SPECT/CT
Basics, Technology Updates,
Quality Assurance, and Applications
S. Cheenu Kappadath, PhD
Department of Imaging Physics
University of Texas M D Anderson Cancer Center, Houston, Texas
skappadath@mdanderson.org
Educational Objectives
1.
2.
3.
Understand the underlying principles of
SPECT/CT image acquisition, processing and
reconstruction
Understand current and future clinical
applications of SPECT/CT imaging
Familiarization with commercially-available
SPECT/CT systems
S. Cheenu Kappadath, PhD
AAPM 2009 - Anaheim, CA
Outline






Review of SPECT principles
Iterative SPECT reconstruction
Hybrid SPECT/CT imaging
SPECT/CT quality assurance
Commercial SPECT/CT systems
SPECT/CT clinical applications
S. Cheenu Kappadath, PhD
AAPM 2009 - Anaheim, CA
SPECT Basics

Single Photon Emission Computed Tomography





Radio-pharmaceutical administration – injected, ingested, or
inhaled
Bio-distribution of pharmaceutical – uptake time
Decay of radionuclide from within the patient – the source of
information
Gamma camera detects gamma rays and images (tomography)
the radio-pharmaceutical distribution within the patient – SPECT
Used for visualization of functional information based on the
specific radio-pharmaceutical uptake mechanism
S. Cheenu Kappadath, PhD
AAPM 2009 - Anaheim, CA
SPECT Hardware
Anatomy of a Gamma camera
1.
2.
3.
4.
5.
Collimator
Scintillation Detector
Photomultiplier Tubes
Position Circuitry
Data Analysis Computer
© U of British Columbia
S. Cheenu Kappadath, PhD
AAPM 2009 - Anaheim, CA
SPECT Back-Projection Model
g(s,) = f(x,y)
along an in-plane
line integral
© Bruyant, P. P., J Nucl Med 2002; 43:1343-1358
S. Cheenu Kappadath, PhD
AAPM 2009 - Anaheim, CA
Crystal Thickness

Thinner crystals   spatial resolution





interactions occur at a better defined depth
multiple interactions less likely
less light spread
 interaction likelihood for higher energy ’s
Thicker crystals   sensitivity



 interaction likelihood (esp. for higher E ’s)
 likelihood of multiple interactions
greater light spread   spatial resolution
S. Cheenu Kappadath, PhD
AAPM 2009 - Anaheim, CA
Spatial Resolution

Intrinsic Spatial and Energy Resolution



# of scintillation photons, N  Gamma-ray energy, E
Spatial Resolution = 100  /N  1/N  1/E
Energy Resolution = 100  FWHM/E  1/E
B
Le
H


Collimator Resolution
System Resolution
S. Cheenu Kappadath, PhD
D ( Le  H  B )
Rg 
Le
Rs2  Ri2  Rg2
Le
D
AAPM 2009 - Anaheim, CA
SPECT Acquisitions

SPECT acquires 2-D projections of a 3-D volume
© SPECT in the year 2000: Basic principles, JNMT 24:233, 2000
© Yale School of Medicine
S. Cheenu Kappadath, PhD
AAPM 2009 - Anaheim, CA
Radon transform angular
symmetry violated in SPECT
P()
Anterior View
S. Cheenu Kappadath, PhD
≠
P(+)
horizontally flipped Posterior
AAPM 2009 - Anaheim, CA
Radon transform angular
symmetry violated in SPECT


Why ?
Due to Differential Attenuation
L
b
a i
c I0
I(i+)
b
I(i)
I(i) = I0 e-a (L)dL
c
I(i+) = I0 e-a (L)dL

Other mediating factors:


S. Cheenu Kappadath, PhD
distance-dependent resolution
depth-dependent scatter
AAPM 2009 - Anaheim, CA
SPECT Acquisitions


SPECT projections acquired over 360°
Exception: Cardiac SPECT acquired over 180°

0°
0°

180°
S. Cheenu Kappadath, PhD
AAPM 2009 - Anaheim, CA
SPECT images have isotropic voxel size
2-D filter of projections  3-D post-reconstruction filter
No volume
smoothing
transverse
sagittal
coronal
Butterworth:
0.6 Nyquist,
10th order
S. Cheenu Kappadath, PhD
AAPM 2009 - Anaheim, CA
SPECT Filtered BackProjection

FBP based on ideal Radon inversion formula


SPECT imaging systems are neither angularly symmetric
nor shift-invariant


assumes a linear, shift-invariant system and angular symmetry of
projections
SPECT projection data affected by attenuation, scatter, and spatial
resolution that are all depth-or distance-dependent
Thus, FBP reconstruction cannot adequately model the
physics of SPECT
S. Cheenu Kappadath, PhD
AAPM 2009 - Anaheim, CA
Conventional SPECT Corrections
Attenuation: Chang post-processing algorithm
L(x,y,i)
I(x,y) = SPECT image w/o AC
I(x,y,i) = IAC(x,y).e-L(x,y,i)
IAC (x,y) = I(x,y) / {(1/M).i
e-L(x,y,i)};
I(x,y,i)
i
i = 1, M
IAC(x,y)
Scatter: Energy window subtraction
Lower
Scatter
Window
PhotoPeak
Window
Upper
Scatter
Window
STD in acrylic
20000
STD in air
Counts
P(x,y) = projections w/ scatter
PLE(x,y) = projection at lower energy
PHE(x,y) = projection at higher energy
PSC (x,y) = P(x,y) – kL.PLE(x,y) – kH.PHE(x,y)
Energy Spectrum of Sm-153
30000
STD in acrylic with
TEW Scatter
Correction
10000
0
25
50
75
100
125
150
Photon Energy [keV]
S. Cheenu Kappadath, PhD
AAPM 2009 - Anaheim, CA
Outline






Review of SPECT principles
Iterative SPECT reconstruction
Hybrid SPECT/CT imaging
SPECT/CT quality assurance
Commercial SPECT/CT systems
SPECT/CT clinical applications
S. Cheenu Kappadath, PhD
AAPM 2009 - Anaheim, CA
SPECT Iterative
Reconstruction
Maximum Likelihood-Expectation Maximization (ML-EM)
 Accounts for the statistical nature of SPECT
imaging
 Incorporates the system response p(b,d) –
the probability that a photon emitted from an
object voxel b is detected by projection pixel
d
voxel
b
detector
d
 p(b,d) captures…
1. Depth-dependent resolution
2. Position-dependent scatter
3. Depth-dependent attenuation
 Use a measured attenuation map along with models of scatter and
camera resolution to perform a far more accurate reconstruction
S. Cheenu Kappadath, PhD
AAPM 2009 - Anaheim, CA
SPECT Iterative Recon: Attenuation Modeling
b
along a line integral …
g(s,) = f(x,y) * pattn(x,y,s,)
pattn(x,y,s,) = probability due to attenuation
pattn(x,y,s,) = exp(-ab(x’,y’)x’,y’))
S. Cheenu Kappadath, PhD
a
AAPM 2009 - Anaheim, CA
SPECT Iterative Recon: System
Resolution Modeling
Distance-dependent
collimator
beam
________
Rs =  Ri2 + Rc2
r
Pencil Beam (FBP)
Intrinsic
Detector
Resolution
Ri
- iterative)
Fan Beam (2D
Cone Beam (3D iterative)
S. Cheenu Kappadath, PhD
AAPM 2009 - Anaheim, CA
SPECT Iterative Recon: Resolution Modeling
2D: g(s,) = f(x,y) * pres(x,y,s,)
3D: g(s,) = f(x,y,z) * pres(x,y,z,s,)
pres = probability due to resolution
“fan of acceptance” (2D fan beam model)
“cone of acceptance” (3D cone beam model)
S. Cheenu Kappadath, PhD
AAPM 2009 - Anaheim, CA
SPECT Imaging: Scatter

Scatter compensation occurs before attenuation





the photopeak window contains scatter
attenuation accounts for the removal of photopeak photons
Scatter contribution estimated as a weighted sum of one or more
adjacent energy window images, Ci(x,y,)
S(x,y,) = i ki × Ci(x,y,)
Subtract scatter prior to reconstruction
Pcorr(x,y,)  P(x,y,) - S(x,y,)
Incorporate scatter into forward projection
P(x,y,)  Pcorr(x,y,) + S(x,y,)
S. Cheenu Kappadath, PhD
SC techniques:
DEW
TEW
ESSE
AAPM 2009 - Anaheim, CA
SPECT Iterative
Reconstruction


True projection intensity =
sum of true voxel intensities
weighted by detection
probabilities
Forward Projection
True voxel intensity = sum
of true detector intensities
weighted by detection
probabilities
Back Projection
S. Cheenu Kappadath, PhD
B
y (d )    (b) p (b, d )
b 1
D
 (b)   y (d ) p (b, d )
d 1
AAPM 2009 - Anaheim, CA
Iterative Reconstruction
Flow Diagram
D
 (b ) 
[k ]
 [ k 1] (b ) 
d 1
y ( d ) p (b , d )
[k ]

 b '1 (b ') p (b ', d )
B
D
 p (b , d )
d 1
In clinical practice, the
stopping criteria is
number of iterations (a
time constraint) instead
of a convergence criteria.
S. Cheenu Kappadath, PhD
AAPM 2009 - Anaheim, CA
Ordered Subset EM (OSEM)




Each OSEM iteration is a ML-EM iteration using an ordered
subset of n (out of N) projections (eg: 4/36 views - 9
subsets, start with 0°,90°,180°,270° views)
The next OSEM iteration starts with the result of the
previous OSEM iterations but uses a different ordered
subset of n projections (next set uses 10°,100°,190°,280°
views)
 rate of convergence by using an ordered subset of all N
projections for each iteration
m OSEM iterations with n subsets each  mn ML-EM
iterations using all N each time
S. Cheenu Kappadath, PhD
AAPM 2009 - Anaheim, CA
OSEM Iterative SPECT Reconstruction:
Attenuation and Scatter Correction
Un-Corrected
Corrected
Note the “hot-rim” artifact
S. Cheenu Kappadath, PhD
AAPM 2009 - Anaheim, CA
OSEM Iterative SPECT Reconstruction:
Collimator Resolution Modeling
99mTc
Bone Scan (osteosarcoma), LEHR Collimator
Standard
Filtered
Backprojection
2-D OSEM
w/ fan beam
modeling
(m=12,n=10)
2-D pre-filter: Butterworth, fc = 0.6 Nyquist, order = 10
3-D OSEM
w/ cone beam
modeling
(m=25,n=10)
S. Cheenu Kappadath, PhD
3-D Gaussian Post-Filter (7.8 mm FWHM)
AAPM 2009 - Anaheim, CA
Outline






Review of SPECT principles
Iterative SPECT reconstruction
Hybrid SPECT/CT imaging
SPECT/CT quality assurance
Commercial SPECT/CT systems
SPECT/CT clinical applications
S. Cheenu Kappadath, PhD
AAPM 2009 - Anaheim, CA
SPECT/CT Hybrid Imaging:
Why?

Non-uniform attenuation maps required



Previous methods used constant  maps that
work for brain but are problematic for thorax and pelvis
radioactive source-based transmission CT – time penalty
Functional-anatomical overlay (image fusion)


Improve localization of uptake regions
Increase confidence in interpretation
S. Cheenu Kappadath, PhD
AAPM 2009 - Anaheim, CA
CT-based AC
for SPECT/CT
CT
CTAC
μ‐map
CT noise reduced
Smooth, re‐bin CT to match SPECT Register CT w/ SPECT
Apply bi‐linear transform on pixel‐by‐pixel basis
Reconstructed SPECT
Transition
Matrix
aijk
S. Cheenu Kappadath, PhD
Other factors: ‐SPECT projections
‐Scatter estimates
‐Collimator response
AAPM 2009 - Anaheim, CA
CT-based  values
Material attenuation versus Energy
Air
Muscle
Bone
Photoelectric effect
Compton scatter
dominant
dominant

0.3


(cm2/g)
0.2

0.1
CT

0
0
100
200
Energy
S. Cheenu Kappadath, PhD
300
400
m = k ¥ CT-HU
(simple but not accurate)
Compton Scatter probability
proportional to e- density
Photoelectric effect
probability proportional to
(Z/E)3
Attenuation mismatch
between PE and CS with
energy for high Z
500
(keV)
AAPM 2009 - Anaheim, CA
CT-based  values
- HU-to-cm-1 conversion
- not linearly related
- piece-wise linear
- bi- or tri-modal
- Effective energy differences
- CT (~ 70 – 80 keV)
- SPECT (nuclide dependent)
eg: 140 keV for Tc-99m
CT Number-to-Tc-99m  v alue Function
0.3
 value (cm-1)
0.25
0.2
0.15
0.1
0.05
1000
200
0
-1000
0
CT Number (HU)
S. Cheenu Kappadath, PhD
AAPM 2009 - Anaheim, CA
SPECT/CT Hybrid Imaging:
Iterative Reconstruction
FBP w/
Butterworth 0.4/5
99mTc
EC-DG (NSCLC)
3-D OSEM w/
resolution modeling
3-D OSEM w/
resolution and attenuation
modeling
S. Cheenu Kappadath, PhD
AAPM 2009 - Anaheim, CA
Outline






Review of SPECT principles
Iterative SPECT reconstruction
Hybrid SPECT/CT imaging
SPECT/CT quality assurance
Commercial SPECT/CT systems
SPECT/CT clinical applications
S. Cheenu Kappadath, PhD
AAPM 2009 - Anaheim, CA
SPECT/CT QA/QC

Planar (AAPM Reports 6 and 9; NEMA NU 1-1994)



SPECT (AAPM Report 22 and 52)



Inherently includes all planar gamma camera QA
Energy/Spatial resolution, uniformity, deadtime, sensitivity,
rotational uniformity, opposed-head registration, etc.
Uniformity and Contrast
Resolution
SPECT/CT (AAPM TG 177: Jim Halama)


NM-CT registration
CT-HU to linear attenuation () transformation
S. Cheenu Kappadath, PhD
AAPM 2009 - Anaheim, CA
NM-CT Registration

Use Co-57 button sources w/ SPECT phantom
S. Cheenu Kappadath, PhD
AAPM 2009 - Anaheim, CA
CT-HU to -map transformation

Use an electron density phantom
CIRS Inc.
CT image: -790 to 235 HU
S. Cheenu Kappadath, PhD
AAPM 2009 - Anaheim, CA
Outline






Review of SPECT principles
Iterative SPECT reconstruction
Hybrid SPECT/CT imaging
SPECT/CT quality assurance
Commercial SPECT/CT systems
SPECT/CT clinical applications
S. Cheenu Kappadath, PhD
AAPM 2009 - Anaheim, CA
Commercial SPECT/CT systems
Siemens SymbiaT
(1-, 2-, 6, 16-slice CT)
GE Hawkeye
(1- or 4-slice CT)
S. Cheenu Kappadath, PhD
Philips BrightView
(Flat-panel CT)
AAPM 2009 - Anaheim, CA
GE – Millennium VG Hawkeye

NM





3/8” and 1” NaI(Tl) crystals
16 simultaneous energy windows
Slip-ring gantry
Body-contouring based on infrared-based transmitters
CT





Co-planar, dental tube, 4-slice 20 mm beam
no additional real estate needed
Resolution: 3.5 or 1.75 mm (transaxial); 5 or 10 mm (axial)
Time-averaged: 23 s per rotation (slow-scan)
kVp: 120 – 140; mA: 1 – 2.5
S. Cheenu Kappadath, PhD
AAPM 2009 - Anaheim, CA
Phillips – BrightView XCT

NM





3/8” and ¾” NaI(Tl) crystals
Energy-independent flood calibration (up to 300 keV)
15 simultaneous energy windows
Body-contouring based on tissue impedance
CT





Co-planar, flat-panel detector, 14 cm axial FOV
no additional real estate needed
High-resolution: 0.33 mm isotropic voxels
Time-averaged: 12 s or 24 s per rotation (slow-scan)
kVp: 120; mA: 5 – 80
S. Cheenu Kappadath, PhD
AAPM 2009 - Anaheim, CA
Siemens - SymbiaT

NM





3/8” and 5/8” NaI(Tl) crystals
Energy-independent flood calibration (up to 300 keV)
6 simultaneous energy windows
Body-contouring based on infrared-based transmitters
CT




Diagnostic CT scanner
kVp: 80/110/130; mA: 20 – 345 (T16) & 30 – 240 (T6)
Scan time: 0.5, 0.6, 1, 1,5 s per rotation
1-, 2-, 6-, and 16-slice CT scanners
S. Cheenu Kappadath, PhD
AAPM 2009 - Anaheim, CA
Outline






Review of SPECT principles
Iterative SPECT reconstruction
Hybrid SPECT/CT imaging
SPECT/CT quality assurance
Commercial SPECT/CT systems
SPECT/CT clinical applications
S. Cheenu Kappadath, PhD
AAPM 2009 - Anaheim, CA
Clinical SPECT/CT Imaging

Stress/Rest Myocardial Perfusion Imaging









Stress: 99mTc-sestaMIBI or 99mTc-Tetrafosmin
Rest: 99mTc-labeled agents or 201Tl-chloride
99mTc-MDP:
bone diseases, bone metasteses
99mTc-sestaMIBI: parathyroid adenomas
99mTc-sulphur colloid: liver/spleen, lymphoscintigraphy
111In-Pentetreotide: neuroendocrine cancers
111In-ProstaScint: prostate cancer
123I/131I-MIBG: pheochromocytoma, neuroblastoma
131I-NaI: thyroid cancer
S. Cheenu Kappadath, PhD
AAPM 2009 - Anaheim, CA
Clinical SPECT/CT Imaging






99mTc-CEA:
colorectal cancer
99mTc-RBCs: hemangioma
99mTc-HMPAO, -ECD: brain perfusion
111In-WBC: infection
67Ga-citrate: inflammation, lymphoma
201Tl-chloride: tumor perfusion
S. Cheenu Kappadath, PhD
AAPM 2009 - Anaheim, CA
Clinical Benefits of SPECT/CT

Visualization, diagnosis and interpretation of
primary and metastatic diseases





higher sensitivity and contrast than Planar imaging
CT scan increases confidence in interpretation of
SPECT examination
Surgical planning and IMRT treatment planning
90Y-microspheres radio-embolotherapy (selective
internal RT or micro-brachytherapy)
Internal radio-pharmaceutical therapy planning
S. Cheenu Kappadath, PhD
AAPM 2009 - Anaheim, CA
SPECT/CT: Limitations

Patient motion



Contrast CT



between SPECT and CT scans
respiratory and cardiac motion during SPECT acquisitions
contrast introduces electron density-material mismatch
 map algorithms do not yet account for contrast CT
Absolute quantification (Bq/ml) not yet fully developed



radionuclide-dependent
acquisition/reconstruction technique-dependent
calibration techniques not yet standardized
S. Cheenu Kappadath, PhD
AAPM 2009 - Anaheim, CA
SPECT/CT: Future Applications





Whole body SPECT/CT (analogous to PET/CT)
Quantification of absolute activity (like PET)
Compensation for CT contrast in  map
Compensation for respiratory, cardiac motion
SPECT/CT-based 3-D dosimetry/treatment
planning
S. Cheenu Kappadath, PhD
AAPM 2009 - Anaheim, CA
Future: Whole-body Bone
SPECT/CT

Tc-99m MDP Bone Imaging
S. Cheenu Kappadath, PhD
AAPM 2009 - Anaheim, CA

99m-Tc MDP
SPECT/CT:
Fused Coronal
views
S. Cheenu Kappadath, PhD
AAPM 2009 - Anaheim, CA
Future: Multi-nuclide
SPECT/CT


Maximum Intensity Projection (MIP) of a dual-isotope (Tc-99m and I-123) SPECT/CT
mouse study.
Published by the Molecular Imaging Center for Excellence newsletter, SNM
publication Volume 2, 2008
S. Cheenu Kappadath, PhD
AAPM 2009 - Anaheim, CA