1. THE INFLUENCE OF QUANTIFICATION ON SPECT 123I-IOFLUPANE
British Nuclear Medicine Society – Spring Meeting Brighton 2015
THE INFLUENCE OF QUANTIFICATION ON SPECT 123I-IOFLUPANE
A Matos1, M Jessop1, AM Peters1, N Singh1, A Hosur1, V Raman1, G Keramida1, M Aplin1, S Dizdarevic1
1- Nuclear Medicine, Department of Imaging, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
April 2015

2. Summary Introduction Purpose Methods Results Discussion Conclusion
THE INFLUENCE OF QUANTIFICATION ON SPECT 123I-IOFLUPANE
Summary
Introduction
Purpose
Methods
Results
Discussion
Conclusion
Acknowledgements
References

3. Disclosure Statement Research Support 1: Nothing to declare.
THE INFLUENCE OF QUANTIFICATION ON SPECT 123I-IOFLUPANE
Disclosure Statement
Research Support 1: Nothing to declare.
____________________________________________________________________________________________ ________
Consultant 2: Nothing to declare.
Speakers Bureau 3: Nothing to declare.
Honoraria and/or Stockholder 4,5: Nothing to declare. __________________________________________________________________________________________ _________
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4. THE INFLUENCE OF QUANTIFICATION ON SPECT 123I-IOFLUPANE
Introduction
Single Photon Emission Computed Tomography (SPECT) with 123I-Ioflupane is a widely available technique evaluating the integrity of nigrostriatal dopaminergic synapses which are affected in presynaptic Parkinsonian syndromes, and helpful in differentiating between Essential Tremor and Parkinsonian Syndromes (1,2).
SPECT 123I-Ioflupane images have been evaluated using visual assessment or by manual regions of interest (ROIs) (3).
Fig. 1 Striatal dopaminergic synapse (2)
Quantification involves placing ROIs over the caudate and putamen and computing ratios to a background region. Some advantages of quantification are: more objective assessment, detection of more subtle changes and an aid to visual interpretations(3).
________________________________________________________________________________________________________________
1- Jan Booij, et al. The clinical benefit of imaging striatal dopamine transporters with [123I]FP-CIT SPET in differentiating patients with presynaptic parkinsonism from those with other forms of parkinsonism. European Journal of Nuclear Medicine Vol. 28, No 3, March 2001.
2- David S.W. Djang, et al. SNM Practice Guideline for Dopamine Transporter Imaging with 123I-Ioflupane SPECT 1.0*. The Journal of Nuclear Medicine Vol. 53 No. 1, January 2012.
3- GE Healthcare. DaTQUANT* White Paper. NU EN-US DOC

5. THE INFLUENCE OF QUANTIFICATION ON SPECT 123I-IOFLUPANE
Purpose
The aim of the study was to assess if DAT quantification influenced confidence of reporting clinicians and final reports.

6. Fig. 2 DaTQUANT VOIs on a SPECT 123I-Ioflupane Image
THE INFLUENCE OF QUANTIFICATION ON SPECT 123I-IOFLUPANE
Methods
Retrospective Study
SPECT 123I-Ioflupane images
Between April and November 2014
Reporting
Visually
Semi-quantitative analysis
Transaxial images
Iterative reconstruction
10 OSEM iterations, 10 subsets
Butterworth post-filter
The application used for quantification was DaTQUANT®, which is based on fully automated registration of the patient’s SPECT scan to the Montreal Neurological Institute MR template, calculating striatal binding and asymmetry ratios. Uptake in the striatal regions is obtained using a volume of interest (VOI) atlas in regions as, caudate, putamen (anterior and posterior), striatum and background.
A score of 1-5 (1 being least) was applied to assess clinicians reporting confidence and quantification usefulness.
A retrospective review of SPECT 123I-Ioflupane images was conducted in our institution between April and November 2014.
All scans were reported visually and assessed by semi-quantitative analysis.
Transaxial images were obtained using iterative reconstruction (10 OSEM iterations, 10 subsets) with a Butterworth post-filter.
Fig. 2 DaTQUANT VOIs on a SPECT 123I-Ioflupane Image

7. Visual Assessment/ Quantification
THE INFLUENCE OF QUANTIFICATION ON SPECT 123I-IOFLUPANE
Results
The study included a total of 96 SPECT 123I-Ioflupane images performed in our institution.
Table 1: Agreement and Disagreement between Visual Assessment and Quantification
Visual Assessment/ Quantification
Frequency
Percentage
Agreement 84
87.5%
Disagreement 12
12.5%
Total 96
100%

8. Quantification Increased Confidence
THE INFLUENCE OF QUANTIFICATION ON SPECT 123I-IOFLUPANE
Results - Confidence
Quantification increased clinicians’ confidence in 40% of the cases where there was agreement.
When in agreement, majority of the cases increased clinicians’ confidence by 1 or 2.
Table 2: Agreement between Visual Assessment and Quantification – Increase of Confidence
Quantification Increased Confidence
Frequency
Percentage
YES 34
40% NO 50
60%
Total 84
100%
Fig. 3 Agreement between Visual Assessment and Quantification – Increase of Confidence Scale (1-5)

9. Results – Change of diagnosis
THE INFLUENCE OF QUANTIFICATION ON SPECT 123I-IOFLUPANE
Results – Change of diagnosis
Where disagreement (12.5%), according to reporting clinicians, diagnosis would have changed in a third of these cases (33%).
Table 3: Disagreement between Visual Assessment and Quantification – Change of Diagnosis
Quantification Change Diagnosis
Frequency
Percentage
YES 4
33% NO 8
67%
Total 12
100%
Fig. 4 Disagreement between Visual Assessment and Quantification – Change of Diagnosis

10. Quantification Usefulness
THE INFLUENCE OF QUANTIFICATION ON SPECT 123I-IOFLUPANE
Results - Usefulness
Quantification was shown to be useful in 60% of cases which were in agreement with visual assessment and 58% of those in disagreement.
Table 4: Agreement/Disagreement between Visual Assessment and Quantification – Overall Usefulness
Quantification Usefulness
Frequency
Percentage
Total
YES NO
Agreement 50 34
60%
40% 84
Disagreement 7 5
58%
42% 12

11. THE INFLUENCE OF QUANTIFICATION ON SPECT 123I-IOFLUPANE
Results - Usefulness
Fig. 5 Agreement between Visual Assessment and Quantification – Overall Usefulness
Fig. 6 Disagreement between Visual Assessment and Quantification – Overall Usefulness

12. Results Case 1 - 72 years old, male
THE INFLUENCE OF QUANTIFICATION ON SPECT 123I-IOFLUPANE
Results
Case 1
- 72 years old, male
- ?Extrapyramidal syndrome. Left-sided slowness. History of subdural on the right in the past
Fig. 7 Display of Summed Image SPECT 123I – Ioflupane
Fig. 8 Analysis review screen of DaTQUANT SPECT 123I – Ioflupane Images

13. Results Case 2 - 57 years old, female
THE INFLUENCE OF QUANTIFICATION ON SPECT 123I-IOFLUPANE
Results
Case 2
- 57 years old, female
- Suspected early Parkinson's disease
Fig. 9 Display of Summed Image SPECT 123I – Ioflupane
Fig. 10 Analysis review screen of DaTQUANT SPECT 123I – Ioflupane Images

14. Results Case 3 - 76 years old, male
THE INFLUENCE OF QUANTIFICATION ON SPECT 123I-IOFLUPANE
Results
Case 3
- 76 years old, male
- Suspected Parkinson's disease; previous stroke
Fig. 11 Display of Summed Image SPECT 123I – Ioflupane
Fig. 12 Analysis review screen of DaTQUANT SPECT 123I – Ioflupane Images

15. Results Case 4 - 66 years old, male - Predominantly right-sided tremor
THE INFLUENCE OF QUANTIFICATION ON SPECT 123I-IOFLUPANE
Results
Case 4
- 66 years old, male
- Predominantly right-sided tremor
Fig. 13 Display of Summed Image SPECT 123I – Ioflupane
Fig. 14 Analysis review screen of DaTQUANT SPECT 123I – Ioflupane Images

16. Results Case 5 - 69 years old, male
THE INFLUENCE OF QUANTIFICATION ON SPECT 123I-IOFLUPANE
Results
Case 5
- 69 years old, male
- ?Cognitive involvement and parkinsonism
Fig. 15 Display of Summed Image SPECT 123I – Ioflupane
Fig. 16 Re-processed Summed Image SPECT 123I – Ioflupane
Fig. 17 Analysis review screen of DaTQUANT SPECT 123I – Ioflupane Images

17. THE INFLUENCE OF QUANTIFICATION ON SPECT 123I-IOFLUPANE
Discussion
The visual assessment of most of the SPECT 123I-Ioflupane images included in the study was in agreement with quantification (DaTQUANT®) however there were cases of disagreement (12.5%).
Quantification was shown to be useful in 60% of cases, when in agreement with visual assessment and useful in 58%, when in disagreement. Overall, quantification was very useful when visual assessment was equivocal.
When in disagreement, in most of the cases (67%), quantification would not change the final diagnosis.
Our results indicate that quantification increases the reporting confidence (40%) in the final report, mainly in borderline cases or when visual assessment is not clear.

18. THE INFLUENCE OF QUANTIFICATION ON SPECT 123I-IOFLUPANE
Conclusion
Quantification is a useful adjuvant tool for 123I-Ioflupane SPECT image reporting, improving reporting confidence and can impact on diagnosis.

19. THE INFLUENCE OF QUANTIFICATION ON SPECT 123I-IOFLUPANE
References
1- Jan Booij, et al. The clinical benefit of imaging striatal dopamine transporters with [123I]FP-CIT SPET in differentiating patients with presynaptic parkinsonism from those with other forms of parkinsonism. European Journal of Nuclear Medicine Vol. 28, No 3, March 2001.
2- David S.W. Djang, et al. SNM Practice Guideline for Dopamine Transporter Imaging with 123I-Ioflupane SPECT 1.0*. The Journal of Nuclear Medicine Vol. 53 No. 1, January 2012.
3- GE Healthcare. DaTQUANT* White Paper. NU EN-US DOC

20. THE INFLUENCE OF QUANTIFICATION ON SPECT 123I-IOFLUPANE
Acknowledgements
Authors would like to thank everyone directly or indirectly involved in this study.

21. THE INFLUENCE OF QUANTIFICATION ON SPECT 123I-IOFLUPANE
“The human brain is a wonderful organ. It starts to work as soon as you are born and doesn't stop until you get up to deliver a speech.”
George Jessel