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. 2024 May 29;11(1):46.
doi: 10.1186/s40658-024-00647-x.

An international phantom study of inter-site variability in Technetium-99m image quantification: analyses from the TARGET radioembolization study

Grace Keane  1 , Rob van Rooij  2 , Marnix Lam  2 , S Cheenu Kappadath  3 , Bilal Kovan  4 , Stephanie Leon  5 , Matthew Dreher  6 , Kirk Fowers  6 , Hugo de Jong  2
Affiliations

An international phantom study of inter-site variability in Technetium-99m image quantification: analyses from the TARGET radioembolization study

Grace Keane et al. EJNMMI Phys. .

Abstract

Background: Personalised multi-compartment dosimetry based on [99mTc]Tc-MAA is a valuable tool for planning 90Y radioembolization treatments. The establishment and effective application of dose-effect relationships in yttrium-90 (90Y) radioembolization requires [99mTc]Tc-MAA SPECT quantification ideally independent of clinical site. The purpose of this multi-centre phantom study was to evaluate inter-site variability of [99mTc]Tc-MAA imaging and evaluate a standardised imaging protocol. Data was obtained from the TARGET study, an international, retrospective multi-centre study including 14 sites across 8 countries. The impact of imaging related factors was estimated using a NEMA IQ phantom (representing the liver), and a uniformly filled cylindrical phantom (representing the lungs). Imaging was performed using site-specific protocols and a standardized protocol. In addition, the impact of implementing key image corrections (scatter and attenuation correction) in the site-specific protocols was investigated. Inter-site dosimetry accuracy was evaluated by comparing computed Lung Shunt Fraction (LSF) measured using planar imaging of the cylindrical and NEMA phantom, and contrast recovery coefficient (CRC) measured using SPECT imaging of the NEMA IQ phantom.

Results: Regarding the LSF, inter-site variation with planar site-specific protocols was minimal, as determined by comparing computed LSF between sites (interquartile range 9.6-10.1%). A standardised protocol did not improve variation (interquartile range 8.4-9.0%) but did improve mean accuracy compared to the site-specific protocols (5.0% error for standardised protocol vs 8.8% error for site-specific protocols). Regarding the CRC, inter-system variation was notable for site-specific SPECT protocols and could not be improved by the standardised protocol (CRC interquartile range for 37 mm sphere 0.5-0.7 and 0.6-0.8 respectively), however the standardised protocol did improve accuracy of sphere:background determination. Implementation of key image corrections did improve inter-site variation (CRC interquartile range for 37 mm sphere 0.6-0.7).

Conclusion: Eliminating sources of variability in image corrections between imaging protocols reduces inter-site variation in quantification. A standardised protocol was not able to improve consistency of LSF or CRC but was able to improve accuracy.

Keywords: Harmonization; Imaging; Macroaggregated-albumin (MAA); Performance; SPECT/CT; Technetium-99m; Yttrium-90.

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Conflict of interest statement

Grace Keane, MSc (GK): Is a consultant for Boston Scientific. Rob van Rooij, PhD (RVR): Is a consultant for Boston Scientific and Quirem Medical. Marnix Lam, MD, PhD (ML): Is a consultant for Boston Scientific, Terumo and Quirem Medical. He receives research support from Boston Scientific, Terumo and Quirem Medical. Cheenu Kappadath, PhD (CK): Is a consultant for Boston Scientific, Sirtex Medicine and Terumo Medical. He receives research support from Boston Scientific, Sirtex Medical and Terumo Medical. Bilal Kovan, PhD (BK): none. Stephanie Leon, PhD (SL): none. Matthew Dreher, PhD (MD): Works for Boston Scientific. Kirk D. Fowers, PhD (KF): Works for Boston Scientific. Hugo de Jong, PhD (HDJ): Is a consultant for Boston Scientific and Quirem Medical.

Figures

Fig. 1
Fig. 1
NEMA and cylindrical phantom positioned for a feet-first protocol
Fig. 2
Fig. 2
LSF as measured on site-specific protocols and the standardised protocol. Boxplots summarizing the lung shunt fraction values for the site-specific (left) and standardised (right) protocols. The box represents the 25th to 75th percentile range and the central horizontal line represents the median value. The whiskers represent the range. The dashed line represents the true LSF value as determined from injected activities
Fig. 3
Fig. 3
CRCs by sphere diameter for inserts 1 to 6 for site-specific acquisition and site-specific reconstruction protocols. A scatter plot of contrast recovery coefficient by sphere diameter for the 25 site-specific protocols
Fig. 4
Fig. 4
CRCs by sphere diameter for inserts 1 to 6 for site-specific acquisition and site-specific reconstruction protocols (paired subgroup) and for the standardised protocol. A A scatter plot of contrast recovery coefficient by sphere diameter for the 11 site-specific protocols which were included in the paired analysis. Protocols include both AC and SC, with the exception of the ‘GE Infinia’ protocol which includes AC and no SC. B A scatter plot of contrast recovery coefficient by sphere diameter for the 11 cameras that provided data acquired via the standardised protocol
Fig. 5
Fig. 5
CRCs by sphere diameter for inserts 1 to 6 for site-specific protocols (paired subgroup) and the standardised protocol. The dashed lines represent the mean CRC across site-specific protocols (paired subgroup) and sites that provide data for the standardised protocol. Boxplots summarizing the CRC range for the site-specific (left) and standardised (right) protocols are included for each sphere diameter. The box represents the 25th to 75th percentile range and the central horizontal line represents the median value. The whiskers represent the range
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