68Ga-DOTATATE PET/CT of the head is performed at either the AMC or the Netherlands Cancer Institute (Gemini ToF, Philips Medical Systems and Biograph mCT, Siemens Healthineers). 68Ga-DOTATATE preparation and quality control is performed according to a standard protocol as described elsewhere.26 (link) Images are acquired approximately 45 min after intravenous bolus injection of 100 MBq 68Ga-DOTATATE with 2.5–3 min per bed position. A low-dose CT scan is acquired for attenuation correction and anatomical correlation. The total estimated radiation exposure of the combined PET/CT is 3.1 mSv.27 (link) PET/CT and pituitary MRI are coregistered manually using Hybrid Viewer (Hermes Medical Solutions). On the fused PET/MR images, 68Ga-DOTATATE uptake is assessed by placement of a circular region of interest within the adenoma while maintaining a clear margin from normal pituitary tissue, and determining the mean standard uptake value (SUVmean).23 (link) An SUVmean of >2 is considered as positive uptake. In the absence of literature on 68Ga-DOTATATE uptake in pituitary adenomas, this value has been chosen to reflect a level of uptake at least similar to that of the normal pituitary, based on a 68Ga-DOTATATE biodistribution study in 42 subjects demonstrating physiological pituitary uptake with a minimum SUVmean of 2.1.28 (link)
Hybrid viewer
Manufactured by Hermes Medical Solutions
Sourced in Sweden
The Hybrid Viewer is a software application designed to display and analyze medical images. It supports a variety of image formats, including DICOM, and provides basic viewing and manipulation tools.
Automatically generated - may contain errors
9 protocols using hybrid viewer
1
Pituitary Adenoma Evaluation with 68Ga-DOTATATE PET/CT
2
PET/CT Imaging of [11C]Acetate Uptake
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[11C]acetate was prepared according to a well-established method [27 (link)]. All PET/CT scans were obtained using combined PET/CT scanner (Siemens Biograph TruePoint 64). According to the routine protocol all patients were asked to fast for at least 6 h before the examination and then received an intra-venous injection of [11C]acetate of 8 MBq/kg of body weight. After 20 min patients were scanned from thorax and abdomen. PET images were reconstructed using the TruX algorithm, with four iterations per 21 subsets, a 5-mm-slice thickness and a 168 × 168 matrix. Helical CT acquisitions were performed with 4 D care dose protocol and the following parameters: a tube current of 230 effective mAs, a tube voltage of 120 kVp, a collimation of 24 × 1.2 mm, a pitch of 0.813, and a scanning time of 0.5 s per rotation. For review, the CT images were reconstructed with a section thickness of 5 mm in 3-mm increments.
PET, non-enhanced CT and fused PET/CT images were generated and reviewed on the computer by a specialized physician, and co-registered images were displayed on special workstation system using Hybrid Viewer (HERMES Medical solutions, Stockholm, Sweden).
PET, non-enhanced CT and fused PET/CT images were generated and reviewed on the computer by a specialized physician, and co-registered images were displayed on special workstation system using Hybrid Viewer (HERMES Medical solutions, Stockholm, Sweden).
3
Quantitative Imaging Biomarkers for Neuroendocrine Tumor Response
4
Optimized OSEM Reconstruction for 90Y SPECT
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HybridRecon (Version 1.1C, HERMES Medical Solutions AB) was used to perform all reconstructions whilst HybridViewer (Version 2.6F, HERMES Medical Solutions AB) was used to view and analyse the reconstructed images. All images were attenuation corrected using CT data and had the resolution recovery option switched on. Where full MC collimator modelling was not enabled, standard MC scatter correction was carried out.
One acquisition of the phantom was reconstructed with OSEM 1–7 iterations and 15 subsets in order to ascertain the optimum OSEM reconstruction. Previous work on optimisation of 99mTc reconstruction in SPECT imaging had shown that five iterations and 16 subsets yield the best compromise between resolution and noise [20 (link)] but owing to the number of projections at which data were acquired at this institution, 16 subsets were not a possible option. Instead, the nearest alternative of 15 subsets was used. The optimum number of OSEM iterations for 90Y was found via quantitative analysis as described below.
Once the optimised OSEM reconstruction had been identified, all three of the acquisitions were reconstructed with the GE default OSEM protocol (2 iterations and 10 subsets) and the optimised OSEM protocol, both with and without full MC collimator modelling.
One acquisition of the phantom was reconstructed with OSEM 1–7 iterations and 15 subsets in order to ascertain the optimum OSEM reconstruction. Previous work on optimisation of 99mTc reconstruction in SPECT imaging had shown that five iterations and 16 subsets yield the best compromise between resolution and noise [20 (link)] but owing to the number of projections at which data were acquired at this institution, 16 subsets were not a possible option. Instead, the nearest alternative of 15 subsets was used. The optimum number of OSEM iterations for 90Y was found via quantitative analysis as described below.
Once the optimised OSEM reconstruction had been identified, all three of the acquisitions were reconstructed with the GE default OSEM protocol (2 iterations and 10 subsets) and the optimised OSEM protocol, both with and without full MC collimator modelling.
5
Semiautomated PET-Based GTV Delineation
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Semiautomated GTV delineation based on the given [F18] FDG-PET was performed using a dedicated software package (Hybrid Viewer, Hermes Medical Solutions, Stockholm, Sweden). Semiautomated GTVs were defined for a set of standardized uptake values (SUV) derived from the maximal SUV (SUVmax): SUV30, SUV35, and SUV40 defined as 30, 35, and 40% of SUVmax. PERCIST-TLG threshold was determined in analogy to the PERCIST criteria based on normal [F18] FDG background activity in a standardized 15 ml VOI in the right hepatic lobe as described by Niyazi et al. [10 (link)]. Schaefer’s threshold was calculated by using the formula TS = axSUV70 + bxBG as described by Schaefer et al. ([22 (link)]; Fig. 4 ).![]()
6
Evaluating 68Ga-PSMA PET/CT for Prostate Cancer Staging
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All scans were analyzed by experienced, board certified specialists in nuclear medicine with common pitfalls in 68 Ga-PSMA PET/CT in mind [10] . Image analysis was performed using Hybrid Viewer (HERMES Medical Solutions AB, Stockholm, Sweden). Images were interpreted according to the PSMA-RADS Version 1.0-criteria [11] . Maximum standardized uptake values (SUV max ) were measured in primary prostate tumors.
All 68 Ga-PSMA PET/CT scans with extraprostatic extension or metastasis were discussed at multidisciplinary team conferences with board-certified oncologists, radiologists, urologists, pathologists, and nuclear medicine physicians. Only patients with localized disease in the prostate (cT1-cT3N0M0) or patients with oligometastatic disease (cT1-cT3N1M0) following primary staging by 68 Ga-PSMA PET/CT, where the suspected regional lymph node metastases were deemed readily accessible for pelvic lymph node dissection, were scheduled for RP. All RP procedures were performed as robot-assisted surgery at the Department of Urology, Aarhus University Hospital, Denmark or the Department of Urology, Holstebro Regional Hospital, Denmark.
All 68 Ga-PSMA PET/CT scans with extraprostatic extension or metastasis were discussed at multidisciplinary team conferences with board-certified oncologists, radiologists, urologists, pathologists, and nuclear medicine physicians. Only patients with localized disease in the prostate (cT1-cT3N0M0) or patients with oligometastatic disease (cT1-cT3N1M0) following primary staging by 68 Ga-PSMA PET/CT, where the suspected regional lymph node metastases were deemed readily accessible for pelvic lymph node dissection, were scheduled for RP. All RP procedures were performed as robot-assisted surgery at the Department of Urology, Aarhus University Hospital, Denmark or the Department of Urology, Holstebro Regional Hospital, Denmark.
7
18F-FDG PET/CT Tumor Quantification
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18F-FDG PET/CT analysis with a pre-defined threshold of 40% of the maximum voxel intensity was performed by a single nuclear medicine/PET physician with >20 years of experience, blinded to MRI and clinical data), by placing a bounding box around the tumor using a standard clinical platform (HybridViewer, Hermes Medical Solutions). Maximum and mean standardized uptake values (SUVmax and SUVmean, respectively), metabolic tumor volume (MTV) and total lesion glycolysis (TLG = SUVmean x MTV) were recorded.
8
Quantitative 18F-FDG PET/CT Analysis of Lymphoma
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18F-FDG PET/CT images were analyzed by author LCG using Hybrid Viewer (Hermes Medical Solutions, Sweden) with the plug-in TumourFinder. Lymphoma lesions were segmented using both a SUV > 2.5 threshold (SUV2.5) as well as > 41% of the SUVmax (SUV41) thresholding. Quantitation parameters metabolic tumor volume (MTV2.5 and MTV41) and total lesion glycolysis (TLG2.5 and TLG41) were recorded for both segmentation methods.
Semi-automated methods and visual assessment of tumor volume and prognosis
| Method | Semi-automated measurements | Visual assessment | |||
|---|---|---|---|---|---|
| MTV2.5 | MTV41 | eMTV | MTVVAS | Prognosis | |
| Description | Metabolic tumor volume delineation > SUV 2.5 | Metabolic tumor volume delineation > 41% of SUVmax | Metabolic tumor volume assessed visually | Degree of metabolic tumor volume assessed on VAS scale | Prognosis assessed visually based on volume, heterogeneity, involvement of extra-nodal organs |
| Parameter | Continous (ml) | Continous (ml) | Continous (ml) | Continous (1–9) | Dichotomous (poor/favorable) |
9
68Ga-PSMA PET/CT Imaging Protocol
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All PET/CT scans were analyzed by experienced, board-certified specialists in nuclear medicine, knowing common pitfalls in 68 Ga-PSMA PET/CT (15) . Image analysis was performed using Hybrid Viewer (Hermes Medical Solutions AB). Images were interpreted according to the PSMA-RADS criteria, version 1.0 (16) . SUV max was measured in primary prostate tumors. Primary tumors were considered avid for 68 Ga-PSMA uptake on visual evaluation without a predefined SUV threshold. Regional pelvic LN metastases (LNMs) below the common iliac artery bifurcation taking up 68 Ga-PSMA were considered positive as N1 disease according to the PROMISE criteria (17) . Similarly, nonregional LNMs above the common iliac artery bifurcation taking up 68 Ga-PSMA were considered positive as M1a disease (extrapelvic). PSMA-avid lesions thought to represent bone metastases (BMs) were reported as M1b disease. Lastly, lesions suggesting visceral metastases were considered M1c disease. The number of metastases was recorded along with the SUV max for each lesion. Advanced disease was defined as having at least 1 extraprostatic PSMA-positive lesion (N1/M1 disease).
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