GE Healthcare

Organ Dose estimates

for Radio-Isotope Therapy
treatment planning purposes
Dosimetry toolkit package
White Paper
Content
Introduction................................................................................................................... 3
Dosimetry Toolkit........................................................................................................ 4
Purpose................................................................................................................................................................................................................. 4
Input....................................................................................................................................................................................................................... 4
Content.................................................................................................................................................................................................................. 4
Output.................................................................................................................................................................................................................... 4
SPECT Reconstruction.................................................................................................................................................................................... 4
Quantitative Reconstruction....................................................................................................................................................................... 5
Registration......................................................................................................................................................................................................... 5
Organs definition.............................................................................................................................................................................................. 6
Segmentation operations........................................................................................................................................................................ 6
ROI/VOI tools:................................................................................................................................................................................................. 6
System sensitivity calibration–standard dose syringe................................................................................................................... 7
Time Activity Curves and fitting................................................................................................................................................................. 8
Saving results..................................................................................................................................................................................................... 8

Algorithms and clinical examples used........................................................... 9

Registration Algorithm................................................................................................................................................................................... 9
Registration stages in Multi WB SPECT/CT scenario................................................................................................................... 9
Registration stages in Hybrid scenario ............................................................................................................................................ 9
Segmentation algorithms...........................................................................................................................................................................10
Threshold criterion for NM image......................................................................................................................................................10
Threshold criterion for CT image........................................................................................................................................................10
Segmentation Propagation...................................................................................................................................................................11
Inner segmentation..................................................................................................................................................................................11
Coronal Overlap (Hybrid scenario).....................................................................................................................................................11
System suggested organs Segmentation:..........................................................................................................................................12
Lungs segmentation.................................................................................................................................................................................12
Liver segmentation...................................................................................................................................................................................12
All bone cavities segmentation...........................................................................................................................................................13
Additional tools for Non-contiguous volumes..............................................................................................................................13
System sensitivity calibration–standard dose syringe.............................................................................................................14

References...................................................................................................................15
Introduction
Radio Isotope therapy is defined as a radiation therapy that
uses administered radiopharmaceutical to transfer radiation
energy to a pathological target tissue in order to achieve a
destructive tissue effect.
The destructive tissue effect depends on the amount of
transferred energy to the tissue, i.e the absorbed radiation
dose, which is measured in units of gray (Gy). It is essential to
be able to calculate the absorbed radiation dose to a targeted
tissue at any stage of treatment in order to enable safe and
effective therapy planning and monitoring.
Note: The term “dose” refers to the “radiation dose” in the SI
unit “grays”. It should not be confused with the frequently used
“dose” to describe the “administered activity” in GBq or mCi.
Targeted Radio Isotope Therapy is used today for single focal
lesion of tumors: breast, lung, prostate, etc. The aim in the
near future is to have personalized therapy based on patients
genetic or protein profiles. Targeted Radio Isotope therapies will
be prescribed based on molecular signatures. Individual patient
dosimetry may support the following goals:
• To determine minimum effective and maximum tolerated
absorbed doses per individual patient
• To monitor tumor response and organ toxicity during treatment
• To predict tumor response and normal organ toxicity based
on pre-therapy dosimetry
• To compare the dose–response results of different
therapy strategies
Radiation in radionuclide therapy is directed to the target
tissue by the radiopharmaceutical. This dynamic metabolic
process creates a complex spatial and temporal radiation
distribution with biochemical and physical variations over
time. Pharmacokinetics as well as biological or physical
bystander effects (on non-target organs) influence the amount
of the radiation dose to the target. In contrast to external-
beam radiation therapy, which uses a controlled and time
limited radiation, radionuclide therapy delivers a low and
continuously decreasing dose rate. Therefore the calculation
of the accumulated radiation dose for radionuclide therapy is
complex. Nuclear Medicine (NM) imaging is used to measure
the activity distribution over time. The calculation of the
absorbed dose in each organ is based on these scans. Due
to the limited spatial resolution of the NM scans, the dosimetry
calculations are always an approximation. Radiation doses to
target organs are usually calculated using the MIRD formalism
by commercially available software such as MIRDOSE3 or
OLINDA/EXM. These models are based on assumptions about
anatomy (standard man and woman) and radiopharmaceutical
distribution (uniformity of uptake in source and target) that are
not necessarily valid in individual patients. Nevertheless they
provide a practical and standardized model for clinical
practice [1].
The aim of the dosimetry toolkit is to simplify the procedure for
quantifying radiopharmaceutical dose, reduce the processing
time and improve accuracy of results, compared to the manual
tools currently used. The Dosimetry toolkit creates an essential
input to other radiotherapy planning SW.
Dosimetry Toolkit
Purpose
Dosimetry Toolkit uses multi WB SPECT/CT and/or WB planar
datasets for quantifying changes in radiopharmaceutical
uptake over time and calculating residence time per organ
for Radio-Isotope Therapy treatment planning purposes.
The purpose of the Dosimetry Toolkit is to define and report
the patient organs volume, activity and residence time of
radiopharmaceutical concentration within patient organs.
These results are based on consecutive patient scans and
can be used as input for Radio-Isotope Therapy planning
applications (such as OLINDA or similar). The organs of interest
in this respect are large organs (more than 50cc), such as liver,
lungs, kidneys, spleen, and heart.
Note: This toolkit is intended to replace tedious manual tools
for organs definition and activity calculations, in order to
enable improved processing workflow and productivity. The
accuracy of the dosimetry toolkit results depends heavily
on user provided quantitative input: injected activity, organ
definition, system sensitivity and reconstruction parameters.
The user is encouraged to verify the dosimetry toolkit results vs.
the existing tools used by the facility. This verification should be
performed prior to the clinical use of the dosimetry Toolkit.
Input
The toolkit supports the following types of input:
• Series of whole body SPECT/CT scans
• Series of Whole Body Planar scans with single SPECT/CT
(Hybrid scenario)
• Series of planar WB (for which Volume results can not
be provided)
• A single time sample of SPECT/CT can be used to determine
the organs volume and activity.
Content
The Dosimetry toolkit includes tools that can help the user to
perform in a quick and convenient way the following tasks:
• Reconstruction of all raw SPECT/CT data, including accurate
SPECT/CT registration adjustment and quality control, along
with patient motion detection and correction, attenuation,
scatter and collimator blurring corrections. Image
reconstruction is performed using iterative algorithm (OSEM).
• Registrations of all the scans to one common reference
with semi-automatic/manual tools that enable the user to
perform local organ registration
• Segmentation of the different organs (such as heart, liver,
lungs, kidneys, spleen, bone marrow), with semi-automatic/
manual tools to differentiate between overlapping organs
• Create time activity curves for each of the organs
• Curve fitting
• Calculate imaging agent Residence time in each organ
Output
The toolkit can export:
• Organs volumes
• Organs activities
• Organs imaging agent time activity curves
• Organs imaging agent residence time
• Individual or combined organ masked volumes as datasets.
These datasets can be exported in Dicom format
• All numerical values (volumes, activities, residence time) can
be exported to MS Excel file
• Time and Percentage of injected dose can be saved in format
suitable for input to OLINDA, avoiding the need to type all the
results in OLINDA interface
SPECT Reconstruction
The quality and quantitative accuracy of SPECT reconstructed
images are affected by noise in the projection data, resolution
degradation caused by the collimator-detector response
(CDR) function of the imaging system, photon attenuation,
and scatter in the patient’s body. Recently, there has been
significant progress in the development of model-based
corrective SPECT image reconstruction methods that include
correction for these image quality-degrading factors. The
corrective image reconstruction package (also referred
to as Resolution Recovery) developed by Johns Hopkins
University (JHU) provides improved SPECT images by including
physical models of the imaging process into iterative image
reconstruction algorithms. In particular, it provides accurate
3D models of the collimator-detector response functions for
a variety of clinical applications. This results in a significant
enhancement in image quality and potential improvement
in diagnostic properties. Clinical application of these
techniques are available and can be applied to reduce SPECT
acquisition time with equal or better image characteristics
when compared to standard reconstructions [5]. Collimator-
detector blur is the main factor affecting the resolution and
noise properties of nuclear medicine images. In reconstructed
SPECT images, these characteristics are strongly affected
by the applied reconstruction algorithm and its parameters.
Collimator Detector Response (CDR) consists of four main
components: intrinsic response (system without collimator), the
geometric, septal penetration and septal scatter components
of the collimator parameters. The geometric component of
CDR results from photons passing through the collimator
holes without interacting with the collimator itself. The septal
penetration component describes the portion of the CDR
where photons reaching the detector after passing through
one or more septa do not scatter. The scatter component
refers to photons that scatter in the septa and are detected.
For the majority of clinically used collimator designs, the last
two components are generally significant for only medium-
and high-energy imaging. For each combination of acquisition
system, radiopharmaceutical and particular acquisition
protocol, the collimator detector response function provides the
probability that a photon emitted from any point of the imaged
object will contribute to a pixel of the resulting image.
By including an accurate model of the collimator-detector
response function in an iterative SPECT reconstruction
algorithm, the blurring effect may be included in the iterative
reconstruction process, resulting in improved spatial resolution.
Current Estimated
Project
estimate projection
Measured
Physics of the
Update projection
imaging prosess Compare
(Date)
Update Error
Back project
coefficients Projection
Figure: Scheme of iterative reconstruction process.
A CDR compensation technique was developed at the
University of North Carolina-Chapel Hill (UNC) and JHU [6,7,8].
The effect of CDR compensation on reconstructed images has
been studied from qualitative [9], quantitative [10,11,12], and
clinical task-based [13, 14, 15] perspectives. It has been found
that CDR corrected images demonstrate not only improved
resolution and signal-to-noise ratio, but also lower noise
variability in reconstructed images. Significant improvement
of the resolution properties requires more iterations of the
reconstruction method with compensation than are usually
recommended for the same data when no compensation
is applied. On the other hand, image noise level tends to
amplify with the number of iterations. Taking into account the
differences in the iterative reconstruction process, with and
without CDR, application-specific optimization of acquisition
and processing parameters is essential to successful utilization
of the corrective reconstruction method [14, 15, 16,17].
Quantitative Reconstruction
Usually the reconstruction used for visualization purposes is
done with limited number of iterations and with postfiltering.
For more accurate quantitative results the number of iterations
should be increased and postfiltering should be avoided.
The resulting image is quantitatively more accurate, but
also noisier and less suitable for visualization purposes. The
reconstruction parameters (number of iterations, number of
subsets) for accurate quantitation should be optimized per
each radiopharmaceutical, collimator and clinical protocol
(scan time, number of views etc…). For example, for quantitative
reconstruction of In111 scans with MEGP collimator, it is
recommended to use 30 iterations with 5 subsets [18,19]. In
order to optimize reconstruction parameters per specific Isotope/
Collimator/Camera combination, the user should use phantom
studies of Jaszczak and/or anthropomorphic phantom(s).
In order to improve quantitative accuracy, reconstruction
should include corrections for patient motion, attenuation,
scatter and collimator blurring.
Registration
The application includes two stages of registration: WB
registration and organ registration. First all the WB scans
(SPECT/CT or WB planar) are registered, to achieve optimal
registration of the complete patient body (or all the scanned
parts of it) between all scans. Although the whole body,
registered as rigid body, may be properly registered, internal
organs may be slightly mis-registered due to local shifts/
rotation. Once the scans are registered, the user can correct
location and shape of each Organ VOI (SPECT/CT) or ROI
(Planar) on each of the images, if needed.
Organs definition
Note: The following is applicable to multiple SPECT/CT or
Hybrid Scenarios Only. Defining an Organ on Multiple
Planar WBs scenario is freehand ROI drawing based on the
operator experience.
• Organs are defined using the CT and NM slices
interchangeably, using threshold-based algorithms. Some
organs may have an initial automated proposal or semi-
automatic proposal; some organs are defined manually. The
defined organ is superimposed over CT and NM slices. All
organs are saved in a mask volume, each with a new color.
• The user must confirm that organs are accurately defined.
In some cases the system may suggest initial segmentation
for specific organs, nevertheless the responsibility always
lies on the user to confirm that the organ volume is
delineated correctly.
• Results are more accurate for large volumes (more than
50cc). For smaller volumes (of organs or lesions), accuracy
of activity quantitation is degraded due to partial volume
effects that are inherent because of the limited gamma
camera spatial resolution.
• The discrepancy between NM and CT resolution causes
organ’s activity to ‘spill over’ the organs contours as depicted
in the CT image. In order to include all the organ’s activity
within the VOI, the organ VOI definition may be expanded
slightly beyond the organ’s limits as depicted in the CT image.
For organs that are defined based on the CT image, the
user may consider slight dilatation of the organ VOI beyond
the CT limits in order to get more accurate organ’s activity
estimation (note that in this case the volume measurement is
less accurate).
• To project the SPECT organs accurately over the WB planar
images, their frontal outline is created. Some organs may
overlap, mostly with the lungs. Overlapped areas may
be removed when projected over the planar images.
Computation of organ activities in the planar images is
extrapolated by the ratio of used/removed volumes.
Segmentation operations are based on the underlying data
and use threshold operators to segment the data. The selected
viewport, CT or NM, is the basis for the threshold segmentation.
For both NM and CT images, the segmentation process starts
at a user selected seed point and propagates in 2D/3D (ROI
or VOI). The segmentation propagates when some or all
the adjacent voxels withstand the threshold criterion. The
propagation is stopped when none of the adjacent voxels
comply with the threshold criterion.
ROI/VOI tools:
ROI tools are working on a single slice (2D). VOI tools act similar
to the ROI tools, extended to 3D. The VOI tools cover large
volumes without the need to go over slice by slice, however
the visualization and ability to control their expansion are more
complex as the screen display is 2D.
Segmentation ROI/VOI Tools available:
• Draw automatic ROI/VOI starting at a user selected
seed point,
• Draw semi automatic ROI/VOI starting at a seed point
(“growing ROI/VOI”),
• Draw manual ROI/VOI starting at a seed point (acts as
a pencil),
• Erase automatic ROI/VOI starting at a seed point,
• Erase semi automatic ROI/VOI starting at a seed point,
• Erase manual ROI/VOI starting at a seed point (acts as
an eraser).
• Dilate Region/Volume voxels
• Erode Region/Volume voxels
• Open Bridges
• Close Gaps
• Auto NM segmentation

Segmentation operations
The application segments the WB SPECT/CT image volume into
different organs–this means that each organ is enclosed by a
VOI. This segmentation is done based on the CT and NM images
and serves as first approximation of the organs volumes. The
user has various tools to correct/improve this automated
segmentation prior to confirming the organ segmentation.
System sensitivity calibration–
standard dose syringe
System sensitivity should be measured for each combination
of camera, collimator and radioisotope used. Accurate
measurement of the patient injected activity dose in a calibrated
dosimeter is required. Time of dosimeter measurement must be
recorded to allow accurate decay correction.
In order to accurately measure system sensitivity and
compensate for variations in system sensitivity between scans,
a standard dose syringe can be used. A syringe with small
amount of dose is placed near to and outside the patient during
the sequence of acquisitions. The initial syringe activity should
be measured by an external dosimeter (time of measurement
should be recorded) and should also be imaged in a separate
scan on the camera. The same syringe (with its decaying activity)
should be used in all patient scans. The user fills a dialog (see
below) with patient and syringe information. The standard dose
syringe images are used to calibrate the patient counts acquired,
based on the known half-life of the isotope used.
If there is no syringe image the application activates a dialog to
specify the system sensitivity by the user.
Commercially available OLINDA software package can be used
for calculation of NM radiopharmaceuticals internal absorbed
doses in organs and tumors.
Time Activity Curves and fitting
Time activity curve is created for each of the organs defined.
These curves are fitted to an exponential function of the form:
y = A eBX
Usually exponential fit is done by taking the logarithm of the
function and looking for the parameters that give the least square
fit. This fit gives greater weights to small y values so, in order to
weight the points equally, it is often better to minimize the function
n
∑ yi (ln yi-a-bxi )2
i =1
See reference [4]
The equal weight exponential fit is used in Dosimetry Toolkit.
Saving results
The picture below shows the final report
The results are saved on the Xeleris workstation. The user is
able to save segmented data and organ names, as part of a
results series. Data recorded at the Xeleris database is DICOM
compatible. It can be exported, backed up and retrieved, and
is transferable between Xeleris 3 Systems. A template for MS
Excel spread sheet is provided for the numerical results.
Time and Percentage of injected dose can be saved in format
suitable for input to OLINDA, avoiding the need to type all the
results in OLINDA interface.
Commercially available OLINDA software package can be used
for calculation of NM radiopharmaceuticals internal absorbed
doses in organs and tumors.
Algorithms and clinical examples used
Registration Algorithm
The registration is performed automatically with a rigid
registration algorithm that utilizes the NLM Insight
Segmentation & Registration Toolkit (ITK). Tools for manual
adjustment of the scans are provided, for small modifications
of the automatic registration results, in order to get the
optimal registration.
Automatic Image registration is an iterative process that
is performed on coarse resampled image with a gradual
increase in resolution, in a stepwise manner to determine
the final translation and rotation parameters. This stepwise
algorithm results in improved registration (over ‘one step
registration’) both in terms of reducing processing time, in its
convergence to accurate true solution and the robustness
of the solution. The automatic registration is based on the
following components:
• The transformation of the image voxel positions to new
3D coordinates (x, y, z position). For rigid registration this
will include translation and rotation.
• A cost function-a metric depicting the adequacy of the
registration.
• The optimizer-determines how to update the transformation
parameters after each iteration, based on the change in
values of the cost function.
Regular Step Gradient Descent optimizer and least mean
Squares cost function are used in all the steps. In the first
coarse steps the transformation include translation operation
only, while in the later finer steps the transformation include
both translation and rotation operators.
Registration stages in Multi WB SPECT/CT
scenario
In the Multi WB SPECT/CT scenario that includes a Series of
Whole Body SPECT/CT scans, there are two stages
of registration:
• WB Registration of all SPECT/CT sets to a common reference–
this stage is performed before organs are defined
• Organs local registration on each of the WB SPECT/CT images
WB registration
After all the NM & CT scans were reconstructed (using standard
Volumetrix MI UI) to create set of 3D whole-body images of the
patient in various time points, all the scans are registered to
one common reference. The reference image is the CT image
of the latest scan, while the moving images (the images that
are moved in order to be registered to the reference) are the CT
images of all the other scans.
Organ registration
After all organs have been defined on the earliest SPECT/CT
image, the organs masks are copied onto all the other
SPECT/CT images (sets) and the user is required to check
organs positions on each set. These sets are already rigidly
registered to a common reference. The program loads the user
selected set of registered NM & CT images. Organs defined on
the first set are copied onto this set. The user has to review
and adjust each organ in the loaded set, if needed. The same
operation is repeated for all SPECT/CT sets.
Registration stages in Hybrid scenario
In the hybrid scenario that includes a Series of Whole Body
Planar scans with single SPECT/CT, there are three stages
of registration:
• Registration of the SPECT scan with the nearest in time
planar WB scan. This stage is performed before organs
are defined
• Registration of all WBs to common planar reference
(used in the previous stage)–this stage is performed after
organs are defined
• Organs local registration on each of the WB planar images
For all these registration stages, the application suggests initial
registration and the user can confirm or modify the registration.
Registration of SPECT image with its conjugate WB planar image
The reference image is the summed coronal slices of the SPECT
image while the moving image is the nearest in time WB planar
image. This WB scan serves as a common reference for all the
other WB scans. Manual adjustment of registration is supported
via a screen based user interface, for small modifications of the
automatic registration, in order to get optimal match of SPECT 3D
scan (single or multi fields of view) with the Wholebody 2D image.
Registration of all WBs to common planar reference
After all organs are segmented and defined on the WB
SPECT/CT image, the 3D organs masks are projected onto the
conjugate WB planar image. All the WB planar images have to
be registered in order to project the organ ROIs at their correct
location over the scans at all times. Initial registration of all
WBs to common planar reference is performed automatically,
without user intervention. The same WB scan that was already
registered to the SPECT image (the WB planar image nearest to
the SPECT image) is used as a reference for the other WB planar
scans to register to.
When the automatic registration is completed, the registered
images are displayed in the order they were acquired. Manual
adjustment of registration is supported via a screen based user
interface to match every pair of WB planar images, for small
modifications of the automatic registration, in order to get
optimal match.
Organ specific registration between consecutive scans
After all the WB planar images are registered to a common
reference, the user is able to manually correct residual local
(organ specific) mis-registration.
Segmentation algorithms
Threshold criterion for NM image
The threshold value is defined by the counts at the seed
point multiplied by the NM Threshold (in the range of 0-1).
All the voxels with counts above the threshold pass the
threshold criterion.
Threshold criterion for CT image
The CT range in Hounsfield Units (HU) is divided into 3 ranges:
• Lungs values–all values below a predefined, customizable value
(default=-400). If the seed point is in the lungs range, all the
voxels in the lungs range (HU <-400) pass the threshold criterion.
• Bones values–all values above a predefined, customizable value
(default=200). If the seed point is in the Bones range, all the
voxels in the Bones range (HU > 200) pass the threshold criterion.
• Soft tissue values–all values between the Lungs and the
Bones. If the seed point is in the soft tissue range
(-400 < HU < 200), the threshold criterion is defined as
follows: The reference value is equal to HU Value at the
Seed point + 1000, and the CT percents from the reference
value define the threshold (in units of HU+1000). All the voxels
with HU values in the range of the reference value +/-CT
percent pass the threshold criterion.
Example: for a seed of HU=100 with a CT percent threshold
of 8%, all voxels in the range of 12HU to 188HU are
searched, as
12 =(100+1000)*(1-0.08)-1000, 188 =(100+1000)*(1+0.08)-1000
Segmentation Propagation
The segmentation process starts at the seed point. All
neighbors within a specified square/cube are checked. Voxels
that comply with the threshold criterion are entered into the
cache and added to organ VOI. When all neighbors of current
voxel were tested, the current voxel is removed from the cache.
This process continues for the neighbors of all the voxels
within the cache and stops when the cache is empty. This
process is referred to as outer segmentation (the default). The
square/cube size to each side of the current voxel is defined
by the “Neighbors” parameter. The default value for outer
segmentation neighbors is 1 so ‘neighbors’ cube size is 3*3*3
voxels (3 voxels include the current voxel and one neighbor at
each side). The picture below demonstrates the segmentation
propagation on an NM image. The segmentation process starts
at the seed point (the left image) and is built up according to
the threshold criterion as shown on the images to the right.
There are 3 modes for Segmentation Propagation:
• Semi-Automatic mode-Holding left mouse button
continuously, without moving it, starts the semi-automatic
segmentation propagation, as shown above. The process
stops on one of the following:
-- when the segmentation ceases to find new points
withstanding the segmentation criterion (empty cache).
An audible note will notify the end of the process.
-- the user releases the mouse button.
-- the user starts to move the mouse.
• Automatic mode-Holding the [Alt] key while clicking the
left mouse button, starts the automatic segmentation
propagation. The process stops when no new points
withstanding the segmentation criterion are found (empty
cache). During the propagation the user does not see the
progress of the segmentation. The automatic segmentation
result is shown only when it is completed (an hourglass
cursor indicates the process).
• Manual mode-Holding and moving left mouse button
(“drag”), starts to paint the segmentation manually, with
the current setting of pen size. (0–5 pixels to each side of
the pointer tip). This mode also holds when one moves the
mouse while the Semi Automatic iteration is in place, as
described above.
Inner segmentation
Holding the [Shift] key prior to starting the automatic and
semiautomatic modes activates an “inner search”. This
continues the propagation only when the full square/cube
around the voxel is passing the threshold criterion (as defined
above). To stop the propagation it is enough to have one voxel
within the cube that does not meet the threshold criterion. The
default value for inner neighbors is 3 (defining 7*7*7 cube).
A practical example: Using outer segmentation by [Alt]+Clicking
on a point inside the Left lung in a CT slice (left image) will look
for all points below–400HU (the default lung threshold) and
continue as long as one of “neighbors” (a 3*3*3 cube) is less
than-400. This “catches” the trachea as part of the lung as
shown on the center image below.
Using the “inner segmentation” technique ([Alt]+[Shift]+Clicking
on a point inside the Left lung), the resultant segmentation
avoids the trachea as shown on the right image below.
Coronal Overlap (Hybrid scenario)
In the case of Hybrid Scenario the 3D organs masks are
projected to the WB planar 2D image. In this case overlap
between projected 2D organs may occur. The toolkit enables
handling this overlap. The 3D presentation menu includes the
[coronal overlap] menu entry. When selected, the 3D image is
projected to the anterior view and all the regions, which contain
more than one organ, are painted in white. The areas in white
do not represent the depth, contradictory to the other surface
rendered parts of this image. They symbolize the fact that there
are overlapped organs along this coronal line. Hovering over
these areas print the organs involved and the Volume/counts of
the overlapped volumes.

By default, the volumes of these overlapped areas are removed
from the planar coronal ROIs. The counts (activities) and volume
of the remaining “partial” organs are extrapolated by the ratio
of the known “full volume” to the “partial volume”, assuming
that the organ has uniformly distributed activity. As this may
not be the case, the user has to determine which organ this sub
volume belongs to.
System suggested organs
Segmentation:
The system can suggest automatic segmentation for several
organs:
• Lungs
• Liver
• All Bone Cavities (bone marrow + spinal cord)
In order to initiate the automatic segmentation the workspace
must be empty (no voxel has been segmented yet). The user
can request automatic segmentation for the 3 organs above
by selecting the organ from the Organ Pick list and click
[Confirm]. The organ is not declared automatically, allowing
the user to edit the VOI before confirming it by pressing
“Confirm” button again.
Additional tools for non contiguous volumes (soft tissue, fat,
soft tissue + fat etc…) are available.
Lungs segmentation
The system suggested lung segmentation is based on the clear
lung boundaries on the CT image. Use of the standard semi-
automatic or automatic propagation segmentation will usually
include the trachea and other air cavities. In order to avoid the
air cavities outside the lungs, the automatic lung segmentation
works as follows:
• A voxel within lung is searched. The algorithm looks for a
sequence of 6 cms of continuous lung voxels all with HU<-
200, that follows a sequence of 4 cms of tissue voxels over
–200HU. The next lung voxel that follows the lung sequence is
determined as the seed point. 8 vectors, starting at the seed
point, along the 8 diagonals, must hit a soft tissue before
reaching the edge of the image. If any vector hits the border,
this seed is not within the lung and a new seed is searched for.
• Once such a seed point is found, an inwards segmentation
below –200 is performed with 3 neighbors. The segmentation
propagation collects only voxels having the full 7*7*7 voxels
(15.4 mm3) cube around them passing the threshold criterion
of HU<-200. As the mainstem bronchial diameter is less
than 15mm (see reference [2,3]), an inward segmentation
with neighborhood of 15.4mm will not include the mainstem
bronchial. Once such ‘inner part’ of the lung is found, dilation
of 3 voxels below –200HU fills back the ‘missing boundaries’.
This is first done for right lung and then for the left.
The picture below displays automatic lung detection Coronal,
sagittal, transaxial and 3D presentation.
Liver segmentation
Liver is considered to have uniform HU values and ‘slow’ edges.
It is also assumed that the boundaries of the liver and other
surrounding soft tissues are well defined. As there are many soft
tissue organs that fill these criteria, the user should triangulate at
the center of the liver prior to call for the automatic segmentation.
This defines both the seed and the mean HU to look for.
An inwards segmentation with 4 neighbors is applied, defining
a neighborhood of 9*9*9 voxels (19.8mm3) cube.
As the boundaries depend on patient motion during the CT
scan, e.g. heavy strikes initiated from breathing,
Heart
Liver
it requires a bit of experience to define a good seed point to get
accurate liver delineation as in the picture below
and not erroneous liver segmentation that includes other
organs (see picture below)
All bone cavities segmentation
Automatic segmentation of all bone cavities can be used to
define bone marrow The automatic search for bone cavities is
performed as follows:
The segmentation is performed on the CT image.
At first stage all the voxels above 100HU are marked regardless
of continuity.
Adding to these voxels additional voxels by starting a
segmentation from a seed point at the top left corner, to
include all the voxels having HU below 100HU (i.e. Soft tissue
and air) with requirement for Continuity.
Previously found voxels (HU>100) block segmentation
propagation from penetrating the bone. The new segmentation
includes all voxels except bone cavities.
Inverse of the result above gives the bone cavities voxels.
The following slices show both marrow in the sternum and
spinal cord.
The segmentation does not separate between Red and Yellow
Marrow tissues.
The quality of the detected cavities depends mostly on the
thickness of the CT slices. Thick slices, such as the above
(4.26mm) will interpolate axial cavities, affecting both the
HU values and the axial resolution.
Additional tools for Non-contiguous volumes
Tools are available for enabling non-standard segmentation in
cases where the volume of interest is not contiguous.
Full Tissue segmentation enables segmentation of spatially
non-contiguous voxels within selected density (HU) range. It is
activated on the CT image by holding the [Alt]+[F]. The HU range
is defined by the HU value of the seed point and the CT percent
threshold. The segmentation marks all voxels that comply with
the threshold criterion based on the seed point and the CT
percent. There is no requirement for continuity of voxels.
Left image shows bone segmentation-seed point selected on
bone, bone CT threshold criterion is used.
Center image shows soft tissue segmentation. Seed point
selected on soft tissue, soft tissue CT threshold criterion is used.
Right image shows fat segmentation. Seed point selected on
fat, soft tissue CT threshold criterion is used.
Bone tissue fat
Further segmentation is available by adding to the current
segments: Below an example of adding fat to soft tissue: First
performing soft tissue segmentation (as described above) then
add fat by holding the [Alt]+[F] while clicking on fat voxel.
System sensitivity calibration–standard
dose syringe
The user fills a dialog with patient and standard dose syringe
information. The standard dose syringe images are used to
calibrate the patient counts acquired, based on the known
half-life of the isotope used. If there is no calibration image the
application activates a dialog to specify the system sensitivity
by the user.
For Hybrid and WB scenarios
If a standard dose syringe is scanned within the patient WB planar
scans, the application detects its location over all the geometrical
mean images, and place ROIs over them. The syringe activity
(counts per pixel) is assumed to be much higher than patient
activity. The user can review and edit these ROIs as needed. In
order to avoid decrease of patient image color dynamic range, the
system finds the maximal count outside the standard dose and
uses it as initial window level. Note that each of the patient scans
are displayed with a different window level, thus the display does
not reflect the relative intensity between scans. Using the standard
dose permits longer late scans to get clearer organs ‘silhouettes’
while maintaining accurate dose calculations.
Multi SPECT/CT scenario
A separate standard dose syringe image may be acquired. The
user has to enter the syringe activity dose used for the calibration
image as part of the patient activity Dialog. Calibration scan
should be acquired as a static dual head image of the standard
dose syringe. The application detects the source using 1% of its
maximum value as the threshold, and the average counts of the 2
images are used to compute the Calibration factor.
References
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