Hybrid systems in Medical Imaging

Hybrid systems in Medical Imaging from PET/CT to PET/MR Osman Ratib, MD, PhD, FAHA Professor and chair Department of Medical Imaging and Information Sciences Head of division of Nuclear Medicine University Hospital of Geneva

History of hybrid imaging Origin of PET / CT 1994 1998 University of Pittsburgh Medical Center

History of hybrid imaging Sequential PET-CT

FDG uptake in Tumors Universal tracer? SUV 15 10 5 Melanoma HG NHL HD Colorectal CA NSCLC Esophageal CA Head/Neck HG sarcoma Infiltrating ductal CA Poorly diff - thyroid Testicular CA Pancreas Recurrent ovarian CA LG NHL Bronchoalveolar CA Cervical CA Renal cell CA Lobular CA Mucinous CA Prostate CA Primary ovarian CA Well diff - thyroid Hot Medium Hot Not So Hot 2009 Hôpitaux Universitaires de Genève

New tracers in PET imaging C11 - ACETATE Applications: - Hepatocellular cancers - Renal cancers - Prostate cancers 2009 Hôpitaux Universitaires de Genève

New tracers in PET imaging F18 - Tyrosine (FET) MRI PET-CT Applications: - Glyomas and brain cancers 2009 Hôpitaux Universitaires de Genève

New tracers in PET imaging 18 F - Choline Applications: 2009 Hôpitaux Universitaires de Genève - Prostate cancers (recurrence)

New tracers in PET imaging 18 F - Dopamine 18 F-FDG 18 F-DOPA Applications: - Endocrine tumors - Carcinoïd tumors 2008 Hôpitaux Universitaires de Genève

New tracers in PET imaging 18 F PET 2009 Hôpitaux Universitaires de Genève

New tracers in PET imaging 18 F - NaF PET Planar SPECT 18 F NaF - PET 2009 Hôpitaux Universitaires de Genève

FDG PET impact on patient management 2011 Hôpitaux Universitaires de Genève 11

FDG PET: Impact on patient management Staging Reference No.pts Change in mgmt Delbeke et al, J Nucl Med 2000; 41: 275P 27 31% Yap et al, J Nucl Med 2000; 41: 109 58 50% Dittman et al, J Nucl Med 2000; 41: 71P 24 8% Seltzer et al, J Nucl Med 2000; 41: 108P 536 50% Kostakoglu et al, J Nucl Med 2000; 41: 118P 62 5% Shah et al, Br J Radiology 2000; 73: 482 29 34% Jerusalem et al, NM Commun 1999; 20: 13 60 3% Moog et al, Radiology 1998; 206: 475 81 16% Bangerter et al, Ann Oncol 1998; 9: 1117 44 14% Hoh et al, J Nucl Med 1997; 38: 343 18 22% Moog et al, Radiology 1997; 203: 795 60 7% Total: 999 21% Recurrence Spaepen et al, J Nucl Med 2000; 41:70 96 14% Kostakoglu et al, J Nucl Med 2000; 41: 118P 62 5% Total: 158 10% 2011 Hôpitaux Universitaires de Genève 12

PET in oncology Impact of PET imaging on clinical management Changes in clinical staging (n = 583) 60 56 50 40 49 Lung Cancer (n = 285) Non-Lung (n = 298) 30 31 25 20 15 14 10 5 5 0 Up Down No Change No Answer Seltzer et al, UCLA School of Medicine 2011 Hôpitaux Universitaires de Genève

PET in oncology Impact of PET imaging on clinical management Changes in treatment (n = 583) 50 43 42 Lung Cancer (n = 285) 40 36 34 Non-Lung (n = 298) 30 % 20 15 18 10 6 6 0 Major Minor No Change No Answer Seltzer et al, UCLA School of Medicine 2011 Hôpitaux Universitaires de Genève

FDG PET vs PET-CT in Oncology 2008 Hôpitaux Universitaires de Genève

PET/CT in oncology Advent of hybrid imaging Currently available data indicate that PET/CT is more sensitive and specific than either of its constituent imaging methods alone and probably more so than images obtained separately from PET and CT and viewed side by side. Published results on the use of PET/CT in oncology are still limited, but several well-designed studies have demonstrated the benefits of PET/CT, especially in staging of non small cell lung cancer, recurrent colorectal cancer, and malignant lymphoma 2008 Hôpitaux Universitaires de Genève

PET/CT in oncology Advent of hybrid imaging 2008 Hôpitaux Universitaires de Genève

2008 Hôpitaux Universitaires de Genève PET/CT in oncology

Hybrid imaging From PET-CT to PET-MR CT PET MRI CT PET-CT PET PET-MRI MRI PET-CT PET-MRI

PET-MRI developements Pioneer work by S. Cherry 1994-1996

PET-MRI developments First animal prototype S. Cherry 2004-2006

Hybrid imaging Whole body PET-MR PET PET-MRI MRI

PET-MRI developments Sequential vs simultaneous acquisition Head Insert Whole body sequential Eur J Nucl Med Mol Imaging (2009) 36 (Suppl 1):S86 S92 DOI 10.1007/s00259-008-1008-6 Whole body simultaneous

PET-MRI hybrid imaging Whole-body PET-MRI 3m MRI PET

First whole-body PET-MRI prototype Two first luminary sites Mount Sinai Medical Center (New York) Pr. Z.Fayad a u r b Fe 0 1 0 ry 2 Geneva University Hospital (Geneva) Pr. O.Ratib

Whole-body PET-MRI MR-based attenuation correction Uncorrected DIXON in phase DIXON fat DIXON water Attenuation map Corrected Bed and surface coils attenuation maps Spine 15ch Cardiac 32ch posterior Breast 7ch Head 8ch NV 16ch +

Whole-body PET-MRI Clinical workflow 1 2 1. Whole body MRI (AC and localization) 2. Whole body PET 3 3. Additional diagnostic MR images

PET-MRI in Geneva Alpha & beta phase 62 patients had a PET-CT followed by a PET-MR Average time between studies was 85 ± 22 minutes ranging from 49 minutes to 120 minutes Most patients had a complementary diagnostic MRI Images were interpreted by a team of radiologists and nuclear medicine physicians PET Image quality was graded and compared between PET-CT and PET-MR SUV were measured and compared on both PET studies

PET-MRI in Geneva Alpha & beta phase PET-CT & PET-MR workflow CT PET 1 CT MR PET 2 MR FDG Iodine Gadolinium 0 15 30 45 60 75 90 105 120 PET-CT PET-MR

PET-MRI in Geneva Resullts No significant difference in image quality and identification of abnormal lesions were found between the two PET scans of each case Images performed on the PET-MR were comparable to those acquired on the PET-CT scanner and often showed higher contrast with less background noise due to a well known FDG redistribution No significant artifacts from attenuation correction or from interference between the two scanners were observed Whole-body MRI sequence were often suboptimal for accurate anatomical localization and additional high resolution images of selected anatomical regions were used

PET-MRI in Geneva Resullts SUV measurements performed on two sequential PET studies (separated by 85 ± 22 minutes) showed a significant variation in biodistribution in different organs, but showed comparable results in tumor lesions PET-CT PET-MR

Clinical Studies

PET-MRI in clinical routine Potential clinical applications Pediatric oncology and epilepsy workup Oncology investigation that require already a diagnostic MRI in addition to PET-CT: Head & Neck cancer (pre and post-op) Prostate cancers Breast imaging New emerging clinical applications: Cardiac imaging (viability, ischemia?) Gynecological cancers Bone metastases (F 18 -NaF)

PET-MR in Geneva Research team Steering committee Osman Ratib Christophe Becker Magalie Vialon Habib Zaidi Jean-Paul Vallée Maria Isabel Vargas Michael Wissmeyer François Riondel Béatrice Paridant Michel Velazquez Jean-Noel Hyacinthe Team (1) Oncology H&N: Minerva Becker Michael Wissmeyer + Olivier Rager Magalie Vialon Team (2) Oncology prostate: Jean Paul Vallée Charles Steiner + Valentina Garibotto Jean-Noel Hyacinthe Team (3) Oncology breast: Pierre Loubeyre Olivier Rager + Jean-Pierre Willi Jean-Noel Hyacinthe Philips support and R&D team Jeffrey Kaste Troy Havens Piotr Maniawski Susanne Heinzer Antonis Kalemis Navdeep Ojha Zhiqiang Hu Kevin Kilroy Michelle Granny Dominique Joliat

PET-MR in Geneva Research team Steering committee Osman Ratib Christophe Becker Magalie Vialon Habib Zaidi Jean-Paul Vallée Maria Isabel Vargas Michael Wissmeyer François Riondel Béatrice Paridant Michel Velazquez Jean-Noel Hyacinthe Team (1) Oncology H&N: Minerva Becker Michael Wissmeyer + Olivier Rager Magalie Vialon Team (2) Oncology prostate: Jean Paul Vallée Charles Steiner + Valentina Garibotto Jean-Noel Hyacinthe Team (3) Oncology breast: Pierre Loubeyre Olivier Rager + Jean-Pierre Willi Jean-Noel Hyacinthe Philips support and R&D team Jeffrey Kaste Troy Havens Piotr Maniawski Navdeep Ojha Zhiqiang Hu Kevin Kilroy Michelle Granny Laurent Renevey Sylvain Sans Dominique Joliat