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J Nucl Med. 2008 July ; 49(7): 1114–1131. doi:10.2967/jnumed.107.050203.

Routine Quality Control of Clinical Nuclear Medicine

Instrumentation: A Brief Review*

Pat Zanzonico
Departments of Medical Physics and Radiology, Memorial Sloan-Kettering Cancer Center, New
York, New York

Abstract
This article reviews routine quality-control (QC) procedures for current nuclear medicine
instrumentation, including the survey meter, dose calibrator, well counter, intraoperative probe,
organ (“thyroid”) uptake probe, γ-camera, SPECT and SPECT/CT scanner, and PET and PET/CT
scanner. It should be particularly useful for residents, fellows, and other trainees in nuclear medicine,
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nuclear cardiology, and radiology. The procedures described and their respective frequencies are
presented only as general guidelines.

Keywords
instrumentation; PET/CT; SPECT/CT; quality control (QC); scanner; survey meter

Nuclear medicine is critically dependent on the accurate, reproducible performance of clinical

radionuclide counting and imaging instrumentation. Quality control (QC), which may be
defined as an established set of ongoing measurements and analyses designed to ensure that
the performance of a procedure or instrument is within a predefined acceptable range, is thus
a critical component of routine nuclear medicine practice. An extensive series of parameters
has been developed over the years for acceptance testing and performance characterization of
γ-cameras, SPECT and PET scanners, and other nuclear medicine instrumentation. And
detailed data acquisition and analysis protocols for this purpose have been promulgated by the
National Electrical Manufacturers Association (NEMA), the American Association of
Physicists in Medicine (AAPM), and other regulatory, advisory, and professional organizations
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(1–9). In practice, however, less time-consuming and less rigorous procedures often suffice
for day-to-day QC. The current article is a brief overview of such routine QC procedures for
current nuclear medicine instrumentation, including the survey meter, dose calibrator, well
counter, intraoperative probe, organ (“thyroid”) uptake probe, γ-camera, SPECT and SPECT/
CT scanner, and PET and PET/CT scanner. The far more rigorous and more extensive
acceptance-testing procedures performed for γ-cameras, SPECT and SPECT/CT scanners, and
PET and PET/CT scanners are beyond the scope of this article, which is not intended to
supersede or replace manufacturer-recommended acceptance-testing, QC, and preventive-
maintenance procedures.

*NOTE: FOR CE CREDIT, YOU CAN ACCESS THIS ACTIVITY THROUGH THE SNM WEB SITE
(http://www.snm.org/ce_online) THROUGH JULY 2009.
For correspondence or reprints contact: Pat Zanzonico, Memorial Sloan-Kettering Cancer Center, 1275 York Ave., New York, NY 10021.
E-mail: E-mail: [email protected].
No potential conflict of interest relevant to this article was reported.
 Zanzonico Page 2

This article should be particularly useful for residents, fellows, and other trainees in nuclear
medicine, nuclear cardiology, and radiology. For technical information on the instrumentation
covered in this article, including further details on QC procedures, additional reading is
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recommended (10–17).

SAFETY AND ELECTROMECHANICAL INSPECTION

For those nuclear medicine instruments that “interface” directly with patients—the
intraoperative probe, organ uptake probe, γ-camera, SPECT and SPECT/CT scanner, and PET
and PET/CT scanner—safety features should be regularly inspected. Such features include
manual emergency-off switches (“panic buttons”), collision-detection switches that
immediately stop all motion if a collision occurs (e.g., between the rotating γ-camera detector
and the patient during a SPECT acquisition), and interlocks that immediately turn off the x-
ray tube of a SPECT/CT or PET/CT scanner if a primary-barrier door is opened during a CT
scan. All position displays on the gantry and computer console and all alignment lasers should
likewise be visually inspected. All manual motion-control functions (e.g., gantry rotation,
detector radial motion, and table translation) should be checked as well. Finally, as with all
electromechanical devices, intraoperative probes, organ uptake probes, γ-cameras, SPECT and
SPECT/CT scanners, and PET and PET/CT scanners should be inspected regularly for frayed
wires and broken or otherwise damaged electrical insulation, loose electrical or mechanical
connections (including missing or visibly loose screws, nuts, or bolts), and dents, sharp edges,
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or other physical damage.

Record Keeping
Documenting of QC procedures and organized recording of the results of such procedures are
requirements of a sound, compliant QC program. A written description of all QC procedures,
including the acceptable (or tolerance) range of the results of each such procedure and the
corrective action for an out-of-tolerance result, should be included in the procedure manual of
the facility; for each procedure, the written description should be signed and dated by the
facility director, physicist, or other responsible individual. For each QC test performed, the
following data, as well as the initials or signature of the individual performing the test, should
be recorded on a structured and suitably annotated form: the test performed; the date and time
of the test; the make, model, and serial number of the device tested; the make, model, and serial
number of any reference sources used; the results of the test; and a notation indicating if the
test result was or was not acceptable (i.e., was or was not within the specified tolerance range).
Such records should be archived in chronologic order in a secure but reasonably accessible
location. It is generally helpful to track the results of QC tests longitudinally (e.g., in the form
of a graph of the numeric result vs. date of the test). In this way, long-term trends in instrument
performance, often imperceptible from one day to the next, may become apparent. Increasingly,
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of course, such records are maintained in electronic form (i.e., are computerized). In many
jurisdictions, records must still be maintained in hard-copy form—and it is advisable to do so
in any case, both as a backup and for convenient review by regulators and other inspectors.

Reference Sources
In many instances, QC tests of nuclear medicine instrumentation are performed not with the
radionuclides that are used clinically but with longer-lived surrogate radionuclides in the form
of so-called reference sources. Such standards are commercially available in various activities
and geometries, depending on the application. Importantly, the certified activities of such
reference sources must be traceable to the National Institute of Standards and Technology
(NIST), formerly the National Bureau of Standards. NIST traceability helps ensure the
accuracy of the calibrated activity. Because such reference sources are long-lived, a single
standard may be used for months to years, avoiding the need to prepare sources on a daily or

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weekly basis and thereby avoiding possible inaccuracies in dispensing activity as well as the
possibility of radioactive contamination. As with all sealed sources, however, reference sources
must be checked for leakage of radioactivity (i.e., wipe-tested) at least annually, and an up-to-
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date inventory of such standards must be maintained. Reference sources are still radioactive
at the end of their useful life span and must therefore be returned to the vendor or an authorized
third party or otherwise disposed of as radioactive waste.

A long-lived radionuclide comprising a reference source must match, in the frequency and
energy of its x- and γ-ray emissions, the clinical radionuclide for which it acts as a surrogate
to ensure that instrument responses to the clinical radionuclide and to its surrogate are
comparable. Surrogate radionuclides commonly used in nuclear medicine and their
physicalproperties andapplicationsare summarized in Table 1.

Survey Meters
Survey meters, an essential component of any radiation safety program, are portable, battery-
operated gas-filled ionization detectors or solid-state scintillation detectors used to monitor
ambient radiation levels, that is, exposure rates (e.g., in mR/h) or counting rates (e.g., in counts
per minute [cpm]). Among ionization-detector survey meters, so-called cutie-pies are relatively
low-sensitivity ionization chambers (i.e., are operated at a relatively low potential difference
between the anode and cathode) and are designed for use where high fluxes of x- and γ-rays
are encountered. The more familiar Geiger counters (or Geiger-Mueller counters) are operated
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at a high potential difference, providing a high electron amplification factor and thus high
sensitivity. Geiger counters are therefore well suited for low-level surveys, for example,
checking for radioactive contamination. Generally, cutie-pies are calibrated in exposure rates
(mR/h) and Geiger counters in counting rates (cpm). As an ionization chamber, the cutie-pie
has an electron signal that depends on the energy of the detected x- or γ-rays and is therefore
directly related to the exposure for all radionuclides. For Geiger counters, the amplitude of the
signal pulses is independent of the energy of the incoming radiation. Therefore, if calibrated
for exposure rates (mR/h), Geiger-counter calibration results apply only to the particular
radionuclides comprising the reference source used in the calibration procedure. Solid-state
detectors use a non–air-equivalent crystal as the detection medium and thus cannot measure
exposure rates; they can measure only counting rates.

QC tests of survey meters generally include a daily battery check, with a display indicating
whether the voltage supplied by the battery is within the acceptable operating range. To confirm
that the survey meter has not been contaminated (i.e., yields a reproducibly low exposure or
counting rate in the absence of radioactivity), the background exposure or counting rate should
be measured daily in an area remote from radioactive sources within the nuclear medicine
facility, if such an area is reasonably accessible. In addition, survey meters should be checked
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daily for constancy of response by measuring the exposure or counting rate of a long-lived
reference source in a reproducible measurement geometry. Aside from the short-term decay
of the reference source, the measured day-to-day exposure or counting rates should agree within
10%; if not, the meter should be recalibrated.

Survey meters should be calibrated—that is, checked for accuracy—using suitable long-lived
reference sources at installation, annually, and after any repair. If the source is small (compared
with the mean free path of its emitted x- and γ-rays within the material comprising the source)
and the distance between the source and meter large (compared with the dimensions of the
source), then a point-source geometry is approximated and the expected exposure rate (in mR/
h), Ẋ, in air is given by the inverse- square law:

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Eq. 1
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where Ao is the activity (in MBq) of the reference source at calibration, λ is the physical decay
constant (in/d) of the radionuclide comprising the reference source, Δt is the time interval (in
d) between the calibration of the reference source and the current measurement, Γ is the specific
γ-ray constant (in mR/h/cm2/MBq) of the radionuclide comprising the reference source, and
d is the distance (in cm) between the reference source and the meter. The reference-source
activity should be sufficient to yield an exposure rate of ~1,000 mR/h under the foregoing
measurement conditions, and the exposure rates should be measured on each scale and, by
appropriate adjustment of the source–meter distance, at 2 readings (~20% and ~80% of the
maximum) on each scale. For all readings, the expected and measured exposure rates should
agree within 10%.

Many nuclear medicine facilities have their survey meters calibrated by the institutional
radiation safety office or by a commercial calibration laboratory. In addition to a calibration
report (typically a 1-page document) specifying the reference sources used, the measurement
procedure, and the measured and expected exposure rates, a dated sticker summarizing the
calibration results should be affixed to the meter itself.
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Dose Calibrators
The dose calibrator is a pressurized gas-filled ionization chamber for assaying activities in
radiopharmaceutical vials and syringes and in other small sources. Among routine dose-
calibrator QC tests, constancy must be checked daily and accuracy and linearity at least
quarterly (7,18,19); daily checks of accuracy are recommended, however. At installation and
after service of a dose calibrator, its geometry (position and volume)-dependent response
for 99mTc must be measured and volume (from 2 to 25 mL)-dependent correction factors
relative to the standard volume (e.g., 10 mL) derived.

For the constancy test, a reference source, such as 57Co, 133Ba, 68Ge, or 137Cs (Table 1), is
placed in the dose calibrator, and the activity reading on each scale is recorded; day-to-day
readings should agree within 10%. For the accuracy test (also sometimes known as the energy
linearity test), NIST-traceable reference sources of at least 2 of the radioisotopes listed in Table
1 are separately placed in the dose calibrator and the activity reading on each scale recorded.
For each source, the measured activity on each scale and its current actual activity should agree
within 10%.
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For the quarterly check of linearity by the so-called decay method, one begins with a high-
activity (~37 GBq), independently calibrated 99mTc source and assays its activity at 12-h
intervals over 3 consecutive days. Over that time, which is equivalent to 12 half-lives
of 99mTc, the activity decays to about 11 MBq. The measured activities are then plotted versus
time on a semilogarithmic graph, and the best-fit straight line drawn through the data points is
plotted (either by eye or by using a least-squares curve-fitting algorithm). For each data point,
the difference between the measured activity and the activity on the best-fit straight line at that
point should be less than 10%. An alternative approach to checking linearity is the so-called
shield method, in which lead sleeves of increasing thickness are placed in the dose calibrator
with a 99mTc source (Fig. 1). By interposing increasing decay-equivalent thicknesses (as
specified by the manufacturer of the set of lead sleeves) between the source and the sensitive
volume of the dose calibrator, a decay-equivalent activity is measured for each sleeve.
Although the shield method is much faster than the decay method for checking linearity (taking

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minutes instead of days), an initial decay-based calibration of the set of sleeves is recommended
to accurately determine the actual decay equivalence of each shield.
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Well Counters
Well counters are used for high-sensitivity counting of radioactive specimens such as blood or
urine samples or “wipes” from surveys of removable contamination (i.e., wipe testing). Such
counting results should be expressed in activity (e.g., μCi), using the appropriate isotope-
specific calibration factor (μCi/cpm). Such devices generally comprise a cylindric scintillation
crystal (most commonly thallium-doped sodium iodide) with a circular bore (well) for the
sample, backed by a photomultiplier tube (PMT) and its associated electronics. Modern
scintillation well counters are often equipped with a multichannel analyzer (MCA) for energy
(i.e., isotope)-selective counting and an automatic sample changer for unattended counting of
multiple samples. Because of their high intrinsic and geometric efficiencies (resulting from the
use of a thick crystal and a well-type counting geometry, respectively), well counters are
extremely sensitive and, in fact, can reliably be used only for counting activities up to
approximately 37 kBq; at higher activities, dead-time counting losses become prohibitive and
the measured counts inaccurate.

The routine QC tests for well counters include checks of the photopeak energy window (i.e.,
energy peaking) if the counter is equipped with an MCA and of background, constancy, and
efficiency (or sensitivity). Before counting samples containing a particular radionuclide, one
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should check the energy spectrum to verify that the counter is properly peaked, that is, that the
photopeak of the radio-nuclide coincides with the preset photopeak energy window. Isotope-
specific radionuclide counting or imaging with a scintillation detector commonly is done using
a 20% photopeak energy window, equivalent to an energy range of Eγ ± 10% (i.e., 0.9–1.1
Eγ), where Eγ is the x- or γ-ray energy of the radionuclide.

For each photopeak energy window used, the background counting rate should be checked
daily. The energy resolution (expressed as the percentage full width at half maximum [FWHM]
of the photopeak) should be checked at least quarterly using a reference-source radionuclide
such as 57Co. Electronic noise and ambient radiation levels, which may be relatively high and
variable in a nuclear medicine facility, will produce a nonzero and potentially fluctuating
background counting rate. Further, even trace contamination of the counting well will produce
inaccurately high counting-rate values. Accordingly, a blank (i.e., an empty counting tube or
vial) should always be included to determine the current background count. To check
constancy, at least 1 NIST-traceable reference source (Table 1) should likewise be counted
each day; day-to-day net (i.e., gross minus background) counting rates should agree within
10%.
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The χ2 test is a statistical method for checking the (short-term) reproducibility of a well counter,
that is, for checking whether the random variation in a set of counting-rate measurements is
consistent with that expected for a Poisson distribution (11). The χ2 statistic for a set of n
counting-rate measurements of a long-lived reference source having a mean N and a standard
deviation SD is:

Eq. 2

Thus, if P and 1 − P represent the probabilities that random variations in a set of measurements
from a Poisson distribution are, respectively, greater than or equal to or smaller than the
calculated χ2 value, a P value (or 1 − P value) of 0.5 indicates the calculated χ2 value is in the
middle of the range expected for a Poisson distribution. Conversely, a P value of less than 0.01

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or greater than 0.99, respectively, indicates that there is only a 1% chance that a Poisson
distribution would yield an χ2 value as large as or as small as that actually calculated. Such
very small or very large P values are problematic, therefore, because they indicate a variation
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in counting-rate measurements inconsistent with a Poisson distribution and are suggestive of

a counter malfunction. χ2 values yielding a P value in the range of 0.05–0.95 are generally
considered acceptable. It is advisable to perform χ2 testing at least quarterly. Compendia of
critical values of the χ2 statistic, as a function of the number of measurements (n), are widely
available in both graphical and tabular forms (11).

For each radionuclide for which a particular well counter is used, the counter should be
calibrated—that is, its efficiency (sensitivity) (in cpm/Bq), ε, should be determined—at
installation, annually, and after any repair:

Eq. 3

where ĊRS is the gross (i.e., total) counting rate of the radionuclide source, ĊBG is the
background counting rate, Ao is the activity (in Bq) of the radionuclide source at calibration,
λ is the physical decay constant of the radio-nuclide comprising the reference source, and Δt
is the time interval between the calibration of the radionuclide source and the current
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measurement. The radionuclide source should be a precisely calibrated sample (~37 kBq in ~1
mL) prepared by appropriate dilution and careful aliquoting of an activity of that radionuclide
sufficiently large to be accurately assayed in a dose calibrator. Because the x- or γ-ray energy
and frequency may differ somewhat between a particular radionuclide and its surrogate (i.e.,
reference-standard) radionuclide (Table 1), the counter efficiencies for that radionuclide and
its surrogate may differ slightly as well. At installation, therefore, the calibrated sample of each
radionuclide (e.g., 99mTc) and its surrogate (e.g., 57Co) should be counted using the photopeak
energy window (e.g., 126–154 keV for 99mTc) and the respective efficiencies determined.
These will yield a factor that can subsequently be used to convert the current efficiency of the
surrogate to the current efficiency of the radionuclide. In this way, annual and other checks of
efficiency can be performed using only the surrogate reference sources, without the need to
dispense, assay, dilute, and aliquot each radionuclide in clinical use.

The minimum detectable activity (MDA) of each radio-nuclide for which a particular well
counter is used is the activity that increases the gross counts over a counting time t by a value
that is significantly greater than that due to random variations in the background counts over
t. In this context, the conventionally applied criterion for statistical significance is a gross
counting rate that exceeds the background counting rate (ĊBG)by at least 3 SDs (11):
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Eq. 4

The MDA should be evaluated at least annually.

Intraoperative Probes
Intraoperative probes (17)—handheld, highly collimated counting devices (i.e., solid-state
scintillation or ionization [i.e., semiconductor] detectors)—are now widely used in the surgical
management of cancer, most commonly to more expeditiously identify and localize sentinel
lymph nodes and thereby reduce the need for more extensive surgery. In addition, such probes
have been used to identify and localize visually occult disease at surgery after systemic

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administration of a radiolabeled antibody or other tumor-avid radiotracer. In addition to daily

battery and background checks (as performed for survey meters), QC tests of intraoperative
probes should include a daily bias check for both the primary and any back-up battery to verify
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that bias voltage (or high voltage) is within the acceptable range. Because intraoperative probes
may not provide a display of the energy spectrum, one may not be able to visually check that
the probe is properly peaked, that is, that the photopeak coincides with the preset photopeak
energy window. The lower counts or counting rates resulting from an inappropriate energy
window may therefore go unnoticed. Thus, a long-lived reference source or set of reference
sources (such as 57Co, 133Ba, 68Ge, or 127Cs [Table 1]) should be available for daily checks
of counting-rate constancy; a marked change (e.g., ±10%) in the net counting rate from one
day to the next may indicate an inappropriate energy window setting or some other technical
problem. Ideally, each reference source should be incorporated into some sort of cap that fits
reproducibly over the probe so that spurious differences in counting rates due to variations in
source–detector geometry are avoided.

Organ Uptake Probes

Historically, organ uptake probes have been used almost exclusively for measuring thyroid
uptake and are thus generally known as thyroid uptake probes. The uptake probe is a
radionuclide counting system comprising a wide-aperture, diverging collimator; a thallium-
doped sodium iodide crystal (typically ~5 cm thick by ~5 cm in diameter); a PMT and
associated electronics; an MCA; and a gantry (stand). Aside from the counting geometry and
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sensitivity, uptake probes and well counters actually have much in common, and the QC
procedures—checks of the photopeak energy window, background, constancy, and efficiency
—are therefore analogous. (Please refer to the section “Well Counters” for further detail.)
However, efficiency of organ uptake probes should be measured more frequently—for each
patient—than for a well counter, so that the probe net counting rates can be reliably converted
to thyroid uptake for individual patients.

γ-Cameras
The γ-camera has long been, and remains, the most widely used imaging device in nuclear
medicine. The performance parameters most commonly evaluated as part of a routine γ-camera
QC program include uniformity, spatial resolution, spatial linearity, and energy resolution and
peaking.

γ-Camera uniformity may be evaluated either intrinsically (i.e., without collimation) or

extrinsically (i.e., with collimation) (Fig. 2). Intrinsically, a point source (<1 mL in volume
and containing ~18.5 MBq) of 99mTc is placed 5 crystal dimensions from and centered over
the uncollimated detector to provide a near-uniform photon flux impinging on the detector. If
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necessary, the activity should be adjusted to yield a measured counting rate of no greater than
25,000 cycles per second (cps), to avoid dead-time counting losses and counting-rate–related
image degradation. Extrinsically, a uniform flood, or sheet source (typically 185–555 MBq)
of 57Co is placed directly on the collimated detector. A total of 10–15 million counts is acquired
and uniformity quantitated for the integral and differential uniformities, which actually express
the deviation from uniformity of the flood image. The integral uniformity (IU) is defined by
the following equation:

Eq. 5

Differential uniformity (DU) is the maximum value of the expression on the right side of
Equation 5 determined for every 5-pixel segment in every row and column of the flood image.

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IUs of 3% or better are routinely obtained for modern γ-cameras. An alternative, and perhaps
even more robust, measure of uniformity is the SD of the counts per pixel in the flood image.
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If γ-camera uniformity for any radionuclide is out of tolerance (i.e., IU or DU > 5%), the
uniformity (or sensitivity) correction table of that radionuclide should be updated. As derived
from a high-count flood image of a particular radionuclide, the uniformity (or sensitivity)
correction table for that radionuclide is essentially the pixel-by-pixel ratio of the calculated
mean count per pixel to the actual count per pixel in the flood image. By pixel-by-pixel
multiplication of a raw (i.e., uncorrected) image by the ratio image thus calculated, an image
corrected for the nonuniformity of the γ-camera is obtained. The necessary data may be
acquired using the same setup as used for the daily uniformity test, except that a much larger
number of counts (60–100 million) must be acquired. In the γ-cameras of today, uniformity
correction tables can be easily updated and the corrections created, processed, stored, and
automatically applied using the integrated software of the system. In addition to an outdated
uniformity correction table, the following are other causes of γ-camera nonuniformity (Fig. 3):
mistuning (detuning), uncoupling of a PMT, a cracked crystal, or corruption or switching off
of 1 or more of the correction tables of the camera. The correction tables include uniformity;
energy, which essentially corrects the γ-camera image for nonuniformities related to
differences among the local-energy spectra; or linearity, which is largely a geometric
correction, correcting the image for nonuniformities related to the position-dependent
differences in the efficiency of light collection from the scintillation crystal by the PMTs (i.e.,
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higher efficiency directly beneath the PMTs vs. lower efficiency between the PMTs).

For radionuclides other than 99mTc used clinically on a particular γ-camera

(i.e., 201Tl, 123I, 111In, 67Ga, or 131I), intrinsic uniformity should be checked at least quarterly.

Spatial resolution and spatial linearity, in practice, are generally assessed semiquantitatively
using some sort of resolution phantom (or mask) such as the 4-quadrant bar phantom (Fig. 4A).
Such a semiquantitative (i.e., visual) assessment is faster and more convenient than actual
measurement of spatial resolution of the FWHM of the line-spread function. A 4-quadrant bar
phantom consists of 4 sectors of radioopaque lead bars and intervening radio-lucent plastic
strips 2, 2.5, 3, and 4 mm in width. A point source of 99mTc is placed 5 crystal dimensions
from and centered over the uncollimated detector, with the phantom placed directly over the
detector. A 5- to 10-million-count transmission image is then acquired and visually inspected.
The lead bars in at least the 2 coarsest quadrants (i.e., with the 3- and 4-mm-wide bars) should
be visually resolvable. Nowadays, at least a portion of the lead bars in the third coarsest
quadrant (i.e., with the 2.5-mm-wide bars) should be visible as well. All bars should appear
straight. Spatial resolution and spatial linearity should be checked with such a phantom at least
weekly.
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γ-Camera energy resolution may be evaluated by the percentage FWHM of the photopeak
energy (Fig. 4B). Although energy resolution per se is often not routinely evaluated, the energy
spectrum for each radionuclide used clinically should be checked at least once a day and ideally
for each patient to verify that the photopeak is centered in the photopeak energy windows
currently set; Figure 4A illustrates the type of suboptimal image that may result with a mistuned
(detuned) γ-camera.

Tomographic Image Reconstruction

Algorithms for reconstruction of tomographic images from projection data—in SPECT as well
as in PET—include analytic techniques such as filtered backprojection and iterative techniques
(11,15,16,20). The basic procedure in filtered backprojection is as follows: each projection is
Fourier transformed from real to frequency space; the projection is filtered in frequency space
using a low-pass (e.g., Hanning or Butterworth) filter to eliminate those spatial frequencies

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above a cutoff frequency and thus reduce statistical uncertainty (or noise); the filtered
projection data are inverse Fourier transformed from frequency back to real space; and the
filtered projections in real space are uniformly distributed, or backprojected, over the
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reconstructed image matrix. Iterative algorithms yield progressively refined estimates of the
activity distribution, rather than directly calculating the distribution, by maximizing or
minimizing some target function. The solution is said to converge when the difference in the
target function between successive estimates (iterations) of the activity distribution is less than
some prespecified value. Iterative reconstruction algorithms allow incorporation of realistic
modeling of the data-acquisition process (including effects of attenuation and of scatter),
modeling of statistical noise, and inclusion of pertinent a priori information (e.g., only
nonnegative count values). The maximum likelihood expectation maximization (MLEM)
algorithm is based on maximizing the logarithm of a Poisson likelihood target function. The
MLEM algorithm suppresses statistical noise, but large numbers of iterations typically are
required for convergence and, therefore, processing times are long. To accelerate this slow
convergence, the ordered-subset expectation maximization (OSEM) algorithm groups the
projection data into subsets comprising projections uniformly distributed around the source
volume. The OSEM algorithm, which is a modified version of the MLEM algorithm because
the target is still maximization of the log likelihood function, converges more rapidly than
MLEM and is now the most widely used iterative reconstruction method in PET and SPECT.

SPECT Scanners
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In addition to the QC procedures for γ-camera imaging listed earlier, rotating-γ-camera SPECT
requires specific QC tests. Among the components of a routine SPECT QC program are
periodic assessment of center-of-rotation (COR) alignment, tomographic uniformity, and, for
lack of a better term, overall system performance (15). These QC tests apply to both SPECT-
only scanners and the SPECT subsystem of SPECT/CT scanners.

In rotating-γ-camera SPECT, the location of the projection of the COR on the projection image
matrix must be independent of the projection-image angle (Fig. 5A). If the mechanical and
electronic CORs are aligned, the pixel location of the projection of the COR onto the projection
image matrix will be the same for all projection images, and for all such images the counts in
each pixel will then be projected across the appropriate row of pixels in the tomographic image
matrix. If, however, the mechanical and electronic CORs are not aligned, the pixel location of
the COR will vary among the projection images, and the counts in each projection-image pixel
will be projected across different locations in the tomographic image matrix and blurred images
will result (Fig. 5A). Proper alignment of the mechanical and electronic CORs is therefore
critical in rotating-γ-camera SPECT and should be checked, and if necessary, the COR
misalignment correction updated, at least weekly. In current SPECT systems, COR
misalignment may be easily measured and corrections created and automatically applied using
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the integrated software of the system (Fig. 5B).

Because tomographic image reconstruction propagates and, in fact, may amplify the effects of
nonuniformities, uniformity of γ-camera response is another consideration in obtaining high-
quality SPECT images. Specifically, the residual, otherwise imperceptible nonuniformity of a
γ-camera with an IU and a DU within tolerance (i.e., <5%) on the basis of the daily flood image
may produce significant ring, or bull’s-eye, artifacts in tomographic images (Fig. 6).
Tomographic uniformity should therefore be evaluated by high-count imaging of a 99mTc-
filled cylinder source (at least 20 cm in diameter by 20 cm in length) and visually inspecting
the resulting reconstructed images for the absence of perceptible nonuniformity artifacts; this
should be done monthly.

Overall system performance may be evaluated using any number of commercially available
fillable phantoms containing nonradioactive (cold) inserts of different sizes and visually

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inspecting the resulting images (Fig. 7). Using such a phantom, so-called cold-sphere contrast
may be evaluated on the basis of the minimum counts in sphere i and the mean counts in the
plain transverse section closest to the sections through the spheres (Figs. 7D and 7C,
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respectively (9)):

Eq. 6

Graham et al. (9) have provided recommendations on acceptable values of this parameter,
ranging from 0.11 to 0.27 for the smallest (i.e., the 15.4-mm-diameter) to 0.53 to 0.73 for the
largest (i.e., the 31.8-mm-diameter) sphere. Such a phantom also includes a plain section that
can be used to simultaneously evaluate tomographic uniformity (Fig. 7C). For such cylinder
phantom studies, a 99mTc activity of about 10 mCi and at least 64 projections at 40 s per
projection or longer are recommended. Overall SPECT system performance should be checked
at least quarterly.

PET Scanners
As is the case for γ-cameras and SPECT scanners, detailed protocols for acceptance testing
and rigorous evaluation of numerous performance parameters of PET scanners have been
developed (4). Additional protocols for acceptance testing of PET and PET/CT scanners are
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currently being developed by Task Group 126 of the AAPM and by the International Atomic
Energy Agency, respectively.

Less rigorous and less extensive procedures are generally performed for routine QC of PET
scanners, however. The most widely used of these are the blank scan and tomographic
uniformity. Periodic evaluation and, if necessary, updating of certain calibrations, most notably
the normalization and the well-counter calibration, are additional components of routine PET
QC. These QC tests and calibrations apply to both PET-only scanners and the PET subsystem
of PET/CT scanners.

Blank scans are performed daily by uniformly irradiating the detector elements using either
the 68Ge or 137Cs transmission source (if applicable) of the scanner without any source or other
attenuating object in the field of view (FOV) or with a uniform source of 511-keV annihilation
photons (most commonly a 20-cm-diameter 68Ge cylinder) centered in the FOV. The term
blank scan, derived from the first of these 2 approaches, reflects the absence of any material
in the FOV; the term is still often applied to the latter approach, even though it involves placing
an object (i.e., the 68Ge source) in the FOV. For PET systems that use 68Ge or 137Cs
transmission data to derive attenuation corrections, the blank scan also provides the reference
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(i.e., unattenuated) transmission data for calculating such corrections. In some respects, the
blank scanner is analogous to the daily uniformity flood image acquired for γ-cameras,
providing an overall assessment of detector response.

One approach to evaluating the daily blank scan is simple visual inspection of its (2-
dimensional) sinograms (Fig. 8A). In emission tomography (SPECT as well as PET), the
emission data are often presented as the 1-dimensional projections (sets of parallel line-
integrals) of the direct planes at the azimuthal, or projection, angle φ relative to the axis of the
scanner. The sinogram (or histogram) (11,16) is the full set of 2-dimensional projection data
represented as a 2-dimensional matrix in polar coordinates (distance r, angle φ) in which each
row represents the projected intensity across a single direct plane and each column the projected
intensity at the same distance r across the projection at successive azimuthal angles φ. The
appearance of a blank, or hypointense, diagonal line (Fig. 8C vs. 8B) or band (Fig. 8D vs. 8B)
in the sinogram indicates that a detector (crystal) element or detector block, respectively, is

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malfunctioning. That is, it is either not functioning or has a substantially lower sensitivity than
the other detectors. In either case, the PMT gain, crystal (detector) map, or photopeak energy
window of the affected detector block may need to be adjusted (11,16), the normalization
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updated, or a faulty hardware component repaired or replaced. As illustrated in Figure 9,

sinograms are more visually discriminating than are the reconstructed images for detecting
faulty detectors. The integrated software of the PET scanner may also include a routine for
quantitative analyses of blank scans and graphical display of the results of these analyses (Fig.
10).

Tomographic uniformity for PET is essentially the same as that for SPECT (Fig. 7C) and may
be evaluated with either a 18F-filled cylinder phantom or a 68Ge cylinder source. In practice,
the use of a long-lived 68Ge cylinder is preferred because constant refilling of a cylinder with
short-lived 18F is avoided. Tomographic uniformity should be evaluated daily or at least
weekly.

In addition to the pronounced differences in sensitivities between direct and cross planes and
artifacts between adjoining detector rings (Fig. 11), even optimally performing PET scanners
exhibit some further nonuniformity of response. Among the 10,000–20,000 detector elements
in a modern ring scanner, slight variations among the detector elements in thickness, light
emission properties, electronics performance, and so on result in slightly different line-of-
response (LOR) counting rates for the same activity. Nonuniform response can be corrected
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by acquiring data for a uniform flux of annihilation γ-rays (11,21). Such a scan is known as a
normalization scan and the uniformity correction thus derived (analogous to the uniformity
correction table of a γ-camera) is known as a normalization. If LORT is the total number of
LORs and a total of NT events is acquired in the normalization scan, the average number of
counts per LOR, N̄LOR, is simply:

Eq. 7

For the LOR between detectors i and j, LORij, with measured number of events Nij, the
normalization factor NFij is:

Eq. 8

and, for the scan of a patient, the normalized, or corrected, number of events, , in this LOR
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is:

Eq. 9

where Cij is the raw, or uncorrected, number of events in the LOR between detectors i and j.

The normalization scan can be performed using a positron-emitting rod source (e.g., 68Ge)
spanning the entire axial FOV and rotating it around the periphery of the FOV, exposing the
detector pairs to a uniform photon flux per revolution (as for the daily blank scan).
Alternatively, a uniform cylinder of a positron-emitting radionuclide can be scanned and the
data thus acquired analytically corrected for attenuation; for a well-defined geometry such as
a uniform cylindric source, this correction is straightforward. However, for 3-dimensional PET,
the contribution of and correction for scatter with such a large-volume source are nontrivial.

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In practice, either approach is somewhat problematic because of limited count statistics (and,
in the case of 3-dimensional PET, because of scatter). The PET scanner normalization should
be created or updated at installation, after major service, whenever deteriorating image quality
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suggests a new normalization is required, or otherwise at least annually.

Once PET emission data have been corrected for dead time, randoms, system response (by
normalization), scatter, and attenuation, the signal per voxel in the reconstructed tomographic
images is proportional to the local activity concentration. To make the images quantitative,
then, the counting rate per voxel (cps), Ċijk, in voxel ijk should be divided by the measured
system calibration factor ([kBq/mL]/[cps/voxel]), CF, to yield the activity concentration:

Eq. 10

where {A}ijk is the activity concentration (kBq/mL) in voxel ijk. The calibration factor, CF, is
derived by the well-counter (or absolute activity) calibration: scanning a calibrated source, that
is, a volume source (often a cylinder ~20 cm in diameter by ~20 cm in length), with a uniform,
well-defined activity concentration at the time of the scan. Implicit in Equation 10 is the
assumption that the branching ratios, ζ, of the positron emitter administered to the patient and
added to the standard are identical. If not, Equation 10 must be appropriately adjusted:
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Eq. 11

where ζPatient and ζStandard are the branching ratios of the positron-emitting isotope
administered to a patient and added to the source, respectively. In principle, differences
between the geometries of the calibrated source and a patient may introduce some inaccuracy
in the determination of activity concentration in situ (Eq. 9 or Eq. 10), but with appropriate
attenuation, scatter, and other corrections such inaccuracies should be minimal. The PET
scanner well-counter calibration should be created or updated at installation, after major
service, or otherwise at least annually.

CT Scanners
CT scanners have been in widespread clinical use long before their incorporation into
multimodality devices (i.e., SPECT/CT and PET/CT scanners), and detailed protocols for
acceptance testing and evaluation of numerous CT performance parameters are well established
(1,2,22). As with SPECT and PET scanners, however, less rigorous and less extensive
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procedures are generally performed for routine CT QC. These QC tests and calibrations apply
to the CT subsystems of both SPECT/CT and PET/CT scanners.

Daily testing of a CT scanner begins with the manufacturer-prescribed x-ray tube warm-up
procedure and automatic monitoring, perhaps at various tube voltage (kVp) or current (mA)
settings, of the tube output and detector response. Assuming the operator has received the
appropriate system-ready message, the daily QC procedures are then performed (12). These
include, at a minimum, evaluation of tomographic uniformity, the accuracy of the CT number
of water, and image noise (i.e., statistical uncertainty), based on scanning a water-filled cylinder
phantom (typically ~20 cm in diameter by ~20 cm in length) (Figs. 12A–12D) (10). These
parameters should be evaluated using a clinically routine set of scan parameters (i.e., kVp,
mAs, pitch, etc.). Acceptable image uniformity may be confirmed by visual inspection (i.e.,
by verifying the absence of perceptible ring, streak, or other artifacts) and by quantitative
region-of-interest (ROI) analysis of the reconstructed image. In the latter approach (Fig. 12C),

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~5-cm-diameter circular or ~5 × 5 cm ROIs (1 at the center and 4 at the periphery, at

approximately the 12-, 3-, 6-, and 9-o’clock positions) are placed on the image and the mean
CT numbers (in Hounsfield units [HU] (23)) compared between the central and each of the
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peripheral ROIs; the maximum difference should not exceed 5 HU. The HU scale is based on
a linear transformation of the linear attenuation coefficient as measured by CT, in which the
radiodensity of water is assigned a value of 0 HU and that of air at standard temperature and
pressure a value of 1,000 HU. For a material X with linear attenuation coefficient μX, the
corresponding HU value is therefore ([μX − μwater]/[μwater − μair]) × 1,000, where μwater and
μair are the linear attenuation coefficients of water and air, respectively.

The accuracy of the CT number of water and image noise can also be evaluated using the same
ROIs. The accuracy of the CT number of water is checked by comparing the mean CT number
for each ROI with the CT number, 0 HU, expected for water. All of the mean CT numbers thus
derived should be within 5 HU of that of water, that is, 0 ± 5 HU. The image noise is evaluated
by comparing the SD of the CT number in each of the ROIs with the benchmark, or reference,
SD of the scanner, established at the time of its installation: for each ROI, the SD should be
no greater than twice the benchmark SD.

In addition to the these daily checks of CT performance, monthly or at least quarterly

evaluations of laser alignment, image slice thickness, spatial resolution, linearity (i.e., CT
number accuracy), and high- and low-contrast contrast resolution are needed. At the same time,
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image uniformity and noise, as discussed earlier, should also be evaluated for different tube
voltages (i.e., kVp) that bracket the range of values used clinically. Evaluation of these
parameters requires appropriate phantoms. The Quality Assurance Phantom (GE Healthcare)
(24), for example, is a water-fillable polymethylmethacrylate (acrylic) cylinder with multiple
sections (i.e., inserts) for measurement of these CT performance parameters (Fig. 12).

These parameters include the following:

• Laser alignment. The laser lights should lie precisely on the circumferential surface
groove of the phantom. If the lasers are properly aligned, the 2 laser alignment cavities
in the reconstructed transverse image will be horizontal and at precisely the same y-
position coordinate (Figs. 12A and 12D).
• Slice thickness. Because the line cavities in each of the 2 slice-thickness measurement
components of the insert are staggered (offset) 1 mm apart in the longitudinal direction
(Figs. 12A and 12D), the number of black lines (using a high-contrast display)
appearing on a transverse reconstructed image corresponds to the slice thickness in
millimeters. However, if 1 of the lines appears as gray rather than black, the slice
thickness in millimeters equals the number of black lines plus one half, with 0.5 mm
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of slice thickness contributed by the cavity appearing as the gray line.

• Spatial resolution. Analogously to assessment of γ-camera resolution using a 4-
quadrant bar phantom (Fig. 4), spatial resolution is assessed by identifying the
narrowest set of line cavities in which the separate cavities can be visualized (Fig.
12A).
• Linearity. Linearity (i.e., CT number accuracy) is checked by verifying that the mean
CT number (in HU) in a 10 × 10 mm ROI in air, water, and acrylic (the dotted squares
in Fig. 12A) matches the expected CT number, −1,000, 0, and 100 HU, respectively.
• High-contrast contrast resolution. High-contrast contrast resolution is expressed as
the SD of the CT number (in HU) in a 10 × 10 mm ROI centered over the coarsest
set of line cavities (i.e., the set in which the lines are 1.6 mm in width) (Fig. 12A).
The higher the image contrast, the larger the difference between the water and the
acrylic CT numbers within this ROI and the higher the SD of the CT number.

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According to information published by GE Healthcare (24), the acceptable value of

the SD of the CT number in this ROI is 37 ± 4 HU (i.e., 33–41 HU).
• Low-contrast contrast resolution. Low-contrast contrast resolution is evaluated using
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the insert and the ROIs (boxes, Fig. 12B), ~400 × 400 mm in area (Fig. 12B), and is
expressed as the percentage difference between the CT numbers (in HU) in the water
and the polystyrene membrane ROIs. According to information published by GE
Healthcare (24), this difference should agree within 0.1% (1 HU) with the benchmark,
or reference, low-contrast contrast resolution of the scanner, established at the time
of its installation. Optionally, low-contrast resolution can also be evaluated as a
function of object size by calculating the foregoing parameter for each of the circular
holes in the polystyrene membrane (Fig. 12B).
Daily and monthly (or quarterly) image uniformity and noise can be evaluated using the
uniform (plain) section of the GE quality assurance phantom. The red boxes in Figure 12C
illustrate the 5 ×5 cm ROIs used for these analyses, as discussed earlier.

Finally, on at least an annual basis, radiation dose should be evaluated by a health physicist or
a medical physicist by measuring the CT dose index (CTDI) for various scan parameters (i.e.,
kVp and mA) which bracket the range of values used clinically. The CTDI is the basic radiation
dose parameter in CT and is defined as the integral under the exposure or absorbed dose profile
along the patient’s longitudinal axis for a single tomographic image (25–27). The volume CTDI
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(CTDIvol) is derived from the CTDI and is the average dose delivered to a scan volume (vol)
for a specific examination. The 100-mm CTDI (CTDI100) is the integral under the exposure
or absorbed dose profile along a 100-mm length of the patient’s longitudinal axis. The weighted
100-mm CTDI (CTDIw) is the weighted average of the CTDI100 measurements at the center
and periphery of a dose-measurement phantom:

Eq. 12

where CTDI100(p) is the CTDI100 at the periphery (p) of a cylindric phantom, CTDI100 (c) is
the CTDI100 at the center (c) of a cylindric phantom and f is the exposure-to-absorbed dose
conversion factor (33.7 Gy/C/kg, or 0.87 rad/R) for water or soft tissue.

The CTDIw thus reflects the mean absorbed dose over the transverse (x and y) dimensions of
such a phantom and is an approximation of the average radiation dose to the cross-section of
a patient. Measurements of the CTDI100 (p) and CTDI100 (c) are typically performed using
ionization chambers or thermoluminescent dosimeters positioned in a commercially available
soft-tissue–equivalent acrylic phantom, cylindric in shape and either 16 or 32 cm in diameter,
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approximating an adult head or torso (body), respectively (Fig. 13). Ionization chambers
actually measure exposure, which is then converted to absorbed dose using the f factor
discussed earlier. Thermoluminescent dosimeters, however, yield absorbed dose directly.

SPECT/CT and PET/CT Image Registration

Multimodality (i.e., SPECT/CT and PET/CT) devices are still fairly new, and so QC procedures
for checking the accuracy of image registration and of CT-based attenuation corrections are
not yet well established. Image registration may be checked using a phantom with well-
delineated point, line, or volume markers that are both SPECT- or PET- and CT-visible (Fig.
14). Each marker, for example, should be fillable with a solution containing both an imageable
radionuclide such as 99mTc (for SPECT) or 18F (for PET) and a radioopaque contrast agent
such as iohexol (Omnipaque; GE Healthcare). Alternatively, sealed reusable markers
composed of long-lived 57Co (for SPECT) or 68Ge (for PET) uniformly dispersed in a
radioopaque resin or plastic may be used. The advantage of phantoms having point or line

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markers (Fig. 14A) is that any misregistration (or offset) between registered images with such
well-defined foci is readily apparent by visual inspection of their overlay, or fused, display.
Although visual assessment may generally suffice, the misregistration may be quantitated as
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the mean or maximum Euclidean distance (in mm), among all the markers, between the
positions of each marker in the 2 modalities. Intuitively, the maximum offset distance should
be no greater than the FWHM spatial resolution of the higher-resolution modality, which is
CT (equivalent to ~1 mm for a SPECT/CT or PET/CT scanner). However, point and line
markers suffer from the disadvantage that their dimensions are typically well below the spatial
resolution of either SPECT or PET scanners and therefore their activities cannot be reliably
measured because of partial-volume averaging (28). As a result, the accuracy of the CT-based
attenuation corrections cannot be meaningfully assessed. For this purpose, a registration
phantom having volume markers with dimensions at least 3 times the SPECT or PET FWHM
spatial resolution (to eliminate underestimation of activity due to partial-volume averaging) is
preferred (Fig. 14B). For such volume markers, the attenuation-corrected SPECT- or PET-
derived activity concentration should be within 10% of the actual activity concentration in the
marker(s) at the time of imaging. Such tests of multimodality image registration should be
performed at least monthly.

CONCLUSION
This article has briefly reviewed, as summarized in Table 2, routine QC procedures of current
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nuclear medicine instrumentation, including the survey meter, dose calibrator, well counter,
intraoperative probe, organ (“thyroid”) uptake probe, γ-camera, SPECT and SPECT/CT
scanner, and PET and PET/CT scanner. These procedures and their respective frequencies are
presented only as general guidelines. Certainly, there are numerous variations of these
procedures that may comprise a sound and compliant QC program.

Acknowledgments
We thank Dr. Barbara Binkert of the New York Presbyterian Hospital; Dr. Sadek Nehmeh, Keith Pentlow, Dr. John
Humm, and Valerie Longo of Memorial Sloan-Kettering Cancer Center; and Dr. Osama Mawlawi of the M.D.
Anderson Cancer Center for their contributions. The author is supported in part by National Institutes of Health (NIH)
Small-Animal Imaging Research Program grant R24 CA83084, NIH Center grant P30 CA08748, and NIH grant P01
CA115675-01.

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FIGURE 1.
Set of lead-lined plastic sleeves (CalicheckDose Calibrator Linearity Test Kit; Fluke
Biomedical) for evaluation of dose-calibrator linearity by shield method. Set is supplied with
0.64-cm-thick lead base, color-coded unlined sleeve (to provide activity measurement
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equivalent to 0 time point measurement of decay method), and 6 color-coded lead-lined sleeves
providing attenuation factors nominally equivalent to decay over 6, 12, 20, 30, 40, and 50 h,
respectively, for 99mTc.
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FIGURE 2.
γ-Camera uniformity may be evaluated either intrinsically or extrinsically. Intrinsically, point
source is placed at least 3, and preferably 5, crystal dimensions from and centered over un-
collimated detector to provide uniform photon flux (left). Extrinsically, uniform flood, or sheet,
source of 57Co is placed directly on collimated detector (right).
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FIGURE 3.
Sources of γ-camera nonuniformity. (A) Mistuning (or detuning), meaning that photopeak of
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radionuclide does not coincide with photopeak energy window of camera, perhaps because
energy window (as shown) or high voltages of PMTs are not set correctly. (B) Uncoupling of
PMT from crystal, resulting in loss of all or part of light signal in resulting air gap between
PMT entrance window and crystal. (Courtesy of Dr. Barbara Binkert, New York Presbyterian
Hospital, New York, NY.) (C) Cracked crystal, either because of mechanical trauma (impact)
or temperature excursion (i.e., temperature increase or decrease at rate faster than ~5°C per
hour, causing crystal to expand or contract, respectively, to point of cracking). Note that it is
rate of temperature change that is critical. Photographs on right show cracked crystal that
produced corresponding image. Even though cracks are grossly imperceptible, artifacts
produced are dramatic. (Courtesy of Dr. Barbara Binkert, New York Presbyterian Hospital,
New York, NY.) (D) Corrupted, deleted, or switched-off software correction tables. Even
perfectly functioning γ-cameras have some nonuniformity due to point-to-point variations in
energy spectra, greater sensitivity at and lower sensitivity between PMTs, and residual
nonuniformity due to ill-defined factors such as variations in crystal thickness. Associated
nonuniformities are measured and used to create energy, linearity, and uniformity (or
sensitivity) correction tables. Note that linearity correction table has biggest effect on
uniformity: if corrupted, deleted, or switched off, PMT pattern becomes grossly apparent, and
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IU approaches 20%. Fortunately, in contrast to uniformity correction table and, to lesser extent,
energy correction table, linearity correction table rarely needs to be updated once γ-camera is
installed; if updating becomes necessary, it is almost always done by field-service personnel
of manufacturer, not by end-user.

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FIGURE 4.
(A) Photograph and γ-camera image of 4-quadrant bar phantom, with schematic diagram
illustrating setup for assessment of spatial resolution using such phantom. (Though seldom
used in practice, sheet source that may be filled with different radionuclides and used to
evaluate extrinsic uniformity is also shown in photograph.) (B) Energy spectrum for 662-keV
γ-ray emitted by 137Cs, illustrating definition of energy resolution as percentage FWHM of
photopeak energy, Eγ.

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FIGURE 5.
(A) COR misalignment and resulting image-blurring artifacts in rotating-γ-camera SPECT.
Degree of blurring is related to magnitude of spatial misalignment of mechanical and electronic
CORs. Misalignment as small as 3.2 mm (or 0.5 pixel for 64 × 64 image matrix) can produce
perceptible blurring in SPECT images, with blurring substantially worse for misalignment of
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6.4 mm (1 pixel). (Adapted from reference (29) with permission.) Note that for cross-sectional
image of line source, COR misalignment blurs expected point into full or partial circle
depending on position of source in FOV: if it is at or near center of FOV, line source appears
as full circle in cross-section; if it is near periphery of FOV, it appears as partial circle. (B)
COR misalignment can be measured and corrected on basis of acquiring 360° circular SPECT
study of 99mTc point source and constructing graphs of x- and y-positions (perpendicular and
parallel to axis of rotation, respectively) of position of maximum-count pixel in each projection
image vs. angular position. x- and y-position vs. angle graphs should be sinusoidal curve and
straight line, respectively. Angle-by-angle deviation between x-position on best-fit sine curve
and x-position of actual maximum-count pixel thus yields correction table, indicating offset
by which each projection image must be shifted at each angular position to align CORs.
Alternatively, average of offsets may used at each angular position. (Adapted from reference
(15) with permission.)

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FIGURE 6.
(A) Severe ring, or bull’s-eye, artifact in transverse SPECT image through 20-cm
diameter 99mTc-filled cylinder phantom resulting from gross γ-camera nonuniformity (i.e., IU
≈ 10%). (B) Appearance of such artifact (arrow) in clinical SPECT image, transverse image
from 99mTc-sulfur colloid liver–spleen study. (C) In contrast to A, this is acceptable transverse
SPECT image through 99mTc-filled cylinder phantom. No perceptible ring, or bull’s-eye,
artifact is demonstrated; IU at time of this acquisition, ~2%, was well within tolerance. In
cylinder phantom images, A and B, analytic postprocessing attenuation correction was applied.
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FIGURE 7.
Photographs of disassembled (end view) (A) and assembled (side view) (B) phantom (Deluxe
Jaszczak Phantom; Data Spectrum Corp.), used for evaluation of overall performance of
tomographic imaging systems. This fillable acrylic phantom is 22 cm in diameter by 19 cm in
length and includes plain section for evaluation of tomographic uniformity (C), section
containing empty (cold) spheres ranging from 9.5 to 31.8 mm in diameter for evaluation of
cold-sphere contrast (D), and section containing solid (cold) rods ranging from 3.2 to 11.1 mm
in diameter for evaluation of reconstructed spatial resolution (E). Images in C–E have been
analytically corrected for attenuation. (Courtesy of Data Spectrum Corp.)
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FIGURE 8.
(A) Sinogram (i.e., histogram) presentation of emission tomography (i.e., SPECT or PET) data.
(B–D) PET sinograms of uniform-cylinder source without any visually perceptible
discontinuities or other artifacts (B), with blank diagonal line indicative of faulty detector
(crystal) element (C), and blank diagonal band indicative of faulty detector block (D).
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FIGURE 9.
Two-dimensional PET sino-grams and reconstructed transverse images through hot-
sphere 18F-filled phantom: sinogram without any perceptible artifacts (A) and corresponding
transverse image (B); sinogram with blank diagonal band, suggestive of faulty detector block
(C) and corresponding transverse image (D). Despite obvious defect in sinogram C,
reconstructed images B and D are virtually indistinguishable. (Courtesy of Dr. Osama
Mawlawi, M.D. Anderson Cancer Center, Houston, TX.)
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FIGURE 10.
Proprietary graphical display (GE Healthcare), detector block–by–detector block, of relative
values of PET scanner operational parameters derived from blank scan, including coincidence
counting rate, singles counting rate, detector dead time, coincidence timing window, and
energy setting. Such display allows operator to quickly and easily discern out-of-tolerance
results, displayed with grossly different (i.e., lower) intensity than within-tolerance results. (A)
Display for acceptable blank scan; that is, blank scan for which all detector parameters are
within tolerance. (B) Display for blank scan in which coincidence counting rate, singles
counting rate, and dead-time results for 1 block detector are out of tolerance, indicated by black
areas (arrows) in respective displays. (Courtesy of Dr. Osama Mawlawi, M.D. Anderson
Cancer Center, Houston, TX.)
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FIGURE 11.
Reconstructed coronal images of 68Ge uniform-cylinder phantom without (A) and with (B)
normalization applied. (A) Unnormalized (i.e., uncorrected) image has obvious artifacts
attributable to differences in sensitivities between direct and cross planes and presence of
separate rings of block detectors. (B) Appropriate normalization virtually eliminates these and
other artifacts related to nonuniformity of scanner response.
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FIGURE 12.
Cross-sectional diagrams of GE quality assurance phantom (24) illustrating respective sections
(inserts) for evaluation of laser-light alignment, image slice thickness, spatial resolution,
linearity, and high-contrast contrast resolution (A); low-contrast uniformity (B); and image
uniformity and noise (C). Various short black lines in acrylic insert in section shown in A are
cavities that fill with water when phantom is filled, providing high contrast between cavities
and acrylic; portion of this section outside this insert, although not shown in black, is also
water-filled. Diagonally arranged sets of line cavities ranges are 1.6 (lower left), 1.3, 1.0, 0.8,
0.6, and 0.5 (upper right) mm in line width and are used to evaluate spatial resolution. Section
shown in B includes polystyrene membrane with series of holes (10, 7.5, 5, 3, and 1 mm in
diameter) that also fill with water when phantom is filled, providing low contrast between holes
and polystyrene. (D) Side-view diagram (not to scale) of section of phantom in A, showing
only 1 of slice-thickness measurement components of insert; these line cavities are air-, not
water-, filled. They are staggered (offset) 1 mm apart in longitudinal direction. Also shown in

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D, as well as in A, is laser-alignment groove around circumference of phantom and 2

corresponding laser-alignment cavities. Boxes indicate pertinent ROIs for different analyses.
(See text for details.)
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FIGURE 13.
Setup for measurement of CT radiation exposures using ionization chamber and 32-cm-
diameter acrylic torso (body) phantom. (Courtesy of Dr. Sadek Nehmeh, Memorial Sloan-
Kettering Cancer Center, New York, NY.)
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FIGURE 14.
Phantoms adaptable to evaluation of accuracy of multimodality image registration. (A)
Uniform phantom with 2 channels for line sources. (Courtesy of Dr. Sadek Nehmeh, Memorial
Sloan-Kettering Cancer Center, New York, NY.) (B) Phantom (NEMA IEC Body Phantom;
Data Spectrum Corp.) with multiple fillable spheres and cylindric insert that can be filled with
polystyrene to provide minimally attenuating material, simulating lung in otherwise uniform
water-filled volume.
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TABLE 1
Long-Lived Radionuclides Comprising Reference Sources for Instrumentation QC

Specific γ-
Energy, Eγ ray
(frequency), of constant, Γ
principal x- or γ- (mR/h/cm2/
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Radionuclide Half-life Decay constant (λ) ray (keV) MBq) Geometry and activity QC application

57 272 d 0.00254/d 122 (86%) 25.1 Test tube–sized rod, ~37 kBq Well-counter constancy and
Co*
accuracy
Vial/small bottle, 185–370 MBq Dose-calibrator accuracy and
constancy
Sheet (up to 50 × 60 cm), 370–740 γ-camera uniformity
MBq
68 287 d 0.00241/d 511 (178%) 14.5 Test tube–sized rod, ~37 kBq Well-counter constancy and
Ge*†
accuracy
Vial/small bottle, 185–370 MBq Dose-calibrator accuracy and
constancy
Cylinder (up to 5 L), up to 370 MBq PET scanner response
133 10.7 y 0.0648/y 356 (62%) 64.9 Test tube–sized rod, ~37 kBq Well-counter constancy and
Ba*
accuracy
Vial/small bottle, 185–370 MBq Dose-calibrator accuracy and
constancy
137
Cs 30 y 0.0231/y 662 (86%) 89.7 Test tube–sized rod, ~37 kBq Well-counter constancy and
accuracy
Vial/small bottle, 185–370 MBq Dose-calibrator accuracy and
constancy

*57
Co, 68Ge, and 133Ba are sometimes known as “mock” 99mTc (Eγ = 140 keV), 18F (Eγ = 511 keV), and 131I (Eγ = 364 keV), respectively.

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†68
Ge in sealed source is in secular equilibrium with its short-lived, positron-emitting daughter, 68Ga (half-life, 68 min).

Information in Table 1 is based on data from Johns and Cunningham (30).

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TABLE 2
Summary of Recommendations for Routine QC of Clinical Nuclear Medicine Instrumentation

Instrument At installation or after repair Annual Quarterly or monthly Weekly Daily

Survey meter Accuracy Accuracy —* —* Battery check

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Background
Constancy
Dose calibrator Geometry(volume)-dependent response N/A Linearity —* Constancy
Accuracy
Well counter Efficiency (sensitivity) Efficiency (sensitivity) —* —* Energy peaking
Background
Constancy
Intraoperative probe —* —* —* —* Battery check
Bias check
Energy peaking(if
applicable)
Background
Constancy
Organ uptake probe —* —* —* —* Energy peaking
Background
Constancy
Efficiency (sensitivity)
γ-camera References 3,5, and 8 —* Uniformity (for radionuclides Spatial resolution Energy peaking
used clinically other than 99mTc Uniformity (for 99mTc
or 57Co) or 57Co)
SPECT scanner or Reference 6 —* Tomographic uniformity COR alignment Energy peaking
SPECT subsystem Overall system performance Uniformity (for 99mTc
of SPECT/CT or 57Co)
scanner
PET scanner or PET Reference 4 Normalization —* Tomographic uniformity Blank scan
subsystem of PET/ Normalization Well-counter calibration
CT scanner Well-counter calibration
CT subsystem of References 1,2, and 22 Dosimetry Laser alignment —* Warm-up

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PET/CT or SPECT/ Image slice thickness Tomographic
CT scanner Spatial resolution uniformity
Linearity Accuracy of CT
High-contrast resolution number of water
Low-contrast resolution Noise
PET/CT or SPECT/ —* —* Accuracy —* —*
CT image CT-based attenuation corrections
registration

*
Other than QC or performance assessment procedures that may be recommended by manufacturer, no such procedure specifically recommended for this time interval exists.
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