Petct In Gynecologic Cancer


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Petct In Gynecologic Cancer

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