Evolve.

Adapt.
Overcome.
CEFI is now ready.

SPECT/CT
ALCANCE ANNE
ALDAY ARMAGNE
ORNEDO STEPHANIE
VERTERA CHERRIEL
VILLA NIERO
 COLLEGE OF RADIOLOGIC TECHNOLOGY

Overview of SPECT/CT
• Functional nuclear medicine imaging with single-photon emission CT (SPECT) in
combination with anatomical CT has been commercially available since the
beginning of this century.
• The combination of the two modalities has improved both the sensitivity and
specificity of many clinical applications and CT in conjunction with SPECT that
allows for spatial overlay of the SPECT data on good anatomy images.
• Introduction of diagnostic CT units as part of the SPECT/CT system has also
potentially allowed for a more cost-efficient use of the equipment. Most of the
SPECT systems available are based on the well-known Anger camera principle
with NaI(Tl) as a scintillation material, parallel-hole collimators and multiple
photomultiplier tubes, which, from the centroid of the scintillation light,
determine the position of an event.
 COLLEGE OF RADIOLOGIC TECHNOLOGY

Overview of SPECT/CT

• Recently, solid-state detectors using cadmium-zinc-telluride

became available and clinical SPECT cameras employing multiple
pinhole collimators have been developed and introduced in the
market.
• However, even if new systems become available with better
hardware, the SPECT reconstruction will still be affected by photon
attenuation and scatter and collimator response. Compensation for
these effects is needed even for qualitative studies to avoid
artefacts leading to false positives.
 COLLEGE OF RADIOLOGIC TECHNOLOGY

Overview of SPECT/CT

• SPECT/CT has proven to be valuable in oncology. For example, in

the case of a patient with metastatic thyroid cancer, neither SPECT
nor CT alone could identify the site of malignancy.

• SPECT/CT, a hybrid image, precisely identified where the surgeon

should operate.

• However SPECT/CT is not just advantageous in oncology. It may also

be used as a one-stopshop for various diseases..
 COLLEGE OF RADIOLOGIC TECHNOLOGY

HYBRID IMAGING
• SPECT and CT are tomographic imaging procedures, each one with
separately proven good diagnostic performance.
• SPECT produces computer-generated images of local radiotracer
uptake, while CT produces 3-D anatomic images of X ray density of
the human body.
• Combined SPECT/CT imaging provides sequentially functional
information from SPECT and the anatomic information from CT,
obtained during a single examination.
• CT data are also used for rapid and optimal attenuation correction of
the single photon emission data
 COLLEGE OF RADIOLOGIC TECHNOLOGY

How a SPECT/CT Scan Works

• A SPECT/CT scan typically involves 3 main components:

1. A radioactive tracer is injected into the body’s bloodstream. This

tracer can be seen by a gamma scanner, which shows metabolic
functions of tissues and organs, such as blood flow and potential
abnormalities in the tissues.

2. A CT scan is taken with an x-ray scanner rotating around the body

region being studied.
 COLLEGE OF RADIOLOGIC TECHNOLOGY

How a SPECT/CT Scan Works

• 3. A SPECT scan is taken with a gamma scanner rotating around the

body region being studied, which takes much longer than the CT
scan.

• Since the SPECT and CT scans both form cross-section images of the
same areas, the computer is able to combine these images. The
resulting cross-section images show the x-ray images of the bones
overlaid with the nuclear imaging.
 COLLEGE OF RADIOLOGIC TECHNOLOGY

General architecture of SPECT/CT devices

• SPECT/CT systems have the same SPECT component as conventional
nuclear medicine systems, the dual-head gamma cameras are
generally used for planar and tomographic imaging of single photon
emitting radiotracers.

• The CT component of the first-generation hybrid devices used a low

resolution CT detector.

• While recently developed, second-generation SPECT/CT systems

incorporate a variety of multi-slice CT scanners.
 COLLEGE OF RADIOLOGIC TECHNOLOGY

General architecture of SPECT/CT devices

• SPECT/CT systems include separate
CT and gamma camera devices
using common or adjacent
mechanical gantries, and sharing
the same scanning table.
Integration of SPECT and X ray
imaging data is performed by a
process that is similar to that of
PET/CT.
SPECT/CT SCANNER 500X500
 COLLEGE OF RADIOLOGIC TECHNOLOGY

• X ray scatter can reach and possibly damage the SPECT detectors designed for
radionuclide low count rate imaging.

• Therefore, in a hybrid system the SPECT detectors are off-set in the axial
direction from the plane of the X ray source and detector. In a hybrid system
both detectors have to be able to rotate and position accurately for
tomographic imaging.

• In this regard, accuracy of translation and angular motion differs from one
imaging system to another.

• While CT requires the highest accuracy, SPECT (with a lower spatial resolution)
can perform clinical images with a motion accuracy of slightly less than one
 COLLEGE OF RADIOLOGIC TECHNOLOGY

• SPECT/CT systems using a low-dose single- or multi-slice CT have both

the SPECT and the CT detectors mounted on the same rotating platform.
• Imaging is performed while the detectors are rotating sequentially
around the patient. While this concept has the advantage of using the
gantry of a conventional gamma camera for both imaging modalities, it
limits the rotational speed of the SPECT/CT option to approximately 20
seconds per rotation.
• In SPECT/CT systems incorporating diagnostic CT scanners, the gamma
camera detectors are mounted on a different platform, separated from
the high speed rotating CT device (0.25 to 0.5 s per revolution).
• This design increases the performance of the CT subsystem, but it also
increases the complexity of the gantry and the cost of the technology.
 COLLEGE OF RADIOLOGIC TECHNOLOGY

• Dual modality imaging requires longer stretchers than single modality

imaging devices.
• While built to support patients weighing up to 500 pounds, these scanning
tables, extended to accommodate the needs of both components (SPECT
and CT), deflect to some degree while loaded with normal adult patients.
• The extension and degree of deflection of the table can introduce a
patient-dependent mis-registration between CT and SPECT data.
• One solution to this problem is the design of a table supported on its base
at the front of the scanner as well as at the far end of the X ray system,
thus minimizing the table deflection.
• Another solution is to use a table fixed on a base, moving on the floor to
introduce the patient into the scanner.
 COLLEGE OF RADIOLOGIC TECHNOLOGY

• The workstation of the SPECT/CT device is responsible for system

control, data acquisition, image reconstruction and display, as well
as data processing and analysis.
• CT data are calibrated in order to obtain attenuation correction
maps for the SPECT images.
• SPECT and CT images are displayed on the same screen in addition
to the fused images, which represent the overlay of a coloured
SPECT over a grey-scale CT image.
• A 3-D display with triangulation options allows to locate lesions and
sites of interest on the CT image and to redisplay them on the
registered SPECT and fused SPECT/CT images.
 COLLEGE OF RADIOLOGIC TECHNOLOGY

SPECT/CT acquisition protocols

• Acquisition on SPECT/CT systems is performed in a sequential mode.

• With devices that have a low-dose CT component, data are typically acquired
by rotating the X ray detector 220° around the patient, with the X ray tube
operated at 140 kV and 2.5 mA.

• The CT images obtained have an in-plane spatial resolution of 2.5 mm, and of
10 mm in the axial direction.

• Scan time is approximately 16 s per slice, for a total study duration of 10 min
for the CT.
 COLLEGE OF RADIOLOGIC TECHNOLOGY

• SPECT/CT systems using a diagnostic CT component are

characterized by higher spatial resolution and faster scanning time
(approximately 30s for the whole field of view), associated however
with higher radiation doses.

• An attenuation map is created at the end of the CT acquisition

time.
 COLLEGE OF RADIOLOGIC TECHNOLOGY

• The SPECT component is represented by a rotating, dual-head,

variable angle sodium-iodide scintillation camera.

• The detectors can be placed either in a 180° or a 90° position.

Regardless of the type of SPECT/CT that is used, SPECT acquisition
currently requires a routine scanning time of approximately 20–30
min, depending on the radiotracer, as for stand-alone SPECT
acquisition protocols.

• SPECT is reconstructed using iterative methods incorporating photon

attenuation correction based on the X ray transmission map and
scatter correction.
 COLLEGE OF RADIOLOGIC TECHNOLOGY

• Since X ray and radionuclide data are not acquired simultaneously,

SPECT images are not contaminated by scatter radiation generated
during the X ray image acquisition.

• Also, since the patient is not removed from the table, both imaging
components are acquired with a consistent and identical patient
position, allowing accurate image registration if we assume that the
patient has not moved during the entire duration of the SPECT/CT
study.
 COLLEGE OF RADIOLOGIC TECHNOLOGY

• CT is usually acquired in matrices of 512 × 512 with the newest CT

scanners, or 256 × 256 in older scanners, and has to be resized into
slices with the same pixel format and slice width as SPECT.

• Spatial registration of the CT and SPECT acquisitions is important

since misalignment of the attenuation map relative to
corresponding radionuclide images can cause ‘edge artefacts’,
bright and dark ‘rims’ across edges of these regions.
 COLLEGE OF RADIOLOGIC TECHNOLOGY

• SPECT/CT image mis-registration or blurring may occur, mainly due to

patient movement as well as respiration, cardiac motion, and peristalsis.

• Differences in urinary bladder filling can lead to erroneous co-

registration between SPECT and CT acquisitions.

• With SPECT/CT devices equipped with low-dose X ray tubes, CT is

performed during shallow breathing to facilitate image registration.
•
• However, the longer acquisition time increases the chances for patient
motion.
 COLLEGE OF RADIOLOGIC TECHNOLOGY

• With hybrid devices equipped with multi-slice CT, anatomic imaging

is acquired following breath-hold, during tidal breathing, or during
a short part of the respiratory cycle, whereas SPECT data are
acquired over several minutes.

• This again can lead to misregistration. In addition to fault

localization, non-registered attenuation maps can lead to under- or
overestimation of radionuclide uptake.
 COLLEGE OF RADIOLOGIC TECHNOLOGY

• The presence of contrast media in the CT images acquired as part of the

SPECT/CT study complicates the attenuation correction process.

• Also, high concentrations of intra-venous contrast material captured

during the CT acquisition may have redistributed by the time the SPECT
acquisition is performed.

• Image segmentation techniques separating different areas inside the

images may solve this problem, or alternatively, a very low powered non-
contrast CT can be performed prior to the SPECT for attenuation
correction, followed by the contrast CT study as the last step.
 COLLEGE OF RADIOLOGIC TECHNOLOGY

Technical staffing for SPECT/CT

• A major asset for proper implementation of novel SPECT/CT procedures is
the technologist.

• It is important to take the time to train and educate the technologists so

that they can deliver an end product of the highest quality.

• While it is preferable for technologists to have their work product directly

checked by the interpreting physician before the patient leaves the
department, in some outpatient settings technologists must make their own
decision, and therefore they need to be well trained and using robust and
reproducible protocols.
 COLLEGE OF RADIOLOGIC TECHNOLOGY

• The new generation technologists therefore have to be trained in nuclear

medicine and CT, to have experience in reviewing scans and to be able to
identify artefacts occurring during acquisition of studies.

• Instructing the technologists about pertinent history questions and designing

a template to be filled out for each patient will ensure that all of the clinical
information to further assist in the reading of the images is available.

• Training requirements for CT and SPECT technologists differ in various

countries.

• Under ideal circumstances a technologist should be fully trained, experienced

and certified in both nuclear and X ray/CT technologies.
 COLLEGE OF RADIOLOGIC TECHNOLOGY

ADVANTAGES OF UTILIZING SPECT/CT

• Image registration is defined as the transfer of two image data sets
into one common coordinate system.

• It may be mono or bimodal, i.e. between images acquired by one

single modality or by two different modalities.

• Depending on the nature of the transformations used, rigid or non-

rigid approaches can be used for this purpose, the former allowing
for non-linear, ‘plastic’ deformation of the image data sets.
 COLLEGE OF RADIOLOGIC TECHNOLOGY

• A further distinction can be made between software based registration of data sets
acquired independently one from each other by two different imaging devices and
hardware based registration where the two data sets are obtained by hybrid
equipment in a single imaging session.

• One major drawback of software based image fusion is logistic in nature: in the daily
clinical routine of many institutions, image data sets from different modalities can be
exchanged between different departments only with some difficulty.

• Although the implementation of hospital embracing picture-archiving systems should

overcome these difficulties, software based registration suffers from anatomical
inaccuracies stemming from different positioning of the patient in the two separate
imaging devices as well as by difficulties in identifying landmarks common to both data
sets to be registered.
 COLLEGE OF RADIOLOGIC TECHNOLOGY

• The development of hybrid imaging devices witnessed in the last decade marks
a new trend in medical imaging involving the registration and fusion of all
image data sets of one individual patient using the same computer platform.

• Current available data has already proven a major clinical impact of this
approach, which is also expected to increase cost effectiveness.

• The field will be driven by the development of new hybrid imaging devices, but
also by significant improvements of software based image fusion.

• Future medical imaging departments will offer a multimodal environment

integrating both hybrid imaging and software based image fusion into the daily
clinical routine.
 COLLEGE OF RADIOLOGIC TECHNOLOGY

Additional information or diagnosis from CT

• With continuous higher-speed and thinner sliced CT, small lung lesions (less
than 1 cm in diameter) showing interval increase in size may often be
detected.

• Small non-specific lymph nodes, low-density hepatic or renal lesion, and

osteolytic or osteoblastic lesion with interval increase in size are also
incidentally identified.

• These lesions are generally beyond the resolution of our current SPECT or PET
system and may require further short term follow-up studies to
confirm/exclude the diagnosis of new metastases.
 COLLEGE OF RADIOLOGIC TECHNOLOGY

Radiation dose of CT from SPECT/CT

• The radiation absorbed dose delivered to the patient from the use of CT in
SPECT/CT study is difficult to measure because of many factors involved,
but the CT Dose Index (CTDI) based on scan parameters can be calculated,
and represents an index of radiation dose to a standard phantom.
• The CT scanners generally provide an X ray tube current modulation
function that makes uniform image quality and dose for various patient
sizes.
• The system will automatically increase or decrease the tube current (mA)
when the user selects a reference effective mA in response to changes in
diameter or tissue density of the patient.
 COLLEGE OF RADIOLOGIC TECHNOLOGY

• The effective mA includes the tube current, rotation speed, and pitch
used for the scan. The user-selected scan parameters that affect patient
dose in CT examinations are effective mA, kVp, detector collimation
setting (affecting the width of the radiation beam in table-travel
direction), beamshaping filter associated with the scan type (body or
head), and number of scans over the same section of the body.

• If the dose distribution from the centre to the edge of the phantom as
well as the pitch used in the scan is taken into account, a term called
CTDIvol can be used to represent the dose index to the volume of the
phantom.
 COLLEGE OF RADIOLOGIC TECHNOLOGY

• The radiation dose is energy absorbed per unit mass.

• The CTDIvol associated with a single CT scan covering one SPECT be

position is the same as the CTDIvol for a CT scan covering two no -
overlapped SPECT bed positions if the same CT scan parameters are
used.

• However, there is a factor of two variation in the radiation risk to

the patient between these two cases. The CTDIvol in milliGray
(mGy) is multiplied by the length of the CT scan in cm, to yield the
dose-length product (DLP).
 COLLEGE OF RADIOLOGIC TECHNOLOGY

• Once the DLP is determined, an effective dose can be estimated

using conversion factors for the relative radiosensitivity of the
organs within the range of the scan.

• Some CT scanners save the CDTIvol and DLP values for a specific
patient scan at the end of the examination.

• If there are multiple CT scans of the same region of the patient,

each scan adds to the radiation dose and risk.
 COLLEGE OF RADIOLOGIC TECHNOLOGY

GENERAL NUCLEAR MEDICINE SPECT/CT PROCEDURES

• The SPECT component of the SPECT/CT procedure is performed using the
acquisition protocols routinely employed for the dual-head gamma camera.
This device is equipped with collimators adequate for the specific
radioisotope in use, such as low energy, high resolution parallel hole
collimators for 99mTc, or medium energy collimators for 67Ga, 111In or 131I.

• Imaging is typically performed with the detectors facing each other at 180°,
typically acquiring 120 projections over a 360° orbit and using a time per
projection of 40–50 s. A 64 × 64 matrix is commonly employed for the low
count isotopes, while the higher resolution 128 × 128 matrix can be applied
for the higher count rates typically generated by 99mTc.
 COLLEGE OF RADIOLOGIC TECHNOLOGY

• CT images are obtained immediately following the SPECT acquisition. For the
low-dose CT devices the acquisition parameters include settings at 140 kV, 1–2.5
mA, 13 s/slice, 256 × 256 image matrix, 5 mm slice thickness and slice spacing.

• For diagnostic CT acquisitions the settings are 140 kV, 80 mA, 1 s/slice, 512 ×
512 image matrix, 48 cm reconstruction diameter, 5 mm slice thickness and slice
spacing.

• Skeletal CTs of diagnostic quality can be performed at lower mAs products to

reduce the radiation exposure of the patient.

• A variety of other settings are possible depending on the specific diagnostic

question asked of the CT scanner.
 COLLEGE OF RADIOLOGIC TECHNOLOGY

• These include, in particular, protocols to perform low powered CT

with the multidetector scanners, e.g. when a CT of diagnostic
quality is already available or high powered CT is not deemed
necessary for the particular question under study.

• Some strategies restrict the CT field of view to the regions

exhibiting SPECT abnormalities, thus reducing the radiation dose
delivered to the patient even further.

• Data are reconstructed using filtered back-projection software and

filters provided by the manufacturer
 COLLEGE OF RADIOLOGIC TECHNOLOGY

• Co-registered CT and SPECT are acquired by translating the patient

from one detector to the other while the patient remains lying on
the same table. This allows the CT and radionuclide images to be
acquired with a consistent scanner geometry and body habitus, and
with a minimal delay between the two acquisitions.
 COLLEGE OF RADIOLOGIC TECHNOLOGY

SPECT/CT Procedures
1. 67Ga-citrate SPECT/CT in lymphoma.
67
Ga-citrate scintigraphy has long been shown to be useful for
evaluating patients with lymphoma, and SPECT/CT has further improved its
diagnostic sensitivity as well as localization of areas with abnormal tracer
uptake.

2. Lymphoscintigraphy .
Accurate lymph node staging is essential for the treatment and
prognosis in patients with cancer. The sentinel lymph node is the first node
to which lymphatic drainage and metastasis from the primary tumour occur.
 COLLEGE OF RADIOLOGIC TECHNOLOGY

3. Skeletal scintigraphy for staging malignant disease.

Scintigraphic imaging of bone metabolism is a cost efficient way to prove or exclude
skeletal metastases in patients with tumours prone to metastasize to the skeleton, such as
breast,prostate, or lung carcinomas.

4. Skeletal SPECT/CT in orthopaedics.

Up until approximately 20 years ago, planar X ray and skeletal scintigraphy were the
imaging procedures of choice in patients with benign orthopaedic disease. Although MRI has
brought a dramatic change to the predominance of radionuclide imaging in this field, skeletal
scintigraphy still holds the promise of sensitively depicting functional alterations of bone.

5. 201Tl-chloride in cerebral masses .

Co-registration and fusion of 201Tl SPECT with CT could thus optimize postoperative
radiation therapy planning through a truly anatomo-metabolic image.
 COLLEGE OF RADIOLOGIC TECHNOLOGY

Other SPECT/CT Procedures

1. 131
I-Iodide SPECT/CT in thyroid cancer .

2. Neural crest and adrenal tumours

3. 111
In-octreotide SPECT/CT for assessing neuroendocrine tumours.

4. 99m
Tc-depreotide in solitary pulmonary nodules .

5. ProstaScintigraphy .

6. SPECT/CT in the preoperative localization of parathyroid adenomas.

7. SPECT/CT for diagnosing infection and inflammation.

 COLLEGE OF RADIOLOGIC TECHNOLOGY

Cardiac SPECT/CT procedures

1. Myocardial perfusion imaging — CT based attenuation correction.

2. Cardiac SPECT/CTA for assessing the significance of coronary artery

lesions.

3. Added values of CT in patients with coronary artery disease .

A. Coronary artery calcium.
B. Coronary computed tomography angiography .
C. Pulmonary artery imaging in pulmonary embolism.
 COLLEGE OF RADIOLOGIC TECHNOLOGY

TABLE 1. SPECIFIC RADIOTRACERS

Character of cancer cells Compounds
• Cellular growth • Tc-deoxyglucose
99m

• 99m
Tc-guanine
• Hypoxia • 99m
Tc-metronidazole
• 99m
Tc-endostatin
• Angiogenesis • 99m
Tc-bevacizumab (against VEGF
receptor)
• Apoptosis • 99mTc-annexin-V

• Hormones • 99m
Tc-estradiol
 COLLEGE OF RADIOLOGIC TECHNOLOGY

References
• IAEA (International Atomic Energy Agency)
https://www.alasbimn.net/biblioteca/publicaciones/Clinical_SPECT-
CT.pdf