New Equipment in Nuclear Medicine,

Part 1: Solid-State Detectors

Cameras that capture photons for nuclear med
icine images are breaking free of several
restrictions imposed by traditional scintilla-
tion/photomultiplier detector technology. New solid-
state detector technology will enable the camera
head to zoom in close to small body parts while
making the whole system smaller, lighter, and
portable. On another technology front, engineers
have developed systems that diminish the border
line between positron emission tomography (PET)
and single-photon emission computed tomography
(SPECT): Some dual-head SPECT systems can Recently cleared for
marketing by the FDA,
produce images from positron tracers that may pro
the Digirad 2020(c
vide a clinically validated substitute for PET scans. Imager substitutes
These hybrid SPECT/PET systems will make flu semiconductors for
orine- 18-fluorodeoxyglucose (FDG) scanning avail vacuum tubes.
able to many oncology patients who don't live any rithm compares the relative signal strengths from
where near a PET scanner. ' all the photomultiplier tubes. "That's why Nal detec
tors have poor energy resolution. And because of
Solid-State Detectors Reflect State-of-the-Art their analog position sensing, they have poor con
Technology
trast," said Doty, formerly a principal materials sci
Solid-state technology, which replaces scintil entist at Digirad.
lation crystals and photomultiplier tubes with solid- In June 1998, Sandia and Digirad signed a three-
state crystals and semiconductor electronics, may year cooperative research and development agree
change nuclear medicine imaging in the same ment. Solid-state detector research at Sandia pri
way it revolutionized television sets and comput marily focuses on large-volume spectrometers for
ers by making vacuum tubes obsolete, predicted nuclear safeguards and treaty verification, but the
Karen Klause, president and CEO of Digirad Corp., technology can sometimes transfer to nuclear med
San Diego. icine, noted Doty, since "all gamma cameras are
In a traditional Anger camera, a gamma ray strikes essentially spectroscopic imagers."
a sodium iodide (Nal) scintillation crystal, which The Digirad 2020/c Imager (Fig. 1), cleared for
transforms that into a flash of light; a photomulti marketing by the U.S. Food and Drug Administra
plier tube then transforms the light photon into an tion (FDA) in June 1997, substitutes semiconduc
electric charge, completing a two-step process. With tor electronics for vacuum tubes. According to
a solid-state detector, a gamma ray strikes a dif Klause, the direct digital conversion improves
ferent type of crystal, such as cadmium zinc tel- energy, contrast and spatial resolution.
luride (CdZnTe, or CZT), which is a semiconduc Under the medical directorship of William L.
tor that converts the photon directly to a digital Ashburn, MD, the company has collected clinical
electronic signal, a one-step process. data, including direct comparisons with conven
"A semiconductor detector is digital in the tional gamma cameras, at several hospitals and
position sense because each pixel is actually a outpatient clinics in southern California. "Because
separate detector, and the photon either hits a detec it's portable, we don't have to install the camera
tor [pixel] or it doesn't. On the other hand, with for very long at any one location. We roll it in, plug
the Nal detector, each photon is absorbed some it in, and it's ready to go. We collect patient images,
where in a big crystal and each photomultiplier tube leave it there for a couple of days, then move it
flashes for each event," explained F. Patrick Doty, to a different site," said Klause. The camera head
PhD, a principal member of the technical staffai weighs about 50 Ibs (22.5 kg) and the whole sys
Sandia National Laboratories, Livermore, CA. To tem, including camera and cart, weighs less than
pinpoint the origin of each event, a complex algo- 300 Ibs ( 135 kg). On the other hand, a traditional
gamma camera system can weigh 3,000 to 5,000
1 Hybrid PET/SPECTwill be covered in Part 2 of this Ibs (1,350 to 2,250 kg).
series. (Continued on page 35N)

Newsline 15N
and to HCFA its advocacy of separate payments for radiophar- pharmaceuticals, Inc. (CORAR) commissioned an additional
maceuticals, apart from APCs, and its insistence that payments study of HCFA databases to gather more up-to-date and more
should be made on the basis of reasonable costs. Alternatively, complete reimbursement data for radiopharmaceuticals.
radiopharmaceuticals could be paid under one of the following The "saga" of development and implementation of APCs will
"backup" proposals: most likely continue during 1998, 1999 and even the year
A separate payment might be based on a national price list for 2000. Comments on the September 8,1998, APC proposal must
radiopharmaceuticals similar to the list developed in 1995 by the be submitted to HCFA by the Nuclear Medicine Task Force
Florida Medicare carrier. This "Florida list" passed the test of and other interested parties by November 9, 1998. Newsline
time and is considered reasonably balanced by Florida providers updates like this one are designed not only to keep JNM read
and the insurer. ers informed about important reimbursement developments, but,
Another option involves distinct APCs for radiopharmaceu very importantly, to strongly encourage you to submit constructive
ticals, paid separately from (and in addition to) the APCs for comments and data to the task force and to HCFA.
nuclear medicine procedures. HCFA proposed such separate Finally, the Nuclear Medicine APC Task Force is an excel
APCs for chemotherapy drugs, and the task force believes that lent example of how coordinated efforts among the members
there is equally strong justification for having separate APCs for of the nuclear medicine community can bring together all key
radiopharmaceuticals because of the similarly broad price range organizations to address important federal policies, develop work
and the lack of correlation between the price of the drug and able solutions and seek to educate HCFA and related federal deci
the price of the procedure in which the drug is being used. sion-makers on the important medical role of nuclear medicine
Finally, if payment for the radiopharmaceutical were to be and radiopharmaceuticals.
included in the APC payment, the component reflecting radio For more information, please contact either Jack Slosky, PhD,
pharmaceuticals should be derived from the most recent cost MBA (978-671-8191, e-mail: jack.j.slosky@dupontpharma.com)
reports available to HCFA and other reliable data sources for or Gordon Schatz, Esq. (202-414-9259, e-mail:
radiopharmaceuticals, which the task force believes would more gbschatz@rssm.com). Both represent CORAR on the Nuclear
accurately portray radiopharmaceuticals than the data from 1996. Medicine APC Task Force.
Since radiopharmaceuticals may be introduced into the mar
ket in the middle of a fiscal year, we also recommend that HCFA —JackJ. Slosky, PhD, MBA
makes clear that outlier payments should be available to hospi DuPont Pharmaceuticals Company,
tals to pay for the costs of new and innovative radiopharmaceu Medical Imaging Division,
N. Billerica, Massachusetts
ticals whose costs have not been incorporated into the APC pay
ment. —Gordon B. Schatz, Esq.
Additionally, in July, the Council on Radionuclides and Radio Reed Smith Shaw & McClay LLP, Washington

Solid-State Detectors ing at Harbor-UCLA Medical Center in Torrance, CA, who

(Continued from page 15N) worked with nuclear medicine physicians and technologists in
Added Views in Scintimammography the mid-1990s to develop the scintimammography procedure
The detector is small (8 in X 8 in or 20.3 cm X 20.3 cm) and using technetium-99m sestamibi (Miraluma, DuPont). Prelim
flat so it can be positioned close to small body parts, a feature inary results of a recent multicenter trial using conventional
particularly useful for breast imaging. "Conventional cameras gamma cameras, in fact, found that the sensitivity of sestamibi
can provide only lateral views of the breast, but with the solid- in nonpalpable lesions was only 47.6% for medial cancers
state detector, our camera can acquire medial, craniocaudal, compared with 65.8% for lateral cancers.2
lateral, and axial views, which enables scintimammography to By using a split-view biplane collimator with the Digirad solid-
simulate the same types of images as a mammogram," said Klause. state camera, the system may serve another role in breast imag
Anger cameras require oversampling, explained Doty, ing by providing scintimammographic data for stereotactic biopsy,
which means that the detector must have photomultiplier tubes said Linda Diggles, CNMT, who works with Khalkhali at Har
around the edge of the crystal, outside the field of view. When bor-UCLA. "The lesion can be located more precisely when the
a conventional detector is placed against the chest wall, most camera obtains the same image from two different angles," she
of the breast lies against a wide perimeter of dead space. With a explained. The biplane collimator was used frequently for car
solid-state detector, however, there is little dead space (0.5 in, 1.3 diac imaging before the advent of SPECT, she added.
cm), so that the detector edge can be positioned perpendicular
to the chest wall for a medial view of the breast.
"Adding the medial view enhances lesion detectability in medi 2 Khalkhali I, Mishkin F, Diggles L, Ashburn W. Value of adding medial
views to routine breast imaging - experience with a solid-state
ally located cancers and may increase the detection rate of (CdZnTe) gamma camera. J NucÃ-Med 1998;39[5][suppl):139P. Abstract
those cancers," said Iraj Khalkhali, MD, director of breast imag 546.

Newsline 35N
 Upright Chair Increases SPECT Fields will pay some premium for the better energy resolution and higher
For SPECT applications, Digirad has designed an upright rotat count rates obtained with solid-state detectors, but not a large
premium," said Mr. Corvo. When CZT crystals can be produced
ing chair so patients rotate in front of the detector instead of
vice versa. The chair, which is not yet FDA-cleared for market at lower cost, solid-state gamma cameras will have larger
ing, enables cardiac imaging patients to sit with their arms rest detector heads.
ing on a bar in front of them, allowing the diaphragm to drop Harrison H. Barrett, PhD, regents professorat the University
down and out of the way. of Arizona Optical Science Center in Tucson, foresees that in 5
With a diverging collimator, the field increases to lung-scan to 10 years, every gamma camera will use a solid-state detec
size(14in X 14 in or 35.5 cm X 35.5 cm). Although initial inter tor. "The technology is advancing very rapidly. 1also think
we'll progress to detectors with much higher spatial resolu
est in the Digirad camera came from departments that wanted
to replace an old portable gamma camera, Klause said that the tion," said Barrett. He and colleagues are working on increas
solid-state system can serve as an all-purpose camera. "The only ing spatial resolution with high numbers of very small pixels (J
procedure it doesn't do is a whole-body bone scan because we NucÃ-Med 1998; 39 [suppl]: 173P). "The system we're operat
don't have a moving table that enables the camera to cover the ing has a 0.38-mm pixel size, much smaller than the pixel size
whole body," she said. Whole-body bone scans can be done on any manufacturer is talking about with solid-state detectors,"
a large-field-of-view camera, and then the patient can be he said.
moved to the solid-state camera for spot views, she added, a "We work closely with NASA Goddard Space Flight Center.
They've built a quite fantastic array with about a half-a-million
scenario that could improve patient throughput.
According to Michael S. Kipper, MD, one of Digirad's clini 0.1-mm pixels. If you want my opinion on the future of nuclear
cal investigators, "I think the camera has a particular niche for medicine detectors, that's it: Very large numbers of pixels. Some
imaging small organs and for portable imaging in the emergency major advances in nuclear medicine technology are coming out
room, intensive care unit and cardiac care unit." Kipper went of the gamma-ray astronomy field," Barrett said.
on to note substantial progress with the technology. "Over the
next few years, we'll see a refinement as it moves toward becom Challenge of Solid-State Detectors for Hybrid SPECT/PET
ing a general-purpose camera," he said.
Systems
Major nuclear medicine equipment manufacturers are also Bicron predicts that gamma cameras may incorporate solid-
planning solid-state detector technology development. General state detectors within 5 to 10 years but at an incremental pace.
Electric Medical Systems, for example, is working with Elscint "Right now the big driver in nuclear medicine is PET, and there
in its ELGEMS joint venture to develop SPECT systems with are some limitations to CZT for PET applications," said Mr.
solid-state detectors based on CZT crystals. Plans are also under Corvo. With the higher 511-keV energy emitted by 1SF-FDG,the
way at Siemens Medical Systems, Inc., to use CZT solid-state crystal needs more stopping power, like a catcher's mitt needs
detectors in future SPECT systems. extra padding.
One of the advantages of CZT crystals for nuclear medicine For hybrid SPECT/PET systems, the market has moved
is that they are readily fabricated as monolithic pixellated arrays. from thin Nal scintillation crystals (3/8 in. [1.0 cm]) to thicker
With current crystal growth technology, according to the con Nal crystals (5/8, 3/4 or 1 in. [1.6, 1.9 or 2.5 cm]). "That's no
sensus among experts, typical efficiency is 4%, "meaning that problem with Nal. We grow big ingots of Nal crystal, and we can
4% of the crystal is operational for solid-state detector applica just cut a thicker slice. However, CZT is a semiconductor, and
tions, but 96% is not," explained Shimon Klier, CEO of Imarad there are some problems with 'charge collection,' or pooling of
Imaging Systems Ltd., Rehovot, Israel. According to Klier, the electrons across the crystal, when CZT is cut to a thicker
company has developed new technology that yields a higher per depth," said Mr. Corvo. Until crystal growers solve this problem,
centage, "almost by an order of magnitude," of operational there will be no wide-scale use of solid-state detectors in nuclear
CZT crystal, which would substantially lower the cost of pro medicine because most facilities that buy a new camera will want
ducing solid-state detectors for gamma cameras. "There's no
hybrid SPECT/PET capability.
point in offering something really good that nobody can pay for," Today, solid-state detectors can be introduced to nuclear med
noted Mr. Klier. icine through niche markets of scintimammography, small-organ
Bicron, Newbury, OH, supplies Nal scintillation crystals to all studies, portable imaging and surgical applications. As CZT pro
of the major gamma camera manufacturers. The company also duction becomes more cost-effective, and when thicker crys
is actively developing CZT-based solid-state detectors, with pro tals for hybrid SPECT/PET systems become available, solid-
duction capacity and product offerings planned for 1999. state detectors may eventually go mainstream for all gamma
"The principle focus of our research program is to better under camera systems.
stand all the characteristics of the CZT crystal to try to develop —Linda E. Kelt-hum
ways to grow it more cost-effectively," said Phillip Corvo, gen
eral manager for scintillation products at Bicron. "This is a
classic price-performance issue. Nuclear medicine physicians

36N THE JOURNALOF NUCLEARMEDICINE•

Vol. 39 •
No. 11 •
November 1998