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    Pet Pet Presentation Transcript

    • P ositron E mission T omography in Clinical Oncology
        • Chun Ki Kim, M.D.
        • Mount Sinai School of Medicine
        • New York, New York
    •  
    •  
    • Commonly used PET Radiotracers
      • [F-18] FDG - Glucose metabolism
      • [C-11] Methionine - Amino acid transport
      • - Incorporation of amino acid
      • into protein fractions
      • [O-15] Water - Blood flow
      • [N-13] Ammonia - Blood flow
      • Rb-82 - Blood flow
      • [C-11] Thymidine Tumor cellular proliferation rate
      • [C-11] Aminoisobutyric acid Tumor amino acid uptake
      • [F-18] 5-FU Prediction/evaluation of ChemoTx
      • [C-11] Tyrosine Tumor metabolism
      • [N-13] Glutamate Tumor metabolism
      • [C-11] Acetate Myocardial oxidative metabolism
      • [C-11] Palmitate Myocardial fatty acid metabolism
      • [F-18] FluoroDOPA Dopamine synthesis
      • Many other receptor agents Dopamine, serotonin, opiate etc.
      Potential PET Radiotracers
    • PET Radiotracer approved by FDA
      • [F-18] FDG (fluoro deoxyglucose)
      •  Malignancy ~  Glucose / FDG uptake
    •  
    • NORMAL TUMOR
      • Overexpression of Glucose transporters
      • Higher levels of Hexokinase
      • Down-regulation of Glucose-6-phosphatase
      • Anaerobic glycolysis, less ATP per glucose molecule,
      • more glucose molecules needed for ATP production
      • General increase in metabolism from high growth rates
      • Malignancy  Glucose/FDG uptake
    • Gallium PET
    • Metastatic Thyroid Ca. to Lung, Mediastinum, and Skeleton
    •  
    • General Indications for FDG-PET Tumor Imaging
          • DDx: Benign versus Malignant
          • Staging & Restaging
          • Metastatic work up: Rising tumor markers
          • Monitoring treatment response
          • Scar/necrosis/fibrosis vs. Recurrent/residual disease
          • Grading/Prognosis
          • Detection of unknown primary
    • New Medicare Coverage Policy for FDG PET
      • Lung Ca (NSC): Dx, Staging & restaging
      • Esophgeal Ca: Dx, Staging & restaging
      • Colorectal Ca: Dx, Staging & restaging
      • Lymphoma: Dx, Staging & restaging
      • Melanoma: Dx, Staging & restaging,
      • Non-covered for evaluating regional nodes
      • Head & Neck Ca: Dx, Staging & restaging
    • Lung Cancer
          • Dx: Solitary Pulmonary Nodule
          • Staging
          • Metastatic work-up
    • Solitary Pulmonary Nodule
      • Incidence detected by CXR: 130,000/year.
      • 50-60% : Benign
      • 20-40%: Invasive nodule biopsy
      • Resection.
    • CT: an indeterminant LUL nodule.
    •  
    • Efficacy of PET Solitary Pulmonary Nodule
      • Sensitivity = 97%
      • Specificity = 78%
      • (Meta-analysis of >40 articles: Gould et al. JAMA 2001 )
    • False Positives: Active Infection/Inflammation TB Pneumonia Cryptococcosis Histoplasmosis Aspergillosis Inflammatory
    • Staging
    •  
    •  
    • 60/M: Lung Ca.
    • 62y/o Lung Ca. with adrenal mass
    •  
    • Colorectal Cancer: Clinical Indications for PET Imaging
          • Staging before primary resection?
          • Detection of Lesions after Primary Resection
            • Staging before resection of recurrent disease.
            • Rising CEA in the absence of a known source.
            • Equivocal/residual lesion on conventional imaging.
            • Patient is clinically symptomatic, but CEA is normal.
          • Monitoring treatment response (pre-op & post-op)
    • Staging before resection of recurrent disease
    • 63 y/o woman with a H/O Colon Ca. and liver metastases
    • 79/M. Resection of Rectal Ca (Dukes B) 4 mos earlier,  CEA, CT: possible local relapse.
    • T1 T2 T1 enhanced T1 enhanced
      • F/68
      • H/O Colon Ca.
      • Rising CEA
      • CT/MRI; multiple cysts
    • Sagittal Transverse Coronal
      • YW: Colon Ca
      • 3/00: (-) CT
      • 5/00: rising CEA
      • 6/00: (+) PET
      • 7/00: CT
    • 58/M - S/P Colon Ca Rising CEA Coronal Coronal Transverse
    • 58/M - S/P Colon Ca Rising CEA Local recurrence Hemangioma
      • 48y/o with Colon Ca.
      • S/P Primary resection.
      • S/P Resection of liver
      • lesion
      • Now with  CEA
      • CT: (-) for mets
      • 48y/o with Colon Ca.
      • S/P Primary resection.
      • S/P Resection of liver
      • lesion
      • Now with  CEA
      • CT: (-) for mets
    • N. G. 8/15/00 Colon cancer with a Hx of UC Proven mesenteric carcinomatosis
    • 1756441
    • Huebner et al. J Nucl Med 2000;41:1177-1189
    • Huebner et al. J Nucl Med 2000;41:1177-1189
    • Colorectal Cancer: A possible algorithm CT evidence of resectable disease in patient suitable for surgery Whole Body PET imaging
    • Colorectal Cancer: A possible algorithm CT evidence of resectable disease in patient suitable for surgery Whole Body PET imaging Further evaluation of CT abnormality All sites negative
    • Colorectal Cancer: A possible algorithm CT evidence of resectable disease in patient suitable for surgery Whole Body PET imaging Further evaluation of CT abnormality Surgery All sites negative PET = CT and other sites negative
    • Colorectal Cancer: A possible algorithm CT evidence of resectable disease in patient suitable for surgery Whole Body PET imaging Further evaluation of CT abnormality Non-surgical management Surgery All sites negative + ve at multiple Sites PET = CT and other sites negative
    • 44/F with Colon Ca, S/P primary resection. CT: multiple liver mets and a lung nodule Treated with systemic chemoTx instead of intra-arterial chemoTx . Staging:
    • Colorectal Cancer: Clinical Indications for PET Imaging
          • Detection of Lesions
            • Staging before resection of recurrent disease.
            • Rising CEA in the absence of a known source.
            • Equivocal/residual lesion on conventional imaging.
            • Patient is clinically symptomatic, but CEA is normal.
          • Monitoring treatment response (pre-op & post-op)
          • Staging before primary resection?
    • S/P ChemoRx
    • Before 2mo after Adjuvant chemo and radioTx Prior to surgery for rectal Ca.
    • Optimal time to scan after treatment?? Uptake may be seen in inflammatory tissue / macrophages. Residual FDG activity after treatment: Not always active tumor
      • 1 month after Chemo.
        • PET findings at 1 mo ~ CT findings at 3 mos
        • Findlay et al. J Clin Oncol 1996
      • Several months after RT?
    • Lymphoma: Indications for PET Imaging
          • Dx
          • Staging
          • Monitoring treatment response
          • Recurrence?
    • Evaluation of early therapeutic response: Is treatment effective? FDG uptake represents cell viability.
          • FDG uptake can be markedly decreased or even completely suppressed after 1 or 2 cycles of chemotherapy
          • Early determination is important: To avoid the toxicity of ineffective therapy. To allow selection of a new therapeutic regimen.
    • 1846641 Lymphoma Before After 2 cylcles of Chemo
    • Lymphoma Before After 2 cylcles of Chemo
    • 56y/o : Lymphoma
    • Before 1 month after XRT
    • Esophageal/Gastro-esophageal Cancer: Clinical Indications for PET Imaging
          • Pre-op staging
          • Monitoring treatment response
          • Suspected recurrence
          • Prognostication
    • Esophageal/ Gastro-esophageal Cancer: Clinical Indications for PET Imaging
          • Pre-op staging
            • CT: Limited sensitivity
            • EUS: More accurate for assessing local invasion and regional nodal mets.
          • Limitations: stenosis,
          • celiac,
          • right hepatic lobe, peritoneum
    • ( Choi et al: J Nucl Med 2000) Evaluation of N stage of patients with Esophageal Cancer: 48 patients underwent esohagectomy and lymph node dissection (2 field=35pts, 3 field=13pts)
    • Evaluation of metastases in Esophageal Cancer: CT versus PET CT PET Kole 1998 Lymph nodes 62% 90% Resectability 65% 88% Choi 2000 Lymph nodes 78% 86% N staging 60% 83% Luketich 1999 Distant mets 63% 84%
    • Rt. Paratracheal Subcarinal Lt. Gastric Common hepatic & Celiac Rt. Paratracheal Subcarinal Lt. Gastric Common hepatic & Celiac
    • 62F: Gastric Ca. S/P Resection CT: Recurrence PET performed to exclude other sites of tumor Ultrasound: confirmed a liver mets Surgery cancelled and the patient treated with Chemo
    •  
    • Gastro-esophageal Cancer: Clinical Indications for PET Imaging
          • Pre-op staging
          • Monitoring treatment response
          • Suspected recurrence
          • Prognostication
    • Before sagittal coronal After Radiochemo 49M: large squamous esophageal Ca. Echo-endoscopy – an enlarged node
    • Gastro-esophageal Cancer: Clinical Indications for PET Imaging
          • Pre-op staging
          • Monitoring treatment response
          • Suspected recurrence
          • Prognostication
    • 45M: S/P esophagectomy, Patient is clinically asymptomatic  alkaline phosphatase
    • Gastro-esophageal Cancer: Clinical Indications for PET Imaging
          • Pre-op staging
          • Monitoring treatment response
          • Suspected recurrence
          • Prognostication
    • Surviavl based on initial PET scan identification of distant versus local disease only: (Luketich et al: Ann Thorac Surg 1999;68)
    • Pancreatic Cancer: Potential Indications for PET Imaging
          • DDx: Chronic pancreatic mass vs. Cancer
          • Staging: Nodal mets and liver mets.
          • Monitoring treatment response
          • Prognostication
    • 53/F: Pancreatic mass
    • 51F: CT: (1) Mass forming pancreatitis vs Cancer (2) Hepatic Hemangioma vs Metastasis Coronal Sagittal
    • Pancreatic Cancer: DDx: Chronic pancreatic mass vs. Cancer Delbeke et al: J Nucl Med 1999
    • Brain Tumor
          • Grading
          • Prognosis/Survival.
          • Necrosis or Residual disease after radiation therapy?
    • High Grade Low Grade
    • Kim CK et al. J Neuro-Oncol 1991
    •  
    • Thyroid Cancer Thyroglobulin (+) Iodine-131 scan (-)
          • FDG PET scan is useful.
    • I V M L FDG-PET I-131 Anterior Posterior M 2 Coronal slices
    • 62 y/o male S/P Resection of transglottic right laryngeal cancer R/O Recurrence
    • FDG PET Imaging Determination of the site of unknown primary tumor 20~30%
    • Prediction of tumor response to treatment: Will the tumor respond to treatment?
          • Labeled Estrogen
          • [F-18] 5-Fluorouracil (5-FU)
    • FDG-PET Tumor Imaging
          • DDx: Is the lesion benign or malignant?
          • Staging: Re-staging:
          • Evaluation of early therapeutic response:
          • Scar/Necrosis vs recurrent/residual disease after surgery. Scar/Necrosis vs recurrent/residual disease after XRT.
          • Histologic grading / P rognosis .
          • Detection of unknown primary.
    • Summary: PET
      • Safe.
      • Shows all the organ systems of the body with one image.
      • Decreases the number of diagnostic (imaging) procedures.
      • Diagnoses disease often before it shows up on other tests.
      • Shows the progress of disease and how the body responds to treatment.
      • Reduces or eliminates ineffective or unnecessary surgical or medical treatments and hospitalization.
      • Significantly reduces multiple medical costs and avoids needless pain to the patient.
    • The influence of blood glucose levels on 18FDG uptake in cancer (Crippa et al. Tumori 1997:83:748-752)
      • 8 patients - 20 liver metastases on CT
      • PET 1: Fasting (92.4±10.2)
        • All 20 were (+) on PET.
      • PET 2: Glucose infusion (158±13.8)
        • 6/20 undetected, and 10 lesions localized less clearly.
      • 70-years-old female smoker
      • CT showed Rt mid lung mass and inhomogeneity throughout the liver
    •  
    • Coronal Sagittal
    • 55 y/o woman Dx’ed with colon ca. S/P resection 2 yrs ago CEA level is rising No evidence of recurrence. CT: normal .