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Artificial intelligence (AI) is an overarching term for a multitude of technologies which are currently being discussed and introduced in several areas of medicine and in medical imaging specifically. There is, however, limited literature and information about how AI techniques can be integrated into the design of clinical imaging trials. This article will present several aspects of AI being used in trials today and how imaging departments and especially nuclear medicine departments can prepare themselves to be at the forefront of AI-driven clinical trials. Beginning with some basic explanation on AI techniques currently being used and existing challenges of its implementation, it will also cover the logistical prerequisites which have to be in place in nuclear medicine departments to participate successfully in AI-driven clinical trials.

Background MRI of lung parenchyma is challenging because of the rapid decay of signal by susceptibility effects of aerated lung on routine fast spin-echo sequences. Objective To assess lung signal intensity in children on ultrashort echo-time sequences in comparison to a fast spin-echo technique. Materials and methods We conducted a retrospective study of lung MRI obtained in 30 patients (median age 5 years, range 2 months to 18 years) including 15 with normal lungs and 15 with cystic fibrosis. On a fast spin-echo sequence with radial readout and an ultrashort echo-time sequence, both lungs were segmented and signal intensities were extracted. We compared lung-to-background signal ratios and histogram analysis between the two patient cohorts using non-parametric tests and correlation analysis. Results On ultrashort echo-time the lung-to-background ratio was age-dependent, ranging from 3.15 to 1.33 with high negative correlation (Rs = −0.86). Signal in posterior dependent portions of the lung was 18% and 11% higher than that of the anterior lung for age groups 0–2 and 2–18 years, respectively. The fast spin-echo sequence showed no variation of signal ratios by age or location, with a median of 0.99 (0.98–1.02). Histograms of ultrashort echo-time slices between controls and children with aggravated cystic fibrosis with mucus plugging and wall thickening exhibited significant discrepancies that differentiated between normal and pathological lungs. Conclusion Signal intensity of lung on ultrashort echo-time is higher than that on fast spin-echo sequences, is age-dependent and shows a gravity-dependent anterior to posterior gradient. This signal variation appears similar to lung density described on CT., Pediatric Radiology, 51 (1)

Funder: Newlife – The Charity for Disabled Children, PURPOSE OF REVIEW: The objective of this review is to document the advances in non-ionising imaging alternatives to CT for the head and neck. RECENT FINDINGS: The main alternative to CT for imaging bone of the head and neck region is MRI, particularly techniques which incorporate gradient echo imaging (Black Bone technique) and ultra-short or zero-echo time imaging. Since these techniques can provide high resolution isometric voxels, they can be used to provide multi-planar reformats and, following post processing, 3D reconstructed images of the craniofacial skeleton. As expected, the greatest advancements in recent years have been focused on enhanced image processing techniques and attempts to address the difficulties encountered at air-bone interfaces. SUMMARY: This article will review the imaging techniques and recent advancements which are bringing non-ionising alternatives to CT imaging of the bone of the head and neck region into the realm of routine clinical application.

When increasing the PET acquisition time to match the longer MRI protocol in simultaneous PET/MR, the injected PET tracer dose can possibly be lowered to reduce radiation exposure. Moreover, applying new commercially available time-of-flight (TOF) block sequential regularized expectation maximization (BSREM)–based reconstruction algorithms could allow for further dose reductions. The purpose of this study was to find the minimal dose of the tracer targeting the prostate specific membrane antigen (68Ga-PSMA-11) for a dedicated 15-min pelvic PET/MR scan that still matches the image quality of a reference 3-min scan at 100% (150 MBq) dose. In this retrospective analysis, 25 patients were included. PET emission datasets were edited to simulate stepwise reductions of injected tracer dose. Reference TOF ordered subset expectation maximum (OSEM) and new TOF BSREM reconstructions were performed and differences in the resulting PET images were visually and quantitatively assessed. Visually, TOF BSREM reconstructions with relatively high regularization parameter (β) values are preferred. Quantitatively, however, high β-values result in lower lesion maximum standardized uptake values (SUVmax) compared to the reference. A β-value of 550 was considered the optimal compromise for the lowest possible 10% dose reconstructions, resulting in comparable visual assessment and lesion SUVmax. This study indicates that the injected 68Ga-PSMA-11 tracer dose for a standard 3-min PET scan can be reduced to approximately 10% (15 MBq) when the PET acquisition time is matched to the 15-min pelvic MRI protocol, and when reconstructed with TOF BSREM using β = 550. This decreases the effective dose from 3.54 to 0.35 mSv. • Low-dose dedicated pelvic 68 Ga-PSMA-11 PET/MR reduces radiation exposure for patients. • Retrospective study investigating the minimal dose needed for adequate image quality for 15-min PET frames over the pelvis showed using quantitative and qualitative analysis that a substantial dose reduction is possible without significant loss of image quality when using the TOF BSREM reconstruction algorithm. • With the introduction of low-dose pelvic 68 Ga-PSMA-11 PET/MR, new potential applications of 68 Ga-PSMA-11 PET for local staging or investigation of equivocal MRI findings could become applicable, even for patients without confirmed prostate cancer.

One of the main challenges of integrated PET/MR is to achieve an accurate PET attenuation correction (AC), especially in brain acquisition. Here, we evaluated an AC method based on zero echo time (ZTE) MRI, comparing it with the single-atlas AC method and CT-based AC, set as reference. Fifty patients (70 ± 11 years old, 28 men) underwent FDG-PET/MR examination (SIGNA PET/MR 3.0 T, GE Healthcare) as part of the investigation of suspected dementia. They all had brain computed tomography (CT), 2-point LAVA-flex MRI (for atlas-based AC), and ZTE-MRI. Two AC methods were compared with CT-based AC (CTAC): one based on a single atlas, one based on ZTE segmentation. Impact on brain metabolism was evaluated using voxel and volumes of interest–based analyses. The impact of AC was also evaluated through comparisons between two subgroups of patients extracted from the whole population: 15 patients with mild cognitive impairment and normal metabolic pattern, and 22 others with metabolic pattern suggestive of Alzheimer disease, using SPM12 software. ZTE-AC yielded a lower bias (3.6 ± 3.2%) than the atlas method (4.5 ± 6.1%) and lowest interindividual (4.6% versus 6.8%) and inter-regional (1.4% versus 2.6%) variabilities. Atlas-AC resulted in metabolism overestimation in cortical regions near the vertex and cerebellum underestimation. ZTE-AC yielded a moderate metabolic underestimation mainly in the occipital cortex and cerebellum. Voxel-wise comparison between the two subgroups of patients showed that significant difference clusters had a slightly smaller size but similar locations with PET images corrected with ZTE-AC compared with those corrected with CT, whereas atlas-AC images showed a notable reduction of significant voxels. ZTE-AC performed better than atlas-AC in detecting pathologic areas in suspected neurodegenerative dementia. • The ZTE-based AC improved the accuracy of the metabolism quantification in PET compared with the atlas-AC method. • The overall uptake bias was 21% lower when using ZTE-based AC compared with the atlas-AC method. • ZTE-AC performed better than atlas-AC in detecting pathologic areas in suspected neurodegenerative dementia.

Purpose Automated bone segmentation from MRI datasets would have a profound impact on clinical utility, particularly in the craniofacial skeleton where complex anatomy is coupled with radiosensitive organs. Techniques such as gradient echo black bone (GRE-BB) and short echo time (UTE, ZTE) have shown potential in this quest. The objectives of this study were to ascertain (1) whether the high-contrast of zero echo time (ZTE) could drive segmentation of high-resolution GRE-BB data to enhance 3D-output and (2) if these techniques could be extrapolated to ZTE driven segmentation of a routinely used non bone-specific sequence (FIESTA-C). Methods Eleven adult volunteers underwent 3T MRI examination with sequential acquisition of ZTE, GRE-BB and FIESTA-C imaging. Craniofacial bone segmentation was performed using a fully automated segmentation algorithm. Segmentation was completed individually for GRE-BB and a modified version of the algorithm was subsequently implemented, wherein the bone mask yielded by ZTE segmentation was used to initialise segmentation of GRE-BB. The techniques were subsequently applied to FIESTA-C datasets. The resulting 3D reconstructions were evaluated for areas of unexpected bony defects and discrepancies. Results The automated segmentation algorithm yielded acceptable 3D outputs for all GRE-BB datasets. These were enhanced with the modified algorithm using ZTE as a driver, with improvements in areas of air/bone interface and dense muscular attachments. Comparable results were obtained with ZTE+FIESTA-C. Conclusion Automated 3D segmentation of the craniofacial skeleton is enhanced through the incorporation of a modified segmentation algorithm utilising ZTE. These techniques are transferrable to FIESTA-C imaging which offers reduced acquisition time and therefore improved clinical utility.

Funding Acknowledgements Type of funding sources: None. Introduction Myocardial delayed enhancement (MDE) MRI plays an important role in the identification of several cardiac conditions, both ischemic and non-ischemic (e.g. myocarditis, IDC, amyloidosis). 3D imaging offers increased resolution, full heart coverage and better depiction of complex pathologies, but its image quality is limited by long acquisition times. Deep learning (DL) models enable advanced reconstruction algorithms that yield regularized images in practical computation times. In this study we evaluate a novel 3D-DL reconstruction to overcome the trade-off between reconstructed quality and acquisition time on MDE data. Methods A group of 14 subjects referred for CMR (5 F / 9 M, 59 ± 11 y.o., 78 ± 13 kg) were scanned with a 3D MDE sequence prototype: SPGR with IR preparation, fat & spatial saturation, respiratory navigator, ARC 2x, FOV 40x40cm, ST 1.4-2.4mm, matrix 280²-320², FA 20deg, BW 62.5 kHz, TE 2.1 ± 0.1ms, TI based on a CINE IR scout. All were retrospectively reconstructed using a 3D DL algorithm, trained on a database of over 700 datasets to reconstruct high-quality images with adjustable noise reduction. The images were compared with standard 3D Cartesian reconstruction by two experienced cardiologists, to identify alterations in morphology or contrast distribution. Noise was estimated using the intensity standard deviation on a blood pool ROI. Feature preservation was estimated using the structural similarity index (SSI). Results The new method improved perceived image quality without loss of structural information or resolution (fig 1). Quantitative analysis (fig 2) confirmed these results: The average coefficient of variation in the blood was 0.08 ± 0.02 in the reference and 0.05 ± 0.02 with the new method; Given a target image noise level, DL reconstruction yielded up to 10% better SSI, compared to anisotropic filtering. The clinical review didn’t reveal diagnostically significant alterations of structure or uptake pattern. A perceived reduction of sharpness was initially reported but individual examination of landmarks (e.g. pulmonary and coronary arteries) confirmed that no relevant features were being lost with the new reconstruction. Discussion The 3D MDE images obtained with DL reconstruction improved the trade-off between image noise -estimated by the blood pool intensity deviation- and feature preservation -estimated by SSI-. Consistent improvement of image quality without morphological alterations of diagnostic relevance indicates that the new method can be considered for clinical practice. The next step in the validation process will require testing the robustness over a large set of cases with heterogeneous acquisition settings. Conclusion We presented the preliminary evaluation of a deep learning reconstruction method with 3D myocardial delayed enhancement data. The results show systematic improvement of overall image quality without loss of relevant diagnostic information. Abstract Figure.

Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): - University, research centre and hospital foundation grants for the contracting of new research staff (FI 2020) - Spanish Ministry of Economy and Competitiveness Retos investigacion project Introduction The assessment of the left atrium (LA) haemodynamics is key to better understand the development of LA-related pathological processes. In this regard 4D flow magnetic resonance imaging (MRI) can provide complementary information to standard Doppler echocardiographic studies and identify complex blood flow patterns. Yet, until recently, the left atrium (LA) has been largely left aside in 4D flow MRI studies. Purpose We aimed at assessing the LA haemodynamics of healthy and hypertrophic cardiomyopathy (HCM) subjects with a qualitative visualization of flow patterns and deriving quantitative indices related to ventricular dysfunction from pulmonary veins (PV) and mitral valve (MV) velocity profiles. Methods Segmentation was performed directly over 4D flow angiograms. A total of 20 cases were processed, 11 healthy and 9 HCM subjects. 4D velocity matrices were masked with the segmented mask to isolate LA haemodynamics. Velocity profiles were then obtained in the PV and MV and integrated over planes perpendicular to the lumen of the vessels to create velocity spectrograms. Fourier spectral analysis was applied to the velocity curves to highlight differences that might go unnoticed in the time domain. In addition, the Q-Criterion was computed for vortex identification, visually inspecting both cohorts across the whole cardiac cycle. Results Fourier spectral analysis of the velocity curves suggested that overall, healthy patients have higher dynamic range of the velocity curves. It can be observed in Figure 1, that the usual E/A MV velocity pattern is preserved in 10 of the 11 healthy subjects while 5 of the HCM patients present significant alterations of said curve. In fact, patients 4, 6, 7 and 8 seem to present a 3 peaked MV velocity curve. The vortex analysis identified 3 main types of vortices in healthy subjects: a ‘filling’ systolic vortex (10/11) arising near the most dominant PV (usually the left superior PV) as seen in Figure 2; a conduit phase vortex (7/11), similar in nature to the preceding systolic vortex; and an E-wave vortex (9/11) attached to the LA ostium. Four of the HCM patients (out of the five with altered MV velocity profile) also showed a systolic vortex, but with more complex blood flow patterns and emerging far from the PVs. One of such vortices is shown in Figure 2, composed of two distinct eddies near the MV. The E-wave vortex was also observed but was less predominant than in healthy subjects (3/9). Conclusions 4D Flow analysis of the LA is feasible and might hold promise in the understanding of the complex haemodynamics in ventricular dysfunction. Abstract Figure. Velocity Spectrograms and Vortices

Three-dimensional (3D) imaging of the craniofacial skeleton is integral in managing a wide range of bony pathologies. The authors have previously demonstrated the potential of "Black Bone" MRI (BB) as a non-ionizing alternative to CT. However, even in experienced hands 3D rendering of BB datasets can be challenging and time consuming. The objectives of this study were to develop and test a semi- and fully-automated segmentation algorithm for the craniofacial skeleton.Previously acquired adult volunteer (n = 15) BB datasets of the head were utilized. Imaging was initially 3D rendered with our conventional manual technique. An algorithm to remove the outer soft-tissue envelope was developed and 3D rendering completed with the processed datasets (semi-automated). Finally, a fully automated 3D-rendering method was developed and applied to the datasets. All 3D rendering was completed with Fovia High Definition Volume Rendering (Fovia Inc, Palo Alto, CA). Analysis was undertaken of the 3D visual results and the time taken for data processing and interactive manipulation.The mean time for manual segmentation was 12.8 minutes, 3.1 minutes for the semi-automated algorithm, and 0 minutes for the fully automated algorithm. Further fine adjustment was undertaken to enhance the automated segmentation results, taking a mean time of 1.4 minutes.Automated segmentation demonstrates considerable potential, offering significant time saving in the production of 3D BB imaging in adult volunteers. the authors continue to undertake further development of our segmentation algorithms to permit adaption to the pediatric population in whom non-ionizing imaging confers the most potential benefit.

Background The purpose of this study was to assess the impact of vendor-provided atlas-based MRAC on FDG PET/MR for the evaluation of Alzheimer’s disease (AD) by using simulated images. Methods We recruited 47 patients, from two institutions, who underwent PET/CT and PET/MR (GE SIGNA) examination for oncological staging. From the PET raw data acquired on PET/MR, two FDG-PET series were generated, using vendor-provided MRAC (atlas-based) and CTAC. The following simulation steps were performed in MNI space: After spatial normalization and smoothing of the PET datasets, we calculated the error map for each patient, PETMRAC/PETCTAC. We multiplied each of these 47 error maps with each of the 203 Alzheimer’s Disease Neuroimaging Initiative (ADNI) cases after the identical normalization and smoothing. This resulted in 203*47 = 9541 datasets. To evaluate the probability of AD in each resulting image, a cumulative t-value was calculated automatically using commercially-available software (PMOD PALZ) which has been used in multiple large cohort studies. The diagnostic accuracy for the discrimination of AD and predicting progression from mild cognitive impairment (MCI) to AD were evaluated in simulated images compared with ADNI original images. Results The accuracy and specificity for the discrimination of AD-patients from normal controls were not substantially impaired, but sensitivity was slightly impaired in 5 out of 47 datasets (original vs. error; 83.2% [CI 75.0%-89.0%], 83.3% [CI 74.2%-89.8%] and 83.1% [CI 75.6%-88.3%] vs. 82.7% [range 80.4–85.0%], 78.5% [range 72.9–83.3%,] and 86.1% [range 81.4–89.8%]). The accuracy, sensitivity and specificity for predicting progression from MCI to AD during 2-year follow-up was not impaired (original vs. error; 62.5% [CI 53.3%-69.3%], 78.8% [CI 65.4%-88.6%] and 54.0% [CI 47.0%-69.1%] vs. 64.8% [range 61.5–66.7%], 75.7% [range 66.7–81.8%,] and 59.0% [range 50.8–63.5%]). The worst 3 error maps show a tendency towards underestimation of PET scores. Conclusion FDG-PET/MR based on atlas-based MR attenuation correction showed similar diagnostic accuracy to the CT-based method for the diagnosis of AD and the prediction of progression of MCI to AD using commercially-available software, although with a minor reduction in sensitivity.

The goal of this study was to determine the level of clinically acceptable 18F-FDG dose reduction in time-of-flight PET/MRI in patients with breast cancer. Methods: Twenty-six consecutive women with histologically proven breast cancer were analyzed (median age, 51 y; range, 34-83 y). Simulated dose-reduced PET images were generated by unlisting the list-mode data on PET/MRI. The acquired 20-min PET frame was reconstructed in 5 ways: a reconstruction of the first 2 min with 3 iterations and 28 subsets for reference, and reconstructions simulating 100%, 20%, 10%, and 5% of the original dose. General image quality and artifacts, image sharpness, image noise, and lesion detectability were analyzed using a 4-point scale. Qualitative parameters were compared using the nonparametric Friedman test for multiple samples and the Wilcoxon signed-rank test for paired samples. Different groups of independent samples were compared using the Mann-Whitney U test. Results: Overall, 355 lesions (71 lesions with 5 different reconstructions each) were evaluated. The 20-min reconstruction with 100% injected dose showed the best results in all categories. For general image quality and artifacts, image sharpness, and noise, the reconstructions with a simulated dose of 20% and 10% were significantly better than the 2-min reconstructions (P ≤ 0.001). Furthermore, 20%, 10%, and 5% reconstructions did not yield results different from those of the 2-min reconstruction for detectability of the primary lesion. For 10% of the injected dose, a calculated mean dose of 22.6 ± 5.5 MBq (range, 17.9-36.9 MBq) would have been applied, resulting in an estimated whole-body radiation burden of 0.5 ± 0.1 mSv (range, 0.4-0.7 mSv). Conclusion: Ten percent of the standard dose of 18F-FDG (reduction of ≤90%) results in clinically acceptable PET image quality in time-of-flight PET/MRI. The calculated radiation exposure would be comparable to the effective dose of a single digital mammogram. A reduction of radiation burden to this level might justify partial-body examinations with PET/MRI for dedicated indications.

The goal of this paper was to assess the longitudinal repeatability of a bone identification method, based on the zero-echo-time MRI pulse sequence. The consistency of the bone maps—with potential applications in magnetic resonance-based attenuation correction of positron emission tomography data—was evaluated for a number of clinically realistic variations of the ideal acquisition conditions. The method was shown to be generally repeatable, with differences in the ±1% range. A number of potential issues were identified (e.g., sinus post-processing region placement variability, false positive bone structures near sharp coil sensitivity transitions, and axial coil coverage limitations) and mitigation strategies designed.

To prospectively evaluate the detection and conspicuity of pulmonary nodules in an oncological population, using a tri-modality PET/CT-MR protocol including a respiration-gated T2-PROPELLER sequence for possible integration into a simultaneous PET/MR protocol.149 patients referred for staging of malignancy were prospectively enrolled in this single-center study. Imaging was performed on a tri-modality PET/CT-MR setup and was comprised of PET/CT and 3T-MR imaging with 3D dual-echo GRE pulse sequence (Dixon) and an axial respiration-gated T2-weighted PROPELLER (T2-P) sequence. Images were assessed for presence, conspicuity, size and interpretation of the pulmonary parenchymal nodules. McNemar's test was used to evaluate paired differences in nodule detection rates between MR and CT from PET/CT. The correlation of pulmonary nodule size in CT and MR imaging was assessed using Pearson correlation coefficient.299 pulmonary nodules were detected on PET/CT. The detectability was significantly higher on T2-P (60%, p0.01) compared to T1-weighted Dixon-type sequences (16.1-37.8%). T2-P had a significantly higher detection rate among FDG-positive (92.4%) and among confirmed malignant nodules (75.9%) compared to T1-Dixon. Nodules10mm were detected less often by MR sequences than by CT (p0.01). However, nodules10mm were detected equally well with T2-P (92.2%) and CT (p0.05). In a per-patient analysis, there was no significant change in the clinical interpretation of the nodules detected with T2-P and CT.Despite the overall lower detection rate compared with CT, the free-breathing respiratory gating T2-w sequence showed higher detectability in all evaluated categories compared to breath-hold T1-weighted MR sequences. Specifically, the T2-P was found to be not statistically different from CT in FDG-positive nodules, in detection of nodules10mm and concerning conspicuity of pulmonary nodules. Overall, the additional time investment into T2-P seems to be justified since clinical relevant assessment of pulmonary lung nodules can mostly be done by T2-P in a whole body PET/MR staging of oncologic patients.

Purpose To determine the level of clinically acceptable reduction in injected fluorine 18 (18F) fluorodeoxyglucose (FDG) dose in time-of-flight (TOF)-positron emission tomography(PET)/magnetic resonance (MR) imaging by using silicon photomultiplier (SiPM) detectors compared with TOF-PET/computed tomography (CT) using Lu1.8Y0.2SiO5(Ce), or LYSO, detectors in patients with different body mass indexes (BMIs). Materials and Methods Patients were enrolled in this study as part of a larger prospective study with a different purpose than evaluated in this study (NCT02316431). All patients gave written informed consent prior to inclusion into the study. In this study, 74 patients with different malignant diseases underwent sequential whole-body TOF-PET/CT and TOF-PET/MR imaging. PET images with simulated reduction of injected 18F-FDG doses were generated by unlisting the list-mode data from PET/MR imaging. Two readers rated the image quality of whole-body data sets, as well as the image quality in each body compartment, and evaluated the conspicuity of malignant lesions. Results The image quality with 70% or 60% of the injected dose of 18F-FDG at PET/MR imaging was comparable to that at PET/CT. With 50% of the injected dose, comparable image quality was maintained among patients with a BMI of less than 25 kg/m2. PET images without TOF reconstruction showed higher artifact scores and deteriorated sharpness than those with TOF reconstruction. Conclusion Sixty percent of the usually injected 18F-FDG dose (reduction of up to 40%) in patients with a BMI of more than 25 kg/m2 results in clinically adequate PET image quality in TOF-PET/MR imaging performed by using SiPM detectors. Additionally, in patients with a BMI of less than 25 kg/m2, 50% of the injected dose may safely be used. © RSNA, 2017 Online supplemental material is available for this article.

PURPOSE: The purpose of this study was to determine the accuracy of "black bone" (BB) MRI for the detection of skull fractures in children with potential abusive head trauma. METHODS: A total of 34 pediatric patients were evaluated for potential abusive head trauma. All patients had both a non-contrast head CT (HCT) with multiplanar reformatted images and 3D volumetric reformatted images where available (gold standard) for fracture diagnosis and BB of the head with multiplanar reformatted images and 3D volumetric images. BB was performed using an ultrashort TE pointwise encoding time reduction with radial acquisition (PETRA) sequence at 1.5 T or 3 T. BB datasets were post-processed and 3D images created using Fovia's High Definition Volume Rendering® software. Two board-certified pediatric neuroradiologists independently reviewed the HCT and BB imaging, blinded to the findings from the other modality. RESULTS: Median patient age was 4 months (range 1.2-30 months). A total of 20 skull fractures in six patients (18% incidence of skull fractures) were detected on HCT. BB demonstrated 83% sensitivity (95%[CI] 36-99%), 100% specificity (95%[CI] 88-100%), 100% PPV (95%[CI] 46-100%), 97% NPV (95%[CI] 82-99%), and 97% accuracy (95%[CI] 85-99%) for diagnosis of a skull fracture. BB detected 95% (19/20) of the skull fractures detected by CT. CONCLUSION: A black bone MRI sequence may provide high sensitivity and specificity for detection of skull fractures in pediatric patients with abusive head trauma.

Identification of pretherapeutic predictive markers in gastro-esophageal cancer is essential for individual-oriented treatment. This study evaluated the relationship of multimodality parameters derived from intravoxel incoherent motion method (IVIM), 18F-FDG-positron emission tomography (PET), computed tomography (CT) perfusion and dynamic contrast enhanced magnetic resonance imaging (MRI) in patients with gastro-esophageal cancer and investigated their histopathological correlation.Thirty-one consecutive patients (28 males; median age 63.9 years; range 37-84 years) with gastro-esophageal adenocarcinoma (N.=22) and esophageal squamous cell carcinoma (N.=9) were analyzed. IVIM parameters: pseudodiffusion (D*), perfusion fraction (fp), true diffusion (D) and the threshold b-value (bval); PET-parameters: SUVinfmax/inf, metabolic tumor volume (MTV) and total lesion glycolysis (TLG); CT perfusion parameters: blood flow (BF), blood volume (BV) and mean transit time (MTT); and MR perfusion parameters: time to enhance, positive enhancement integral, time-to-peak (TTP), maximum-slope-of-increase, and maximum-slope-of-decrease were determined, and correlated to each other and to histopathology.IVIM and PET parameters showed significant negative correlations: MTV and bval (rinfs/inf=-0.643, P=0.002), TLG and bval (rinfs/inf=-0.699, P0.01) and TLG and fp (rinfs/inf=-0.577, P=0.006). Positive correlation was found for TLG and D (rinfs/inf=0.705, P=0.000). Negative correlation was found for bval and staging (rinfs/inf=0.590, P=0.005). Positive correlation was found for positive enhancement interval and BV (rinfs/inf=0.547, P=0.007), BF and regression index (rinfs/inf=0.753, P=0.005) and for time-to-peak and staging (rinfs/inf=0.557, P=0.005).IVIM parameters (bval, fp, D) provide quantitative information and correlate with PET parameters (MTV, TLG) and staging. IVIM might be a useful tool for additional characterization of gastro-esophageal cancer.

This work demonstrates how computational and physical modelling of the positron emission tomography (PET) image acquisition process for a state-of-the-art integrated PET and magnetic resonance imaging (PET-MR) system can produce images comparable to the manufacturer. The GE SIGNA PET/MR scanner is manufactured by General Electric and has time-of-flight (TOF) capabilities of about 390 ps. All software development took place in the Software for Tomographic Image Reconstruction (STIR: http://stir.sf.net ) library, which is a widely used open source software to reconstruct data as exported from emission tomography scanners. The new software developments will be integrated into STIR, providing the opportunity for researchers worldwide to establish and expand their image reconstruction methods. Furthermore, this work is of particular significance as it provides the first validation of TOF PET image reconstruction for real scanner datasets using the STIR library. This paper presents the methodology, analysis, and critical issues encountered in implementing an independent reconstruction software package. Acquired PET data were processed via several appropriate algorithms which are necessary to produce an accurate and precise quantitative image. This included mathematical, physical and anatomical modelling of the patient and simulation of various aspects of the acquisition. These included modelling of random coincidences using ‘singles’ rates per crystals, detector efficiencies and geometric effects. Attenuation effects were calculated by using the STIR’s attenuation correction model. Modelling all these effects within the system matrix allowed the reconstruction of PET images which demonstrates the metabolic uptake of the administered radiopharmaceutical. These implementations were validated using measured phantom and clinical datasets. The developments are tested using the ordered subset expectation maximisation (OSEM) and the more recently proposed kernelised expectation maximisation (KEM) algorithm which incorporates anatomical information from MR images into PET reconstruction.

BACKGROUND To compare the diagnostic accuracy of PET/MR and PET/CT in patients with suspected occult primary tumors. METHODS This prospective study was approved by the institutional review board. Sequential PET/CT-MR was performed in 43 patients (22 male subjects; median age, 58 years; range, 20-86 years) referred for suspected occult primary tumors. Patients were assessed with PET/CT and PET/MR for the presence of a primary tumor, lymph node metastases, and distant metastases. Wilcoxon signed-rank test was performed to compare the diagnostic accuracy of PET/CT and PET/MR. RESULT According to the standard of reference, a primary lesion was found in 14 patients. In 16 patients, the primary lesion remained occult. In the remaining 13 patients, lesions proved to be benign. PET/MR was superior to PET/CT for primary tumor detection (sensitivity/specificity, 0.85/0.97 vs 0.69/0.73; P = 0.020) and comparable to PET/CT for the detection of lymph node metastases (sensitivity/specificity, 0.93/1.00 vs 0.93/0.93; P = 0.157) and distant metastases (sensitivity/specificity, 1.00/0.97 vs 0.82/1.00; P = 0.564). PET/CT tended to misclassify physiologic FDG uptake as malignancy compared with PET/MR (8 patients vs 1 patient). CONCLUSIONS PET/MR outperforms PET/CT in the workup of suspected occult malignancies. PET/MR may replace PET/CT to improve clinical workflow.

Our objective was to determine clinically the value of time-of-flight (TOF) information in reducing PET artifacts and improving PET image quality and accuracy in simultaneous TOF PET/MR scanning. A total 65 patients who underwent a comparative scan in a simultaneous TOF PET/MR scanner were included. TOF and non-TOF PET images were reconstructed, clinically examined, compared and scored. PET imaging artifacts were categorized as large or small implant-related artifacts, as dental implant-related artifacts, and as implant-unrelated artifacts. Differences in image quality, especially those related to (implant) artifacts, were assessed using a scale ranging from 0 (no artifact) to 4 (severe artifact). A total of 87 image artifacts were found and evaluated. Four patients had large and eight patients small implant-related artifacts, 27 patients had dental implants/fillings, and 48 patients had implant-unrelated artifacts. The average score was 1.14 ± 0.82 for non-TOF PET images and 0.53 ± 0.66 for TOF images (p

Purpose The purpose of this study was to evaluate the effect of defective positron emission tomography (PET) detectors on clinical PET image quality in simultaneous PET/magnetic resonance imaging (MRI) for both time-of-flight (TOF) and non-TOF reconstructed images.

A silicon photomultiplier (SiPM)-based time-of-flight capable PET detector has been integrated with a 70 cm wide-bore 3T MR scanner for simultaneous whole-body imaging (MR750w, GE Healthcare, Waukesha, WI). After insertion of the PET detector, the final PET/MR bore is 60 cm wide (SIGNA PET/MR, GE Healthcare, Waukesha, WI). The MR performance was compared before and after the PET ring insertion. ${\rm B}_0$ homogeneity, ${\rm B}_1^ + $ uniformity of the body coil along with peak ${\rm B}_1^ + $ , coherent noise, and FBIRN (Function Biomedical Informatics Research Network) tests are used to compare the MR performance. It is shown that ${\rm B}_0$ homogeneity and coherent noise have not changed according to the system specifications. Peak ${\rm B}_1^ + $ is increased by 33% and ${\rm B}_1^ + $ inhomogeneity is increased by 4% after PET ring insertion due to a smaller diameter body coil design. The FBIRN test shows similar temporal stability before and after PET ring insertion. Due to a smaller body coil on the PET/MR system, the signal fluctuation to noise ratio (SFNR) and SNR for body receive coil, are improved by ${\sim} 40\%$ and ${\sim} 160\%$ for Echo Planar Imaging (EPI) and spiral sequences respectively. Comparison using RF- and gradient-intensive clinical sequences shows inserting the PET detectors into the wide-bore MRI has not compromised the MR image quality according to these tests.

A recent entry into the rapidly evolving field of integrated PET/MR scanners is presented in this paper: a whole body hybrid PET/MR system (SIGNA PET/MR, GE Healthcare) capable of simultaneous acquisition of both time-of-flight (TOF) PET and high resolution MR data. The PET ring was integrated into an existing 3T MR system resulting in a (patient) bore opening of 60 cm diameter, with a 25 cm axial FOV. PET performance was evaluated both on the standalone PET ring and on the same detector integrated into the MR system, to assess the level of mutual interference between both subsystems. In both configurations we obtained detector performance data. PET detector performance was not significantly affected by integration into the MR system. The global energy resolution was within 2% (10.3% versus 10.5%), and the system coincidence time resolution showed a maximum change of < 3% (385 ps versus 394 ps) when measured outside MR and during simultaneous PET/MRI acquisitions, respectively. To evaluate PET image quality and resolution, the NEMA IQ phantom was acquired with MR idle and with MR active. Impact of PET on MR IQ was assessed by comparing SNR with PET acquisition on and off. B0 and B1 homogeneities were acquired before and after the integration of the PET ring inside the magnet. In vivo brain and whole body head-to-thighs data were acquired to demonstrate clinical image quality.

Integrated positron-emission tomography and computed tomography (PET/CT) is one of the most important imaging techniques to have emerged in oncological practice in the last decade. Hybrid imaging, in general, remains a rapidly growing field, not only in developing countries, but also in western industrialised healthcare systems. A great deal of technological development and research is focused on improving hybrid imaging technology further and introducing new techniques, e.g., integrated PET and magnetic resonance imaging (PET/MRI). Additionally, there are several new PET tracers on the horizon, which have the potential to broaden clinical applications in hybrid imaging for diagnosis as well as therapy. This article aims to highlight some of the major technical and clinical advances that are currently taking place in PET/CT and PET/MRI that will potentially maintain the position of hybrid techniques at the forefront of medical imaging technologies.

Purpose: The GE SIGNA PET/MR is a new whole body integrated time-of-flight (ToF)-PET/MR scanner from GE Healthcare. The system is capable of simultaneous PET and MR image acquisition with sub-400 ps coincidence time resolution. Simultaneous PET/MR holds great potential as a method of interrogating molecular, functional, and anatomical parameters in clinical disease in one study. Despite the complementary imaging capabilities of PET and MRI, their respective hardware tends to be incompatible due to mutual interference. In this work, the GE SIGNA PET/MR is evaluated in terms of PET performance and the potential effects of interference from MRI operation. Methods: The NEMA NU 2-2012 protocol was followed to measure PET performance parameters including spatial resolution, noise equivalent count rate, sensitivity, accuracy, and image quality. Each of these tests was performed both with the MR subsystem idle and with continuous MR pulsing for the duration of the PET data acquisition. Most measurements were repeated at three separate test sites where the system is installed. Results: The scanner has achieved an average of 4.4, 4.1, and 5.3 mm full width at half maximum radial, tangential, and axial spatial resolutions, respectively, at 1 cm from the transaxial FOV center. The peak noise equivalent count rate (NECR) of 218 kcps and a scatter fraction of 43.6% are reached at an activity concentration of 17.8 kBq/ml. Sensitivity at the center position is 23.3 cps/kBq. The maximum relative slice count rate error below peak NECR was 3.3%, and the residual error from attenuation and scatter corrections was 3.6%. Continuous MR pulsing had either no effect or a minor effect on each measurement. Conclusions: Performance measurements of the ToF-PET whole body GE SIGNA PET/MR system indicate that it is a promising new simultaneous imaging platform.

Software for Tomographic Image Reconstruction (STIR: http://stir.sf.net) is an open source C++ library available for reconstruction of emission tomography data. This work aims at the incorporation of the GE SIGNA PET/MR scanner in STIR and enables PET image reconstruction with data corrections. The data extracted from the scanner after an acquisition includes a list of raw data files (emission, normalisation, geometric and well counter calibration (wcc) factors), magnetic resonance attenuation correction (MRAC) images and the scanner-based reconstructions. The listmode (LM) file stores a list of ’prompt’ events and the singles per crystal per second. MRAC images from the scanner are used for attenuation correction. The modifications to STIR that allow accurate histogramming of this LM data in the same sinogram organisation as the scanner are also described. This allows reconstruction of acquisition data with all data corrections using STIR, and independent of any software supplied by the manufacturer. The implementations were validated by comparing the histogrammed data, data corrections and final reconstruction using the ordered subset expectation maximisation (OSEM) algorithm with the equivalents from the GE-toolbox, supplied by the manufacturer for the scanner. There is no difference in the histogrammed counts whereas an overall relative difference of 6.7 × 10−8% and from 0.01% to 0.86% is seen in the normalisation and randoms correction sinograms respectively. The STIR reconstructed images have similar resolution and quantification but have some residual differences due to wcc factors, decay and deadtime corrections, as well as the offset between PET and MR gantries that will be addressed in future work. This work will enable the use of all current and future STIR algorithms, including penalized image reconstruction, motion correction and direct parametric image estimation, on data from GE SIGNA PET/MR scanners.