Total-Body PET: Maximizing Sensitivity to Create New Opportunities for Clinical Research and Patient Care

PET/CT for Brain Amyloid: A Feasibility Study for Scan Time Reduction by Deep Learning

PURPOSE

This study was to develop a convolutional neural network (CNN) model with a residual learning framework to predict the full-time 18F-florbetaben (18F-FBB) PET/CT images from corresponding short-time scans.

METHODS

In this retrospective study, we enrolled 22 cognitively normal subjects, 20 patients with mild cognitive impairment, and 42 patients with Alzheimer disease. Twenty minutes of list-mode PET/CT data were acquired and reconstructed as the ground-truth images. The short-time scans were made in either 1, 2, 3, 4, or 5 minutes. The CNN with a residual learning framework was implemented to predict the ground-truth images of 18F-FBB PET/CT using short-time scans with either a single-slice or a 3-slice input layer. Model performance was evaluated by quantitative and qualitative analyses. Additionally, we quantified the amyloid load in the ground-truth and predicted images using the SUV ratio.

RESULTS

On quantitative analyses, with increasing scan time, the normalized root-mean-squared error and the SUV ratio differences between predicted and ground-truth images gradually decreased, and the peak signal-to-noise ratio increased. On qualitative analysis, the predicted images from the 3-slice CNN model showed better image quality than those from the single-slice model. The 3-slice CNN model with a short-time scan of at least 2 minutes achieved comparable, quantitative prediction of full-time 18F-FBB PET/CT images, with adequate to excellent image quality.

CONCLUSIONS

The 3-slice CNN model with a residual learning framework is promising for the prediction of full-time 18F-FBB PET/CT images from short-time scans.

Practice and prospects for PET/CT guided interventions

During the past 10 years, performing real-time molecular imaging with positron emission tomography (PET) in combination with computed tomography (CT) during interventional procedures has undergone rapid development. Keeping in mind the interest of the nuclear medicine readers, an update is provided of the current workflows using real-time PET/CT in percutaneous biopsies and tumor ablations. The clinical utility of PET/CT guided biopsies in cancer patients with lung, liver, lymphoma, and bone tumors are reviewed. Several technological developments, including the introduction of new PET tracers and robotic arms as well as opportunities provided through acquiring radioactive biopsy specimens are briefly reviewed.

Cross-validation study between the HRRT and the PET component of the SIGNA PET/MRI system with focus on neuroimaging

Background

The Siemens high-resolution research tomograph (HRRT - a dedicated brain PET scanner) is to this day one of the highest resolution PET scanners; thus, it can serve as useful benchmark when evaluating performance of newer scanners. Here, we report results from a cross-validation study between the HRRT and the whole-body GE SIGNA PET/MR focusing on brain imaging.

Phantom data were acquired to determine recovery coefficients (RCs), % background variability (%BG), and image voxel noise (%). Cross-validation studies were performed with six healthy volunteers using [¹¹C]DTBZ, [¹¹C]raclopride, and [¹⁸F]FDG. Line profiles, regional time-activity curves, regional non-displaceable binding potentials (BP_ND) for [¹¹C]DTBZ and [¹¹C]raclopride scans, and radioactivity ratios for [¹⁸F]FDG scans were calculated and compared between the HRRT and the SIGNA PET/MR.

Results

Phantom data showed that the PET/MR images reconstructed with an ordered subset expectation maximization (OSEM) algorithm with time-of-flight (TOF) and TOF + point spread function (PSF) + filter revealed similar RCs for the hot spheres compared to those obtained on the HRRT reconstructed with an ordinary Poisson-OSEM algorithm with PSF and PSF + filter. The PET/MR TOF + PSF reconstruction revealed the highest RCs for all hot spheres. Image voxel noise of the PET/MR system was significantly lower. Line profiles revealed excellent spatial agreement between the two systems. BP_ND values revealed variability of less than 10% for the [¹¹C]DTBZ scans and 19% for [¹¹C]raclopride (based on one subject only). Mean [¹⁸F]FDG ratios to pons showed less than 12% differences.

Conclusions

These results demonstrated comparable performances of the two systems in terms of RCs with lower voxel-level noise (%) present in the PET/MR system. Comparison of in vivo human data confirmed the comparability of the two systems. The whole-body GE SIGNA PET/MR system is well suited for high-resolution brain imaging as no significant performance degradation was found compared to that of the reference standard HRRT.

Field-programable-gate-array-based distributed coincidence processor for high count-rate online positron emission tomography coincidence data acquisition

For positron emission tomography (PET) online data acquisition, a centralized coincidence processor (CCP) with single-thread data processing has been used to select coincidence events for many PET scanners. A CCP has the advantages of highly integrated circuit, compact connection between detector front-end and system electronics and centralized control of data process and decision making. However, it also has the drawbacks of data process delay, difficulty in handling very high count-rates of single and coincidence events and complicated algorithms to implement. These problems are exacerbated when implementing a CCP on a field-programable-gate-array (FPGA) due to increased routing congestion and reduced data throughput. Industry companies have applied non-centralized or distributed data processing to solve these problems, but those solutions remain either proprietary or lack full disclosure of technical details that make the techniques unclear and difficult to adapt for most research communities. In this study, we investigated the use of a set of distributed coincidence processors (DCP) that can address the CCP problems and be implemented relatively easily. Each coincidence processor exclusively connects one detector pair and selects coincidence events from this detector pair only, which breaks a centralized coincidence process to a collection of independent and parallel processes. DCP can significantly minimize the data process delay, maximize count-rates of coincidence events and simplify implementation by implementing a single coincidence processor with one detector pair and replicating it to the rest. A prototype DCP with 42 coincidence processors was implemented on an off-the-shelf FPGA development board for a small PET with 12 detectors configured with 42 detector pairs. DCP performances were tested with both pulsed signals and gamma ray interactions. There was no coincidence data loss up to the detector's maximum singles count-rate (250 k s^-1). Approximately 1.2 k registers were utilized for each coincidence processor and the FPGA resource utilization was proportional to the number of coincidence processors. Coincidence timing spectra showed the results from accurately acquired coincidence events. In conclusion: complementary to CCP, DCP can provide high count-rate capability, with a simplified algorithm for implementation and potentially a practical solution for online acquisition of a PET with a larger number of detector pairs or for ultrahigh-throughput imaging.

PET/CT Imaging for Personalized Management of Infectious Diseases

Positron emission tomography combined with computed tomography (PET/CT) is a nuclear imaging technique which is increasingly being used in infectious diseases. Because infection foci often consume more glucose than surrounding tissue, most infections can be diagnosed with PET/CT using 2-deoxy-2-[18F]fluoro-D-glucose (FDG), an analogue of glucose labeled with Fluorine-18. In this review, we discuss common infectious diseases in which FDG-PET/CT is currently applied including bloodstream infection of unknown origin, infective endocarditis, vascular graft infection, spondylodiscitis, and cyst infections. Next, we highlight the latest developments within the field of PET/CT, including total body PET/CT, use of novel PET radiotracers, and potential future applications of PET/CT that will likely lead to increased capabilities for patient-tailored treatment of infectious diseases.

A layered single-side readout depth of interaction time-of-flight-PET detector

We are exploring a scintillator-based PET detector with potential of high sensitivity, depth of interaction (DOI) capability, and timing resolution, with single-side readout. Our design combines two previous concepts: (1) multiple scintillator arrays stacked with relative offset, yielding inherent DOI information, but good timing performance has not been demonstrated with conventional light sharing readout. (2) Single crystal array with one-to-one coupling to the photodetector, showing superior timing performance compared to its light sharing counterparts, but lacks DOI. The combination, where the first layer of a staggered design is coupled one-to-one to a photodetector array, may provide both DOI and timing resolution and this concept is here evaluated through light transport simulations. Results show that: (1) unpolished crystal pixels in the staggered configuration yield better performance across all metrics compared to polished pixels, regardless of readout scheme. (2) One-to-one readout of the first layer allows for accurate DOI extraction using a single threshold. The number of multi pixel photon counter (MPPC) pixels with signal amplitudes exceeding the threshold corresponds to the interaction layer. This approach was not possible with conventional light sharing readout. (3) With a threshold of 2 optical photons, the layered approach with one-to-one coupled first layer improves timing close to the MPPC compared to the conventional one-to-one coupling non-DOI detector, due to effectively reduced crystal thickness. Single detector timing resolution values of 91, 127, 151 and 164 ps were observed per layer in the 4-layer design, to be compared to 148 ps for the single array with one-to-one coupling. (4) For the layered design with light sharing readout, timing improves with increased MPPC pixel size due to higher signal per channel. In conclusion, the combination of straightforward DOI determination, good timing performance, and relatively simple design makes the proposed concept promising for DOI-Time-of-Flight PET detectors.

Applications of nuclear-based imaging in gene and cell therapy: probe considerations

Several types of gene- and cell-based therapeutics are now emerging in the cancer immunotherapy, transplantation, and regenerative medicine landscapes. Radionuclear-based imaging can be used as a molecular imaging tool for repetitive and non-invasive visualization as well as in vivo monitoring of therapy success. In this review, we discuss the principles of nuclear-based imaging and provide a comprehensive overview of its application in gene and cell therapy. This review aims to inform investigators in the biomedical field as well as clinicians on the state of the art of nuclear imaging, from probe design to available radiopharmaceuticals and advances of direct (probe-based) and indirect (transgene-based) strategies in both preclinical and clinical settings. Notably, as the nuclear-based imaging toolbox is continuously expanding, it will be increasingly incorporated into the clinical setting where the distribution, targeting, and persistence of a new generation of therapeutics can be imaged and ultimately guide therapeutic decisions.

Radiolabelling of nanomaterials for medical imaging and therapy

Nanomaterials offer unique physical, chemical and biological properties of interest for medical imaging and therapy. Over the last two decades, there has been an increasing effort to translate nanomaterial-based medicinal products (so-called nanomedicines) into clinical practice and, although multiple nanoparticle-based formulations are clinically available, there is still a disparity between the number of pre-clinical products and those that reach clinical approval. To facilitate the efficient clinical translation of nanomedicinal-drugs, it is important to study their whole-body biodistribution and pharmacokinetics from the early stages of their development. Integrating this knowledge with that of their therapeutic profile and/or toxicity should provide a powerful combination to efficiently inform nanomedicine trials and allow early selection of the most promising candidates. In this context, radiolabelling nanomaterials allows whole-body and non-invasive in vivo tracking by the sensitive clinical imaging techniques positron emission tomography (PET), and single photon emission computed tomography (SPECT). Furthermore, certain radionuclides with specific nuclear emissions can elicit therapeutic effects by themselves, leading to radionuclide-based therapy. To ensure robust information during the development of nanomaterials for PET/SPECT imaging and/or radionuclide therapy, selection of the most appropriate radiolabelling method and knowledge of its limitations are critical. Different radiolabelling strategies are available depending on the type of material, the radionuclide and/or the final application. In this review we describe the different radiolabelling strategies currently available, with a critical vision over their advantages and disadvantages. The final aim is to review the most relevant and up-to-date knowledge available in this field, and support the efficient clinical translation of future nanomedicinal products for in vivo imaging and/or therapy.

Liquid biopsy enters the clinic - implementation issues and future challenges

Historically, studies of disseminated tumour cells in bone marrow and circulating tumour cells in peripheral blood have provided crucial insights into cancer biology and the metastatic process. More recently, advances in the detection and characterization of circulating tumour DNA (ctDNA) have finally enabled the introduction of liquid biopsy assays into clinical practice. The FDA has already approved several single-gene assays and, more recently, multigene assays to detect genetic alterations in plasma cell-free DNA (cfDNA) for use as companion diagnostics matched to specific molecularly targeted therapies for cancer. These approvals mark a tipping point for the widespread use of liquid biopsy in the clinic, and mostly in patients with advanced-stage cancer. The next frontier for the clinical application of liquid biopsy is likely to be the systemic treatment of patients with 'ctDNA relapse', a term we introduce for ctDNA detection prior to imaging-detected relapse after curative-intent therapy for early stage disease. Cancer screening and diagnosis are other potential future applications. In this Perspective, we discuss key issues and gaps in technology, clinical trial methodologies and logistics for the eventual integration of liquid biopsy into the clinical workflow.

Scanner Design Considerations for Long Axial Field-of-View PET Systems

This article describes aspects of PET scanner design for long axial field-of-view systems and how these choices have an impact on scanner performance.

Review: PET imaging with macro- and middle-sized molecular probes

Recent progress in radiolabeling of macro- and middle-sized molecular probes has been extending possibilities to use PET molecular imaging for dynamic application to drug development and therapeutic evaluation. Theranostics concept also accelerated the use of macro- and middle-sized molecular probes for sharpening the contrast of proper target recognition even the cellular types/subtypes and proper selection of the patients who should be treated by the same molecules recognition. Here, brief summary of the present status of immuno-PET, and then further development of advanced technologies related to immuno-PET, peptidic PET probes, and nucleic acids PET probes are described.

Theranostics: The Role of Quantitative Nuclear Medicine Imaging

Theranostics is a precision medicine discipline that integrates diagnostic nuclear medicine imaging with radionuclide therapy in a manner that provides both a tumor phenotype and personalized therapy to patients with cancer using radiopharmaceuticals aimed at the same target-specific biological pathway or receptor. The aim of quantitative nuclear medicine imaging is to plan the alpha or beta-emitting therapy based on an accurate 3-dimensional representation of the in-vivo distribution of radioactivity concentration within the tumor and normal organs/tissues in a noninvasive manner. In general, imaging may be either based on positron emission tomography (PET) or single photon emission computed tomography (SPECT) invariably in combination with X-ray CT (PET/CT; SPECT/CT) or, to a much lesser extent, MRI. PET and SPECT differ in terms of the radionuclides and physical processes that give rise to the emission of high energy photons, as well as the sets of technologies involved in their detection. Using a variety of standardized quantitative parameters, system calibration, patient preparation, imaging acquisition and reconstruction protocols, and image analysis protocols, an accurate quantification of the tracer distribution can be obtained, which helps prescribe the therapeutic dose for each patient.

New probe for the improvement of the Spatial Resolution in total-body PET (PROScRiPT)

In recent decades, PET scanners have been widely used for diagnosis and treatment monitoring in nuclear medicine. The continuous effort of the scientific community has led to improvements in scanner performance. Total-body PET is one of the latest upgrades in PET scanners. These kinds of scanners are able to scan the whole body of the patient with a single bed position, since the scanner tube is long enough for the patient to fit inside. While these scanners show unprecedented efficiency and extended field-of-view, a drawback is their low spatial resolution compared to dedicated scanners. In order to improve the spatial resolution of specific areas when measuring with a total-body PET scanner, the IRIS group at IFIC-Valencia is developing a probe. The proposed setup of the probe contains a monolithic scintillation crystal and a SiPM. The signal of the probe is read out by a TOFPET2 ASIC from PETsys, which has shown good performance for PET in terms of spatial and time resolutions. Furthermore, the PETsys technology generates a trigger signal that will be used to time synchronise the probe and the scanner. The proof-of-concept of the probe will be tested in a Preclinical Super Argus PET/CT scanner for small animals located at IFIC. Preliminary simulations of the scanner and the probe under ideal conditions show a slight improvement in the position reconstruction compared to the data obtained with the scanner, therefore we expect a considerable improvement when using the probe in a total-body PET scanner. Characterisation tests of the probe have been performed with a 22Na point-like source, obtaining an energy resolution of 9.09% for the 511 keV energy peak and a temporal resolution of 619 ps after time walk correction. The next step of the project is to test the probe measuring in temporal coincidence with the scanner.

Practical joint reconstruction of activity and attenuation with autonomous scaling for time-of-flight PET

Recent research has showed that attenuation images can be determined from emission data, jointly with activity images, up to a scaling constant when utilizing the time-of-flight (TOF) information. We aim to develop practical CT-less joint reconstruction for clinical TOF PET scanners to obtain quantitatively accurate activity and attenuation images. In this work, we present a joint reconstruction of activity and attenuation based on MLAA (maximum likelihood reconstruction of attenuation and activity) with autonomous scaling determination and joint TOF scatter estimation from TOF PET data. Our idea for scaling is to use a selected volume of interest (VOI) in a reconstructed attenuation image with known attenuation, e.g. a liver in patient imaging. First, we construct a unit attenuation medium which has a similar, though not necessarily the same, support to the imaged emission object. All detectable LORs intersecting the unit medium have an attenuation factor of e -1≈ 0.3679, i.e. the line integral of linear attenuation coefficients is one. The scaling factor can then be determined from the difference between the reconstructed attenuation image and the known attenuation within the selected VOI normalized by the unit attenuation medium. A four-step iterative joint reconstruction algorithm is developed. In each iteration, (1) first the activity is updated using TOF OSEM from TOF list-mode data; (2) then the attenuation image is updated using XMLTR-a extended MLTR from non-TOF LOR sinograms; (3) a scaling factor is determined based on the selected VOI and both activity and attenuation images are updated using the estimated scaling; and (4) scatter is estimated using TOF single scatter simulation with the jointly reconstructed activity and attenuation images. The performance of joint reconstruction is studied using simulated data from a generic whole-body clinical TOF PET scanner and a long axial FOV research PET scanner as well as 3D experimental data from the PennPET Explorer scanner. We show that the proposed joint reconstruction with proper autonomous scaling provides low bias results comparable to the reference reconstruction with known attenuation.

Where to next prostate-specific membrane antigen PET imaging frontiers?

PURPOSE OF REVIEW

Technical improvements in imaging equipment and availability of radiotracers, such as PSMA-ligands have increased the synergy between Urology and Nuclear Medicine. Meanwhile artificial intelligence is introduced in Nuclear Imaging. This review will give an overview of recent technical and clinical developments and an outlook on application of these in the near future.

RECENT FINDINGS

Digital PET/CT has shown gradual improvement in lesion detection and demarcation over conventional PET/CT, but total-body PET/CT holds promise for a magnitude of improvement in scan duration and quality, quantification, and dose optimization. PET-guided decision-making with the application of PSMA-ligands has been shown useful in demonstrating and biopting primary prostate cancer (PCa) lesions, guiding radiotherapy, guiding surgical resection of recurrent PCa, and assessing therapy response in PCa. Artificial intelligence made its way into Nuclear Imaging just recently, but encouraging progress promises clinical application with unprecedented possibilities.

SUMMARY

Evidence is growing on clinical usefulness of PET-guided decision-making with the still relatively new PSMA ligands as a prime example. Rapid evolution of PET instrumentation and clinical introduction of artificial intelligence will be the gamechangers of nuclear imaging in the near future, though its powers should still be mastered and incorporated in clinical practice.

Quantitative positron emission tomography imaging in the presence of iodinated contrast media using electron density quantifications from dual-energy computed tomography

PURPOSE

As preparation for future positron emission tomography (PET)/dual-energy computed tomography (DECT)T imaging modality and new possible clinical applications, the study aimed to evaluate the utility of clinically available spectral results from a DECT system for improving attenuation corrections of PET acquisitions in the presence of iodinated contrast media. The dependence of the accuracy of PET quantification values, reconstructed with conventional and spectral-based attenuation corrections, was examined as a function of the amount of iodine content and x-ray radiation exposure.

METHODS

Measurements were performed on commercial PET/CT and DECT systems, using a semi-anthropomorphic phantom with seven centrifuge tubes in its bore. Five different configurations of tube contents were scanned by both PET/CT and DECT. With the aim of mimicking clinically observed concentrations, in all phantom configurations the center tube contained a high concentration of radionuclide while the peripheral tubes contained a lower concentration of radionuclide. Iodine content was incrementally increased between phantom configurations by replacing iodine-free tubes with tubes that contained the original radionuclide concentration within a 10 mg/ml iodine dilution. DECT-based attenuation correction maps were generated by scaling electron density spectral results into corresponding 511 keV photon linear attenuation coefficients.

RESULTS

Mean SUV values obtained from the nominal PET reconstruction, using conventional CT images as input for the attenuation correction, demonstrate a monotonic increase of 8.6% when the water and radionuclide mixtures were replaced by iodine, water, and radionuclide (same level of activity) mixture. Mean SUV values obtained from the DECT-based reconstruction, in which the attenuation correction utilizes electron density values as input, demonstrate different, more stable behavior across all iodine insert configurations, with a standard deviation to mean ratio of less than 1%. This observed behavior was independent of the area size used for measurement. A minor radiation dose dependency of the electron density values (below 0.5%) was observed. This resulted in consistent (iodine independent) PET quantification behavior, which persisted even at the lowest radiation dose levels tested in our experiment, that is, 25% of the radiation dose utilized for CT acquisition in the clinical PET/CT protocol.

CONCLUSIONS

Utilization of DECT-generated electron density estimations for attenuation correction benefit PET quantification consistency in the presence of iodine and at nominal and low DECT radiation exposure levels. The ability to correctly account for iodinated contrast media in PET acquisitions will allow the development of new clinical applications that rely on the quantitative capabilities of spectral CT technologies and modern PET systems.

Consensus Recommendations on the Use of 18F-FDG PET/CT in Lung Disease

PET with 18F-FDG has been increasingly applied, predominantly in the research setting, to study drug effects and pulmonary biology and to monitor disease progression and treatment outcomes in lung diseases that interfere with gas exchange through alterations of the pulmonary parenchyma, airways, or vasculature. To date, however, there are no widely accepted standard acquisition protocols or imaging data analysis methods for pulmonary 18F-FDG PET/CT in these diseases, resulting in disparate approaches. Hence, comparison of data across the literature is challenging. To help harmonize the acquisition and analysis and promote reproducibility, we collated details of acquisition protocols and analysis methods from 7 PET centers. From this information and our discussions, we reached the consensus recommendations given here on patient preparation, choice of dynamic versus static imaging, image reconstruction, and image analysis reporting.

Quantitative Whole-Body Imaging of I-124-Labeled Adeno-Associated Viral Vector Biodistribution in Nonhuman Primates

A method is presented for quantitative analysis of the biodistribution of adeno-associated virus (AAV) gene transfer vectors following in vivo administration. We used iodine-124 (I-124) radiolabeling of the AAV capsid and positron emission tomography combined with compartmental modeling to quantify whole-body and organ-specific biodistribution of AAV capsids from 1 to 72 h following administration. Using intravenous (IV) and intracisternal (IC) routes of administration of AAVrh.10 and AAV9 vectors to nonhuman primates in the absence or presence of anticapsid immunity, we have identified novel insights into initial capsid biodistribution and organ-specific capsid half-life. Neither I-124-labeled AAVrh.10 nor AAV9 administered intravenously was detected at significant levels in the brain relative to the administered vector dose. Approximately 50% of the intravenously administered labeled capsids were dispersed throughout the body, independent of the liver, heart, and spleen. When administered by the IC route, the labeled capsid had a half-life of ∼10 h in the cerebral spinal fluid (CSF), suggesting that by this route, the CSF serves as a source with slow diffusion into the brain. For both IV and IC administration, there was significant influence of pre-existing anticapsid immunity on I-124-capsid biodistribution. The methodology facilitates quantitative in vivo viral vector dosimetry, which can serve as a technique for evaluation of both on- and off-target organ biodistribution, and potentially accelerate gene therapy development through rapid prototyping of novel vector designs.

Potential Cardiovascular Applications of Total-body PET Imaging

Cardiovascular conditions can exist as part of a systemic disorder (eg, sarcoidosis, amyloidosis, or vasculitis) or have systemic consequences as a result of the cardiovascular insult (eg, myocardial infarction). In other circumstances, multisystem evaluation of metabolism and blood flow might be key for evaluation of multisystemic syndromes or conditions. Long axial field-of-view PET/computed tomography systems hold the promise of transforming the investigation of such systemic disorders. This article aims at reviewing some of the potential cardiovascular applications of this novel instrumentation device.

Positron annihilation localization by nanoscale magnetization

In positron emission tomography (PET), the finite range over which positrons travel before annihilating with an electron places a fundamental physical limit on the spatial resolution of PET images. After annihilation, the photon pair detected by the PET instrumentation is emitted from a location that is different from the positron-emitting source, resulting in image blurring. Here, we report on the localization of positron range, and hence annihilation quanta, by strong nanoscale magnetization of superparamagnetic iron oxide nanoparticles (SPIONs) in PET-MRI. We found that positron annihilations localize within a region of interest by up to 60% more when SPIONs are present (with [Fe] = 3 mM) compared to when they are not. The resulting full width at half maximum of the PET scans showed the spatial resolution improved by up to \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\approx$$\end{document}≈ 30%. We also found evidence suggesting that the radiolabeled SPIONs produced up to a six-fold increase in ortho-positronium. These results may also have implications for emerging cancer theranostic strategies, where charged particles are used as therapeutic as well as diagnostic agents and improved dose localization within a tumor is a determinant of better treatment outcomes.

Total-body PET Imaging: A New Frontier for the Assessment of Metabolic Disease and Obesity

Obesity and associated metabolic syndrome are a global public health issue. Understanding the pathophysiology of this systemic disease is of critical importance for the development of future therapeutic interventions to improve clinical outcomes. The multiorgan nature of the pathophysiology of obesity presents a unique challenge. Total-body PET imaging, either static or dynamic, provides a vital set of tools to study organ crosstalk. The visualization and quantification of tissue metabolic kinetics with total-body PET in health and disease provides essential information to better understand disease physiology and potentially develop diagnostic and therapeutic modalities.

Assessment of Total-Body Atherosclerosis by PET/Computed Tomography

Atherosclerotic burden has become the focus of cardiovascular risk assessment. PET/computed tomography (CT) imaging with the tracers 18F-fluorodeoxyglucose and 18F-sodium fluoride shows arterial wall inflammation and microcalcification, respectively. Arterial uptake of both tracers is modestly age dependent. 18F-sodium fluoride uptake is consistently associated with risk factors and more easily measured in the heart. Because of extremely high sensitivity, ultrashort acquisition, and minimal radiation to the patient, total-body PET/CT provides unique opportunities for atherosclerosis imaging: disease screening and delayed and repeat imaging with global disease scoring and parametric imaging to better characterize the atherosclerosis of individual patients.

Augmented Whole-Body Scanning via Magnifying PET

A novel technique, called augmented whole-body scanning via magnifying PET (AWSM-PET), that improves the sensitivity and lesion detectability of a PET scanner for whole-body imaging is proposed and evaluated. A Siemens Biograph Vision PET/CT scanner equipped with one or two high-resolution panel-detectors was simulated to study the effectiveness of AWSM-PET technology. The detector panels are located immediately outside the scanner's axial field-of-view (FOV). A detector panel contains 2 ×8 detector modules each consisting of 32 ×64 LSO crystals ( 1.0 ×1.0 ×10.0 mm3 each). A 22Na point source was stepped across the scanner's FOV axially to measure sensitivity profiles at different locations. An elliptical torso phantom containing 7×9 spherical lesions was imaged at different axial locations to mimic a multi-bed-position whole-body imaging protocol. Receiver operating characteristic (ROC) curves were analyzed to evaluate the improvement in lesion detectability by the AWSM-PET technology. Experimental validation was conducted using an existing flat-panel detector integrated with a Siemens Biograph 40 PET/CT scanner to image a torso phantom containing spherical lesions with diameters ranging from 3.3 to 11.4 mm. The contrast-recovery-coefficient (CRC) of the lesions was evaluated for the scanner with or without the AWSM-PET technology. Monte Carlo simulation shows 36%-42% improvement in system sensitivity by a dual-panel AWSM-PET device. The area under the ROC curve is 0.962 by a native scanner for the detection of 4 mm diameter lesions with 5:1 tumor-to-background activity concentration. It was improved to 0.977 and 0.991 with a single- and dual-panel AWSM-PET system, respectively. Experimental studies showed that the average CRC of 3.3 mm and 4.3 mm diameter tumors were improved from 2.8% and 4.2% to 7.9% and 11.0%, respectively, by a single-panel AWSM-PET device. With a high-sensitivity dual-panel device, the corresponding CRC can be further improved to 11.0% and 15.9%, respectively. The principle of the AWSM-PET technology has been developed and validated. Enhanced system sensitivity, CRC and tumor detectability were demonstrated by Monte Carlo simulations and imaging experiments. This technology may offer a cost-effective path to realize high-resolution whole-body PET imaging clinically.

PET Parametric Imaging: Past, Present, and Future

Positron emission tomography (PET) is actively used in a diverse range of applications in oncology, cardiology, and neurology. The use of PET in the clinical setting focuses on static (single time frame) imaging at a specific time-point post radiotracer injection and is typically considered as semi-quantitative; e.g. standardized uptake value (SUV) measures. In contrast, dynamic PET imaging requires increased acquisition times but has the advantage that it measures the full spatiotemporal distribution of a radiotracer and, in combination with tracer kinetic modeling, enables the generation of multiparametric images that more directly quantify underlying biological parameters of interest, such as blood flow, glucose metabolism, and receptor binding. Parametric images have the potential for improved detection and for more accurate and earlier therapeutic response assessment. Parametric imaging with dynamic PET has witnessed extensive research in the past four decades. In this paper, we provide an overview of past and present activities and discuss emerging opportunities in the field of parametric imaging for the future.

Roadmap toward the 10 ps time-of-flight PET challenge

Since the seventies, positron emission tomography (PET) has become an invaluable medical molecular imaging modality with an unprecedented sensitivity at the picomolar level, especially for cancer diagnosis and the monitoring of its response to therapy. More recently, its combination with x-ray computed tomography (CT) or magnetic resonance (MR) has added high precision anatomic information in fused PET/CT and PET/MR images, thus compensating for the modest intrinsic spatial resolution of PET. Nevertheless, a number of medical challenges call for further improvements in PET sensitivity. These concern in particular new treatment opportunities in the context personalized (also called precision) medicine, such as the need to dynamically track a small number of cells in cancer immunotherapy or stem cells for tissue repair procedures. A better signal-to-noise ratio (SNR) in the image would allow detecting smaller size tumours together with a better staging of the patients, thus increasing the chances of putting cancer in complete remission. Moreover, there is an increasing demand for reducing the radioactive doses injected to the patients without impairing image quality. There are three ways to improve PET scanner sensitivity: improving detector efficiency, increasing geometrical acceptance of the imaging device and pushing the timing performance of the detectors. Currently, some pre-localization of the electron-positron annihilation along a line-of-response (LOR) given by the detection of a pair of annihilation photons is provided by the detection of the time difference between the two photons, also known as the time-of-flight (TOF) difference of the photons, whose accuracy is given by the coincidence time resolution (CTR). A CTR of about 10 picoseconds FWHM will ultimately allow to obtain a direct 3D volume representation of the activity distribution of a positron emitting radiopharmaceutical, at the millimetre level, thus introducing a quantum leap in PET imaging and quantification and fostering more frequent use of 11C radiopharmaceuticals. The present roadmap article toward the advent of 10 ps TOF-PET addresses the status and current/future challenges along the development of TOF-PET with the objective to reach this mythic 10 ps frontier that will open the door to real-time volume imaging virtually without tomographic inversion. The medical impact and prospects to achieve this technological revolution from the detection and image reconstruction point-of-views, together with a few perspectives beyond the TOF-PET application are discussed.

Performance comparison of dual-ended readout depth-encoding PET detectors based on BGO and LYSO crystals

The performance of dual-ended readout depth-encoding PET detectors based on bismuth germanate (BGO) coupled to silicon photomultipliers (SiPM) arrays was measured for the first time and compared to lutetium-yttrium oxyorthosilicate (LYSO) based detectors using the same readout. The BGO and LYSO crystal arrays all had a crystal pitch of 2.2 mm and were coupled to 8 × 8 SiPM arrays with a matching pitch of 2.2 mm, using a one-to-one coupling configuration. Three types of crystals with Toray reflector were used: polished LYSO, polished BGO, and unpolished BGO, and for two different crystal thicknesses of 20 mm and 30 mm. All the crystal elements in the BGO arrays were clearly resolved in the flood histogram. Better flood histograms were obtained using the LYSO arrays for a selected crystal thickness, and better flood histograms were obtained using the 20 mm thick crystal arrays for a selected crystal type. The average crystal level energy resolution and timing resolution for 20 mm polished LYSO, polished BGO and unpolished BGO crystals at their optimal SiPM bias voltage were 18.6 ± 1.3 % and 1.19 ± 0.20 ns, 17.8 ± 0.8 % and 4.43 ± 0.47 ns, and 18.0 ± 1.0 % and 4.68 ± 1.0 ns, respectively. Depth-of-interaction (DOI) resolution of the 20 mm polished LYSO array was 2.31 ± 0.17 mm and for the 20 mm unpolished BGO array was 3.53 ± 0.25 mm. However, polished BGO arrays with Toray reflector did not provide DOI information. Our key conclusion is that dual-ended readout depth-encoding 20 mm thick unpolished BGO detectors are good candidates for low-activity PET systems with small field-of-view and low timing performance requirements, such as preclinical or compact organ-dedicated PET systems, with the advantage over LYSO of having no background radiation and significantly lower cost.

Multiparametric Cardiac 18F-FDG PET in Humans: Kinetic Model Selection and Identifiability Analysis

Cardiac ¹⁸F-FDG PET has been used in clinics to assess myocardial glucose metabolism. Its ability for imaging myocardial glucose transport, however, has rarely been exploited in clinics. Using the dynamic FDG-PET scans of ten patients with coronary artery disease, we investigate in this paper appropriate dynamic scan and kinetic modeling protocols for efficient quantification of myocardial glucose transport. Three kinetic models and the effect of scan duration were evaluated by using statistical fit quality, assessing the impact on kinetic quantification, and analyzing the practical identifiability. The results show that the kinetic model selection depends on the scan duration. The reversible two-tissue model was needed for a one-hour dynamic scan. The irreversible two-tissue model was optimal for a scan duration of around 10-15 minutes. If the scan duration was shortened to 2-3 minutes, a one-tissue model was the most appropriate. For global quantification of myocardial glucose transport, we demonstrated that an early dynamic scan with a duration of 10-15 minutes and irreversible kinetic modeling was comparable to the full one-hour scan with reversible kinetic modeling. Myocardial glucose transport quantification provides an additional physiological parameter on top of the existing assessment of glucose metabolism and has the potential to enable single tracer multiparametric imaging in the myocardium.

Potentials and caveats of AI in hybrid imaging

State-of-the-art patient management frequently mandates the investigation of both anatomy and physiology of the patients. Hybrid imaging modalities such as the PET/MRI, PET/CT and SPECT/CT have the ability to provide both structural and functional information of the investigated tissues in a single examination. With the introduction of such advanced hardware fusion, new problems arise such as the exceedingly large amount of multi-modality data that requires novel approaches of how to extract a maximum of clinical information from large sets of multi-dimensional imaging data. Artificial intelligence (AI) has emerged as one of the leading technologies that has shown promise in facilitating highly integrative analysis of multi-parametric data. Specifically, the usefulness of AI algorithms in the medical imaging field has been heavily investigated in the realms of (1) image acquisition and reconstruction, (2) post-processing and (3) data mining and modelling. Here, we aim to provide an overview of the challenges encountered in hybrid imaging and discuss how AI algorithms can facilitate potential solutions. In addition, we highlight the pitfalls and challenges in using advanced AI algorithms in the context of hybrid imaging and provide suggestions for building robust AI solutions that enable reproducible and transparent research.

Spatiotemporal PET Imaging Reveals Differences in CAR-T Tumor Retention in Triple-Negative Breast Cancer Models

Chimeric antigen receptor T cell therapy (CAR-T) has been rolled out as a new treatment for hematological malignancies. For solid tumor treatment, CAR-T has been disappointing so far. Challenges include the quantification of CAR-T trafficking, expansion and retention in tumors, activity at target sites, toxicities, and long-term CAR-T survival. Non-invasive serial in vivo imaging of CAR-T using reporter genes can address several of these challenges. For clinical use, a non-immunogenic reporter that is detectable with exquisite sensitivity by positron emission tomography (PET) using a clinically available non-toxic radiotracer would be beneficial. Here, we employed the human sodium iodide symporter to non-invasively quantify tumor retention of pan-ErbB family targeted CAR-T by PET. We generated and characterized traceable CAR T cells and examined potential negative effects of radionuclide reporter use. We applied our platform to two different triple-negative breast cancer (TNBC) models and unexpectedly observed pronounced differences in CAR-T tumor retention by PET/CT (computed tomography) and confirmed data ex vivo. CAR-T tumor retention inversely correlated with immune checkpoint expression in the TNBC models. Our platform enables highly sensitive non-invasive PET tracking of CAR-T thereby addressing a fundamental unmet need in CAR-T development and offering to provide missing information needed for future clinical CAR-T imaging.

Reinventing Molecular Imaging with Total-Body PET, Part II: Clinical Applications

Total-body PET scans will initiate a new era for the PET clinic. The benefits of 40-fold effective sensitivity improvement provide new capabilities to image with lower radiation dose, perform delayed imaging, and achieve improved temporal resolution. These technical features are detailed in the first of this 2-part series. In this part, the clinical impacts of the novel features of total-body PET scans are further explored. Applications of total-body PET scans focus on the real-time interrogation of systemic disease manifestations in a variety of practical clinical contexts. Total-body PET scans make clinical systems biology imaging a reality.

Rapidly (and Successfully) Translating Novel Brain Radiotracers From Animal Research Into Clinical Use

The advent of preclinical research scanners for in vivo imaging of small animals has added confidence into the multi-step decision-making process of radiotracer discovery and development. Furthermore, it has expanded the utility of imaging techniques available to dissect clinical questions, fostering a cyclic interaction between the clinical and the preclinical worlds. Significant efforts from medicinal chemistry have also made available several high-affinity and selective compounds amenable for radiolabeling, that target different receptors, transporters and enzymes in vivo. This substantially increased the range of applications of molecular imaging using positron emission tomography (PET) or single photon emission computed tomography (SPECT). However, the process of developing novel radiotracers for in vivo imaging of the human brain is a multi-step process that has several inherent pitfalls and technical difficulties, which often hampers the successful translation of novel imaging agents from preclinical research into clinical use. In this paper, the process of radiotracer development and its relevance in brain research is discussed; as well as, its pitfalls, technical challenges and future promises. Examples of successful and unsuccessful translation of brain radiotracers will be presented.

Performance Characteristics of Long Axial Field-of-View PET Scanners with Axial Gaps

The introduction of long (>60 cm) axial field-of-view (LAFOV) PET systems has shown their potential for clinical and research applications. LAFOV scanners are expensive, so there is interest in designing systems with longer axial coverage while mitigating cost by introducing detector gaps. We used measurements on the PennPET Explorer (64-cm AFOV prototype) and simulations of scanners up to 143-cm long to assess scanner performance with axial gaps introduced by varying the number of detector rows in each ring. Removing detectors reduces the total sensitivity and results in a non-uniform axial noise profile. Axial resolution shows small (<0.5 mm) loss from the edge of the AFOV to the center, even for a 143-cm AFOV scanner with an unrestricted acceptance angle. The presence of large axial gaps increases the variability in axial resolution and contrast recovery across the AFOV compared to a system without gaps. More modest axial gaps show less variable behavior. The results suggest that designs where the gap is no larger than one-half of the width of a detector ring may be preferred, although the optimal choice of scanner design with the trade-offs of performance and AFOV will depend on its intended usage.

Evaluation of Various Scintillator Materials in Radiation Detector Design for Positron Emission Tomography (PET)

The performance of radiation detectors used in positron-emission tomography (PET) is determined by the intrinsic properties of the scintillators, the geometry and surface treatment of the scintillator crystals and the electrical and optical characteristics of the photosensors. Experimental studies were performed to assess the timing resolution and energy resolution of detectors constructed with samples of different scintillator materials (LaBr3, CeBr3, LFS, LSO, LYSO: Ce, Ca and GAGG) that were fabricated into different shapes with various surface treatments. The saturation correction of SiPMs was applied for tested detectors based on a Tracepro simulation. Overall, we tested 28 pairs of different forms of scintillators to determine the one with the best CTR and light output. Two common high-performance silicon photomultipliers (SiPMs) provided by SensL (J-series, 6 mm) or AdvanSiD (NUV, 6 mm) were used for photodetectors. The PET detector constructed with 6 mm CeBr3 cubes achieved the best CTR with a FWHM of 74 ps. The 4 mm co-doped LYSO: Ce, Ca pyramid crystals achieved 88.1 ps FWHM CTR. The 2 mm, 4 mm and 6 mm 0.2% Ce, 0.1% Ca co-doped LYSO cubes achieved 95.6 ps, 106 ps and 129 ps FWHM CTR, respectively. The scintillator crystals with unpolished surfaces had better timing than those with polished surfaces. The timing resolution was also improved by using certain geometric factors, such as a pyramid shape, to improve light transportation in the scintillator crystals.

Adding the temporal domain to PET radiomic features

Background

Radiomic features, extracted from positron emission tomography, aim to characterize tumour biology based on tracer intensity, tumour geometry and/or tracer uptake heterogeneity. Currently, radiomic features are derived from static images. However, temporal changes in tracer uptake might reveal new aspects of tumour biology. This study aims to explore additional information of these novel dynamic radiomic features compared to those derived from static or metabolic rate images.

Methods

Thirty-five patients with non-small cell lung carcinoma underwent dynamic [¹⁸F]FDG PET/CT scans. Spatial intensity, shape and texture radiomic features were derived from volumes of interest delineated on static PET and parametric metabolic rate PET. Dynamic grey level cooccurrence matrix (GLCM) and grey level run length matrix (GLRLM) features, assessing the temporal domain unidirectionally, were calculated on eight and sixteen time frames of equal length. Spearman’s rank correlations of parametric and dynamic features with static features were calculated to identify features with potential additional information. Survival analysis was performed for the non-redundant temporal features and a selection of static features using Kaplan-Meier analysis.

Results

Three out of 90 parametric features showed moderate correlations with corresponding static features (ρ≥0.61), all other features showed high correlations (ρ>0.7). Dynamic features are robust independent of frame duration. Five out of 22 dynamic GLCM features showed a negligible to moderate correlation with any static feature, suggesting additional information. All sixteen dynamic GLRLM features showed high correlations with static features, implying redundancy. Log-rank analyses of Kaplan-Meier survival curves for all features dichotomised at the median were insignificant.

Conclusion

This study suggests that, compared to static features, some dynamic GLCM radiomic features show different information, whereas parametric features provide minimal additional information. Future studies should be conducted in larger populations to assess whether there is a clinical benefit of radiomics using the temporal domain over traditional radiomics.

Noise reduction with cross-tracer and cross-protocol deep transfer learning for low-dose PET

Previous studies have demonstrated the feasibility of reducing noise with deep learning-based methods for low-dose fluorodeoxyglucose (FDG) positron emission tomography (PET). This work aimed to investigate the feasibility of noise reduction for tracers without sufficient training datasets using a deep transfer learning approach, which can utilize existing networks trained by the widely available FDG datasets. In this study, the deep transfer learning strategy based on a fully 3D patch-based U-Net was investigated on a 18F-fluoromisonidazole (18F-FMISO) dataset using single-bed scanning and a 68Ga-DOTATATE dataset using whole-body scanning. The datasets of 18F-FDG by single-bed scanning and whole-body scanning were used to obtain pre-trained U-Nets separately for subsequent cross-tracer and cross-protocol transfer learning. The full-dose PET images were used as the labels while low-dose PET images from 10% counts were used as the inputs. Three types of U-Nets were obtained: a U-Net trained by FDG dataset, a pre-trained FDG U-Net fine-tuned by another less-available tracer (FMISO/DOATATE), and a U-Net completely trained by a large number of less-available tracer datasets (FMISO/DOATATE), used as the reference U-Net. The denoising performance of the three types of U-Nets was evaluated on single-bed 18F-FMISO and whole-body 68Ga-DOTATATE separately and compared using normalized root-mean-square error (NRMSE), signal-to-noise ratio (SNR), and relative bias of region of interest (ROI). For cross-tracer transfer learning, all the U-Nets provided denoised images with similar quality for both tracers. There was no significant difference in terms of NRMSE and SNR when comparing the former two U-Nets with the reference U-Net. The ROI biases for these U-Nets were similar. For cross-tracer and cross-protocol transfer learning, the pre-trained single-bed FDG U-Net fine-tuned by whole-body DOTATATE data provided the most consistent images with the reference U-Net. Fine-tuning significantly reduced the NRMSE and the ROI bias and improved the SNR when comparing the fine-tuned U-Net with the U-Net trained by single-bed FDG only (NRMSE: 96.3% ± 21.1% versus 120.6% ± 18.5%, ROI bias: -10.5% ± 13.0% versus -14.7% ± 6.4%, SNR: 4.2 ± 1.4 versus 3.9 ± 1.6, for fine-tuned U-Net and the U-Net trained by single-bed FDG, respectively, with p < 0.01 in all cases). This work demonstrated that it is feasible to utilize existing networks well-trained by FDG datasets to reduce the noise for other less-available tracers and other scanning protocols by using the fine-tuning strategy.

Understanding the in vivo Fate of Advanced Materials by Imaging

Engineered materials are ubiquitous in biomedical applications ranging from systemic drug delivery systems to orthopedic implants, and their actions unfold across multiple time- and length-scales. The efficacy and safety of biologics, nanomaterials, and macroscopic implants are all dictated by the same general principles of pharmacology as apply to small molecule drugs, comprising how the body affects materials (pharmacokinetics, PK) and conversely how materials affect the body (pharmacodynamics, PD). Imaging technologies play an increasingly insightful role in monitoring both of these processes, often simultaneously: translational macroscopic imaging modalities such as MRI and PET/CT offer whole-body quantitation of biodistribution and structural or molecular response, while ex vivo approaches and optical imaging via in vivo (intravital) microscopy reveal behaviors at subcellular resolution. In this review, the authors survey developments in imaging the in situ behavior of systemically and locally administered materials, with a particular focus on using microscopy to understand transport, target engagement, and downstream host responses at a single-cell level. The themes of microenvironmental influence, controlled drug release, on-target molecular action, and immune response, especially as mediated by macrophages and other myeloid cells are examined. Finally, the future directions of how new imaging technologies may propel efficient clinical translation of next-generation therapeutics and medical devices are proposed.

Oxygen and brain death; back from the brink

NEW FINDINGS

• What is the topic of this review? To explore the unique evolutionary origins of the human brain and critically appraise its energy budget, including limits of oxygen and glucose deprivation during anoxia and ischaemia. • What advances does it highlight? The brain appears to be more resilient to substrate depletion than traditionally thought, highlighting greater resilience and an underappreciated capacity for functional recovery.

ABSTRACT

The human brain has evolved into an unusually large, complex and metabolically expensive organ that relies entirely on a continuous supply of O₂ and glucose. It has traditionally been assumed that its exorbitant energy budget, combined with little to no energy reserves, renders it especially vulnerable to anoxia and ischaemia, with substrate depletion and progression towards cell death largely irreversible and rapid. However, new and exciting evidence suggests that neurons can survive for longer than previously thought, highlighting an unexpected resilience and underappreciated capacity for functional recovery that has changed the way we think about brain cell death. Nature has the potential to unlock some of the mysteries underlying ischaemic survival, with select vertebrates having solved the problem of anoxia-hypoxia tolerance over millions of years of evolution. Better understanding of their survival strategies, including remarkable adaptations in brain physiology and redox homeostasis, might help to identify new therapeutic targets for human diseases characterized by O₂ deprivation, ischaemia-reperfusion injury and ageing.