The introduction of clinical Positron Emission Tomography (PET) in oncology in the 1990s has substantially changed the management of patients with cancer and become one of the diagnostic modalities with the fastest growth worldwide (Buck et al., 2010). The major hurdle delaying the proliferation of PET was partly due to its high initial investment and insufficient third-party reimbursement (Keppler & Conti, 2001). Hong Kong, a region with about half the economic strength of Germany, was able to sustain a higher ratio of PET-CT scanners than that of Germany. Through the study of the PET utilization in Hong Kong, this research is to (i) explore the factors contributing to this phenomenon; and (ii) find out if those factors are applicable to other developing countries. The key factors found contributed to a higher ratio of PET-CT scanners in Hong Kong were: 1) medical expertise in a regionally profound disease; 2) the direct payment culture which enables an economically efficient and a cost-effective operation; 3) the influx of patients from neighboring countries; and 4) the reputation of its medical services. Applying these factors, citizens in developing countries were able to have access to the latest and expensive medical technology.

L’imagerie en oncologie a fait des progrès considérables ces dernières années avec l’introduction du CT scan spiralé, de la résonance magnétique, de la mammographie digitalisée et du PET scan. Des combinaisons de différentes techniques ont vu le jour, telles que le PET/CT, et améliorent encore les possibilités de stadification de la maladie cancéreuse ainsi que le monitoring de son évolution dans le temps, et notamment sous traitement.Parallèlement, de grands progrès thérapeutiques ont étés réalisés en oncologie, en particulier le développement de médicaments « ciblés » dont l’efficacité dépend de l’expression par la cellule tumorale d’une molécule cible jouant un rôle important dans sa survie et/ou sa prolifération. L’expression de la molécule cible est une condition nécessaire mais pas suffisante pour observer une réponse au traitement ciblé :l’échec de ce dernier peut aussi s’expliquer par des altérations moléculaires en amont ou en aval de la « cible ».Le cancer du sein dit « HER2 positif » représente 20 à 25% des cancers du sein. Celui-ci est caractérisé par l’expression membranaire, en quantités importantes, d’une protéine, appelée HER2, qui lui confère une biologie agressive et un mauvais pronostic. L’expression de HER2 au niveau de la tumeur, déterminée en routine clinique par immunohistochimie et/ou par hybridation in situ en fluorescence, est le seul biomarqueur validé aujourd’hui dans le cancer du sein HER2 positif pour prédire l’efficacité des traitements ciblés anti-HER2. Cette prédiction est toutefois peu satisfaisante en termes de valeur prédictive positive (50% environ). Après une revue de la litérature sur les études d’imagerie fonctionnelle, peu nombreuses, réalisées dans le cancer du sein HER2 positif, nous avons décidé d’explorer le rôle de l’imagerie moléculaire avec la technologie PET/CT dans l’individualisation de la prise en charge du cancer du sein HER2 positif avec deux radio traceurs (FDG et zirconium89-trastuzumab), et ce, dans deux contextes cliniques distincts :dans la maladie précoce soumise à un traitement neoadjuvant et dans le contexte métastatique, en cas de traitement par le T-DM1. / Doctorat en Sciences médicales (Médecine) / info:eu-repo/semantics/nonPublished

For classical and intensity modulated radiation therapy of deep-seated tumors, high-energy photons are the optimal radiation modality from an integral dose point of view. By using narrow scanned beams the treatment outcome can be improved substantially by delivering biologically optimized intensity modulated distributions often with sharp dose gradients. This requires using photons with energies well above 15 MV enabling verification of the treatment delivery in vivo by PET/CT imaging in a manner not previously possible. This new technique is based on the production of positron emitting radionuclides when the incoming high-energy photons interact through photonuclear reactions with the body tissues. The produced radionuclides, commonly 11C, 15O and 13N can then be monitored by PET and the distribution of activated nuclei show exactly where the radiation has penetrated the patient. In the subcutaneous fat, present in all humans, a high induced activity produces a perfect visualization of the location and even the intensity modulation of the incident beams. The reason for this is the high carbon content in combination with a low biological perfusion in fat tissues. Errors in the patient positioning such as setup errors or misplacement of the beams will thus show up in the PET images as a deviation from the actual radiation treatment plan. Interestingly, the imaged activity distribution from the subcutaneous fat also visualizes how the dose delivery can be deformed when the patient is erroneously positioned on the treatment couch as seen on the cover figure. Furthermore, the different half-lives of the produced radionuclides (20 min, 2 min, and 10 min, for 11C, 15O and 13N, respectively) allows for analysis of the dynamic behavior of tissue activity with the possibility of retrieving information such as tissue composition, biological and physical half-lives. The present thesis shows that considerable clinical information regarding the treatment delivery with high-energy photon beams can be obtained using PET/CT imaging. Although the study is based on the use of 50 MV photons the method may apply for beams with energies &gt; 20 MV at higher doses. / <p>At the time of the doctoral defense, the following papers were unpublished and had a status as follows: Paper 2: Submitted. Paper 3: Submitted. Paper: Manuscript.</p>

A study was done at Steve Biko Academic hospital to determine the influence that respiratory gating will have on target volumes used in radiotherapy treatment planning. The primary objective was to compare target volumes of respiratory gated scans to ungated scans and to determine whether it will be meaningful to permanently implement a 4D respiratory gating system on CT scanners in the South African public health sector and to use these images for target volume delineation in radiotherapy planning. The study consisted of three sections. In the first section, 4D respiratory gated CT images were obtained and delineated with 4D software. The full-inspiration and full-expiration phases of the gated scans were then fused to obtain ungated images which were also delineated. The gross tumor volumes (GTVs) of the gated phases were compared to the ungated GTVs, and found that on average the volumes decreased by 14.63% with a standard deviation of 7.96% when gating was applied. Yet another aim was to determine the influence that 4D imaging will have on radiotherapy treatment planning. One of the 4D study sets was imported to the XIO treatment planning system where IMRT treatment plans were created on both the gated and ungated scans. The plans conformed to the treatment aims and restrictions when clinical parameters such as DVHs were used to evaluate it. The planned target volume coverage differed by less than 1% between the gated and the ungated plans, but significant dose reductions to the OARs of up to 32.65% to the contralateral lung were recorded on the gated plan. In the second section of this study, respiratory gated CT scans were simulated by applying the breath-hold technique to lung cancer patients. The technique was applied during full-inspiration which fundamentally represents the maximum peak of the sinusoidal respiratory waveform. An ungated scan was also acquired during normal respiration. The clinical target volumes (CTVs) were identified on both scans by three oncologists and the average CTVs were compared. It was found that the CTVs decreased significantly by an average of 14.33%. Palliative patients receive parallel opposing field therapy which is planned from 2D films. It is very unlikely that these opposing field sizes will differ when gating is applied. It was therefore concluded that only radical lung patients, which was estimated to be a mere 0.03% of the total radiation therapy patient population, will benefit by implementing respiratory gating or any motion-reduction technique. For the third section of the study, respiratory gated PET scans were acquired on a PET/CT scanner to evaluate external, non-technical parameters that will influence respiratory gating. The results indicated that time and patient participation were not limiting factors. The biggest concerns however were the effectiveness of the gating system, software limitations and the gated results. These problems might be minimized with thorough training on the system. All three sections as well as the financial implications were considered to conclude that it will not be meaningful to implement 4D respiratory gating techniques in the South African public health sector Copyright / Dissertation (MSc)--University of Pretoria, 2013. / Medical Oncology / unrestricted

No description available.

Introduction: Despite the relatively low dose (0.5 mSv – 1 mSv) generated by Attenuation Correction CT (ACCT) in PET examinations, the ALARA principle is still applicable. The currently used ACCT standard protocol at the Karolinska University Hospital in Solna uses 7.6 effective mAs (mAseff) and 120 kVp, but reducing mAseff and/or kVp would decrease patient dose as well as facilitate an increased number of research subjects. A CT reconstruction algorithm called Quantification Achieved Consistently (Q.AC.) (Lonn, 2012) has recently been developed to enable reduced doses from ACCT, while preserving quantitative PET data. The purposes of this study were to investigate possible limitations of the Q.AC. with respect to patient size, and to optimise protocols, aiming at minimising ACCT dose in terms of Volumetric Computer Tomography Dose Index CTDIvol. Methods: Measurements were performed with a GE PET/CT Discovery system, which offers Q.AC. reconstruction. The NEMA NU-2 protocol was followed to quantify PET quality, including evaluations of relative count error in the artificial lung in the phantom centre (lung), hot- and cold-sphere contrast (Q), and background variability (N). Two phantoms were used; the NEMA body phantom (elliptical cross section sized 30 cm laterally and 23 cm anterior-posterior (AP)), here representing paediatric patients and small-sized adults, and the same phantom with an additional (20 cm laterally and 4 cm AP) ellipsoid plastic (PMMA) extension ring, representing mid- and large-sized patients. ACCTs were acquired with 15 mAseff values, range [2.3 - 260], in combination with four kVp values [80, 100, 120, 140] and reconstructed with two algorithms (Q.AC. and a regular soft CT algorithm). Consequently, PET reconstructions were performed based on each mAseff, kVp and CT-reconstruction combination. Results: Quantitatively similar PET results to the standard protocol were achieved with the Q.AC. CT reconstruction algorithm using a CTDIvol = 0.06 mGy (2.3 mAseff and 80 kVp) for the NEMA body phantom, respectively a CTDIvol = 0.20 mGy (2.3 mAseff and 120 kVp) for the phantom with additional extension ring. Conclusions: This study indicates that the Q.AC. CT reconstruction algorithm enables accurate PET results at lower ACCT mAseff and kVp settings than the currently used clinical standard protocol. For paediatric patients and small-sized adults, a reduction of CTDIvol by approximately 90% may be achieved, while for mid- and large-sized patients, the CTDIvol can be reduced by approximately 70% without loss of quantitative PET data.

京都大学 / 0048 / 新制・課程博士 / 博士(医学) / 甲第22739号 / 医博第4657号 / 新制||医||1046(附属図書館) / 京都大学大学院医学研究科医学専攻 / (主査)教授 武藤 学, 教授 佐藤 俊哉, 教授 椛島 健治 / 学位規則第4条第1項該当 / Doctor of Medical Science / Kyoto University / DGAM

[18F]Fluorodeoxyglucose ([18F]FDG) Positron Emission Tomography/Computed Tomography (PET/CT) imaging is a powerful tool in the diagnosis of cancer and subsequent treatment planning. New state-of-the-art PET/CT scanners have the capacity to generate images of superb quality. The new scanners feature detectors with increased sensitivity and a new generation of reconstruction algorithms that produce higher quality images than the scanners they are replacing. In addition to the scanner, the scan duration, amount of administered [18F]FDG activity, and the anatomy of the patients themselves are also determining factors of image quality. There is evidence suggesting that [18F]FDG PET image quality is significantly reduced for larger patients, jeopardizing lesion detection. Two possible solutions to this problem are to (i) increase injected activity or (ii) increase scan duration. Increasing scan duration is preferable but not always possible in a busy clinic. Increasing injected activity is necessary but a proper scaling regimen with patient size must be determined in order to achieve consistent image quality. The aim of the work presented in this thesis was to achieve higher quantification accuracy and consistent image quality for all patients scanned with [18F]FDG PET. Because quantitative PET/CT images require corrections for image degrading effects, for which attenuation correction is the main contributor and is performed based on CT images, the first step in this project was to develop software tools to automate the analysis of phantom images for CT quality assurance. The next step was to optimize the reconstruction parameters for whole body [18F]FDG PET based on a phantom experiment. Finally, a retrospective study was conducted using patient [18F]FDG PET images to characterize the relationship between patient anatomical characteristics and image quality. This work concludes by suggesting optimized reconstruction parameters and a scaling regimen for injected [18F]FDG activity. With the implementation of these recommendations it can be possible to obtain images with increased quantitative value while delivering less dose to patients and maintaining a uniform level of image quality between different patients. / Graduate

Im Rahmen dieser Arbeit wurde ein Algorithmus zur semiautomatischen Detektion von pathologischen, skelettalen Mehranreicherungen in der 18F-FDG-PET entwickelt, der gleichzeitig als Grundlage für die Ermittlung des metabolischen, skelettalen Tumorvolumens diente. Hierzu wurden PET/CT-Datensätze von Kindern und Jugendlichen, die an einem Hodgkin-Lymphom erkrankt waren und im Zeitraum von 2007 bis 2013 in der EuroNet-PHL-C1-Studie behandelt wurden, analysiert. Bei 142 Kindern war im Rahmen einer zentralen Referenzbeurteilung im PET/CT ein Skelettbefall diagnostiziert und dokumentiert worden. Auf dieser Basis (Goldstandard) erfolgte die Testung verschiedenster Methoden, von denen sich die nachfolgende als die am besten geeignete erwies: Als Referenzregion zur Bestimmung eines physiologischen Stoffwechselniveaus im Skelett (SUVmean) wurde eine 15 bis 30 ml große VOI in einem nach visueller Einschätzung nicht tumorbefallenen Wirbelkörper (meist LWK 4) platziert. Auf Grundlage des damit ermittelten physiologischen Skelettstoffwechselniveaus identifizierte das Suchprogramm skelettale Läsionen, sofern diese einen SUV > (SUVmean + 2,5 SD) aufwiesen. Dieser in das Programm implementierte Algorithmus wurde an den PET/CT-Datensätzen der 142 Patienten mit visuell detektiertem Skelettbefall validiert. Dabei wurde ein Skelettbefall bei 130 von 142 Patienten (Sensitivität auf Patientenebene von 91,5 Prozent) programmbasiert korrekt diagnostiziert. Von 1015 visuell erfassten skelettalen Läsionen wurden 774 durch das Suchprogramm richtig erkannt (Sensitivität auf Regionenebene von 76,3 Prozent). Von 5375 nicht befallenen Regionen wurden 5137 korrekterweise auch nicht als Läsionen durch das Programm angezeigt (Spezifität auf Regionenebene von 95,6 Prozent). Das Ausmaß das Skelettbefalls in Form des metabolischen, skelettalen Tumorvolumens wurde mit dem ereignisfreien Überleben und dem Gesamtüberleben verglichen: Es ergab sich keine Korrelation. Die Arbeit umfasst 156 Seiten, 59 Abbildungen, 31 Tabellen und 96 Literaturangaben.

Ces travaux de thèse portent sur la proposition de stratégies de segmentation des tumeurs cancéreuses dans un contexte multimodal et multitemporel. La multimodalité fait référence au couplage de données TEP/TDM pour exploiter conjointement les deux sources d’information pour améliorer les performances de la segmentation. La multitemporalité fait référence à la disposition des images acquises à différents dates, ce qui limite une correspondance spatiale possible entre elles.Dans une première méthode, une structure arborescente est utilisée pour traiter et pour extraire des informations afin d’alimenter une segmentation par marche aléatoire. Un ensemble d'attributs est utilisé pour caractériser les nœuds de l'arbre, puis le filtrer et projeter des informations afin de créer une image vectorielle. Un marcheur aléatoire guidé par les données vectorielles provenant de l'arbre est utilisé pour étiqueter les voxels à des fins de segmentation.La deuxième méthode traite le problème de la multitemporalité en modifiant le paradigme de voxel à voxel par celui de nœud à nœud. Deux arbres sont alors modélisés à partir de la TEP et de la TDM avec injection de contraste pour comparer leurs nœuds par une différence entre leurs attributs et ainsi correspondre à ceux considérés comme similaires en supprimant ceux qui ne le sont pas.Dans une troisième méthode, qui est une extension de la première, l'arbre calculé à partir de l'image est directement utilisé pour mettre en œuvre l'algorithme développé. Une structure arborescente est construite sur la TEP, puis les données TDM sont projetées sur l’arbre en tant qu’informations contextuelles. Un algorithme de stabilité de nœud est appliqué afin de détecter et d'élaguer les nœuds instables. Des graines, extraites de la TEP, sont projetées dans l'arbre pour fournir des étiquettes (pour la tumeur et le fond) à ses nœuds correspondants et les propager au sein de la hiérarchie. Les régions évaluées comme incertaines sont soumises à une méthode de marche aléatoire vectorielle pour compléter l'étiquetage de l'arbre et finaliser la segmentation. / This work focuses on the proposition of cancerous tumor segmentation strategies in a multimodal and multitemporal context. Multimodal scope refers to coupling PET/CT data in order to jointly exploit both information sources with the purpose of improving segmentation performance. Multitemporal scope refers to the use of images acquired at different dates, which limits a possible spatial correspondence between them.In a first method, a tree is used to process and extract information dedicated to feed a random walker segmentation. A set of region-based attributes is used to characterize tree nodes, filter the tree and then project data into the image space for building a vectorial image. A random walker guided by vectorial tree data on image lattice is used to label voxels for segmentation.The second method is geared toward multitemporality problem by changing voxel-to-voxel for node-to-node paradigm. A tree structure is thus applied to model two hierarchical graphs from PET and contrast-enhanced CT, respectively, and compare attribute distances between their nodes to match those assumed similar whereas discarding the others.In a third method, namely an extension of the first one, the tree is directly involved as the data-structure for algorithm application. A tree structure is built on the PET image, and CT data is then projected onto the tree as contextual information. A node stability algorithm is applied to detect and prune unstable attribute nodes. PET-based seeds are projected into the tree to assign node seed labels (tumor and background) and propagate them by hierarchy. The uncertain nodes, with region-based attributes as descriptors, are involved in a vectorial random walker method to complete tree labeling and build the segmentation.