Philips 882482 User Manual Product Brochure Bright View SPECT/CT System XCT 24deb4f48194490fb1c3a77c01574e41
User Manual: Philips 882482 Product Brochure Philips BrightView SPECT/CT system XCT Philips - BrightView XCT SPECT/CT system882482
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Volume 2 Clinical case study collection Philips BrightView XCT nuclear medicine system Contents Five key advantages Cardiology Oncology Orthopedics Infection Other localization Case parameters 2 4 6 9 33 49 56 66 BrightView XCT A technologically advanced SPECT/CT system designed entirely for nuclear medicine At Philips, we are dedicated to providing innovative, integrated solutions to give you the tools you need to accurately diagnose abnormalities early in disease progression. We are tirelessly focused on image quality and flexibility, throughput, and patient care. With that in mind, we have compiled this second volume of actual clincial case studies. Philips thanks those customers who have collaborated with us and contributed their findings to this effort. We hope that you find this an informative reference in your quest to provide the best in diagnostic care for your patients. Five key advantages BrightView XCT – Fits you like no other 1 Registration confidence with CoPlanar • No bed index between SPECT and CT, in most cases, for 14 cm axial coverage. 2 Flexible breathing • Tidal respiration (60 sec) for CT-AC to match SPECT breathing • Breathhold (12 sec) for localization 3 High resolution – low dose • Isotropic voxels – high quality CT images when viewed at any angle • Sub-mm (0.33 mm) slice thickness for high resolution bone • Flexible X-ray current (5-80 mA) to fit the clinical need 4 Nuclear medicine – tailored workflow • Same capabilities as BrightView SPECT • Plan SPECT/CT from the p-scope • Option for in-room CT acquisition control 5 Fits the nuclear medicine space • Fits in a small nuclear-medicine-sized room (15'6'' x 11'7''; 4.72 x 3.53 M) • Low system weight (4500 lb; 2045 kg) • Separate control room not required 4 Full Iterative Technology (FIT) Philips introduces Full Iterative Technology (FIT) – the first hybrid system to provide both iterative SPECT and CT reconstruction capabilities. The advanced CT reconstruction algorithm improves CT image quality by reducing noise and improving uniformity. FIT builds on the value of Astonish SPECT reconstruction, iterative technology that has been proven in practice to improve image quality and reduce dose. This leading technology provides the necessary foundation for advancing future developments in iterative CT reconstruction. Filtered Back Projection FIT-Iterative CT Reconstruction 5 Cardiology Trusted attenuation correction Confidence in the registration accuracy between SPECT and CT BrightView XCT has several advantages for The entire heart volume is sampled in a single cardiac attenuation correction. The gantry 14 cm axial field of view with no stair-step rotation can be set to 60 seconds to allow artifacts as a result of the isotropic resolution. for tidal respiration during multiple respiratory cycles over a single 360° rotation. This technique The CT field of view overlaps the SPECT blurs the CT to match resolution of the SPECT field of view so that little to no table index image, leading to excellent diaphragm alignment. is required between acquisition steps, resulting in registration confidence. Attenuation correction – CT acquisition 6 Attenuation correction – SPECT acquisition 1 Cardiology case study Inferior wall attenuation correction Courtesy of Xiamen No. 1 Hospital, Xiamen, China Patient information • 58-year-old male • Evaluate for myocardial ischemia Procedure • Tc-99m MIBI cardiac perfusion and function Findings from SPECT/CT study • Defect in inferior-septal wall but improved significantly with attenuation correction • Normal ejection fraction Physician impression of SPECT/CT • Further investigation demonstrated patient to be normal Top row – no attenuation correction Bottom row – with attenuation correction 7 2 Cardiology case study Anterior wall attenuation correction Courtesy of Wollongong Nuclear Medicine, New South Wales, Australia Patient information • 86-year-old female • Abnormal stress EKG (posterior and lateral hypokinesis); high probability of ischemia Findings from SPECT/CT study • Reduced perfusion in anterior wall which normalized with CT attenuation correction • Normal study: LVEF = 68% Procedure • Tc-99m Myoview perfusion and function Physician impression of SPECT/CT • SPECT/CT with attenuation correction completely changed the initial high patient probability to low probability Stress Uncorrected and Corrected 8 Rest Uncorrected and Corrected Oncology Low dose localization Designed entirely for nuclear medicine BrightView XCT offers premium CT resolution Flexible breathing protocols during localization at low dose levels – a fraction of a conventional studies allow for a breathhold CT acquisition helical CT. to be obtained in as short a time as 12 seconds. Providing 14 cm of axial coverage in a single breathhold helps to maintain image resolution and required anatomic detail. Image quality s y ar tion im a Pr plic ap M N AC Localization Diagnostic Radiation dose (mAs or mGy) 9 1 Oncology Neuroblastoma Courtesy of National Center for Child Health and Development, Tokyo, Japan Patient information • 11-year-old female • Neuroblastoma, post chemotherapy and tumor resection; one year later, tumor found in left posterior cranial fossa on MRI • Lately tumor growing so pre-surgical MIBG was ordered Procedure • Tc-99m MIBG scan Findings from SPECT/CT study • Intracranial MIBG uptake seen at left posterior cranial fossa and sphenoidal sinus; check of previous MRI T1-CE found sphenoidal sinus enhanced mass as well as left posterior cranial fossa mass Physician impression of SPECT/CT • Difficult to localize a small lesion by SPECT-only; SPECT/CT shows location easily • Sphenous sinus uptake was shown correctly and position matched MRI lesion • Information of a single or multiple lesions is very important • Biopsy of left posterior cranial lesion was ganglioneuroma, not malignancy 1 mm isotropic voxels 10 2 Oncology MAA mapping for radioembolization Courtesy of University of Washington Medical Center, Seattle, Washington Patient information • 70-year-old male • Multifocal hepatocellular cancer presenting for MAA mapping and hepatopulmonary shunt study in preparation for Y-90 radioembolization • Status post coil embolization of gastroduodenal artery, right gastric artery, and supraduodenal branch artery Procedure • Tc-99m MAA Findings from SPECT/CT study • Increased uptake in hepatic lobes at known hepatic metastases • Large extrahepatic focus in left lower hemothorax corresponding with left cardiophrenic recess in inferior mediastinum • No visual pulmonary uptake, estimated hepatopulmonary shunt ratio 4.91%, within normal limits Physician impression of SPECT/CT • Hepatomediastinal shunt from aberrant mediastinal vessel arising from distal left hepatic artery • In order to undergo safe Y-90 radioembolization, patient will need coil embolization to avoid damage to left mediastinum 1 mm isotropic voxels 11 3 Oncology Carcinoma of the penis Courtesy of Innsbruck Medical University, Tyrol, Austria Patient information • 58-year-old male • Carcinoma of the penis • Localize sentinel lymph node Procedure • Tc-99m Colloid Findings from SPECT/CT study • Moderate uptake in the right inguinal region Physician impression of SPECT/CT • SPECT/CT revealed inguinal lymph node, not visible on planar • Sentinel lymph node was removed; histology showed atrophic lymph node, no sign of malignancy 1 mm isotropic voxels 12 4 Oncology Post Lu-177 DOTA-TATE therapy Courtesy of Innsbruck Medical University, Tyrol, Austria Patient information • 56-year-old female • Post Lu-177 DOTA-TATE therapy evaluation of neuroendocrine tumor Findings from SPECT/CT study • Somatostatin receptor lesion is located in the musculus rectus inferior Procedure • Lu-177 DOTA-TATE Physician impression of SPECT/CT • Patient was referred to a specialized ophthalmologist 1 mm isotropic voxels 13 5 Oncology Incidental pulmonary nodule Courtesy of Nepean Nuclear Medicine and PET, Sydney, Australia Patient information • 81-year-old female • Breast cancer; three weeks of left sternal pain with positive regional lymph nodes Procedure • Tc-99m HDP bone scan Findings from SPECT/CT study • Intense uptake in manubrium consistent with recent fracture with evidence of ongoing new bone formation; no skeletal metastases; end-plate degeneration at L2-3 and L4-5 • Incidental finding of pulmonary nodule in right upper lobe Physician impression of SPECT/CT • Identified fracture instead of metastatic disease • Incidental finding of pulmonary nodule which will help for further surveillance 1 mm isotropic voxels 14 6 Oncology Benign reactive lymph node Courtesy of University of Washington Medical Center, Seattle, Washington Patient information • 73-year-old male • Nonfunctioning pancreatic endocrine tumor; pancreaticoduodenectomy with clear margins, negative lymph nodes six years ago • Multiple Octreoscans; last two years – stable focus of uptake in mid abdomen without findings on CT, unclear significance Procedure • In-111 Octreotide Findings from SPECT/CT study • Focus of mid abdominal uptake again seen • SPECT/CT correlates precisely with soft tissue density located within the mesentary posterior to transverse colon, 8.3 cm anterior to L1 vertebral body endplate Physician impression of SPECT/CT • SPECT/CT demonstrated uptake to a normal-sized mesenteric lymph node; this had not been possible on planar images • Uptake within benign reactive lymph nodes is a known false positive in Octreoscans 1 mm isotropic voxels 15 7 Oncology Right breast mass Courtesy of Fletcher Allen Health Care University, Burlington, Vermont Patient information • 55-year-old female • Three-month history of nonexertional chest discomfort, left arm numbness, shortness of breath Findings from SPECT/CT study • Normal stress test • Mass with uptake of MIBI in axillary part of right breast seen on low dose CT Procedure • Tc-99m Sestamibi Physician impression of SPECT/CT • Patient underwent diagnostic breast mammography and ultrasound followed by biopsy • Infiltrating ductal carcinoma on pathology 1 mm isotropic voxels 16 8 Oncology Metastatic neuroblastoma Courtesy of Clinique Universitaires St-Luc, Brussels, Belgium Patient information • 4-year, 10-month-old female • Metastatic neuroblastoma, surgery unable to find lymph nodes • Prior MIBG scan positive in right groin, decided to rescan after SPECT/CT installed, then schedule surgery Procedure • I-123 MIBG Findings from SPECT/CT study • Discrete focus of abnormal activity in right groin; fusion with CT indicates abnormality is in root of the sartoris muscle, extremely rare site of metastasis from a neuroblastoma Physician Impression of SPECT/CT • Surgery with assistance of gamma probe allowed removal of a single intramuscular metastasis; SPECT/CT demonstrated the focus of MIBG did not correspond to a lymph node 1 mm isotropic voxels 17 9 Oncology Lymphoscintigraphy of the penis Courtesy of The Harley Street Clinic, London, UK Patient information • 85-year-old male • Penile cancer Procedure • Tc-99m Nanocolloid Findings from SPECT/CT study • Localization of sentinel nodes in left and right inguinal-femoral regions • Measurement of depth from skin surface taken to assist surgeon Physician impression of SPECT/CT • Helped to assist surgeon in location of sentinel lymph nodes prior to biopsy • Astonish reconstruction software assists greatly as the SNI doses are very low, so count recovery reconstruction assists in image quality 1 mm isotropic voxels 18 10 Oncology Sarcoma in pubic symphysis Courtesy of Sydney X-Ray, Sydney, Australia Patient information • Rule out osteitis pubis Procedure • Tc-99m bone scan Findings from SPECT/CT study • Early and delayed planar images were consistent with a severe osteitis pubis • SPECT/CT, however, clearly demonstrated a lytic lesion in right pubic symphysis Physician impression of SPECT/CT • Rather than continued ineffective treatment of suspected osteitis pubis, a biopsy was performed which confirmed sarcoma; patient then proceeded to appropriate treatment 1 mm isotropic voxels 19 11 Oncology Pheochromocytoma in adrenal nodule Courtesy of University of Washington Medical Center, Seattle, Washington Patient information • 63-year-old female • Hyperparathyroidism; bilateral adrenal nodules on CT, left suspicious for malignancy • Evaluate for pheochromocytoma in one or both adrenal nodules Procedure • I-123 MIBG Findings from SPECT/CT study • Intense uptake within 3 cm left adrenal nodule consistent with pheochromocytoma • Mild diffuse uptake in right adrenal gland, likely physiologic; second pheochromocytoma cannot be excluded Physician impression of SPECT/CT • Intense uptake in left adrenal region seen on planar images but could not be confidently localized to adrenal gland; SPECT/CT readily localized uptake to the suspicious nodule • Given clinical suspicion for bilateral pheochromocytoma, contrast resolution of SPECT was necessary to demonstrate no significant uptake in left adrenal gland • Successful left adrenalectomy and discontinuation of catecholamine-blocking medicine, confirming correct finding of unilateral pheochromocytoma 1 mm isotropic voxels 20 12 Oncology Calcification of tibial-fibular ligament Courtesy of Washington Hospital Center, Washington DC Patient information • 63-year-old male • Lung cancer, assess for bony metastases Procedure Tc-99m MDP bone scan Findings from SPECT/CT study • Calcification of left tibial-fibular ligament Physician impression of SPECT/CT • SPECT/CT helped precisely identify post-traumatic calcification of a ligament as etiology of activity on bone scan • Fracture and/or metastasis was ruled out 0.33 mm isotropic voxels 21 13 Oncology Thyroid cancer Courtesy of Washington Hospital Center, Washington DC Patient information • 47-year-old male • Thyroid cancer; evaluate for metastatic disease and staging Procedure • I-124 scan Physician impression of SPECT/CT • Precisely identified sinus polyp activity as inflammatory and not metastatic, identified a large submental lymph node metastasis, identified known macronodular pulmonary metastases • I-124 imaging as part of dosimetry provides low resolution SPECT images and requires proper anatomic localization achieved with SPECT/CT Findings from SPECT/CT study • SPECT/CT Head/Neck – sinus polyp, submental lymph node metastases • SPECT/CT Chest – macronodular lung metastases (known) 1 mm isotropic voxels 22 14 Oncology Neuroendocrine tumor of ilium Courtesy of University Hospital of Halle, Halle, Germany Patient information • 47-year-old male • Suspected neuroendocrine tumor after abdominal lymph node biopsy, unknown primary; gastroscopy, rectal procto-colonoscopy, and endosonocapsule without pathologic findings Procedure • In-111 Octreotide scan Findings from SPECT/CT study • High intensive focus on ileum loop • High intensive focus in middle abdomen, area of pathological lymphadenopathy Physician impression of SPECT/CT • Clear localization of pathological somatostatinreceptor binding led to total resection of primary tumor located in ileum • Pathology showed well differentiated neuroendocrine carcinoma of ileum with infiltration of mesenterial fat tissue, serosa, lymphatic vessels, and locoregional lymph node metastasis • Follow-up is planned with Octreoscan and evaluation for DOTA-TATE therapy 1 mm isotropic voxels 23 15 Oncology Melanoma at the right ear Courtesy of Innsbruck Medical University, Tyrol, Austria Patient information • 68-year-old male • Excision of melanoma at right ear • Localize sentinel lymph node Procedure • Tc-99m Colloid Findings from SPECT/CT study • Hot spot dorsal to right jaw angle and additional hot spots downstream in cervical region Physician impression of SPECT/CT • Sentinel node dorsal to right jaw was only visible on SPECT/CT, not visible on planar • Sentinel lymph node was extracted and showed no sign of malignancy 1 mm isotropic voxels 24 16 Oncology Pheochromocytoma Courtesy of Nepean Nuclear Medicine and PET, Sydney, Australia Patient information • 52-year-old male • Left adrenal mass Findings from SPECT/CT study • Abnormally increased MIBG uptake in the left adrenal gland suspicious of pheochromocytoma Procedure • I-123 MIBG Physician impression of SPECT/CT • Strong indication of pheochromocytoma which influences treatment 1 mm isotropic voxels 25 17 Oncology Bilateral breast cancer Courtesy of Innsbruck Medical University, Tyrol, Austria Patient information • 58-year-old female • Cancer in left breast, ductal carcinoma in situ right breast • Localize sentinel lymph nodes Procedure • Tc-99m Colloid Findings from SPECT/CT study • Sentinel lymph nodes in bilateral axillary regions; right side next to 4th rib, left side intercostal space of 4th to 5th ribs Physician impression of SPECT/CT • Exact localization of sentinel nodes using ribs as reference • Sentinel lymph nodes were resected and showed no sign of malignancy 1 mm isotropic voxels 26 18 Oncology Left adrenal mass Courtesy of Washington Hospital Center, Washington DC Patient information • 52-year-old male • Left adrenal mass on CT; evaluate for pheochromocytoma and metastases Procedure • I-123 MIBG Findings from SPECT/CT study • Left adrenal gland pheochromocytoma with central necrosis, no evidence of metastases elsewhere Physician impression of SPECT/CT • SPECT/CT helped precisely correlate I-123 MIBG avid tissue to the mass described but not adequately characterized by the prior CT images alone 1 mm isotropic voxels 27 19 Oncology Hemangioendothelioma Courtesy of Washington Hospital Center, Washington DC Patient information • 64-year-old female • Hemangioendothelioma; post tumor resection involving proximal right tibia and right medial cuneiform Procedure • Tc-99m MDP bone scan Findings from SPECT/CT study • Right-sided distal tibia and right calcaneum tumor recurrence • Post-surgical inflammatory changes of proximal right tibia and medial cuneiform Physician impression of SPECT/CT • In the setting of post-surgical changes and lytic nature of the tumor, SPECT/CT helped correctly identify tumor recurrence in new sites; lytic lesions are not greatly avid with bone agents • SPECT/CT helped identify activity (malignancy) in periphery of the lytic lesions 0.33 mm isotropic voxels 28 20 Oncology Sclerotic bony metastases Courtesy of Washington Hospital Center, Washington DC Patient information • 85-year-old male • Prostate cancer, assess for bony metastases Findings from SPECT/CT study • Right pubic ramus metastasis extending into anterior aspect of right acetabulum Procedure • Tc-99m MDP bone scan Physician impression of SPECT/CT • On planar images, activity appears to be in superior lip of right acetabulum, common site for degenerative changes • SPECT/CT helped precisely identify location to areas of sclerotic bony metastases. Management is 100% different 1 mm isotropic voxels 29 21 Oncology Multiple degenerative mutations of spine Courtesy of University Hospital Freiburg, Germany Patient information • 63-year-old female • Colon carcinoma, persisting pain in spine Procedure • Tc-99m DPD bone scan Findings from SPECT/CT study • Focal uptake in right paramedian thoracic spine at 5th, 9th, 10th, and 12th thoracic vertebral bodies; distinct osteochondrosis in same region • No focal uptake in region of the bone island in transverse process of 5th thoracic vertebral body Physician impression of SPECT/CT • No proof of bone metastases; multiple obvious degenerative mutations in the spine 1 mm isotropic voxels 30 22 Oncology Lung cancer evaluation for bone mets Courtesy of Huadong Hospital, Shanghai, China Patient information • 72-year-old male • Lung cancer; evaluate for metastases Findings from SPECT/CT study • T12 compression fracture • Right ankle joint degeneration Procedure • Tc-99m MDP bone scan Physician impression of SPECT/CT • No metastases were identified; active treatment 1 mm isotropic voxels 31 Orthopedics High resolution – low CT dose Unique combination of design and technology The high resolution CT images of the BrightView XCT are a result of the small detector element size (<200 microns). It has been shown (Optimizing Detector Size in X-ray Imaging; Kachelrieb & Kalender; IEEE 2005) that significant dose reductions can be achieved with such fine sampling. Our design allows for very high resolution (0.33 mm thick) CT slices, ideal for extremity bone imaging. Additionally, high image quality is apparent with data viewed at any angle, not just the transverse data. 32 1 Orthopedics Multiple fractures in Down’s Syndrome patient Courtesy of Sutherland Nuclear Medicine, Sydney, Australia Patient information • 44-year-old female • Down’s Syndrome; injury to left foot and ankle, difficulty explaining location and severity of pain Procedure • Tc-99m HDP bone scan Findings from SPECT/CT study • Acute fracture of distal left fibula • Fracture of anterolateral lip of left distal fibula • Injury, possible incomplete fracture of base of 2nd metatarsal, bone contusion of base of 4th metatarsal Physician impression of SPECT/CT • Provided detail and clarity to the extent of injury that planar imaging was unable to identify • Diagnosis of mutiple fracture sites helped patient management by necessitating immobilization in a patient that was unable to fully understand and cooperate 0.33 mm isotropic voxels 33 2 Orthopedics Early pars stress fracture Courtesy of Frimley Park Hospital NHS Foundation Trust, Surrey, United Kingdom Patient information • 16-year-old male • Sudden onset back pain in junior professional football player, no improvement with physiotherapy; MRI normal Procedure • Tc-99m MDP bone scan Findings from SPECT/CT study • Increased uptake in L5 pars interarticularis, normal facet joint Physician impression of SPECT/CT • Early stress fracture not visualized on other imaging • Critical diagnosis in a professional football player 1 mm isotropic voxels 34 3 Orthopedics Scaphoid fracture Courtesy of The Royal Wolverhampton Hospitals NHS Trust, Surrey, United Kingdom Patient information • 22-year-old male • 12 weeks post scaphoid fracture, still tender Procedure • Tc-99m MDP bone scan Physician impression of SPECT/CT • SPECT/CT provided information that allowed more aggressive orthopedic treatment with subsequent good outcome • Fracture now healed and patient is symptom-free Findings from SPECT/CT study • Confirmed scaphoid fracture with incomplete union 0.33 mm isotropic voxels 35 4 Orthopedics Right foot pain Courtesy of Nepean Nuclear Medicine and PET, Sydney, Australia Patient information • 47-year-old male • Right foot pain Findings from SPECT/CT study • Active and osteoblasic process at right 2nd metatarsal shaft consistent with recent fracture Procedure • Tc-99m HDP bone scan Physician impression of SPECT/CT • SPECT/CT confirmed fracture and excluded infection and other causes which led to appropriate management 0.33 mm isotropic voxels 36 5 Orthopedics Torus palatini Courtesy of University of Washington Medical Center, Seattle, Washington Patient information • 51-year-old female • Long history of multiple bony growths in maxilla, mandible, hands, right shoulder, likely hereditary multiple exostosis • Bony growth in hard palate causing bleeding; look for malignant transformation Procedure • Tc-99m MDP bone scan Findings from SPECT/CT study • Mild uptake in oropharynx corresponding to large growth on CT with well-corticated margins and small medullary space; has appearance of torus palatini • Minimal uptake within exostoses in mandible, shoulder, and calvarium Physician impression of SPECT/CT • CT clarified the hard palate growth was a torus palatini rather than exostosis • Concern of malignant transformation excluded despite troubling clinical history 1 mm isotropic voxels 37 6 Orthopedics Biceps enthesopathy Courtesy of GZA Sint-Augustinus, Antwerp, Belgium Patient information • 49-year-old male • Chronic elbow pain (mostly right); rule out epicondylitis radialis Procedure Tc-99m MDP bone scan Findings from SPECT/CT study • Planar images show hot spot on bilater proximal forearm, possibly radius • SPECT/CT of right elbow accurately localizes the intense uptake to radial tuberosity, compatible with biceps enthesopathy • Only subtle increased uptake at medial and lateral epicondyle Physician impression of SPECT/CT • Clearly visualizes focal bone lesion – different diagnosis than orthopedic surgeon suspected • Compared to planar images (difficult anatomical interpretation), SPECT/CT gives more accurate localization of hot spot and shows no evident stress fracture 0.33 mm isotropic voxels 38 7 Orthopedics Osteonecrosis Courtesy of Universitair Ziekenhuis Brussel, Brussels, Belgium Patient information • 30-year-old female • Lupus nephretis (under immunosuppression) and sickle cell disease with pain in right knee, medial aspect of right foot, and left ankle Procedure • Tc-99m MDP bone scan Findings from SPECT/CT study • MDP accumulation corresponding with a serpigenous margin of increased density which runs along arc-like radioluscent lesions, characteristic for osteonecrosis in a healing phase • Bone infarctions within the epiphysis with a necrotic center of medullar bone surrounded by viable marrow and bone Physician impression of SPECT/CT • Osteonecrosis with signs indicating repair; could be due to embolization of small feeding blood vessels related to sickle cell disease or induced by corticosteroid use 0.33 mm isotropic voxels 39 8 Orthopedics Calcaneal fracture Courtesy of Sydney X-Ray, Sydney, Australia Patient information • Right heel pain for a few months Procedure • Tc-99m bone scan Findings from SPECT/CT study • Intense uptake in right calcaneous along a fracture line posteriorly in the CT, which also demonstrated malalignment and impaction of the fracture Physician impression of SPECT/CT • Patient was managed appropriately for the stress fracture and orthopedic review was arranged to assess the malalignment of the fracture • No further imaging was required 0.33 mm isotropic voxels 40 9 Orthopedics Cervical spine pain Courtesy of Innsbruck Medical University, Tyrol, Austria Patient information • 59-year-old female • Cervical spine pain x 1 year; fusion of C5-6 and C6-7 in 2003 • MRI showed no significant clinical information Findings from SPECT/CT study • Pathologic bone metabolism in fusion area of C5-6 and C6-7 • Easing/relaxation of the “cage” material used in the operation Procedure • Tc-99m DPD bone scan Physician impression of SPECT/CT • SPECT/CT guided physician to perform an infiltration of cervical spine in fusion area 1 mm isotropic voxels 41 10 Orthopedics Navicular arthropathy Courtesy of Sydney X-Ray, Sydney, Australia Patient information • 80-year-old • Severe right ankle pain with suspected stress fracture Procedure • Tc-99m bone scan Findings from SPECT/CT study • Markedly increased vascularity and delayed uptake in the hind foot; demonstrated intense uptake in right talo navicular region with severe degenerative change on low dose CT (sub articular cyst formation, joint narrowing and Peri articular sclerosis) Physician impression of SPECT/CT • Patient treated appropriately for inflammatory arthropathy of right talo navicular joint rather than incorrectly for a stress fracture which may not have been appreciated without SPECT/CT 0.33 mm isotropic voxels 42 11 Orthopedics Sacroiliitis Courtesy of Fletcher Allen Health Care University, Burlington, Vermont Patient information • 40-year-old male • Chronic back pain radiating to lower extremities, rule out occult fractures, assess active disease and guide level for facet injection or MBB +/- RFA • MRI showed L4-5 disc degeneration and facet arthropathy L4-5, L5-S1 Procedure • Tc-99m bone scan Findings from SPECT/CT study • No significant uptake in facet joints nor discogenic endplate changes • Intense uptake associated with SI joints consistent with sacroiliitis Physician impression of SPECT/CT • Patient referred from ortho/spine clinic to rheumatology clinic 1 mm isotropic voxels 43 12 Orthopedics Guide facet block or medial branch block Courtesy of Fletcher Allen Health Care University, Burlington, Vermont Patient information • 47-year-old male • Low back pain in construction worker, increasing throughout the day • MRI showed L3-4, L4-5, L5-S1 disc degeneration, lateral bulges L3-4, L4-5 • Bone scan to guide facet blocks or MBB +/- RFA and possible fusion Procedure • Tc-99m bone scan Findings from SPECT/CT study • Planar uptake increased L5-S1 but could be mistaken for facet joints • SPECT/CT clearly identifies increased uptake corresponding to discogenic endplate changes L5-S1 Physician impression of SPECT/CT • Patient was offered medial branch block with radiofrequency ablation of medial branch if diagnostic MBB is effective • If MBB is ineffective, L5-S1 spinal fusion will be offered 1 mm isotropic voxels 44 13 Orthopedics Facet joint arthropathy Courtesy of Washington Hospital Center, Washington DC Patient information • 61-year-old male • Right-sided back pain Procedure • Tc-99m MDP bone scan Findings from SPECT/CT study • Right-sided L4-5 facet joint arthropathy • No evidence of spondylolysis, spondylolisthesis, or pars fracture Physician impression of SPECT/CT • Demonstration of inflammatory process versus fracture as etiology of back pain • Guided referring physician to conservative medical management 1 mm isotropic voxels 45 14 Orthopedics Stress fracture of tibia Courtesy of Wollongong Nuclear Medicine, New South Wales, Australia Patient information • 34-year-old male • Six-week history of left proximal tibia pain, query AVN or osteomyelitis Findings from SPECT/CT study • Intense HDP uptake in left proximal tibia, associated with fracture line seen in the low dose CT • Recent stress fracture of left proximal tibia Procedure • Tc-99m HDP bone scan Physician impression of SPECT/CT • SPECT/CT allowed clear localization and diagnosis of fracture, ruling out AVN and osteomyelitis 0.33 mm isotropic voxels 46 15 Orthopedics Pseudoarthrosis Courtesy of Sutherland Nuclear Medicine, Sydney, Australia Patient information • 52-year-old male • Right shin pain, no clear trauma Physician impression of SPECT/CT • Without SPECT/CT, delayed images would have been diagnosed as stress fracture of tibia • SPECT/CT helped find it was an old injury with incomplete fusion and corresponding pseudoarthrosis rather than acute injury, therefore changed patient’s treatment Procedure • Tc-99m HDP bone scan Findings from SPECT/CT study • Exostosis at medial margin of right tibia with avid uptake at its base, correlates to incomplete fusion/ pseudoarthrosis rather than acute injury • Second focus of new bone formation and corresponding pseudoarthrosis 0.33 mm isotropic voxels 47 16 Orthopedics Atypical insufficiency fractures Courtesy of Wollongong Nuclear Medicine, New South Wales, Australia Patient information • 73-year-old female • Known stress fractures of femora related to long-term biphosphonate therapy; increasing low back pain Findings from SPECT/CT study • Presence of reaction to resolving stress/insufficiency fractures in lateral cortical margins of both distal femora • Evidence of bilateral L5-S1 facet joint and L4-5 right facet joint arthropathy Procedure • Tc-99m HDP bone scan Physician impression of SPECT/CT • Revealed atypical insufficiency fractures of both femora, secondary to long-term biphosphonate therapy – a new, recently described, and controversial condition 1 mm isotropic voxels 48 0.33 mm isotropic voxels Infection Isotropic voxels High quality images regardless of viewing angle By acquiring in isotropic voxels, BrightView XCT provides the same high resolution in all orientations of the CT images. Coronal and sagittal slices will have the same resolution as the transverse slices, without the stair-step artifact common to non-isotropic techniques. Localization – CT acquisition Localization – SPECT acquisition 49 1 Infection Pelvic graft infection Courtesy of North Carolina Baptist Hospital, Winston-Salem, North Carolina Patient information • 60-year-old male • Right side pelvic pain; CT showed mass on right side, rule out infected pelvic graft Findings from SPECT/CT study • Increased activity in right groin adjacent to graft (femoral artery anastomosis) corresponding to edema and cellulitis in right groin, likely infection Procedure • In-111 WBC scan Physician impression of SPECT/CT • SPECT/CT showed the uptake was not over the bone and confirmed the CT findings 1 mm isotropic voxels 50 2 Infection Foot and shin ulcers Courtesy of Wollongong Nuclear Medicine, New South Wales, Australia Patient information • 80-year-old female • Ulcers on right heel and left lower shin; rule out osteomyelitis Findings from SPECT/CT study • Bone findings – highly suspicious for osteomyelitis of right calcaneous inferiorly; may represent periosteal reaction of left shin but may be osteomyelitis • Gallium findings – mild Gallium uptake in calcaneum, faint uptake in shin • Combined – does not suggest osteomyelitis Procedure • Tc-99m HDP bone scan and Ga-67 scan Physician impression of SPECT/CT • SPECT/CT demonstrated superb localization of Gallium distinct from MDP uptake region, excluding osteomyelitis • Antibiotics were changed to reflect a non-osseous infection Bone scan Gallium scan 0.33 mm isotropic voxels 51 3 Infection Apophysitis verses Brodie’s abscess Courtesy of Nepean Nuclear Medicine and PET, Sydney, Australia Patient information • 10-year-old female • Localized pain in left calcaneous medioposteriorly with low-grade fever Procedure • Tc-99m HDP bone scan Findings from SPECT/CT study • Consistent with left calcaneal apophysitis • No evidence of Brodie’s abscess Physician impression of SPECT/CT • Able to exclude Brodie’s abscess, therefore changed management of patient 0.33 mm isotropic voxels 52 4 Infection Osteomyelitis with sequester Courtesy of GZA Sint-Augustinus, Antwerp, Belgium Patient information • 5-year-old male • Fever, pain of distal thigh, limping; rule out osteomyelitis Procedure • Tc-99m MDP bone scan Findings from SPECT/CT study • Planar images show hyperemia and diffuse increased uptake in distal right femur • SPECT/CT confirms increased uptake of distal femoral growth plate with a central defect; on low dose CT, there is a clear central endomedullary irregular lesion suspect for abscess or bone sequester Physician impression of SPECT/CT • Classic bone scan diagnosis of osteomyelitis • SPECT/CT showed addition of intra-osseous sequester, which requires more intensive antibiotic therapy and follow-up (possible surgery) 0.33 mm isotropic voxels 53 5 Infection Occult fracture Courtesy of Universitair Ziekenhuis Brussel, Brussels, Belgium Patient information • 30-year-old female • Persistent pain two months following surgery for halux valgus; rule out osteomyelitis Procedure • Tc-99m Granuloscint Findings from SPECT/CT study • WBC accumulation in soft tissue surrounding head of the screw • Some bone resorption at proximal level of the screws, no increased bone uptake nor interruption of the bony cortex; osteomyelitis was excluded • Straight radioluscent line at metaphysis of metatarsal bone marks presence of recent non-displaced transcortical occult fracture Physician impression of SPECT/CT • This single examination rules out the important diagnosis of osteomyelitis, confirms soft tissue infection, and demonstrates an occult fracture as source of the pain 0.33 mm isotropic voxels 54 Other localization Workflow tailored for nuclear medicine Continue working the way you already do Having all of the capabilities of the popular BrightView SPECT camera, BrightView XCT simplifies workflow to help improve clinical results and lower lifecyle costs. The low complexity design is compact, fitting in a standard nuclear-medicine-sized room. An in-room CT control option allows you to be closer to your patient and avoid the costs associated with a separate control room. SPECT/CT planning is done from the nuclear medicine p-scope, as simple as planning for a SPECT-only procedure. Compact, low complexity design suitable for a standard nuclear-medicine-sized room 55 1 Other localization Pulmonary embolism Courtesy of Affiliated Hospital of Xuzhou Medical College, Jiangsu, China Patient information • 72-year-old male • Gasping and chest pain Procedure • Tc-99m MAA lung perfusion Findings from SPECT/CT study • Significant defect in the lingular segment of the superior lobe of the left lung; pulmonary embolism should be considered Physician impression of SPECT/CT • Based on the SPECT/CT findings, thrombolysis therapy was recommended 1 mm isotropic voxels 56 2 Other localization Biliary leak Courtesy of North Carolina Baptist Hospital, Winston-Salem, North Carolina Patient information • 59-year-old male • Abdominal pain post recent cholecystectomy; displaced tube post surgery Findings from SPECT/CT study • Extraluminal activity extending from gallbladder fossa was noted in the right paracolic gutter and pelvis; positive biliary leak Procedure • Tc-99m HIDA Physician impression of SPECT/CT • SPECT/CT showed the leak and extent of the leak; CT only showed leak around liver 1 mm isotropic voxels 57 3 Other localization Lymphatic fluid leak Courtesy of Osaka City University Hospital, Osaka, Japan Patient information • 59-year-old female • Esophageal cancer; two-week leakage of lymphatic fluid after esophagectomy Procedure • Tc-99m HAS-D Findings from SPECT/CT study • Uptake of leak point was found in middle of the mediastinum, placed between the bronchus and aorta Physician impression of SPECT/CT • The surgical ligation of main lymph duct was easily planned as a result of accurate regional identification of the lymphoid leak point by SPECT/CT 1 mm isotropic voxels 58 4 Other localization Hyperparathyroidism Courtesy of Nepean Nuclear Medicine and PET, Sydney, Australia Patient information • 46-year-old female • Hyperparathyroidism; assess for parathyroid adenoma Findings from SPECT/CT study • Moderate focal retention present at superoposterior aspect of left thyroid lobe Procedure • Tc-99m Sestamibi Physician impression of SPECT/CT • Identified and localized parathyroid adenoma which helped with surgical planning 1 mm isotropic voxels 59 5 Other localization Lung perfusion with unusual anatomy Courtesy of University of Washington Medical Center, Seattle, Washington Patient information • 27-year-old female • Complex congenital heart disease; transposition of great arteries, dexocardia, bilateral superior vena cava • Single functional ventricle and multiple pulmonary AVMs • New onset of palpitations and dyspnea; evaluate for worsening of R-L shunt Procedure • Tc-99m MAA perfusion and Tc-99m DTPA ventilation 1 mm isotropic voxels 60 Findings from SPECT/CT study • Significantly decreased perfusion to entire right lung, focally more severe perfusion defect in lateral aspect of right upper lobe seen better on SPECT/CT • 32% right-to-left shunt likely explains the patient’s symptoms Physician impression of SPECT/CT • SPECT/CT provided additional anatomic information to better understand the perfusion in patient with unusual anatomy • Planar images were challenging to interpret 6 Other localization Venogram Courtesy of Osaka City University Hospital, Osaka, Japan Patient information • 74-year-old female • Illustrate accurate regions and degrees of venous embolisms of the lower limb Findings from SPECT/CT study • Before warfarization, many uptakes were found in both lower limbs along the veins on the SPECT/CT; found to be venous embolisms • Two weeks after warfarization, fewer uptakes of both lower limbs were illustrated than before the treatment Procedure • Tc-99m MAA venogram Physician impression of SPECT/CT • Warfarization treatment was initiated as a result of accurate regional identification and degree of venous embolism on the SPECT/CT • After treatment, the comparison SPECT/CT easily showed a therapeutic response so warfarization was able to be stopped Initial study Follow-up study 1 mm isotropic voxels 61 7 Other localization GI bleeding Courtesy of Wollongong Nuclear Medicine, New South Wales, Australia Patient information • 70-year-old female • GI blood loss resulting in anemia, requiring blood transfusions; multiple efforts to identify source including 2 x endoscopy Procedure • Tc-99m tagged RBCs Findings from SPECT/CT study • No active bleed in early phase • At 24 hours, abnormal activity in entire transverse colon, halfway along ascending colon and entire descending colon prior to sigmoid junction; ultrasound confirmation was recommended Physician impression of SPECT/CT • SPECT/CT provided a specific target to allow subsequent endoscopic confirmation of source of bleeding; endoscopy demonstrated lesion in ascending colon region (hemangioma/angiodysplasia) 1 mm isotropic voxels 62 8 Other localization Hyperparathyroidism Courtesy of Washington Hospital Center, Washington DC Patient information • 54-year-old female • Hyperparathyroidism; identify parathyroid adenoma Procedure • Tc-99m Sestamibi Findings from SPECT/CT study • Extrathyroidal MIBI focus posteromedial to upper pole of left thyroid lobe • No evidence of ectopic parathyroid tissue in mediastinum Physician impression of SPECT/CT • SPECT/CT helped precisely identify parathyroid adenoma location • Precise surgical guidance was achieved for resection 1 mm isotropic voxels 63 Case study acquisition parameters 64 Case study CT scan parameters SPECT scan parameters Page 1 Cardiology 5mA; 60 seconds Astonish; 4 iterations, 8 subsets, Hanning filter 1.0 7 2 Cardiology 5mA; 60 seconds Astonish; 4 iterations, 8 subsets, Hanning filter 1.0 8 1 Oncology 2mA; 12 seconds Astonish; 2 iterations, 12 subsets, Hanning filter 1.2 10 2 Oncology 30mA; 12 seconds Astonish; 2 iterations, 16 subsets, Hanning filter 1.0 11 3 Oncology 20mA; 24 seconds Astonish; 2 iterations, 16 subsets, Hanning filter 1.2 12 4 Oncology 80mA; 24 seconds Astonish; 2 iterations, 15 subsets, Hanning filter 1.2 13 5 Oncology 20mA; 12 seconds Astonish; 4 iterations, 8 subsets, no filter 14 6 Oncology 30mA; 12 seconds Astonish; 3 iterations, 8 subsets, no filter 15 7 Oncology 5mA; 60 seconds MLEM; Butterworth; cutoff 0.66, Order 5.0, 30 iterations 16 8 Oncology 5mA; 12 seconds OSEM; Butterworth; cutoff 0.50, Order 5.0, 16 iterations, 8 subsets 17 9 Oncology 20mA; 12 seconds Astonish; 3 iterations, 16 subsets, no filter 18 10 Oncology 80mA; 24 seconds Astonish; 4 iterations, 8 subsets, no filter 19 11 Oncology 20mA; 12 seconds Astonish; 2 iterations, 16 subsets, Hanning filter 1.0 20 12 Oncology 80mA; 24 seconds Astonish; 2 iterations, 16 subsets, Hanning filter 2.0 21 13 Oncology 20mA; 12 seconds Astonish; 4 iterations, 8 subsets, Hanning filter 2.0 22 14 Oncology 20mA; 12 seconds Astonish; 2 iterations, 16 subsets, Hanning filter 1.0 23 15 Oncology 20mA; 24 seconds Astonish; 4 iterations, 16 subsets, Hanning filter 1.2 24 16 Oncology 20mA; 12 seconds Astonish; 3 iterations, 8 subsets, no filter 25 Case study CT scan parameters SPECT scan parameters Page 17 Oncology 20mA; 24 seconds Astonish; 4 iterations, 16 subsets, Hanning filter 1.2 26 18 Oncology 30mA; 12 seconds Astonish; 6 iterations, 8 subsets, Hanning filter 0.95 27 19 Oncology 80mA; 24 seconds Astonish; 2 iterations, 16 subsets, Hanning filter 2.0 28 20 Oncology 20mA; 12 seconds Astonish; 6 iterations, 8 subsets, Hanning filter 2.0 29 21 Oncology 30mA; 12 seconds Astonish; 4 iterations, 15 subsets, no filter 30 22 Oncology Chest: 20mA; 12 seconds Chest: Astonish; 4 iterations, 16 subsets, no filter Ankle: 80mA; 24 seconds Ankle: Astonish; 4 iterations, 16 subsets, no filter 31 1 Orthopedics 80mA; 24 seconds Astonish; 3 iterations, 8 subsets, no filter 33 2 Orthopedics 20mA; 12 seconds Astonish; 3 iterations, 8 subsets, no filter 34 3 Orthopedics 20mA; 12 seconds Astonish; 4 iterations, 8 subsets, no filter 35 4 Orthopedics 80mA; 24 seconds Astonish; 4 iterations, 8 subsets, no filter 36 5 Orthopedics 80mA; 24 seconds Astonish; 2 iterations, 16 subsets, Hanning filter 1.0 37 6 Orthopedics 80mA; 24 seconds Astonish; 3 iterations, 8 subsets, no filter 38 7 Orthopedics 80mA; 24 seconds Astonish; 2 iterations, 32 subsets, no filter 39 8 Orthopedics 80mA; 24 seconds Astonish; 2 iterations, 8 subsets, no filter 40 9 Orthopedics 20mA; 24 seconds OSEM; Butterworth; cutoff 0.60, Order 1.0, 3 iterations, 8 subsets 41 10 Orthopedics 80mA; 24 seconds Astonish; 2 iterations, 8 subsets, no filter 42 11 Orthopedics 20mA; 12 seconds Astonish; 4 iterations, 16 subsets, Hanning filter 1.3 43 65 Case study acquisition parameters continued 66 Case study CT scan parameters SPECT scan parameters Page 12 Orthopedics 20mA; 12 seconds Astonish; 4 iterations, 16 subsets, Hanning filter 1.3 44 13 Orthopedics 20mA; 12 seconds Astonish; 2 iterations, 16 subsets, Hanning filter 2.0 45 14 Orthopedics 80mA; 24 seconds Astonish; 3 iterations, 8 subsets, no filter 46 15 Orthopedics 80mA; 24 seconds Astonish; 3 iterations, 8 subsets, no filter 47 16 Orthopedics 20mA; 12 seconds Astonish; 3 iterations, 8 subsets, no filter 48 1 Infection 30mA; 12 seconds Astonish; 3 iterations, 8 subsets, Hanning filter 2.0 50 2 Infection 80mA; 24 seconds Astonish; 3 iterations, 8 subsets, no filter 51 3 Infection 80mA; 24 seconds Astonish; 4 iterations, 8 subsets, no filter 52 4 Infection 80mA; 24 seconds Astonish; 3 iterations, 8 subsets, Hanning filter 1.5 53 5 Infection 80mA; 24 seconds Astonish; 2 iterations, 32 subsets, no filter 54 1 Other localization 20mA; 12 seconds Astonish; 3 iterations, 8 subsets, no filter 56 2 Other localization 20mA; 12 seconds Astonish; 3 iterations, 8 subsets, Hanning filter 2.0 57 3 Other localization 20mA; 12 seconds Astonish; 2 iterations, 16 subsets, Hanning filter 1.0 58 4 Other localization 20mA; 12 seconds Astonish; 4 iterations, 8 subsets, no filter 59 5 Other localization 30mA; 12 seconds Astonish; 2 iterations, 16 subsets, Hanning filter 1.0 60 Initial: 20mA; 12seconds; 6 Other localization Follow-up: 30mA; 12 seconds Initial & Follow-Up: Astonish; 2 iterations, 16 subsets, Hanning filter 1.5 61 7 Other localization 80mA; 24 seconds Astonish; 2 iterations, 8 subsets, no filter 62 8 Other localization 20mA; 12 seconds Astonish; 6 iterations, 16 subsets, no filter 63 Philips Healthcare is part of Royal Philips Electronics How to reach us www.philips.com/healthcare healthcare@philips.com Asia +49 7031 463 2254 Europe, Middle East, Africa +49 7031 463 2254 Latin America +55 11 2125 0744 North America +1 425 487 7000 800 285 5585 (toll free, US only) Please visit www.philips.com/brightviewxct © 2012 Koninklijke Philips Electronics N.V. All rights are reserved. Philips Healthcare reserves the right to make changes in specifications and/or to discontinue any product at any time without notice or obligation and will not be liable for any consequences resulting from the use of this publication. Printed in The Netherlands. 4522 962 83701 * Apr 2012
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xmp.iid:1D3F7CBF0C2068118083C01D7B55D097, xmp.iid:1E3F7CBF0C2068118083C01D7B55D097, xmp.iid:1F3F7CBF0C2068118083C01D7B55D097, xmp.iid:203F7CBF0C2068118083C01D7B55D097, xmp.iid:179CC4C60E2068118083C01D7B55D097, xmp.iid:189CC4C60E2068118083C01D7B55D097, xmp.iid:782652EA0E2068118083C01D7B55D097, xmp.iid:792652EA0E2068118083C01D7B55D097, xmp.iid:F6F0DE1A0F2068118083C01D7B55D097, xmp.iid:F7F0DE1A0F2068118083C01D7B55D097, xmp.iid:F8F0DE1A0F2068118083C01D7B55D097 History When : 2009:08:14 09:56:55+02:00, 2009:08:14 09:56:55+02:00, 2009:08:14 10:00:26+02:00, 2009:08:14 10:00:26+02:00, 2009:08:14 10:24:14+02:00, 2009:08:21 11:53:25+02:00, 2009:12:22 14:06:46+01:00, 2009:12:22 15:15:22+01:00, 2009:12:22 16:21:46+01:00, 2009:12:23 14:36:28+01:00, 2010:01:07 10:58:07+01:00, 2010:01:07 11:32:02+01:00, 2010:01:07 11:32:13+01:00, 2010:01:07 11:32:13+01:00, 2010:03:31 10:42:57+02:00, 2010:03:31 10:42:57+02:00, 2010:05:31 16:10:26+02:00, 2010:05:31 16:10:35+02:00, 2010:05:31 16:24:54+02:00, 2010:05:31 16:24:54+02:00, 2010:05:31 16:31:13+02:00, 2010:05:31 16:41:11+02:00, 2010:05:31 16:47:31+02:00, 2010:05:31 16:51:56+02:00, 2010:05:31 17:24:15+02:00, 2010:05:31 18:06:03+02:00, 2010:06:01 11:24:31+02:00, 2010:06:01 14:36:47+02:00, 2010:06:01 15:54:19+02:00, 2010:06:01 15:54:19+02:00, 2010:06:01 15:57:05+02:00, 2010:06:16 10:51:21+02:00, 2010:06:16 11:07:11+02:00, 2010:06:16 11:07:11+02:00, 2011:10:03 15:22:21+02:00, 2011:10:03 15:22:21+02:00, 2011:10:03 15:38:24+02:00, 2011:10:03 15:38:56+02:00, 2011:10:03 15:38:56+02:00, 2011:10:03 15:40:17+02:00, 2011:10:03 15:40:17+02:00, 2011:10:03 15:51:52+02:00, 2011:10:03 15:59:10+02:00, 2011:10:03 16:04:25+02:00, 2011:10:03 16:12:41+02:00, 2011:10:03 16:16+02:00, 2011:10:03 16:16:35+02:00, 2011:10:03 16:22:38+02:00, 2011:10:03 16:45:09+02:00, 2011:10:03 17:01:35+02:00, 2011:10:03 17:05:37+02:00, 2011:10:03 17:08:46+02:00, 2011:10:04 10:16:47+02:00, 2011:10:04 10:21:06+02:00, 2011:10:04 10:23:07+02:00, 2011:10:04 10:28:57+02:00, 2011:10:04 10:38:30+02:00, 2011:10:04 10:56:47+02:00, 2011:10:04 11:07:54+02:00, 2011:10:04 11:15:22+02:00, 2011:10:04 11:27:43+02:00, 2011:10:04 11:41:16+02:00, 2011:10:04 11:44:14+02:00, 2011:10:04 11:47:34+02:00, 2011:10:04 11:49:52+02:00, 2011:10:04 11:50:03+02:00, 2011:10:04 12:16:29+02:00, 2011:10:04 12:24:55+02:00, 2011:10:04 12:33:32+02:00, 2011:10:04 12:56:46+02:00, 2011:10:04 13:07:30+02:00, 2011:10:04 15:07:35+02:00, 2011:10:04 15:09:50+02:00, 2011:10:04 15:16:28+02:00, 2011:10:04 15:17+02:00, 2011:10:04 15:26:09+02:00, 2011:10:04 15:30:21+02:00, 2011:10:04 15:38:30+02:00, 2011:10:04 15:39:58+02:00, 2011:10:04 15:41:42+02:00, 2011:10:04 15:45:17+02:00, 2011:10:04 15:47:38+02:00, 2011:10:04 15:50:31+02:00, 2011:10:04 15:52:23+02:00, 2011:10:04 15:53:11+02:00, 2011:10:04 15:59:13+02:00, 2011:10:04 16:33:46+02:00, 2011:10:04 16:53:08+02:00, 2011:10:04 17:00:29+02:00, 2011:10:04 17:04:17+02:00, 2011:10:04 17:05:56+02:00, 2011:10:04 17:07:28+02:00, 2011:10:04 17:08:48+02:00, 2011:10:04 17:10:07+02:00, 2011:10:04 17:10:55+02:00, 2011:10:04 17:11:10+02:00, 2011:10:04 17:13:53+02:00, 2011:10:04 17:19:08+02:00, 2011:10:04 17:20:08+02:00, 2011:10:04 17:21:16+02:00, 2011:10:04 17:23+02:00, 2011:10:04 17:25:25+02:00, 2011:10:04 17:26:45+02:00, 2011:10:04 17:32:19+02:00, 2011:10:04 17:33:18+02:00, 2011:10:04 17:34:27+02:00, 2011:10:04 17:35:31+02:00, 2011:10:04 17:39:32+02:00, 2011:10:04 17:48:24+02:00, 2011:10:04 17:52:51+02:00, 2011:10:04 17:57:09+02:00, 2011:10:04 18:01:07+02:00, 2011:10:04 18:04:27+02:00, 2011:10:04 18:05:46+02:00, 2011:10:07 15:30:16+02:00, 2011:10:07 15:38:20+02:00, 2011:10:07 15:54:11+02:00, 2011:10:07 15:59:02+02:00, 2011:10:07 16:04:34+02:00, 2011:10:07 16:09+02:00, 2011:10:07 16:13:28+02:00, 2011:10:07 16:25:48+02:00, 2011:10:07 16:33:20+02:00, 2011:10:07 16:37:54+02:00, 2011:10:07 16:41:46+02:00, 2011:10:07 16:53:43+02:00, 2011:10:07 17:00:26+02:00, 2011:10:07 17:04:43+02:00, 2011:10:07 17:08:32+02:00, 2011:10:07 17:10:04+02:00, 2011:10:07 17:13:02+02:00, 2011:10:07 17:19:37+02:00, 2011:10:10 10:54:11+02:00, 2011:10:10 15:12:52+02:00, 2011:10:10 16:31:23+02:00, 2011:10:10 17:37:18+02:00, 2011:10:13 00:48:26+02:00, 2011:10:13 09:31:13+02:00, 2011:10:17 14:54:37+02:00, 2011:10:17 14:59:47+02:00, 2011:10:18 09:18:47+02:00, 2011:10:18 09:20:31+02:00, 2011:10:18 10:13:56+02:00, 2011:10:18 14:46:12+02:00, 2011:10:20 13:10+02:00, 2011:10:20 16:25:21+02:00, 2011:10:23 11:51+02:00, 2011:10:23 12:01:12+02:00, 2011:10:23 19:28:27+02:00, 2011:10:24 15:22:49+02:00, 2011:10:24 16:17:59+02:00, 2011:10:24 16:21:43+02:00, 2011:10:24 16:22+02:00, 2011:10:24 16:24:36+02:00, 2011:10:24 16:34:22+02:00, 2011:10:24 16:40:27+02:00, 2011:10:24 16:43:28+02:00, 2011:10:24 16:46:06+02:00, 2011:10:24 16:48:26+02:00, 2011:10:24 17:01:32+02:00, 2011:10:24 17:07:13+02:00, 2011:10:24 17:09:23+02:00, 2011:10:24 17:09:52+02:00, 2011:10:24 17:20:20+02:00, 2011:10:24 17:20:20+02:00, 2011:12:07 14:27:26-05:00, 2011:12:07 14:27:26-05:00, 2011:12:07 14:27:55-05:00, 2011:12:07 15:52:31-05:00, 2011:12:07 16:13:11-05:00, 2011:12:07 16:30:15-05:00, 2011:12:07 16:34:11-05:00, 2011:12:07 16:49:51-05:00, 2011:12:07 16:51:15-05:00, 2011:12:07 16:54:21-05:00, 2011:12:07 16:55:56-05:00, 2011:12:07 18:00-05:00, 2011:12:07 18:02:47-05:00, 2011:12:07 18:39:25-05:00, 2011:12:07 18:41:36-05:00, 2011:12:07 19:37:10-05:00, 2011:12:07 19:40:21-05:00, 2011:12:08 06:24:42-05:00, 2011:12:08 06:30:54-05:00, 2011:12:08 06:37:36-05:00, 2011:12:08 06:51:25-05:00, 2011:12:08 06:55:11-05:00, 2011:12:08 07:10:10-05:00, 2011:12:08 07:11:46-05:00, 2011:12:08 07:14:38-05:00, 2011:12:08 07:14:55-05:00, 2011:12:08 07:19:48-05:00, 2011:12:08 07:23:46-05:00, 2011:12:08 07:24:07-05:00, 2011:12:08 12:17:54-05:00, 2011:12:08 12:21:03-05:00, 2011:12:08 12:29:25-05:00, 2011:12:09 09:36:51-05:00, 2011:12:09 09:39:51-05:00, 2011:12:09 09:41:05-05:00, 2011:12:09 09:41:28-05:00, 2011:12:09 09:52:40-05:00, 2011:12:09 09:54:55-05:00, 2011:12:09 09:56:35-05:00, 2011:12:09 09:56:47-05:00, 2011:12:09 09:58:37-05:00, 2011:12:09 11:06:06-05:00, 2011:12:09 11:10:01-05:00, 2011:12:09 11:59:10-05:00, 2011:12:09 12:00:19-05:00, 2011:12:09 12:02:36-05:00, 2011:12:09 13:19:38-05:00, 2011:12:09 13:29:16-05:00, 2011:12:09 13:39:55-05:00, 2011:12:09 14:29:43-05:00, 2011:12:11 16:44:14-05:00, 2011:12:11 16:45:32-05:00, 2011:12:11 16:46:32-05:00, 2011:12:11 16:53:35-05:00, 2011:12:11 16:55:20-05:00, 2011:12:11 16:56:28-05:00, 2011:12:14 14:27:05-05:00, 2011:12:14 14:27:57-05:00, 2011:12:14 14:29:11-05:00, 2011:12:14 14:29:39-05:00, 2011:12:14 14:39:09-05:00, 2011:12:14 14:54:07-05:00, 2011:12:14 14:55:32-05:00, 2011:12:14 15:26:22-05:00, 2011:12:14 15:51:03-05:00, 2011:12:14 15:53:34-05:00, 2011:12:14 15:53:57-05:00, 2011:12:14 15:58:41-05:00, 2011:12:14 16:00:18-05:00, 2011:12:14 16:02:18-05:00, 2011:12:14 16:03:01-05:00, 2011:12:14 16:10:23-05:00, 2011:12:14 16:15:52-05:00, 2011:12:16 10:46:03-05:00, 2011:12:16 10:54:41-05:00, 2011:12:16 10:55:59-05:00, 2011:12:16 10:59:03-05:00, 2011:12:16 11:08:22-05:00, 2011:12:16 11:13:38-05:00, 2011:12:16 11:16:33-05:00, 2011:12:16 11:20:30-05:00, 2011:12:16 11:23:50-05:00, 2011:12:16 11:28:25-05:00, 2011:12:16 11:29:38-05:00, 2011:12:16 11:30:25-05:00, 2011:12:16 11:31:15-05:00, 2011:12:16 11:32:31-05:00, 2011:12:16 11:33:36-05:00, 2011:12:16 11:34:26-05:00, 2011:12:18 21:34:17-05:00, 2011:12:18 21:39:47-05:00, 2011:12:18 21:43:52-05:00, 2011:12:18 21:50:23-05:00, 2011:12:18 21:52:42-05:00, 2011:12:18 21:55:05-05:00, 2011:12:18 21:57:25-05:00, 2011:12:18 21:59:55-05:00, 2011:12:18 22:01:40-05:00, 2011:12:18 22:04:24-05:00, 2011:12:18 22:05:01-05:00, 2011:12:18 22:06:38-05:00, 2011:12:19 06:29:56-05:00, 2011:12:19 06:41:13-05:00, 2011:12:19 06:43:28-05:00, 2011:12:19 06:45:10-05:00, 2011:12:19 06:51:08-05:00, 2011:12:19 06:52:20-05:00, 2011:12:19 06:56:20-05:00, 2011:12:19 06:58-05:00, 2011:12:19 06:59:49-05:00, 2011:12:19 07:00:57-05:00, 2011:12:19 07:03:11-05:00, 2011:12:19 07:06-05:00, 2011:12:19 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07:08:25-05:00, 2011:12:23 07:11:34-05:00, 2011:12:23 07:12:44-05:00, 2011:12:23 07:14:20-05:00, 2011:12:23 07:14:33-05:00, 2011:12:23 14:58:19-05:00, 2012:02:06 22:55:46-05:00, 2012:02:07 09:22:18-05:00, 2012:02:07 10:01:27-05:00, 2012:02:07 10:03:48-05:00, 2012:02:07 10:08:20-05:00, 2012:02:07 10:11:42-05:00, 2012:02:07 10:22:45-05:00, 2012:02:07 10:25:11-05:00, 2012:02:07 10:25:42-05:00, 2012:02:07 10:26:36-05:00, 2012:02:07 10:28-05:00, 2012:02:07 10:30:43-05:00, 2012:02:07 10:32:10-05:00, 2012:02:07 10:32:55-05:00, 2012:02:07 10:33:37-05:00, 2012:02:07 10:35:39-05:00, 2012:02:07 10:36:10-05:00, 2012:02:07 10:36:53-05:00, 2012:02:07 10:37:58-05:00, 2012:02:07 10:41:41-05:00, 2012:02:07 10:44:07-05:00, 2012:02:07 11:10:40-05:00, 2012:02:07 13:33:41-05:00, 2012:02:07 13:45:39-05:00, 2012:02:07 14:03:54-05:00, 2012:02:07 14:06:27-05:00, 2012:02:07 14:09:25-05:00, 2012:02:07 14:11:32-05:00, 2012:02:07 15:00:53-05:00, 2012:02:07 15:11:28-05:00, 2012:02:07 15:15:51-05:00, 2012:02:07 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