Physical background

Physical Background & Technical Aspects of

PET/CT
For the past few years PET/CT has grown because the PET portion
provides metabolic information that is not obtainable with other imaging
modalities (Alavi A et al, 2004). PET have new advances regarding
tumor imaging as cell proliferation, tumor hypoxia, detection of cell
death (apoptosis), angiogenesis, tumor receptors and antigens, labeled
amino acids and labeled hormones (Messa C et al, 2004).
Addition of CT (anatomical imaging) to PET (metabolic imaging)
improves specificity foremost, but also sensitivity, and the addition of
PET to CT adds sensitivity and specificity in tumor imaging. Thus,
PET/CT is a more accurate test than either of its individual components
and is probably also better than side-by-side viewing of images from
either modality (Von Schulthess G, et al 2006).
With the introduction of the combined PET/CT scanner, a more
hardware-oriented approach to image fusion, accurately registered
anatomic and functional images can be acquired in a single examination.
Current designs constitute a CT scanner in tandem with a PET scanner,
with a common patient bed for both systems. Although in most designs,
the scanner appears externally to be a single device, internally there is
little or no mechanical integration (Blodgett T et al, 2007).

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 Physical background

Figure (9): Illustrative diagram of combined PET/CT scanner components (Lin and Alavi,
2009)
.

Limitations and advantages of anatomical and metabolic imaging:

Limitations of anatomical imaging include; inability to determine
if a mass is benign or malignant, or to determine if enlarged lymph nodes
contain cancer, unable to detect small tumor foci in lymph nodes or
elsewhere, inability to determine whether a residual–recurrent
abnormality present after treatment represents scar or tumor and extreme
difficulty in separating benign postoperative or post radiation changes
from viable tumor (Antoch G et al, 2004).
Advantages of metabolic imaging; ability to distinguish viable
metabolically active tissue from scars, potential to detect functional
changes in response to chemo or radio-therapy before there is any change
in clinical or radiological size of a mass and detection is dependent on the
intensity of the FDG uptake rather than the lesion size (Antoch G et al,
2004).
Limitations of metabolic imaging, PET with 18F-FDG provides
functional information, but its main drawback of showing few anatomic
landmarks impedes precise localization of sites of pathologic 18F-FDG

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 Physical background

uptake. In addition, there are some issues regarding specificity, because

18F-FDG is taken up not only by many malignant tumors but also by
sites of active inflammation and physiologically by some organs
(Rodriguez-Vigil B et al, 2006).

Fundamentals of PET/CT imaging

While 18F-FDG uptake is not specific to cancer, it is well known
that there is increased transport of glucose into malignant cells and up-
regulation of enzymatic activity resulting in increased tracer uptake.
Combined PET/CT facilitates the separation of normal physiologic
uptake from pathologic uptake, provides accurate localization of
functional abnormalities, and reduces the incidence of false-positive and
false-negative imaging results. (Blodgett T et al, 2007).

The CT serves three functions: (1) provides the anatomical

correlation for the functional information, (2) the means for CT-based
attenuation correction of the PET data and (3) provide clinical diagnostic-
quality CT images (Townsend DW, 2010).

The PET scanner is located behind the CT scanner and housed in

the same extended-length gantry. CT images are acquired first and are
used to generate attenuation-correction factors (ACFs) to be applied to
the PET data to correct for the effect of photon attenuation (Blodgett T et
al, 2007).

PET is performed following the CT study without moving the

patient for the same axial extent. Approximately six to seven bed
positions are planned in the three-dimensional acquisition mode for
scanning the entire patient with 5-7-minute acquisition at each bed
position (Beyer T, et al 2010).

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The volume of data generated is enormous. Hundreds of transaxial

PET and CT images are first reconstructed. These are then reformatted
into coronal and sagittal images to facilitate image interpretation. For
each of these sets of PET and CT images, corresponding “fusion” images,
combining the two types of data, also are generated (Steinert and Von
Schulthess, 2002 & Griffeth, 2005).

Figure (10): Photograph (side view) of a hybrid PET-CT scanner shows the PET
(P) and CT (C) components. The distance between the PET and CT scanner is 80
cm, The PET and CT scanners are mechanically independent and can be used in
isolation for PET and CT only (Kapoor V et al, 2004)

Figure (11): Typical imaging protocol for combined PET/CT: Topogram (A), or
scout scan, is obtained for positioning. Spiral CT scan (B) is obtained, followed by
a PET scan (C) over the same axial range as B. CT-based attenuation-correction
factors are generated (D), and attenuation PET emission data are reconstructed
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(E).Finally, fused CT and PET images are displayed (F) (Blodgett et al, 2007).
 Physical background

Basics of Positron Emission Tomography

PET is based on the physical properties of certain radioactive isotopes.
A radioactive isotope can be combined with a biologically active
molecule or drug (radiotracer) that acts as a carrier, to determine its bio-
distribution. It will lodge in specific metabolic pathways. It is
administered in sub-pharmacologic doses to trace a particular pathologic
process in the body enabling detection and measurement (Krause B, et al
2009). When the radioactive isotopes undergo radioactive decay, they
emit positrons. Because positrons are particles that carry a positive
charge, they travel only a very short distance, before encountering a
negatively charged electron. When a positron and electron collide, the
particles are annihilated, resulting in the creation of two high energy
gamma photons that travel approximately 180 degrees from one another.
These high energy annihilation photons are not detected efficiently by a
conventional gamma camera, and a specialized ring of detectors is used
(Workman R & Coleman R, 2006).
The energy of each coincident photon produced by the annihilation
reaction is approximately 511 Kilo electron Volt (keV). PET detectors are
specially engineered to handle these high energy photons, and because
there is a ring of detectors, there is no need for the ring to rotate in order
to obtain a tomographic image (Workman R & Coleman R, 2006).

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Figure (12): Positron-electron annihilation reaction (Workman R & Coleman

R, 2006).

PET Radioisotopes and Radiopharmaceuticals

The radioisotopes used in PET imaging have fewer neutrons than their
nonradioactive stable counterparts. The relative paucity of neutrons
within these radionuclides results in protons that are closer together, and
repel one another making their nuclei unstable. This repulsion and
instability in a proton-rich nucleus is the basis for positron decay, in
which a positively charged particle leaves the nucleus and a proton
becomes a neutron (Workman R & Coleman R, 2006).

Another characteristic is the short half-life of these positron emitters.

The short half-life is one of the main reasons that, until recently, PET
imaging was limited to institutions equipped with an on-site circular
particle accelerator, called a cyclotron, to make the positron-emitting
radioisotopes (Workman R & Coleman R, 2006).

Today, the most widely used PET radiopharmaceutical is 18F-2-fluoro-2-

deoxy-D-glucose, also known as fluorodeoxyglucose (18F-FDG). 18F-

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FDG has very similar structure and biochemical behavior to glucose

(Workman R & Coleman R, 2006).

Gluc
ose
undergoes several

Figure (13): Glucose and fluorodeoxyglucose structure (Workman

R & Coleman R, 2006).

chemical reactions within the cells of the body to ultimately produce

water, carbon dioxide, and most importantly energy. Glycolysis, the
Krebs cycle and the electron transport chain are all instrumental in
generating the energy needed to operate our bodies at the cellular level
(Workman R & Coleman R, 2006).

Figure (14): Uptake of 18F-FDG. 18F-FDG is a glucose analog that is taken up by

metabolically active cells by means of facilitated transport via glucose transporters
(Glut) in the cell membrane. In the cell cytoplasm, 18F-FDG undergoes
phosphorylation to form FDG-6-phosphate (6P), which unlike glucose, cannot
undergo further metabolism and becomes trapped within the cell. N=nucleus (Kapoor
V et al, 2004).

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 Physical background

How molecular imaging detect cancer?

Malignant cells have increased glucose utilization due to up
regulation of hexokinase activity. Glucose is taken up by tumor cells by
facilitated transport (via glucose transporters [GLUT]) and then
undergoes glycolysis with the formation of pyruvate under aerobic con-
ditions. However, under hypoxic conditions (in a necrotic tumor), glucose
is metabolized under anaerobic conditions with resultant increased tumor
lactate levels. 18F-FDG is taken up by metabolically active tumor cells
using facilitated transport similar to that used by glucose. The rate of
uptake of 18F-FDG by the tumor cells is proportional to their metabolic
activity. Like glucose, it undergoes phosphorylation to form 18F-FDG-6-
phosphate; however, unlike glucose, it does not undergo further
metabolism, thereby becoming trapped in metabolically active cells
(Kapoor V et al, 2004).

The metabolic differences between normal tissue and

cancer:
Cancer tissue generally has, increased glycolysis, protein synthesis,
more anoxic and hypoxic cells, increased or decreased receptors and
increased DNA synthesis, increased blood flow and increased amino acid
transport (Pannu HK et al, 2004). The disproportionately higher
metabolic rate in malignant cells combined with 18F-FDG’s resemblance
to glucose is the basis behind tumor imaging with 18F-FDG-PET
(Workman R & Coleman R, 2006).

Mechanisms of increased uptake of 18F-FDG in cancer cells

include the following: increased glucose transport because of an

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 Physical background

increased density of plasma membrane GLUT molecules (Au Yong TK et

al, 2005), increase in vascularity with endothelial cell uptake of 18F-FDG
and increased enzyme activity in the glycolytic pathway (Maschauer S et
al, 2004).

General Principles of 18F-FDG Production

18
Bombarding O-enriched water with protons in the cyclotron
18
results in a mixture of H2 (F-18) and O-enriched water. Synthesis of
18F-FDG from this mixture is an automated computer-controlled
radiochemical process that takes approximately 50 minutes to complete.
The 18F-FDG thus produced is a sterile, non-pyrogenic, colorless, and
clear liquid, with residual solvent of less than 0.04 %. The radioactive
purity is greater than 95%, and the residual activity is approximately one-
third to one-half of the original activity (which may vary depending on
the synthesis process) (Kapoor V et al, 2004).

Hardware of PET
Scintialltor crystal
Instead of traditional sodium iodide (NaI) crystals, PET ring detector
crystals are composed of compounds such as bismuth germanate (BGO),
lutetium oxyorthosilicate (LSO), or gadolinium oxyorthosilicate (GSO).
All of these compounds are used by different PET/CT manufacturers, and
they have physical properties which make them well suited to PET
imaging. For a comparison of the imaging properties of these compounds
(Workman R & Coleman R, 2006).

Table 4: Imaging properties of various PET crystals (Workman R & Coleman

R, 2006)

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 Physical background

 Coincidence efficiency is related to count sensitivity and should be as close to

100% as possible.
 Energy resolution is related to scatter rejection and the closer it is to 0%, the
better it is at rejecting scatter.
 Decay time is a measure of how long the scintillation light persists; longer
times limit count rate capability.

The absorption efficiency of BGO crystals is greater than that of

LSO crystals due to its higher effective atomic number; however, LSO
crystals emit fivefold as much light as BGO crystals, and the decay time
for LSO is lower at 40 nsec compared with 300 nsec for BGO. This
enables the necessary counts or scintillation events required for image
formation to be obtained in less time when LSO crystals are used, thereby
significantly decreasing the scanning time and increasing patient through-
put. GSO has a lower effective atomic number than BGO and LSO
crystals. GSO crystals emit slightly more light than BGO and have a
decay time of approximately 50 nsec (Kapoor V et al, 2004).

Detector design:
In PET imaging, scintillators convert high energy (511-Kev)
photons to low energy photons. Then the photomultiplier tubes (PMTs)
convert the low energy photons into an electrical signal. There are
generally only three widely used techniques of arranging the scintillation
crystals and coupling them to photodetectors: one to one coupling, in
which a single crystal is glued to individual photodetector (Zeigler SI et
al, 2001), anger detector uses large sodium iodide crystal glued to an
array of PMTs with a light guide, to achieve spatial resolution of 5mm
(Surti S & Karp JS, 2004) and the block detector design uses 8x4 array
of 6x14x30 mm BGO crystals glued to a slotted light guide (Surti S et al,
2004).

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The BGO, LSO, or GSO scintillation crystals are made into block
detectors. Each detector is coupled to four photomultiplier tubes, and they
are arranged in ring geometry with as many as 250 blocks in a ring
(Kapoor V et al, 2004).

Image Acquisition and Interpretation PET imaging can be

obtained in either a two-dimensional (2D) or three dimensional (3D)
manners.

In 2D PET, parallel lead septa are extended from the detector array,
thereby restricting detection of photons to only those detectors that are in
the same or nearby planes. Conversely, in 3D PET the lead septa are not
used and photon detection can occur across all detector planes. 2D
imaging reduces overall count rate, scatter and random coincidences, and
allows for rapid image reconstruction. 3D imaging greatly increases
system sensitivity (overall counts), but also increases scatter and random
coincidences, and the image reconstruction algorithm takes more time to
process (Workman R & Coleman R, 2006).

Factors degrading PET imaging

The images generated by PET scanners are accurate
representations of the objects being analyzed, but there are several factors
that can degrade image quality. Absorption and scatter are two such
factors.

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Attenuation refers to the decrease in intensity of a photon signal as

it passes through matter either by absorption or by scatter. Attenuation
effects are directly proportional to the density and thickness of the
various tissues through which photons travel. If the matter through which
a photon is traveling stops the photon completely, it is called absorption.
Scatter refers to the alteration in the direction of a photon’s path due to its
interaction with matter (e.g. tissues) along that path. These effects are
related, and both give rise to image reconstruction errors that can
adversely affect the accuracy of a PET scan (Workman R & Coleman R,
2006).

CT-BASED ATTENUATION CORRECTION

Attenuation correction is a technique in which quantitative
methods are used to partially offset the effects of attenuation on an image.
In conventional dedicated PET systems, a transmission image using
photons from a germanium-68 (68Ge) source is generated to create what
can be conceptualized as an attenuation map (µ map) of the patient. In
this way, the PET system computer obtains data about the attenuation
effects of each individual patient’s body. The transmission image,
together with the emission image, enables the PET scanner to create an
“attenuation-corrected” image of the patient (Workman R & Coleman R,
2006).

 The use of the CT scan for attenuation correction not only reduces
whole-body scanning times by at least 40% but also provides essentially
noiseless attenuation-correction factors, compared with those from
standard PET transmission measurements. Scaling algorithms typically
use a bilinear function to transform the attenuation values above and
below a given threshold with different factors (Blodgett T et al, 2007).

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 Physical background

The composition of biologic tissues other than bone exhibits little

variation in effective atomic number and can be well represented by a
mixture of air and water. Bone tissue does not follow the same trend as
soft tissue because of the calcium and phosphorus content; thus, a
different scaling factor is required that reflects instead a mixture of water
and cortical bone. The break point between the two mixture types has
been variously set at 300 and 0 Hounsfield units (HU). However, some
tissue types, such as muscle (60 HU) and blood (40 HU), have attenuation
values greater than 0 HU and yet are clearly not a water-bone mix. A
break point at around 100 HU would therefore appear to be optimal. The
scaled CT images are then interpolated from the CT to the PET spatial
resolution, and the attenuation correction factors are generated by
reprojecting the interpolated images (Blodgett T et al, 2007).

Figure (15): Graph shows bilinear scaling function used to convert CT numbers to linear
attenuation values at 511 KeV. Linear attenuation coefficient 511 KeV is a function of
corresponding CT value ((in Hounsfield units) and is based on measurement from electron
density CT phantom with tissue-equivalent materials. Separation between soft tissue (air-
water mix) and bonelike tissue (water-bone mix) is around 100HU (Blodgett T et al, 2007).

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Finally, the attenuation-corrected PET data and the CT data are

viewed conjointly by using appropriate software. The data thus obtained
can also be transmitted to a radiation therapy planning system and can be
used there (Von Schulthess G, et al 2006).

Technical Limitations of PET Scanners: radial blurring, photons

close to the edge of the field of view may penetrate more than one crystal
before being detected (Kapoor V et al, 2004), positron range blurring and
annihilation angle blurring, coincidence imaging and intrinsic spatial
resolution of the detector (Surti S & Karp JS, 2004).

Figure
Figure (17):
(16): Coincidence
Mean positron imaging. Although
range and the photons
annihilation angle emitted
blurring.byPositrons
annihilation
(β+)points
travelAa
and C are in coincidence, the distances that the coincident photons a
small distance called the mean positron range (a) before annihilating with electrons and a1 and c and(β-).
c1
will travel before they reach the scintillation crystals are different. There is a predetermined
This change in position between the origin of the positron and its site of annihilation results
time windowrange
in positron within which detected
blurring, photons
thus limiting theare considered
spatial to be in
localization thatcoincidence. Therefore,
can be achieved with
even though photons a and a1 and c and C1 are coincident, they will be
PET. In addition, positrons and electrons are in motion when they annihilate; therefore, the electronically
rejected as noncoincident.
annihilation photons are notHowever, the180°
at exactly coincident
to eachphotons
other. Thefromunpredictable
point B are likely to reach
0.5° variation
the scintillation crystals within the time window and will be accepted as coincident
(b) between the annihilation photons (γ) results in additional spatial degradation, which (Kapoor is
V et al, annihilation
called 2004) angle blurring. N neutron, P proton (Kapoor V et al, 2004)

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Technology Overview

The first prototype of an integrated PET/CT system was developed

in collaboration with a group of investigators at the University of
Pittsburgh. Several manufacturers are now offering integrated PET/CT
systems combining different models of dedicated PET scanners and
multislice CT scanners in line with a common imaging bed (Coleman RE
et al, 2005).

Figure (18): Current commercial PET/CT scanners from 4 major vendors of PET imaging
equipment: (A) Hawkeye (GE Medical Systems); (B) biograph (Siemens Medical
Solutions) or Reveal (CTI, Inc.); (C) Discovery LS (GE Medical Systems); (D) Discovery
ST (GE Medical Systems); (E) Gemini (Philips Medical); (F) biograph Sensation 16
(Siemens Medical Solutions) or Reveal XVI (CTI, Inc.) (Townsend DW et al, 2004)

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 Physical background

Practical Points in the Interpretation of PET/CT

Scans
Assessment of radiotracer uptake:
There are different methods for assessment of radiotracer uptake by
normal and pathologic tissues, such as visual inspection, the standardized
uptake value (SUV), and the glucose metabolic rate. Visual inspection is
frequently used in analysis of PET/CT results by viewing fused PET/CT
images (Kapoor V et al, 2004). The standardized uptake value of a lesion
is calculated to determine if the lesion is more likely to be benign or
malignant. The SUV is dependent on many variables, including body
mass and the region of interest, and is higher in obese patients and with
smaller regions of interest (Reske SN & Kotzerke J, 2010).
Standardized Uptake Value
The SUV is a unit-less ratio that can be understood as the
concentration of 18F-FDG within a lesion divided by the concentration of
radiotracer distributed throughout the body. Mathematically, it can be
expressed as follows:
SUV=C (T)/(dose injected/body weight)

Where C is the tissue concentration of 18F-FDG at time T

(Workman R & Coleman R, 2006). An SUV is a simplified index of
18F-FDG uptake and provides a relative indication of the degree of
metabolism within the lesion being evaluated. The SUV measurement is
directly proportional to metabolic activity. SUV can be notated as the
maximum value within a lesion (SUVmax), or the average value within a
region of interest drawn around a lesion (SUVavg). The SUVmax is more
robust because it is more reproducible, being less affected by the size and
placement in the region of interest. The SUV should be used with caution

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as it is affected by multiple factors and it is subjected to error (Workman

R & Coleman R, 2006).

18F-FDG Uptake Normal Versus Abnormal:

A) Sites of normal 18F-FDG uptake:

18F-FDG accumulation is most intense in the cerebral cortex, basal
ganglia, thalamus, and cerebellum, since the brain is exclusively
dependent on glucose metabolism (Kostakogky L et al, 2004).
Myocardial uptake is variable in patients who have fasted for 4 -18 hours.
18F-FDG is excreted by the kidneys, and intense activity is seen in the
ureters and bladder. Less intense radiotracer activity is present in the
liver, spleen, bone marrow, and renal cortex. At one hour after radiotracer
injection, blood pool activity results in moderate background activity in
the mediastinum, whereas lung activity is low (Kostakogky L et al,
2004).
Significant muscle uptake is observed in the skeletal muscles with
exercise or after insulin administration or insulin release from recent
ingestion of food (skeletal muscle glucose receptors are insulin sensitive)
(Kostakogky L et al, 2004). It is usually easy to be distinguished from
malignancy by comparison with the CT images for a focal lesion or mass,
as the uptake of 18F-FDG in normal muscles is diffuse, linear and
asymmetric if related to muscle activity (Kapoor V et al, 2004).

Brown fat has recently been recognized as an important cause of

altered 18F-FDG biodistribution. Brown fat is involved in
thermoregulation prior to the point of shivering. It is often found in the
neck, along the spine, and occasionally in the abdomen .Patients that are
cold may show spotty uptake in the neck and along the spine due to the
brown fat (Jadvar & Parker, 2005).

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18F-FDG uptake in brown fat is typically bilateral and symmetric.

Uptake in brown fat is more common in children than in adults and is
most common during winter (Parysow et al, 2007).

Figure (19): Normal distribution of 18F-FDG. Coronal CT (a), PET (b), and PET/CT
fusion (c) images demonstrate the physiologic accumulation of 18F-FDG in the cerebral-
cerebellar cortex at the base of the skull and in the myocardium, liver, kidneys, renal pelvis,
bone marrow, and urinary bladder. Note also the minimal uptake in the mediastinum and
bilaterally in the lower cervical and psoas muscles (Kostakogky L et al, 2004).

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Figure (20): Physiologic muscle activity. Coronal fused 18F-FDG PET–CT image of the
back shows bilateral, diffuse, moderate hypermetabolism in the paraspinal muscles
(arrows). Muscular activity due to activity by the patient before or after 18F-FDG
administration may result in this pattern of radiopharmaceutical uptake (Kamel EM et al,
2003)

Uptake in lymphatic tissues and salivary glands may also be seen

as a normal variant. Uptake in the gastrointestinal tract is variable.

Normal stomach, small intestine, and colon may demonstrate increased

18F-FDG uptake due to a combination of factors, including smooth
muscle contraction and metabolically active mucosa (Kostakoglu et al,
2004).

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Figure (21): Bowel uptake. 18F-FDG-PET whole-body scan for staging of inflammatory
carcinoma of the left breast. There is diffuse increased radiotracer uptake in the colon,
which is a normal variant (Kostakoglu et al, 2004).

B) Sites of Benign Pathologic 18F-FDG Uptake:-

Healing Bone: healing bone is associated with elevated FDG uptake

(Meyer et al, 2004)

Lymph nodes: 18F-FDG uptake in lymph nodes is not specific for a

malignant neoplasm. Active granulomatous diseases such as tuberculosis
and sarcoidosis cause high 18F-FDG uptake in involved lymph nodes
(Strauss, 2006), the generalized inflammatory response of regional lymph
nodes to infection or recent instrumentation is a common source of
elevated 18F-FDG uptake in noncancerous lymph nodes (Paul et al,
2003).
Joints: It is common to see increased uptake of 18F-FDG around joints,
particularly in association with periarticular inflammation. Close
anatomic localization can be useful in distinguishing joint inflammatory
disease from bone marrow metastatic disease (Jadvar & Parker, 2005).

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Sites of Infection or Inflammation: Glycolytic metabolism is

elevated in the leukocytic infiltration associated with inflammatory
processes with consequent elevated 18F-FDG uptake resulting in overlap
between benign inflammatory disease and malignancy. Inflammatory
processes, particularly granulomatous infections and conditions such as
sarcoidosis, can have increased 18F-FDG uptake that is just as intense as
that seen in malignancy (Workman R & Coleman R, 2006).

C) Image Artifacts of PET-CT

In general, image artifacts can be defined as any area where there
are systematic discrepancies between an object and the image of that
object. The presence of artifacts in a CT image data set will result in
errors in the generated attenuation map. In turn, applying this incorrect
attenuation map to the PET images will result in an apparent increase or
decrease in activity levels in some areas of the images. It is important,
therefore, to ensure that CT artifacts are minimized when they are used
for attenuation maps (Kapoor V et al, 2004). The artifacts are primarily
related to two major factors:
 Attenuation correction artifacts due to differences in attenuation
of structures between PET and CT.
 Misregistration due to differences in position of structures
between PET and CT (Von Schulthess et al, 2006).
Attenuation correction artifacts secondary to dense material:
I. Contrast medium, if contrast-enhanced pixels are misidentified as
being of a water-bone mix, the scaling factor will be incorrect and the

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erroneously scaled pixels may generate artifacts on the PET image

(Blodgett et al, 2007).

II. Metallic implants; beam hardening in CT images results in erroneous

correction of PET emission images in the vicinity of metallic implants,
which can lead to the appearance of artificially increased uptake
masquerading as a lesion (Von Schulthess et al, 2006). A visual
comparison of attenuation-corrected against non-attenuation-corrected
PET images will help to identify artifacts (Goerres et al, 2003).

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III. Attenuation (transmission)

correction
artifacts; they can
occur where there
are highly
attenuating objects

Figure (23): (A) High-density metallic implants generate streaking artifacts and high CT
numbers (arrow) on CT image. (B) High CT numbers will then be mapped to high PET
attenuation coefficients, leading to overestimation of activity concentration (C) PET images
without attenuation correction help to rule out metal-induced artifacts (Suresbabu W and
Mawlawi O 2005).

in the path of the CT beam, such as contrast-enhanced vessels PET/CT

attenuation correction software corrects (or overcorrects) photopenic
areas adjacent to high-attenuation structures at CT and makes them
appear hyper metabolic on the attenuation-corrected PET images
(Kapoor et al, 2004).

Figure (24): (a) Attenuation-corrected axial fused 18F-FDG PET/CT image shows a
focus of hypermetabolism in the left axilla (arrow). (b) Attenuation-uncorrected fused
18F-FDG PET/CT image obtained at the same level shows lack of activity in the
intensely enhancing (high-attenuation) left axillary vein (arrow) (Kamel EM et al, 2003)

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Misregistration artifacts

I. Respiratory motion, the artifact is due to the discrepancy between the

chest position on the CT image and the chest position on the PET image
(Beyer T et al, 2003), the major artifacts occur in regions adjacent to the
heart and diaphragm. Specifically, PET data are acquired most frequently
during free breathing, which corresponds largely to the end-expiratory
position of the diaphragm, while CT data are normally acquired at
maximum inspiration (Von Schulthess et al, 2006).
The most common type of breathing artifact results in curvilinear cold
areas. Additionally, respiratory motion artifact can have a profound
impact on patients with proven liver lesions. A liver lesion can
erroneously appear at the base of the lung, mimicking a lung nodule. This
artifact is usually referred to as a misregistration of lesions (Suresbabu
W and Mawlawi O 2005).

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Figure (25): Curvilinear cold artifact (arrow) is commonly seen on

dome of diaphragm/liver or at lung base because of respiration mismatch
on PET images with CT attenuation correction (Suresbabu W and
Mawlawi O 2005).

II. Patient motion; it can produce

Figure (26): (A) 58-y-old man with colon cancer. Lesion at dome of liver is mislocalized to
right lung (arrow) because of respiratory motion. (B) Image without attenuation correction
shows that all lesions are confined to liver (Suresbabu W and Mawlawi O)

significant artifacts on the fused images and may cause confusion as to

the correct position of the origin of the detected photon. Patient motion is
minimized by, carefully instructing patients not to move during the study;
placing them in a comfortable position before the start of the study; en-
suring that they are not taking diuretics, which may otherwise require

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them to evacuate the bladder during the study; and having patients empty
their bladder before the start of the study (Kapoor V et al, 2004).

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