Clinical Implementation of Total-Body PET in China.

Total-body (TB) PET/CT is a groundbreaking tool that has brought about a revolution in both clinical application and scientific research. The transformative impact of TB PET/CT in the realms of clinical practice and scientific exploration has been steadily unfolding since its introduction in 2018, with implications for its implementation within the health care landscape of China. TB PET/CT's exceptional sensitivity enables the acquisition of high-quality images in significantly reduced time frames. Clinical applications have underscored its effectiveness across various scenarios, emphasizing the capacity to personalize dosage, scan duration, and image quality to optimize patient outcomes. TB PET/CT's ability to perform dynamic scans with high temporal and spatial resolution and to perform parametric imaging facilitates the exploration of radiotracer biodistribution and kinetic parameters throughout the body. The comprehensive TB coverage offers opportunities to study interconnections among organs, enhancing our understanding of human physiology and pathology. These insights have the potential to benefit applications requiring holistic TB assessments. The standard topics outlined in The Journal of Nuclear Medicine were used to categorized the reviewed articles into 3 sections: current clinical applications, scan protocol design, and advanced topics. This article delves into the bottleneck that impedes the full use of TB PET in China, accompanied by suggested solutions.

Performance and application of the total-body PET/CT scanner: a literature review.

BACKGROUND: The total-body positron emission tomography/computed tomography (PET/CT) system, with a long axial field of view, represents the state-of-the-art PET imaging technique. Recently, the total-body PET/CT system has been commercially available. The total-body PET/CT system enables high-resolution whole-body imaging, even under extreme conditions such as ultra-low dose, extremely fast imaging speed, delayed imaging more than 10 h after tracer injection, and total-body dynamic scan. The total-body PET/CT system provides a real-time picture of the tracers of all organs across the body, which not only helps to explain normal human physiological process, but also facilitates the comprehensive assessment of systemic diseases. In addition, the total-body PET/CT system may play critical roles in other medical fields, including cancer imaging, drug development and immunology. MAIN BODY: Therefore, it is of significance to summarize the existing studies of the total-body PET/CT systems and point out its future direction. This review collected research literatures from the PubMed database since the advent of commercially available total-body PET/CT systems to the present, and was divided into the following sections: Firstly, a brief introduction to the total-body PET/CT system was presented, followed by a summary of the literature on the performance evaluation of the total-body PET/CT. Then, the research and clinical applications of the total-body PET/CT were discussed. Fourthly, deep learning studies based on total-body PET imaging was reviewed. At last, the shortcomings of existing research and future directions for the total-body PET/CT were discussed. CONCLUSION: Due to its technical advantages, the total-body PET/CT system is bound to play a greater role in clinical practice in the future.

Performance of the Iterative OSEM and HYPER Algorithm for Total-body PET at SUVmax with a Low 18F-FDG Activity, a Short Acquisition Time and Small Lesions.

OBJECTIVE: The primary objective of this comparative investigation was to examine the qualitative attributes of image reconstructions utilizing two distinct algorithms, namely OSEM and HYPER Iterative, in total-body 18F- FDG PET/CT under various acquisition durations and injection activities. METHODS: An initial assessment was executed using a NEMA phantom to compare image quality engendered by OSEM and HYPER Iterative algorithms. Parameters such as BV, COV, and CRC were meticulously evaluated. Subsequently, a prospective cohort study was conducted on 50 patients, employing both reconstruction algorithms. The study was compartmentalized into distinct acquisition time and dosage groups. Lesions were further categorized into three size-based groups. Quantifiable metrics including SD of noise, SUVmax, SNR, and TBR were computed. Additionally, the differences in values, namely ΔSUVmax, ΔTBR, %ΔSUVmax, %ΔSD, and %ΔSNR, between OSEM and HYPER Iterative algorithms were also calculated. RESULTS: The HYPER Iterative algorithm showed reduced BV and COV compared to OSEM in the phantom study, with constant acquisition time. In the clinical study, lesion SUVmax, TBR, and SNR were significantly elevated in images reconstructed using the HYPER Iterative algorithm in comparison to those generated by OSEM (p < 0.001). Furthermore, an amplified increase in SUVmax was predominantly discernible in lesions with dimensions less than 10 mm. Metrics such as %ΔSNR and %ΔSD in HYPER Iterative exhibited improvements correlating with reduced acquisition times and dosages, wherein a more pronounced degree of enhancement was observable in both ΔSUVmax and ΔTBR. CONCLUSION: The HYPER Iterative algorithm significantly improves SUVmax and reduces noise level, with particular efficacy in lesions measuring ≤ 10 mm and under conditions of abbreviated acquisition times and lower dosages.

The efficacy of short acquisition time using 18F-FDG total-body PET/CT for the identification of pediatric epileptic foci.

BACKGROUND: 18F-FDG positron emission tomography (PET) plays a crucial part in the evaluation for pediatric epileptic patients prior to therapy. Short-term scanning holds significant importance, especially for pediatrics epileptic individuals who exhibited involuntary movements. The aim was to evaluate the effects of short acquisition time on image quality and lesion detectability in pediatric epileptic patients using total-body (TB) PET/CT. A total of 25 pediatric patients who underwent TB PET/CT using uEXPLORER scanner with an 18F-FDG administered dose of 3.7 MBq/kg and an acquisition time of 600 s were retrospectively enrolled. Short acquisition times (60 s, 150 and 300 s) were simulated by truncating PET data in list mode to reduce count density. Subjective image quality was scored on a 5-point scale. Regions of interest analysis of suspected epileptogenic zones (EZs), corresponding locations contralateral to EZs, and healthy cerebellar cortex were used to compare the semi-quantitative uptake indices of short-time images and then were compared with 600 s images. The comparison of EZs detectability based on time-dependent PET images was performed. RESULTS: Our study demonstrated that a short acquisition time of 150 s is sufficient to maintain subjective image quality and lesion significance. Statistical analysis revealed no significant difference in subjective PET image quality between imaging at 300 s and 150 s (P > 0.05). The overall impression scores of image quality and lesion conspicuity in G60s were both greater than 3 (overall quality, 3.21 ± 0.46; lesion conspicuity, 4.08 ± 0.74). As acquisition time decreased, the changes of SUVmax and SD in the cerebellar cortex gradually increased (P < 0.01). There was no significant difference in asymmetry index (AI) difference between the groups and the AIs of EZs were > 15% in all groups. In 26 EZs of 25 patients, the lesion detection rate was still 100% when the time was reduced to 60 s. CONCLUSIONS: This study proposed that TB PET/CT acquisition time could be reduced to 60 s with acceptable lesion detectability. Furthermore, it was suggested that a 150 s acquisition time would be sufficient to achieve diagnostic performance and image quality for children with epilepsy.

Metabolic interactions between organs in overweight and obesity using total-body positron emission tomography.

BACKGROUND AND OBJECTIVES: Overweight and obesity is a complex condition resulting from unbalanced energy homeostasis among various organs. However, systemic abnormalities in overweight and obese people are seldom explored in vivo by metabolic imaging techniques. The aim of this study was to determine metabolic abnormities throughout the body in overweight and obese adults using total-body positron emission tomography (PET) glucose uptake imaging. METHODS: Thirty normal weight subjects [body mass index (BMI) < 25 kg/m2, 55.47 ± 13.94 years, 16 men and 14 women], and 26 overweight and obese subjects [BMI ≥ 25 kg/m2, 52.38 ± 9.52 years, 21 men and 5 women] received whole-body 18F-fluorodeoxyglucose PET imaging using the uEXPLORER. Whole-body standardized uptake value normalized by lean body mass (SUL) images were calculated. Metabolic networks were constructed based on the whole-body SUL images using covariance network approach. Both group-level and individual-level network differences between normal weight and overweight/obese subjects were evaluated. Correlation analysis was conducted between network properties and BMI for the overweight/obese subjects. RESULTS: Compared with normal weight subjects, overweight/obese subjects exhibited altered network connectivity strength in four network nodes, namely the pancreas (p = 0.033), spleen (p = 0.021), visceral adipose tissue (VAT) (p = 1.12 × 10-5) and bone (p = 0.021). Network deviations of overweight/obese subjects from the normal weight were positively correlated with BMI (r = 0.718, p = 3.64 × 10-5). In addition, overweight/obese subjects experienced altered connections between organs, and some of the altered connections, including pancreas-right lung and VAT-bilateral lung connections were significantly correlated with BMI. CONCLUSION: Overweight/obese individuals exhibit metabolic alterations in organ level, and altered metabolic interactions at the systemic level. The proposed approach using total-body PET imaging can reveal individual metabolic variability and metabolic deviations between organs, which would open up a new path for understanding metabolic alterations in overweight and obesity.

Investigation of the quarter-dose 18 F-FDG total-body PET in routine clinical practice and its clinical value.

OBJECTIVE: The purpose of the study was to evaluate the routine clinical application of total-body PET with quarter-dose 18 F-FDG. METHODS: The contrast recovery coefficient (CRC) and coefficient of variation (COV) were evaluated among full-, half-, and quarter-dose groups with an acquisition duration of 10-, 5-, 3-, and 1-min in the NEMA (IQ) phantom test. Fifty patients undergoing total-body PET/CT with quarter-dose (0.925MBq/kg) of 18 F-FDG were included in the prospective study. The acquisition time was 10 min, divided into duration groups of 5-, 3-, and 1-min, referred to as G10, G5, G3, and G1. Visual scores were assessed based on overall visual assessment, noise scoring, and lesion conspicuity. Lesion SUV max and TBR were evaluated in semi-quantitative analysis. G10 was used as the gold reference to evaluate lesion detectability. RESULTS: In the phantom study, the COV value of the images with quarter-dose 18 F-FDG and 10-min acquisition time was 11.52%. For spheres with 10 mm diameter, the CRC of quarter-dose PET images was relatively stable compared to that of full-dose groups with all acquisition durations. In the human study, the visual score in G10, G5, and G3 was significantly higher than that in G1. The differences in lesion SUV max and TBR for G1-G10 were significantly higher than that for G5-G10 and G3-G10. All lesions in G10 could be identified in G5 and G3. CONCLUSION: The phantom and human findings demonstrated the feasibility of quarter-dose 18 F-FDG PET with 3-min acquisition time, which can maintain image quality with reduced radiation dose.

Rabbit systemic glucose metabolism map by total-body dynamic PET/CT technology.

BACKGROUND: This study evaluated total-body glucose metabolism in a preclinical lab animal, the rabbit, by employing a dynamic glucose metabolic image obtained with total-body fluorine-18 fluorodeoxyglucose ( 18 F-FDG) PET/computed tomography (PET/CT). METHODS: The dynamic total-body PET/CT system was used to obtain glucose metabolic imaging from 10 sedated body-matched rabbits. The standard uptake value (SUV) of 18 F-FDG was used to evaluate glucose metabolism. In addition, the correlation between glucose metabolism and sexes was assessed, as well as metabolic differences between left- and right sides. RESULTS: We found significant distribution heterogeneity of glucose in several organs across the entire body. There were no significant metabolic differences between sexes and between bilateral sides in the 10 rabbits. Thereafter, we assayed the major organ SUV changes by dynamic PET/CT of the major organs. The heart, liver, and urinary system showed more 18 F-FDG, whereas the skeletal muscle, brain, spinal cord, and lungs incorporated less 18 F-FDG. The phenotype of 18 F-FDG uptake was highly correlated with the physiological functions. The 18 F-FDG accumulation in urinary system were observed which could reflect the renal parenchyma glucose metabolism indirectly. However, the low 18 F-FDG uptake in the brain and spinal cord was due to sedation. CONCLUSION: The total-body glucose metabolic atlas depicted with 18 F-FDG dynamic PET/CT may be used as a reference for assessing pathological 18 F-FDG uptake. Furthermore, this study could be a reference for preclinical research involving abnormality of glucose metabolism.

The feasibility of quantitative assessment of dynamic 18F-fluorodeoxyglucose PET in Takayasu's arteritis: a pilot study.

PURPOSE: PET has been demonstrated to be sensitive for detecting active inflammation in Takayasu's arteritis (TAK) patients, but semi-quantitative-based assessment may be susceptible to various biological and technical factors. Absolute quantification via dynamic PET (dPET) may provide a more reliable and quantitative assessment of TAK-active arteries. The purpose of this study was to investigate the feasibility and efficacy of dPET in quantifying TAK-active arteries compared to static PET. MATERIALS AND METHODS: This prospective study enrolled 10 TAK-active patients (fulfilled the NIH criteria) and 5 control participants from March to October 2022. One-hour dPET scan (all TAK and control participants) and delayed static PET scan at 2-h (all TAK patients) were acquired. For 1-h static PET, summed images from 50 to 60 min of the dPET were extracted. PET parameters derived from 1- and 2-h static PET including SUV (SUV1H and SUV2H), target-to-background ratio (TBR) (TBR1H and TBR2H), net influx rate (Ki), and TBRKi extracted from dPET were obtained. The detectability of TAK-active arteries was compared among different scanning methods using the generalized estimating equation (GEE) with a logistic regression with repeated measures, and the GEE with gamma distribution and log link function was used to evaluate the different study groups or scanning methods. RESULTS: Based on the disease states, 5 cases of TAK were classified as untreated and relapsed, respectively. The SUVmax on 2-h PET was higher than that on 1-h PET in the untreated patients (P < 0.05). However, no significant differences were observed in the median SUVmax between 1-h PET and 2-h PET in the relapsed patients (P > 0.05). The TBRKi was significantly higher than both TBR1H and TBR2H (all P < 0.001). Moreover, the detectability of TAK-active arteries by dPET-derived Ki was significantly higher than 1-h and 2-h PET (all P < 0.001). Significant differences were observed in Kimax, SUVmax-1H, TBR1H, and TBRKi among untreated, relapsed, and control groups (all P < 0.05). CONCLUSIONS: Absolute quantitative assessment by dPET provides an improved sensitivity and detectability in both visualization and quantification of TAK-active arteries. This elucidates the clinical significance of dPET in the early detection of active inflammation and monitoring recurrence.

Glucose uptake and distribution across the human skeleton using state-of-the-art total-body PET/CT.

A growing number of studies have demonstrated that the skeleton is an endocrine organ that is involved in glucose metabolism and plays a significant role in human glucose homeostasis. However, there is still a limited understanding of the in vivo glucose uptake and distribution across the human skeleton. To address this issue, we aimed to elucidate the detailed profile of glucose uptake across the skeleton using a total-body positron emission tomography (PET) scanner. A total of 41 healthy participants were recruited. Two of them received a 1-hour dynamic total-body 18F-fluorodeoxyglucose (18F-FDG) PET scan, and all of them received a 10-minute static total-body 18F-FDG PET scan. The net influx rate (Ki) and standardized uptake value normalized by lean body mass (SUL) were calculated as indicators of glucose uptake from the dynamic and static PET data, respectively. The results showed that the vertebrae, hip bone and skull had relatively high Ki and SUL values compared with metabolic organs such as the liver. Both the Ki and SUL were higher in the epiphyseal, metaphyseal and cortical regions of long bones. Moreover, trends associated with age and overweight with glucose uptake (SULmax and SULmean) in bones were uncovered. Overall, these results indicate that the skeleton is a site with significant glucose uptake, and skeletal glucose uptake can be affected by age and dysregulated metabolism.

Role of breath-hold lung PET in stage IA pulmonary adenocarcinoma.

BACKGROUND: Respiratory motion during PET acquisition may result in image blurring and resolution loss, reduced measurement of radiotracer uptake, and consequently, inaccurate lesion quantification and description. With the introduction of the total-body PET system, short-time PET acquisition is feasible due to its high sensitivity and spatial resolution. The purpose of this study was to evaluate the additional value of 20-s breath-hold (BH) lung PET in patients with stage IA pulmonary adenocarcinoma. METHODS: Forty-seven patients with confirmed stage IA pulmonary adenocarcinoma were enrolled in this retrospective study. All patients underwent a 300-s FB whole-body PET, followed by a BH lung PET. The SUVmax, TBR of the lesions and the percentage difference in nodule SUVmax (%ΔSUVmax) and TBR (%ΔTBR) between the two acquisitions was also calculated. The lesions were further divided by distance from pleura for subgroup analysis. The lesion detectability on PET images was the percentage of FDG-positive lesions. RESULTS: Among 47 patients, the BH lung PET images identified all lung nodules, and there was a significant difference in overall nodule SUVmax and TBR between BH PET and FB PET (both p < 0.01). The %ΔSUVmax and %ΔTBR were significantly higher in nodules adjacent to pleura (≤ 10 mm in distance) than those away from pleura (both p < 0.05). The lesion detectability of BH lung PET was significantly higher than that of FB PET (p < 0.01). CONCLUSION: BH PET acquisition is a practical way to minimize motion artifacts in PET which has the potential to improve lesion detection for stage IA pulmonary adenocarcinoma. CRITICAL RELEVANCE STATEMENT: BH PET acquisition is a practical way to minimize motion artifacts in PET which has the potential to improve lesion detection for stage IA pulmonary adenocarcinoma.

Expert consensus on oncological [18F]FDG total-body PET/CT imaging (version 1).

BACKGROUND: [18F]FDG imaging on total-body PET/CT (TB PET/CT) scanners, with improved sensitivity, offers new potentials for cancer diagnosis, staging, and radiation treatment planning. This consensus provides the protocols for clinical practices with a goal of paving the way for future studies with the total-body scanners in oncological [18F]FDG TB PET/CT imaging. METHODS: The consensus was summarized based on the published guidelines and peer-reviewed articles of TB PET/CT in the literature, along with the opinions of the experts from major research institutions with a total of 40,000 cases performed on the TB PET/CT scanners. RESULTS: This consensus describes the protocols for routine and dynamic [18F]FDG TB PET/CT scanning focusing on the reduction of imaging acquisition time and FDG injected activity, which may serve as a reference for research and clinic oncological PET/CT studies. CONCLUSION: This expert consensus focuses on the reduction of acquisition time and FDG injected activity with a TB PET/CT scanner, which may improve the patient throughput or reduce the radiation exposure in daily clinical oncologic imaging. KEY POINTS: • [18F]FDG-imaging protocols for oncological total-body PET/CT with reduced acquisition time or with different FDG activity levels have been summarized from multicenter studies. • Total-body PET/CT provides better image quality and improved diagnostic insights. • Clinical workflow and patient management have been improved.

Accurate total-body Ki parametric imaging with shortened dynamic 18 F-FDG PET scan durations via effective data processing.

BACKGROUND: Total-body dynamic positron emission tomography (dPET) imaging using 18 F-fluorodeoxyglucose (18 F-FDG) has received widespread attention in clinical oncology. However, the conventionally required scan duration of approximately 1 h seriously limits the application and promotion of this imaging technique. In this study, we investigated the possibility and feasibility of shortening the total-body dynamic scan duration to 30 min post-injection (PI) with the help of a novel Patlak data processing algorithm for accurate Ki estimations of tumor lesions. METHODS: Total-body dPET images acquired by uEXPLORER (United Imaging Healthcare Inc.) using 18 F-FDG of 15 patients with different tumor types were analyzed in this study. Dynamic images were reconstructed into 25 frames with a specific temporal dividing protocol for the scan data acquired 1 h PI. Patlak analysis-based Ki parametric imaging was conducted based on the imaging data corresponding to the first 30 min PI, during which a Patlak data processing method based on cubic Hermite interpolation was applied. The resultant Ki images acquired by 30 min dynamic PET data and the standard 1 h Ki images were compared in terms of visual imaging effect, region signal-to-noise ratio, and Ki estimation accuracy to evaluate the performance of the proposed Ki imaging method with a shortened scan duration. RESULTS: With the help of Patlak data processing, acceptable Ki parametric images were obtained from dynamic PET data acquired with a scan duration of 30 min PI. Compared with Ki images obtained from unprocessed Patlak data, the resulting images from the proposed method performed better in terms of noise reduction. Moreover, Bland-Altman plot and Pearson correlation coefficient analysis showed that that 30 min Ki images obtained from the processed Patlak data had higher accuracy for tumor lesions. CONCLUSION: Satisfactory Ki parametric images with high tumor accuracy can be acquired from dynamic imaging data corresponding to the first 30 min PI. Patlak data processing can help achieve higher Ki imaging quality and higher accuracy regarding tumor lesion Ki values. Clinically, it is possible to shorten the dynamic scan duration of 18 F-FDG PET to 30 min to acquire an accurate tumor Ki and further effective tumor detection with uEXPLORER scanners.

Total-body low-dose CT image denoising using a prior knowledge transfer technique with a contrastive regularization mechanism.

PURPOSE: Reducing the radiation exposure experienced by patients in total-body computed tomography (CT) imaging has attracted extensive attention in the medical imaging community. A low radiation dose may result in increased noise and artifacts that greatly affect the subsequent clinical diagnosis. To obtain high-quality total-body low-dose CT (LDCT) images, previous deep learning-based research works developed various network architectures. However, most of these methods only employ normal-dose CT (NDCT) images as ground truths to guide the training process of the constructed denoising network. As a result of this simple restriction, the reconstructed images tend to lose favorable image details and easily generate oversmoothed textures. This study explores how to better utilize the information contained in the feature spaces of NDCT images to guide the LDCT image reconstruction process and achieve high-quality results. METHODS: We propose a novel intratask knowledge transfer (KT) method that leverages the knowledge distilled from NDCT images as an auxiliary component of the LDCT image reconstruction process. Our proposed architecture is named the teacher-student consistency network (TSC-Net), which consists of teacher and student networks with identical architectures. By employing the designed KT loss, the student network is encouraged to emulate the teacher network in the representation space and gain robust prior content. In addition, to further exploit the information contained in CT scans, a contrastive regularization mechanism (CRM) built upon contrastive learning is introduced. The CRM aims to minimize and maximize the L2 distances from the predicted CT images to the NDCT samples and to the LDCT samples in the latent space, respectively. Moreover, based on attention and the deformable convolution approach, we design a dynamic enhancement module (DEM) to improve the network capability to transform input information flows. RESULTS: By conducting ablation studies, we prove the effectiveness of the proposed KT loss, CRM, and DEM. Extensive experimental results demonstrate that the TSC-Net outperforms the state-of-the-art methods in both quantitative and qualitative evaluations. Additionally, the excellent results obtained for clinical readings also prove that our proposed method can reconstruct high-quality CT images for clinical applications. CONCLUSIONS: Based on the experimental results and clinical readings, the TSC-Net has better performance than other approaches. In our future work, we may explore the reconstruction of LDCT images by fusing the positron emission tomography (PET) and CT modalities to further improve the visual quality of the reconstructed CT images.

Recognizing Tumor Origin for Lymphoid Tumor of Unknown Primary via Total-Body PET/CT Scan-Case Report.

Localizing the site of tumor origin for patients with lymphoid tumor is fairly difficult before the definitive detection of the primary tumor, which causes redundant imaging examinations and medical costs. To circumvent this obstacle, the emergence of the world's first total-body positron emission tomography/computed tomography (PET/CT) provides a transformative platform for simultaneously static and dynamic human molecular imaging. Here, we reported a case of lymph node metastasis from an unknown primary tumor, and the primary tumor was detected with the aid of the total-body PET/CT scanner. This patient with right neck mass was subjected to static and dynamic PET scan, as the static PET imaging found irregular thickening of the upper rectal wall and the dynamic PET imaging recognized the associations between the lymph metastasis and the rectal tumor lesions. The diagnosis by the total-body PET/CT was confirmed by pathological examination.