Avaliação da viabilidade miocárdica pós-enfarte: Gated-SPECT versus Gated-PET

Mestrado em Medicina Nuclear - Ramo de especialização: Tomografia por Emissão de Positrões

Níveis de referência em diagnóstico em tomografia computorizada para planeamento em radioterapia

Mestrado em Radiações Aplicadas às Tecnologias da Saúde- Ramo de especialização: Terapia com Radiações

As competências dos técnicos de radiologia: um contributo para a sua identificação e definição

Mestrado em Intervenção Sócio-Organizacional em Saúde - Ramo de especialização: Políticas de Administração e Gestão de Serviços de Saúde

Dosimetric effect of tissue heterogeneity for 125I prostate implants

Aim - To use Monte Carlo (MC) together with voxel phantoms to analyze the tissue heterogeneity effect in the dose distributions and equivalent uniform dose (EUD) for (125)I prostate implants. Background - Dose distribution calculations in low dose-rate brachytherapy are based on the dose deposition around a single source in a water phantom. This formalism does not take into account tissue heterogeneities, interseed attenuation, or finite patient dimensions effects. Tissue composition is especially important due to the photoelectric effect. Materials and Methods - The computed tomographies (CT) of two patients with prostate cancer were used to create voxel phantoms for the MC simulations. An elemental composition and density were assigned to each structure. Densities of the prostate, vesicles, rectum and bladder were determined through the CT electronic densities of 100 patients. The same simulations were performed considering the same phantom as pure water. Results were compared via dose-volume histograms and EUD for the prostate and rectum. Results - The mean absorbed doses presented deviations of 3.3-4.0% for the prostate and of 2.3-4.9% for the rectum, when comparing calculations in water with calculations in the heterogeneous phantom. In the calculations in water, the prostate D 90 was overestimated by 2.8-3.9% and the rectum D 0.1cc resulted in dose differences of 6-8%. The EUD resulted in an overestimation of 3.5-3.7% for the prostate and of 7.7-8.3% for the rectum. Conclusions - The deposited dose was consistently overestimated for the simulation in water. In order to increase the accuracy in the determination of dose distributions, especially around the rectum, the introduction of the model-based algorithms is recommended.

OPTIMAX 2014 - Radiation dose and image quality optimisation in medical imaging

Medical imaging is a powerful diagnostic tool. Consequently, the number of medical images taken has increased vastly over the past few decades. The most common medical imaging techniques use X-radiation as the primary investigative tool. The main limitation of using X-radiation is associated with the risk of developing cancers. Alongside this, technology has advanced and more centres now use CT scanners; these can incur significant radiation burdens compared with traditional X-ray imaging systems. The net effect is that the population radiation burden is rising steadily. Risk arising from X-radiation for diagnostic medical purposes needs minimising and one way to achieve this is through reducing radiation dose whilst optimising image quality. All ages are affected by risk from X-radiation however the increasing population age highlights the elderly as a new group that may require consideration. Of greatest concern are paediatric patients: firstly they are more sensitive to radiation; secondly their younger age means that the potential detriment to this group is greater. Containment of radiation exposure falls to a number of professionals within medical fields, from those who request imaging to those who produce the image. These staff are supported in their radiation protection role by engineers, physicists and technicians. It is important to realise that radiation protection is currently a major European focus of interest and minimum competence levels in radiation protection for radiographers have been defined through the integrated activities of the EU consortium called MEDRAPET. The outcomes of this project have been used by the European Federation of Radiographer Societies to describe the European Qualifications Framework levels for radiographers in radiation protection. Though variations exist between European countries radiographers and nuclear medicine technologists are normally the professional groups who are responsible for exposing screening populations and patients to X-radiation. As part of their training they learn fundamental principles of radiation protection and theoretical and practical approaches to dose minimisation. However dose minimisation is complex – it is not simply about reducing X-radiation without taking into account major contextual factors. These factors relate to the real world of clinical imaging and include the need to measure clinical image quality and lesion visibility when applying X-radiation dose reduction strategies. This requires the use of validated psychological and physics techniques to measure clinical image quality and lesion perceptibility.

PET/CT com 18-fluor-fluorodeoxiglucose no seguimento do melanoma maligno cutâneo

Introdução – O melanoma maligno cutâneo (MMC) é considerado uma das mais letais neoplasias e no seu seguimento recorre-se, para além dos exames clínicos e da análise de marcadores tumorais, a diversos métodos imagiológicos, como é o exame Tomografia por Emissão de Positrões/Tomografia Computorizada (PET/CT, do acrónimo inglês Positron Emission Tomography/Computed Tomography) com 18fluor-fluorodeoxiglucose (18F-FDG). O presente estudo tem como objetivo avaliar a utilidade da PET/CT relativamente à análise da extensão e à suspeita de recidiva do MMC, comparando os achados imagiológicos com os descritos em estudos CT. Metodologia – Estudo retrospetivo de 62 estudos PET/CT realizados em 50 pacientes diagnosticados com MMC. Excluiu-se um estudo cujo resultado era duvidoso (nódulo pulmonar). As informações relativas aos resultados dos estudos anatomopatológicos e dos exames imagiológicos foram obtidas através da história clínica e dos relatórios médicos dos estudos CT e PET/CT. Foi criada uma base de dados com os dados recolhidos através do software Excel e foi efetuada uma análise estatística descritiva. Resultados – Dos estudos PET/CT analisados, 31 foram considerados verdadeiros positivos (VP), 28 verdadeiros negativos (VN), um falso positivo (FP) e um falso negativo (FN). A sensibilidade, especificidade, o valor preditivo positivo (VPP), o valor preditivo negativo (VPN) e a exatidão da PET/CT para o estadiamento e avaliação de suspeita de recidiva no MMC são, respetivamente, 96,9%, 96,6%, 96,9%, 96,6% e 96,7%. Dos resultados da CT considerados na análise estatística, 14 corresponderam a VP, 12 a VN, três a FP e cinco a FN. A sensibilidade, especificidade, o VPP e o VPN e a exatidão da CT para o estadiamento e avaliação de suspeita de recidiva no MMC são, respetivamente, 73,7%, 80,0%, 82,4%, 70,6% e 76,5%. Comparativamente aos resultados CT, a PET/CT permitiu uma mudança na atitude terapêutica em 23% dos estudos. Conclusão – A PET/CT é um exame útil na avaliação do MMC, caracterizando-se por uma maior acuidade diagnóstica no estadiamento e na avaliação de suspeita de recidiva do MMC comparativamente à CT isoladamente.

Effect of technical parameters on dose and image quality in a computed radiography system

The discovery of X-rays was undoubtedly one of the greatest stimulus for improving the efficiency in the provision of healthcare services. The ability to view, non-invasively, inside the human body has greatly facilitated the work of professionals in diagnosis of diseases. The exclusive focus on image quality (IQ), without understanding how they are obtained, affect negatively the efficiency in diagnostic radiology. The equilibrium between the benefits and the risks are often forgotten. It is necessary to adopt optimization strategies to maximize the benefits (image quality) and minimize risk (dose to the patient) in radiological facilities. In radiology, the implementation of optimization strategies involves an understanding of images acquisition process. When a radiographer adopts a certain value of a parameter (tube potential [kVp], tube current-exposure time product [mAs] or additional filtration), it is essential to know its meaning and impact of their variation in dose and image quality. Without this, any optimization strategy will be a failure. Worldwide, data show that use of x-rays has been increasingly frequent. In Cabo Verde, we note an effort by healthcare institutions (e.g. Ministry of Health) in equipping radiological facilities and the recent installation of a telemedicine system requires purchase of new radiological equipment. In addition, the transition from screen-films to digital systems is characterized by a raise in patient exposure. Given that this transition is slower in less developed countries, as is the case of Cabo Verde, the need to adopt optimization strategies becomes increasingly necessary. This study was conducted as an attempt to answer that need. Although this work is about objective evaluation of image quality, and in medical practice the evaluation is usually subjective (visual evaluation of images by radiographer / radiologist), studies reported a correlation between these two types of evaluation (objective and subjective) [5-7] which accredits for conducting such studies. The purpose of this study is to evaluate the effect of exposure parameters (kVp and mAs) when using additional Cooper (Cu) filtration in dose and image quality in a Computed Radiography system.

The influence of number of counts in the myocardium in the determination of reproducible functional parameters in gated-SPECT studies simulated with GATE

Myocardial perfusion gated-single photon emission computed tomography (gated-SPECT) imaging is used for the combined evaluation of myocardial perfusion and left ventricular (LV) function. The aim of this study is to analyze the influence of counts/pixel and concomitantly the total counts in the myocardium for the calculation of myocardial functional parameters. Material and methods: Gated-SPECT studies were performed using a Monte Carlo GATE simulation package and the NCAT phantom. The simulations of these studies use the radiopharmaceutical 99mTc-labeled tracers (250, 350, 450 and 680MBq) for standard patient types, effectively corresponding to the following activities of myocardium: 3, 4.2, 5.4-8.2MBq. All studies were simulated using 15 and 30s/projection. The simulated data were reconstructed and processed by quantitative-gated-SPECT software, and the analysis of functional parameters in gated-SPECT images was done by using Bland-Altman test and Mann-Whitney-Wilcoxon test. Results: In studies simulated using different times (15 and 30s/projection), it was noted that for the activities for full body: 250 and 350MBq, there were statistically significant differences in parameters Motility and Thickness. For the left ventricular ejection fraction (LVEF), end-systolic volume (ESV) it was only for 250MBq, and 350MBq in the end-diastolic volume (EDV), while the simulated studies with 450 and 680MBq showed no statistically significant differences for global functional parameters: LVEF, EDV and ESV. Conclusion: The number of counts/pixel and, concomitantly, the total counts per simulation do not significantly interfere with the determination of gated-SPECT functional parameters, when using the administered average activity of 450MBq, corresponding to the 5.4MBq of the myocardium, for standard patient types.

Maintaining image quality for paediatric chest CTs while lowering dose: FBP versus SAFIRE

Objectives: Children have a greater risk from radiation, per unit dose, due to increased radiosensitivity and longer life expectancies. It is of paramount importance to reduce the radiation dose received by children. This research concerns chest CT examinations on paediatric patients. The purpose of this study was to compare the image quality and the dose received from imaging with images reconstructed with filtered back projection (FBP) and five strengths of Sinogram-Affirmed Iterative Reconstruction (SAFIRE). Methods: Using a multi-slice CT scanner, six series of images were taken of a paediatric phantom. Two kVp values (80 and 110), 3 mAs values (25, 50 and 100) and 2 slice thicknesses (1 mm and 3 mm) were used. All images were reconstructed with FBP and five strengths of SAFIRE. Ten observers evaluated visual image quality. Dose was measured using CT-Expo. Results: FBP required a higher dose than all SAFIRE strengths to obtain the same image quality for sharpness and noise. For sharpness and contrast image quality ratings of 4, FBP required doses of 6.4 and 6.8 mSv respectively. SAFIRE 5 required doses of 3.4 and 4.3 mSv respectively. Clinical acceptance rate was improved by the higher voltage (110 kV) for all images in comparison to 80 kV, which required a higher dose for acceptable image quality. 3 mm images were typically better quality than 1 mm images. Conclusion: SAFIRE 5 was optimal for dose reduction and image quality.

The impact of Sinogram-Affirmed Iterative Reconstruction on patient dose and image quality compared to filtered back projection: a narrative review

Objective: Summarize all relevant findings in published literature regarding the potential dose reduction related to image quality using Sinogram-Affirmed Iterative Reconstruction (SAFIRE) compared to Filtered Back Projection (FBP). Background: Computed Tomography (CT) is one of the most used radiographic modalities in clinical practice providing high spatial and contrast resolution. However it also delivers a relatively high radiation dose to the patient. Reconstructing raw-data using Iterative Reconstruction (IR) algorithms has the potential to iteratively reduce image noise while maintaining or improving image quality of low dose standard FBP reconstructions. Nevertheless, long reconstruction times made IR unpractical for clinical use until recently. Siemens Medical developed a new IR algorithm called SAFIRE, which uses up to 5 different strength levels, and poses an alternative to the conventional IR with a significant reconstruction time reduction. Methods: MEDLINE, ScienceDirect and CINAHL databases were used for gathering literature. Eleven articles were included in this review (from 2012 to July 2014). Discussion: This narrative review summarizes the results of eleven articles (using studies on both patients and phantoms) and describes SAFIRE strengths for noise reduction in low dose acquisitions while providing acceptable image quality. Conclusion: Even though the results differ slightly, the literature gathered for this review suggests that the dose in current CT protocols can be reduced at least 50% while maintaining or improving image quality. There is however a lack of literature concerning paediatric population (with increased radiation sensitivity). Further studies should also assess the impact of SAFIRE on diagnostic accuracy.

A comparison of Sinogram Affirmed Iterative Reconstruction and filtered back projection on image quality and dose reduction in paediatric head CT: a phantom study

Background: Computed tomography (CT) is one of the most used modalities for diagnostics in paediatric populations, which is a concern as it also delivers a high patient dose. Research has focused on developing computer algorithms that provide better image quality at lower dose. The iterative reconstruction algorithm Sinogram-Affirmed Iterative Reconstruction (SAFIRE) was introduced as a new technique that reduces noise to increase image quality. Purpose: The aim of this study is to compare SAFIRE with the current gold standard, Filtered Back Projection (FBP), and assess whether SAFIRE alone permits a reduction in dose while maintaining image quality in paediatric head CT. Methods: Images were collected using a paediatric head phantom using a SIEMENS SOMATOM PERSPECTIVE 128 modulated acquisition. 54 images were reconstructed using FBP and 5 different strengths of SAFIRE. Objective measures of image quality were determined by measuring SNR and CNR. Visual measures of image quality were determined by 17 observers with different radiographic experiences. Images were randomized and displayed using 2AFC; observers scored the images answering 5 questions using a Likert scale. Results: At different dose levels, SAFIRE significantly increased SNR (up to 54%) in the acquired images compared to FBP at 80kVp (5.2-8.4), 110kVp (8.2-12.3), 130kVp (8.8-13.1). Visual image quality was higher with increasing SAFIRE strength. The highest image quality was scored with SAFIRE level 3 and higher. Conclusion: The SAFIRE algorithm is suitable for image noise reduction in paediatric head CT. Our data demonstrates that SAFIRE enhances SNR while reducing noise with a possible reduction of dose of 68%.

X Radiation dose implications in screening patients with ferromagnetic IOFBs prior to MRI: a literary review

Patients scheduled for a magnetic resonance imaging (MRI) scan sometimes require screening for ferromagnetic Intra Orbital Foreign Bodies (IOFBs). To assess this, they are required to fill out a screening protocol questionnaire before their scan. If it is established that a patient is at high risk, radiographic imaging is necessary. This review examines literature to evaluate which imaging modality should be used to screen for IOFBs, considering that the eye is highly sensitive to ionising radiation and any dose should be minimised. Method: Several websites and books were searched for information, these were as follows: PubMed, Science Direct, Web of Knowledge and Google Scholar. The terms searched related to IOFB, Ionising radiation, Magnetic Resonance Imaging Safety, Image Quality, Effective Dose, Orbits and X-ray. Thirty five articles were found, several were rejected due to age or irrelevance; twenty eight were eventually accepted. Results: There are several imaging techniques that can be used. Some articles investigated the use of ultrasound for investigation of ferromagnetic IOFBs of the eye and others discussed using Computed Tomography (CT) and X-ray. Some gaps in the literature were identified, mainly that there are no articles which discuss the lowest effective dose while having adequate image quality for orbital imaging. Conclusion: X-ray is the best method to identify IOFBs. The only problem is that there is no research which highlights exposure factors that maintain sufficient image quality for viewing IOFBs and keep the effective dose to the eye As Low As Reasonably Achievable (ALARA).

Reducing effective dose to a paediatric phantom by using different combinations of kVp, mAs and additional filtration whilst maintaining image quality

Purpose: To determine whether using different combinations of kVp and mAs with additional filtration can reduce the effective dose to a paediatric phantom whilst maintaining diagnostic image quality. Methods: 27 images of a paediatric AP pelvis phantom were acquired with different kVp, mAs and additional copper filtration. Images were displayed on quality controlled monitors with dimmed lighting. Ten diagnostic radiographers (5 students and 5 experienced radiographers) had eye tests to assess visual acuity before rating the images. Each image was rated for visual image quality against a reference image using 2 alternative forced choice software using a 5-point Likert scale. Physical measures (SNR and CNR) were also taken to assess image quality. Results: Of the 27 images rated, 13 of them were of acceptable image quality and had a dose lower than the image with standard acquisition parameters. Two were produced without filtration, 6 with 0.1mm and 5 with 0.2mm copper filtration. Statistical analysis found that the inter-rater and intra-rater reliability was high. Discussion: It is possible to obtain an image of acceptable image quality with a dose that is lower than published guidelines. There are some areas of the study that could be improved. These include using a wider range of kVp and mAs to give an exact set of parameters to use. Conclusion: Additional filtration has been identified as amajor tool for reducing effective dose whilst maintaining acceptable image quality in a 5 year old phantom.

Numerical 3D modeling of heat transfer in human tissues for microwave radiometry monitoring of Brown fat metabolismo

Background: Brown adipose tissue (BAT) plays an important role in whole body metabolism and could potentially mediate weight gain and insulin sensitivity. Although some imaging techniques allow BAT detection, there are currently no viable methods for continuous acquisition of BAT energy expenditure. We present a non-invasive technique for long term monitoring of BAT metabolism using microwave radiometry. Methods: A multilayer 3D computational model was created in HFSS™ with 1.5 mm skin, 3-10 mm subcutaneous fat, 200 mm muscle and a BAT region (2-6 cm3) located between fat and muscle. Based on this model, a log-spiral antenna was designed and optimized to maximize reception of thermal emissions from the target (BAT). The power absorption patterns calculated in HFSS™ were combined with simulated thermal distributions computed in COMSOL® to predict radiometric signal measured from an ultra-low-noise microwave radiometer. The power received by the antenna was characterized as a function of different levels of BAT metabolism under cold and noradrenergic stimulation. Results: The optimized frequency band was 1.5-2.2 GHz, with averaged antenna efficiency of 19%. The simulated power received by the radiometric antenna increased 2-9 mdBm (noradrenergic stimulus) and 4-15 mdBm (cold stimulus) corresponding to increased 15-fold BAT metabolism. Conclusions: Results demonstrated the ability to detect thermal radiation from small volumes (2-6 cm3) of BAT located up to 12 mm deep and to monitor small changes (0.5°C) in BAT metabolism. As such, the developed miniature radiometric antenna sensor appears suitable for non-invasive long term monitoring of BAT metabolism.

Imaging in neurological and vascular brain diseases (SPECT and SPECT/CT)

Since the first in vivo studies of cerebral function with radionuclides by Ingvar and Lassen, nuclear medicine (NM) brain applications have evolved dramatically, with marked improvements in both methods and tracers. Consequently it is now possible to assess not only cerebral blood flow and energy metabolism but also neurotransmission. Planar functional imaging was soon substituted by single-photon emission computed tomography (SPECT) and positron emission tomography (PET); it now has limited application in brain imaging, being reserved for the assessment of brain death.