April 11, 2012 - Siemens Healthcare is the first company worldwide to announce a complete integrated diagnostic imaging solution proposed for the detection of amyloid plaques — one of the necessary pathological features of Alzheimer’s disease [1,2,3] — in the living brain.
The latest elements of Siemens’ integrated solution came with the company’s U.S. Food and Drug Administration (FDA) 510(k) application for its syngo PET Amyloid Plaque  proprietary neurology quantification software, as well as the recent FDA approval of Eli Lilly and Company’s Amyvid (Florbetapir F 18 Injection), a radioactive diagnostic agent indicated for brain imaging of beta-amyloid plaques in patients with cognitive impairment who are being evaluated for Alzheimer’s disease and other causes of cognitive decline. 
Siemens integrated amyloid imaging solution encompasses three unique elements — the new Biograph mCT PET•CT scanner, FDA 510(k)- pending syngo.PET Amyloid Plaque neurology quantification software and the manufacturing and distribution of Amyvid. All are examples of Siemens Healthcare’s innovative power and competitiveness, which are two goals of the company’s global initiative, Agenda 2013.
As the largest producer and distributor of Amyvid, PETNET Solutions, Siemens’ network of PET drug manufacturing establishments, will begin supplying Amyvid to imaging centers in limited U.S. markets beginning in June 2012. Complementing the new radioactive diagnostic agent, Siemens pending software could potentially support the quantification of amyloid plaque in the brain. Combined with the company’s family of high-resolution PET imaging scanners, Siemens now announces for the first time an integrated diagnostic tool for patients with cognitive impairment who are being evaluated for Alzheimer’s disease and other causes of cognitive decline.
“Siemens is proud to be the first and only company to implement an integrated solution to support the evaluation of Alzheimer’s disease and other causes of cognitive decline,” said Britta Fuenfstueck, CEO of Molecular Imaging, Siemens Healthcare. “The combination of reliable manufacturing and distribution of Amyvid with Siemens’ new Biograph CT PET•CT and our pending syngo.PET Amyloid Plaque neurology quantification software will give physicians in the U.S. additional tools for the evaluation of Alzheimer's disease and other neurologic conditions.”
A negative Amyvid scan indicates sparse to no amyloid plaques are currently present, which is inconsistent with a neuropathological diagnosis of Alzheimer’s disease and reduces the likelihood that a patient’s cognitive impairment is due to Alzheimer’s disease.  A positive Amyvid scan indicates moderate to frequent amyloid plaques are present; this amount of amyloid plaque is present in patients with Alzheimer’s disease, but may also be present in patients with other types of neurologic conditions and in older people with normal cognition. [2, 5,7]
It is important to note that Amyvid is an adjunct to other diagnostic evaluations. A positive Amyvid scan does not establish a diagnosis of Alzheimer’s disease or other cognitive disorder. Additionally, the safety and effectiveness of Amyvid have not been established for predicting development of dementia or other neurologic condition, or monitoring responses to therapies. Amyvid images should be interpreted only by readers who successfully complete a special training program, which will be provided by Lilly. 
Because some amyloid tracer is naturally retained in the normal brain, it is important to appropriately differentiate between white matter uptake and gray matter amyloid plaque deposits. While amyloid within the brain’s white matter is, in most cases, considered normal, uptake in the gray matter may indicate abnormal activity.8 Because gray and white matter are interlaced in such a compact way, distinguishing the two can be challenging. Once localized, accurately quantifying the presence of amyloid plaques may help to more confidently interpret an amyloid scan.  In cases where the intensity of amyloid uptake is insufficient, it may become challenging to accurately interpret based on visual assessment alone. Therefore, equally important to localization is quantification. [8,9]
Traditional scanners in use today often lack the fine volumetric resolution and high-contrast ratio required to precisely differentiate between gray and white matter. Inherent scanner drift as well as inaccurate attenuation correction impact the accuracy of acquired quantitative data. In addition, conventional interpretation software does not offer automatic quantification and leaves the reader to rely solely on subjective interpretation.
With the new Biograph mCT from Siemens, physicians can attain the highest image quality  and quantifiable results that are accurate. With its OptisoHD Detection System, UltraHD•PET and acquisition matrix of 400 x 400, Biograph mCT enables physicians to visualize different brain matter with the industry’s finest volumetric resolution  of 87mm³ and four times improvement in contrast (signal to noise). With its unique combination of daily calibration and precise anatomical and functional co-registration, Biograph mCT can make a quantifiable improvement in diagnostic confidence in dementia diagnosis.
syngo.PET Amyloid Plaque, Siemens’ proprietary quantification software, is intended to take a patient’s PET amyloid exam and automatically register it against a reference model of a PET amyloid brain. Siemens’ proprietary affine registration algorithm has been shown in research  to have a correlation coefficient of 0.98 to the Fleisher method.  Pioneered by Dr. Adam Fleisher, this reference model identifies six optimal zones to evaluate pathological levels of amyloid plaque burden. syngo.PET Amyloid Plaque enables physicians to calculate uptake ratios. Uptake ratios, such as SUVr, can be compared to Fleisher thresholds, thus allowing to reflect pathological levels of amyloid.  Combined with visual assessment, these capabilities may give physicians added confidence in determining amyloid plaque burden — for instance, in borderline cases, which otherwise could result in inconclusive or false scanning reports.
Support for establishing new imaging services
Siemens has a recognized portfolio of programs to help customers establish and grow their PET imaging offerings and provide new services to their communities. Siemens imaging outreach program includes a broad range of exclusive offerings, including business plan development, site readiness consulting, optimized scanner protocols, workflow consulting, training and marketing support.
The impact of Alzheimer’s disease
With aging populations and extended life expectancies, the number of Alzheimer’s cases in the United States and worldwide is growing at epidemic levels. Progressing steadily and unmercifully, Alzheimer’s disease is now the sixth leading cause of death in the United States. With 5.4 million Americans living with the disease — and another person joining that group every 69 seconds — this number is predicted to triple by 2050.  As deaths from stroke, cancer and heart disease decreased significantly between 2000 and 2008, Alzheimer’s-related deaths rose 66%.  It is estimated that one in five patients diagnosed with probable Alzheimer’s disease do not end up having Alzheimer’s disease pathology upon autopsy. [13,14]
A positive Amyvid scan does not establish a diagnosis of AD or other cognitive disorder. Additionally, the safety and effectiveness of Amyvid have not been established for predicting development of dementia or other neurologic condition or monitoring responses to therapies. Amyvid is supplied in 10 mL, 30 mL, or 50 mL multidose vials containing 500-1900 MBq/mL Florbetapir F 18.
For more information: http://pi.lilly.com/us/amyvid-uspi.pdf and www.siemens.com/healthcare
1 Hyman BT, Phelps CH, Beach TG, et al. National Institute on Aging–Alzheimer’s Association guidelines for the neuropathologic assessment of Alzheimer’s Disease. Alzheimers Dement. 2012;8:1-13.
2 Mirra SS, Heyman A, McKeel D, et al; and participating CERAD neuropathologists. The Consortium to Establish a Registry for Alzheimer’s Disease (CERAD): part II: standardization of the neuropathologic assessment of Alzheimer’s disease. Neurology. 1991;41(4):479–486.
3 Thies W, Bleiler L; Alzheimer’s Association. Alzheimer’s Association report: 2012 Alzheimer’s disease facts and figures. Alzheimers Dement. 2012;8:131-168.
4 The syngo.PET Amyloid Plaque neurology software is pending 510(k) clearance, and is not yet commercially available.
5 Amyvid [package insert]. Indianapolis, IN: Eli Lilly and Company; 2012.
6 McKhann GM, Knopman DS, Chertkow H, et al. The diagnosis of dementia due to Alzheimer’s Disease: recommendations from the National Institute on Aging-Alzheimer’s Association workgroups on diagnostic guidelines for Alzheimer’s Disease. Alzheimers Dement. 2011;7:263-269.
7 Sperling RA, Aisen PS, Beckett LA, et al. Toward defining the preclinical stages of Alzheimer’s Disease: recommendations from the National Institute on Aging-Alzheimer’s Association workgroups on diagnostic guidelines for Alzheimer’s Disease. Alzheimers Dement. 2011;7(3):280–292.
8 Adam S. Fleisher et al: “Using Positron Emission Tomography and Florbetapir F 18 to Image Cortical Amyloid in Patients With Mild Cognitive Impairment or Dementia Due to Alzheimer Disease”, Archives of Neurology, July 12, 2011
9 Camus et al EJNMMI (2012) 39:621-631; Using PET with 18F-AV-45 (florbetapir) to quantify brain amyloid load in a clinical environment; Qualitative visual assessment of the PET scansshowed a sensitivity of 84.6%; however, the quantitative assessment of the global cortex SUVr showed a sensitivity of 92.3%.
10 2011 PET Image Quality Survey conducted in the U.S. and Europe as a custom study by IMV, a neutral third party market research company.
11 Based on Competitive literature available at time of publications. Data on file.
12 J.-M. Peyrat, A. Joshi, M. Mintun, J. Declerck: “An automatic method for the quantification of uptake with Florbetapir imaging”, SNM Publication No.: 210, Reference #: 1311229, http://www.snm.org/index.cfm?PageID=11533
13 Lim A, Tsuang D, Kukull W, et al. Clinico-neuropathological correlation of Alzheimer’s disease in a community-based case series. J Am Geriatr Soc. 1999;47(5):564–569.
14 Petrovitch H, White LR, Ross GW, et al. Accuracy of clinical criteria for AD in the Honolulu- Asia Aging Study, a population-based study. Neurology. 2001;57(2):226–234