Fusion Imaging:

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  • From Dr. Henkin’s presentation, if not before, we all realize how exciting the concept of fusion imaging is. The advent of PET/CT has revolutionized oncological diagnosis and treatment, and is enjoying widespread application in other areas. However, on the technical side of its application, concerns and questions have surfaced. The questions are varied in scope, but center ultimately around those performing these new procedures. What are the qualifications needed by an individual in order to perform a fusion imaging procedure ?????? In fact, some of us have began to refer to fusion imaging as >>> next slide<<<
  • Before next slide, again ask the question; What is Fusion Imaging ?
  • In medical imaging, this terms means depicting human anatomy Radiographically. Current modalities include conventional radiography, computed tomography, magnetic resonance, angiography, cardiac catheterization, ultrasound, and nuclear medicine.
  • In the course of fusing imaging modalities, we have also fused the technologists. As noted, fusion imaging creates a new (hybrid) image, therefore creating the need for hybrid technologists.
  • There is currently discussion and research into fusing CT/MRI. CTA, MRA, and Conventional Angiography images may also be fused. SPECT/CT is in the offing. And Ultrasound images might possibly be fused with other images also. The possibilities are conceptually possible, but………
  • As an academician, I know of but one way to derive knowledge in a subject area, and that is to research the topic. So for this topic, I went on a search and discovery mission called research. I was fortunate in that several facilities in my area (Birmingham, Alabama) are performing PET/CT, including two on the University of Alabama at Birmingham Medical Center Campus; Birmingham Veterans Administration Medical Center and Kirklin Clinic. I spent several days at these facilities, as an observer, on my search and discovery mission. BVAMC PET/CT procedures are performed in the Nuclear Medicine Department and Kirklin Clinic recently opened a stand-alone PET/CT Department. PET/CT at the VA is performed with a hybrid scanner capable of performing low-dose non-diagnostic CT scans and full PET capabilities. The Kirklin Clinic PET/CT scanner is a state-of-the-art, fully diagnostic, spiral capable CT scanner, and PET scanner.
  • These two entities convened a consensus conference on July 31, 2002, in New Orleans, Louisiana. Those participating in the conference included representatives from the ASRT and SNMTS, American Registry of Radiologic Technologists, American College of Radiology, Joint Review Committees on Education in Radiologic and Nuclear Medicine Technology, administrators, educators, equipment and state regulatory agency reps, physicians and other interested parties. Noticeably absent from the roster of those attending, however, was even one individual certified in Computed Tomography (CT) and/or Radiation Therapy.
  • The ideal technologist is not readily available. So what do we do to provide those individuals deemed qualified under the consensus statement, with the “ appropriate additional education or training and demonstrated competency “? First, we need to understand
  • Specific program patient care, education and management courses incorporate areas that are core to all imaging modalities , such as vital signs, but also differ, because of educational focus of programs. But PET/CT courses on this subject must cover areas specific to this new hybrid. Example; Radiography and Nuclear Medicine courses include venapuncture, but Radiation Therapy courses generally do not. A PET/CT technologist, because of the need to administer intravenous radiopharmaceuticals and Radiographic Contrast Media, needs this educational preparatory knowledge.
    Radiation Physics courses, depending on the modality focus, contain information pertinent to ionizing radiation. While the focus in Nuclear Medicine is Nuclear Physics, with definite attention paid to the characteristics of radioactive decay, nuclear transformation, particulate interaction with matter, and the attenuation equation, radiography and radiation therapy physics courses will generally place focus on other areas. Attenuation though, is included in all three areas, however the realization is that radiography will focus on attenuation as it relates to radiation being transmitted through body tissues, nuclear medicine will focus on it from the standpoint of radiation being emitted from body tissues, while radiation therapy will focus on it from the standpoint of radiation dose distribution in treatment of cancer patients.
    Radiation Biology courses in all three curricula, provide knowledge concerning the ability of radiation to produce biological alterations. The aspect of Radiation Protection is where variations in these courses are likely. Since the radiation therapists’ focus is generally limited to non exposure of aspects of the patient’s body not requiring treatment or to protection from implantable sources, and the Nuclear Medicine focus may be limited to protection of the technologist, and others from the radiation emanating from the patient’s body, the radiographer will focus on protection of self, others remaining in the room of the source, and limiting patient dose by altering position and technical factors.
    Cross-Sectional anatomy is an essential aspect of PET/CT. Most radiography curricula include the study of cross-sectional anatomy to some extent. Courses range from 1 – 4 semester hour credit. Some are limited to the head, while still others cover the entire body. The course I teach is structural anatomy, as demonstrated on CT and MR, sometimes ultrasound, with cadaver correlation. The researched Cross-section course in nuclear medicine is geared towards functional anatomy, and even though some radiation therapy programs integrate cross-sectional anatomy courses into their curricula, many do not. PET/CT Cross-Sectional anatomy courses must present both functional and structural aspects.
    For any individual performing specific imaging procedures, such as PET and CT, knowledge of the modality is a must. The PET/CT Technologist must have knowledge of particular aspects of both. For example, it is essential that those operating CT scanners have knowledge of:
    data acquisition (radiographic tube, filtration, collimators, detector systems, and selectable scan factors influencing the scanners operation and output)
    a.SFOV
    b.DFOV
    c.window level/window width
    d.kVp and Ma selection
    e.mode(conventional vs. spiral) (if spiral, then pitch)
    f.etc,
    image reconstruction, especially the reconstruction algorithm
    display, manipulation and archival.
    Those operating Nuclear Medicine need knowledge of the imaging system, including:
    Detection Systems (gas or solid state)
    Planar Scintillation Cameras
    Multicrystal scintillation Cameras
    SPECT Imaging Systems
    PET Imaging Systems
    Image display and recording. The computer systems of both need to be understood.
    An integration or fusion of this knowledge needs to be present in the intellectual persona of the PET/CT Technologist.
    The administration of Radiopharmaceuticals is specific to nuclear medicine. The administration of Radiographic Contrast Media is specific to radiography, including CT. Neither is specific to Radiation Therapy. Since PET/CT is a Nuclear Medicine/Radiographic Procedure, education must take place concerning both. This has been clearly demonstrated in current literature reporting artifacts being seen on PET/CT images originating from the administration of radiographic contrast media.
    Last, but of no less importance, is structuring a course specific to the operation, maintenance, and instrumentation of the PET/CT Unit. We must not forget that this is a hybrid machine, so neither technology currently has courses, other than applications training, dedicated to it.
  • Fusion Imaging:

    1. 1. Fusion Imaging: Presenting New Educational Challenges Bettye G. Wilson, M.A. Ed., RT(R)(CT), RDMS Birmingham, Alabama
    2. 2. For copies of this presentation go to: http://main.uab.edu/show.asp?durki=37659 For other correspondence: wilsonbg@uab.edu
    3. 3. Con-Fusion Imaging
    4. 4. Fusion Imaging from the Technologists’ Perspective ♦ Just what is fusion imaging ? ♦ What type of technologists are currently involved in the performance of fusion imaging procedures ? ♦ What are the educational needs of technologists performing fusion imaging procedures ?
    5. 5. Fusion: “The union of different things by, or as if by, melting……” Imaging: “Making a representation or imitation of an object.
    6. 6. Fusion Imaging: Melting together images from different modalities to create a new (hybrid) image.
    7. 7. Remember; Fusion Imaging, combines more than the imaging modalities. It also combines the technical expertise of the differing technologies, therefore it also creates combination (Hybrid) technologists.
    8. 8. It is possible to fuse images from almost any imaging modality
    9. 9. Currently, the most discussed fusion imaging technique is PET/CT
    10. 10. Positron Emission Tomography Image of the Chest
    11. 11. Computed Tomography Image of the Chest
    12. 12. Fused Image (PET/CT) of the Chest
    13. 13. Research Equals Knowledge ♦ Where is PET/CT being performed ♦ Who’s performing PET/CT ♦ What education/skills are required
    14. 14. Some PET/CT Procedures are being performed in Nuclear Medicine Departments by Nuclear Medicine Technologists
    15. 15. Some PET/CT Procedures are being performed in CT Departments by CT Technologists
    16. 16. Other facilities have created stand-alone PET/CT Departments staffed by CT and Nuclear Medicine Technologists, only Nuclear Medicine Technologists, or only CT Technologists
    17. 17. In some cases, nurses are also employed, to administer I.V. Contrast Media, and/or Radiopharmaceuticals
    18. 18. Confusion Abounds 1.Professional organizations have formed task forces or committees to examine this issue 2.Educators in the Radiologic Sciences have been made increasingly aware of the need to incorporate diverse information into their curricula 3.Imaging Technologists are again facing the educational demands of uncharted territory
    19. 19. Gaining Consensus ♦ American Society of Radiologic Technologists (ASRT) ♦ Society of Nuclear Medicine Technologist Section (SNMTS)
    20. 20. PET/CT Consensus Conference Statements ♦ Statement No. 1 Personnel Qualified to Operate PET/CT Equipment Statement No. 2 Regulation of Personnel Who Operate PET/CT Equipment
    21. 21. Consensus Statement Number 1 “Any registered radiographer with the credentials R.T. ( R ), registered radiation therapist with the credentials R.T. ( T ), or a registered nuclear medicine technologist with the credentials R.T. ( N ) or CNMT may operate PET-CT equipment after obtaining appropriate additional education or training and demonstrated competency.”
    22. 22. The Ideal Pet-CT Technologist ? Joanne Doe, R.T. ( R ) ( N ) ( T ) ( CT ) Or Joanne Doe, R.T. ( R ) ( T ) ( CT ), CNMT
    23. 23. What are the Commonalities ? ♦ All are Radiologic Sciences Professionals ♦ All have completed educational programs specific to their disciplines ♦ All are Certified and Registered Technologists
    24. 24. What are the real Differences ? ♦ Do not necessarily have the same basic knowledge ♦ Come from diverse educational backgrounds ♦ Practice generally specific to discipline ♦ May not be as cognizant of other imaging modalities as required ♦ May believe profession other than own, “piece of cake”
    25. 25. Educational Needs of PET/CT Technologists ♦ Patient Care, Education, and Management ♦ Radiation Physics ♦ Radiation Biology and Protection ♦ Cross-Sectional Anatomy ♦ CT Knowledge ♦ Nuclear Medicine Knowledge (PET) ♦ Radiopharmaceuticals ♦ Contrast Media ♦ PET/CT Equipment Operation, Maintenance, and Instrumentation
    26. 26. So what is the answer to the educational challenges presented by fusion imaging technology ??????
    27. 27. Short Term = Applications Training for technologists performing PET/CT and continuing education courses designed to educate practitioners
    28. 28. Long Term = Fusion of discipline specific courses to provide an essential “core” of courses for all students
    29. 29. Still Con-FUSED ???? While the educational challenges created by fusion imaging technology are rather daunting, collaborative efforts between educators and professional organizations, with input from the diverse constituency, will lead to solutions
    30. 30. For copies of this presentation go to: http://main.uab.edu/show.asp?durki=37659 For other correspondence: wilsonbg@uab.edu

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