Alessio - PET/CT Instrumentation 11/26/07

Motivations for PET/CT Imaging

PET/CT Instrumentation Basics
• Desire for aligned anatomical and functional images
1. Motivations for PET/CT imaging
2. What is a PET/CT Scanner
3. Typical Protocols
4. CT Attenuation Correction
5. Problems and Challenges with PET/CT
6. Examples

Adam Alessio
Department of Radiology
CT image shows good PET image contains useful
University of Washington
aalessio@u.washington.edu anatomical detail but no functional information but
206.543.2419 functional information poor anatomical detail
11/27/07
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Software Based Image Fusion/Registration What is PET/CT?

Registration kidneys
Software • A device with shared mechanical components
providing aligned anatomic (CT) and functional (PET)
images.

bladder

Anatomy (CT) Function (FDG-PET)

• Logistical Challenge (schedule 2 studies, image manipulation, …)

• Error prone due to topology differences (and patient positioning, disease PET CT “PET/CT”
progression between scans, internal motion)
• Better to acquire scans at same time with same device
- Hardware Registration 3/36 4/36

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Alessio - PET/CT Instrumentation 11/26/07

Aside: Why are PET images less visually

What is a PET/CT scanner?
appealing than CT?
A. Resolution is worse: PET limited by
1. Positron Range
2. Emitted photons are not exactly anti-parallel (slight angular spread)
3. Intrinsic spatial resolution of detectors (high energy photons travel some
distance in detectors)
4. Sampling of detectors
B. Signal to noise ratio worse: PET images are noisy/blurry because:
1. Have much less good counts than CT
2. Have more contributions of “bad” counts (scattered and random events)
(Noisy images are then blurred for visual appeal leading to even worse resolution)

So why bother?

Answer: Sensitivity Typical whole-body PET system can detect ~2% of all
emitted photons, thus we can image almost any biological compound.

In comparison CT looks at an energy-weighted density and MR (mostly) looks

at proton (hydrogen) density PET/CT Scanner consists of separate CT and PET
Components
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Some Background Benefits of PET/CT?

• First PET/CT scanner introduced in 1998 by University of Pittsburgh,
NCI, and CTI PET Systems (Knoxville, TN) • Primary: Mechanically Aligned Anatomical and
• Combination of independent scanner components still standard Functional images
– “Fusion” - images not “fused”, simply overlaid - “alpha”
blending

Siemens/CTI/Hitachi Phillips/ADAC GE Medical Systems

Biograph/Reveal Gemini (GSO) Discovery LS, ST, STE
(BGO or LSO) Gemini TF (LYSO) (BGO)
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Multimodality Imaging Benefits of PET/CT?

• Primary: Mechanically Aligned Anatomical and Functional
images
– “Fusion” - images not “fused”, simply overlaid - “alpha” blending

• Secondary: CT scan provides attenuation correction

information for PET Reconstruction
– Much faster than conventional PET transmission scan
(20 sec vs. ~20 min)
– Less noise than conventional PET transmission scan
– Shorter overall scan time
• Wholebody PET/CT ~ 30 min
• Wholebody PET ~ 50 min

• Tertiary:
– CT scan used for scatter correction
– CT image could add in resolution recovery in PET image
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PET/CT scan protocol

The most significant error in PET data:
1. Scout scan
(5-20 sec)
2. Selection
of scan
Attenuation
region
(1-2 min) detector expected
ring counts
measured
scanner counts
CT PET
FOV
data
acquisition
Scout scan image

3 or 4. Helical 3 or 4. Whole-body
CT (1-2 min) PET (6-40 min) FDG in
patient
attenuation by a
factor of 10 to 100
(!)
• Attenuation is mainly due to scatter
CT PET CT PET • It is by far the most important effect for both noise (due to
reduced counts) and qualitative image appearance (greater than
11/36 scatter, randoms, deadtime, normalization…) 12/36

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PET Attenuation Correction-Transmission Scan Methods

Effects of attenuation on qualitative appearance:
Patient example Coincident photon Single photon X-ray (CT)
Ge-68/Ga-68 (511 keV) Cs-137 (662 keV) (~30-140kVp)

Rod source

PET Detectors

Transmission: Emission: FDG Emission: FDG high noise lower noise Virtually no noise
~12-45 min whole body scan ~4-20 min scan time ~20 sec scan time
tissue density (Attenuation (not corrected no bias some bias potential for significant bias
corrected) for attenuation) post injection contamination post injection contamination no post injection contamination

HISTORY:
There are striking changes in appearance with and without attenuation correction Past: Siemens and GE PET Scanners and Past: Philips PET Scanners Past: not on PET Scanners
original PET/CT scanners
Now: not available on any new systems Now: only option with new PET/CT
13/36 Now: not available for AC on any new systems 14/36
system

Why are PET Attenuation Correction Factors potentially

Why are PET Attenuation Correction Factors potentially biased when derived from CT Transmission scan?
biased when derived from CT Transmission scan?

• Source for CT x-rays (tube) is

1. at a lower energy level and
2. a distribution of energies
• For any given material a stream of 70keV photons will be
attenuated differently than 511keV photons
– Most materials fairly straightforward to convert from 70 keV to
511keV
– Contrast agents complicate conversion

spectra X-ray source positron source γ-ray source

Intensity
I0(E)
0
Linear attenuation coefficients for bone and muscle tissue in the range of 10 to
30 120 E (keV) 511 662
1000 keV. Photoelectric absorption is the main contributor to the attenuation of
photons at lower energies whereas Compton scattering dominates at higher
energies.

PET emission data attenuated at 511 keV

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Why are PET Attenuation Correction Factors potentially

Bias in AC Factors
biased when derived from CT Transmission scan?

Illustrates that mass attenuation coefficient of iodine is appreciably different from

biological tissue at CT energies while similar at PET 511keV energy.

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Converting CT Numbers to
Flowchart of typical PET/CT Operation
PET Attenuation Values
• Linear Scaling Method maps Hounsfield Units to Attenuation correction
coefficients at 511keV

Attenuation correction factors can be obtained from either (A) CT-based or

(B) conventional PET transmission source (rare on recent systems)

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Comparing PET/CT Scanners* Challenges & Problems with PET/CT

Scanner PET CT PET TX FOV Patient co-scan max bed room size 1. Functional and Anatomical Image Alignment
Componen Component** Mode Modes diam port (cm) length load (lbs) (feet)
t (cm) (cm) – Possible Movement between scans
GEH LS NXi (BGO) Lightspeed Plus 2D/3D X-ray 50 (CT) 70 (CT) 160/200 400 14 x 24 – Respiratory Motion (breath hold protocol?)
(4,8, or 16 68Ge 55 (PET) tapered to
slice)
• Several organs deviate in volume and position (liver, spleen,…)
59 (PET)
– Calibration of CT gantry, PET gantry, and bed
GEH ST wide-bore Lightspeed Plus 2D/3D X-ray 501 (CT) 70 160 400 14 x 24
NXi (BGO) (4,8, or 16
2. CT Based Attenuation Correction
70 (PET)
slice) (in my order of least to most important)
Siemens wide-bore SOMATOM 3D X-ray 501 (CT) 70 182 450 15 x 25 – Truncation Errors from arms down in FOV ⇒ Artifacts in
*** PICO Accel (2 or 16 slice) 58.5 corresponding regions in PET image
(LSO) (PET)
– Biases in AC factors from conversion of X-ray energies to PET
Siemens wide-bore SOMATOM 3D X-ray 501 (CT) 70 182 450 15 x 25
HIREZ Accell (6 or 16 slice)
energies ⇒ Incorrect Values in PET Image
60 (PET)
(LSO) • Contrast agents, Prostheses, implants
Philips Allegro Philips 3D X-ray 501 (CT) 70 (CT) 190 430 14 x 24 – Movement between Scans
Gemini (GSO) MX8000 Dual or 137Cs 60 (PET) 63 (PET) – Respiratory Motion ⇒ Can cause artifacts near dome of liver (in
Brilliance 16
cardiac PET, causes defects in cardiac values)

*Based on published specifications - OUT OF DATE

**CT sub-system options are changing rapidly
***CPS products sold through CTI as Reveal and Siemens as Biograph 21/36 22/36

CT Based AC Problems
(Bias in AC Factors)

General Rule:
• If one over attenuation corrects (uses higher (”more dense”) than
true correction factors for a region), will get artifactually high PET
values
– Example: Contrast agents in CT image, when scaled to PET energies, Artifact Examples…
are higher than should be leading to artifactual focal hot spots.
• If one under attenuation corrects (uses lower than true factors for
a region), will get artifactually low PET values
– Example: Respiratory motion can replace diaphragm in PET image
with lung space in CT image. Causes photopenic region (banana
artifact) along diaphragm in PET image.

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