Impact of Ge-68∕Ga-68-based versus CT-based attenuation correction on PET

Introduction to the analysis of PET data in oncology

Several reviews on specific topics related to positron emission tomography (PET) ranging in complexity from introductory to highly technical have already been published. This introduction to the analysis of PET data was written as a simple guide of the different phases of analysis of a given PET dataset, from acquisition to preprocessing, to the final data analysis. Although sometimes issues specific to PET in neuroimaging will be mentioned for comparison, most of the examples and applications provided will refer to oncology. Due to the limitations of space we couldn't address each issue comprehensively but, rather, we provided a general overview of each topic together with the references that the interested reader should consult. We will assume a familiarity with the basic principles of PET imaging.

SUV-measurements and patient-specific corrections in pediatric Hodgkin-lymphoma: is there a benefit for PPV in early response assessment by FDG-PET?

BACKGROUND

To evaluate the influence of different SUV-measurements and patient-specific corrections thereof on the positive predictive value (PPV) of FDG-PET in pediatric Hodgkin lymphoma (pHL) using SUV-based response assessment.

METHODS

PET-datasets of 33 children [female, n = 13, male, n = 20; range of age, 8.0-17.8 (mean, 15.0) years; follow-up, 44.5-83.3 (mean 63.0) months] with HL were analyzed retrospectively. PET-scans were obtained baseline (PET1) and after two cycles of chemotherapy (PET2). Within the leading lesion maximal SUV (SUVmax) and mean SUVs were generated by using isocontur-thresholds for different volumes of interest: Absolute, SUV2.5; relative to SUVmax, SUVmean40% to SUVmean70%. Generated SUVs were adjusted to body weight (SUV) and corrected for body surface area (SUV_BSA), patient's blood glucose and a combination thereof. The decrease in SUV or respective derivates thereof between PET1 and PET2 (ΔSUV) was assessed for response prediction using receiver operating characteristics (ROC)-analysis.

RESULTS

Three patients had recurrence of disease. ROC-analysis showed the most accurate differentiation of responders and non-responders for ΔSUVmax_BSA [AUC, 0.97; P = 0.0026; sensitivity, 100%; specificity, 93.3%; PPV, 60.0%; negative predictive value (NPV), 100%; accuracy, 93.3%]. However, comparable results were obtained for conventional ΔSUVmax-determination (AUC, 0.96; P = 0.0112; sensitivity, 100%; specificity, 90.0%; PPV, 50.0%; NPV, 100%; accuracy, 90.9%). Threshold-based approaches were less effective or technically not performable in all patients.

CONCLUSIONS

At early response assessment by FDG-PET, patient-specific correction of ΔSUVmax by BSA improves PPV without impairment of excellent NPV in pHL. However, it is not statistically superior to simple ΔSUVmax-analyses. Larger cohorts are needed to investigate this observation.

68Ga-labelled exendin-3, a new agent for the detection of insulinomas with PET

Purpose

Insulinomas are neuroendocrine tumours derived from pancreatic β-cells. The glucagon-like peptide 1 receptor (GLP-1R) is expressed with a high incidence (>90%) and high density in insulinomas. Glucagon-like peptide 1 (GLP-1), the natural ligand of GLP-1R, is rapidly degraded in vivo. A more stable agonist of GLP-1R is exendin-3. We investigated imaging of insulinomas with DOTA-conjugated exendin-3 labelled with ⁶⁸Ga.

Methods

Targeting of insulinomas with [Lys⁴⁰(DOTA)]exendin-3 labelled with either ¹¹¹In or ⁶⁸Ga was investigated in vitro using insulinoma tumour cells (INS-1). [Lys⁴⁰(¹¹¹In-DTPA)]Exendin-3 was used as a reference in this study. In vivo targeting was investigated in BALB/c nude mice with subcutaneous INS-1 tumours. PET imaging was performed using a preclinical PET/CT scanner.

Results

In vitro exendin-3 specifically bound and was internalized by GLP-1R-positive cells. In BALB/c nude mice with subcutaneous INS-1 tumours a high uptake of [Lys⁴⁰(¹¹¹In-DTPA)]exendin-3 in the tumour was observed (33.5 ± 11.6%ID/g at 4 h after injection). Uptake was specific, as determined by coinjection of an excess of unlabelled [Lys⁴⁰]exendin-3 (1.8 ± 0.1%ID/g). The pancreas also exhibited high and specific uptake (11.3 ± 1.0%ID/g). High uptake was also found in the kidneys (144 ± 24%ID/g) and this uptake was not receptor-mediated. In this murine tumour model optimal targeting of the GLP-1R expressing tumour was obtained at exendin doses ≤0.1 µg. Remarkably, tumour uptake of ⁶⁸Ga-labelled [Lys⁴⁰(DOTA)]exendin-3 was lower (8.9 ± 3.1%ID/g) than tumour uptake of ¹¹¹In-labelled [Lys⁴⁰(DTPA)]exendin-3 (25.4 ± 7.2%ID/g). The subcutaneous tumours were clearly visualized by small-animal PET imaging after injection of 3 MBq of [Lys⁴⁰(⁶⁸Ga-DOTA)]exendin-3.

Conclusion

[Lys⁴⁰(⁶⁸Ga-DOTA)]Exendin-3 specifically accumulates in insulinomas, although the uptake is lower than that of [Lys⁴⁰(¹¹¹In-DTPA)]exendin-3. Therefore, [Lys⁴⁰(⁶⁸Ga-DOTA)]exendin-3 is a promising tracer to visualize insulinomas with PET.

Positron emission tomography/computed tomography

Accurate anatomical localization of functional abnormalities obtained with the use of positron emission tomography (PET) is known to be problematic. Although tracers such as (18)F-fluorodeoxyglucose ((18)F-FDG) visualize certain normal anatomical structures, the spatial resolution is generally inadequate for accurate anatomic localization of pathology. Combining PET with a high-resolution anatomical imaging modality such as computed tomography (CT) can resolve the localization issue as long as the images from the two modalities are accurately coregistered. However, software-based registration techniques have difficulty accounting for differences in patient positioning and involuntary movement of internal organs, often necessitating labor-intensive nonlinear mapping that may not converge to a satisfactory result. Acquiring both CT and PET images in the same scanner obviates the need for software registration and routinely provides accurately aligned images of anatomy and function in a single scan. A CT scanner positioned in line with a PET scanner and with a common patient couch and operating console has provided a practical solution to anatomical and functional image registration. Axial translation of the couch between the 2 modalities enables both CT and PET data to be acquired during a single imaging session. In addition, the CT images can be used to generate essentially noiseless attenuation correction factors for the PET emission data. By minimizing patient movement between the CT and PET scans and accounting for the axial separation of the two modalities, accurately registered anatomical and functional images can be obtained. Since the introduction of the first PET/CT prototype more than 6 years ago, numerous patients with cancer have been scanned on commercial PET/CT devices worldwide. The commercial designs feature multidetector spiral CT and high-performance PET components. Experience has demonstrated an increased level of accuracy and confidence in the interpretation of the combined study as compared with studies acquired separately, particularly in distinguishing pathology from normal, physiologic tracer uptake and precisely localizing abnormal foci. Combined PET/CT scanners represent an important evolution in technology that has helped to bring molecular imaging to the forefront in cancer diagnosis, staging and therapy monitoring.

Does reducing CT artifacts from dental implants influence the PET interpretation in PET/CT studies of oral cancer and head and neck cancer?

In patients with oral head and neck cancer, the presence of metallic dental implants produces streak artifacts in the CT images. These artifacts negate the utility of CT for the spatial localization of PET findings and may propagate through the CT-based attenuation correction into the PET images. In this study, we evaluated the efficacy of an algorithm that reduces metallic artifacts in CT images and the impact of this approach on the quantification of PET images.

METHODS

Fifty-one patients with and 9 without dental implants underwent a PET/CT study. CT images through the patient's dental implants were reconstructed using both standard CT reconstruction and an algorithm that reduces metallic artifacts. Attenuation correction factors were calculated from both sets of CT images and applied to the PET data. The CT images were evaluated for any reduction of the artifacts. The PET images were assessed for any quantitative change introduced by metallic artifact reduction.

RESULTS

For each reconstruction, 2 regions of interest were defined in areas where the standard CT reconstruction overestimated the Hounsfield units (HU), 2 were defined in underestimated areas, and 1 was defined in a region unaffected by the artifacts. The 5 regions of interest were transferred to the other 3 reconstructions. Mean HU or mean Bq/cm(3) were obtained for all regions. In the CT reconstructions, metallic artifact reduction decreased the overestimated HUs by approximately 60% and increased the underestimated HUs by approximately 90%. There was no change in quantification in the PET images between the 2 algorithms (Spearman coefficient of rank correlation, 0.99). Although the distribution of attenuation (HU) changed considerably in the CT images, the distribution of activity did not change in the PET images.

CONCLUSION

Our study demonstrated that the algorithm can enhance the structural and spatial content of CT images in the presence of metallic artifacts. The CT artifacts do not propagate through the CT-based attenuation correction into the PET images, confirming the robustness of CT-based attenuation correction in the presence of metallic artifacts. The study also demonstrated that considerable changes in CT images do not change the PET images.

Advances in Attenuation Correction Techniques in PET

Molecular imaging using PET has evolved from a vigorous academic field into the clinical arena. Considerable advances have been made in the design of high-resolution standalone PET and combined PET/CT units dedicated to clinical whole-body scanning. Likewise, much worthwhile research focused on the development of quantitative imaging protocols incorporating accurate data correction techniques and sophisticated image reconstruction algorithms. Since its inception, photon attenuation in biological tissues has been identified as the most important physical degrading factor affecting PET image quality and quantitative accuracy. Various strategies have been devised to determine an accurate attenuation map to enable correction for nonlinear photon attenuation in whole-body PET studies. This article presents the physical and methodological basis of photon attenuation and summarizes state-of-the-art developments in algorithms used to derive the attenuation map aiming at accurate attenuation compensation of PET data. Future prospects, research trends, and challenges are identified, and directions for future research are discussed.