HYBRID IMAGING IN CONVENTIONAL NUCLEAR MEDICINE A TECHNOLOGIST’S GUIDE Produced with the kind support of Table of contents Foreword 4 Andrea Santos Introduction 6 Marius Mada, MarieClaire Attard and Agata Pietrzak Chapter 1 Physics and reconstruction methods for SPECT/CT 9 Anne Larsson Strömvall Chapter 2 QC of Hybrid Systems 31 Sebastijan Rep Chapter 3 Quantitative SPECT 45 John Dickson Chapter 4 Bone Scintigraphy 65 Vladimir Vukomanovic, Vesna Ignjatovic, Milos Stevic, Nenad Mijatovic and Marija Z. Jeremic Chapter 5 Lung Imaging 81 Bozena Birkenfeld, Jacek Iwanowski and Monika Gawron Chapter 6 Clinical use of SPECT/CT: imaging of neuroendocrine tumours and sentinel node imaging 95 Luka Lezaic Chapter 7 Myocardial Perfusion Imaging 105 MarieClaire Attard and Hein Verberne Chapter 8 Accomplishing Good Diagnostic Examinations 117 from the Paediatric Population Pietro Zucchetta Chapter 9 Inflammation/Infection Studies 129 Andor W. J. M. Glaudemans Chapter 10 Parathyroid and Thyroid Imaging 143 Martin Gotthardt Chapter 11 The Contribution of Hybrid Imaging to Radionuclide therapy 163 Jan Taprogge, Paul Gape, Carla Abreu and Glenn Flux EANM TECHNOLOGIST’S GUIDE 3 HYBRID IMAGING IN CONVENTIONAL NUCLEAR MEDICINE FOREWORD FOREWORD Foreword Since the introduction of hybrid imaging, nuclear medicine has experienced a great development within its practices and conventional nuclear medicine has benefited greatly from the application of hybrid imaging. The definition of hybrid being the that bridge the gap between all the of molecular therapy and outline hybrid support. Last but not least, I thank the product of combining two or more background science and engineering imaging’s contribution to this field. EANM Board and Executive Office for their different things, it is evident that the and the patient. These professionals are It is with immense gratitude that I tireless efforts which have made this series purpose of any such combination is to equipped with the skills necessary to highlight the great contribution made of publications possible. extract the best qualities from them both use the imaging technology, for which by all the authors who gave their Hybrid Imaging in Conventional Nuclear and minimise their respective limitations. they require a combination of theoretical knowledge to this project. Here, special Medicine was only possible thanks to the It is thus vitally important that both and practical competencies. With this in acknowledgment is due to the Physics, contribution of everyone mentioned technologies are profoundly understood, mind, this book starts by outlining the Paediatric and Cardiovascular Committees before. Thank you all very much! not only in their individual characteristics basic concepts of physics, reconstruction of the EANM, who have supported us but also in their combined use. The de- methods and quality control procedures throughout as well as furnishing their own sired synergies can only be realised if the that allow image formation. This is followed contribution. Andrea Santos hybrid application makes optimum use of by a discussion of clinical applications A special word of appreciation goes Chair, EANM Technologist Committee the respective technologies. of hybrid conventional imaging, with a to the EANM-TC editorial group, who Nuclear medicine technologists interact practical focus to facilitate implementation have dedicated their time to putting this directly with the patient in the imaging and develop good practice. The later publication together, and also to Angela context, and are thus the professionals chapters of the book address the topic Parker, for her editing, reviewing and 4 EANM TECHNOLOGIST’S GUIDE EANM TECHNOLOGIST’S GUIDE 5 HYBRID IMAGING IN CONVENTIONAL NUCLEAR MEDICINE HYBRID IMAGING IN CONVENTIONAL NUCLEAR MEDICINE INTRODUCTION INTRODUCTION Introduction After nearly two decades since its first edition, the Technologist’s Guide is an established tradition and a valuable product of the nuclear medicine technologists’ community. We are all facing unprecedented challenges, both in our profession and in our homes. Seeing this Guide published in these circumstances is a tribute to our great colleagues, friends and our sponsor, who have dedicated time and other resources to ensure the tradition is kept alive. Every year the Tech Guide, as we all know The Tech Guide is a partnership between the contribution of hybrid imaging to for all your passion and dedication to it, aims to bring together experts from the EANM committees, between physicians, radionuclide therapy. patient care. We wanted to showcase field and present concise opinion and scientists and technologists, and this As ever, the Tech Guide has a practical the impact of our profession within the guidance on a specific topic to support year’s edition is no different. We partnered content, with a focus on hands-on advice nuclear medicine community, as well as the workforce of technologists working with the Physics Committee to cover the for technologists, showing the artefacts the high standard of quality delivered by in nuclear medicine. This year the topic is technical aspects of the imaging modality, and pitfalls when imaging and the role technologists across Europe. hybrid imaging in conventional nuclear as well as with the Paediatric Committee for of the technologist in achieving high We trust that you will find the Tech medicine. When choosing the theme their chapter. We wanted to acknowledge standards of quality. The Technologists’ Guide enjoyable reading, and would like to for the Tech Guide, the Technologists’ the achievements of fellow technologists Committee also plays an important role in thank you all for taking part in the success Committee had in mind the impact of non- like Dr Sebastijan Rep, who is not only an defining our communication strategy with of this project. PET hybrid imaging on nuclear medicine ambassador for the technologist’s role in patients in nuclear medicine, and we have practice. Moreover, SPECT-CT and the Tech quality assurance and quality control, but tried to include this new topic in this year’s Guide are of similar age, so we wanted to also a new PhD graduate. Other chapters Tech Guide. focus on collating conventional hybrid were co-authored by technologists and For us in the editorial team, publishing Marius Mada, MarieClaire Attard imaging practice in one concise and up- physicians or scientists, such as those this Guide is a way of saying thank you and Agata Pietrzak to-date guidance document. on myocardial perfusion imaging and to the nuclear medicine community Editorial team 6 EANM TECHNOLOGIST’S GUIDE EANM TECHNOLOGIST’S GUIDE 7 HYBRID IMAGING IN CONVENTIONAL NUCLEAR MEDICINE HYBRID IMAGING IN CONVENTIONAL NUCLEAR MEDICINE PHYSICS AND RECONSTRUCTION METHODS FOR SPECT/CT by Anne Larsson Strömvall1 CHAPTER 1 CHAPTER 1 PHYSICS AND RECONSTRUCTION AND METHODS SPECT/CT FOR PHYSICS PHYSICS AND RECONSTRUCTION AND METHODS SPECT/CTPHYSICS FOR INTRODUCTION and relatively slow CT provided 10 mm CT positions, for example with the detectors slices. Although somewhat rough, SPECT/ 180 degrees (H-mode, see Fig. 1) or 90 In scintigraphy, the distribution of an administered gamma photon- CT image fusion then became an option degrees (L-mode) apart. The detectors can emitting radiopharmaceutical in vivo is visualised using external for routine clinical work, as well as CT-based usually also be flipped to point outwards detectors. The technique is sensitive and can image very small amounts attenuation correction. The Hawkeye was from the gantry, or can be arranged side of the injected radiopharmaceutical in the order of nanograms. Two- later upgraded to a 4-slice system with 5.0 by side if needed. It is possible to select dimensional images can be acquired using a stationary detector, while mm slices, which improved image quality whether both detectors or only one three-dimensional images can be acquired using single-photon emission and reduced CT acquisition time by a should be used in the imaging protocol. computed tomography (SPECT). The phrase “single photon” indicates factor of 2. Nowadays there are several For a high image resolution, it is important that in SPECT, single photons emitted from the radionuclides are traced manufacturers providing fully diagnostic that the detectors are positioned as close to their origin, in contrast to positron emission tomography (PET), where integrated CTs that can help to improve to the patient as possible. Their position two simultaneous annihilation photons are detected by rings of detectors nuclear medicine diagnostics and therapy. can be automatically adjusted using body in a coincidence circuit. In most cases SPECT images are used for visual For more information on the historical contour detectors mounted on the side of interpretation, but quantitative analyses are becoming increasingly development of SPECT and SPECT/CT, a the detectors. popular. well-written review on the subject (1) can The patient table can be adjusted in be recommended. height for loading and unloading the The SPECT/CT gantry consists of a CT patient, and to centre the patient in the SPECT is mostly used for diagnostic with a half-life of 6 h and a relatively pure bore and typically two gamma camera scanner. Lasers can be used to help centre purposes but can also be used for gamma photon emission of 140 keV. The heads which are mounted on the front the patient correctly. Special solutions with planning and monitoring of radionuclide most common radionuclide for therapy side. An example can be seen in Fig. 1. cantilevered tables have been developed therapies. Radionuclides used for is [131I] for treatment of thyroid diseases, for a precise SPECT/CT registration in the diagnostics are primarily chosen to with a half-life of 8 days and mostly beta axial direction, since the two examinations have characteristics for high-quality radiation emission. Emitted gamma are performed sequentially with different imaging and low radiation dose to the photons of relatively high energy, 364 keV, table positions. The table is usually patient, including a relatively short half- can however be used for imaging. equipped with a low-attenuation top of life.