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Petct In Gynecologic Cancer
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Petct In Gynecologic Cancer

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  • 1. PET/CT in gynecologic cancer Anne Kiil Berthelsen, PET & Cyclotron Unit, Dept of Radiation Oncology Rigshospitalet, Copenhagen University Hospital, Denmark
  • 2. 1 PET scanner 2 PET/CT 1 CT-scanner 2 Cyclotrons 2 Radiochemistry Laboratories 9 Accelerators, 1 dedicated for Stereotactic Treatment
  • 3.
    • PET/CT in Cervical cancer, diagnostic
    • PET/CT in Radiotherapy planning
    • PET/CT in Ovarian cancer, diagnostic
  • 4. PET/CT IN THE DIAGNOSTIC PROCEDURE OF CERVICAL CANCER.
  • 5. Staging of cervical cancer
    • FIGO
    • Clinical examination in anesthesia
    • cystoscopy, urography, thorax X-ray.
  • 6. Staging of cervical cancer
    • No imaging of the primary tumor is included!
    • No investigation of lymph nodes metastases are included!
  • 7. Staging of cervical cancer
    • Surgical staging (stages IIB to IVA):
    • - 25 % para-aortic metastases
    • - Para-aortic nodal status is the most significant prognostic factor
  • 8. Copenhagen cervical cancer PET/CT study Results
  • 9. Aim Evaluate PET/CT in the diagnostic of cervical cancer.
  • 10. STUDY
    • Prospective study
    • 120 consecutive patients
    • Nov 2002- Oct 2005
    • cervical cancer, stage ≥ 1B
    • Mean age 48 years (19-81)
    • Written informed consent
  • 11. FIGO STAGE 5 4A 44 3B 1 3A 31 2B 7 2A 4 1B Bulky 28 1B
  • 12. Methods
    • PET/CT procedure
      • - GE Discovery LS PET/CT scanner
      • - 400 MBq 18F-FDG
      • - Min. 6 hours fasting
      • - Emission 3-5 minutes per bed position, depending on the weight of the patient.
  • 13. Methods
    • PET/CT procedure
      • CT as a diagnostic CT
      • 4 slice spiral CT
      • Intravenous contrast media injected automatically with a 40 sec delay.
      • Oral contrast media 30 minutes before scan start.
      • 140 kV, 80-120 mA
      • Arms above the head
  • 14. Methods
    • nuclear medicine
    • radiologist
  • 15. Results Surgery
    • Of the 28 operated patients, true positive metastases were found in 4 (14%).
    • Most common were pelvic nodes
  • 16. Results Surgery
    • 1 false negative
    • A para-cervical lymph node found at operation
  • 17. Results Surgery
    • 3 patients had false positive foci
      • Iliac lymph node
      • Inguinal lymph node
      • Axillary lymph node
      • Small bone focus
  • 18. Results Radiotherapy
    • Para-aortic lymph node metastases in 19 pt.
    • Other distant foci in 10 of these.
    • A new primary (lung cancer) in 1 pt.
  • 19. Para-aortic lymph node metastases
  • 20. Results Radiotherapy
    • 7 false positive PET/CT
      • 4 small bone lesions
      • 2 histiocytosis
      • 1 granuloma
    Histiocytosis
  • 21. Results Radiotherapy
    • Distant metastases
      • Neck
      • Mediastinum
      • Bone
      • Omentum
      • Lung
      • Liver
      • Adrenal gland
    Neck node metastasis Adrenal gland metastasis
  • 22. Pulmonary metastasis
  • 23. Liver metastasis
  • 24. Conclusion
    • PET/CT is a useful tool in cervical cancer.
    • 20% of the patients had more extensive disease than demonstrated with conventional staging.
  • 25. PET/CT for radiotherapy
  • 26. Advantages of PET/CT for RT
    • Only one scanning procedure
    • Precise anatomical localisation and function
  • 27. Whole body PET/CT
    • Improved the diagnose
    • Para-aortic metastases
    • Iliac lymph nodes
    • Distant metastases
  • 28. 4-fields box technique
  • 29. Cervical cancer Para-aortic LN
  • 30. Intensity Modulated Radiotherapy IMRT
    • Allows dose escalation to the target volume
    • Reduce dose to organs at risk
  • 31. PET/CT for Radiotherapy. What do you need?
  • 32. Special flat top bed
  • 33. External LAP laser system
  • 34. Automatic iv contrast media
  • 35. Fix point tattoo
  • 36. Well educated staff
  • 37. Time!!!!
  • 38. PET/CT RT planning in 2005
    • 157 PET/CT treatment planning scans
    • 31 of these were cervical cances (20 %)
    • 13 of these were treated with IMRT (42 %)
  • 39. Tumour delineation on PET/CT GTV PET (Gross tumour volume defined by PET) drawn as a ROI on each PET/CT slice and transfered to eclipse.
  • 40. Delineation
    • GTV (radiologist)
    • GTV PET (Nuclear medicine)
    • CTV (Radiation oncologist)
    • Organs at risk : (Radiation oncologist)
    • Retroperitoneum, Bladder, Rectum, Intestine, Spinalcord, Kidney, Liver, Bone marrow
  • 41. Vessels,pet pos gtv,gtv
  • 42. Kidney,bladder,rectum
  • 43. Retroperitoneum,intestine
  • 44. Cervical cancer with PET pos LN
    • PET pos LN 64 Gy
    • Uterus – before IMRT 46 Gy + 35 Gy BT
    • Uterus – with IMRT 50 Gy + 35 Gy BT
  • 45. Tumour definition and organs at risk
  • 46. Dose plan
  • 47. Dose plan. Coronal view.
  • 48. Cervical cancer- remember the whole-body scan!
  • 49. Conclusion
    • In Radiotherapy, PET/CT optimises treatment planning by increasing information about
      • Staging
      • Viable tumour tissue
    • Important for IMRT
  • 50. Pelvic Mass project:
  • 51. Background
    • 5th most common cancer in Danish women
    • 70% have advanced disease at time of diagnosis
    • Today we us UL and CA-125 to measure Risk of Malignancy Index.
  • 52. Aim
    • To improve diagnosis and staging
    • Compare PET/CT with
      • UL
      • Clinical investigations
        • Tumour markers
        • CA-125
        • New markers
      • Operative findings and histology
  • 53. Pt Inclusion
    • Patients with a pelvic mass
    • High RMI index
    • A high suspicion of malignant disease
  • 54. Strategy for patient
    • Clinical examination including UL
    • Bloodtest
    • PET/CT
    • Operation
  • 55. Protocol
    • Started September 2004
    • 165 patients in total
    • Uptil now 100 pt
    • Evaluated 77 pt
    • Study time approximately 2 years
    • Participation from other gyn/onc clinics
  • 56. Benign-looking tumour. Histology: benign cyst
  • 57. Fibroma
  • 58. Ovarian Cancer with involment of the Spleen
  • 59. Looks supicious on CT and UL- benign-looking on PET. Histology: Benign cyst
  • 60. Thank you
    • Cervical cancer group:
    • Annika Loft, Henrik Roed, Christan Ottosen, Lene Lundvall, Jens Knudsen, Hanne Sandstrøm, Liselotte Højgaard, Svend Aage Engelholm
    • Ovarian cancer group:
    • Signe Risum, Svend Aage Engelholm, Henrik Roed, Annika Loft, Claus Høgdall, Estrid Høgdall
    • Radiotherapy group:
    • Flemming Kjær Christoffersen, Henrik Roed, Håkon Nystrøm, Silke Sphan-Horn, Svend Aage Engelholm