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PET-RM: APLICACIONES CLÍNICAS
José Luis Carreras Delgado
17 Enero 2014
CURSO DE ACTUALIZACIÓN EN TOMOGRAFÍA POR EMISIÓN DE POSITRONES
16 y 17 de enero de 2014
SOCIEDADVALENCIANADE MEDICINANUCLEAR
SOCIEDADVALENCIANADE MEDICINANUCLEAR
Algunas de las imágenes que se van amostrar han sido facilitadas por Siemens
y General Electric. No existen en estapresentación ningún otro potencial conflicto
de intereses.
IMAGING SYSTEMS VARY IN SENSITIVITY &
TEMPORAL & SPATIAL RESOLUTION
Hybrid systems combine the properties of individual technologies
Anatomy
Biology
MRS
NM/PET
MRI
X Ray Angio
Ultrasound
X Ray
MSCT
Optical
MetabolismReceptors
Pump function
Perfusion
Gene expression
Signal transductionStem cell function
Nanosystems Protein dynamicsZeptomolar
Femtomolar
Picomolar
Micromolar
Millimolar
Nanomolar
Attomolar
~102 atoms/cell
~3x107 atoms/cell
~109 atoms/cell
Physiology
Biochemistry
fMRI
EL TRIANGULO DE LA IMAGEN
CONTRASTE/FUNCION(Capacidad de valorar las diferencias entre detalles)
RESOLUCION ESPACIAL(Capacidad de ver pequeños detalles)
RESOLUCION TEMPORAL/ VELOCIDAD(Capacidad de ver rápidas variaciones en el tiempo)
PETSPECT
MRI
CT US
PET-CT
© Gustav K. von Schulthess, Nuc. Medicine, University Hospital, Zurich, Switzerland
GG
CTSPECT
MRIPET
PHILIPSIngenuity TF
GE HealthcareTri-modality
SIEMENSBiograph mMR
GE Healthcare?????-TOF
Soluciones PET-RM de cuerpo entero
PET/RM RM/PET MRM
Imagen multimodalidad con adquisición simultánea y
procesado integrado
4 minutos por posición de bedMenos de 30 min para un PET/RM de cuerpo completo
© Siemens AG 2013. All rights reserved.
BIOGRAPH MMR
EXCELLENT IMAGE QUALITY…
… of PET
Largest PET FoV in industry*
Highest sensitivity in industry*
Highest spatial resolution in industry
(acc. NEMA)*
… of MR
3T magnet
Same gradient performance and
magnet homogeneity as our high-
end clinical MR scanners
Tim technology
*Based on competitive literature available at
time of publication. Data on File.
© Siemens AG 2013. All rights reserved.
BIOGRAPH MMR
ULTRA-LOW-DOSE EXAMS
Pediatric* dose burden:
Up to
80% reduced
dose relative to other
hybrid PET systems11Chawla et al.: Estimated cumulative radiation dose from PET/CT in children with malignancies: a 5-year retrospective study. Pediatr Radiol (2010)
*MR scanning has not been established as safe for imaging fetuses and infants under two years of age. The responsible
physician must evaluate the benefit of the MRI examination in comparison to other imaging procedures.
The statements by Siemens’ customers described herein are based on results that were achieved in the customer's unique setting. Since
there is no "typical" setting and many variables exist there can be no guarantee that other customers will achieve the same results.
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CORRECCIÓN DE ATENUACIÓN (CA) BASADA EN
RM: MÉTODO DIXON PARA SEPARACIÓN
GRASA/AGUA
TAC aporta Unidades Hounsfield fácilmente aplicable
a la CA
RM: diversos grupos Múnich: Segmentación en 4 tipos de tejidos
Aire Pulmón Grasa Agua (no considera hueso)
El método basado en segmentación es rápido y fiable.Ligero error (5 a 13%) para lesiones óseas
Martínez–Moeller A, Nekolla SG, et al. JNM 2009
EXPECTATIVAS – PET/RM
CA basada en método Dixon para referencia
anatómica
35 pacientesPara localización anatómica:No diferencias significativas en 81 lesiones PET positivas (p
0,19)
TAC superior para ganglios pequeños
Método Dixon aportó resultados favorables en tumores de
partes blandas como tumores de cabeza y cuello y mtx
hepáticas
Eiber M, Beer AJ et al. 2011 manuscript submitted
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cm-1
Dual-echo UTE (TE=0.07/2.46 ms, TA=3:20)
Attenuation correction factors derived from the CT
segmented (upper row) and MRsegmented (bottom row).
Reconstructed PET images with MR
and CT AC methods
CT corrected
MR correctedAC
MR AC data
CT segmented
MR AND CT ATTENUATION CORRECTION
MR segmented
Massachusetts General Hospital, Boston, USA
MRI-BASED PET MOTION CORRECTION
EPI-based motion estimates
Plots of motion estimates:
translations along (black) and
rotations about (gray) 3
orthogonal axes.
PET data reconstructed before
(left) and after (right) motion
correction. Substantial
improvement in image quality
is observed after correction.
Catana et al.: PET/MRI for Neurologic Applications; JNM 2012
© Siemens AG 2013. All rights reserved.
BIOGRAPH MMR
REDUCED MOTION EFFECTS
University Hospital, Tübingen, Germany
mMR
sequential
PARTIAL-VOLUME EFFECT (PVE) CORRECTION
Left to right
MRI image for automatic segmentation of brain structures; original PET;
correction factors calculated via geometric transfer matrix (segmented MRI and
original PET as input); original PET after application of recovery coefficients
Catana et al.: PET/MRI for Neurologic Applications; JNM 2012
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Cortex_left Cortex_right Thalamus
CaPuPa WM CSF
MPRAGE
BRAIN SEGMENTATION
TOF MRADynamic PET framesArterial input function and time activity curve
MR-ASSISTED DYNAMIC PET DATA ANALYSIS
Dynamic PET data collected
simultaneously with MR
MR angiography used to define arterial
input function (AIF)
Time activity curve (TAC) in structure of
interest is segmented from combined MR
and PET dataMassachusetts General Hospital, Boston, USA
RESULTADOS– SUV
Relación entre captación basada en ROI o en SUV en lesiones sospechosas
en PET–RM y PET–TAC
SUV comparables PET–RM y PET–TAC
Ratio más elevado en regiones prob
debido a acquisición más tardía de la PET–
RM
© Siemens AG 2013. All rights reserved.
BIOGRAPH MMR
CLINICAL EXPERIENCE AT KLINIKUM
RECHTS DER ISAR, MUNICH
Aim
“…to evaluate comparability of the
clinical performance between
conventional PET/CT and PET/MR...“
Method
32 patients
Oncological diagnoses
Single-injection exam
PET/CT followed by MR/PETConclusion
PET/MR is "feasible in a clinical setting with high quality and in a short examination time.“1
1Drzezga et al.: Integrated simultaneous whole-body MR/PET: First comparison between
MR/PET and PET/CT in patients. J Nucl Med (2012)
The statements by Siemens’ customers described herein are based on results that were
achieved in the customer's unique setting. Since there is no "typical" setting and many
variables exist there can be no guarantee that other customers will achieve the same results.
EXPECTATIVAS – PET/RM
Aplicaciones clínicasDiagnóstico temprano de enfermedadesDeterminación precisa de la extensiónMejora del proceso diagnóstico y flujo de trabajoDesarrollo de una medicina personalizada
InvestigaciónCompresión de los mecanismos de los procesos
fisiopatológicosApoyo a la investigación translacionalHerramienta para el desarrollo y validación de nuevos
fármacos
EXPECTATIVAS – PET/RM
Aplicaciones (Neurología)
Integración de RM y PET en tumores cerebrales y
enfermedades neurodegenerativas
Combinación de RM funcional con PET
Valoración simultánea de RM funcional y cinética
de trazadores (cuantificación vol sanguíneo, flujo,
etc)
Estudios de compartimentos y permeabilidad
(farmacología in vivo)
EXPECTATIVAS – PET/RM
Aplicaciones (Neurología)
Deterioro cognitivo y E. Alzheimer
Epilepsia del lóbulo temporal
Tumores cerebrales
NEUROIMAGEN CON PET/RM: MÚLTIPLES OPCIONES EN UNA
ÚNICA SESIÓN (1H)
Resting state connectivity BOLD–fMRI
Arterial Spin
Labelling
(ASL)
Spectroscopy
TOF–AngiographyVoxel–based morphometry
Diffusion–MRI(fibre–tracking)
BIOGRAPH MMR
CLINICAL CASE: 70-YEAR-OLD FEMALE, GLIOBLASTOMA
FETmMR Munich (TUM/LMU), funded by the DFG
DIFFERENT TRACERS FOR DIFFERENT
METABOLIC PROCESSES
sugar metabolism
hypoxia
cell proliferation
animo acid metabolism
(tyrosine)Catana et al.: PET/MRI for
Neurologic Applications; JNM 2012
MRI aloneMR+ [11C] MET-PET
MRI with Spectroscopy
MR and MRS indicates high-grade lesion in the right hemisphere (glioma)
[11C]* MET-PET reveals additional pathologic cell growth in the left hemisphere
Combined MR and PET provided critical biopsy guidance
THE POWER OF MR AND PET
COMBINED
UKT, Tübingen, Germany
PET-RM con 68Ga-DOTATOC en paciente con meningioma
68Ga-DOTATATE
Institute of Medical Physics (IMP) and University Hospital,
Erlangen, Germany
THERAPY PLANNING IN CASE OF
RECURRENT MENINGEOMA
AD IMAGING WITH FGD (UPTAKE PATTERN)
mMR study in Alzheimer
disease patient
(Top) Axial 18F-FDG PET,
high-resolution MRI, and
fusion image. Areas with
reduced metabolism (green)
representing impaired
neuronal function are visible
in left temporo-parietal
cortex.
(Middle and bottom) Surface
projections of cerebral
metabolism and of z score
images (comparison with
controls).
Catana et al.: PET/MRI for Neurologic Applications; JNM 2012
AD IMAGING WITH FGD (UPTAKE PATTERN)
Dementia MRI FDG-PET Fusion
mMR Munich (TUM/LMU), funded by the DFG
© Siemens AG 2013. All rights reserved.
BIOGRAPH MMR
AMYLOID IMAGING
Getting the full picture
Barthel,…, Sabri; Lancet Neurol (2011)
© Siemens AG 2013. All rights reserved.
EPILEPSY
mMR study in epilepsy patient. From left to right are shown axial FDG PET
(60–75 min after injection), high-resolution MRI, and fusion image. Distinct
hypometabolism is visible in polar region of left temporal lobe, typically
corresponding to epileptogenic focus.
Catana et al.: PET/MRI for Neurologic Applications; JNM 2012
EXPECTATIVAS – PET/RM
Aplicaciones (Cardiología)
No hay aplicaciones clínicas inmediatas
Integración de RM con PET para validación cruzada de
mediciones fisiológicas (ej. perfusión)
Combinación de RM y PET para viabilidad de tejidos
Imagen vascular para la detección de placas
vulnerables usando señales moleculares
Imagen estructural y molecular para establecer el
fenotipo del fallo cardiaco y el remodelado
© Siemens AG 2013. All rights reserved.
BIOGRAPH MMR
TEMPORAL CO-REGISTRATION
Simultaneously gated PET and cardiac MR images
PET data acquired in list mode and binned retrospectively
MRI acquired in diastole, fused with diastolic PET data
Cardiac one-stop shop
Mallinckrodt Institute of Radiology, Washington University, St. Louis, USA
EXPECTATIVAS – PET/RM
Aplicaciones (Oncología)
Mejora del proceso diagnóstico y flujo de
trabajo
Estadificación con menor exposición a
radiaciones (pediatría)
Combinación de RM y PET para tumores de
cabeza y cuello, mama y próstata
Evaluación de la respuesta usando las señales
de la RM y PET
Imagen estructural, funcional y molecular para
establecer el fenotipo del tumor
MRM: PRIMERAS EXPERIENCIAS CON PET–RM
SIMULTÁNEO
PET positivo / RM negativo (grasa parda)
Mejor contraste de tejidos blandos de RM comparado a TAC en cabeza y cuello
Menos artefactos por implantes dentales
Potencial para combinar DCE–RM y DWI con PET
Mejor definición de: Lesiones hepáticas Lesiones óseasPróstata
MRM: PRIMERAS EXPERIENCIAS CON PET–RM
SIMULTÁNEO
Estudio de la heterogeneidad tumoral: perfil de
biología tumoral, relacionando zonas actividad
metabólica y angiogénica, mediante estudios
cuantitativos para monitorizar el efecto de
intervenciones
BIOGRAPH MMR
ANATOMY, FUNCTION, AND
METABOLISM IN ONE EXAM
11 yo boy with T-cell
lymphoma; DWI and PET
provide the full picture
Hirsch et al.: PET/MR in children. Initial clinical experience in pediatric
oncology using an integrated PET/MR scanner. Pediatr Radiol (2013)
© Siemens AG 2013. All rights reserved.
BIOGRAPH MMR
CLINICAL EXPERIENCE AT UNIVERSITY
HOSPITAL TÜBINGEN
Conclusion
“MR/PET imaging of the lung is
feasible and provides diagnostic
image quality in the assessment
of pulmonary masses.”
“[…] simultaneous MR/PET
imaging offers an alternative
modality in thoracic imaging with
markedly reduced radiation
exposure: approximately 75%
reduction in dose“ compared to
other hybrid PET systems.11Schwenzer et al.: Pulmonary Lesion Assessment: Comparison of Whole-Body
Hybrid MR/PET and PET/CT Imaging – Pilot Study; Radiology (2012)
The statements by Siemens’ customers described herein are based on results that were achieved
in the customer's unique setting. Since there is no "typical" setting and many variables exist there
can be no guarantee that other customers will achieve the same results.
© Siemens AG 2013. All rights reserved.
BIOGRAPH MMR
EXCELLENT SPATIAL REGISTRATION
Center for Modern Diagnostics (CEMODI), Bremen, Germany
BIOGRAPH MMR
BEST PRACTICE FROM UNIVERSITY OF LEIPZIG
Conclusion:
“Clinical advantages of PET/MR in children* […] rest in the significantly greater value of MR over CT“
“Initial experience in children* suffering from multifocal, oncological diseases shows that a PET/MR examination […] provides all relevant information for paediatric surgeons and oncologists“
„PET/MR including whole-body diffusion demonstrates a new quality in imaging and functional diagnostics“1
1 Hirsch et al.: PET/MR in children. Initial clinical experience in
pediatric oncology using an integrated PET/MR scanner. Pediatr
Radiol (2013)
* MR scanning has not been established as safe for imaging fetuses and infants
under two years of age. The responsible physician must evaluate the benefit of the
MRI examination in comparison to other imaging procedures.
The statements by Siemens’ customers described herein are based on results that were achieved in the
customer's unique setting. Since there is no "typical" setting and many variables exist there can be no
guarantee that other customers will achieve the same results.
CONCLUSIONES Y PERSPECTIVAS
PET–RM multimodalidad (WB) es muy prometedora para aplicaciones clínicas e investigación cuando los protocolos hayan sido validados
Aplicaciones clínicas rutinarias: “dos en uno“ cuando RM y PET se harían de todas formas (ej glioblastoma, EA)
Ca próstata, lesiones hepáticas, Ca mama, TOD, SCCHN, oncología pediátrica
Integración de parámetros diagnósticos para incrementar la exactitud diag.
Aplicaciones de investigación: Valoración del fenotipo funcional y biológico de la enfermedad
Combinación de la imagen molecular y funcional para planificación de terapia
Desarrollo de fármacos y estudios fase 1/2, valoración temprana de respuesta
Formación: Se requiere amplia formación en RM y PET de todo el personal
Es necesario un nuevo curriculum para “especialistas en imagen molecular multimodalidad“ que incluya biología y física para la investigación académica
¡ Gracias por su atención !