External phantom-based validation of a deep-learning network trained for upscaling of digital low count PET data.

Background A reduction of dose and/or acquisition duration of PET examinations is desirable in terms of radiation protection, patient comfort and throughput, but leads to decreased image quality due to poorer image statistics. Recently, different deep-learning based methods have been proposed to improve image quality of low-count PET images. For example, one such approach allows the generation of AI-enhanced PET images (AI-PET) based on ultra-low count PET/CT scans. The performance of this algorithm has so far only been clinically evaluated on patient data featuring limited scan statistics and unknown actual activity concentration. Therefore, this study investigates the performance of this deep-learning algorithm using PET measurements of a phantom resembling different lesion sizes and count statistics (from ultra-low to high) to understand the capabilities and limitations of AI-based post processing for improved image quality in ultra-low count PET imaging.Methods A previously trained pix2pixHD Generative Adversarial Network was evaluated. To this end, a NEMA PET body phantom filled with two sphere-to-background activity concentration ratios (4:1 and 10:1) and two attenuation scenarios to investigate the effects of obese patients was scanned in list mode. Images were reconstructed with 13 different acquisition durations ranging from 5 s up to 900 s. Image noise, recovery coefficients, SUV-differences, image quality measurement metrics such as the Structural Similarity Index Metric, and the contrast-to-noise-ratio were assessed. In addition, the benefits of the deep-learning network over Gaussian smoothing were investigated.Results The presented AI-algorithm is very well suitable for denoising ultra-low count PET images and for restoring structural information, but increases image noise in ultra-high count PET scans. The generated AI-PET scans strongly underestimate SUV especially in small lesions with a diameter ≤ 17 mm, while quantitative measures of large lesions ≥ 37 mm in diameter were accurately recovered. In ultra-low count or low contrast images, the AI algorithm might not be able to recognize small lesions ≤ 13 mm in diameter. In comparison to standardized image post-processing using a Gaussian filter, the deep-learning network is better suited to improve image quality, but at the same time degrades SUV accuracy to a greater extent than post-filtering and quantitative SUV accuracy varies for different lesion sizes.Conclusions Phantom-based validation of AI-based algorithms allows for a detailed assessment of the performance, limitations, and generalizability of deep-learning based algorithms for PET image enhancement. Here it was confirmed that the AI-based approach performs very well in denoising ultra-low count PET images and outperforms traditional Gaussian post-filtering. However, there are strong limitations in terms of quantitative accuracy and detectability of small lesions.