An early PET advocate recounts the origins of PET implementation at Royal Prince Alfred Hospital in Australia and today achieves even higher levels of patient care and research using Biograph Vision Quadra鈩.
Data courtesy of Royal Prince Alfred Hospital, Sydney, Australia.
As a pioneer in the use of PET since the late 1980s, Professor Michael Fulham, MBBS, of the Royal Prince Alfred Hospital (RPA) and the University of Sydney in Australia, recalls technical challenges and the difficulty convincing clinicians of the value of positron emission tomography (PET) when he first returned to Australia from the United States.听
Those challenges are a distant memory for Fulham and RPA, where he is the director of the Department of Molecular Imaging and the clinical director of Medical Imaging in Sydney Local Health District (SLHD). The hospital recently surpassed the milestone of 120,000 PET and PET/computed tomography (CT) scans and has the distinction of being the first hospital in Australia and the second hospital worldwide to install Siemens Healthineers鈥 Biograph Vision Quadra PET/CT scanner.听
With the 106-cm axial PET field of view Biograph Vision Quadra offers, Fulham and his colleagues have achieved an even higher level of patient care and research excellence made possible by whole-body, vertex-to-thighs imaging. 鈥淲hen you can see everything at once鈥攖he brain, the heart, the liver, the abdomen, the pelvis鈥攖hat to me is a game changer,鈥 Fulham says. 鈥淲hy? Because you鈥檝e got true simultaneity, both for clinical work and for research.鈥
Explore the images
A crane lowers Biograph Vision Quadra through the roof during the installation at Royal Prince Alfred Hospital, Sydney, Australia, in 2020.
Timeline of changing paradigms in medical imaging
Fulham conducted research on the capabilities of PET in the late 1980s at the National Institutes of Health in Bethesda, MD, USA, before returning to RPA in 1993, shortly after the hospital launched its PET program. RPA, voted as the best hospital in Australia in a 2022 survey, has long been one of Australia鈥檚 premier tertiary referral hospitals and the principal teaching hospital of the University of Sydney.1
Fulham notes that early PET scanners had gantries that could only accommodate the head, but the development of CTI ECAT 951 opened up a new era by enabling the imaging of all body parts. The Siemens ECAT 951 was the scanner installed in RPA in 1992. He recalls that surgical oncologists at RPA, rather than medical oncologists, were the most enthusiastic early adopters of PET imaging. Its utility in guiding and improving treatment for patients with cancer of the skin (melanoma), liver, lung, and stomach formed the foundation that later convinced other clinicians, such as hematologists, respiratory physicians, medical oncologists, radiation oncologists, of its potential. 鈥淲e aim for the best,鈥 Fulham says, 鈥渁nd that鈥檚 really what鈥檚 driven our program.鈥
RPA鈥檚 early adoption of imaging modalities to improve patient care is consistent with its history of medical innovation and leadership, both as a teaching hospital and as a referral hospital that has cared for patients since 1882. Fulham emphasizes that results drive the hospital鈥檚 decision-making and enable him to make the case for new investments in technology. 听
Move the slider left and right to compare the images from 1992 to 2021
Image left of slider: PET (ECAT 951R) 鈥渂ed positions鈥 scans at RPA in 1992. Data courtesy of Royal Prince Alfred Hospital, Sydney, Australia.
Image right of slider: From ECAT to Biograph Vision Quadra in 2021 at RPA (13-minute scan). Data courtesy of Royal Prince Alfred Hospital, Sydney, Australia.
鈥淢y approach is that if you鈥檝e got meaningful and accurate data, it鈥檚 very hard to argue against it,鈥 he says. 鈥淲hat鈥檚 important is to demonstrate how imaging with PET changes patient care and how it can be efficient and productive. And we鈥檝e done all of those things.鈥
Advances in scanner reliability and image quality continued throughout the 1990s, 鈥渂ut when PET/CT was released at RSNA 2000, it was clear that the paradigm would change,鈥 Fulham says. At that stage, Fulham said that 8 to 9 scans were the most scans that could be done in one day. Each scan took 64 minutes to acquire data from the base of the skull to the upper thighs. 鈥淚t鈥檚 not just about anatomical localization,鈥 he added. 鈥淚t鈥檚 really about how both work together. The PET in the Biograph鈩 Duo PET/CT had LSO detectors that were so much faster. So coupled with the anatomical data from the CT, the introduction of PET/CT was a tremendous advance鈥攚e could do faster and better scans.鈥
Fulham says the central role that PET/CT now plays in patient care at RPA and how quickly the technology has evolved are perhaps best illustrated by looking back at the number of scans the hospital has performed. When he began working at RPA in the early 1990s, the hospital scanned its first 100 patients over a span of 10 months. Scanning the first 1,000 patients took 25 months. Fast forward to July 2019, and RPA reached a milestone of 100,000 patient scans. By the end of March 2022, it had already reached 120,000 scans.听
RPA installed two Biograph Vision鈩 scanners in 2019. With 3.2-mm LSO crystals that deliver high spatial resolution and fast time of flight, the scanners enabled Fulham and his colleagues to confidently detect small sites of disease that would otherwise be missed.听
鈥淲ith Biograph Vision, the crystal size was smaller, and the sensitivity increased compared to our Biograph mCTs,鈥 he says. 鈥淭he image quality, which was already very good on the two Biograph mCTs we had, improved yet again, and with it came the confidence in detecting sites of disease in even smaller structures. This, once again, changed patient management.鈥
Today鈥檚 install increases patient throughput and comfort
By incorporating four detector-block assemblies found in Biograph Vision alongside each other, Biograph Vision Quadra significantly enhances effective sensitivity. Fulham describes the decision to install it at RPA as 鈥渁 no brainer.鈥澨
鈥淚 had no doubt about its value to patients because it was 16 times more sensitive than most conventional PET/CT scanners and 10 times more sensitive than Biograph Vision, and Biograph Vision was the most sensitive scanner that鈥檚 been made by Siemens Healthineers until Biograph Vision Quadra came along,鈥 Fulham says.a 鈥淪o, I knew that we would be able to get more precision in what we did, and everything would be better鈥攖he scan duration would be shorter, the dose lower, and we would have superb images.鈥
Explore Biograph Vision Quadra images in the gallery
Metastic lung cancer patient: two positions/12-minute torso and 1-minute legs, using Biograph Vision Quadra. Data courtesy of Royal Prince Alfred Hospital, Sydney, Australia.
A workhorse for clinical care and research in PET/CT imaging
Fulham emphasizes the importance of being able to scan multiple organs simultaneously, noting that it enables the assessment of tracer kinetics. He and his colleagues are assessing optimal scan acquisition time and dose and adapting the parameters for different body types. 鈥淭here鈥檚 so much potential in Biograph Vision Quadra that it really is untapped,鈥 he says. 鈥淲e鈥檙e only just starting to scratch the surface of what it can do in our research areas.鈥澨
In clinical care, Fulham noted that the image quality that Biograph Vision Quadra produces with shorter scan durations and with reduced doses is 鈥榬idiculously good.鈥櫶
鈥淣othing can detect disease in small nodes in prostate cancer like a PSMA scan with Biograph Vision Quadra,鈥 Fulham says. 鈥淲e pick up nodes as small as 2 mm that have uptake in them, and the scanner gives you the confidence that it鈥檚 real, it鈥檚 there, and it means better patient care.鈥 He added that 鈥渨e have scanned some patients where the image quality at a 1-min acquisition is diagnostic, which is unbelievable.鈥
The rapid scan times that Biograph Vision Quadra enables have increased patient throughput at RPA and, importantly, patient comfort. He recalls a patient with a very high body mass index (BMI =64.2, 419 lb/190 kg) who had been scanned previously on the Biograph Vision scanner. 鈥淪he was blown away when she was on the bed for 12 minutes,鈥 Fulham says. 鈥淭he patient asked the tech, 鈥業s it done? The last time I was here I was on the bed for 45 minutes.鈥 This is incredibly meaningful for the patient, and not only that, the image quality was truly unbelievable for a patient with a high BMI.鈥
For Fulham, outcomes such as these reaffirm how the early adoption of new technologies can benefit patients. 鈥淭he journey has been focused predominantly on making sure that we do the right thing by the patient, having fantastic technology, and a receptive vendor who鈥檚 prepared to push the envelope,鈥 he says. 鈥淥ur relationship [with Siemens Healthineers] has been based on a solid understanding of what the technology is capable of and what we need.鈥
"When you can see everything at once鈥攖he brain, the heart, the liver, the abdomen, the pelvis鈥攖hat to me is a game changer. Why? Because you鈥檝e got true simultaneity, both for clinical work and for research."
Fulham emphasizes that RPA plans to continue growing its PET/CT program to better serve its patients and to continue to advance the field through innovative research.听
鈥淲as it the right decision to get a Biograph Vision Quadra?鈥 Fulham asks rhetorically. 鈥淵es. And what are we going to do next? Of course, we are going to get another one!鈥澨
鈥淲e鈥檙e expanding the department in the near future, and I hope to have a PET/MR as well as a new PET/CT scanner. The workhorse will be Biograph Vision Quadra, and it鈥檒l be the workhorse both for research and for clinical care.鈥
About the author
Sameh Fahmy, MS, is an award-winning freelance medical and technology journalist based in Athens, Georgia, USA.
