Quantification of 18F-Fluoride Kinetics: Evaluation of Simplified Methods

Correlation of the quantitative methods for the measurement of bone uptake and plasma clearance of 18F-NaF using positron emission tomography. Systematic review and meta-analysis

PURPOSE

¹⁸F-NaF PET is valuable for detecting bone metabolism through osteoblastic activity in the assessment of bone disease. Hawkins, Patlak, and standardised uptake value (SUV) are the most common quantitative measurements used to evaluate bone metabolism. This systematic review evaluates the correlation between quantitative positron emission tomography (PET) methods and to compare their precision.

METHODS

A systematic search in Medline, PubMed, SCOPUS, and Web of Science was undertaken to find relevant papers published from 2000. All studies with human adults undergoing ¹⁸F-NaF PET, PET/CT, or PET/MRI were included except for subjects diagnosed with non-diffuse metabolic bone disease or malignancy. Quality Assessment Tool for Studies of Diverse Designs (QATSDD) was used to assess risk of bias. A qualitative review and meta-analysis using Hedges random-effect model was used producing summary size effects of the correlation between methods in healthy and unhealthy bone sites and assessing study heterogeneity.

RESULTS

228 healthy and unhealthy participants were included across 12 studies resulted from the systematic search. One-third of studies had a moderate quality percentage while the rest had relatively high quality. The pooled correlation coefficient in meta-analysis showed a high correlation of more than 0.88 (0.71-1.05. 95 %CI) between SUV and Hawkins and more than 0.96 (0.88-1.03. 95 %CI) between Patlak and Hawkins within all subgroups, suggesting all methods yield similar results in healthy and unhealthy bone sites. SUV has the lowest precision error followed by Patlak while Hawkins method showed the highest precision error.

CONCLUSION

Patlak is the best within research and SUV is better within clinical practice.

Assessment of quantitative [18F]Sodium fluoride PET measures of knee subchondral bone perfusion and mineralization in osteoarthritic and healthy subjects

OBJECTIVE

Molecular information derived from dynamic [18F]sodium fluoride ([18F]NaF) PET imaging holds promise as a quantitative marker of bone metabolism. The objective of this work was to evaluate physiological mechanisms of [18F]NaF uptake in subchondral bone of individuals with and without knee osteoarthritis (OA).

METHODS

Eleven healthy volunteers and twenty OA subjects were included. Both knees of all subjects were scanned simultaneously using a 3T hybrid PET/MRI system. MRI MOAKS assessment was performed to score the presence and size of osteophytes, bone marrow lesions, and cartilage lesions. Subchondral bone kinetic parameters of bone perfusion (K1), tracer extraction fraction, and total tracer uptake into bone (Ki) were evaluated using the Hawkins 3-compartment model. Measures were compared between structurally normal-appearing bone regions and those with structural findings.

RESULTS

Mean and maximum SUV and kinetic parameters Ki, K1, and extraction fraction were significantly different between Healthy subjects and subjects with OA. Between-group differences in metabolic parameters were observed both in regions where the OA group had degenerative changes as well as in regions that appeared structurally normal.

CONCLUSIONS

Results suggest that bone metabolism is altered in OA subjects, including bone regions with and without structural findings, compared to healthy subjects. Kinetic parameters of [18F]NaF uptake in subchondral bone show potential to quantitatively evaluate the role of bone physiology in OA initiation and progression. Objective measures of bone metabolism from [18F]NaF PET imaging can complement assessments of structural abnormalities observed on MRI.

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.

Diagnosis and Monitoring of Osteoporosis with Total-Body 18F-Sodium Fluoride-PET/CT

In recent years, ¹⁸F-Sodium Fluoride (NaF)-PET/CT has seen its role in the detection and management of osteoporosis increase. This article reviews the extent of this application in the literature, its efficacy compared with other comparable imaging tools, and how total-body PET/CT combined with global disease assessment can revolutionize measurement of total osteoporotic disease activity. NaF-PET/CT eventually can be the modality of choice for metabolic bone disorders, especially with these advances in technology and computation.

Kinetic [18F]-Fluoride of the Knee in Normal Volunteers

PURPOSE

[F]-sodium fluoride ([F]NaF) is a well-established bone-seeking agent that has shown promise to assess bone turnover in a variety of disorders, but its distribution in healthy knee joints has not been explored. This study aimed to investigate parametric values for [F]NaF uptake in various bone tissues types of the knee and their spatial distributions.

METHODS

Twelve healthy subjects were hand-injected with 92.5 MBq of [F]NaF and scanned on a 3-T PET/MRI system. Listmode PET data for both knees were acquired for 50 minutes from injection simultaneously with MRI Dixon and angiography data. The image-derived input function was determined from the popliteal artery. Using the Hawkins model, Patlak analysis was performed to obtain Ki (Ki) values and nonlinear regression analysis to obtain Ki, K1, k3/(k2 + k3), and blood volume. Comparisons for the measured kinetic parameters, SUV, and SUVmax were made between tissue types (subchondral, cortical, and trabecular bone) and between regional subsections of subchondral bone.

RESULTS

Cortical bone had the highest [F]NaF uptake differing significantly in all measured parameters when compared with trabecular bone and significantly higher SUVmax and K1 than subchondral bone. Subchondral bone also had significantly higher SUV, SUVmax, and Ki than trabecular bone tissue. Regional differences were observed in K1 and k3/(k2 + k3) values.

CONCLUSIONS

Quantitative [F]NaF PET is sensitive to variations in bone vascularization and metabolism in the knee joint.

How Long of a Dynamic 3'-Deoxy-3'-[18F]fluorothymidine ([18F]FLT) PET Acquisition Is Needed for Robust Kinetic Analysis in Breast Cancer?

PURPOSE

To quantitatively evaluate the minimally required scanning time of 3'-deoxy-3'-[¹⁸F]fluorothymidine ([¹⁸F]FLT) positron emission tomography (PET) dynamic acquisition for accurate kinetic assessment of the proliferation in breast cancer tumors.

PROCEDURES

Within a therapeutic intervention trial, 26 breast tumors of 8 breast cancer patients were analyzed from 30-min dynamic [¹⁸F]FLT-PET acquisitions. PET/CT was acquired on a Gemini TF 64 system (Philips Healthcare) and reconstructed into 26 frames (8 × 15 s, 6 × 30 s, 5 × 1 min, 5 × 2 min, and 2 × 5 min). Maximum activity concentrations (Bq/ml) of volume of interests over tumors and plasma in descending aorta were obtained over time frames. Kinetic parameters were estimated using in-house developed software with the two-tissue three-compartment irreversible model (2TCM) (K₁, k₂, k₃, and K_i; k₄ = 0) and Patlak model (K_i) based on different acquisition durations (T_d) (10, 12, 14, 16, 20, 25, and 30 min, separately). Different linear regression onset time (T₀) points (1, 2, 3, 4, and 5 min) were applied in Patlak analysis. K_i of the 30-min data set was taken as the gold standard for comparison. Pearson product-moment correlation coefficient (R) of 0.9 was chosen as a limit for the correlation.

RESULTS

The correlation of kinetic parameters between the gold standard and the abbreviated dynamic data series increased with longer T_d from 10 to 30 min. k₂ and k₃ using 2TCM and K_i using Patlak model revealed poor correlations for dynamic PET with T_d ≤ 14 min (k₂: R = 0.84, 0.85, 0.86; k₃: R = 0.67, 0.67, 0.67; K_i: R = 0.72, 0.78, 0.87 at T_d = 10, 12, and 14 min, respectively). Excellent correlations were shown for all kinetic parameters when T_d ≥ 16 min regardless of the kinetic model and T₀ value (R > 0.9).

CONCLUSIONS

This study indicates that a 16-min dynamic PET acquisition appears to be sufficient to provide accurate [¹⁸F]FLT kinetics to quantitatively assess the proliferation in breast cancer lesions.

[18F]NaF PET/CT scan as an early marker of heterotopic ossification in fibrodysplasia ossificans progressiva

Fibrodysplasia ossificans progressiva (FOP) is a rare genetic disease with a progressive course characterized by episodically local flare-ups, which often but not always leads to heterotopic bone formation (HO). Recently, we showed that [18F]NaF PET/CT may be the first tool to monitor progression of a posttraumatic flare-up leading to new HO, which was demonstrated in a patient with FOP who underwent a maxillofacial surgery. This paper evaluates [18F]NaF PET/CT as a marker of FOP disease activity, comparing its use with other imaging modalities known in literature. In addition, the follow-up of a spontaneous flare-up in a 19-year old patient is presented showing high muscle [18F]NaF uptake in one defined part within the flare-up area after three weeks. During follow-up [18F]NaF PET /CT scan revealed newly formed heterotopic bone but only in this previously active [18F]NaF region. In conclusion, increased muscle [18F]NaF uptake may predict future HO development in FOP patients. At present [18F]NaF PET/CT appears to be a sensitive imaging modality to serve as a noninvasive marker for bone formation and to monitor disease activity during flare-ups in FOP.

Imaging Bone-Cartilage Interactions in Osteoarthritis Using [18F]-NaF PET-MRI

Purpose:

Simultaneous positron emission tomography–magnetic resonance imaging (PET-MRI) is an emerging technology providing both anatomical and functional images without increasing the scan time. Compared to the traditional PET/computed tomography imaging, it also exposes the patient to significantly less radiation and provides better anatomical images as MRI provides superior soft tissue characterization. Using PET-MRI, we aim to study interactions between cartilage composition and bone function simultaneously, in knee osteoarthritis (OA).

Procedures:

In this article, bone turnover and remodeling was studied using [¹⁸F]-sodium fluoride (NaF) PET data. Quantitative MR-derived T_1ρ relaxation times characterized the biochemical cartilage degeneration. Sixteen participants with early signs of OA of the knee received intravenous injections of [¹⁸F]-NaF at the onset of PET-MR image acquisition. Regions of interest were identified, and kinetic analysis of dynamic PET data provided the rate of uptake (K_i) and the normalized uptake (standardized uptake value) of [¹⁸F]-NaF in the bone. Morphological MR images and quantitative voxel-based T_1ρ maps of cartilage were obtained using an atlas-based registration technique to segment cartilage automatically. Voxel-by-voxel statistical parameter mapping was used to investigate the relationship between bone and cartilage.

Results:

Increases in cartilage T_1ρ, indicating degenerative changes, were associated with increased turnover in the adjoining bone but reduced turnover in the nonadjoining compartments. Associations between pain and increased bone uptake were seen in the absence of morphological lesions in cartilage, but the relationship was reversed in the presence of incident cartilage lesions.

Conclusion:

This study shows significant cartilage and bone interactions in OA of the knee joint using simultaneous [¹⁸F]-NaF PET-MR, the first in human study. These observations highlight the complex biomechanical and biochemical interactions in the whole knee joint in OA, which potentially could help assess therapeutic targets in treating OA.

Flare-Up After Maxillofacial Surgery in a Patient With Fibrodysplasia Ossificans Progressiva: An [18F]-NaF PET/CT Study and a Systematic Review

Fibrodysplasia ossificans progressiva (FOP) is a rare genetic disorder leading to progressive heterotopic ossifications (HO) of muscles, tendons, and ligaments, which can be induced by trauma or by surgery. Despite strong medical advice to the contrary, an FOP patient insisted on surgery to alleviate her complete trismus, which caused an unbearable impact on her quality of life (QOL). The entire trismus history of this FOP patient is presented. [¹⁸F]‐NaF position emission tomography/computed tomography (PET/CT) scans were introduced as an imaging method for heterotopic bone formation activity. To place our findings into context, a systematic review on jaw surgery in FOP was performed. After falling down the stairs, a 9‐year‐old patient developed mobility impairment of her left‐sided jaw. During the following 13 years bone scintigraphy showed persistent activity of the disease leading to progressive left‐sided zygomatico‐mandibular fusion by HO, resulting in complete trismus. Within 1 month after HO removal on the left side and a matching right coronoidectomy, [¹⁸F]‐NaF PET/CT demonstrated a substantial flare‐up activity followed by new HO in both masseter and temporalis muscles. Despite recurrent HO and trismus her QOL increased due to a stable increased interincisal opening of 5.5 mm. Although systematic review reveals a 100% risk of HO recurrence after jaw surgery, information on improved QOL is scarce. In conclusion, surgery in FOP may be beneficial for QOL despite new HO formation. Assessment of disease activity using [¹⁸F]‐NaF PET/CT is possible before HO is evident on CT and may serve as a new and quantitative marker of the disease. © 2017 The Authors. JBMR Plus Published by Wiley Periodicals, Inc. on behalf of the American Society for Bone and Mineral Research.

Blood perfusion in osteomyelitis studied with [15O]water PET in a juvenile porcine model

Background

Osteomyelitis is a serious disease which can be difficult to treat despite properly instituted antibiotic therapy. This appears to be related at least partly to degraded vascularisation in the osteomyelitic (OM) lesions. Studies of perfusion in OM bones are, however, few and not quantitative. Quantitative assessment of perfusion could aid in the selection of therapy. A non-invasive, quantitative way to study perfusion is dynamic [¹⁵O]water positron emission tomography (PET). We aim to demonstrate that the method can be used for measuring perfusion in OM lesions and hypothesize that perfusion will be less elevated in OM lesions than in soft tissue (ST) infection. The study comprised 11 juvenile pigs with haematogenous osteomyelitis induced by injection of Staphylococcus aureus into the right femoral artery 1 week before scanning (in one pig, 2 weeks). The pigs were dynamically PET scanned with [¹⁵O]water to quantify blood perfusion. OM lesions (N = 17) in long bones were studied, using the left limb as reference. ST lesions (N = 8) were studied similarly.

Results

Perfusion was quantitatively determined. Perfusion was elevated by a factor 1.5 in OM lesions and by a factor 6 in ST lesions.

Conclusions

Blood perfusion was successfully determined in pathological subacute OM lesions; average perfusion was increased compared to that in a healthy bone, but as hypothesized, the increase was less than in ST lesions, indicating that the infected bone has less perfusion reserve than the infected soft tissue.

Electronic supplementary material

The online version of this article (doi:10.1186/s13550-016-0251-2) contains supplementary material, which is available to authorized users.

(18)F-fluoride-PET for dynamic in vivo monitoring of bone formation in multiple myeloma

Background

Bone disease in multiple myeloma is characterized by reduced bone formation. The gold standard of bone formation is the mineral apposition rate (MAR), an invasive technique reflecting bone formation at a single site. We compared ¹⁸F-fluoride-PET with the MAR in myeloma patients.

Methods

Bone formation was measured before and after bortezomib treatment by determination of the MAR in iliac bone marrow biopsies and the measurement of ¹⁸F-uptake.

Results

The inter- and intra-individual variations in ¹⁸F-uptake (SUV_A50%) were pronounced as 33.50 (range 4.42 to 37.92) and 27.18 (range 4.00 to 31.18), respectively. A significant correlation between the MAR and ¹⁸F-uptake was found (r = 0.80, p = 0.017). There was a heterogeneous response after treatment varying from −2.20 to 4.53.

Conclusions

Iliac ¹⁸F-uptake was associated with the local MAR in myeloma patients. Furthermore, ¹⁸F-fluoride-PET demonstrated the heterogeneity of in vivo bone formation, enabling monitoring during treatment.

Electronic supplementary material

The online version of this article (doi:10.1186/s13550-016-0197-4) contains supplementary material, which is available to authorized users.

Using PET/CT Bone Scan Dynamic Data to Evaluate Tibia Remodeling When a Taylor Spatial Frame Is Used: Short and Longer Term Differences

Eighteen consecutive patients, treated with a Taylor Spatial Frame for complex tibia conditions, gave their informed consent to undergo Na¹⁸F⁻ PET/CT bone scans. We present a Patlak-like analysis utilizing an approximated blood time-activity curve eliminating the need for blood aliquots. Additionally, standardized uptake values (SUV) derived from dynamic acquisitions were compared to this Patlak-like approach. Spherical volumes of interest (VOIs) were drawn to include broken bone, other (normal) bone, and muscle. The SUV_m(t) (m = max, mean) and a series of slopes were computed as (SUV_m(t_i) − SUV_m(t_j))/(t_i − t_j), for pairs of time values t_i and t_j. A Patlak-like analysis was performed for the same time values by computing ((VOI_p(t_i)/VOI_e(t_i))−(VOI_p(t_j)/VOI_e(t_j)))/(t_i − t_j), where p = broken bone, other bone, and muscle and e = expected activity in a VOI. Paired comparisons between Patlak-like and SUV_m slopes showed good agreement by both linear regression and correlation coefficient analysis (r = 84%, r_s = 78%-SUV_max, r = 92%, and r_s = 91%-SUV_mean), suggesting static scans could substitute for dynamic studies. Patlak-like slope differences of 0.1 min⁻¹ or greater between examinations and SUV_max differences of ~5 usually indicated good remodeling progress, while negative Patlak-like slope differences of −0.06 min⁻¹ usually indicated poor remodeling progress in this cohort.

Evaluation of a short dynamic 18F-fluoride PET/CT scanning method to assess bone metabolic activity in spinal orthopedics

OBJECTIVE

A complication after spinal fusion surgery is pseudarthrosis, but its radiological diagnosis is of limited value. (18)F-fluoride PET with its ability to assess bone metabolism activity could be of value. The goal of this study was to assess the clinical feasibility of calculating the static standardized uptake value (SUV) from a short dynamic scan without the use of blood sampling, thereby obtaining all dynamic and static parameters in a scan of only 30 min. This approach was tested on a retrospective patient population with persisting pain after spinal fusion surgery.

METHODS

In 16 patients, SUVs (SUV max, SUV mean) and kinetic parameters (K 1, k 2, k 3, v b, K i,NLR, K 1/k 2, k 3/(k 2 + k 3), K i,patlak) were derived from static and dynamic PET/CT scans of operated and control regions of the spine, after intravenous administration of 156-214 MBq (18)F-fluoride. Parameter differences between control and operated regions, as well as between pseudarthrosis and fused segments were evaluated. SUVmean at 30 and 60 min was calculated from kinetic parameters obtained from the dynamic data set (SUV mean,2TCM). Agreement between measured and calculated SUVs was evaluated through Bland-Altman plots.

RESULTS

Overall, statistically significant differences between control and operated regions were observed for SUV max, SUV mean, K i,NLR, K i,patlak, K 1/k 2 and k 3/(k 2 + k 3). Diagnostic CT showed pseudarthrosis in 6/16 patients, while in 10/16 patients, segments were fused. Of all parameters, only those regarding the incorporation of bone [K i,NLR, K i,patlak, k 3/(k 2 + k 3)] differed statistically significant in the intervertebral disc space between the pseudarthrosis and fused patients group. The mean values of the patient-specific blood clearance rate [Formula: see text] differed statistically significant between the pseudarthrosis and the fusion group, with a p value of 0.011. This may correspond with the lack of statistical significance of the SUV values between pseudarthrosis and fused patients. Bland-Altman plots show that calculated SUV mean,2TCM values corresponded well with the measured SUV mean values.

CONCLUSION

This study shows the feasibility of a 30-min dynamic (18)F-fluoride PET/CT scanning and this may provide dynamic parameters clinically relevant to the diagnosis of pseudarthrosis.