Original Research
Nuclear Medicine
November 2006

Optimal CT Breathing Protocol for Combined Thoracic PET/CT

Abstract

OBJECTIVE. The objective of this study was to determine the optimal breathing protocol for combined PET/CT scans of the thorax.
SUBJECTS AND METHODS. Eighty combined PET/CT scans were obtained in 64 patients (30 women, 34 men; mean age, 57 years; range, 19-86 years). The 80 PET/CT scans consisted of five group of patients (16 PET/CT scans per group) who underwent whole-body combined 18F-FDG PET/CT with different CT breathing protocols: expiration, mid suspended breath-hold, quiet breathing, small breath in, and regular breath in. The quality of alignment was analyzed at the diaphragm, aortic arch, heart, thoracic spine, and lung apices using a scale of ratings from 1 (very poor) to 5 (excellent). The Kruskal-Wallis test was used to compare alignment between breathing protocols for each anatomic reference point.
RESULTS. Alignment of the PET and CT data sets was excellent with three breathing protocols: expiration, mid suspended breath-hold, and quiet breathing, with no statistical differences. Significant misalignment occurred at the diaphragm (p < 0.0001) and heart (p < 0.0001) with the small breath-in and regular breath-in techniques.
CONCLUSION. Excellent image fusion of combined PET/CT data sets in the thorax, especially at the diaphragm and heart, can be achieved with expiration, mid suspended breath-hold, or quiet breathing. Quiet breathing is recommended for optimal patient comfort during acquisition of attenuation-correction CT data sets.

Introduction

Integrated PET/CT allows the combination of anatomic and functional imaging to evaluate known or suspected malignancies. Recent studies have shown that the fusion of CT and PET data sets leads to significant improvement in both the sensitivity and specificity in the staging of thoracic malignancies [1-3] and the detection of metastatic and recurrent tumor [4].
For optimal image fusion with PET/CT, the lung volumes should be well matched during emission PET and transmission CT acquisition. This alignment will prevent attenuation-correction errors in the lower lungs, peridiaphragmatic regions, and upper abdomen. The emission PET scan is acquired over approximately 30 minutes during quiet respiration. Transmission attenuation-correction CT data sets, however, are acquired in seconds, during which the patient is instructed to breathe quietly or to perform a breath-hold maneuver.
Goerres et al. [5, 6] evaluated the impact of different breathing maneuvers during attenuation-correction CT on anatomic alignment of combined PET/CT scans. They evaluated free breathing, maximum inspiration, normal expiration, and maximum expiration. They found that optimal image fusion occurred when CT data sets were acquired during normal expiration. Similar studies also have shown a reduction in the severity and frequency of respiratory motion artifacts when a limited expiratory breath-hold protocol was used [7, 8].
Sustained expiratory breath-hold during whole-body CT scan acquisition may be difficult in elderly patients or in those with underlying lung disease. In such instances, significant respiratory motion artifact may result if a patient resumes respiration (which can be heavy because of compensation) during the latter part of the CT scan. Misalignment may occur in the lower lungs, diaphragm, and as a result, the upper abdomen. Therefore, additional breathing maneuvers such as suspended breath-hold or quiet breathing may be more appropriate.
None of these maneuvers—expiration, suspended breath-hold, or quiet breathing—is optimal for diagnostic imaging of the lungs. Inspiration is necessary to overcome atelectasis and fully display the lung parenchyma. To our knowledge, there has been no prior study that has comprehensively evaluated this full spectrum of breathing maneuvers. Therefore, the purpose of this study was to determine which of the following breathing protocols provides the best anatomic fusion: expiration, mid suspended breath-hold, quiet breathing, small breath in, or regular breath in.

Subjects and Methods

Patient Population

Whole-body combined PET/CT scans were obtained in 64 patients (30 women, 34 men; mean age, 57 years; range, 19-86 years). The patients were outpatients referred for combined PET/CT because of the following clinical histories: staging or restaging of tumors of the lung (n = 13), breast (n = 3), genitourinary tract (n = 4), gastrointestinal tract (n = 13), or head and neck (n = 2); staging or restaging of lymphoma (n = 18) or of carcinoma of an unknown primary (n = 2); or assessment of solitary pulmonary nodules (n = 8) or lymphadenopathy (n = 1). None of the patients had a history of shortness of breath at the time of scan acquisition.
Eighty PET/CT data sets from these 64 patients were analyzed. The 80 PET/CT data sets consisted of five groups of 16 PET/CT scans. In each group (n = 16 patients), the CT scans were acquired using a different breathing protocol—normal expiration, mid suspended breath-hold, quiet breathing, small breath in, or regular breath in. The patient groups, breathing protocol, and numbers of patients are summarized in Table 1.
TABLE 1: CT Scan Source for Five Breathing Protocols
Group No.Transmission CTDiagnostic CTNo. of Patients
1Expiratory 16
2Mid suspended breath-hold 16
3Quiet breathing 16a
4 Small breath in16a
5

Regular breath in
16
a
For these 16 patients, the quiet breathing transmission CT is used for group 3 and the additional diagnostic small breath-in CT is used for group 4
The study groups were derived from clinical whole-body PET/CT scans obtained from March 2004 through November 2004. During this period, our institution's combined PET/CT protocol consisted of a whole-body attenuation-correction CT scan and a subsequent contrast-enhanced diagnostic CT scan of the chest and upper abdomen during the same imaging session. From March through November 2004, breathing protocols were modified during attenuation-correction CT acquisition to optimize image fusion and patient comfort. Breathing instructions evolved from expiration (group 1), to suspended breath-hold (group 2), to our currently used quiet-breathing protocol (group 3). For the subsequent diagnostic contrast-enhanced CT scans obtained during the same imaging session, we instructed our patients to take a small breath in (group 4) not only to optimize lung imaging but also to avoid significant mismatch in the lower thorax and upper abdomen. The patients who did not receive IV contrast material (due to allergy or renal insufficiency) received a single whole-body CT scan that functioned both as the attenuation-correction CT and diagnostic CT scan. In this group, an additional CT scan of the thorax (from the lung apices through the upper abdomen) was acquired at full breath in (group 5) to comprehensively image the lung parenchyma.

Combined PET/CT Imaging

Combined FDG PET/CT was performed on a 16-MDCT scanner (Biograph Sensation 16, Siemens Molecular Imaging). This system consists of an in-line combined PET/CT system with a lutetium oxyorthosilicate (LSO) detector and a 16-MDCT unit (Somatom Sensation, Siemens Medical Solutions). Approximately 555 MBq (15 mCi) of 18F-FDG was administered IV as a bolus, and imaging was performed 60 minutes later.
Unenhanced attenuation-correction CT was performed from the skull base through the upper thighs with the arms positioned overhead. Each attenuation-correction CT scan was obtained with the following parameters: variable milliampere settings, 0.5 seconds per tube rotation, 120-kV tube voltage, helical pitch of 1.5, reconstructed slice thickness of 5 mm, and 16 simultaneous slice acquisitions. The average scan duration was 15 seconds. The attenuation-correction CT data sets were obtained with one of three breathing protocols: expiration (group 1, n = 16), mid suspended breath-hold (group 2, n = 16), or quiet breathing (group 3, n = 16).
The PET emission scan data sets were acquired from the mid thigh level to the skull base. The spatial resolution of the PET scanner was 4.6 mm full width at half maximum (FWHM) with a slice thickness of 3.5 mm.
For all patients, a subsequent diagnostic CT scan was obtained during the same imaging session (without moving the patient) with the following CT parameters: variable milliampere settings, 0.5 seconds per tube rotation, 140-kV tube voltage, helical pitch of 1.5, reconstructed slice thickness of 2 mm, and 16 simultaneous slice acquisitions. The average scan duration was 20 seconds. IV contrast material (ioxilan 300 mg I/mL) was administered at an injection rate 2 mL/s to all patients except the 16 patients in group 5 who had contraindications to contrast material (allergy or renal insufficiency). The diagnostic CT scan was obtained with a small breath in (group 4, n = 16) or regular breath in (group 5, n = 16).
For all CT scans, breathing instructions were given and rehearsed with the patient before image acquisition. For the expiratory breath-hold technique, each patient was asked to breath normally, release a small breath out, and then stop breathing. For the mid suspended breath-hold technique, each patient was asked to stop in the middle of a normal breath whether during inspiration or expiration. For the quiet-breathing technique, each patient was asked to continuously breathe quietly in small breaths with no large breaths in or out. For the small breath-in technique, each patient was asked to take a small breath in and hold it. For the regular breath-in protocol, each patient was instructed to take a deep breath in and hold it.

Image Reconstruction and Analysis

Attenuation correction was system-generated. PET image reconstruction was performed with Fourier rebinning (FORE) and attenuation-weighted ordered subsets expectation maximization (AW-OS-EM). All PET/CT data sets were displayed on a workstation (Reveal-MVS, Mirada Solutions Ltd.) as stand-alone or superimposed data sets of axial, coronal, and sagittal reformatted images. Image registration using software was not performed.
Combined PET/CT data sets were analyzed for quality of alignment at five anatomic locations: the diaphragm, aortic arch, left ventricle contour, thoracic spine, and lung apices. The quality of alignment was rated on a scale of 1 (very poor or complete lack of superimposition of the anatomic structure on axial, coronal, and sagittal views) to 5 (excellent or complete superimposition of the anatomic structure on axial, coronal, and sagittal views). Image analysis and scoring were performed by two radiologists experienced in PET, CT, and combined PET/CT image interpretation. All disputes were handled by consensus. The data sets were evaluated in a random order, and the reviewers were blinded to the breathing maneuver performed.

Statistical Analysis

The Kruskal-Wallis test was used to compare alignment between breathing protocols for each anatomic reference point. If the test was not significant, no further analysis was performed. If the test was significant, the most discrepant group was removed and the Kruskal-Wallis test was applied to the remaining groups until the test was not significant. A p value of less than 0.05 was considered to be statistically significant. The mean scores for the quality of the alignment were calculated at the five anatomic locations to compare alignment among breathing protocols.

Results

The mean scores for the quality of alignment for each breathing method at the five key anatomic reference points are summarized in Table 2. The quality of alignment was rated on a scale from 1 (very poor) to 5 (excellent). Excellent anatomic alignment was found with normal expiration, mid suspended breath-hold, and quiet breathing (Fig. 1). The mean scores for quality of alignment for these three breathing maneuvers ranged from 4.69 to 5 at all key anatomic reference points.
TABLE 2: Average Scores of Anatomic Alignment for Five Breathing Protocols
Group No.ProtocolDiaphragmAortic ArchHeartThoracic SpineLung Apices
1Normal expiration4.885555
2Mid suspended breath-hold4.9454.555
3Quiet breathing4.8854.6955
4Small breath in4.064.884.1954.94
5
Regular breath in
3
4.81
3.44
5
4.88
Note—Alignment was scored on a scale of 1 (very poor) to 5 (excellent)
Excellent thoracic anatomic alignment was also found at the aortic arch, spine, and lung apices using the small breath-in and regular breath-in breathing methods. The mean scores ranged from 4.81 to 5. However, significant misalignment of anatomic structures occurred at the diaphragm and heart (Fig. 2). For the small breath-in technique, the mean score at the diaphragm was 4.06 and at the heart was 4.19. For the regular breath-in technique, the mean score at the diaphragm was 3 and at the heart was 3.44.
When comparing breathing methods, no statistically significant difference was found among variations in anatomic alignment for groups 1 (expiration), 2 (mid suspended breath-hold), and 3 (quiet breathing) at any of the anatomic reference points; p values ranged from 0.0579 and 1.0000. Statistically significant misalignment was found at the diaphragm (p < 0.0001) and heart (p < 0.0001) for groups 4 (small breath in) and 5 (regular breath in). No statistically significant difference was found among variations in anatomic alignment at the aortic arch, spine, and lung apices for the small breath-in (group 4) and regular breath-in (group 5) techniques, with p values between 0.0708 and 1.000.
Fig. 1 Excellent anatomic alignment using quiet-breathing CT protocol in 68-year-old man with history of non-Hodgkin's lymphoma. Axial (left), coronal (middle), and sagittal (right) fused PET/CT images show excellent anatomic alignment (score, 5) at diaphragm, heart, aortic arch, lung apices, and spine.
Fig. 2 Anatomic misalignment using regular breath-in CT protocol in 63-year-old man with history of non-small cell lung cancer. Axial (left), coronal (middle), and sagittal (right) fused PET/CT images show misalignment (arrows) at diaphragm (score, 3) and heart (score, 3).

Discussion

The optimal CT breathing protocol for combined PET/CT of the thorax should provide both accurate image fusion and high-quality diagnostic images. To achieve accurate image fusion, the lung volumes on PET and the CT data sets must be matched to achieve a “best fit.” Because PET emission data sets are obtained over 30 minutes and during quiet breathing, a CT data set acquired during quiet breathing or expiration would theoretically provide the best results for image fusion. In two previous studies, Goerres et al. [5, 6] evaluated the effect of various breathing protocols on combined PET/CT image registration in the thorax [5, 6]. In those studies, image registration was assessed using free breathing, maximal inspiration, maximal expiration, and normal expiration CT breathing protocols. They found that optimal image fusion occurred when the CT data set was obtained during normal expiration.
A challenge that we encountered in our practice in using expiratory transmission CT was patient compliance and comfort. Although we found that expiratory data sets provided excellent image alignment, many patients were incapable of maintaining the expiratory breath-hold for the duration of the whole-body CT examination. This resulted in greater compensatory breathing artifacts at the mid scan level (the lower thorax to the upper abdomen) when the patient resumed breathing. We therefore evaluated alternative methods, including mid suspended breath-hold, small breath in, and quiet breathing, to determine whether other methods could provide adequate fusion of PET and CT data sets and maintain patient compliance. We also evaluated fusion of PET with the full inspiratory CT images (group 5) that were obtained during the same scanning session.
Our results show that anatomic alignment was similar whether patients had attenuation-correction CT acquired during expiration, mid suspended breath-hold, or quiet breathing. All three methods produced excellent data set superimposition, with no significant difference in scoring. Inspiratory maneuvers, such as small breath in and regular breath in, however, led to significant misalignment of PET and CT data sets at the heart and diaphragm. Although previous studies reported that shallow expiration provides optimal image coregistration over quiet breathing, our data indicate that expiration, quiet breathing, and mid suspended breath-hold protocols provide equally accurate fusion.
Quiet breathing, suspended breath-hold, and expiration during CT acquisition, however, preclude the acquisition of a truly diagnostic-quality CT scan. Inspiratory CT is important for adequate imaging of most of the thorax and upper abdomen, particularly the lung parenchyma. Significant lung disease, including nodules, interstitial lung disease, and pneumonia, may be masked by atelectasis and motion artifacts. However, the degree of misalignment of the diaphragm and heart between PET and CT during both small breath-in and regular breath-in protocols proves that neither method is appropriate for attenuation-correction CT.
In conclusion, for combined PET/CT of the thorax, excellent image fusion was achieved during expiration, mid suspended breath-hold, and quiet breathing with no significant variation in scoring of anatomic alignment. Inspiratory maneuvers, however, resulted in significant thoracic misalignment, primarily at the heart and diaphragm.
We recommend quiet breathing during attenuation-correction CT acquisition to achieve optimal image fusion and consistent patient compliance. However, for optimal image quality and diagnostic evaluation of the lung parenchyma, an additional diagnostic CT at full inspiration during the same session is recommended.

Footnote

Address correspondence to S. L. Aquino ([email protected]).

References

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Information & Authors

Information

Published In

American Journal of Roentgenology
Pages: 1357 - 1360
PubMed: 17056929

History

Submitted: August 15, 2005
Accepted: October 7, 2005

Keywords

  1. computer-assisted
  2. image analysis
  3. CT
  4. image reconstruction
  5. positron emission
  6. PET/CT

Authors

Affiliations

Matthew D. Gilman
Department of Radiology, Massachusetts General Hospital, FND 202, 55 Fruit St., Boston, MA 02114.
Present address: Department of Radiology, University of Cincinnati Medical Center, Cincinnati, OH.
Alan J. Fischman
Department of Radiology, Massachusetts General Hospital, FND 202, 55 Fruit St., Boston, MA 02114.
Vikram Krishnasetty
Department of Radiology, Massachusetts General Hospital, FND 202, 55 Fruit St., Boston, MA 02114.
Elkan F. Halpern
Institute for Technology Assessment, Massachusetts General Hospital, Boston, MA.
Suzanne L. Aquino
Department of Radiology, Massachusetts General Hospital, FND 202, 55 Fruit St., Boston, MA 02114.

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