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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.


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

0

0.151

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


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


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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


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.


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


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)


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).


AD IMAGING WITH FGD (UPTAKE PATTERN)

Dementia MRI FDG-PET Fusion

mMR Munich (TUM/LMU), funded by the DFG


BIOGRAPH MMR

AMYLOID IMAGING

Getting the full picture

Barthel,…, Sabri; Lancet Neurol (2011)


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.



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


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


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)


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.


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 !

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