PET-CT and PET-MRI in Oncology: A Practical Guide (Medical Radiology)
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Are you a frequent reader or book collector? Social responsibility Did you know that since , Biblio has used its profits to build 12 public libraries in rural villages of South America? At our institutions, we do not have direct experience with this system. This technology employs an MR scanner and PET scanner with a single bed that facilitates moving between the two systems such that the patient is scanned through the PET system and then sequentially scanned through the MR system Fig.
PET/MRI in Oncological Imaging: State of the Art
Similar to the trimodality system, this technology requires advanced software for post-processing. Advantages of this system is a reduced risk of mis-registration given the temporal nature of the system one scan immediately after the other. Furthermore, there are specific, complex shielding requirements given that the PET system is immediately adjacent to the MR system.
At our institutions, we do not have experience with this system. MR images are utilized for attenuation correction in addition to anatomic information, thereby eliminating the need for CT acquisition, and thus significantly reducing radiation exposure, a major advantage.
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Attenuation correction on integrated systems is performed by acquiring Dixon sequences and improving attenuation correction algorithms with MR-based mu maps remains an area of active research. The major advantage is that mis-registration is significantly reduced and that the PET and MR data are acquired without temporal delay. The major disadvantages include technical complexity and cost associated with the purchase of a dedicated system. We will share our experience with this system in this article.
On the other hand, the sequential and simultaneous construct offers a flexible fusion architecture allowing for wider latitude of scanning parameters utilizing simultaneous or near simultaneous acquisition of MR and PET. Thus, they have smaller footprints but are more expensive options. Solutions will most likely vary on the institutional need, physical space, and monetary constraints. Although essentially self-evident depending on the type of system purchased, space requirements will vary. Integrated system space requirements are similar to those for typical MRI scanners.
With respect to the hardware elements of the PET machine, there is no real shielding requirement for the detector elements; solid state detector elements are not severely impacted by the MR gradients and radiofrequency signals. Room shielding requirements are similar to that of a standalone MR system and a standalone PET system. Hotlabs are configured with the standard array of equipment dose calibrators, well counters, lead shielding, shielded receptacles for storage of discarded radioactive materials, etc. Isotopes are delivered from commercial or on-site radio-pharmacies using standard procedures.
For short-lived isotopes, a workflow must exist whereby the cyclotron and PET systems are in close physical proximity to one another, so that the decay of the short-half-life radiotracers is not significant. For relatively longer half-life agents, other possibilities such as quick transport between the radiopharmacy and scanner may be a feasible option. Special care is taken when handling lead-shielded syringes in the scanner room due to the risk of the lead-containing shield being pulled toward the magnet. MR-compatible contrast injectors with the capability to automatically inject both radiopharmaceuticals, and MR contrast agents are in a prototype phase with FDA-approved devices expected in the near future.
PET/MRI in Oncological Imaging: State of the Art
Non-attenuating head cushions and MR safe survey meters are also used at our institution. For example, hotlab work, dealing with a patient after radiotracer injection, and monitoring the patient while on the scanner due to the regulatory requirements for supervision of nuclear exams represent separate requirements above and beyond those of the traditional MRI technologists. It should be noted that these nuclear medicine requirements are typically mandated at the state level, and therefore, for example, New York State requires that the nuclear medicine certified technologist must be present at the scanner console to monitor the patient during image acquisition.
As outlined above, certifications of each type of technologist typically vary according to state regulations, and at our institution, there are no additional or special certifications held by the two technologists overseeing the scanner. Although each technologist is dual trained, such that a single technologist can operate the scanner individually, it is important to recognize that redundancy in training for both PET scanning and MR scanning is paramount.
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The troubleshooting skills required for operating the hybrid machine require good understanding of the physics that underlie image generation via both modalities, as well as the post-processing necessary to produce clinically relevant and interpretable images. These skills sometimes require active management at the scanner by the radiologist along with the technologist. In other words, the same routines are followed as if our facility were operating a standalone PET and MR systems, although the frequency of certain tests is different. Additionally, the technologist has the option at any time to perform an MR coil check with a water bottle phantom on the head and neck coil, which currently takes approximately 10 min.
Although there are no additional QA requirements for the integrated system as compared to the standalone PET or MRI scanners, there are certain preventative parameters that require attention.
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Preventative maintenance checkups for the integrated system are performed by the engineer on a monthly or quarterly basis. This test checks to see if any detectors have moved or drifted, and also if a given detector should be replaced.
We predict that technologist and physicist experiences will vary widely depending on the comfort level of the radiologists and nuclear medicine physicians overseeing these examinations, as well as on the type of scanning system employed. Pages Head and Neck Subramaniam, Rathan M. Chest Subramaniam, Rathan M. Breast Cancer Mercier, Gustavo A. Gastrointestinal Hustinx, Roland Pages Genitourinary Brunetti, Jacqueline et al. Gynecologic Peller, Patrick J. Musculoskeletal Peterson, Jeffrey J. Hematology Subramaniam, Rathan M. Dermatological Brandon, David et al. Pediatric Jadvar, Hossein et al.