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Nuclear Oncology for Medical Students


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  • 1. Nuclear Oncology gy for medical students Jiraporn Sriprapaporn,M.D. Div N l Di Nuclear medicine di i Siriraj Hospital Mahidol University Bangkok
  • 2. Nuclear OncologyN l O l Conventional Tumor Imaging WB+ Planar SPECT SPECT/CT Onco PET (Positron Emission Tomography) PET PET/CT J Sriprapaporn
  • 3. Objectives of Tumor Imaging Diagnosis g Staging Guiding for biopsy Follow-up Follow up & monitoring treatment Detect tumor recurrence J Sriprapaporn
  • 4. Nuclear Oncology Functional Med LN Sensitive Whole-body Whole body evaluation ADR Specific-some tumors p RP LN J Sriprapaporn
  • 5. Conventional Tumor ImagingGa-67Ga 67 citrate I-131 I 131 (DTC)Tl-201 I-131 MIBG (neuralTc-99mT 99 MIBI crest tumors)Tc-99m Tetrofosmin Receptor imaging eg. eg somatostatin Radiolabelled MoAb imaging J Sriprapaporn
  • 6. Fever of unknown origin (FUO)Gallium-67G lli 67Nonspecific for infection-inflammation & tumorsMechanism : bind to iron transport proteins eg eg.transferrin, lactoferrinExcretion: kidneys & large bowelE ti kid l b lDose :5-10 mCi IV.Scan at 24-72 hr. pi.Tumors : Lymphoma (Hodgkins lymphoma) Hodgkin s ),Bronchogenic carcinoma, Malignant melanoma,Hepatoma J Sriprapaporn
  • 7. Objectives of Ga-67 Imagingin lymphoma Staging Follow up Follow-up & monitoring treatment Detect tumor recurrence J Sriprapaporn
  • 8. Gallium-67 & LG lli 67 Lymphoma h Right paratracheal lymphadenopathy Planar Images SPECT Images J Sriprapaporn
  • 9. Tc-99mT 99 MIBI & Tl 201 Tl-201Nonspecific tumor imaging p g gCan be applied in several types oftumorsRapid information imaging at 10- information-imaging 1020 min. pi.Uptake in viable tumor but not inscarred tissue J Sriprapaporn
  • 10. Objectives of Tumor ImagingLocalize site for biopsyDetermine grade of malignancyEvaluate the response of preoperativeCMT or RTDetermine residual tumor &/or localrecurrenceDifferentiate post-therapy tissue necrosisor fib o i f om lo l eo fibrosis from local recurrence en e J Sriprapaporn
  • 11. IndicationsI di i Brain tumors Bronchogenic carcinoma Thyroid carcinoma Parathyroid adenoma Bone & soft ti B ft tissue sarcoma Breast cancer Lymphoma : Head & neck cancers J Sriprapaporn
  • 12. Bone Tumor PO. withRecurrence Tc-99m MDP Tl-201 J Sriprapaporn
  • 13. Parathyroid AdP h id Adenoma Tc-99m T 99 Tc-99m T 99 MIBI J Sriprapaporn
  • 14. I-131I 131 MIBG S ScanI-131 MetaiodobenzylguanidineNoradrenaline analogN d li lLocalizes in adrenergic tissues,catecholamine-producing tumors & theirmetastasesFirst synthesized by Wieland et al. in 1979Patient Preparation: Withdrawal of drugs interfering MIBG uptake Lugol s Lugol’s solution to block thyroid uptake of free iodide J Sriprapaporn
  • 15. I-131 MIBG-Avid TI 131 MIBG A id Tumors Pheochromocytoma/ eoc o ocyto a/ Paraganglioma Neuroblastoma Medullary thyroid carcinoma M d ll th id i (MTC) Carcinoid tumor J Sriprapaporn
  • 16. Bone Scan in Neuroblastoma20 2 4420-2-44 (PreRx) 4 6 44 4-6-44 (PostRx) 3 yo girl NBM stage IV with multiple bone metastases 2-44 Pre & post CMT 4 courses (induction) J Sriprapaporn
  • 17. I-131 MIBG in Neuroblastoma ANT POST3 yo girl, NBM stage IV with multiple bone metas 2 44 il t ith lti l b t 2-44Pretreatment staging J Sriprapaporn
  • 18. I-131 MIBG in Neuroblastoma Girl, 3 yo. Neuroblastoma stage IV with multiple bone metastases 2-44 Post 4 courses of CMT (induction) ( ) F/U after RxANT POST ANT POST28-2-44 (PreRx) 6-6-44 (PostRx) J Sriprapaporn
  • 19. J J Sriprapaporn 2011 Sriprapaporn
  • 20. What iWh is PET? PET =Positron Emission Tomography PET emitters emit positron from their nuclei Positron then reacts with electron annihilation 2 gamma photons, photons 511 keV moving in opposite direction J Sriprapaporn
  • 21. Principal Positron EmittersPET Radionuclides Physical T1/2 C-11 20 min N-13 10 min O-15 2 min F-18 110 min J Sriprapaporn
  • 22. Steps for PET PET IMAGINGImaging Production of positron- emitting Rdn. Rdn Labeling a selected CYCLOTRON compound with a positron-emitting Rdn. RADIOPHARM Administration into a PATIENT patient (IV, inhalation) Imaging t e patient ag g the pat e t PET SCANNER Reconstruction & display (Q p y (Quantitation) ) COMPUTER J Sriprapaporn
  • 23. PET/CT Imaging PET-CT PET CT I Imaging i CT PETScout C CTCT low mA*PET scan-Non AC scan NonPET-ACPET(AC) CTPET(AC)-CT J Sriprapaporn
  • 24. Integrated PET/CT SI d Scan J Sriprapaporn
  • 25. PET/CTScanners Siriraj J Sriprapaporn
  • 26. FDG F-18 F 18 FDGFirst synthesis by Ido et al (1974) atBrookhaven National Laboratory brain scanat HUP in 1976FDG= Fluorodeoxyglucose, glucose analogue,represents glucose metabolism FDG enters the cells using the same p pathway as g y glucose (glucose transporter (g p proteins) [R23: Mochizuki T, et al. JNM 2001] but is not used in glycolysis and is metabolically trapped inside the cells after phophorylation (FDG-6-phosphate). FDG is excreted in large quantities by kidney unlike glucose. J Sriprapaporn
  • 27. FDG Metabolism Glut 1 Glycolysis 2 G-6-P isomerase 1 (Buck AK JNM 2004) Glut Glycolysis 2Enz1 = Hexokinase -- PhosphorylationEnz2= Glucose-6-phosphatase J SriprapapornTumor cells higher glycolytic rate than normal tissue.
  • 28. Normal FDG PET/CT Imaging J Sriprapaporn
  • 29. PET/CT vs SPECT Higher sensitivity Higher image quality Better anatomical localization with CT Whole-body imaging y g g More accurate quantification Metabolic i M t b li imaging at cellular level i t ll l l l J Sriprapaporn
  • 30. Mechanism of F 18 FDG Uptake F-18 Malignant cells have increased g glucose utilization due to Over expression of membrane glucose O i f b l transporter receptors, especially Glut-1 and Glut-3 on surface of tumor cells. Increased hexokinase activity Decreased level of G-6-phosphatase J Sriprapaporn
  • 31. Clin Indications for PET/CT DDx single pulmonary nodule, Grading tumors Staging Monitoring treatment g DDx post therapeutic fibrosis & residual/recurrent tumor J Sriprapaporn
  • 32. Table1: Medicare-approved Oncologic Indications for PET l i di i f*Special Medicare restrictions exist for these indications p J Sriprapaporn Griffeth LK 2005
  • 33. PET-CT Reimbursement inThailand [26-11-07] From 1 JAN 2008, 40,000 Baht/test for only 2Indications: Colon cancer & NSCLC Colon cancer 1. KPS > 70 S 0 2. Suspected tumor recurrence due to rising CEA 3. Negative or unclear CT or MRI of abdomen to document recurrence 4. Abnormal CT or MRI supposed to be completely resected. (for curative aim) 5. If th first PET-CT scan as i di t d i negative, the the fi t PET CT indicated is ti th PET study can be repeated at duration not less than 3 mos. J Sriprapaporn
  • 34. PET-CT Reimbursement inThailand [26-11-07] Non-small cell lung cancer 1. KPS > 70 2. Staging for curative aim 2.1 Clinical stage T2-3,N1-2 and Mo 2.2 The patient had previous CT scan p p of chest adrenal and bone scan done. (no distant metas) J Sriprapaporn
  • 35. Imaging T h iI i Techniques Fasting for 4-6 hrs prior to PET/CT study Inject F-18 FDG 10-20 mCi IV Wait for 45-60 minutes to scan Scanning time is about 30 minutes to complete PET/CT studies. SUVmax SUV J Sriprapaporn
  • 36. FDG PET-Single Pulmonary Nodule (SPN)To identify p y pulmonary malignancy: y g y sens 82-100%, spec 67-100%, and accuracy 79-94%Figure: SPN NSCLC CT scan: a small nodule in the LUL PET-FDG: intense accumulation J Sriprapaporn
  • 37. PET for N-Staging of NSCLCCT: Left NSCLC w a pathologic AP window node (N2) (white),and a non-pathologic retrocaval-pretracheal contralateralmediastinal node (N3) (y ( ) (yellow). )PET-FDG images: increased tracer accumulation within bothnodes, consistent with metastases.Thus,Thus PET is more sensitive than CT in detect smallhypermetabolic LN metas. J Sriprapaporn
  • 38. FDG PETMonitoring CMT Response i i C Baseline PET study is required! Intense tumor uptake and nodal uptake of FDG p Reduced metabolic activity response to treatment J Sriprapaporn
  • 39. Colorectal CA w LiverMetas.: P PM Pre-Post R Rx Patient with colorectal metastases and previous left hemihepatectomy. hemihepatectomy A CT shows two hypodense nodules with contrast enhancement. B PET/CT fusion indicates a metastatic recurrent tumor beside a scar after operation. C CT after radiofrequency ablation shows a large area without contrast enhancement (arrow). D PET/CT f i after fusion f radiofrequency ablation indicates complete ablation of the recurrent metastasis with a photopenic lesion. J Sriprapaporn
  • 40. Colorectal CA w LiverMetas-Recurrence A CT 3 month after radiofrequency ablation shows no sign of l h f local recurrence. l B PET/CT 3 month after radiofrequency ablation demonstrates a l d t t local recurrent t l t tumor. J Sriprapaporn
  • 41. Malignant Melanoma wDisseminated Metastases J Sriprapaporn