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PET/CT Quality Control

Department of Radiology

The University of Chicago

Clinical Physicist for the Nuclear Medicine Section

Bill C. O’Brien-Penney

Associate Professor of Radiology

Disclosures and Conflicts of Interest

• None

Bill O’Brien-Penney

Operator’s

Guide,

biograph 16

HI-REZ,

Siemens

Medical,

phantom

Operator’s

Guide,

biograph 16

HI-REZ,

Siemens

Medical,

PET Ge-68

QC tub

phantom

Outline

• Motivation and overall guidelines

• PET QC

• CT QC

• CT Dosimetry

• PET/CT QC

Reference

• IMAGING GUIDELINES FOR NUCLEAR

CARDIOLOGY PROCEDURES, E. Gordon DePuey

EG, Ed., pp 1-186, ASNC Imaging Guidelines, ASNC,

Motivation

• “Agencies that accredit facilities for medical use take Quality Assurance programs seriously.”

• “Over the past few years there has been a growing trend among medical insurance companies to require that a facility be accredited by an external agency as a prerequisite for reimbursement of medical imaging procedures.”

DePuey GE, 2006, pp. 4

Motivation

• “The ACR equipment guidelines require proof of both a

Quality Assurance program specific to … PET

cameras… including the submission of images of …

multipurpose Plexiglas PET phantoms, and equipment

acceptance testing reports.”

• “The ICANL equipment guidelines also require proof via

written documentation of ongoing camera and non-

imaging equipment QC that is reviewed during the site

visit.”DePuey GE, 2006, pp. 5

Quality Control

“A detailed description of the quality control procedures

for all instruments. This should include the testing

frequency, imaging or data format, and data analysis and

action levels.”

Society of Nuclear Medicine Procedure

Guideline for General Imaging, SNM, 2004

Site for SNM guidelines

http://interactive.snm.org/index.cfm?PageID=772

Quality Control Records

Society of Nuclear Medicine Procedure

Guideline for General Imaging, SNM, 2004

Records of all quality control procedures should be

maintained for the time specified by regulatory agencies.

A log of all instrument problems should be maintained,

and all problems should be reported to the chief

technologist or supervisor.

ICANL requirements: Equipment Quality Control

Essentials and Standards, ICANL, 2003

“The facility must have written protocols for and

maintain records of all routine quality control of

imaging and non-imaging equipment. There must also

be records of service and maintenance.”

• Principlesa. Regular performance

b. Prompt interpretation of results

c. Accurate and timely record keeping

QC principles - ASRT

PET-CT Curriculum, ASRT, pp.15, 2006

FOLLOW-UP PROCEDURES AND

WRITTEN SURVEY REPORT

The medical physicist … shall report the findings to the

physician(s), to the responsible professional(s) in charge of

obtaining or providing necessary service to the equipment,

… and, if appropriate, initiate the required service. Action

should be taken immediately by direct verbal communica-

tion if there is imminent danger to patients or staff using the

equipment due to unsafe conditions. Written survey reports

shall be provided in a timely manner consistent with the

importance of any adverse findings.

ACR Tech. STD for Med. Nuc. Phys. … of PET-CT …, 2006

http://www.crcpd.org/Pubs/PET-CT-Fusion/

02-16-04_1000_Fairobent.pdf(Note: 2004)

Reference

REGULATION: QUALITY ASSURANCE PROGRAMS

FOR MEDICAL DIAGNOSTIC X-RAY

INSTALLATIONS N.J.A.C. 7:28-22, New Jersey

Department of Environmental Protection

Bureau of Radiological Health, 2001

Website: http://www.state.nj.us/dep/rpp

7:28-22.4 QUALITY ASSURANCE PROGRAM MANUAL

(a) The registrant of any diagnostic medical x-ray equipment

used in the healing arts shall develop and continuously

implement a quality assurance program that includes a

quality assurance program manual that contains the following

elements:

1. A list of clearly identified individuals and assigned

responsibilities for maintaining the quality assurance program

and for performing the quality control tests.

New Jersey Regs, 7:28-22, 2001

7:28-22.4 QUALITY ASSURANCE PROGRAM MANUAL

2. Quality Control (QC) measures which shall include:

i. QC Tests to be performed and the frequency of each test;

ii. List of equipment to be tested;

iii. Acceptability limits for each test performed;

iv. Description of each QC test procedure;

v. Sample forms for each QC test performed;

vi. Processor and solutions maintenance; and

vii. Annual Medical Physicist’s QC Survey.

New Jersey Regs, 7:28-22, 2001

PET QC

Reference

• Positron Emission Tomography (PET) – Computed

Tomography (CT) Curriculum, American Society of

Radiologic Technologists, 15000 Central Ave. SE,

Albuquerque, NM, 2004.

PET QC mentioned by ASRT

•Quality Controla) Normalization

b) Blank scan (rotating rod source)

c) Gains (singles)

d) Cross-calibration

PET-CT Curriculum, ASRT, pp.6, 2006

• System performancea) Scatter fraction

b) Noise equivalent count rate

c) NEMA standards and testing

70cm long NEMA 2001 scatter and rate phantom

Placement of

scatter phantom

Area under scatter curve (1994 NEMA)

Area under Scatter curve Noise Equivalent Count rate

NEMA 2001 sensitivity phantom

NEMA body phantom reconstruction

Reference

• ACR TECHNICAL STANDARD FOR

MEDICAL NUCLEAR PHYSICS

PERFORMANCE MONITORING OF PET-CT

IMAGING EQUIPMENT, ACR, 2006

ACR PET QC Standards - ANNUAL

1. Spatial resolution (radial, tangential, and axial)

2. Count rate performance, including count loss

correction factor.

– a. System dead time

– b. Count rate versus activity

• i. Prompt coincidences

• ii. Random coincidences

• iii. Background coincidences

• iv. Net true coincidences

3. Sensitivity (cps/MBq/ml) 2D and 3D modes as

applicable.

4. Uniformity (plane-by-plane in 2D and 3D modes

as applicable).

5. Attenuation-correction calibration accuracy

(quantification).

6. Linearity of bed motion.

7. Reproducibility of transmission rod motion (extension and retraction) as applicable.

8. Reproducibility of lead septa motion (extension and retraction) as applicable.

9. Image contrast and full system test (phantom scan).

10. Reproducibility and accuracy of standardized uptake value (SUV) as applicable.

Reference

PET Phantom Instructions for Evaluation of PET

Image Quality, ACR, 2006 American College of Radiology

1891 Preston White Dr., Reston, VA 20191

ACR PET phantom

PET Phantom Instr. for Eval. of PET Image Qual., ACR, 2006

ACR PET phantom

Large “background”

ROI and small ROI

just inside largest

“hot” cylinder

ACR PET phantom

Apply small ROI to

the “hot” and “cold”

cylinders. Determine

max for hot cylinder

ROIs and min and

mean for cold and

background cylinders.

ICANL requirements

Essentials and Standards, ICANL, 2003

ASNC recommended QC

ACCEPTANCE TESTING

For 3D whole body imaging, use the methods described in

the recent NEMA standards (NU 2-2001) for acceptance

testing.

Using the older NEMA standard (NU 2-1994) may be more

appropriate for brain imaging and pediatric imaging. If you

are using 2D whole body imaging, these methods may be

easier and more relevant.

DePuey EG, ASNC imaging guidelines, 2006

ASNC recommended PET QC

• Sensitivity

• Transverse Resolution

• Scatter Fraction

• Accuracy of attenuation correction

and overall clinical image quality

(body phantom)

ASNC suggested QC Procedures:

Dedicated PET imaging devices

annualTransverse Resolution

(or at least weekly)

Sensitivity and overall

system performance

Once upon delivery and

upon major hardware

upgrades

Acceptance testing as per

NEMA NU 2-2001

FrequencyProcedure

annualAccuracy of Attenuation

correction

annualScatter Fraction

annualAccuracy

(corrections for count losses

and randoms)

FrequencyProcedure

As per the manufacturerMeasurements Specified by

the Manufacturer

annualImage Quality

FrequencyProcedure

Schelbert HR, et al., Society of Nuclear Medicine Procedure

Guideline for Tumor Imaging Using F-18 FDG,

(http://www.snm.org/guidelines), 1999

“For semiquantitative or quantitive studies, accurate

calibration of scanner counts to well counter counts is

needed; therefore, a cylindrical type calibration should be

performed on that day or at regular intervals, typically

once or twice a week. The dose injected into the patient

should also be recorded as accurately as possible.”

1999 SNM FDG imaging guidelines

Delbeke1 D, et al., Procedure Guideline for Tumor Imaging with

18F-FDG PET/CT 1.0, (http://www.snm.org/guidelines), 2006

2006 SNM FDB imaging guidelines

The quality control procedures for PET should include a

calibration measurement of activity in a phantom containing

a known concentration, generally as a function of axial

position within the scanner field of view. A daily check on

the stability of the individual detectors also should be

performed to identify detector failures and drifts

PET QC a CNMT might do

Society of Nuclear Medicine Performance and

Responsibility Guidelines for NMT, SNM, 2003

(a) Sinogram acquisition and evaluation;

(b) Well counter standard uptake value calibration;

(c) PET/CT system alignment calibration;

(d) CT system quality assurance;

(e) Glucometer quality assurance…; and

(f) Rubidium generator quality assurance to include

dose calibrator/generator calibration and

parent/daughter breakthrough.

Sinogram of a Tub phantom

CT Scanner QC

David E. Hintenlang, Ph.D., DABRMedical Physics Program Director

Department of Nuclear and Radiological Engineering Department of Biomedical Engineering

Presented by:

American College of Medical Physics 2004 Annual MeetingScottsdale Arizona

RADIATION PROTECTION IN

DIAGNOSTIC AND

INTERVENTIONAL RADIOLOGY

Part 18: Optimization of protection in CT scanner

Practical exercise - Quality Control

IAEA Training Material on Radiation Protection in

Diagnostic and Interventional Radiology

Compliance Guidance for COMPUTED TOMOGRAPHY

QUALITY CONTROL, New Jersey Department of

Environmental Protection, Bureau of Radiological Health,

Website: http://www.state.nj.us/dep/rpp

New Jersey BRH, 2001Mutic, S, et. al., .. Simulator QC… Med. Phys. 30: 2762-92, 2003

Mutic, S, et. al., Med. Phys. 30: 2762-92, 2003Mutic, S, et. al., Med. Phys. 30: 2762-92, 2003

AAPM REPORT NO. 74: QUALITY CONTROL

IN DIAGNOSTIC RADIOLOGY, AAPM, 2002

DailyCT Number Accuracy of Water,

Image Noise,

Image Uniformity

Artifacts.

AAPM REPORT NO. 74: QUALITY CONTROL

IN DIAGNOSTIC RADIOLOGY, AAPM, 2002

SemiannuallyImaged Slice Thickness (Slice Sensitivity Profile, SSP)

Dose Profile Width

Slice Positioning Accuracy

CT Number Scale Accuracy and Stability

Spatial Resolution (Image Sharpness)

Low-Contrast Detectability

Dosimetry of Axial Scans

Dosimetry of the Digital Survey Radiograph

Resolution, Gray Scale, Image Distortion, and Artifacts

in the Video Monitor and the Hard Copy

Annual Medical Physicist Survey

• Alignment light accuracy

• Alignment of Table to gantry

• Table/gantry tilt

• Slice localization from scanned projection radiograph

(localization image)

• Table incrementation accuracy

• Slice thickness

• CT number accuracy and linearity

ACR - CT Accreditation Program Requirements, ‘07

Slice Thickness

The slice thickness is determined in the center

of the field of view as the distance between

the two points on the sensitivity profile along

the axis of rotation at which response has

fallen to 50%.

IAEA, Part 18

Measurement of Measurement of

irradiated slice irradiated slice

widths for a range widths for a range

of nominal slice of nominal slice

width settingswidth settings

Dose Profiles (Irradiated slice width)

IAEA, Part 18

Dose Profiles (Irradiated slice width)

• Measurement of irradiated slice widths, for all nominal slice width settings, provides a direct test of pre-patient beam collimation functionality and allows geometric efficiencies to be calculated for the scanner

• Geometric efficiency (GE) is defined as:

GE = width slice irradiated x 100 %

width slice imaged

• It is recommended that GE value is displayed on the console if it is less than 70%

IAEA, Part 18

• Image quality

– 1. High-contrast (spatial) resolution

– 2. Low-contrast resolution

– 3. Image uniformity

– 4. Noise

– 5. Artifact evaluation

• Other tests as required by state or local regulations

• Display devices

– 1. Video display

– 2. Hard-copy display

• Dosimetry

– 1. Computed tomography

• dosimetry index (CTDI)

– 2. Patient radiation dose for representative

examinations

Continuous Quality Control

• Frequency – per physicist, at least manufacturer’s

recommendations

• Done according to written protocols

• Physicist reviews at least annually

• Deficiencies found are corrected, actions documented

• Preventative maintenance on schedule, documented, and

done by qualified personnel.

• Service log maintained

Reference

McCollough CH, et al., “The phantom portion of the

American College of Radiology .ACR. Computed

Tomography .CT. accreditation program: Practical tips,

artifact examples, and pitfalls to avoid”, Med. Phys., 31:

2423-2442, 2004

ACR phantom (Gammex 464)

McCollough CH, et al., 2004

McCollough CH,

et al., 2004

Alignment

Accuracy

(good)

Slice thickness

Hintenlang DE, CT Scanner QC, ACMP 2004

Slice thickness estimation

CT # accuracy

CT Number Calibration

• ROIs must be placed within the cylinders

• Polyethylene mean CT number must be between

–107 and –87 HU

• Water mean CT number must be between

–7 and +7 HU (± 5 HU preferred)

ACR - Phantom Testing Criteria., ‘03

CT Number Calibration

• Acrylic mean CT number must be between +110 and +130 HU

• Bone mean CT number must be between +850 and +970 HU

• Air mean CT number must be between –1005 and –970 HU

• The adult abdomen protocol from Table 1 must be used

Standards for Quality Control at Canadian Radiation Treatment

Centres: CT-Simulators, Canadian Association of Provincial

Cancer Agencies, 2005

Reference

Electron

Density

phantom

Slice thickness

Slice Thickness

• Image data required for HRC, ~ 3, ~ 5, and ~ 7 mm slice

thicknesses

• Water mean CT number must be between –7 and +7 HU

(± 5 HU preferred)

• The slice width must be within 1.5 mm of the prescribed

Low contrast

section

Low contrast

section

Uniformity and noise

section

Uniformity and noise

section

T h e P h a n t o m L a b o r a t o r y,

C a t p h a n ® 500 and 600 M a n u a l, 2006

T h e P h a n t o m L a b o r a t o r y,

C a t p h a n ® 500 and 600 M a n u a l, 2006

Water vs. kVp

• Image data are required for all selectable kVp

settings

• Water mean CT number must be between

–7 and +7 HU (± 5 HU preferred)

McCollough CH,

et al., 2004

High contrast

section

(Numbers

Indicate

Line-pairs / cm)

McCollough CH,

et al., 2004

high contrast

section

Philips’ CT head and body phantom

Gemini GXL manual, Philips, 2005

Display and film QC

• SMPTE or other video test pattern must be present in

the first box of each film sheet

• The 95% square must be visible (whites must not be

saturated)

• The 5% square must be visible (blacks must not be

saturated)

• No aliasing of bar patterns or other artifacts

SMPTE pattern for display testing

Dosimetry

RADIATION SAFETY IN IMAGING

Radiologists, radiologic technologists, and all supervising

physicians have a responsibility to minimize radiation

dose to individual patients, to staff, and to society as a

whole, while maintaining the necessary diagnostic image

quality. This is the concept “As Low As Reasonably

Achievable (ALARA).”

ACR Tech. STD for Med. Nuc. Phys. … of PET …, 2006

RADIATION SAFETY IN IMAGING

Facilities, in consultation with the medical physicist,

should have in place and should adhere to policies and

procedures, in accordance with ALARA, to vary

examination protocols to take into account patient body

habitus, such as height and/or weight, body mass index or

lateral width.

ACR Tech. STD for Med. Nuc. Phys. … of PET …, 2006 Capintec website, 2003

CT “head” dose phantom, with “body” ring

CIRS, model 007,

CIRS website,

Dosimetry

Note other holes

are filled,

Ionization chamber

Is in center hole

Abdominal

dosimetry

Note other holes

are filled,

Ionization chamber

Is in center hole

Dosimetry - CTDI in Perspex Phantoms

• The body phantom placed on the patient table and the

head phantom is supported in the head rest

• Phantoms are aligned centered at the scan isocentre

• The ion chamber is inserted into either the central or one

of the peripheral cavities of the phantom (all other

cavities being filled with Perspex rods)

IAEA, Part 18

• Dose measurements at the center are used to calculate the

central CTDI

• Peripheral CTDI is measured in at least four positions

around the phantom, so as to achieve a true average

Note: if gantry rotation is initiated from different angular

positions for successive scans it may be necessary to take

a number of measurements at each position in order to

get a representative mean dose

IAEA, Part 18

Head phantomHead phantomBody phantom Body phantom (or annulus (or annulus

to fit over head phantom)to fit over head phantom)

Insert to plug holesInsert to plug holes

IAEA, Part 18

• Central and peripheral CTDI’s are used to

calculate weighted CTDI, CTDIw:

• CTDIws can be compared against diagnostic

reference levels for standard scan examinations

IAEA, Part 18

)( CTDI3

2+CTDI

1=CTDI p100,c100,wn

ACR recommended maximum doses

PET/CT QC

Reference

• ACR TECHNICAL STANDARD FOR

MEDICAL NUCLEAR PHYSICS

PERFORMANCE MONITORING OF PET-CT

IMAGING EQUIPMENT, ACR, 2006

ACR PET-CT QC Standards

The results of the QC program shall be monitored

annually by the medical physicist. If measured values of

QC parameters fall outside the control limits, the physicist

should initiate appropriate investigative or corrective

actions. A medical physicist should be available to assist

in prescribing corrective actions for unresolved problems.

ACR PET-CT QC Standards

Specific Tests for PET-CT

“The performance of either the PET or CT system can affect the overall performance of dual-modality imaging. Each system should be tested individually, as listed previously, and together to examine coregistration. For this purpose, specially designed phantoms shall be scanned on both PET and CT systems. Accuracy of coregistration shall be determined by established procedure.”

Delbeke1 D, et al., Procedure Guideline for Tumor Imaging with

18F-FDG PET/CT 1.0, (http://www.snm.org/guidelines), 2006

“In addition, for PET/CT, a check on the alignment

between the CT and the PET scanners should be

performed periodically. Such a gantry alignment check

should determine any offset between the CT and the

PET scanners to be incorporated into the fused image

display to ensure accurate image alignment.”

PET/CT image alignment accuracy

Lubberink M:

Quality control

of PET and

PET/CT

scanners

Crossed

rod source

PET/CT

registration

Phantom

Used by

Siemens

GEMINI GXL –

Instructions

for Use,

Philips

Medical

Systems, 2005

alignment

calibration

holder

ASNC recommended PET-CT QC

• Registration accuracy

• Accuracy of attenuation correction

– Compare to rotating-rod-source based correction

if possible.

– Use phantom with non-uniform attenuation and “hot” and “cold” spots

– Also use a uniform activity and attenuation tub

Combined PET/CT QC Procedures:

MandatoryAttenuation Correction

Accuracy

MandatoryRegistration

RequirementTest

Inspect Clinical Images for Artifacts

“Streak artifacts result from problems with CT

transmission images, such as insufficient X-ray tube

intensity in obese individuals, breathing mismatch,

truncation, and beam hardening resulting from bone

(arms down) or metal adjacent to the heart

(pacemakers and internal defibrillators) “

DePuey EG, ASNC imaging guidelines, pp.141, 2006

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