Multi-modality nuclear medicine imaging: artefacts, pitfalls and recommendations

Emergence of "Big Data" and Its Potential and Current Limitations in Medical Imaging

Although electronic imaging was performed in the early 1950s in nuclear medicine, it was the introduction of computed tomography in 1972 that caused a revolution in medical imaging in that it marked the beginning of the inevitable transformation to digital imaging. This transformation is now more or less complete. While initially these CT images were relatively small, comprised of only about 6400 pixels per slice, the steady move toward higher spatial resolution, multislice imaging, digital radiography, and fluoroscopy rapidly increased the size of images and the amount of data required to be stored, processed, displayed, and moved about in a medical imaging department. The more recent introduction of digital pathology with submicron-sized pixels and the need for color further increases these demands. Rising work volumes in hospital, a push for cost containment, and a move toward greater precision in diagnosis and treatment of disease all work together to motivate the development of automated image analysis algorithms and techniques to improve efficiencies in in vivo imaging and pathology. This may require bringing together information from different imaging and nonimaging sources within the institution. While technological development has provided practical means for storage of the burgeoning data load and the use of multiple processors and high-speed networks has enabled more sophisticated analysis locally or in the cloud, challenges remain in terms of the ability to integrate data from different systems, the development of appropriately annotated image bases for training and testing of algorithms, and issues around privacy and ownership in obtaining access to patient-related data.

Non-invasive molecular imaging for preclinical cancer therapeutic development

Molecular and non-invasive imaging are rapidly emerging fields in preclinical cancer drug discovery. This is driven by the need to develop more efficacious and safer treatments, the advent of molecular-targeted therapeutics, and the requirements to reduce and refine current preclinical in vivo models. Such bioimaging strategies include MRI, PET, single positron emission computed tomography, ultrasound, and optical approaches such as bioluminescence and fluorescence imaging. These molecular imaging modalities have several advantages over traditional screening methods, not least the ability to quantitatively monitor pharmacodynamic changes at the cellular and molecular level in living animals non-invasively in real time. This review aims to provide an overview of non-invasive molecular imaging techniques, highlighting the strengths, limitations and versatility of these approaches in preclinical cancer drug discovery and development.

Qualitative and quantitative comparison of PET/CT and PET/MR imaging in clinical practice

The aim of this study was to prospectively compare whole-body PET/MR imaging and PET/CT, qualitatively and quantitatively, in oncologic patients and assess the confidence and degree of inter- and intraobserver agreement in anatomic lesion localization.

METHODS

Fifty patients referred for staging with known cancers underwent PET/CT with low-dose CT for attenuation correction immediately followed by PET/MR imaging with 2-point Dixon attenuation correction. PET/CT scans were obtained according to standard protocols (56 ± 20 min after injection of an average 367 MBq of (18)F-FDG, 150 MBq of (68)Ga-DOTATATE, or 333.8 MBq of (18)F-fluoro-ethyl-choline; 2.5 min/bed position). PET/MR was performed with 5 min/bed position. Three dual-accredited nuclear medicine physicians/radiologists identified the lesions and assigned each to an exact anatomic location. The image quality, alignment, and confidence in anatomic localization of lesions were scored on a scale of 1-3 for PET/CT and PET/MR imaging. Quantitative analysis was performed by comparing the standardized uptake values. Intraclass correlation coefficients and the Wilcoxon signed-rank test were used to assess intra- and interobserver agreement in image quality, alignment, and confidence in lesion localization for the 2 modalities.

RESULTS

Two hundred twenty-seven tracer-avid lesions were identified in 50 patients. Of these, 225 were correctly identified on PET/CT and 227 on PET/MR imaging by all 3 observers. The confidence in anatomic localization improved by 5.1% when using PET/MR imaging, compared with PET/CT. The mean percentage interobserver agreement was 96% for PET/CT and 99% for PET/MR imaging, and intraobserver agreement in lesion localization across the 2 modalities was 93%. There was 10% (5/50 patients) improvement in local staging with PET/MR imaging, compared with PET/CT.

CONCLUSION

In this first study, we show the effectiveness of whole-body PET/MR imaging in oncology. There is no statistically significant difference between PET/MR imaging and PET/CT in respect of confidence and degree of inter- and intraobserver agreement in anatomic lesion localization. The PET data on both modalities were similar; however, the observed superior soft-tissue resolution of MR imaging in head and neck, pelvis, and colorectal cancers and of CT in lung and mediastinal nodal disease points to future tailored use in these locations.

Recommendations of the Spanish Societies of Radiation Oncology (SEOR), Nuclear Medicine & Molecular Imaging (SEMNiM), and Medical Physics (SEFM) on (18)F-FDG PET-CT for radiotherapy treatment planning

Positron emission tomography (PET) with (18)F-fluorodeoxyglucose (FDG) is a valuable tool for diagnosing and staging malignant lesions. The fusion of PET and computed tomography (CT) yields images that contain both metabolic and morphological information, which, taken together, have improved the diagnostic precision of PET in oncology. The main imaging modality for planning radiotherapy treatment is CT. However, PET-CT is an emerging modality for use in planning treatments because it allows for more accurate treatment volume definition. The use of PET-CT for treatment planning is highly complex, and protocols and standards for its use are still being developed. It seems probable that PET-CT will eventually replace current CT-based planning methods, but this will require a full understanding of the relevant technical aspects of PET-CT planning. The aim of the present document is to review these technical aspects and to provide recommendations for clinical use of this imaging modality in the radiotherapy planning process.

Gd(III) functionalized gold nanorods for multimodal imaging applications

We demonstrate a novel noncovalent method for producing Gd(III)-functionalized gold nanorods as multimodal contrast agents for MRI and CT imaging. The ligand is connected to the surface of the gold nanorods by a noncovalent bond making the Gd(III) ions directly accessible to water molecules, and resulting in a longitudinal relaxivity as high as 21.3 mM(-1) s(-1). In addition, compared with spherical gold nanoparticles, gold nanorods have more binding sites for Gd(III) ions due to their large surface-to-volume ratio. Benefiting from the advantages of the new type of carry material and the novel fabrication approach, the multimodal imaging probes exhibit a high longitudinal relaxivity r(1) on the order of 1.1 × 10(7) mM(-1) s(-1) on a per-particle basis, which is 24 times higher than that of Gd(III)-ion-functionalized spherical gold nanoparticles. Furthermore, CT imaging shows that such nanoprobes could induce an efficient contrast enhancement when the gold concentration is at least equal to 1.31 mg ml(-1). These results demonstrate that the as-prepared Gd functionalized gold nanorods could provide a new and versatile platform for the development of multimodal imaging probes.

Gd-DTPA-loaded PLGA microbubbles as both ultrasound contrast agent and MRI contrast agent--a feasibility research

OBJECTIVE

To prepare the Gd-DTPA-loaded poly (lactic-co-glycolic acid) (PLGA) microbubbles for both ultrasound imaging and MRI imaging.

METHODS

Biodegradable high-molecular-weight poly (lactic-co-glycolic acid) (PLGA) was used as an encapsulating vehicle to fabricate a contrast agent composed of gadolinium diethylenetriamine pentaacetic acid (Gd-DTPA) and fluorocarbon-filled microbubbles by using double emulsion method. The morphology, size, and Gd loading capacity of PLGA microparticles were assessed. The efficacy of the contrast agent for ultrasound and magnetic resonance (MR) imaging was evaluated by in vivo imaging of hepatic vessels and the liver parenchyma of rabbit following injection of the contrast agent. Additionally, the liver and kidney functions were examined before and at 7, 14, 30 days after injection.

RESULTS

Electron microscopy showed Gd loaded PLGA microbubbles were spherical in shape. The mean diameter were 1.47 +/- 0.38 microm and the Gd loading was 25 +/- 2 microg/mg. Right after the injection of the PLGA microbubbles, the ultrasound echo intensity of hepatic vessels and the liver parenchyma was significantly enhanced. Moreover, enhanced signal intensity of the liver parenchyma on MR images was observed for approximately 30 min after injection of the contrast agent. Neither marked changes in the liver and kidney functions nor other severe complications were detected during the follow-up period.

CONCLUSION

Gd-DTPA-loaded PLGA microbubbles could enhance both ultrasound imaging and MRI imaging.

The growing development of multimodality imaging in oncology

The first decade of the century has been the beginning of an era of new practice in daily medical imaging, that is the multimodality involving functional or metabolic imaging brought by nuclear medicine techniques directly associated with anatomical information brought by CT (Computed X-Ray Tomography) devices combined with nuclear medicine detectors. PET (Positron Emission Tomography)/CT and SPECT (Single Photon Emission Computed Tomography)/CT are now established to further increase the interest of PET and SPECT, thanks to improved localization of the pathologic processes, and in many instances thanks to a gain in specificity. An even better use of the combined information will necessitate redefining some protocols and indications, and the future will probably see the continued development of multimodality imaging in practice. Besides the combination with CT, another modality is expected in the future: PET/MRI (Magnetic Resonance Imaging).