GE Healthcare
Publication Date: December 7, 2006
1.0 SNM VOICE CE Credit
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  1. 1. GE Healthcare Publication Date: December 7, 2006 1.0 SNM VOICE CE Credit imagination at work TiP-TV™ Training in Partnership Program Supplement and Test for Imaging Professionals NM/PET: Image Fusion
  2. 2. © 2006 General Electric Company. All rights reserved. 2 of 14 GE Healthcare NM/PET: Image Fusion REV 0 Program Supplement and Test TABLE OF CONTENTS PROGRAM SUMMARY................................................................................................................................................... 3 CONTINUING EDUCATION CREDIT ............................................................................................................................. 4 INTRODUCTION............................................................................................................................................................. 5 WHAT IS IMAGE FUSION? ............................................................................................................................................ 5 Single Photon Emission Computed Tomography (SPECT)/CT ................................................................................ 5 PET/CT ..................................................................................................................................................................... 6 Comparison with Other Methods .............................................................................................................................. 6 BENEFITS....................................................................................................................................................................... 7 TECHNICAL CONSIDERATIONS................................................................................................................................... 8 Hawkeye 4 ................................................................................................................................................................ 8 Cross Training and Licensure ................................................................................................................................... 8 CASE REVIEW................................................................................................................................................................ 9 Diagnostic Accuracy ............................................................................................................................................... 10 APPENDIX A: PRESENTERS ...................................................................................................................................... 11 APPENDIX B: RESOURCES ....................................................................................................................................... 12 APPENDIX C: POST-TEST .......................................................................................................................................... 13
  3. 3. 3 of 14 © 2006 General Electric Company. All rights reserved. GE Healthcare NM/PET: Image Fusion REV 0 Program Supplement and Test PROGRAM SUMMARY This page provides an overview of the program content and learning objectives. Please refer to the Table of Contents for a detailed list of the topics covered. We encourage you to file a copy of this Program Summary and the Table of Contents with your continuing education certificate. We also recommend that you provide a copy of this information to your manager as a record of your educational achievement. PROGRAM DESCRIPTION As imaging technologies have advanced, so have new ways to combine them. In this program, we explore the ways that the different modalities can be used in conjunction with nuclear medicine and PET to improve diagnosis and treatment. PROGRAM OBJECTIVES By the end of this program, the viewer should be able to: 1. State the basic principles of fusion imaging. 2. Describe image fusion methods. 3. Discuss the benefits of image fusion for patient management. 4. Discuss the technical considerations for fusion imaging. TARGET AUDIENCE Course objectives for this program specifically target nuclear medicine and PET technologists. NOTE: While not limited to this audience group, the technical content is most effective when applied to people with this training. Regardless of your imaging specialty, you may apply for continuing education credit. Refer to the Continuing Education Credit page for additional information. CONTINUING EDUCATION CREDIT 1.0 SNM VOICE CE Credit
  4. 4. 4 of 14 © 2006 General Electric Company. All rights reserved. GE Healthcare NM/PET: Image Fusion REV 0 Program Supplement and Test CONTINUING EDUCATION CREDIT After viewing the TiP-TV video presentation and reading this program supplement, please complete the required online CE credit activities (test and feedback form). The TiP-TV test measures knowledge gained and/or provides a means of self-assessment on a specific topic. The feedback form provides us with valuable information regarding your thoughts on the program’s quality and effectiveness. Online Process for CE Credit 1. View the entire video presentation – this is a requirement for obtaining CE credit. This supplement is not intended to replace watching the video presentation. 2. Go to the GE Healthcare Learning System (HLS) web site at hls.gehealthcare.com and complete the feedback form. 3. Complete the post-program test. You have up to three attempts to successfully complete the test with a passing score of 80% or higher. The test must be completed without aids or assistance of any kind; this is an individual effort. 4. Upon successful completion of the online CE information, you can instantly print a certificate. CONTINUING EDUCATION CREDIT ELIGIBILITY – IMPORTANT NOTICE! A GE Healthcare TiP-TV course may be available in several different formats, such as, but not limited to, a broadcast, online web course, or videotape. You may only be able to receive CE credit once for a particular course, regardless of the format in which it was viewed. If you have already applied for and/or received CE credit for this course, you are encouraged to contact your CE certification organization (ARRT, ARDMS, NMTCB, etc.) to determine if you can repeat this course for CE credit. Thank you for choosing GE Healthcare as your continuing education partner. We hope you will join us for other TiP-TV programs in the future. For more details and program schedule information, please visit: www.gehealthcare.com/education If you have a question or comment on the program content, please send a message to: PSTIPApps-nm@med.ge.com TiP-TV satellite broadcast subscribers can go online to obtain CE credit – quickly and easily! hls.gehealthcare.com
  5. 5. 5 of 14 © 2006 General Electric Company. All rights reserved. GE Healthcare NM/PET: Image Fusion REV 0 Program Supplement and Test INTRODUCTION These days, you can hardly pick up a trade magazine, journal, or attend a diagnostic imaging conference without seeing something about image fusion, or hybrid imaging. Image fusion has been around for quite some time; however, advances in equipment and software continues to improve the fusion of the various modalities. In this program, we review some basics of nuclear medicine and positron emission tomography (PET) image fusion. WHAT IS IMAGE FUSION? Nuclear medicine and PET are used to image functionality, while other modalities, such as computed tomography (CT), are primarily used to image anatomy. While there have been advances with regard to functional imaging in other modalities, this program focuses on the nuclear medicine department. Fusion is the process of fusing or melting together – in other words, the merging of different elements into a union. So, by fusing images, you can fuse anatomy and physiology into one image, thereby increasing specificity in diagnosis. One of the problems that nuclear medicine and PET have always had, is that they are very sensitive to changes in the function of the cells, but not very specific to exactly where those changes are taking place. So, by fusing these two different techniques, you get the best of both worlds: specificity and sensitivity. SINGLE PHOTON EMISSION COMPUTED TOMOGRAPHY (SPECT)/CT The SPECT/CT hybrid system is also referred to as an in-line scanner. The gantry used is a slip-ring gantry, which allows for continuous fast rotation. The x-ray tube is at the top of the scanner. It is a long-life, fixed anode tube that emits a 2.5 milliampere (mA) x-ray, resulting in a low dose to the patient as well as low scatter to the operator. The CT detector array is 180 degrees opposed to the tube. It consists of 384 1.8 x 28 millimeter (mm) solid-state detectors and allows a slice thickness of 10 mm. The CT images are acquired first by generating a transmission map. This is followed by the emission acquisition. The patient does not move between imaging sessions. When using the CT images from Hawkeye for attenuation correction, the nuclear tomogram is acquired, and the attenuation map can then be applied. The Hawkeye system can also be used for localization of lesions. Again, the CT tomogram is acquired first, and generates low-resolution CT images throughout the area of interest. Because the patient is on the same table and does not move between imaging sessions, these images are inherently registered with the emission images. This system would not be used for diagnostic CT imaging purposes. The emission data is then acquired, producing standard tomographic data. Cross-sectional attenuation correction images are created with filtered back-projection reconstruction. This data is then automatically fused with the CT images, and the user can now triangulate and locate any area of interest.
  6. 6. 6 of 14 © 2006 General Electric Company. All rights reserved. GE Healthcare NM/PET: Image Fusion REV 0 Program Supplement and Test PET/CT The PET/CT scanner combines two stand-alone gantries. The CT scanner that is included is a multi-detector CT (MDCT). This can be used for diagnostic CT studies. MDCT: • Multislice – Originally: 2 to 4 slices/rotation – Now: 8,16, 64 slices/rotation – 0.5 seconds/rotation • Helical scan – 17 seconds/meter Notes: Dr. Delbeke, Professor of Radiology and Director of NM and PET at Vanderbilt University in Nashville, Tennessee COMPARISON WITH OTHER METHODS There are several methods that can be used for image registration. The first is to line up the images by eye, comparing landmarks and possibly even markers. Obviously, this is not the most accurate method. The second is the use of software and markers to register and fuse inter- or intra-modality images acquired at different times on different equipment. This is more accurate, but it does have some inherent problems in that the patient has been moved between the images. The factors that can cause difficulties for accurate registration and fusion by these methods include: • Weight change of the patient. • Lack of availability of anatomical images. • Positional differences of the patient. Another method uses an integrated localization device to register and fuse images of different imaging modalities. This is accomplished using radionuclide transmission maps. The benefit here is that the patient remains in the same position, so the images can be registered automatically without the subjectivity of the human eye. Notes: Dr. Delbeke
  7. 7. 7 of 14 © 2006 General Electric Company. All rights reserved. GE Healthcare NM/PET: Image Fusion REV 0 Program Supplement and Test BENEFITS One of the most common uses of SPECT fusion imaging is bone imaging. This might seem unusual, but one of the problems with bone imaging is that it may not be very specific in locating an abnormality. With the routine use of the SPECT/CT hybrid system for nearly all tomographic bone imaging, the studies can be more specific. You see a whole new level of disease when you have the localizing images for bone tomography. This increases the confidence level when reading these images. Before attenuation correction, lesions on bone tomographic studies often appeared hotter than on the planar images. Attenuation has helped compensate for that and now they are much more similar. As with all tomographic studies, a good quality control step is to review the volume rendered images. Another routine use of hybrid imaging is monoclonal antibody scans. Hybrid imaging allows you to do a much better job of localization, and improves the accuracy of the results. Additionally, it can be helpful in gallium imaging, parathyroid imaging, and white blood cell imaging. The limitations of a hybrid imaging system include: • The use of a non-diagnostic CT, which makes it difficult to localize very small lesions. • It is a very low order CT, and it takes roughly 17 to 20 seconds per slice to get the transaxial plane used for attenuation correction and localizing. This can cause some streak artifacts, particularly in the abdomen. • It's a fairly low milliampere, which also decreases the contrast. • The slices are rather thick, on the order of one centimeter. • It takes an additional 10 minutes to acquire a full set of matching CT transaxial planes. For cardiac imaging, the SPECT/CT hybrid system should be used for individuals who are overweight and those patients who are imaged in a more unconventional fashion, or have other attenuating issues related to their disease. In general, what attenuation correction achieves is a gender-free way of looking at the patient. Another benefit to using a hybrid imager for attenuation correction is that there is no need for costly replacement of transmission sources. In PET, the primary use of fusion imaging is for anatomical landmarks. By combining stand-alone PET and CT systems you eliminate the patient positioning issues you would see with other methods of image fusion. The built-in CT can also be used as the attenuation correction device. PET/CT is most often used for oncology studies, but can also be used for cardiac scans. PET/CT is being used more often for radiation therapy planning. Notes: Dr. Delbeke
  8. 8. 8 of 14 © 2006 General Electric Company. All rights reserved. GE Healthcare NM/PET: Image Fusion REV 0 Program Supplement and Test TECHNICAL CONSIDERATIONS Notes: Dr. Delbeke HAWKEYE 4 4-slice CT in SPECT/CT system: • Improved CT image quality. • 5 mm slice thickness at iso-center. • Less than half the Infinia Hawkeye field-of-view (FOV) time. – 4 slices at a time. • Improved CT-nuclear medicine registration. New CT options: • Helical/axial • New reconstruction options CROSS TRAINING AND LICENSURE Notes: Dr. Delbeke Notes: Christine Lung, Director of Government Relations for the American Society of Radiologic Technologists in Albuquerque, New Mexico The primary challenge radiology department administrators face regarding fusion imaging is the availability of cross-trained technologists and whether or not state laws allow licensed radiographers to administer radiopharmaceuticals to perform the nuclear medicine portion of an examination, or if nuclear medicine technologists are legally able to perform the CT image acquisition. Since fusion imaging is so new, most states have not been able to keep pace with the technology and amend their licensure standards to allow just one technologist to perform the examination, unless that technologist is licensed in both radiography and nuclear medicine. American Society of Radiologic Technologists (ASRT) and the Society of Nuclear Medicine Technologist Section (SNMTS) have been working with states to create a process through which technologists can perform enough supervised examinations in nuclear medicine or CT to be eligible to take the appropriate examinations to become licensed.
  9. 9. 9 of 14 © 2006 General Electric Company. All rights reserved. GE Healthcare NM/PET: Image Fusion REV 0 Program Supplement and Test ASRT's position statement, passed by the ASRT House of Delegates regarding the performance of fusion imaging is: "The American Society of Radiologic Technologists (ASRT) recommends that personnel utilizing hybrid imaging equipment and performing fusion imaging with components requiring multiple modality competencies should be registered by the American Registry of Radiologic Technologists (ARRT), Nuclear Medicine Technology Certification Board (NMTCB), or other nationally recognized certifying agency. The ASRT also recommends that these technologists have appropriate clinical and didactic education in each additional component of the specific fusion examination and demonstrate competency in all data acquisition phases of the diagnostic procedure. ASRT's position on licensure is that the licensure of radiologic technologists protects the American public from the potential harmful effects of excess radiation exposure that may be posed by persons performing medical imaging examinations and radiation therapy treatments." ASRT and the SNMTS conjointly published a curriculum for supplementary training that addresses the needs of practicing technologists who wish to gain competency in PET/CT. PET/CT imaging combines skills held by the technologists who perform CT and PET separately. Radiographers, who perform CT, lack nuclear medicine-specific training, and nuclear medicine technologists, who perform PET, lack background in CT techniques. Radiation therapists may also use PET/CT to provide precise tumor location information for planning intensity modulated radiation therapy (IMRT), where high doses of cancer-killing radiation are delivered directly to cancer cells, sparing the surrounding tissue. The PET/CT curriculum addresses the question of which skills each type of practicing technologist needs to add to their existing skill set in order to become competent in both PET and CT. In the future, as more imaging modalities such as PET/magnetic resonance and PET/mammography are fused together, technologists will need to be multi-credentialed and competent in more than just one imaging discipline. It will be important for technologists to engage in professional development activities that will broaden their skills and allow them to become certified in additional areas such as CT and PET. For example, many radiographers perform CT examinations, but never earn post-primary credentials in CT. In order to meet the increasing technical demands of fusion imaging, technologists who work in this environment should earn additional credentials indicating their advanced skills in this modality. CASE REVIEW Notes: Dr. Ziffer, Medical Director of Nuclear Medicine and PET at Baptist Cardiac & Vascular Institute in Miami, Florida Notes: Dr. Delbeke
  10. 10. 10 of 14 © 2006 General Electric Company. All rights reserved. GE Healthcare NM/PET: Image Fusion REV 0 Program Supplement and Test DIAGNOSTIC ACCURACY Integrated PET/CT Fluorodeoxyglucose (FDG) PET: superior diagnostic accuracy over conventional imaging for staging and restaging FDG-avid malignancies. PET/CT: incremental impact on diagnostic accuracy – 40% to 50% of patients. • Discriminates metastatic from physiologic foci. • Improves lesions detection on both PET and CT. • Localizes precisely metastatic foci. Impact on management: • FDG PET: ~30% patients (range 10% to 60%). • PET/CT: incremental impact on patient’s management – 10% to 20% patients, including: – Planning radiation therapy. – Guiding biopsies. Notes: Dr. Delbeke Integrated SPECT/CT Clinical indications: • Cardiac attenuation correction • Neoplasms • Parathyroid adenoma (99m Technetium-Sestamibi) • Thyroid carcinoma (131Iodine) • Somatostatin receptor-positive tumors (111Indium-Octreotide) • Lymphoma (67 Gallium) • Hemangioma (99mTechnetium-red blood cells) • Prostate carcinoma: (111Indium-Prostascint) • Sentinel node localization • Infection (111Indium-white blood cells and 67Ga) • Bone trauma (99mTc-HDP) Notes:
  11. 11. 11 of 14 © 2006 General Electric Company. All rights reserved. GE Healthcare NM/PET: Image Fusion REV 0 Program Supplement and Test APPENDIX A: PRESENTERS Lisa K. Armstrong, B.S., CNMT Molecular Imaging TiP-TV Program Manager GE Healthcare Dominique Delbeke, M.D., Ph.D. Professor of Radiology Director of NM and PET Vanderbilt University Nashville, Tennessee Special Contributors Christine Lung, CAE Director of Government Relations American Society of Radiologic Technologists Albuquerque, New Mexico Fred S. Vernacchia, M.D. Medical Director San Luis Diagnostic Center San Luis Obispo, California Jack A. Ziffer, Ph.D., M.D., F.A.C.C. Medical Director of Nuclear Medicine and PET Baptist Cardiac & Vascular Institute Miami, Florida
  12. 12. 12 of 14 © 2006 General Electric Company. All rights reserved. GE Healthcare NM/PET: Image Fusion REV 0 Program Supplement and Test APPENDIX B: RESOURCES References Delbeke, D., The Cancer Journal, 2004;10 (4):201-213. Delbeke, D., et. al., Seminars in Nuclear Medicine, 2004; 34(3):209-223. Supplement to The Journal of Nuclear Medicine, 2001; 42: May 2001, Guest editor: Sanjiv S. Gambhir. Supplement to The Journal of Nuclear Medicine, 2004; 45: January 2004, Guest editor: Johannes Czernin. Keidar, Z., et. al., Seminars in Nuclear Medicine, 2003; 33 (3):205-218. Tharp, K., et. al., European Journal of Nuclear Medicine, 2004; 31 (10):1435-1442. Electronic Resources American Society of Radiologic Technologists: http://www.asrt.org Society of Nuclear Medicine: http://www.snm.org NOTE: The Internet is an ever-evolving environment and links are subject to change without notice.
  13. 13. 13 of 14 © 2006 General Electric Company. All rights reserved. GE Healthcare NM/PET: Image Fusion REV 0 Program Supplement and Test APPENDIX C: POST-TEST To be eligible for CE credit, you MUST view the video presentation first and then submit your answers using the online process (go to hls.gehealthcare.com). The post-test must be completed by the due date listed online for this program. NM/PET: Image Fusion LMS Course Number: 3113 1. Nuclear medicine and PET are very _____ to changes in the function of the cells, but not very _____ to exactly where those changes are taking place. a. sensitive; specific b. sensitive;sensitive c. specific; sensitive d. specific; specific 2. With the fusion of anatomical and functional imaging, you get _____ resolution and _____ sensitivity when making a diagnostic decision. a. increased; decreased b. increased; increased c. decreased; decreased d. decreased; increased 3. The x-ray tube is a long-life, fixed anode tube that emits a _____ mA x-ray, resulting in a low dose to the patient as well as low scatter to the operator. a. 0.5 b. 1.5 c. 2.5 d. 3.5 4. The CT detector array on the hybrid imager is 180 degrees opposed to the x-ray tube. It consists of 384 1.8 x 28 mm solid-state detectors and allows a slice thickness of _____ mm. a. 2 b. 5 c. 10 d. 12 5. The attenuation map is applied during the _____. a. quality control procedures b. acquisition of images c. display of images d. processing of images 6. The _____ allows continuous fast rotation of both the gamma-camera detectors and the x-ray system. a. slip-ring gantry b. support ring c. source assembly d. mutually referenced support system 7. The current PET/CT scanners have a maximum of a _____slice CT. a. 4- b. 8- c. 16- d. 64-
  14. 14. 14 of 14 © 2006 General Electric Company. All rights reserved. GE Healthcare NM/PET: Image Fusion REV 0 Program Supplement and Test 8. All of the following are difficulties for accurate registration and fusion EXCEPT _____. a. weight change of the patient b. inherently registered x-ray and nuclear tomographic images c. positional differences d. lack of availability of anatomical images 9. One of the most common uses of SPECT fusion imaging is _____ imaging. a. bone b. hepatobiliary c. myocardial d. pulmonary 10. The common artifact you might see due to the low order CT images is a _____ artifact in the abdomen. a. motion b. ring c. streak d. shading 11. The new systems for SPECT/CT include a _____slice CT. a. 2- b. 4- c. 8- d. 16- 12. The ASRT and the _____ have been working with states to create a process through which technologists can perform enough supervised examinations in nuclear medicine or CT to be eligible to take the appropriate examinations to become licensed for PET/CT. a. American Medical Association (AMA) b. ARRT c. MNTCB d. SNMTS 13. The incremental impact on diagnostic accuracy with PET/CT occurs in _____% to _____% of the patients. a. 10; 20 b. 20; 30 c. 30; 40 d. 40; 50 14. The incremental impact on patient management with PET/CT occurs in _____% to _____% of the patients. a. 10; 20 b. 20; 30 c. 30; 40 d. 40; 50 15. The clinical indications for SPECT/CT include all of the following EXCEPT _____. a. hemangioma b. lymphoma c. precise localization of metastatic foci d. parathyroid adenoma

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