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  • Medicare approved indications for PET include 9 cancers. PET is approved for diagnosis, staging, and restaging in most cases, with a few notable exceptions.
  • The National Comprehensive Cancer Network is a consortium of 19 U.S. cancer centers that meet regularly to make evidence based recommendations on cancer diagnosis, staging, and treatment.
  • The NCCN publishes practice guidelines for 30 types of cancer. These guidelines are available at www.nccn.org
  • Cancers in which PET/CT is recommended.
  • T7823. 47 y/o man incidentally discovered lung nodule following MVA 12/20/05. PET on 1/9/06 showed high FDG uptake. Thoracotomy on 2/24/06, frozen section showed no cancer, so patient had a wedge resection. Final path report showed poorly differentiated lung cancer, so patient had a left upper lobectomy on 3/6/06.
  • V9153. 84 year old man with chronic cough. CXR on 6/10/05 showed a pulmonary nodule. CT on 7/16/05 showed a 13 mm nodule in the LLL with subtle rim calcification. No change on CXR done 11/22/05. PET on 12/12/05 was negative. No further imaging as of 3/28/06.
  • 73 year-old woman who had a hemi-colectomy for colon cancer. Her CEA level began to rise post-operatively. She had CT, but intravenous contrast could not be used because her creatinine level was elevated. CT was normal, but PET showed a solitary hypermetabolic focus in the left lobe of the liver. The patient had a laporotomy and wedge resection based on the PET findings. Pathological examination confirmed metastatic colon cancer.
  • H6636. CT (VA Fresno 5/2008) PET/CT 6/20/2008
  • 47 year old man who had biopsy proven recurrent thyroid cancer 3 months after thyroidectomy. The PET scan shows multiple hypermetabolic lymph nodes in the right neck and supraclavicular region, which were not visible with radioiodine.
  • E1638. PET/CT 10/17/07.
  • 49 year-old man with newly diagnosed lung cancer. CT of the thorax showed a mass in the upper lobe of the upper lobe of the left lung. There was no sign of metastatic disease.
    PET showed the primary tumor, as well as a hypermetabolic mass in the pelvis. Fused transaxial PET-CT images showed probable metastatic disease behind the left psoas muscle. CT with IV contrast was subsequently performed, and showed an enhancing mass in the same area.
    The patient developed additional distant metastases and died a few months later.
  • M6736. PET/CT 9/25/07.
  • H5493. PET/CT before chemotherapy 7/24/07; after chemotherapy 11/1/07
  • D1693. PET/CT 5/24/07.
  • A8665. PET/CT 6/6/07.
  • L0918. PET/CT 9/11/07.
  • L0918. PET/CT 9/11/07.
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    1. 1. George Segall, M.D. VA Palo Alto Health Care System Stanford University PET/CT in Oncology
    2. 2. Evolution of Technology CT PET 1973 2000 PET/CT 2001
    3. 3. CT - Topogram (scout) - CT scan (1 min) PET - Brain (10 min) - Heart (10 min) - Body (20 min) <130 Imaging Protocol Patient - Fast 4 hrs prior to exam - Inject tracer - Start scan 60 min later
    4. 4. PET Tracer: FDG Glucose FDG Glucose FDG Glucose-6-P FDG-6-P Plasma Cell 18F-fluorodeoxyglucose (FDG) is taken up by cells proportionate to their metabolic rates
    5. 5. KVs mAs Slice 130 kV 75 mA 5 mm FDG Bed 15 mCi 1 min CT (1 min) H.S., 077-64-28 PET CT PET/CT
    6. 6. What Are the Advantages of PET/CT? Advantages of CT • high spatial resolution Advantages of PET • better lesion characterization • enhanced lesion detection
    7. 7. Applications of PET-CT 76% Body 90% Brain 5% Heart 5% • epilepsy • tumor • dementia • perfusion • viability • tumor • infection • bone 1.5 million exams performed annually
    8. 8. PET - CT in Tumor Imaging • Detect radiographically occult lesions • Characterize radiographic abnormalities • Evaluate extent of disease • Evaluate response to therapy
    9. 9. Normal PET - CT Body Scan
    10. 10. Normal PET/CT scan QuickTime™ and a decompressor are needed to see this picture. PET CT PET/CT
    11. 11. Abnormal PET - CT Body Scan
    12. 12. Diagnosis, Staging, and Restaging (unless otherwise indicated) • Head & Neck • Thyroid • Breast • Lung • Esophagus • Colon & Rectum • Cervix • Lymphoma • Melanoma • Other Cancers Medicare Approved Indications for PET-CT follicular: I -131 neg, Tg >10 ng/dL not breast masses or regional nodes CT/MRI neg for extra-pelvic mets not regional nodes only non-small cell when enrolled in NOPR
    13. 13. National Oncologic PET Registry http://www.cancerpetregistry.org Sponsored by AMI and managed by ACR for CMS April 15, 2008 1,728 facilities - 74,541 scans since May 2006
    14. 14. http://www.cancerpetregistry.org Pre PET/CT Form • Indication for PET/CT • Cancer type and extent • Management plan Post PET/CT Form • Change in assessment of extent of disease • Change in management plan National Oncologic PET Registry
    15. 15. Acute Myeloid Leukemia Bladder Cancer Bone Cancer Breast Cancer Central Nervous System Tumors Cervical Cancer Chronic Myelogenous Leukemia Colorectal Cancer Esophageal Cancer Gastric Cancer Head and Neck Cancer Hepatobiliary Cancer Hodgkin’s Disease Kidney Cancer Melanoma Practice Guidelines in Oncology Myelodysplastic Syndromes Multiple Myeloma Neuroendocrine Tumors Non Hodgkin’s Lymphoma Non-Small Cell Lung Cancer Occult Primary Cancer Ovarian Cancer Pancreatic Cancer Prostate Cancer Soft Tissue Sarcoma Skin Cancer (except Melanoma) Small Cell Lung Cancer Testicular Cancer Thyroid Cancer Uterine Cancer National Comprehensive Cancer Network
    16. 16. Bone Cancer Breast Cancer Cervical Cancer Colorectal Cancer Esophageal Cancer Head and Neck Cancer Hodgkin’s Disease Melanoma Practice Guidelines in Oncology Multiple Myeloma Non Hodgkin’s Lymphoma Non-Small Cell Lung Cancer Occult Primary Cancer Ovarian Cancer Soft Tissue Sarcoma Small Cell Lung Cancer Testicular Cancer Thyroid Cancer National Comprehensive Cancer Network
    17. 17. 47 year old man with multiple trauma from a MVA who was incidentally discovered to have a pulmonary nodule Lesion Characterization
    18. 18. 84 year old man with chronic cough found to have a 13 mm nodule on CXR Lesion Characterization
    19. 19. 73 year old woman s/p resection for colon cancer, rising CEA level and negative CT Enhanced Detection
    20. 20. Enhanced Detection
    21. 21. 70 y/o male with H&N cancer Enhanced Detection
    22. 22. FDG PETI-131 47 year old man with biopsy proven recurrent thyroid cancer 3 months after thyroidectomy Enhanced Detection
    23. 23. Unknown Primary QuickTime™ and a decompressor are needed to see this picture. 68 year old man who presented with right neck mass
    24. 24. 49 year old man with new lung cancer Staging
    25. 25. Recurrent Disease QuickTime™ and a decompressor are needed to see this picture. 64 year old man s/p laryngectomy, now has dysphagia
    26. 26. Monitoring Response 63 year old man stage 3A lung cancer, has received 4 cycles of chemotherapy
    27. 27. CT + PET/CT vs PET/ CT MOST CASES • Standard CT followed by PET/CT if needed SOME CASES • PET/CT CT component can be low resolution or optimized
    28. 28. Problems and Pitfalls • False positive findings Normal physiology Granulomas and other infections Adenomas Tumor histology Lesions smaller than 8 mm Diabetes/Non-fasting patients • False negative findings
    29. 29. 56 year man with HCV, end stage liver disease, and presumed hepatoma Standard CT PET/CT
    30. 30. Physiologic Uptake: Brown Fat
    31. 31. Infection 68 year old man with solitary lung nodule. Biopsy: aspergillosis
    32. 32. Granulomatous Disease QuickTime™ and a decompressor are needed to see this picture. 62 year old man with hilar and mediastinal adenopathy. Biopsy: sarcoidosis
    33. 33. Adenoma QuickTime™ and a decompressor are needed to see this picture. 82 year old man with wt loss and liver masses
    34. 34. Adenoma QuickTime™ and a decompressor are needed to see this picture. 82 year old man with wt loss and liver masses
    35. 35. Clinical Impact of PET/CT • More accurate diagnosis • Avoidance of unnecessary tests, and (potentially) harmful procedures • Better treatment or management
    36. 36. http://www.cancerpetregistry.org National Oncologic PET Registry 36.5% change in decision to treat or not treat
    37. 37. Conclusions 1. CT is the first imaging test of choice in most cases 2. PET - CT is more accurate than CT alone • Characterizing lesions difficult to biopsy • Detecting occult cancer • Determining extent of cancer and response to therapy 3. PET - CT changes management 36%
    38. 38. Why PET-CT?

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