Petct In Gynecologic Cancer

PET/CT in gynecologic cancer Anne Kiil Berthelsen, PET & Cyclotron Unit, Dept of Radiation Oncology Rigshospitalet, Copenhagen University Hospital, Denmark

1 PET scanner 2 PET/CT 1 CT-scanner 2 Cyclotrons 2 Radiochemistry Laboratories 9 Accelerators, 1 dedicated for Stereotactic Treatment

PET/CT in Cervical cancer, diagnostic
PET/CT in Radiotherapy planning
PET/CT in Ovarian cancer, diagnostic

PET/CT IN THE DIAGNOSTIC PROCEDURE OF CERVICAL CANCER.

Staging of cervical cancer
FIGO
Clinical examination in anesthesia
cystoscopy, urography, thorax X-ray.

No imaging of the primary tumor is included!
No investigation of lymph nodes metastases are included!

Surgical staging (stages IIB to IVA):
- 25 % para-aortic metastases
- Para-aortic nodal status is the most significant prognostic factor

Copenhagen cervical cancer PET/CT study Results

Aim Evaluate PET/CT in the diagnostic of cervical cancer.

STUDY
Prospective study
120 consecutive patients
Nov 2002- Oct 2005
cervical cancer, stage ≥ 1B
Mean age 48 years (19-81)
Written informed consent

FIGO STAGE 5 4A 44 3B 1 3A 31 2B 7 2A 4 1B Bulky 28 1B

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.

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

Methods
nuclear medicine
radiologist

Results Surgery
Of the 28 operated patients, true positive metastases were found in 4 (14%).
Most common were pelvic nodes

Results Surgery
1 false negative
A para-cervical lymph node found at operation

Results Surgery
3 patients had false positive foci
Iliac lymph node
Inguinal lymph node
Axillary lymph node
Small bone focus

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.

Para-aortic lymph node metastases

7 false positive PET/CT
4 small bone lesions
2 histiocytosis
1 granuloma
Histiocytosis

Distant metastases
Neck
Mediastinum
Bone
Omentum
Lung
Liver
Adrenal gland
Neck node metastasis Adrenal gland metastasis

Pulmonary metastasis

Liver metastasis

Conclusion
PET/CT is a useful tool in cervical cancer.
20% of the patients had more extensive disease than demonstrated with conventional staging.

PET/CT for radiotherapy

Advantages of PET/CT for RT
Only one scanning procedure
Precise anatomical localisation and function

Whole body PET/CT
Improved the diagnose
Para-aortic metastases
Iliac lymph nodes
Distant metastases

4-fields box technique

Cervical cancer Para-aortic LN

Intensity Modulated Radiotherapy IMRT
Allows dose escalation to the target volume
Reduce dose to organs at risk

PET/CT for Radiotherapy. What do you need?

Special flat top bed

External LAP laser system

Automatic iv contrast media

Fix point tattoo

Well educated staff

Time!!!!

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 %)

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.

Delineation
GTV (radiologist)
GTV PET (Nuclear medicine)
CTV (Radiation oncologist)
Organs at risk : (Radiation oncologist)
Retroperitoneum, Bladder, Rectum, Intestine, Spinalcord, Kidney, Liver, Bone marrow

Vessels,pet pos gtv,gtv

Kidney,bladder,rectum

Retroperitoneum,intestine

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

Tumour definition and organs at risk

Dose plan

Dose plan. Coronal view.

Cervical cancer- remember the whole-body scan!

Conclusion
In Radiotherapy, PET/CT optimises treatment planning by increasing information about
Staging
Viable tumour tissue
Important for IMRT

Pelvic Mass project:

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.

Aim
To improve diagnosis and staging
Compare PET/CT with
UL
Clinical investigations
Tumour markers
CA-125
New markers
Operative findings and histology

Pt Inclusion
Patients with a pelvic mass
High RMI index
A high suspicion of malignant disease

Strategy for patient
Clinical examination including UL
Bloodtest
PET/CT
Operation

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

Benign-looking tumour. Histology: benign cyst

Fibroma

Ovarian Cancer with involment of the Spleen

Looks supicious on CT and UL- benign-looking on PET. Histology: Benign cyst

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

Petct In Gynecologic Cancer

by fondas vak on Feb 01, 2010

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