Toward Simultaneous Real-Time Fluoroscopic and Nuclear Imaging in the Intervention Room

Progress in large field-of-view interventional planar scintigraphy and SPECT imaging

INTRODUCTION

Handheld gamma cameras and gamma probes have been successfully implemented for enabling nuclear image or radio-guidance in minimally-invasive procedures. There is an opportunity for large field-of-view interventional planar scintigraphy and SPECT imaging to complement these small field-of-view devices for two reasons. First, a large field-of-view camera enables imaging of relatively larger organs and activity accumulations that are not close to the patient's skin. And second, more precise corrections can be implemented in the SPECT reconstruction algorithm, improving its quality.

AREAS COVERED

This review article discusses the progress that has been made in the field of large field-of-view interventional planar scintigraphy and SPECT imaging. First, an overview of planar scintigraphy and SPECT is provided. Second, an exploration is given of the potential applications where large field-of-view interventional planar scintigraphy and SPECT imaging may be employed. And third, the requirements for scanner hardware are discussed and an overview of the possible system configurations is provided.

EXPERT OPINION

We believe that there is an opportunity for large field-of-view interventional planar scintigraphy and SPECT imaging to assist clinical workflows. A major effort is now required to evaluate the prototype systems in clinical studies so that valuable practical experience can be obtained.

Nuclear Cardiac Imaging in the Interventional Suite

PURPOSE OF REVIEW

This review presents the current state of imaging approaches that enable real-time molecular imaging in the interventional suite and discusses the potential future use of integrated nuclear imaging and fluoroscopy for intraprocedural guidance in the evaluation and treatment of both cardiovascular and oncological diseases.

RECENT FINDINGS

Although there are no commercially available real-time hybrid nuclear imaging devices that are approved for use in the interventional suite, prototype open gantry hybrid nuclear imaging and x-ray c-arm imaging systems and theranostic catheter for location radiotracer detection are currently undergoing development and testing by multiple groups. The integration of physiological and molecular targeted nuclear imaging for real-time delivery of targeted theranostics in the interventional laboratory may enable more personalized care for a wide variety of cardiovascular procedures and improve patient outcomes.

A compact and mobile hybrid C-arm scanner for simultaneous nuclear and fluoroscopic image guidance

Purpose

This study evaluates the performance of a mobile and compact hybrid C-arm scanner (referred to as IXSI) that is capable of simultaneous acquisition of 2D fluoroscopic and nuclear projections and 3D image reconstruction in the intervention room.

Results

The impact of slightly misaligning the IXSI modalities (in an off-focus geometry) was investigated for the reduction of the fluoroscopic and nuclear interference. The 2D and 3D nuclear image quality of IXSI was compared with a clinical SPECT/CT scanner by determining the spatial resolution and sensitivity of point sources and by performing a quantitative analysis of the reconstructed NEMA image quality phantom. The 2D and 3D fluoroscopic image of IXSI was compared with a clinical CBCT scanner by visualizing the Fluorad A+D image quality phantom and by visualizing a reconstructed liver nodule phantom. Finally, the feasibility of dynamic simultaneous nuclear and fluoroscopic imaging was demonstrated by injecting an anthropomorphic phantom with a mixture of iodinated contrast and ^99mTc.

Conclusion

Due to the divergent innovative hybrid design of IXSI, concessions were made to the nuclear and fluoroscopic image qualities. Nevertheless, IXSI realizes unique image guidance that may be beneficial for several types of procedures.

Key Points

• IXSI can perform time-resolved planar (2D) simultaneous fluoroscopic and nuclear imaging.

• IXSI can perform SPECT/CBCT imaging (3D) inside the intervention room.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00330-021-08023-4.

Current Status and Future Direction of Hepatic Radioembolisation

Radioembolisation is a locoregional treatment modality for hepatic malignancies. It consists of several stages that are vital to its success, which include a pre-treatment angiographic simulation followed by nuclear medicine imaging, treatment activity choice, treatment procedure and post-treatment imaging. All these stages have seen much advancement over the past decade. Here we aim to provide an overview of the practice of radioembolisation, discuss the limitations of currently applied methods and explore promising developments.

Performance of a dual-layer scanner for hybrid SPECT/CBCT

Fluoroscopic procedures involving radionuclides would benefit from interventional nuclear imaging by obtaining real-time feedback on the activity distribution. We have previously proposed a dual-layer detector that offers such procedural guidance by simultaneous fluoroscopic and nuclear planar imaging. Acquisition of single photon computed tomography (SPECT) and cone beam computed tomography (CBCT) could provide additional information on the activity distribution. This study investigates the feasibility and the image quality of simultaneous SPECT/CBCT, by means of phantom experiments and simulations. Simulations were performed to study the obtained reconstruction quality for (i) clinical SPECT/CT, (ii) a dual-layer scanner configured with optimized hardware, and (iii) our (non-optimized) dual-layer prototype. Experiments on an image quality phantom and an anthropomorphic phantom (including extrahepatic depositions with volumes and activities close to the median values encountered in hepatic radioembolization) were performed with a clinical SPECT/CT scanner and with our dual-layer prototype. Nuclear images were visually and quantitatively evaluated by measuring the tumor/non-tumor (T/N) ratio and contrast-to-noise ratio (CNR). The simulations showed that the maximum obtained CNR was 38.8  ±  0.8 for the clinical scanner, 30.2  ±  0.9 for the optimized dual-layer scanner, and 20.8  ±  0.4 for the prototype scanner. T/N ratio showed a similar decline. The phantom experiments showed that performing simultaneous SPECT/CBCT is feasible. The CNR obtained from the SPECT reconstruction of largest sphere in the image quality phantom was 43.1 for the clinical scanner and 28.6 for the developed prototype scanner. The anthropomorphic phantom showed that the extrahepatic depositions were detected with both scanners. A dual-layer detector is able to simultaneously acquire SPECT and CBCT. Both CNR and T/N ratio are worse than that of a clinical system, but the phantom experiments showed that extrahepatic depositions with volumes and activities close to the median values encountered in hepatic radioembolization could be distinguished.

Theranostics in Interventional Oncology: Versatile Carriers for Diagnosis and Targeted Image-Guided Minimally Invasive Procedures

We are continuously progressing in our understanding of cancer and other diseases and learned how they can be heterogeneous among patients. Therefore, there is an increasing need for accurate characterization of diseases at the molecular level. In parallel, medical imaging and image-guided therapies are rapidly developing fields with new interventions and procedures entering constantly in clinical practice. Theranostics, a relatively new branch of medicine, refers to procedures combining diagnosis and treatment, often based on patient and disease-specific features or molecular markers. Interventional oncology which is at the convergence point of diagnosis and treatment employs several methods related to theranostics to provide minimally invasive procedures tailored to the patient characteristics. The aim is to develop more personalized procedures able to identify cancer cells, selectively reach and treat them, and to assess drug delivery and uptake in real-time in order to perform adjustments in the treatment being delivered based on obtained procedure feedback and ultimately predict response. Here, we review several interventional oncology procedures referring to the field of theranostics, and describe innovative methods that are under development as well as future directions in the field.

A Dual-layer Detector for Simultaneous Fluoroscopic and Nuclear Imaging

Purpose To develop and evaluate a dual-layer detector capable of acquiring intrinsically registered real-time fluoroscopic and nuclear images in the interventional radiology suite. Materials and Methods The dual-layer detector consists of an x-ray flat panel detector placed in front of a γ camera with cone beam collimator focused at the x-ray focal spot. This design relies on the x-ray detector absorbing the majority of the x-rays while it is more transparent to the higher energy γ photons. A prototype was built and dynamic phantom images were acquired. In addition, spatial resolution and system sensitivity (evaluated as counts detected within the energy window per second per megabecquerel) were measured with the prototype. Monte Carlo simulations for an improved system with varying flat panel compositions were performed to assess potential spatial resolution and system sensitivity. Results Experiments with the dual-layer detector prototype showed that spatial resolution of the nuclear images was unaffected by the addition of the flat panel (full width at half maximum, 13.6 mm at 15 cm from the collimator surface). However, addition of the flat panel lowered system sensitivity by 45%-60% because of the nonoptimized transmission of the flat panel. Simulations showed that an attenuation of 27%-35% of the γ rays in the flat panel could be achieved by decreasing the crystal thickness and housing attenuation of the flat panel. Conclusion A dual-layer detector was capable of acquiring real-time intrinsically registered hybrid images, which could aid interventional procedures involving radionuclides. Published under a CC BY-NC-ND 4.0 license. Online supplemental material is available for this article.

Fast technetium-99m liver SPECT for evaluation of the pretreatment procedure for radioembolization dosimetry

PURPOSE

The efficiency of radioembolization procedures could be greatly enhanced if results of the 99m Tc-MAA pretreatment procedure were immediately available in the interventional suite, enabling 1-day procedures as a result of direct estimation of the hepatic radiation dose and lung shunt fraction. This would, however, require a relatively fast, but still quantitative, SPECT procedure, which might be achieved with acquisition protocols using nonuniform durations of the projection images.

METHODS

SPECT liver images of the 150-MBq 99m Tc-MAA pretreatment procedure were simulated for eight different lesion locations and two different lesion sizes using the digital XCAT phantom for both single- and dual-head scanning geometries with respective total acquisition times of 1, 2, 5, 10, and 30 min. Three nonuniform projection-time acquisition protocols ("half-circle SPECT (HCS)," "nonuniform SPECT (NUS) I," and "NUS II") for fast quantitative SPECT of the liver were designed and compared with the standard uniform projection-time protocol. Images were evaluated in terms of contrast-to-noise ratio (CNR), activity recovery coefficient (ARC), tumor/non-tumor (T/N) activity concentration ratio, and lung shunt fraction (LSF) estimation. In addition, image quality was verified with a physical phantom experiment, reconstructed with both clinical and Monte Carlo-based reconstruction software.

RESULTS

Simulations showed no substantial change in image quality and dosimetry by usage of a nonuniform projection-time acquisition protocol. Upon shortening acquisition times, CNR dropped, but ARC, T/N ratio, and LSF estimates were stable across all simulated acquisition times. Results of the physical phantom were in agreement with those of the simulations.

CONCLUSION

Both uniform and nonuniform projection-time acquisition liver SPECT protocols yield accurate dosimetric metrics for radioembolization treatment planning in the interventional suite within 10 min, without compromising image quality. Consequently, fast quantitative SPECT of the liver in the interventional suite is feasible.

Fast quantitative reconstruction with focusing collimators for liver SPECT

BACKGROUND

Generation of a SPECT scan during procedure may aid in the optimization of treatments as liver radioembolization by offering image-guided dosimetry. This, however, requires both shortened acquisition times and fast quantitative reconstruction. Focusing collimators increase sensitivity and thus may speed up imaging. Monte Carlo-based iterative reconstruction has shown to provide quantitative results for parallel hole collimators but may be slow. The purpose of this work is to develop fast Monte Carlo-based reconstruction for focusing collimators and to evaluate the impact of reconstruction and collimator choice on quantitative accuracy of liver dosimetry by means of simulations.

RESULTS

The developed fast Monte Carlo simulator was found to accurately generate projections compared to a full Monte Carlo simulation, providing projections in several seconds instead of several days. Monte Carlo-based scatter correction was superior to other scatter correction methods in describing recovered activity and reached similar noise levels as dual-energy window scatter correction. Although truncation artifacts were present in the cone beam collimator (50 cm), the region inside the field of view (FOV) could be reconstructed without loss of accuracy. Provided the object to image is inside the FOV, the focusing collimator with 50 cm focal distance could retrieve the same noise levels as a parallel hole collimator in 68% of the total scanning time, the multifocal collimator in 73% of the time, and the 100-cm focal distance collimator in 84% of the time.

CONCLUSION

Focusing collimators combined with Monte Carlo-based reconstruction have the ability to enable quantitative imaging of the FOV in a significantly shorter timeframe. The proposed approach to the forward projector will additionally make it possible to reconstruct within minutes. These are crucial steps in moving toward real-time dosimetry during interventions.

The physics of radioembolization

Radioembolization is an established treatment for chemoresistant and unresectable liver cancers. Currently, treatment planning is often based on semi-empirical methods, which yield acceptable toxicity profiles and have enabled the large-scale application in a palliative setting. However, recently, five large randomized controlled trials using resin microspheres failed to demonstrate a significant improvement in either progression-free survival or overall survival in both hepatocellular carcinoma and metastatic colorectal cancer. One reason for this might be that the activity prescription methods used in these studies are suboptimal for many patients.In this review, the current dosimetric methods and their caveats are evaluated. Furthermore, the current state-of-the-art of image-guided dosimetry and advanced radiobiological modeling is reviewed from a physics' perspective. The current literature is explored for the observation of robust dose-response relationships followed by an overview of recent advancements in quantitative image reconstruction in relation to image-guided dosimetry.This review is concluded with a discussion on areas where further research is necessary in order to arrive at a personalized treatment method that provides optimal tumor control and is clinically feasible.

Technical Advances in Image Guidance of Radionuclide Therapy

Internal radiation therapy with radionuclides (i.e., radionuclide therapy) owes its success to the many advantages over other, more conventional, treatment options. One distinct advantage of radionuclide therapies is the potential to use (part of) the emitted radiation for imaging of the radionuclide distribution. The combination of diagnostic and therapeutic properties in a set of matched radiopharmaceuticals (sometimes combined in a single radiopharmaceutical) is often referred to as theranostics and allows accurate diagnostic imaging before therapy. The use of imaging benefits treatment planning, dosimetry, and assessment of treatment response. This paper focuses on a selection of advances in imaging technology relevant for image guidance of radionuclide therapy. This involves developments in nuclear imaging modalities, as well as other anatomic and functional imaging modalities. The quality and quantitative accuracy of images used for guidance of radionuclide therapy is continuously being improved, which in turn may improve the therapeutic outcome and efficiency of radionuclide therapies.

Estimation of lung shunt fraction from simultaneous fluoroscopic and nuclear images

Radioembolisation with yttrium-90 (⁹⁰Y) is increasingly used as a treatment of unresectable liver malignancies. For safety, a scout dose of technetium-99m macroaggregated albumin (^99mTc-MAA) is used prior to the delivery of the therapeutic activity to mimic the deposition of ⁹⁰Y. One-day procedures are currently limited by the lack of nuclear images in the intervention room. To cope with this limitation, an interventional simultaneous fluoroscopic and nuclear imaging device is currently being developed. The purpose of this simulation study was to evaluate the accuracy of estimating the lung shunt fraction (LSF) of the scout dose in the intervention room with this device and compare it against current clinical methods.

METHODS

A male and female XCAT phantom, both with two respiratory profiles, were used to simulate various LSFs resulting from a scout dose of 150 MBq ^99mTc-MAA. Hybrid images were Monte Carlo simulated for breath-hold (5 s) and dynamic breathing (10 frames of 0.5 s) acquisitions. Nuclear images were corrected for attenuation with the fluoroscopic image and for organ overlap effects using a pre-treatment CT-scan. For comparison purposes, planar scintigraphy and mobile gamma camera images (both 300 s acquisition time) were simulated. Estimated LSFs were evaluated for all methods and compared to the phantom ground truth.

RESULTS

In the clinically relevant range of 10-20% LSF, hybrid imaging overestimated LSF with approximately 2 percentage points (pp) and 3 pp for the normal and irregular breathing phantoms, respectively. After organ overlap correction, LSF was estimated with a more constant error. Errors in planar scintigraphy and mobile gamma camera imaging were more dependent on LSF, body shape and breathing profile.

CONCLUSION

LSF can be estimated with a constant minor error with a hybrid imaging device. Estimated LSF is highly dependent on true LSF, body shape and breathing pattern when estimated with current clinical methods. The hybrid imaging device is capable of accurately estimating LSF within a few seconds in an interventional setting.

Simultaneous fluoroscopic and nuclear imaging: impact of collimator choice on nuclear image quality

PURPOSE

X-ray-guided oncological interventions could benefit from the availability of simultaneously acquired nuclear images during the procedure. To this end, a real-time, hybrid fluoroscopic and nuclear imaging device, consisting of an X-ray c-arm combined with gamma imaging capability, is currently being developed (Beijst C, Elschot M, Viergever MA, de Jong HW. Radiol. 2015;278:232-238). The setup comprises four gamma cameras placed adjacent to the X-ray tube. The four camera views are used to reconstruct an intermediate three-dimensional image, which is subsequently converted to a virtual nuclear projection image that overlaps with the X-ray image. The purpose of the present simulation study is to evaluate the impact of gamma camera collimator choice (parallel hole versus pinhole) on the quality of the virtual nuclear image.

METHODS

Simulation studies were performed with a digital image quality phantom including realistic noise and resolution effects, with a dynamic frame acquisition time of 1 s and a total activity of 150 MBq. Projections were simulated for 3, 5, and 7 mm pinholes and for three parallel hole collimators (low-energy all-purpose (LEAP), low-energy high-resolution (LEHR) and low-energy ultra-high-resolution (LEUHR)). Intermediate reconstruction was performed with maximum likelihood expectation-maximization (MLEM) with point spread function (PSF) modeling. In the virtual projection derived therefrom, contrast, noise level, and detectability were determined and compared with the ideal projection, that is, as if a gamma camera were located at the position of the X-ray detector. Furthermore, image deformations and spatial resolution were quantified. Additionally, simultaneous fluoroscopic and nuclear images of a sphere phantom were acquired with a physical prototype system and compared with the simulations.

RESULTS

For small hot spots, contrast is comparable for all simulated collimators. Noise levels are, however, 3 to 8 times higher in pinhole geometries than in parallel hole geometries. This results in higher contrast-to-noise ratios for parallel hole geometries. Smaller spheres can thus be detected with parallel hole collimators than with pinhole collimators (17 mm vs 28 mm). Pinhole geometries show larger image deformations than parallel hole geometries. Spatial resolution varied between 1.25 cm for the 3 mm pinhole and 4 cm for the LEAP collimator. The simulation method was successfully validated by the experiments with the physical prototype.

CONCLUSION

A real-time hybrid fluoroscopic and nuclear imaging device is currently being developed. Image quality of nuclear images obtained with different collimators was compared in terms of contrast, noise, and detectability. Parallel hole collimators showed lower noise and better detectability than pinhole collimators.

Multimodality calibration for simultaneous fluoroscopic and nuclear imaging

Background

Simultaneous real-time fluoroscopic and nuclear imaging could benefit image-guided (oncological) procedures. To this end, a hybrid modality is currently being developed by our group, by combining a c-arm with a gamma camera and a four-pinhole collimator. Accurate determination of the system parameters that describe the position of the x-ray tube, x-ray detector, gamma camera, and collimators is crucial to optimize image quality. The purpose of this study was to develop a calibration method that estimates the system parameters used for reconstruction.

A multimodality phantom consisting of five point sources was created. First, nuclear and fluoroscopic images of the phantom were acquired at several distances from the image intensifier. The system parameters were acquired using physical measurement, and multimodality images of the phantom were reconstructed. The resolution and co-registration error of the point sources were determined as a measure of image quality. Next, the system parameters were estimated using a calibration method, which adjusted the parameters in the reconstruction algorithm, until the resolution and co-registration were optimized. For evaluation, multimodality images of a second set of phantom acquisitions were reconstructed using calibrated parameter sets. Subsequently, the resolution and co-registration error of the point sources were determined as a measure of image quality. This procedure was performed five times for different noise simulations. In addition, simultaneously acquired fluoroscopic and nuclear images of two moving syringes were obtained with parameter sets from before and after calibration.

Results

The mean FWHM was significantly lower after calibration than before calibration for 21 out of 25 point sources. The mean co-registration error was significantly lower after calibration than before calibration for all point sources. The simultaneously acquired fluoroscopic and nuclear images showed improved co-registration after calibration as compared with before calibration.

Conclusions

A calibration method was presented that improves the resolution and co-registration of simultaneously acquired hybrid fluoroscopic and nuclear images by estimating the geometric parameter set as compared with a parameter set acquired by direct physical measurement.

Electronic supplementary material

The online version of this article (doi:10.1186/s40658-016-0156-1) contains supplementary material, which is available to authorized users.