Terbium-149 PET/CT: First Quantitative Imaging with a Clinical Long-Axial Field-of-View Scanner
Introduction: Terbium-149 ($^{149}$Tb) is a promising radionuclide for targeted $\alpha$ therapy that has a non-zero branching ratio (BR) for positron decay. However, its relatively low positron branching fraction and multiple prompt $\gamma$ emissions may challenge quantitative imaging. This study evaluates, for the first time, the imaging performance and quantitative accuracy of $^{149}$Tb using a clinical long axial field-of-view (LAFOV) PET/CT system. Methods: Quantitative accuracy of $^{149}$Tb was assessed with a NEMA IEC body phantom, which was filled with about 45 MBq $^{149}$Tb and a sphere-to-background ration of 10:1. The phantom was scanned for 20 min and shorter scan times and lower activities were simulated. Recovery coefficients, coefficient of variation, and lung residual error were evaluated for different reconstruction settings and compared to the EARL standard 2 for $^{18}$F. Results: High-quality PET images of $^{149}$Tb were obtained, even with a simulated total activity of 4.5 MBq. The 20 min and full activity scan yielded a mean recovery coefficient $RC_\textit{mean}$ of $0.55$, $0.69$, $0.73$, $0.76$, $0.79$, and $0.81$ for the six phantom spheres. Despite the low count statistics, the coefficient of variation stays mostly below $15\,\%$. Relative scatter correction combined with prompt $\gamma$ modeling provided robust quantification. Conclusion: $^{149}$Tb can be imaged using a commercial LAFOV PET/CT with a quantitative accuracy comparable to the EARL standard 2 for $^{18}$F. These findings demonstrate the feasibility of PET-based treatment verification and dosimetry for targeted $\alpha$ therapy with $^{149}$Tb.