as glucose within tissue then trapped intracellularly (Ahman 2006).
However, many other cells in the body require glucose to function, this is enhanced by any
physical activity and brain stimulation (Romans 2011). Anatomical areas where normal
metabolic uptake of 18F-FDG is most often observed is in tissue which require high amounts
of glucose to function (Goerres 2002) such as the below examples:

- Brain: has a very significant radiotracer uptake (approximately 6% of total

administered dose) in cerebral cortex and basal ganglia, glucose is the predominant
substrate for brain metabolism (Ahman 2006)
- Heart: heart muscles main energy source is oxidization of fatty acids, however in
fasting state it relies more heavily on glucose to function (Romans 2011). Its uptake
is highly variable and affected by many factors such as nutrition, hormones, fitness
etc.
- Lung: If disease is present, such as chronic obstructive pulmonary disease accessory
muscles of thorax are required to contract excessively on expiration resulting in
increased intercostal uptake, this uptake can be misinterpreted (Romans 2011).
- Kidneys, bladder and urinary collecting systems often show intense well-defined
regions of activity, through these organs glucose is excreted so FDG collects in these
areas, activity mostly normal (Goerres 2002) As previously mentioned adequate
hydration may minimise effect of this (Surasi 2014).

33
 - Liver, spleen and bone marrow usually show low homogenous uptake (Ahmad 2006).
Chemotherapy may increase uptake in some areas so radiographers must be aware
of current treatments and clinical history (Surasi 2014).

It is vital radiographers recognise the areas of normal uptake of FDG so it can be identified
to be of no significance (Ahman 2006).

6. Explain the purpose of attenuation correction in PET CT scanning.

Attenuation occurs in most radiographic techniques, beam is absorbed and scattered out of
the field by differing densities in the body leading too inaccurate detection of ‘true’
coincidence events (Romans 2011). A true event is when two gamma ray photons (resultant
from positron annihilation) are simultaneously detected, this allows for accurate distance
from emission to be detected, giving anatomical location (Romans 2011). However, a large
portion of detected events (50-90% depending on patient size) are not true events which
increases images noise, distortion and artefacts (Romans 2011). It causes underestimation
of uptake activity with common artefacts including “hot” lungs which is increased activity in
pulmonary regions (Lee 2016), blurring at body surface, ill-defined regions of activity due to
scatter (Ahmad 2006). Attenuation correction reduces effects of these, the CT scan is used
to map patients varying body densities and once PET is completed this map is used to
correct inaccuracies (Lee 2016). The process adds counts into areas of higher attenuation,
deeper denser structures, and subtracts counts from less attenuating areas like skin surface
and lungs (Romans 2011). This attenuation-corrected data is then used to calculate a
Standard Uptake Value(SUV) for specific Regions of Interest(ROI), a SUV value of greater
than 2.5 is considered as a possible malignant tissue (Lee 2016). Thus, without attenuation
correction, data from PET images would not be an accurate diagnostic tool to identify
malignant tissues.

7. Explain the importance of patient preparation required for PET CT utilising 18F-FDG.
Ensure you include in your answer an outline of the necessary preparation and the
consequences if the preparation is not followed properly.

34
Extensive patient preparation plays a vital role in obtaining good quality diagnostic PET
images, scans utilise 18F-FDG tracer that is only usable for small windows of time and its
uptake is affected by many physical and environmental factors (Surasi 2014). Preparation
can include anything from restrictions in diet, physical activity to medications (Romans
2011). Firstly, patient will book the scan, generally PET has been explained to them or they
have been given an information flyer by their doctor.
One day prior patient is called, and the following checks/preparations are confirmed:

- Fasting: ensuring patient has fasted correctly usually 6 hours prior to scan (Romans
2011). This is done to minimise dietary glucose-related competitive inhibition of the
tracer uptake (Surasi 2014). Checking over the phone will allow them to cancel and
rebook scan if necessary.
- Medications: some medications must be temporarily stopped as they have a risk of
interfering with the scan (Romans 2011). Most common example of this is diabetic
medication which contains glucose and insulin, restricting tracer from being taken up
properly (Surasi 2014). PET technician will confirm the appropriate times to stop
medication, usually at least 6 hours prior (Surasi 2014).
- Time frame: a day prior the approximate duration of hospital stay/scan time will be
confirmed, usually 3-4 hours (Surasi 2014). If not confirmed it may lead to
complications impacting on other patients and staff in addition to the booked
patient. In addition, PET tracers are expensive and ordered specific for each patient’s
appointment time and have a very short half-life meaning it will be unable to be
used if cancelled on the day of (Surasi 2014).
- Patient transport: usually it is suggested patients not drive or commute alone if
possible, ask if they have transport arrangements organised.
- Clothing: patient is told to wear warm clothes and minimise metal that could
obscure anatomy. If patient is cold shivering or thermogenesis has the potential to
mask or mimic malignant lesions (Surasi 2014). For this reason PET CT rooms have
warm blankets to be utilised and are kept at a minimum of 24 degrees Celsius (Surasi
2014).
- Mobility: patient is asked whether they are able to lay flat, if not extra preparations
would have to be made requiring extra time, possible need for pain medication

35
 - Mental impairments: this information is needed in case sedation may be necessary,
for example someone with severe claustrophobia may need this due to length of
scan in small gantry. Anaesthetist would need to be contacted in advance to assess
patients need.
- Diet: the day before scan patients are often given a sample menu describing a
specific ‘low carb/high fat’ diet to induce ketosis and increase free fatty acids (Surasi
2014). This is done in order to minimise physiologic-cardiac uptake of 18F-FDG
allowing more intricate details to be obtained from target structures (Surasi 2014).
- Physical activity: exercise is asked to be avoided or kept to absolute minimum for 24-
48 hours pre-scan to reduce uptake of radiotracer in skeletal muscles (Surasi 2014).
Usually muscle activity is symmetric and easily differentiated from abnormal activity
but sometimes it may be focal and make images difficult to interpret (Romans 2011).
This can include jogging, strenuous house work, sexual activity and even chewing
gum (Surasi 2014).
- Pregnancy check: may not be able to move forward with scan, situational (Romans
2011).

Preparation on the day after arrival:

- Explanation: nurse explains scan including any breathing instructions or other

requirements.
- Patient measurements: height and weight taken (this is important as patients are
given weight dependant doses of tracer (Surasi 2014)), cannulation all done in a
warm waiting room to ensure patient doesn’t get cold pre-scan.
- Hydration: patient is asked to drink a good amount (1 litre) of water in the hours
leading up to the scan to ensure low 18F-FDG concentration in urine, this is mainly
for radiation safety reasons (Surasi 2014). Patients will be asked to void just before
the scan, this minimises possible normal activity in bladder.
- Administration: through intravenous power injector, 30-60 minutes post
administration patient is placed on examination table (romans 2011), delay allows
adequate tracer uptake (Ahman 2006). During this time, it is imperative patient
remains at rest, arms by side, warm blanket, music is allowed except when imaging
the brain as this may induce brain activity increasing uptake (Surasi 2014).

36
In conclusion, without proper patient preparation PET images would be rendered almost
useless with increased difficulty differentiating between normal anatomical uptake and
pathological uptake of 18F-FDG tracer (Ahman 2006).

8. Discuss the advantages of hybrid PET CT imaging compared to PET imaging alone.
What information do the individual scans i.e. PET and CT provide and what is the
benefit of fusing the two scans?

CT is an anatomical modality thus will only demonstrate pathology when it distorts anatomy
(Hofer 2010). PET scans have the ability to assess chemical and physiological changes
related to metabolic uptake of tissues regardless of their anatomical distortion (Ahman
2006), this is vital for detection of disease in early stages as studies have shown functional
changes usually occur before structural (Romans 2011). PET however lacks morphological
information needed to accurately localise abnormal tissues (Lee 2016). Additionally, it is
easy to see how normal physiological uptake of 18F-FDG may make assessing images
difficult looking at PET alone (Romans 2011). Originally CT scan would first be done on one
machine, then patient moved to have their PET done on another (Ahman 2006). However,
challenges emerged when comparing images, patient position was often different making
for inaccurate overlap (Romans 2011). Hybrid PET CT combines both into single machine
providing superior functional and morphological imaging in a single exam (Lee 2016). First
the CT component of the scan is performed, then without patient moving or changing
position PET scan acquired using exact same field of view giving attenuation corrected PET,
CT and a fused PET CT image in all three planes for evaluation (Ahman 2006). A Fused PET
CT images is when the data of both imaging methods are overlayed electronically and
displayed on a work station which allows manipulation and post processing as CT, PET or
superimposed CT PET data at any percent desired (Romans 2011)

Major advantages of hybrid PET CT imaging compared to PET alone:

- Improved localisation of disease as less image alignment errors would occur when
one system is used rather than multiple separately acquired images (Lee 2016)
(Ahman 2006). This increases confidence level in image interpretation, with fused

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 PET CT radiologist can say with higher confidence that an area of increased uptake is
pathological not normal (Romans 2011)
- Improved attenuation correction (Ahman 2006) as there is reduced problems
associated with patient movement, repositioning and ability to coregister PET and CT
precisely (Romans 2011). Data required for attenuation correction generated from
CT and applied to PET data (Romans 2011).
- Reduced time and cost as there is no longer the need to transmit scan for
attenuation correction, they can be fused with CT providing anatomical information
needed to correctly calculate Standard Uptake Values (Lee 2016).
- Ability to detect, in detail with localisation, malignant or pathological changes in
early stages of disease (Romans 2011).
- Patient convenience and comfort: In just one appointment a complete assessment of
the metabolic and anatomical status of disease can be obtained, often not taking
more than a few hours (Lee 2016).

9. Identify the anatomy on the following CT image, labels 1-15

1. bladder 9.

2. Left external iliac artery 10. pubis

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 3. Left external iliac vein 11. right external iliac artery

4. 12.right external iliac vein

5. 13. rectus abdominis muscle

6. rectum 14. quadriceps femoris muscle

7. Tip of coccyx 15. prostate gland

8. ischium 16. iliopsoas muscle

10. Identify the anatomy on the following CT image, labels 1-15

1. bladder 9. ilium

2. Sigmoid colon 10. Gluteus maximus muscle

3. Left external iliac artery 11. sacrum

4. left external iliac vein 12. piriformis muscle

5. Gluteus minimus muscle 13. rectum

6. gluteus medius muscles 14. right ovary

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 7. left ovary 15. iliacus muscle

8. uterus(IUD present) 16. right external iliac artery

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