CLINICAL IMPLEMENTATION OF HYBRID IMAGING CLINICAL IMPLEMENTATION OF HYBRID IMAGING COMBINED IMAGING CLINICAL IMPLEMENTATION OF

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1 HYBRID OBJECTIVES OF ADDING CT-SCANNING TO NM? CLINICAL IMPLEMENTATION OF François Jamar UCL, Brussels ABR-BVS Workshop, Antwerp, Feb. 18, 2011 HYBRID COMBINED COMBINED ( PET AND CT) In-WBC 111 In COMBINED ( PET AND CT) GUSTAV K. VON SCHULTHESS, UNIVERSITY HOSPITAL, ZURICH, SWITZERLAND

2 HYBRID HYBRID GUSTAV K. VON SCHULTHESS, UNIVERSITY HOSPITAL, ZURICH, SWITZERLAND GUSTAV K. VON SCHULTHESS, UNIVERSITY HOSPITAL, ZURICH, SWITZERLAND GUSTAV K. VON SCHULTHESS, UNIVERSITY HOSPITAL, ZURICH, SWITZERLAND EQUIPMENT (PET-CT) FACT NUMBERS (PET-CT) FACT NUMBERS (SPECT OR PET-CT) PET and PET/CT Reports: Observations from the National Oncologic PET Registry R. Edward Coleman JNM 2010 PET equipments purchased today in most countries are PETCTs SPECT equipments purchased are 60-80% SPECT-CTs (Belgium 2010) Economic Evaluation of PET and PET/CT in Oncology: Evidence and Methodologic Approaches. AK. Buck et al. JNM 2010

3 OBJECTIVES OF ADDING CT-SCANNING TO NM IMAGE-GUIDED RESECTION o to combine functional and morphological imaging o to improve attenuation correction (also to perform) o to help for anatomical localization (specificity) o to enhance diagnostic information o to optimize patient throughput o to provide a precise tool for image-guided radiotherapy o to allow metabolic guided biopsy / resection 123 I-MIBG SPECT-CT BEFORE GUIDED SURGERY 123 I-MIBG OBJECTIVES OF ADDING CT-SCANNING TO NM o to combine functional and morphological imaging o to improve attenuation correction o to help for anatomical localization (surgery/specificity) o to enhance diagnostic information o to optimize patient throughput o to give a precise tool for image-guided radiotherapy o to allow metabolic guided biopsy HYBRID IMPROVED LOCALIZATION IMPROVED LOCALIZATION 99m Tc-WBC

4 IMPROVED LOCALIZATION HYBRID ACCURATE DIAGNOSIS HYBRID ACCURATE DIAGNOSIS HYBRID ACCURATE DIAGNOSIS Final diagnosis: Miliary tuberculosis in immunocompromised patient with vertebral osteomyelitis IMPROVED SPECIFICITY (BROWN FAT) IMPROVED SPECIFICITY (AVASCULAR NECROSIS)

5 BONE SCANNING PLANAR AND SPECT BONE SPECT-CT: DIAGNOSTIC INFORMATION FROM CT HYBRID RELATED PROBLEMS o Training and certification/authorization o Change in diagnostic patterns o Technical issues: artifacts, contrast media, organization, o Quality control and quality assurance o Radiation protection TRAINING, CERTIFICATION, QC, QA o Need for common training in nuclear medicine and radiology: «White paper» o Proposal of common curriculum by the ESR and EANM o Change in FANC authorizations o Authorizations fo medical physicists o The major issue in medical physics is not QC but QA, i.e. everyday improvement of practice and reduction of radiation exposure CHANGES IN DIAGNOSTIC PATTERNS BY COMPLEMENTARITY TECHNICAL ISSUES: ARTIFACTS METALLIC DEVICES No AC AC ( 68 Ga) AC + IR AC + IR ( 68 Ga) TP/TP Fukushi et al., J Vasc Surg TN/FP Goerres et al, Radiology, 2003

6 TECHNICAL ISSUES: RESPIRATORY MOTION TECHNICAL ISSUES: CONTRAST MEDIA Blocked inspiration Free breathing FUTURE DEVELOPMENTS COMBINED PET AND MRI INSTEAD OF CT Gaemperli, J Nucl Cardiol, 2007 Small, The Lancet, Neurology, Feb 2008 CONCLUSIONS (1) CONCLUSIONS (2) o The move from single-modality to hybrid imaging o The radiation protection issues had to be carefully is almost fully achieved for PET and it is unconceivable to go backwards o The added value of adding CT to SPECT on a large scale basis remains to be determined, and patient selection needs to be carefully examined weighted and must include: Justification: per se, multiplication of procedures, esp. over a few days Optimization: specific protocol for specific questions Long-term effects of repeated irradiation should be examined in selected groups of patients (e.g. non fatal cancer, pediatrics, benign disorders, ) Cancer risk related to low-dose ionizing radiation from cardiac imaging in patients after acute myocardial infarction MJ. Eisenberg et al. CMAJ, 2011

7 CONCLUSIONS (3) o Changes in imaging practices need changes in training, continuing education and regulations o This should ideally be organized at the international level by the scientific and professional societies o The impact on patient management must be evaluated using cost effectiveness analyses (SPECT >> PET) o The future of hybrid imaging will include PET-MRI, which can reduce the radiation burden