Atlas of Hybrid Imaging Sectional Anatomy for PET/CT, PET/MRI and SPECT/CT Vol. 3: Heart, Lymph Node and Musculoskeletal System: Sectional Anatomy for PET/CT, PET/MRI and SPECT/CT 0443188181, 9780443188183

Table of contents :
Front Cover
Atlas of Hybrid Imaging
Atlas of Hybrid Imaging
Copyright
Dedication
Contents
Preface
Acknowledgments
1 - Heart
Introduction: 3D-CT volume rendering of anatomy
1.1 Myocardial imaging
1.1.1 Short axis
1.1.2 Horizontal long axis
1.1.3 Vertical long axis
1.2 Clinical cases, tricks, and pitfalls
1.2.1 18F-FDG
1.2.2 99mTc-tetrofosmin
1.2.3 99mTc-MIBI
1.2.4 123I-MIBG
1.2.5 99mTc-MDP
References
2 - Lymph nodes
Introduction: 3D-CT volume rendering of anatomy
2.1 Head and neck
2.2 Thorax
2.3 Abdomen
2.4 Pelvis
2.5 Clinical cases, tricks, and pitfalls
2.5.1 18F-FDG
2.5.2 18F-choline
2.5.3 64Cu-PSMA
2.5.4 68Ga-DOTATOC
2.5.5 99mTc-radiocolloid
References
3 - Musculoskeletal system
Introduction: 3D-CT volume rendering of anatomy
3.1 Spinal column
3.2 Joints
3.2.1 Shoulder
3.2.2 Hip
3.2.3 Knee
3.3 Clinical cases, tricks, and pitfalls
3.3.1 18F-FDG
3.3.2 18F-NaF
3.3.3 18F-choline
3.3.4 99mTc-labeled leukocytes
3.3.5 99mTc-MDP
References
Index
Vol. 3
Back Cover

Citation preview

Atlas of Hybrid Imaging Sectional Anatomy for PET/CT, PET/MRI and SPECT/CT Vol. 3: Heart, Lymph Node and Musculoskeletal System

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Atlas of Hybrid Imaging

Sectional Anatomy for PET/CT, PET/MRI and SPECT/CT Vol. 3: Heart, Lymph Node and Musculoskeletal System

Mario Leporace Department of Nuclear Medicine and Theranostics, Cosenza Hospital, Italy

Ferdinando Calabria Department of Nuclear Medicine and Theranostics, Cosenza Hospital, Italy

Eugenio Gaudio Department of Human Anatomy, “La Sapienza” University, Rome, Italy

Orazio Schillaci Department of Biomedicine and Prevention, “Tor Vergata” University, Rome, Italy

Alfonso Ciaccio Department of Nuclear Medicine and Theranostics, Cosenza Hospital, Italy

Antonio Bagnato Department of Nuclear Medicine and Theranostics, Cosenza Hospital, Italy

Academic Press is an imprint of Elsevier 125 London Wall, London EC2Y 5AS, United Kingdom 525 B Street, Suite 1650, San Diego, CA 92101, United States 50 Hampshire Street, 5th Floor, Cambridge, MA 02139, United States The Boulevard, Langford Lane, Kidlington, Oxford OX5 1GB, United Kingdom Copyright © 2023 Elsevier Inc. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Details on how to seek permission, further information about the Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website: www. elsevier.com/permissions. This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein). Notices Knowledge and best practice in this field are constantly changing. As new research and experience broaden our understanding, changes in research methods, professional practices, or medical treatment may become necessary. Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds, or experiments described herein. In using such information or methods they should be mindful of their own safety and the safety of others, including parties for whom they have a professional responsibility. To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume any liability for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein. ISBN: 978-0-443-18818-3 For information on all Academic Press publications visit our website at https://www.elsevier.com/books-and-journals

Publisher: Stacy Masucci Acquisitions Editor: Katie Chan Editorial Project Manager: Sam W. Young Production Project Manager: Omer Mukthar Cover Designer: Christian J. Bilbow Typeset by TNQ Technologies

Dedication To my wife Fedora, my great love, and Luigivittorio and Niccolo`, my beloved children.

ML

To Giuliana, my best friend and one true love, and to Vittoria and Francesca Junia, the sweetest things of our life.

FC

To Ida, my beloved wife.

EG

To Nicoletta, Maria Beatrice, and Agnese Felicia.

OS

To my father Severino, better than a hundred teachers. AC To Mariella.

AB

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Contents Preface Acknowledgments

ix xi

1. Heart Introduction: 3D-CT volume rendering of anatomy Introduction: 3D-18F-FDG PET volume rendering of myocardial viability 1.1 Myocardial imaging 1.1.1 Short axis 1.1.2 Horizontal long axis 1.1.3 Vertical long axis 1.2 Clinical cases, tricks, and pitfalls 1.2.1 18F-FDG 1.2.2 99mTc-tetrofosmin 1.2.3 99mTc-MIBI 1.2.4 123I-MIBG 1.2.5 99mTc-MDP References

2 6 10 10 22 34 46 46 49 51 53 54 55

2. Lymph nodes Introduction: 3D-CT volume rendering of anatomy 2.1 Head and neck 2.2 Thorax 2.3 Abdomen

58 72 90 110

2.4 Pelvis 2.5 Clinical cases, tricks, and pitfalls 2.5.1 18F-FDG 2.5.2 18F-choline 2.5.3 64Cu-PSMA 2.5.4 68Ga-DOTATOC 2.5.5 99mTc-radiocolloid References

122 136 136 153 157 159 161 163

3. Musculoskeletal system Introduction: 3D-CT volume rendering of anatomy 3.1 Spinal column 3.2 Joints 3.2.1 Shoulder 3.2.2 Hip 3.2.3 Knee 3.3 Clinical cases, tricks, and pitfalls 3.3.1 18F-FDG 3.3.2 18F-NaF 3.3.3 18F-choline 3.3.4 99mTc-labeled leukocytes 3.3.5 99mTc-MDP References Index

168 176 196 196 206 218 238 238 252 255 258 263 272 275

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Preface The advent of hybrid scanners in nuclear medicine has considerably improved quality of the discipline. To date, SPECT/CT and PET/CT play a crucial role in diagnosis, treatment planning, and assessment of response to therapy in oncology, with novel applications in neurology, cardiology, and infectious diseases. More recently, PET/MRI has considerably enlarged the panorama of hybrid imaging and is opening new challenges in neurooncology, oncology, and neurodegenerative disorders. In fact, the high sensitivity provided by nuclear medicine imaging finds a valid counterpart in the better specificity provided by the low-dose CT, generally associated with PET, and, when possible, SPECT scans. The added value of this coregistered low-dose CT is defined by a better diagnostic accuracy due to higher specificity, allowing adequate anatomical localization of pathologic functional findings and accurate depiction of false-positive or false-negative cases that can occur in clinical practice with all radiopharmaceuticals. All PET scans in oncology are coregistered with a low-dose CT for attenuation correction and anatomical landmarks. The CT component of a PET/CT scan is also an authentic trait d’union between nuclear medicine imaging and contrast enhanced CT and MRI, being an anatomical basis for comparison of functional imaging with advanced morphological imaging. This feature is of the utmost importance; in fact, though not accurate as full-dose contrast-enhanced CT, the lowdose CT of PET/CT offers significant anatomical information (i.e., on the lungs, bones, and soft tissues) strengthening confidence in diagnosis and helping nuclear physicians to compose more exhaustive medical reports. These characteristics will have a significantly higher impact in PET/MRI realm, considering the large availability of sequences, the optimal power resolution limit of MRI, and correlative advanced studies of molecular imaging as DiffusionWeighted Imaging or MR Spectroscopy. Therefore, the challenge for nuclear physicians in the rising era of hybrid imaging is due to the following: l l

the definitive transition from 2D to 3D medical images; accurate knowledge of anatomical landmarks in multiplanar hybrid views.

The 2.0 nuclear medicine should be aimed to improve the quality of postprocessing and reports in order to optimize the dialogue with radiologists as well as oncologists and clinicians of diverse specialties. It is also necessary to state that the versatility of 18F-FDG (the miliar stone among PET tracers), and the rapid development of a large amount of PET tracers, enlarged PET molecular imaging to new fields of interest in neurology, cardiology, infectious diseases, and neurooncology, while new molecular frontiers are under investigation. Some of these new molecular probes, 18FeNaF, amyloid tracers, amino acid radiopharmaceuticals such as 18F-FET, 18 F-DOPA, radiolabeled choline, and 68Ga-labeled somatostatin analogues, significantly expanded the panorama of molecular imaging with PET. Finally, the advent of theragnostics, a new discipline where diagnosis and therapy are strictly linked and modulated by radiopharmaceuticals and PET imaging, imposes to improve the knowledge of sectional anatomy for an optimal assessment of response to therapy. It is worth to mention that hybrid, molecular imaging is the pillar of the new era of nuclear medicine, an eclectic discipline which is skin changing and evolving as leading medical specialty. Several atlas are already available for intepretation of CT and MRI, but these volumes are generally aimed to radiologists. In our opinion of nuclear physicians and radiologists with expertise on hybrid imaging, a volume focused on residents in nuclear medicine and/or radiology or young specialists is still needed, as a daily guide to medical reports; however, it could easily be useful for nuclear physicians and/or radiologists aiming to improve experience in hybrid imaging or for specialists interested in diagnostic imaging (radiotherapists, cardiologists, neurologists, etc.). The aim of our book is to give to young nuclear physicians and radiologists a rapid, concise guide to radiological anatomy as support for nuclear medicine findings, with emphasis on the role of coregistered CT and MRI in improving

ix

x Preface

diagnosis and correctly detect false-positive and false-negative cases. Therefore, each chapter is focused on a specific segment of the human body, with three-dimensional introductive views followed by commented low-dose CT views in every plane, to depict sectional anatomy. Terminology of anatomical landmarks is preferentially in accordance with the International Anatomical Terminology, following guidelines of the Federative International Programme for Anatomical Terminology (FIPAT) of the International Federation of Associations of Anatomists (IFAA), with the addendum, when proper, of a correlative radiological synonym in routine practice. All low-dose CT views are associated with corresponding PET/CT views and, as standard of quality imaging, contrastenhanced CT or MRI. CT, MRI, and PET/CT images are also provided, when needed, by brief comments on their features, especially on the visual and/or semiquantitative assessment of tracer uptake in tissues, in order to introduce the reader to the analysis of fused PET/CT images, in color scale. This volume provides a complete coverage of CT sectional anatomy of the brain, neck, thorax, abdomen, and pelvis, while special chapters are focused on the musculoskeletal system, cardiac imaging, and lymph nodes. PET/MRI schemes are also provided for some peculiar anatomical districts as the brain, neck, and pelvis. Anatomical terms and descriptions are prevalently based on Terminologia Anatomica. Moreover, only literature data explain the most commonly used PET tracers, depicting their peculiar molecular pathways, the physiological distribution, common pathologic findings, and diagnostic pitfalls. The currently available atlas of imaging, only focused on anatomy, does not address these contents. At the end of each chapter, a special paragraph shows and discusses clinical cases, pitfalls, and anatomical variants, in order to explain peculiarities, intrinsic properties, concordance, or mismatches between nuclear medicine findings and CT or MRI, as well as teaching points to explain radiological imaging criteria. Clinical cases and pitfalls are referred to several PET and SPECT radiopharmaceuticals, in order to show and discuss peculiar conditions linked to specific tracers. Essential references are reported in order to allow the readers to refer back to any source that can be linked to covered topics. We hope to have centered our ambitious scope: to offer to nuclear physicians and colleagues a rapid, easy to consult, didactic guide toward hybrid, molecular imaging. Mario Leporace Ferdinando Calabria

Acknowledgments We wish to express very great appreciation to our colleagues for their recommendations, enthusiastic encouragement, and help in difficult situations: Rosanna Tavolaro, Maria Toteda, Stefania Cardei, and Antonio Lanzillotta. A debt of gratitude is owed to our Roman colleagues for their valuable suggestions: Armando Mancinelli and Mauro Di Roma. A special thanks to Professor Antonio Cerasa: we carefully followed your experience! We would like to particularly extend thanks to Daniela de Silva and technicians radiologists, and nurses of our department for their work and patients care. Humbly, we are grateful to our professors and to the pioneers of our discipline for letting us see further by standing on their shoulders.

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Chapter 1

Heart Abstract The 18F-FDG is the most available tracer for myocardial imaging, showing high sensitivity for the detection of hibernating/viable myocardium; this radiopharmaceutical is also useful in the management of endocarditis. However, myocardial PET cannot replace myocardial perfusion SPECT. PET/SPECT and cardiac CT provide complementary information on myocardial perfusion/viability, to improve the detection and monitoring of coronary artery disease. Cardiac CT can identify location and severity of stenoses, while SPECT may detect effective perfusion defects and 18F-FDG PET may assess viable myocardium. This chapter offers multiplanar views of 18 F-FDG PET of the left ventricle on short axis, vertical, and horizontal long axes related to corresponding cardiac CT and MRI views, in order to improve confidence in hybrid evaluation of the heart, being all these diagnostic tools mutually reinforcing. PET and SPECT clinical cases with different radiopharmaceuticals (18F-FDG, 99mTc-Tetrofosmin, 99mTc-MIBI, 123I-MIBG, 99mTc-MDP) are reported, particularly emphasizing the role of multimodal imaging. Keywords:

18

F-FDG;

99m

Tc-MIBI; Cardiac CT; Coronaries; Ischemia; Myocardium; Perfusion; PET/CT; SPECT; Viability

Atlas of Hybrid Imaging. https://doi.org/10.1016/B978-0-443-18818-3.00001-2 Copyright © 2023 Elsevier Inc. All rights reserved.

1

2

Atlas of Hybrid Imaging

Introduction: 3D-CT volume rendering of anatomy

Coronary (atrioventricular) sulcus Longitudinal (interventricular) sulcus (anterior and posterior)

Heart Chapter | 1

The crux cordis or crux of the heart is the zone of juncon of the coronary sulcus and the posterior longitudinal sulcus [1].

Ao PA RAA RA RVOT RV SVC IVC LA LAA LV RPV LPV

See Ref [1]

Aorta Pulmonary artery Right atrial appendage (right auricle) Right atrium Right ventricular outflow tract (pulmonary conus) Right ventricle Superior vena cava Inferior vena cava Left atrium Left atrial appendage (left auricle) Left ventricle Right pulmonary vein Left pulmonary vein

3

4

Atlas of Hybrid Imaging

Heart Chapter | 1

The coronary artery are classified according to the American Heart Association into 15 segments model [2].

1 2 3 4 5 6 7 8

RCA e Right coronary artery/proximal RCA e Right coronary artery/middle RCA e Right coronary artery/distal PDA e Posterior descending artery LCA e Left main coronary artery LAD e Left anterior descending artery/proximal LAD e Left anterior descending artery/middle LAD e Left anterior descending artery/distal

See Ref [2]

9 10 11 12 13 14 15

D1 e First diagonal branch D2 e Second diagonal branch LCX e (Left) Circumflex artery/proximal OM e (Left) Obtuse marginal branch LCXe (Left) Circumflex artery/distal PL e Posterolateral branch PD e Posterior descending branch

5

6

Atlas of Hybrid Imaging

Introduction: 3D-18F-FDG PET volume rendering of myocardial viability

Heart Chapter | 1

1

2

3

4

Gated SPECT/PET myocardial imaging offers the opportunity to display 3D images of the left ventricle, from end-diastole to endsystole, which may be rotated to view all angles, also assessing ventricular kinetic, wall motion and ejection fraction with dynamic cine views, in a single imaging session [3]. 1 2 3 4 See Ref [3]

Anterior wall Lateral wall Inferior wall Septum

5 Apex 6 Mitral annular plane 7 Ventricular cavity

7

Polar maps are twodimensional displays of the 3D tracer distribution in the myocadium, looking from the center (apex) to the base of the heart. Polar maps can be divided following myocardial walls, territories of coronary arteries and myocardial segments [4].

Relation between coronaries and myocardial viability with 18F-FDG PET on the basis of the right coronary arterial dominance, documented in the majority of patients. The current scheme does not account anatomical variants and potential myocardial vascularization territory overlap [5].

Heart Chapter | 1

1 2 3 4 5 6 7 8 9 See Refs [4,5]

Basal anterior Basal anteroseptal Basal inferoseptal Basal inferior Basal inferolateral Basal anterolateral Mid anterior Mid anteroseptal Mid inferoseptal

10 11 12 13 14 15 16 17

Mid inferior Mid inferolateral Mid anterolateral Apical anterior Apical septal Apical inferior Apical lateral Apex

9

1.1 Myocardial imaging 1.1.1 Short axis

Heart Chapter | 1

1

The diffuse 18F-FDG uptake in the myocardium, following oral glucose and intravenous insulin loading, allows imaging of myocardial metabolism and viability by means of PET [6].

Left Anterior Descending (LAD) Right Coronary Artery (RCA) (Left ) Circumflex Artery (LCX)

1 Apex See Ref [6]

11

Computed Tomography of the heart or cardiac CT is routinely performed to gain knowledge about cardiac or coronary anatomy, to diagnose coronary artery disease, to evaluate coronary artery bypass grafts or implanted coronary stents or to evaluate volumetry and cardiac function [7].

Heart Chapter | 1

13

1

2

3

4

Left Anterior Descending (LAD) Right Coronary Artery (RCA) (Left ) Circumflex Artery (LCX) 1 Ventricular septum 2 Anterior wall

See Ref [7]

3 Inferior wall 4 Lateral wall

Cardiac MRI is a diagnostic tool for noninvasive assessment of the function and structure of the cardiovascular system. Indications include assessment of myocardial ischemia and viability, cardiomyopathies, myocarditis, iron overload, vascular diseases, and congenital heart disease [8].

Heart Chapter | 1

15

1

2

3

4

Left Anterior Descending (LAD) Right Coronary Artery (RCA) (Left ) Circumflex Artery (LCX) 1 Anteroseptal wall 2 Anterolateral wall See Ref [8]

3 Inferoseptal wall 4 Inferolateral wall

Heart Chapter | 1

17

1

2

3

4

5

Left Anterior Descending (LAD) Right Coronary Artery (RCA) (Left ) Circumflex Artery (LCX) The superior papillary muscle is perfused from the le coronary system. The inferior papillary muscle can be perfused from the le coronary system or from the right system [9]. 1 Anterior wall 2 Superior papillary muscle 3 Septal wall See Ref [9]

4 Lateral wall 5 Inferior wall

Cardiac CT demonstrates high accuracy for the detection of obstructive coronary artery stenosis, representing a robust non-invasive method to rule out obstructive coronary artery stenosis in patients without known coronary artery disease, particularly in the low-intermediate pre-test probability group [10].

Heart Chapter | 1

19

1

2

3

4

5

Left Anterior Descending (LAD) Right Coronary Artery (RCA) (Left ) Circumflex Artery (LCX) 1 Anterior wall 2 Superior papillary muscle 3 Septal wall See Ref [10]

4 Lateral wall 5 Inferior wall

Heart Chapter | 1

21

1

2

3

4

5

Left Anterior Descending (LAD) Right Coronary Artery (RCA) (Left ) Circumflex Artery (LCX)

Machine learning with support vector machines allows automatic and accurate mitral valve plane localization, decreasing user dependence in SPECT quantification [11]. 1 Anteroseptal wall 2 Mitral annular plane 3 Inferolateral wall See Ref [11]

4 Anterolateral wall 5 Inferoseptal wall

1.1.2 Horizontal long axis

Heart Chapter | 1

Correct integration of data on coronary anatomy and myocardial perfusion allows clinical decisions concerning opmal diagnosis and treatment of coronary artery disease [5].

1

Left Anterior Descending (LAD) (Left ) Circumflex Artery (LCX)

1 Anterior wall See Ref [5]

23

Heart Chapter | 1

25

2

1

Left Anterior Descending (LAD) (Left ) Circumflex Artery (LCX) 1 Septal wall

2 Lateral wall

Cardiac CT has progressively established itself as a logiscally simple, accurate and low-risk non-invasive test to diagnose or rule out coronary artery disease [12].

Heart Chapter | 1

27

1

2

3

4

Left Anterior Descending (LAD) (Left) Circumflex Artery (LCX) 1 Septal wall 2 Superior papillary muscle See Ref [12]

3 Lateral wall 4 Mitral annular plane

Heart Chapter | 1

29

1

2

3

4

5

Left Anterior Descending (LAD) Right Coronary Artery (RCA) (Left ) Circumflex Artery (LCX) 1 Apex 2 Inferior papillary muscle 3 Septal wall

4 Mitral annular plane 5 Lateral wall

Heart Chapter | 1

2

1

4

3

Left Anterior Descending (LAD) Right Coronary Artery (RCA) (Left) Circumflex Artery (LCX) Gated 18F-FDG PET protocol minimizes the influence of internal motion on cardiac accumulation and allows assessment of global function of the left ventricle, with measurement of ejection fraction, and diastolic/systolic volumes [13]. 1 Septal wall 2 Apex See Ref [13]

31

3 Inferior papillary muscle 4 Lateral wall

Cardiac MRI plays a critical role in myocardial ischemic and non-ischemic diseases to establishing diagnosis, determining prognosis, and guiding therapeutic management [14].

Heart Chapter | 1

1

Left Anterior Descending (LAD) Right Coronary Artery (RCA) (Left ) Circumflex Artery (LCX) 1 Inferior wall

See Ref [14]

33

1.1.3 Vertical long axis

Multiple studies have shown that cardiac MR stress perfusion imaging has excellent diagnostic accuracy for coronary artery disease [15, 16, 17].

Heart Chapter | 1

1

Left Anterior Descending (LAD) Right Coronary Artery (RCA)

1 Septal wall See Refs [15e17]

35

Heart Chapter | 1

1

37

2

Left Anterior Descending (LAD) Right Coronary Artery (RCA)

1 Inferior wall

2 Anterior wall

Heart Chapter | 1

1

39

2

3

Left Anterior Descending (LAD) Right Coronary Artery (RCA)

1 Anterior wall 2 Apex

3 Inferior wall

Myocardial late enhancement in contrast-enhanced cardiac MRI reflects irreversible damage after chronic myocardial infarction [18].

Heart Chapter | 1

1

41

2 4

3 5

Left Anterior Descending (LAD) Right Coronary Artery (RCA) (Left) Circumflex Artery (LCX) The inferior myocardial wall is a common site of variable attenuation artifacts produced by the left hemidiaphragm. The ECG-gated acquisition protocol can improve wall motion visualization and perfusion/viability [4]. 1 Anterior wall 2 Apex 3 Superior papillary muscle See Ref [18] See Ref [4]

4 Inferior wall 5 Mitral annular plane

Ischemia is directly proporonal to the severity of the luminal stenosis. A luminal stenosis ≥90% in Cardiac CT is a strong predictor of ischemia on perfusion SPECT. A luminal stenosis