Maximizing the Utility of Integrated PET/MRI in Clinical Applications
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1 Maximizing the Utility of Integrated PET/MRI in Clinical Applications Spencer Behr, MD Department of Nuclear Medicine & Abdominal Imaging University of California, San Francisco
2 PET/MR at UCSF Device: GE s SIGNA PET/MR Concurrent System 3 Tesla MRI (750w system) PET Silicon based PMT TOF
3 From PET/CT to PET/MR: Considerations 1. Protocol/Workflow 2. Reporting 3. Technologists
4 Clinical PET/MR: Protocols/Workflow-Reporting-Technologists 1. Clear indications for both PET & MRI Ø Not by tumor type, but study type
5 Clinical PET/MR: Protocols/Workflow-Reporting-Technologists PET/MR Neurology Brain Oncology Brain, Liver, Pelvis Cardiac
6 Clinical PET/MR: Protocols/Workflow-Reporting-Technologists Order Study Protocol PET/MR Brain Brain MRI with FDG Brain MRI and Amyvid PET Seizure Protocol Tumor Protocol Dementia Protocol PET/MR WB with Brain Brain MRI with WB PET Screening MR brain PET/MR WB with Liver PET/MR WB with pelvis FDG PET and liver MRI FDG PET and pelvis MRI WB + Eovist Liver WB + Gadavist Liver WB + Rectal protocol WB + Uterine protocol
7 Clinical PET/MR: FUTURE PROTOCOLS HEAD AND NECK Challenge: MR protocol Time: 2 to 3 months CARDIAC Challenges: 1. Technical development 2. Indication (ischemia, sarcoid, etc) Time: To be determined
8 What is going to be largest volume? PET/MR Abdomen and pelvis Large volume already Surgical planning PET/MR Head and Neck PET/MR BRAIN Epilepsy Dementia Amyloid Current low clinical PET Volume
9 Clinical PET/MR: Protocols/Workflow-Reporting-Technologists 1. Overlapping PET & MRI study types 2. Total Examination Time Challenge: MR protocols
10 PET/MR: Clinical Examination Times Currently: 90 minutes Goal: 60 minutes 5 to 10 min 20 minutes 20 minutes Set up Dedicate MR WB PET
11 Clinical PET/MR: Protocols/Workflow-Reporting-Technologists 1. Overlapping PET & MRI study types 2. Total Examination Time 3. Protocols
12 1 st Clinical PET/MR: Metastatic Prostate Cancer MR MIP PET/MR
13 Clinical PET/MR: Rectal Cancer 1. FDG PET 2. Rectal MR FINDING: - T2 disease MR - No LN or Mets MIP PET/MR
14 Clinical PET/MR: Protocols/Workflow-Reporting-Technologists 1. Dual Readout a. Nuclear Medicine b. Specific Section for MR 2. Two separate reports a. PET specific b. Dedicated MR
15 Clinical PET/MR: Protocols/Workflow-Reporting-Technologists Need at least one NM technologist 2 Technologists 1 NM 1 MRI 1 Technologist Trained in both NM&MR Not common training Solution: NM tech with onsite MR training
16 PET/MR Challenges Acceptance of PET/MR Ø Imagers Ø Referring Physicians
17 MODALITY ATTENUATION CORRECTION PET Only Emission PET/CT CT Attenuation Map PET/MR Atlas Segmentation Sequences
18 PET/MR Challenges: Imagers-Referrers Q: How reliable is PET Quantification? Accurate PET quantification essential Staging, treatment response, restaging Several papers have found SUV mean/max comparable between PET/MR and PET/CT Except lung, bone and mediastinal blood For MRAC, bone currently ignored ê standard uptake value (SUV)
19 MR Bone: Cortical Bone/AC Maps Conventional MR sequences too short Ignored in most MRAC Solution: Bone Mu maps (atlas), Zero Echo Time (ZTE) Delso G et al. JNM. 2015; 56:
20 MR Lung: Pulmonary Nodules CT method of choice for pulmonary nodules Studies have shown that MR and CT detect pulmonary nodules at a similar rate 3D Dixon-based, dual-echo GRE Similar findings at UCSF with Ultra-short Echo Time (UTE) Stolzmann P. Invest Radiol 2013 May (4): 241-6
21 MR Lung: Pulmonary Nodules CT MR: UTE?? Two Nodules (1) 10 mm (2) 4 mm MR: LAVA MR: UTE -Both nodules seen MR: LAVA -10 mm seen - 4 mm not seen Courtesy of Nicholas Burris & Tom Hope
22 PET/MR Challenges: Imagers-Referrers Hesitant to change current clinical practice PET/CT à CT chest for pulmonary nodules PET/MR à Seen as experimental Perception of full body MR Scant clinical data comparing current standard-of-care imaging
23 PET/MR Challenges: Imagers-Referrers Uncertainty of how to integrate PET/MR into the current clinical practice Epilepsy: Ictal studies In hospital SPECT with EEGs on
24 What have we learned? Take away: 1. Clinical PET/MR is gaining momentum 2. Need to be patient PET/MR is still young and developing Similar to PET/CT, PET/MR needs to find its fit compared to SOC imaging
25 What have we learned? Take away: 3. Imagers and referrers have to work together a. Expectations and education a. Referrers b. None PET readers 4. MR and PET imagers need to work closely a. MR pulmonary nodule evaluation b. Compare PET/MR to SOC imaging
26 PET/MR: Future Determine PET/MR role in clinical environments: Multisite trials Cost effectiveness Refine MR bone/lung sequences Refinement of MRAC and workflow Reimbursement
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