Ultra staging to unmask the prescribing of adjuvant therapy in cancer patients: the future opportunity to image micrometastases using total-body 18F-FDG PET scanning

Self-supervised neural network for Patlak-based parametric imaging in dynamic [18F]FDG total-body PET

PURPOSE

The objective of this study is to generate reliable Ki parametric images from a shortened [18F]FDG total-body PET for clinical applications using a self-supervised neural network algorithm.

METHODS

We proposed a self-supervised neural network algorithm with Patlak graphical analysis (SN-Patlak) to generate Ki images from shortened dynamic [18F]FDG PET without 60-min full-dynamic PET-based training. The algorithm deeply integrates neural network architecture with a Patlak method, employing the fitting error of the Patlak plot as the neural network's loss function. As the 0-60 min blood time activity curve (TAC) required by the standard Patlak plot is unobtainable from shortened dynamic PET scans, a population-based "normalized time" (integral-to-instantaneous blood concentration ratio) was used for the linear fitting of Patlak plot of t* to 60 min, and the modified Patlak plot equation was then incorporated into the neural network. Ki images were generated by minimizing the difference between the input layer (measured tissue-to-blood concentration ratios) and the output layer (predicted tissue-to-blood concentration ratios). The effects of t* (20 to 50 min post injection) on the Ki images generated from the SN-Patlak and standard Patlak was evaluated using the normalized mean square error (NMSE), and Pearson's correlation coefficient (Pearson's r).

RESULTS

The Ki images generated by the SN-Patlak are robust to the dynamic PET scan duration, and the Ki images generated by the SN-Patlak from just a 10-minute (50-60 min post-injection) dynamic [18F]FDG total-body PET scan are comparable to those generated by the standard Patlak method from 40-min (20-60 min post injection) with NMSE = 0.15 ± 0.03 and Pearson's r = 0.93 ± 0.01.

CONCLUSIONS

The SN-Patlak parametric imaging algorithm is robust and reliable for quantification of 10-min dynamic [18F]FDG total-body PET.

Role of 18F-FDG PET/CT in Head and Neck Squamous Cell Carcinoma: Current Evidence and Innovative Applications

This article provides an overview of the use of 18F-FDG PET/CT in various clinical scenarios of head-neck squamous cell carcinoma, ranging from initial staging to treatment-response assessment, and post-therapy follow-up, with a focus on the current evidence, debated issues, and innovative applications. Methodological aspects and the most frequent pitfalls in head-neck imaging interpretation are described. In the initial work-up, 18F-FDG PET/CT is recommended in patients with metastatic cervical lymphadenectomy and occult primary tumor; moreover, it is a well-established imaging tool for detecting cervical nodal involvement, distant metastases, and synchronous primary tumors. Various 18F-FDG pre-treatment parameters show prognostic value in terms of disease progression and overall survival. In this scenario, an emerging role is played by radiomics and machine learning. For radiation-treatment planning, 18F-FDG PET/CT provides an accurate delineation of target volumes and treatment adaptation. Due to its high negative predictive value, 18F-FDG PET/CT, performed at least 12 weeks after the completion of chemoradiotherapy, can prevent unnecessary neck dissections. In addition to radiomics and machine learning, emerging applications include PET/MRI, which combines the high soft-tissue contrast of MRI with the metabolic information of PET, and the use of PET radiopharmaceuticals other than 18F-FDG, which can answer specific clinical needs.

The clinical acceptability of short versus long duration acquisitions for head and neck cancer using long-axial field-of-view PET/CT: a retrospective evaluation

PURPOSE

To evaluate the utility of long duration (10 min) acquisitions compared to standard 4 min scans in the evaluation of head and neck cancer (HNC) using a long-axial field-of-view (LAFOV) system in 2-[18F]FDG PET/CT.

METHODS

HNC patients undergoing LAFOV PET/CT were included retrospectively according to a predefined sample size calculation. For each acquisition, FDG avid lymph nodes (LN) which were highly probable or equivocal for malignancy were identified by two board certified nuclear medicine physicians in consensus. The aim of this study was to establish the clinical acceptability of short-duration (4 min, C40%) acquisitions compared to full-count (10 min, C100%) in terms of the detection of LN metastases in HNC. Secondary endpoints were the positive predictive value for LN status (PPV) and comparison of SUVmax at C40% and C100%. Histology reports or confirmatory imaging were the reference standard.

RESULTS

A total of 1218 records were screened and target recruitment was met with n = 64 HNC patients undergoing LAFOV. Median age was 65 years (IQR: 59-73). At C40%, a total of 387 lesions were detected (highly probable LN n = 274 and equivocal n = 113. The total number of lesions detected at C100% acquisition was 439, of them 291 (66%) highly probable LN and 148 (34%) equivocal. Detection rate between the two acquisitions did not demonstrate any significant differences (Pearson's Chi-Square test, p = 0.792). Sensitivity, specificity, PPV, NPV and accuracy for C40% were 83%, 44%, 55%, 76% and 36%, whilst for C100% were 85%, 56%, 55%, 85% and 43%, respectively. The improved accuracy reached borderline significance (p = 0.057). At the ROC analysis, lower SUVmax was identified for C100% (3.5) compared to C40% (4.5).

CONCLUSION

In terms of LN detection, C40% acquisitions showed no significant difference compared to the C100% acquisitions. There was some improvement for lesions detection at C100%, with a small increment in accuracy reaching borderline significance, suggestive that the higher sensitivity afforded by LAFOV might translate to improved clinical performance in some patients.

Deep learning-based dynamic PET parametric Ki image generation from lung static PET

OBJECTIVES

PET/CT is a first-line tool for the diagnosis of lung cancer. The accuracy of quantification may suffer from various factors throughout the acquisition process. The dynamic PET parametric K_i provides better quantification and improve specificity for cancer detection. However, parametric imaging is difficult to implement clinically due to the long acquisition time (~ 1 h). We propose a dynamic parametric imaging method based on conventional static PET using deep learning.

METHODS

Based on the imaging data of 203 participants, an improved cycle generative adversarial network incorporated with squeeze-and-excitation attention block was introduced to learn the potential mapping relationship between static PET and K_i parametric images. The image quality of the synthesized images was qualitatively and quantitatively evaluated by using several physical and clinical metrics. Statistical analysis of correlation and consistency was also performed on the synthetic images.

RESULTS

Compared with those of other networks, the images synthesized by our proposed network exhibited superior performance in both qualitative and quantitative evaluation, statistical analysis, and clinical scoring. Our synthesized K_i images had significant correlation (Pearson correlation coefficient, 0.93), consistency, and excellent quantitative evaluation results with the K_i images obtained in standard dynamic PET practice.

CONCLUSIONS

Our proposed deep learning method can be used to synthesize highly correlated and consistent dynamic parametric images obtained from static lung PET.

KEY POINTS

• Compared with conventional static PET, dynamic PET parametric K_i imaging has been shown to provide better quantification and improved specificity for cancer detection. • The purpose of this work was to develop a dynamic parametric imaging method based on static PET images using deep learning. • Our proposed network can synthesize highly correlated and consistent dynamic parametric images, providing an additional quantitative diagnostic reference for clinicians.

Advantages and Applications of Total-Body PET Scanning

Recent studies have focused on the development of total-body PET scanning in a variety of fields such as clinical oncology, cardiology, personalized medicine, drug development and toxicology, and inflammatory/infectious disease. Given its ultrahigh detection sensitivity, enhanced temporal resolution, and long scan range (1940 mm), total-body PET scanning can not only image faster than traditional techniques with less administered radioactivity but also perform total-body dynamic acquisition at a longer delayed time point. These unique characteristics create several opportunities to improve image quality and can provide a deeper understanding regarding disease detection, diagnosis, staging/restaging, response to treatment, and prognostication. By reviewing the advantages of total-body PET scanning and discussing the potential clinical applications for this innovative technology, we can address specific issues encountered in routine clinical practice and ultimately improve patient care.

A depth-encoding PET detector that uses light sharing and single-ended readout with silicon photomultipliers

Detectors with depth-encoding capability and good timing resolution are required to develop high-performance whole-body or total-body PET scanners. In this work, depth-encoding PET detectors that use light sharing between two discrete crystals and single-ended readout with silicon photomultipliers (SiPMs) were manufactured and evaluated. The detectors consisted of two unpolished 3  ×  3  ×  20 mm³ LYSO crystals with different coupling materials between them and were read out by Hamamatsu 3  ×  3 mm² SiPMs with one-to-one coupling. The ratio of the energy of one SiPM to the total energy of two SiPMs was used to measure the depth of interaction (DOI). Detectors with different coupling materials in-between the crystals were measured in the singles mode in an effort to obtain detectors that can provide good DOI resolution. The DOI resolution and energy resolution of three types of detector were measured and the timing resolution was measured for the detector with the best DOI and energy resolution. The optimum detector, with 5 mm optical glue, a 9 mm triangular ESR and a 6 mm rectangular ESR in-between the unpolished crystals, provides a DOI resolution of 2.65 mm, an energy resolution of 10.0% and a timing resolution of 427 ps for events of E  >  400 keV. The detectors simultaneously provide good DOI and timing resolution, and show great promise for the development of high-performance whole-body and total-body PET scanners.

Development and Evaluation of mini-EXPLORER: A Long Axial Field-of-View PET Scanner for Nonhuman Primate Imaging

We describe a long axial field-of-view (FOV) PET scanner for high-sensitivity and total-body imaging of nonhuman primates and present the physical performance and first phantom and animal imaging results. Methods: The mini-EXPLORER PET scanner was built using the components of a clinical scanner reconfigured with a detector ring diameter of 43.5 cm and an axial length of 45.7 cm. National Electrical Manufacturers Association (NEMA) NU-2 and NU-4 phantoms were used to measure sensitivity and count rate performance. Reconstructed spatial resolution was investigated by imaging a radially stepped point source and a Derenzo phantom. The effect of the wide acceptance angle was investigated by comparing performance with maximum acceptance angles of 14°-46°. Lastly, an initial assessment of the in vivo performance of the mini-EXPLORER was undertaken with a dynamic ¹⁸F-FDG nonhuman primate (rhesus monkey) imaging study. Results: The NU-2 total sensitivity was 5.0%, and the peak noise-equivalent count rate measured with the NU-4 monkey scatter phantom was 1,741 kcps, both obtained using the maximum acceptance angle (46°). The NU-4 scatter fraction was 16.5%, less than 1% higher than with a 14° acceptance angle. The reconstructed spatial resolution was approximately 3.0 mm at the center of the FOV, with a minor loss in axial spatial resolution (0.5 mm) when the acceptance angle increased from 14° to 46°. The rhesus monkey ¹⁸F-FDG study demonstrated the benefit of the high sensitivity of the mini-EXPLORER, including fast imaging (1-s early frames), excellent image quality (30-s and 5-min frames), and late-time-point imaging (18 h after injection), all obtained at a single bed position that captured the major organs of the rhesus monkey. Conclusion: This study demonstrated the physical performance and imaging capabilities of a long axial FOV PET scanner designed for high-sensitivity imaging of nonhuman primates. Further, the results of this study suggest that a wide acceptance angle can be used with a long axial FOV scanner to maximize sensitivity while introducing only minor trade-offs such as a small increase in scatter fraction and slightly degraded axial spatial resolution.

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

PET is widely considered the most sensitive technique available for noninvasively studying physiology, metabolism, and molecular pathways in the living human being. However, the utility of PET, being a photon-deficient modality, remains constrained by factors including low signal-to-noise ratio, long imaging times, and concerns about radiation dose. Two developments offer the potential to dramatically increase the effective sensitivity of PET. First by increasing the geometric coverage to encompass the entire body, sensitivity can be increased by a factor of about 40 for total-body imaging or a factor of about 4-5 for imaging a single organ such as the brain or heart. The world's first total-body PET/CT scanner is currently under construction to demonstrate how this step change in sensitivity affects the way PET is used both in clinical research and in patient care. Second, there is the future prospect of significant improvements in timing resolution that could lead to further effective sensitivity gains. When combined with total-body PET, this could produce overall sensitivity gains of more than 2 orders of magnitude compared with existing state-of-the-art systems. In this article, we discuss the benefits of increasing body coverage, describe our efforts to develop a first-generation total-body PET/CT scanner, discuss selected application areas for total-body PET, and project the impact of further improvements in time-of-flight PET.

Total-body imaging: Transforming the role of positron emission tomography

The first total-body positron emission tomography (TB-PET) scanner represents a radical change for experimental medicine and diagnostic health care.

The extent to which standardized uptake values reflect FDG phosphorylation in the liver and spleen as functions of time after injection of 18F-fluorodeoxyglucose

Purpose

In FDG PET/CT, standardized uptake value (SUV) is used to measure metabolic activity but detects un-phosphorylated FDG as well as phosphorylated FDG (FDG6P). Our aim was to determine the proportions of intrahepatic and intrasplenic FDG that are phosphorylated after FDG injection and compare them with SUVs.

Methods

Sixty patients undergoing whole-body PET/CT 60 min post-injection of FDG first had dynamic PET imaging for 30 min with measurement of hepatic and splenic FDG clearances using Patlak-Rutland analysis. The gradient of the Patlak-Rutland plot, which is proportional to clearance (Ki), was normalized to the intercept, which is proportional to FDG distribution volume (V(0)) with the same proportionality constant. Using measured values of Ki/V(0), FDG6P/FDG ratios as functions of time in the two organs were measured for assumed FDG blood disappearance half-times of 40, 50 and 60 min. Hepatic and splenic SUVs were measured from whole-body PET/CT.

Results

The mean (SD) Ki/V(0) was 0.0036 (0.0021) and 0.0060 (0.0041) ml/min/ml for the liver and spleen, respectively, but the hepatic SUV was 1.36-fold higher than the splenic SUV. This discrepancy was explained by the hepatic V(0) being 1.6-fold higher than the splenic V(0). The percentages of FDG phosphorylated 60 min post-injection were 27, 25 and 23% for the liver and 39, 36 and 34% for the spleen, for blood clearance half-times of 40, 50 and 60 min, respectively. SUV indices correlated poorly with Ki/V(0) for both organs.

Conclusions

SUV is largely determined by un-phosphorylated FDG in dynamic exchange with blood FDG, explaining the poor correlations between SUV indices and Ki/V(0).

History and future technical innovation in positron emission tomography

Instrumentation for positron emission tomography (PET) imaging has experienced tremendous improvements in performance over the past 60 years since it was first conceived as a medical imaging modality. Spatial resolution has improved by a factor of 10 and sensitivity by a factor of 40 from the early designs in the 1970s to the high-performance scanners of today. Multimodality configurations have emerged that combine PET with computed tomography (CT) and, more recently, with MR. Whole-body scans for clinical purposes can now be acquired in under 10 min on a state-of-the-art PET/CT. This paper will review the history of these technical developments over 40 years and summarize the important clinical research and healthcare applications that have been made possible by these technical advances. Some perspectives for the future of this technology will also be presented that promise to bring about new applications of this imaging modality in clinical research and healthcare.

A combined time-of-flight and depth-of-interaction detector for total-body positron emission tomography

PURPOSE

In support of a project to build a total-body PET scanner with an axial field-of-view of 2 m, the authors are developing simple, cost-effective block detectors with combined time-of-flight (TOF) and depth-of-interaction (DOI) capabilities.

METHODS

This work focuses on investigating the potential of phosphor-coated crystals with conventional PMT-based block detector readout to provide DOI information while preserving timing resolution. The authors explored a variety of phosphor-coating configurations with single crystals and crystal arrays. Several pulse shape discrimination techniques were investigated, including decay time, delayed charge integration (DCI), and average signal shapes.

RESULTS

Pulse shape discrimination based on DCI provided the lowest DOI positioning error: 2 mm DOI positioning error was obtained with single phosphor-coated crystals while 3-3.5 mm DOI error was measured with the block detector module. Minimal timing resolution degradation was observed with single phosphor-coated crystals compared to uncoated crystals, and a timing resolution of 442 ps was obtained with phosphor-coated crystals in the block detector compared to 404 ps without phosphor coating. Flood maps showed a slight degradation in crystal resolvability with phosphor-coated crystals; however, all crystals could be resolved. Energy resolution was degraded by 3%-7% with phosphor-coated crystals compared to uncoated crystals.

CONCLUSIONS

These results demonstrate the feasibility of obtaining TOF-DOI capabilities with simple block detector readout using phosphor-coated crystals.

Parallax error in long-axial field-of-view PET scanners-a simulation study

There is a growing interest in the design and construction of a PET scanner with a very long axial extent. One critical design challenge is the impact of the long axial extent on the scanner spatial resolution properties. In this work, we characterize the effect of parallax error in PET system designs having an axial field-of-view (FOV) of 198 cm (total-body PET scanner) using fully-3D Monte Carlo simulations. Two different scintillation materials were studied: LSO and LaBr₃. The crystal size in both cases was 4  ×  4  ×  20 mm³. Several different depth-of-interaction (DOI) encoding techniques were investigated to characterize the improvement in spatial resolution when using a DOI capable detector. To measure spatial resolution we simulated point sources in a warm background in the center of the imaging FOV, where the effects of axial parallax are largest, and at several positions radially offset from the center. Using a line-of-response based ordered-subset expectation maximization reconstruction algorithm we found that the axial resolution in an LSO scanner degrades from 4.8 mm to 5.7 mm (full width at half max) at the center of the imaging FOV when extending the axial acceptance angle (α) from  ±12° (corresponding to an axial FOV of 18 cm) to the maximum of  ±67°-a similar result was obtained with LaBr₃, in which the axial resolution degraded from 5.3 mm to 6.1 mm. For comparison we also measured the degradation due to radial parallax error in the transverse imaging FOV; the transverse resolution, averaging radial and tangential directions, of an LSO scanner was degraded from 4.9 mm to 7.7 mm, for a measurement at the center of the scanner compared to a measurement with a radial offset of 23 cm. Simulations of a DOI detector design improved the spatial resolution in all dimensions. The axial resolution in the LSO-based scanner, with α  =  ± 67°, was improved from 5.7 mm to 5.0 mm by incorporating a two-layer DOI detector. These results characterize the maximum axial blurring for a fully open 2 m long PET scanner and demonstrate that large sensitivity gains are possible with a modest reduction in resolution when using current clinical detector technology with no DOI capability.

Dual-time-point Imaging and Delayed-time-point Fluorodeoxyglucose-PET/Computed Tomography Imaging in Various Clinical Settings

The techniques of dual-time-point imaging (DTPI) and delayed-time-point imaging, which are mostly being used for distinction between inflammatory and malignant diseases, has increased the specificity of fluorodeoxyglucose (FDG)-PET for diagnosis and prognosis of certain diseases. A gradually increasing trend of FDG uptake over time has been shown in malignant cells, and a decreasing or constant trend has been shown in inflammatory/infectious processes. Tumor heterogeneity can be assessed by using early and delayed imaging because differences between primary versus metastatic sites become more detectable compared with single time points. This article discusses the applications of DTPI and delayed-time-point imaging.

Image-driven pharmacokinetics: nanomedicine concentration across space and time

Clinical pharmacokinetics (PK) primarily measures the concentration of drugs in the blood. For nanomedicines it may be more relevant to determine concentration within a target tissue. The emerging field of image-driven PK, which utilizes clinically accepted molecular imaging technology, empirically and noninvasively, measures concentration in multiple tissues. Image-driven PK represents the intersection of PK and biodistribution, combining to provide models of concentration across space and time. Image-driven PK can be used both as a research tool and in the clinic. This review explores the history of pharmacokinetics, technologies used in molecular imaging (especially positron emission tomography) and research using image-driven pharmacokinetic analysis. When standardized, image-driven PK may have significant implications in preclinical development as well as clinical optimization of targeted nanomedicines.