Impact of time-of-flight PET on quantification accuracy and lesion detection in simultaneous 18F-choline PET/MRI for prostate cancer

Developments in Dedicated Prostate PET Instrumentation

This article summarizes the evolution of dedicated prostate PET instrumentation. It starts by introducing prostate cancer, as well as the most common diagnostic and staging methods that are used in the clinics. Then, it describes the key aspects of PET detectors and their assembly in full PET scanners highlighting the most suitable geometries for prostate examination, and a review on the existing prostate dedicated PET. Finally, the next steps for extending the use of PET in the daily diagnose, staging, and image-guided biopsy of patients with prostate cancer are discussed.

A review of PET attenuation correction methods for PET-MR

Despite being thirteen years since the installation of the first PET-MR system, the scanners constitute a very small proportion of the total hybrid PET systems installed. This is in stark contrast to the rapid expansion of the PET-CT scanner, which quickly established its importance in patient diagnosis within a similar timeframe. One of the main hurdles is the development of an accurate, reproducible and easy-to-use method for attenuation correction. Quantitative discrepancies in PET images between the manufacturer-provided MR methods and the more established CT- or transmission-based attenuation correction methods have led the scientific community in a continuous effort to develop a robust and accurate alternative. These can be divided into four broad categories: (i) MR-based, (ii) emission-based, (iii) atlas-based and the (iv) machine learning-based attenuation correction, which is rapidly gaining momentum. The first is based on segmenting the MR images in various tissues and allocating a predefined attenuation coefficient for each tissue. Emission-based attenuation correction methods aim in utilising the PET emission data by simultaneously reconstructing the radioactivity distribution and the attenuation image. Atlas-based attenuation correction methods aim to predict a CT or transmission image given an MR image of a new patient, by using databases containing CT or transmission images from the general population. Finally, in machine learning methods, a model that could predict the required image given the acquired MR or non-attenuation-corrected PET image is developed by exploiting the underlying features of the images. Deep learning methods are the dominant approach in this category. Compared to the more traditional machine learning, which uses structured data for building a model, deep learning makes direct use of the acquired images to identify underlying features. This up-to-date review goes through the literature of attenuation correction approaches in PET-MR after categorising them. The various approaches in each category are described and discussed. After exploring each category separately, a general overview is given of the current status and potential future approaches along with a comparison of the four outlined categories.

Quantitative Assessment of Myocardial Ischemia With Positron Emission Tomography

Recent advances in positron emission tomography (PET) technology and reconstruction techniques have now made quantitative assessment using cardiac PET readily available in most cardiac PET imaging centers. Multiple PET myocardial perfusion imaging (MPI) radiopharmaceuticals are available for quantitative examination of myocardial ischemia, with each having distinct convenience and accuracy profile. Important properties of these radiopharmaceuticals ( 15 O-water, 13 N-ammonia, 82 Rb, 11 C-acetate, and 18 F-flurpiridaz) including radionuclide half-life, mean positron range in tissue, and the relationship between kinetic parameters and myocardial blood flow (MBF) are presented. Absolute quantification of MBF requires PET MPI to be performed with protocols that allow the generation of dynamic multiframes of reconstructed data. Using a tissue compartment model, the rate constant that governs the rate of PET MPI radiopharmaceutical extraction from the blood plasma to myocardial tissue is calculated. Then, this rate constant ( K1 ) is converted to MBF using an established extraction formula for each radiopharmaceutical. As most of the modern PET scanners acquire the data only in list mode, techniques of processing the list-mode data into dynamic multiframes are also reviewed. Finally, the impact of modern PET technologies such as PET/CT, PET/MR, total-body PET, machine learning/deep learning on comprehensive and quantitative assessment of myocardial ischemia is briefly described in this review.

Impact of TOF on Brain PET With Short-Lived 11C-Labeled Tracers Among Suspected Patients With AD/PD: Using Hybrid PET/MRI

Objective

To explore the impact of the time-of-flight (TOF) reconstruction on brain PET with short-lived 11C-labeled tracers in PET magnetic resonance (PET/MR) brain images among suspected patients with Alzheimer's and Parkinson's disease (AD/PD).

Methods

Patients who underwent 11C-2-ß-carbomethoxy-3-b-(4-fluorophenyl) tropane (11C-CFT) and 2-(4-N-[11C] methylaminophenyl)-6-hydroxybenzothiazole (11C-PiB) PET/MRI were retrospectively included in the study. Each PET LIST mode data were reconstructed with and without the TOF reconstruction algorithm. Standard uptake values (SUVs) of Caudate Nucleus (CN), Putamen (PU), and Whole-brain (WB) were measured. TOF and non-TOF SUVs were assessed by using paired t-test. Standard formulas were applied to measure contrast, signal-to-noise ratio (SNR), and percentage relative average difference of SUVs (%RAD-SUVs).

Results

Total 75 patients were included with the median age (years) and body mass index (BMI-kg/m2) of 60.2 ± 10.9 years and 23.9 ± 3.7 kg/m2 in 11C-CFT (n = 41) and 62.2 ± 6.8 years and 24.7 ± 2.9 kg/m2 in 11C-PiB (n = 34), respectively. Higher average SUVs and positive %RAD-SUVs were observed in CN and PU in TOF compared with non-TOF reconstructions for the two 11C-labeled radiotracers. Differences of SUVmean were significant (p < 0.05) in CN and PU for both 11C-labeled radiotracers. SUVmax was enhanced significantly in CN and PU for 11C-CFT and CN for 11C-PiB, but not in PU. Significant contrast enhancement was observed in PU for both 11C-labeled radiotracers, whereas SNR gain was significant in PU, only for 11C-PiB in TOF reconstruction.

Conclusion

Time-of-flight leads to a better signal vs. noise trade-off than non-TOF in 11C-labeled tracers between CN and PU, improving the SUVs, contrast, and SNR, which were valuable for reducing injected radiation dose. Improved timing resolution aided the rapid decay rate of short-lived 11C-labeled tracers, and it shortened the scan time, increasing the patient comfort, and reducing the motion artifact among patients with AD/PD. However, one should adopt the combined TOF algorithm with caution for the quantitative analysis because it has different effects on the SUVmax, contrast, and SNR of different brain regions.

18F-choline PET/MRI on initial staging of prostate cancer. Impact on therapy approach

AIM

Evaluate the therapy impact of initial staging in patients diagnosed with prostate cancer by ¹⁸ F-choline PET/MRI hybrid technique.

MATERIAL

A prospective study which included 31 patients diagnosed with prostate cancer; Gleason > 7; mean PSA 13.6 ng/mL (range 6.3-20.6). PET/MRI studies were acquired simultaneously with hybrid equipment (SIGNA.3T, GE) following intravenous injection of 185 ± 18.5MBq of ¹⁸F-choline: - Early/prostate imaging: PET emission + multiparametric MR: DIXON-T1-T2-diffusion-gadolinium. - Late/whole-body imaging: PET emission + MR: DIXON-T1-T2-diffusion-STIR sequences. Images were visually evaluated. SUV & ADC & textures were also calculated. Treatment selection was based upon Oncology Committee consensus decision.

RESULTS

Procedure was well tolerated in all patients, and no artifacts were reported. MRI was superior in T staging in eight patients (25.8%) (Likert: 2-3), whereas PET increased MRI sensitivity in three patients (9.7%) (PIRADS: 3).

PROSTATE LESION LOCATION

Peripheral 91.4%, transitional 8.6%. SUVmax threshold: 2.95: sensitivity 92.9%, specificity 66.7%. No correlation SUV vs. ADC. Better distinction between stage T2 vs. T3 using the DiscrLin model with NG = 16 (AUC 0.7767 ± 0.3386). PET was superior to T2 in textures analysis (0.588 vs. 0.412). Seventeen patients (54.8%) were staged ≥ T3, with surgical treatment being contraindicated. Fifteen patients (48.4%) presented with extra-prostatic disease: 8/31 oligometastatic and 7/31 multiple metastasis. Therapy approach following PET/MRI was: radical treatment in 24/31 patients (77.4%), 14 radical prostatectomy and 10 MRI-guided radiotherapy; systemic treatment in 7/31 patients (22.6%).

CONCLUSION

¹⁸F-choline PET/MRI had a complementary role for the T staging, with a high detection rate for NM infiltration. PET/MRI findings allowed patients to be directed either to prostatectomy or MRI-guided radiotherapy, and thus avoiding radicaltreatment in 22.6% of patients.

PET/MRI in prostate cancer: a systematic review and meta-analysis

Aim

In recent years, the clinical availability of scanners for integrated positron emission tomography (PET) and magnetic resonance imaging (MRI) has enabled the practical potential of multimodal, combined metabolic-receptor, anatomical, and functional imaging to be explored. The present systematic review and meta-analysis summarize the diagnostic information provided by PET/MRI in patients with prostate cancer (PCa).

Materials and methods

A literature search was conducted in three different databases. The terms used were “choline” or “prostate-specific membrane antigen - PSMA” AND “prostate cancer” or “prostate” AND “PET/MRI” or “PET MRI” or “PET-MRI” or “positron emission tomography/magnetic resonance imaging.” All relevant records identified were combined, and the full texts were retrieved. Reports were excluded if (1) they did not consider hybrid PET/MRI; or (2) the sample size was < 10 patients; or (3) the raw data were not enough to enable the completion of a 2 × 2 contingency table.

Results

Fifty articles were eligible for systematic review, and 23 for meta-analysis. The pooled data concerned 2104 patients. Initial disease staging was the main indication for PET/MRI in 24 studies. Radiolabeled PSMA was the tracer most frequently used. In primary tumors, the pooled sensitivity for the patient-based analysis was 94.9%. At restaging, the pooled detection rate was 80.9% and was higher for radiolabeled PSMA than for choline (81.8% and 77.3%, respectively).

Conclusions

PET/MRI proved highly sensitive in detecting primary PCa, with a high detection rate for recurrent disease, particularly when radiolabeled PSMA was used.

Electronic supplementary material

The online version of this article (10.1007/s00259-020-05025-0) contains supplementary material, which is available to authorized users.

Design, evaluation and comparison of endorectal coils for hybrid MR-PET imaging of the prostate

Prostate cancer is one of the most common cancers among men and its early detection is critical for its successful treatment. The use of multimodal imaging, such as MR-PET, is most advantageous as it is able to provide detailed information about the prostate. However, as the human prostate is flexible and can move into different positions under external conditions, it is important to localise the focused region-of-interest using both MRI and PET under identical circumstances. In this work, we designed five commonly used linear and quadrature radiofrequency surface coils suitable for hybrid MR-PET use in endorectal applications. Due to the endorectal design and the shielded PET insert, the outer face of the coils investigated was curved and the region to be imaged was outside the volume of the coil. The tilting angles of the coils were varied with respect to the main magnetic field direction. This was done to approximate the various positions from which the prostate could be imaged. The transmit efficiencies and safety excitation efficiencies from simulations, together with the signal-to-noise ratios from the MR images were calculated and analysed. Overall, it was found that the overlapped loops driven in quadrature were superior to the other types of coils we tested. In order to determine the effect of the different coil designs on PET, transmission scans were carried out, and it was observed that the differences between attenuation maps with and without the coils were negligible. The findings of this work can provide useful guidance for the integration of such coil designs into MR-PET hybrid systems in the future.

Evaluation of improved attenuation correction in whole-body PET/MR on patients with bone metastasis using various radiotracers

Purpose

This study evaluates the quantitative effect of improved MR-based attenuation correction (AC), including bone segmentation and the HUGE method for truncation correction in PET/MR whole-body hybrid imaging specifically of oncologic patients with bone metastasis and using various radiotracers.

Methods

Twenty-three patients that underwent altogether 28 whole-body PET/MR examinations with findings of bone metastasis were included in this study. Different radiotracers (¹⁸F-FDG, ⁶⁸Ga-PSMA, ⁶⁸Ga-DOTATOC, ¹²⁴I–MIBG) were injected according to appropriate clinical indications. Each of the 28 whole-body PET datasets was reconstructed three times using AC with (1) standard four-compartment μ-maps (background air, lung, muscle, and soft tissue), (2) five-compartment μ-maps (adding bone), and (3) six-compartment μ-maps (adding bone and HUGE truncation correction). The SUV_max of each detected bone lesion was measured in each reconstruction to evaluate the quantitative impact of improved MR-based AC. Relative difference images between four- and six-compartment μ-maps were calculated. MR-based HUGE truncation correction was compared with the PET-based MLAA truncation correction method in all patients.

Results

Overall, 69 bone lesions were detected and evaluated. The mean increase in relative difference over all 69 lesions in SUV_max was 5.4 ± 6.4% when comparing the improved six-compartment AC with the standard four-compartment AC. Maximal relative difference of 28.4% was measured in one lesion. Truncation correction with HUGE worked robust and resulted in realistic body contouring in all 28 exams and for all 4 different radiotracers. Truncation correction with MLAA revealed overestimations of arm tissue volume in all PET/MR exams with ¹⁸F-FDG radiotracer and failed in all other exams with radiotracers ⁶⁸Ga-PSMA, ⁶⁸Ga-DOTATOC, and ¹²⁴I- MIBG due to limitations in body contour detection.

Conclusion

Improved MR-based AC, including bone segmentation and HUGE truncation correction in whole-body PET/MR on patients with bone lesions and using various radiotracers, is important to ensure best possible diagnostic image quality and accurate PET quantification. The HUGE method for truncation correction based on MR worked robust and results in realistic body contouring, independent of the radiotracers used.

Time efficient scatter correction for time-of-flight PET: the immediate scatter approximation

Utilization of time-of-flight (TOF) information allows us to improve image quality and convergence rate in iterative PET image reconstruction. In order to obtain quantitatively correct images accurate scatter correction (SC) is required that accounts for the non-uniform distribution of scatter events over the TOF bins. However, existing simplified TOF-SC algorithms frequently exhibit limited accuracy while the currently accepted reference method-the TOF extension of the single scatter simulation approach (TOF-SSS)-is computationally demanding and can substantially slow down the reconstruction. In this paper we propose and evaluate a new accelerated TOF-SC algorithm in order to improve this situation. The key idea of the algorithm is the use of an immediate scatter approximation (ISA) for scatter time distribution calculation which speeds up estimation of the required TOF scatter by a factor of up to five in comparison to TOF-SSS. The proposed approach was evaluated in dedicated phantom measurements providing challenging high activity contrast conditions as well as in representative clinical patient data sets. Our results show that ISA is a viable alternative to TOF-SSS. The reconstructed images are in excellent quantitative agreement with those obtained with TOF-SSS while overall reconstruction time can be reduced by a factor of two in whole-body studies, even when using a listmode reconstruction not optimized for speed.

Correction to: impact of time-of-flight PET on quantification accuracy and lesion detection in simultaneous 18F-choline PET/MRI for prostate cancer

Unfortunately, after publication of this article [1], it was noticed that the name of Urs J. Muehlematter was incorrectly displayed as Urs J. Mühlematter. The corrected author list can be seen above and the original article has been corrected to reflect this.