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Clinical evaluation of data-driven respiratory gating for PET/CT in an

oncological cohort of 149 patients: impact on image quality and patient
management

Article in The British journal of radiology · September 2021

DOI: 10.1259/bjr.20201350

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Cite this article as:

Messerli M, Liberini V, Grünig H, Maurer A, Skawran S, Lohaus N, et al. Clinical evaluation of data-­driven respiratory gating for PET/CT in
an oncological cohort of 149 patients: impact on image quality and patient management. Br J Radiol 2021; 94: 20201350.

FULL PAPER

Clinical evaluation of data-­driven respiratory gating for

PET/CT in an oncological cohort of 149 patients: impact
on image quality and patient management
1,2
MICHAEL MESSERLI, MD, 1VIRGINIA LIBERINI, MD, 1,2HANNES GRÜNIG, MD, 1,2ALEXANDER MAURER, MD,
1,2
STEPHAN SKAWRAN, MD, 2,3NIKLAS LOHAUS, MD, 1,2LARS HUSMANN, MD, 1ERIKA ORITA, MD,
1
JOSEPHINE TRINCKAUF, MTRA, 1,2PHILIPP A. KAUFMANN, MD and 1,2MARTIN W. HUELLNER, MD
1
Department of Nuclear Medicine, University Hospital Zurich, Zurich, Switzerland
2
University of Zurich, Zurich, Switzerland
3
Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, Zurich, Switzerland

Address correspondence to: Michael Messerli

E-mail: ​michael.​messerli@​usz.​ch

Objectives: To evaluate the impact of fully automatic scan time increase of 4:37 min per patient in the whole
motion correction by data-­ driven respiratory gating study cohort (n = 149). General image quality was not
(DDG) on positron emission tomography (PET) image rated differently for PETnonDDG and PETDDG images (p =
quality, lesion detection and patient management. 1.000) while motion effects (i.e. indicating general blur-
Materials and Methods: A total of 149 patients under- ring) was rated significantly lower in PETDDG images
going PET/CT for cancer (re-­)staging were retrospec- and organ contours, including liver and spleen, were
tively included. Patients underwent a PET/CT on a digital rated significantly sharper using PETDDG as compared
detector scanner and for every patient a PET data set to PETnonDDG (all p < 0.001). In 27% of patients, PETDDG
where DDG was enabled (PETDDG) and as well as where resulted in a change of the report and in a total of 12
DDG was not enabled (PETnonDDG) was reconstructed. cases (8%), PETDDG resulted in a change of further clin-
All PET data sets were evaluated by two readers which ical management.
rated the general image quality, motion effects and Conclusion: Deviceless DDG provided reliable fully auto-
organ contours. Further, both readers reviewed all scans matic motion correction in clinical routine and increased
on a case-­ by-­
case basis and evaluated the impact of lesion detectability and changed management in a
PETDDG on additional apparent lesion, change of report, considerable number of patients.
and change of management. Advances in knowledge: DDG enables PET/CT with
Results: In 85% (n = 126) of the patients, at least one respiratory gating to be used routinely in clinical prac-
bed position was acquired using DDG, resulting in mean tice without external gating equipment needed.

INTRODUCTION However, PET image quality may be significantly degraded

Positron emission tomography (PET) images radiotracer by respiratory motion, among other causes.9 The radio-
uptake in patients, thereby enabling the detection and quan- tracer distribution appears blurred on images affected
tification of physiologic and pathophysiological processes by motion, rendering exams suboptimal for diagnostic
in vivo.1 In oncological patients, 18F-­fludeoxyglucose (18F-­ purposes and/or quantitative assessment, particularly in
FDG) PET is used to assess increased glucose metabolism in the chest and upper abdomen.10 To overcome this issue
primary tumors, lymph node or distant metastases,2,3 whereas (i.e. to decrease the effect of motion), respiratory gating can
CT enables a detailed assessment of morphological disease be applied. This requires the acquisition of a gating signal,
extent with a high spatial resolution.4,5 Therefore, hybrid which is usually done by external devices, such as a pres-
imaging with 18F-­FDG PET/CT has evolved as an important sure belt or a video camera tracing infrared markers, both
tool for staging of cancer patients in many different etiolo- of which may be inconvenient for the patient, and may also
gies.3 Further substances tracing prostate-­specific membrane prolong the examination time owing to device mounting
antigen (PSMA) and DOTA-­peptides (DOTATATE) play and unmounting.11 Also, a single misregistration may spoil
also an important role in PET imaging, namely for the assess- motion correction of the exam, in fact an erroneous misreg-
ment of prostate cancer and neuroendocrine tumors.6–8 istration of the underlying static attenuation maps may
 BJR Messerli et al

cause an over- or underestimation of activity of the region. A Table 1. Demographic data of study subjects (n = 149)
respiratory gating signal may also be extracted from the acquired
PET raw data using different methods, generally referred to as
Female/male, n (%) 61 (41%) / 88 (59%)
data-­driven gating (DDG).12,13 Until recently, this method was Age, years 61 ± 15 (24 - 89)
mainly reserved to academic environments and could only be Body weight, kg 76 ± 18 (40 - 142)
used retrospectively (i.e. based on list-­mode raw data) and not
Body height, m 1.72 ± 0.1 (1.50–1.95)
under real-­world conditions while scanning patients,14 although
2
nowadays DDG has become available on the market and is BMI, kg/m 25.6 ± 5.5 (14.9–43.4)
becoming more widespread. Injected dose, MBq 190 ± 74 (88 - 317)
Type of primary disease
Recently, a new digital PET detector system with lutetium-­based
scintillator crystal arrays and silicon photomultipliers was intro-  Head and neck cancer 14 (9.4%)
duced. A first study carried out in a mixed population of cancer  Breast cancer 15 (10.1%)
patients showed an improved performance of digital PET/CT
 Lung cancer 19 (12.8%)
with regard to pathologic and physiologic structures.15 This may
potentially be further enhanced by the use of DDG.  Esophageal cancer 3 (2.0%)
 Small bowel cancer 0 (0%)
Accordingly, the purpose of our study was to evaluate the impact  Colon cancer 8 (5.4%)
of DDG using the latest generation digital PET/CT scanner with
regard to PET (a) image quality, (b) lesion detection and (c)  Pancreatic cancer 7 (4.7%)
patient management in an unselected oncological cohort.  Cholangiocarcinoma 4 (2.7%)
 Urogenital cancer 18 (12.1%)
METHODS AND MATERIALS  Melanoma 27 (18.1%)
Patients
 Lymphoma 12 (8.1%)
This retrospective study included consecutive patients (n = 149)
who underwent a clinical PET/CT for (re-­)staging of oncolog-  Cancer of unknown origin 3 (2.0%)
ical diseases during a pilot evaluation phase of 6 weeks at the  Neuroendocrine tumor 10 (6.7%)
Department of Nuclear Medicine of the University Hospital of
 Paraneoplastic syndrome 9 (6.0%)
Zurich who gave general written informed consent for the use
of their data for scientific purposes. Overall, 132 patients (89%) Tracer used
underwent an 18F-­FDG PET/CT scan and 17 (11%) underwent  FDG 132 (88.6%)
a non-­FDG PET/CT scan (n = 7 PSMA; n = 9 DOTATATE; n =  PSMA 7 (4.7%)
1 DOPA), Table 1. The local ethics committee approved the study
protocol (Trial-­No. BASEC 2019-00207).  DOTATATE 9 (6.0%)
 DOPA 1 (0.7%)
PET/CT imaging protocol BMI = body mass index; MBq = Mega-­ Becquerel; PET = positron
All patients underwent a PET/CT on a digital detector scanner emission tomography.
(GE Discovery Molecular Insights - DMI PET/CT, GE Health- Values are given as absolute numbers and percentages in parenthesis
or mean ± standard deviation (range).
care, Waukesha, WI) with a high intrinsic system sensitivity of
22 cps/kBq.
axial 3.09 mm, as assessed by full width at half maximum (FWHM)
132 patients (89%) underwent an 18F-­ FDG PET with a body measurements at 1 cm from center of field of view were.17
mass index (BMI)-­adapted 18F-­FDG dosage regimen, as previ-
ously described16 and presented in Table 2. Participants fasted for 17 patients (11%) underwent a PET/CT scan with a tracer
at least 4 h prior to the scan, and blood glucose levels were below other than 18F-­FDG. The imaging protocols used for PSMA,
160 mg dl−1 at the time of the 18F-­FDG injection. A free-­breathing DOTATATE and DOPA-­imaging were described previously,18
CT scan was performed from the vertex of the skull to the mid-­ and are presented in Table 2.
thighs (or feet), and used for attenuation correction purposes as well
as for anatomic localization of 18F-­FDG uptake. The CT scan was Use of DDG for PET acquisition
performed using automated dose modulation (range 15–100 mA, In our study, we used a software-­based prospective DDG algo-
120 kV). Immediately after the CT scan, PET images were acquired rithm (MotionFree, GE Healthcare, Waukesha, WI) that was
covering the identical anatomical region. The PET acquisition time recently introduced on DMI PET/CT, in combination with
was set to 2.5 min per bed position, with 6–11 bed positions per a motion correction algorithm (Q.Static, GE Healthcare,
patient (depending on patient size), with an overlap of 23%. All Waukesha, WI) that utilizes the quiescent phase of the respira-
PET images were reconstructed using a Bayesian penalized likeli- tory cycle. Unlike externally driven respiratory gating, which
hood reconstruction method (Q.Clear, GE Healthcare, Waukesha, usually relies on infrared camera tracking of chest motion, DDG
WI). Data sets were reconstructed with a 256 × 256 pixel matrix. methods solely use PET raw data in combination with dimen-
Spatiel resolution were radial 1.62 mm, tangential 2.30 mm and sionality reduction techniques, in order to extract the respiratory

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Table 2. PET imaging protocols for the tracers used in the study group (n = 149)

Tracer Scan time p.i. Injected activity Bed time Reconstruction setting
a
FDG 60 min BMI-­adapted 2.5 min Q.Clear (β-­value of 450)
b
PSMA 90 min 3 MBq/Kg 2.5 min Q.Clear (β-­value of 1200)
DOTA 60 min 150 MBq 2.0 min Q.Clear (β-­value of 1000)
DOPA 60 min 150 MBq 2.5 min Q.Clear (β-­value of 1000)
BMI, body mass index; FDG = Fludeoxyglucose; MBq = Mega-­Becquerel; PET = Positron emission tomography; PSMA = prostate-­specific membrane
antigen.
a
FDG-­dose of 1.5 MBq/kg body weight was injected for patients with a BMI of <20 kg/m2, 2 MBq/kg body weight for patients with a BMI of
20–24.5 kg/m2, and 3.1 MBq/kg body weight for patients with a BMI >24.5 kg/m2 (without exceeding a maximum injected FDG dose of 320 MBq).
b
minimum = 200 MBq, maximum = 300 MBq.

signal. This technique utilizes a principal component analysis of respiration mismatch on PET images with CT attenuation
to compute the spatiotemporal variation of list mode data. The correction.
algorithm measures respiration-­like frequencies within the PET
data. At the end of base acquisition time, for each bed position In a second session performed 8 week after initial scanning, both
for which motion screening was prescribed, an on-­the-­fly deci- readers reviewed all scans in consensus on a case-­by-­case basis.
sion is made as whether motion has been detected. The whole Decisions were made for every patient as (a) whether additional
body DDG reconstructed image is composed of a non-­gated lesions were apparent using PETDDG, (b) whether the use of
part for bed positions that were not triggered, and a quies- PETDDG led to a change of report, and (c) whether PETDDG resulted
cent gated part on the bed positions that were triggered; with in a change of management according to the institutional protocols
the non-­gated bed positions being 2.5 min in duration, and the that is based on international, interdisciplinary guidelines.
gated positions being 5 min (i.e. doubling the per-­bed acquisition
time) in duration but with only 50% of coincidences retained, Statistical analyses
namely those occurring in the defined quiescent periods. The Categorical variables are expressed as proportions, and contin-
algorithm provides a signal-­to-­noise measure of respiration-­like uous variables are presented as mean ± standard deviation or
frequencies within the data, denoted as R-­value, that is config- median (range), depending on the distribution of values. Quali-
urable (R-­value threshold). The R-­factor (i.e. signal-­to-­noise tative image ratings (i.e. overall image quality, motion artefacts,
ratio of respiration-­like frequencies within the data operating as and organ contours) were compared of PETnonDDG and PETDDG
threshold for triggering) was set to R > 10.0.19,20 reconstruction using the Wilcoxon matched pairs signed rank
test. Analyses were carried out using SPSS release 25.0 (IBM
For further analysis, for every patient a PET data set where DDG Corporation, Armonk, NY) and MedCalc v. 15.8 (MedCalc
was enabled (hereafter referred to as PETDDG) and another Software, Ostend, Belgium). A two-­tailed p-­value of <0.05 was
data set where DDG was not enabled (hereafter referred to as considered to indicate statistical significance.
PETnonDDG) was reconstructed; PETnonDDG was processed using
a non-­gated reconstruction using the first 2.5 min per bed posi- RESULTS
tion, with the additional 2.5 min of data that were collected on A total of 149 patients (61 female, 88 male, mean age 61 ± 15
DDG-­triggered bed positions discarded. years) referred for the initial staging (n = 41) or restaging (n
= 108) of different oncological diseases undergoing PET/CT
Subjective PET image analysis and assessment of participated in our study. Detailed demographic information is
clinical impact of DDG presented in Table 1.
All PET data sets were evaluated by two readers (M.M. and M.W.H.,
with 3 and 8 years of experience in PET/CT reading, respectively)
Table 3. Subjective image quality scores
blinded to the acquisition mode used. All scans were reviewed inde-
pendently on a dedicated workstation (Advantage Workstation, v. Overall image quality 1 = poor
4.6; GE Healthcare, Waukesha, WI) and in random order. Readers 2 = acceptable
were blinded to the clinical information. In case of discrepancy of 3 = good
4 = very good
image rating, a final decision was reached by consensus.
Motion effects 1 = no
2 = slight
The readers first rated the general image quality, motion effects 3 = moderate
and organ contours. For this purpose, data sets were viewed 4 = severe
using maximum intensity projection (MIP) views of PET and
Organ contoursa 1 = ill-­defined
axial views with reformatted sections. The two readers evalu- 2 = moderate blurring
ated the images according the scores described in Table 3. The 3 = slight blurring
frequency of attenuation correction artifacts in PETnonDDG and 4 = sharp
PETDDG was assessed by noting the presence of curvilinear cold a
Organ contour assessment included liver, spleen, stomach, kidney,
artifacts on dome of liver/diaphragm or at lung base because collecting system, bowel, heart.

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Table 4. Technical aspects of DDG in study group Technical aspects of DDG in study cohort
The results of the technical aspects using DDG in the study
Gating yes / gating no 126 (84.6%) / 23 (15.4%)
cohort are given in Table 4. Overall, in 85% of the patients at
 Gating yes FDG 109/132 (83%) least one bed was acquired using DDG, leading to an average
 Gating yes PSMA 7/7 (100%) scan time increase of 4:37 min in the whole study cohort (n =
149), and 5:28 min in the subgroup of patients whose exams were
 Gating yes DOTATATE 9/9 (100%)
triggered by DDG (n = 126).
 Gating yes DOPA 1/1 (100%)
Number of bed positions acquired 6 ± 1 (5–11) Impact of DDG on subjective image quality
Amount of bed positions triggered 1.69 ± 0.1 (1.48–1.94) The results of the subjective image assessment including all study
subjects are given in Table 5. General image quality was not
 no gating 23 (15%)
rated differently for PETnonDDG and PETDDG images (p = 1.000).
 one bed triggered 18 (12%) Motion effects (i.e. indicating general blurring) were rated signifi-
 two beds triggered 68 (46%) cantly lower in PETDDG images and contours of different organs,
including liver and spleen, were rated sharper using PETDDG as
 three beds triggered 32 (21%)
compared to PETnonDDG (all p < 0.001), Table 5. The improvement
 four beds triggered 8 (5%) of organ contours was most pronounced for the liver, spleen, heart
Total scan time, min 15:16 ± 3:02 (10:00 - 27:30) and collecting system, and less pronounced for the stomach, kidney
and bowel, see Table 5. Overall, there were nine cases of attenua-
Total time increase per study in 4:37 ± 3:02 (0:00 - 10:00)
whole cohorta, min tion correction artefacts in PETDDG as compared to seven cases in
PETnonDDG, respectively.
Total time increase per study in 5:28 ± 1:52 (2:30 - 10:00)
DDG cohortb, min
Impact of DDG on lesion detectability and clinical
DDG, Data-­driven gating.
management
Values are given as absolute numbers and percentages in parenthesis
or mean ± standard deviation (range). Overall, in 40/149 patients (27%) PETDDG resulted in a change
a
n = 149. of the report, mainly due to additional apparent lesions, Figure 1.
b
n = 126. When reviewing all cases, we observed that in a total of 12 cases

Table 5. Subjective images analysis comparing

PETnonDDG PETDDG p-­value

a
Overall image quality 3.8 3.8 1.000
b
Motion effects 1.2 1.0 <0.001
c
Organ contours
 Liver 3.5 3.8 <0.001
 Spleen 3.6 3.9 <0.001
 Stomach 3.8 3.9 <0.001
 Kidney 3.8 4.0 <0.001
 Collecting system 3.6 4.0 <0.001
 Bowel 3.6 3.8 <0.001
 Heart 3.5 3.8 <0.001
Mean increase in organ contour rating, %
 Liver reference +9.7%
 Spleen reference +10.6%
 Stomach reference +3.1%
 Kidney reference +6.5%
 Collecting system reference +12.8%
 Bowel reference +6.3%
 Heart reference +10.0%
DDG = Data-­driven gating; PET = Positron emission tomography.
a
Overall image quality scale: 1, poor; 2, acceptable; 3, good; 4, very good.
b
Motion effects scale: 1, no; 2, slight; 3, moderate; 4, severe.
c
Organ contours: 1, ill-­defined; 2, moderate blurring; 3, slight blurring; 4, sharp.

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Figure 1. Impact of DDG in the study cohort (n = 149) on lesion The major findings of our study are as follows: (1) the real-­
detectability and patient management. DDG, data-­driven res- time use of DDG was feasible in clinical routine during a test
piratory gating. period of 6 weeks; (2) DDG was activated in 85% of the patients,
resulting in a mean time increase by 4:37 min (mean total scan
time 15:16 min); (3) while general image quality was not affected
by DDG, its use resulted in a significant reduction of motion
artifacts and sharper delineation of organs (particularly liver and
spleen); and (4) the use of DDG resulted in additional apparent
lesions in 27% of patients and (5) the use of DDG translated into
a change of management in 8% of patients. Following the results
of our study, we have implemented DDG in our clinical routine
and use it in our standard protocols.

PET/CT has evolved as an invaluable tool for staging of cancer

patients in many different etiologies.3 Respiratory motion during
image acquisition may, however, significantly degrade PET
image quality and even render the detectability of small lung or
liver lesions impossible.9,10,21 To decrease the effect of motion,
respiratory gating can be used. This requires the acquisition of a
gating signal, usually by external devices, such as a pressure belt
or a video camera, which may be inconvenient for the patient
(8%), PETDDG resulted in a change of further clinical management, and technically challenging for technicians.11
Table 6.
Contrarily, software-­based DDG is able to detect respiratory
A representative case illustrating an additional apparent lesion with motion within PET data, using the static phase for reconstruc-
PETDDG is presented in Figure 2. Representative cases with change of tion, without the need for additional hardware or inreased radi-
clinical management by using PETDDG for 18F-­FDG, DOTATATE, ation dose.22 Indeed, the DDG software used in our study was
and 18F-­DOPA, respectively, are presented in Figures 3–5. introduced to our clinical routine from the beginning without
any specific patient preparation or instruction used, and after
DISCUSSION minimal training of staff. Using an R-­factor of >10.0, the fully
This study sought to evaluate the impact of DDG (i.e. software-­ automated respiratory gating method was activated in the
based respiratory PET gating) on image quality, lesion detection majority of patients (i.e. in 85%). This prolonged the scan time
and patient management in an unselected oncological cohort by 4:37 min in the whole cohort (up to 10 min in single subjects).
using a latest generation silicon-­based digital detector PET/CT One may argue that this is a relevant time increase which poten-
scanner. tially impacts on clinical workflow. However, given the significant

Table 6. Cases (12/149) of patients where DDG led to change in management

Patient Tracer Indication for PET Advantage of DDG Change in management

#01 FDG Paraneoplastic inflammatory syndrome Detection of increased uptake in adrenal Initiation of laboratory work-­up and
gland hormone substitution

#02 FDG Follow-­up of pancreatic carcinoma Liver metastasis detected Upstaging and change of therapy regimen

#03 DOTA Staging of pancreatic neuroendocrine tumor Correct identification of intrapancreatic Biopsy obviated
accessory spleen

#04 FDG Staging of pancreatic carcinoma Additional lymph node detected Alteration of surgical approach

#05 DOPA Search for pheochromocytoma Detection of small pheochromocytoma Surgical resection

#06 FDG Follow-­up of breast cancer Focal lesion in breast detected Initiation of breast ultrasound and biopsy

#07 FDG Follow-­up of chorioncarcinoma Liver metastasis detected Change of therapy regimen

#08 FDG Follow-­up of nasal carcinoma Additional lymph node detected Radiotherapy-­field adapted

#09 FDG Staging of cerebral lymphoma Focal lesion in liver detected MRI of liver performed

#10 FDG Follow-­up of thyroid cancer Homogenous liver uptake (focal lesion in Refrain from additional work-­up
non-­DDG images)

#11 DOTA Staging of gastric neuroendocrine tumor Lymph node metastasis detected Upstaging and change of therapy regimen

#12 DOTA Staging of familial MEN1 Retroperitoneal NET detected Upstaging

DDG = Data-­driven gating, FDG = Fludeoxyglucose, PET = Positron emission tomography.

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Figure 2. Representative case of 18F-­FDG-­PET/CT imaging of a 62-­year-­old female with breast cancer, using a digital PET/CT
system without respiratory gating (a–d) as well as using DDG;(e–h) . An additional apparent lesion in the liver (arrow) was noted
in PET images using DDG leading to a change of report but in this case not clinical management as there are multiple other liver
metastasis present; (SUVmax in PETnonDDG = 3.2; and SUVmax in PETDDG = 6.1). DDG, data-­driven respiratory gating; FDG, fludeoxy-
glucose; PET, positron emission tomography; SUV standardized uptake value.

reduction of motion artifacts, improved visualization of various quantification of lung lesions by increasing the overall accuracy
organ and particularly the amount of additional apparent lesions, in lung lesion detection and characterization.25 In another multi-
we believe this approach may merit consideration. center, retrospective study Crivellaro et al reported respiratory-­
gated PET/CT technique as a valuable clinical tool in diagnosing
Previous studies already reported an advantage of respiratory liver lesions by reducing undetermined findings, improving
gating for PET/CT.23–25 Guerra et al, e.g. described in a multi- diagnostic accuracy, and confidence in reporting.24 Further,
center, retrospective study the benefits in reporting accuracy and benefits from PET respiratory gating in a prospective study of 74

Figure 3. Representative case of 18F-­FDG-­PET/CT imaging of a 37-­year-­old female (corresponding to patient #7 of Table 5) with
chorioncarcinoma undergoing PET/CT for follow-­up. PET/CT images without respiratory gating (a–c) as well as using (d–f). A
tiny focus of increased FDG-­uptake in the liver is noted (arrow) only in PET images using DDG compatible with a liver metastasis
(SUVmax in PETnonDDG = 3.7; and SUVmax in PETDDG = 4.6). DDG, data-­driven respiratory gating; FDG, fludeoxyglucose; PET, positron
emission tomography; SUV standardized uptake value.

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Figure 4. Representative case of 68Ga-­DOTATATE-­PET/CT imaging of a 60-­year-­old male (corresponding to patient #11 of Table 5)
with neuroendocrine tumor of the stomach undergoing PET/CT for follow-­up. PET/CT images without respiratory gating (a–c) as
well as using (d–f). A new retroperitoneal lymph node metastasis was detected (arrow) only in PET images using DDG; with mag-
nified images of the retroperitoneal region (asterisk), (SUVmax in PETnonDDG = 5.7; and SUVmax in PETDDG = 8.5). DDG, data-­driven
respiratory gating; FDG, fludeoxyglucose; PET, positron emission tomography; SUV standardized uptake value.

patients were described by Büther et al.23; improvements in diag- undergoing whole-­body 18F-­FDG PET, Buther et al26 found that
nostic image quality, increase in SUV, and decrease in metabolic DDG-­based motion-­correction delivered qualities comparable
volumes were reported with gated PET images as compared to to hardware-­ based approaches, even if SUV measurements
non-­gated PET images. were significantly higher in both reconstruction compared to
static images (p < 0.001). On a larger cohort of 144 whole-­body
18
More recently, two different prospective studies aimed to directly F-­FDG PET examinations, Walker et al20 found that the use
compare the data-­driven method to an external device-­based of DDG resulted in an increase in lesions’ SUVmax (i.e. 0.66 ±
system for the respiratory gating in PET. In a cohort of 56 patients 0.1 g ml−1, p < 0.0005) and a reduction in lesions’ PET volume

Figure 5. Representative case of 18F-­DOPA-­PET/CT imaging of a 48-­year-­old female (corresponding to patient #5 of Table 5) with
previous pheochromocytoma on the left side that was surgically resected now undergoing PET/CT search for pheochromocytoma
on the right side. PET/CT images without respiratory gating (a–d) as well as using (e–h). A tiny focus of increased DOPA-­uptake
in the right adrenal gland is noted (arrow) and the patient underwent surgical resection of the adrenal where a small pheochro-
mocytoma was proven, (SUVmax in PETnonDDG = 5.5; and SUVmax in PETDDG = 10.3). DDG, data-­driven respiratory gating; FDG,
fludeoxyglucose; PET, positron emission tomography; SUV standardized uptake value.

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compared to the external device-­based system. Moreover, while other techniques based on a optical flow-­based de-­blurring of
the device-­based gated reconstruction failed in 16% of exams, the motion effects within image reconstruction.26
ones using DDG always provided a clinically acceptable image.
In another recent study by Walker et al, the authors concluded In conclusion, the deviceless DDG based on a principal component
that DDG provided superior performances to that of an external analysis of PET data was evaluated. It provided reliable fully auto-
device-­based system.27 We observed a slightly higher rate of matic motion correction in clinical routine, and increased lesion
attenuation correction artifacts in DDG compared to non-­gated detectability and changed management in a considerable number
images (9 cases vs to 7 cases), although not statistically signifi- of patients. Thanks to this new technique, PET/CT with respiratory
cant, this is an issue that should be investigated further. gating can be used routinely in clinical practice without external
gating equipment needed. Future studies should systematically
We acknowledge that our study has some limitations. First, assess the impact of DDG in different disease entities and radio-
this current evaluation of DDG included an unselected onco- tracers to further improve the clinical value of this technique.
logical cohort of consecutive patients which resulted in a rela-
tively heterogenous study population. The impact of DDG in ACKNOWLEDGMENT
different diseases and different tracers used may vary, espe- Dr. Stephan Skawran is supported by a grant form the Palatin-­
cially as different radiotracers have different distribution prop- Foundation, Switzerland. Dr. Michael Messerli received a
erties and are thus expected to result in more or less successful research grant from the Iten-­Kohaut Foundation, Switzerland.
gating outcomes. We therefore strongly ecourage future Dr. Martin W. Huellner received grants from GE Healthcare and
studies to systematicelly assess the impact and value of DDG a fund by the Alfred and Annemarie von Sick grant for transla-
in different diseases and radiotracers. Second, a clinical reader tional and clinical cardiac and oncological research. The authors
assessment as the one performed in our study, might carry would like to thank Corina Weyermann, Michèle Hug, Freya
an inherent bias since it is virtually impossible to completely Klein and Juliana Koller for their excellent technical support.
blind readers to the image ‘appearance’ of different reconstruc-
tion algorithms. Third, results in our study are based on an CONFLICT OF INTEREST
R-­factor of >10.0. The use of other R-­factors leads to a different Dr. Martin W. Huellner is a recipient of speaker’s fees and research
time consumption of DDG and may ultimately also differently grants by GE Healthcare (unrelated to the current study). Apart
impact lesion detection and patient management. Fourth, we from that the authors of this manuscript declare no relationships
did not compare DDG with an external gating technique in with any companies, whose products or services may be related
our study. Fifth, we did not compare the impact of prolonged to the subject matter of the article.
non-­gated PET acqusition on image quality nor compared a
prolonged non-­gated PET with DDG. Sixth, we only evaluated FUNDING
one respiratory gating method in our study using prospective The University Hospital Zurich holds a research agreement
on-­console reconstruction, which roughly doubles the acqui- with GE Healthcare (unrelated to the current study). No further
sition time of gated bed positions, and not includes remote specific grants from funding agencies in the public, commercial,
offline reconstruction of 4D respiratory phase-­matched PET or not-­for-­profit sectors were received for this study.
data. While the DDG approach used in our study involves
additional acquisition time in beds where motion was detected INFORMED CONSENT
(in our cohort on average 1.8 bed positons per patient, if Only patients with documented willingness to the use of their
motion was detected), other techniques, being partly not clin- medical data for research were included.
ically available yet, do not prolong the acquisition times and
may thereby be more accepted in clinical environments. Such ETHICS APPROVAL
techniques rely on post-­processing of gated PET image data- The present study was approved by the local ethics committee
sets of step-­and-­shoot acquisition, utilizing 100% of coinci- and was conducted in compliance with ICH-­GCP rules and the
dence events, or on continuous-­bed-­motion acquisition28 or Declaration of Helsinki.

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