MBF Quantitation with SPECT: Is It Ready for Clinical Use¨±百靈.pdf · Baseline MBF (3V CAD, 2014-02-26) Perfusion . Pre PCI Post PCI 70% residual non-obstructive lesions RCA

MBF Quantitation with SPECT:

Is It Ready for Clinical Use ?

Bailing Hsu, PhD University of Missouri-Columbia, Missouri, USA

Disclosure: Co-funder of Bailing Cloud Biomedical Technologies Innovation (BCBTI), Taiwan

Practical Challenges to Widespread Clinical Utilization of PET MBFQ

Commercialized myocardial PET perfusion tracers are only available in some areas (North America, Europe) rather than worldwide

High cost to adopt myocardial perfusion PET imaging into the clinical environment

Cyclotron (High Start-up cost)

82Rb Generator (High ongoing cost)

http://www.google.com/url?sa=i&rct=j&q=&esrc=s&frm=1&source=images&cd=&cad=rja&docid=7_5ctkT6HTbrhM&tbnid=-0neRkrQ-O2WMM:&ved=0CAUQjRw&url=http://braccoimaging.de/index.php?option=com_content&task=view&id=24&Itemid=176&ei=QGFfUqefE7a54AOhi4GICA&bvm=bv.54176721,d.dmg&psig=AFQjCNHDlNQOfYRODf1TT-Aeo4kiPzU8Jw&ust=1382068907232732http://www.google.com/url?sa=i&rct=j&q=&esrc=s&frm=1&source=images&cd=&cad=rja&docid=nX79RUi9xu3vaM&tbnid=pNJhwpfETrYdYM:&ved=0CAUQjRw&url=http://www3.gehealthcare.com/en/Products/Categories/PET-Radiopharmacy/TRACER_Center_Equipment/MINItrace_Cyclotron&ei=f2FfUp_CEKjk4AO4pICABg&bvm=bv.54176721,d.dmg&psig=AFQjCNEkbsw5UPKAHNHWtbb3eOeKKyw4Tw&ust=1382068986443709

Benefits of SPECT MBFQ over PET MBFQ (Requisite: Accuracy of SPECT MBFQ must be close to PET MBFQ)

Higher Tracer Availability

SPECT (worldwide) , PET (USA, Europe)

Lower Tracer Cost

SPECT (affordable), PET (too costly for Asian area)

Lower Camera Cost

SPECT, SPECT/CT ($), PET, PET/CT($$)

Simplifier for Clinical Utilization:

SPECT (routine), Rb-82 PET (routine), NH3 PET (research)

Higher Clinical Throughput:

SPECT (higher), Rb-82 (high), NH3 PET (low)

SPECT MBFQ: The Alterative Solution

0

50000

100000

150000

200000

250000

300000

350000

0 100 200 300 400 500 600

Bq

/ml

Time (sec)

Stress MIBI

Arterial Input

Myocardial Uptake

0

20000

40000

60000

80000

100000

120000

140000

0 100 200 300 400 500 600

Bq

/ml

Time (sec)

Rest MIBI

Arterial Input

Myocardial Uptake

Frame Definition: 10x10sec+5x20sec+4x60sec+280sec= 12 min

Eur J Nucl Med Mol Imaging. 2014;41(12):2294-306

D1: Total

Occlusion

Siemens Symbia SPECT/CT

GE 530c CZT SPECT

Comparison Between SPECT MBFQ and PET MBFQ

Human MIBI extraction fraction curve

(world first)

Curtesy of Dr. Wu Tau-Chen, Cardiology, VGHTPE, Taiwan

SPECT MBFQ can reach 95% accuracy of PET MBFQ

2.7

-1.0

-0.6

-0.2

0.2

0.6

1.0

All Subjects

1 2 3 4 5

Mean of MIBI MFR and NH3 MFR

MIB

I M

FR

- N

H3 M

FR

Mean

0.07

-1.96 SD

-0.73

+1.96 SD

0.87

0

1

2

3

4

5

6

All Subjects

0 1 2 3 4 5 6

NH3 MFR

MIB

I M

FR

-0.8

-0.6

-0.4

-0.2

0.0

0.2

0.4

0.6

All Subjects

0 1 2 3 4 5

Mean of MIBI Flow and NH3 Flow (mL/min/g)

MIB

I F

low

- N

H3 F

low

(m

L/m

in/g

)

Mean

-0.02

-1.96 SD

-0.52

+1.96 SD

0.48

-1

0

1

2

3

4

5

All Subjects

-1 0 1 2 3 4 5

NH3 Flow (mL/min/g)

MIB

I F

low

(m

L/m

in/g

)

y=1.02x-0.50, R2= 0.93

y=0.87x+0.46, R2= 0.78

A B

C D

n=28, 56 flow points

Added Clinical Values of SPECT MBFQ Compared with SPECT Perfusion

3V CAD Angiography normal

Enhanced Sensitivity: eliminate balanced ischemia (false-negative) due to multi-vessel CAD

Enhanced Specificity: eliminate (false-positive) due to attenuation artifact in perfusion

Chen LC and et al, Clin Nucl Med. 2016 Jan;41(1):e60-2

Added Clinical Values of SPECT MBFQ Compared with SPECT Perfusion

Eur J Nucl Med Mol Imaging. 2014;41(12):2294-306

Patient-based

MBFQ: sensitivity= 84.6 , specificity= 100

Perfusion: sensitivity=69.2, specificity= 70.1

Vessel-based

MBFQ: sensitivity= 76.0 , specificity= 84.2

Perfusion: sensitivity=56.0 , specificity= 62.8

Multi-vessel CAD= 62%

Reclassification of CAD Diagnosis with SPECT MBFQ

48%

52%

Non-CAD CAD

18%

82%

Non-CAD CAD

37%

38%

25%

Non-CAD CAD Unchanged

Non-CAD (n=23) CAD (n=17) Equivocal (n=8)

Coronary Angiography (CAG)Non-CAD=17; CAD=31

Diagnosis by SPECT Perfusion

Non-CAD (n=19) CAD (n=29)Diagnosis by

SPECT MBF/MFR

Diagnosis Reclassification by

SPECT MBF/MFR and Confirmed with CAG

Courtesy of Dr. Long-Ging Chen and Dr. Yuan-Guang Chen from SKH, Taiwan

Importance of Full Physical Corrections in Dynamic Images for SPECT MBFQ

-2

0

2

4

6

8

10

0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5

All Corr

NR

-2

0

2

4

6

0 1 2 3 4 5 6 7

Mean of NR and All Corr

NR

- A

ll C

orr

Mean

0.9

-1.96 SD

-1.0

+1.96 SD

2.8

-2

0

2

4

6

8

0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5

All Corr

NR

+S

C

-2

0

2

4

6

0 1 2 3 4 5 6

Mean of NR+SC and All Corr

NR

+S

C -

All

Co

rr

Mean

0.7

-1.96 SD

-1.0

+1.96 SD

2.5

-2

0

2

4

6

8

10

0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5

All Corr

NR

+S

C+

RR

-2

0

2

4

6

0 1 2 3 4 5 6 7

Mean of NR+SC+RR and All Corr

NR

+S

C+

RR

- A

ll C

orr

Mean

0.7

-1.96 SD

-1.1

+1.96 SD

2.6

y = 1.7162 x + 0.2777R2= 0.5717

y = 1.5958 x + 0.2023 R2= 0.5221

y = 1.6715 x + 0.1114 R2= 0.5577

-2

0

2

4

6

8

10

0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5

All Corr

NC

y = 1.6305 x + 0.7779 R2= 0.3721

-2

0

2

4

6

0 1 2 3 4 5 6 7

Mean of NC and All Corr

NC

- A

ll C

orr

Mean

1.3

-1.96 SD

-1.2

+1.96 SD

3.8

-2

0

2

4

6

8

10

0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5

All Corr

NR

-2

0

2

4

6

0 1 2 3 4 5 6 7

Mean of NR and All Corr

NR

- A

ll C

orr

Mean

0.9

-1.96 SD

-1.0

+1.96 SD

2.8

-2

0

2

4

6

8

0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5

All Corr

NR

+S

C

-2

0

2

4

6

0 1 2 3 4 5 6

Mean of NR+SC and All Corr

NR

+S

C -

All

Co

rr

Mean

0.7

-1.96 SD

-1.0

+1.96 SD

2.5

-2

0

2

4

6

8

10

0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5

All Corr

NR

+S

C+

RR

-2

0

2

4

6

0 1 2 3 4 5 6 7

Mean of NR+SC+RR and All Corr

NR

+S

C+

RR

- A

ll C

orr

Mean

0.7

-1.96 SD

-1.1

+1.96 SD

2.6

y = 1.7162 x + 0.2777R2= 0.5717

y = 1.5958 x + 0.2023 R2= 0.5221

y = 1.6715 x + 0.1114 R2= 0.5577

-2

0

2

4

6

8

10

0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5

All Corr

NC

y = 1.6305 x + 0.7779 R2= 0.3721

-2

0

2

4

6

0 1 2 3 4 5 6 7

Mean of NC and All Corr

NC

- A

ll C

orr

Mean

1.3

-1.96 SD

-1.2

+1.96 SD

3.8

Curtesy of Dr. Wei Fan, Fuwai Hospital, Beijing, China

No inherent technical issues for SPECT MBFQ.

Introduction to MyoFlowQ-LiteTM SPECT Flow Quantitation Software System

高端、創新技術全球首創核醫學SPECT進行心肌血流絕對定量評估系統

影像重建採用完整物理校正，定量SPECT影像格式與PET同等

心肌血流計算採用雙腔室生理數學模型，定量方法學與PET同等

左、右心室擴散效應雙校正，準確測量整體與分區心肌血流量

滿足臨床需求簡易標準化影像處理流程，高臨床檢查Throughput

DICOM血流評估報告格式與醫院PACs系統兼容

支持各大廠牌(Siemens、GE)的SPECT與SPECT/CT機型

“MyoFlowQ”一個不再需要仰賴昂貴PET心臟檢查，即可透過SPECT心肌血流定量準確評估心血管病的臨床工具

All Rights Reserved2016.1

DICOM SC compatible to PACs

Quality Control

DICOM SC compatible to PACs

Report

MyoFlowQ Supported SPECT Camera Models with Dynamic SPECT Capability

Symbia Family

Siemens

GE

530c 570c

ECAM

http://www.google.com.tw/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwjo0bTkgeDJAhWBW5QKHRiQAqEQjRwIBw&url=http://www3.gehealthcare.com/en/products/categories/nuclear_medicine/cardiac_imaging/discovery_nm570c&psig=AFQjCNElnlgg7NmGgunZaVyX4_xdr331Ow&ust=1450342711430110http://www.google.com.tw/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwjp-Zf1_9_JAhWJlJQKHYuuDNoQjRwIBw&url=http://www.medwow.com/med/gamma-camera-scanning/siemens/ecam-duet/31886.model-spec&psig=AFQjCNE0RJUmOSqv_5xNH1poKt6vpDaj1A&ust=1450342212394388

MBFQ SPECT Imaging Protocols

Stress Dynamic

SPECT (12 min)

Siemens Cameras:

ECG-gated

SPECT (10 min)

Rest Dynamic

SPECT (12 min)

10 mCi MIBI 30 mCi MIBI

Dipyridamole

Infusion

c

MBF Perfusion

Peak-stress

Early post-stress

Rest

Function

Rest Listmode SPECT

(12 min)

Stress Listmode SPECT

(10 min)

7 mCi MIBI 21 mCi MIBI

Dipyridamole

Infusion

GE CZT Camera:

Siemens

GE

Total dose=40 mCi

Total dose=28 mCi

Early CAD: Post Medical Therapy Evaluation

Baseline MBF Perfusion

Male, 70 yrs, 155 cm, 64 kg,

BMI= 26.6, no CAD history,

Uncontrolled risks

Follow-up MBF (7 months after) Perfusion


Guidance to Sequential CAD Management


• Male

• 56 yrs

• Previous LCX PCI

Baseline MBF (3V CAD, 2014-02-26) Perfusion

Pre PCI Post PCI

70%

residual non-

obstructive lesions

RCA

80%

LCX



• Male

• 56 yrs

• Previous LCX, RCA PCI

1st Follow-up MBF (2V CAD, 2014-12-09) Perfusion

RCA

Pre PCI

77%

76%

Post PCI

LCX

80%



• Male

• 56+1yrs

• Previous LCX, RCA PCI

2nd Follow-up MBF (1V CAD, 2015-03-31) Perfusion


80%

Pre PCI Post PCI

LCX

Diffuse CAD in RCA

Courtesy of Dr. Ching-Pi Chen and Dr. Ming-Jou Chang from CCH, Taiwan

Pre PCI Post PCI

• Male

• 44 yrs

• Previous MI

• Previous RCA PCI

52%

FFR=0.77, Pre PCI

Perfusion

FFR=0.97, post PCI

MBF

Heart Failure (Ischemic Cardiomyopathy)

• Male

• 71yrs

• Heart Failure

• Stress EF= 17%

• Rest EF=14%

MBF Perfusion

Courtesy of from Dr. Kuan-Rau Chio and Dr. Ging Hu, VGHKS, Taiwan

Apical Hypertrophy with Diffuse Fibrosis (2)

Courtesy of from Dr. Kuan-Rau Chio and Dr. Ging Hu, VGHKS, Taiwan

• Male

• 45 yrs

• Stress EF= 32%

• Rest EF= 47%

MBF Perfusion

Mixture of Apical Transmural Scar and Ischemia

• Male

• 69 yrs

• Stress EF= 29%

• Rest EF= 19%

MBF Perfusion

Courtesy of from Dr. Chien-Chien Chen and Dr. Guang-Uei Huang, SCMH, Taiwan

Historical Development of SPECT MBFQ and toward Clinical Utilization in Taiwan

First Patient-in on Siemens

Symbia SPECT/CT

2010.12

2013.05

First Patient-in on Siemens ECAM

2016.01

TFDA Approval

First Patient-in on

Siemens ECAM

2013.09

2014.07

First Patient-in on Siemens

Symbia SPECT/CT

2016.02

First Patient-in on GE 530c

CZT SPECT

First Patient-in on

Siemens Symbia-E

2015.03

Widespread

the clinical utilization

http://wd.vghtpe.gov.tw/cv/Index.actionhttp://wd.vghtpe.gov.tw/nmed/Index.actionhttp://www.cch.org.tw/home.aspxhttp://cms03p.vghks.gov.tw/Chinese/MainSitehttp://www.mmh.org.tw/index_big5.htmlhttp://www.google.com.tw/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwiT3qHP3bLLAhUiFqYKHWivBCYQjRwIBw&url=http://www.ohayoo.com.tw/%E5%85%A8%E5%9C%8B%E5%90%84%E5%A4%A7%E9%86%AB%E9%99%A2.htm&psig=AFQjCNH0Kn3Ky4vWAz1G2kNGQFjIL85BpA&ust=1457582672049208

Thank You

Documents

MBF Quantitation with SPECT: Is It Ready for Clinical Use¨±百靈.pdf · Baseline MBF (3V CAD, 2014-02-26) Perfusion . Pre PCI Post PCI 70% residual non-obstructive lesions RCA