Positron Emission Tomography In Oncology

2,033 views

Published on

Published in: Health & Medicine, Technology
0 Comments
4 Likes
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total views
2,033
On SlideShare
0
From Embeds
0
Number of Embeds
29
Actions
Shares
0
Downloads
223
Comments
0
Likes
4
Embeds 0
No embeds

No notes for slide

Positron Emission Tomography In Oncology

  1. 1. POSITRON EMISSION TOMOGRAPHY IN ONCOLOGY F De Winter, C Van de Wiele, RA Dierckx Ghent University and University Hospital, Belgium
  2. 2. POSITRON EMISSION TOMOGRAHY <ul><li>PET technique : ‘a diagnostic method that creates high resolution, 3 dimensional tomographic images of the quantitative distribution of positron emitting radionuclides in the human body’ </li></ul><ul><li>PET imaging : functional (<=> anatomical) indexes of blood flow, glucose metabolism, amino acid transport, protein metabolism, neuroreceptor status, oxygen consumption or even cell division… </li></ul><ul><li>Oncology : F-18 FDG, C-11 methionine, C-11 thymidine, C-11 tyrosine, etc…. </li></ul>
  3. 3. NUCLEAR MEDICINE : DIAGNOSIS <ul><li>Conventional : </li></ul><ul><li>planar, wholebody,SPECT,.. </li></ul><ul><li>single photon emitters : </li></ul><ul><li>Tc-99m, I-123 </li></ul><ul><li>PET versus SPE(C)T </li></ul><ul><li>quantitation </li></ul><ul><li>sens & resolution +++ </li></ul><ul><li>dual photon emitters : </li></ul><ul><li>C-11, N-13, O-15 </li></ul><ul><ul><ul><li>F-18 FDG </li></ul></ul></ul>
  4. 4. Radiopharmaceutical (eg FDG) electron 511 keV gamma ray 511 keV gamma ray positron positron + electron = 2 * 511 Kev (180°)
  5. 5. BABY CYCLOTRON
  6. 6. POSITRON EMISSION TOMOGRAHY SYSTEM
  7. 7. 18 FLUORINE BONE PET
  8. 8. 18 FLUORO DEOXYGLUCOSE (FDG)
  9. 9. FDG UPTAKE MECHANISM
  10. 10. NORMAL FDG PET SCAN
  11. 12. REIMBURSEMENT FOR FDG PET IN BELGIUM <ul><li>Before July 1999 : </li></ul><ul><ul><li>evaluation of myocardial viability before revascularisation </li></ul></ul><ul><ul><li>evaluation of suspected epileptogenic foci in refractory epilepsy </li></ul></ul><ul><ul><li>differentiation of tumour and radiation necrosis in brain tumours </li></ul></ul><ul><li>After July 1999 : </li></ul><ul><ul><li>new indications in oncology reimbursed </li></ul></ul><ul><ul><li>13 PET centres allowed </li></ul></ul>
  12. 13. REIMBURSEMENT FOR FDG PET <ul><li>A) SUSPICION OF LOCOREGIONAL RELAPSE = RESTAGING </li></ul><ul><li>1) BRAIN TUMOUR </li></ul><ul><li>2) BUCCAL OR PHARYNGEAL TUMOUR </li></ul>When other imaging modalities are not conclusive...
  13. 14. REIMBURSEMENT FOR FDG PET <ul><li>B ) SUSPICION OF RELAPSE = RESTAGING </li></ul><ul><li>a) LYMPHOMA </li></ul><ul><li>b) OVARIUM CARCINOMA </li></ul><ul><li>c) COLORECTAL TUMOUR </li></ul>When other imaging modalities are not conclusive...
  14. 15. REIMBURSEMENT FOR FDG PET <ul><li>C ) WHEN DECISION OF SURGERY MIGHT BE ALTERED IN THE WORKOUT = STAGING </li></ul><ul><li>a) LUNG TUMOUR </li></ul><ul><li>b) MALIGNANT MELANOMA </li></ul><ul><li>c) PANCREATIC TUMOUR </li></ul>
  15. 17. LOCOREGIONAL RESTAGING : BRAIN TUMOR RECURRENCE <ul><li>PET : </li></ul><ul><ul><li>FDG </li></ul></ul><ul><ul><li>Amino acid analogues </li></ul></ul><ul><li>SPECT alternatives : </li></ul><ul><ul><li>Thallium-201 :”potassium analogue” </li></ul></ul><ul><ul><li>Sesta MIBI : “mitochondrial activity” </li></ul></ul><ul><ul><li>Alfa methyltyrosine : aminoacid analogue </li></ul></ul><ul><ul><ul><ul><li>Low grade astrocytomas </li></ul></ul></ul></ul>
  16. 19. LOCOREGIONAL RESTAGING : HEAD AND NECK CANCER
  17. 20. POSSIBLE PET INDICATIONS FOR HEAD AND NECK CANCER <ul><li>I STAGING OF THE NECK </li></ul><ul><li>II DIAGNOSIS OF RECURRENCE </li></ul><ul><li>III EVALUATION OF TREATMENT </li></ul><ul><li>IV EVALUATION OF CUP- SYNDROME </li></ul>
  18. 21. HEAD AND NECK CANCER <ul><li>5% of all carcinomas world-wide (increasing) </li></ul><ul><ul><li>vast majority squamous cell carcinoma </li></ul></ul><ul><ul><li>40% early stage at diagnosis </li></ul></ul><ul><ul><li>problem of subclinical disease </li></ul></ul><ul><li>LN involvement most important prognostic factor </li></ul><ul><ul><li>N0: 5year survival > 50% </li></ul></ul><ul><ul><li>N+: 5year survival < 30% </li></ul></ul><ul><li>Therapy </li></ul><ul><ul><li>Early stages (40%): surgery or RT alone. </li></ul></ul><ul><ul><li>Late stages (60%) : surgery and (chemo)RT </li></ul></ul>
  19. 22. HEAD AND NECK CANCER : II LOCAL RECURRENCE <ul><li>Incidence : </li></ul><ul><ul><li>up to 50 % => initiation of salvage therapy </li></ul></ul><ul><li>Diagnosis </li></ul><ul><ul><ul><li>clinical </li></ul></ul></ul><ul><ul><ul><ul><ul><li>delayed mucosal healing </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>persistent wound infection </li></ul></ul></ul></ul></ul><ul><ul><ul><li>CT, MRI </li></ul></ul></ul><ul><ul><ul><ul><ul><li>edema and / or fibrosis </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>haematoma </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><li>DD : post-therapeutic changes </li></ul></ul></ul></ul><ul><ul><ul><li>FNA </li></ul></ul></ul><ul><ul><ul><ul><ul><li> FN, morbidity </li></ul></ul></ul></ul></ul>
  20. 23. HEAD AND NECK CANCER : LOCAL RECURRENCE <ul><ul><li>n sens spec </li></ul></ul><ul><li>Lapela, 1995 15 PET 88 % 86 % </li></ul><ul><li>Anzai, 1995 12 PET 88 %/ 25% MRI-CT 100 %/ 75 % </li></ul><ul><li>Fishbein *, 1998 35 PET 100 % 64 % </li></ul><ul><li>Collins, 1998 37 PET 94 % 88 % </li></ul><ul><li>Farber, 1999 28 PET 86 % 93 % </li></ul><ul><li>Lapela, 2000 56 PET 84-95 % 84-93 % </li></ul><ul><li>* gold standard : > 6 M follow-up </li></ul>
  21. 24. HEAD AND NECK CANCER CLINICAL STUDY <ul><li>44-year-old woman treated for carcinoma in the left retromolar trigonum; CT showed post-radiation necrosis; </li></ul><ul><li>routine PET suggestive for relapse: confirmed by surgery </li></ul>
  22. 25. HEAD AND NECK CANCER CLINICAL STUDY <ul><li>57-year-old man with larynxca irradiated 18 months earlier; </li></ul><ul><li>Clinic and CT : left cervical, submental and submandibular nodes </li></ul><ul><li>PET : confirmation + supraclavicular and lung lesions. </li></ul><ul><li>RX thorax normal; lung metastases confirmed by CT </li></ul>
  23. 27. RESTAGING OF LYMPHOMA <ul><li>High percentage of relapse </li></ul><ul><li>CT : 64% pts persistent abnormalities after completion of chemotherapy </li></ul><ul><li>Gallium-67 : </li></ul><ul><ul><li>Sens for high grade of 85 %, for low grade of 60 % </li></ul></ul><ul><ul><li>Limitations = abdomen, resolution, scan after 24 hrs, dosimetry </li></ul></ul><ul><li>In 9 studies using FDG PET in 192 pts sens of 80-100 % (Romer and Shwaiger, 1998) </li></ul><ul><ul><li>PET and CT = in 89% </li></ul></ul><ul><ul><li>PET > CT in 10% </li></ul></ul><ul><ul><li>PET < CT in 1% </li></ul></ul>
  24. 28. RESTAGING OF LYMPHOMA <ul><li>PET versus CT post Rx for detection of residual disease in 34 (17 NHL; 17 HD) patients undergoing RT and chemo (De Wit et al, Ann. Oncol 1997). Similar results Mikhaeel et al, Ann Oncol 2000, n 32 </li></ul><ul><li>Caveats </li></ul><ul><li>diffusely increased uptake in bone marrow may be due to chemotherapy </li></ul><ul><li>in immunodepressed pts infections may mimic residual tumor </li></ul>
  25. 29. LYMPHOMA <ul><li>At present the data suggests FDG PET is superior to CT (and Ga-67) in: </li></ul><ul><ul><li>detection of residual disease </li></ul></ul><ul><ul><li>detection of relapse </li></ul></ul><ul><li>Data are forthcoming on the value of FDG PET relative to CT for </li></ul><ul><ul><li>staging (Shah et al, Brit J Radiol 2000; n 29, 12 HD, 17 NHL : change in management in 34 %) </li></ul></ul><ul><ul><li>p redicting response and monitoring therapy </li></ul></ul>
  26. 31. RESTAGING OF OVARIUM CARCINOMA <ul><li>Limited (and less convincing) data in mixed populations </li></ul><ul><li>Romer et al, ROFO 1997; n 19 : sens of 83 %; spec of 54 % </li></ul><ul><li>Zimny et al; Nuklearmedizin 1997; n 26 : “PET is of limited value in the dd between ovarium ca and inflammatory processes” </li></ul><ul><li>Grab et al, Gynecol Oncol 2000; n 101 adnexal masses, 12 ovarian cancers : “negative MRI or PET results do not rule out early stage ovarian cancer” </li></ul><ul><li>Kubik-Huch et al, Eur Radiol 2000; n 19 : no significant difference between CT, MRI and PET for lesion characterization or detection of recurrent disease </li></ul>
  27. 33. COLORECTAL CARCINOMA : RESTAGING <ul><li>15 % of malignant tumors </li></ul><ul><ul><ul><li>70 % operable  1/3 recurrence </li></ul></ul></ul><ul><li>CT/MRI : DD posttherapeutic changes </li></ul><ul><ul><ul><li>edema </li></ul></ul></ul><ul><ul><ul><li>fibrosis (scar) </li></ul></ul></ul><ul><li>For PET reimbursement no CEA criteria </li></ul>
  28. 34. COLORECTAL CARCINOMA : RESTAGING <ul><li>Patient based 18-FDG PET results </li></ul><ul><li>Authors n(pts) n(sites) Sens Spec </li></ul><ul><li>Schiepers, 1995 76 94 % 98 % </li></ul><ul><li>Pounds, 1995 33 47 96 % 87 % </li></ul><ul><li>Daenen, 1996 19 29 95 % 67 % </li></ul><ul><li>Ogunbiyi, 1997 58 96 % 86 % </li></ul><ul><li>Delbeke, 1998 52 166 92 % 92 % </li></ul><ul><li>TOTAL 238 94 % 87 % </li></ul>
  29. 35. COLORECTAL CARCINOMA : RESTAGING <ul><li>18-FDG PET results, local pelvic recurrence </li></ul><ul><li>Authors n sens spec accur </li></ul><ul><li>Schiepers, 1995 </li></ul><ul><ul><ul><ul><ul><li>76, PET 93 % 97 % 95 % </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>CT 60 % 72 % 65 % </li></ul></ul></ul></ul></ul><ul><li>Hustinx, 1998 </li></ul><ul><ul><ul><ul><ul><li>27 PET 90 % 71 % 85 % </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>CT 85 % 60 % 80 % </li></ul></ul></ul></ul></ul><ul><li>Ogunbiyi, 1997 </li></ul><ul><ul><ul><ul><ul><li>47 PET 91 % 100 % 95 % </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>CT 52 % 80 % 70 % </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>MRI 64 % 75 % 65 % </li></ul></ul></ul></ul></ul><ul><li>Ito,, 1996 </li></ul><ul><ul><ul><ul><ul><li>37 PET 100 % 100 % 100 % </li></ul></ul></ul></ul></ul><ul><li>Keogan, 1997 , </li></ul><ul><ul><ul><ul><ul><li>18 PET 92 % 80 % 89 % </li></ul></ul></ul></ul></ul>
  30. 38. STAGING OF LUNG CARCINOMA <ul><li>I SOLITARY PULMONARY NODULE </li></ul><ul><li>II MEDIASTINAL STAGING IN NSCLC </li></ul><ul><li>III DISTANT METASTASIS </li></ul>
  31. 39. LUNG CARCINOMA : I SOLITARY PULMONARY NODULE DIFFERENTIAL DIAGNOSIS <ul><li>malignant tumours : lung, lymphoma, metastasis… </li></ul><ul><li>benign tumours : hamartoma, lipoma </li></ul><ul><li>infectious : abscess, tuberculoma… </li></ul><ul><li>vasculitis : RA, sarcoidosis… </li></ul><ul><li>congenital : bronchogenic cyst </li></ul><ul><li>various : hematoma, infarct… </li></ul>
  32. 40. SOLITARY PULMONARY NODULE <ul><li>Belgium: ± 5000 new cases/yr </li></ul><ul><ul><li>50-60% of SPN are benign (Khouri et al, 1987) </li></ul></ul><ul><ul><li>20-40% of resected nodules are benign (Midthun et al, 1992) </li></ul></ul><ul><li>Few CT criteria for diagnosis (Quint et al, 1995) </li></ul><ul><ul><li>Detection of benign pattern of calcification </li></ul></ul><ul><ul><li>Stability of the nodule over the last 2 years </li></ul></ul><ul><ul><li>Size < 20 mm 80% benign; > 40 mm always malignant (Vaylet, 1999) </li></ul></ul>
  33. 41. SOLITARY PULMONARY NODULE gold standard histology <ul><li>Authors n sensitivity specificity </li></ul><ul><li>Patz, 1993 51 89 % 100 % </li></ul><ul><li>Dewan, 1993 30 95 % 80 % </li></ul><ul><li>Wahl, 1994 23 100 % 100 % </li></ul><ul><li>Lowe, 1994 88 97 % 88 % </li></ul><ul><li>Dewan, 1995 35 100 % 78 % </li></ul><ul><li>Duhaylonso,1996 87 97 % 82 % </li></ul><ul><li>Gupta, 1996 61 93 % 88 % </li></ul><ul><li>Bury, 1996 103 98 % 95 % </li></ul><ul><li>Lowe, 1998 89 92 % 90 % </li></ul>
  34. 42. SOLITARY PULMONARY NODULE <ul><li>FDG PET: </li></ul><ul><ul><li>high sensitivity of ± 96% and specificity of ± 90% for malignancy ; </li></ul></ul><ul><ul><li>depending on local prevalence of known causes of FP (aspergillosis, tuberculosis…) </li></ul></ul><ul><li>PET versus CT + TTNA </li></ul><ul><ul><li>PPV of 94 % for PET versus 86 % for CT + TTNA (Dewan et al, Chest 1995 on 35 pts) </li></ul></ul><ul><ul><li>TTNA: high complication rate (pneumothorax, hemoptoe) </li></ul></ul><ul><li>FDG PET gives additional information on N and M stage (> 50% M+ at diagnosis) </li></ul>
  35. 43. DIFFERENTIAL DIAGNOSIS OF SOLITARY PULMONARY NODULES
  36. 44. SOLITARY PULMONARY NODULES: CONCLUSIONS (Rigo et al) <ul><li>FDG PET for 15 mm < SPN < 40 mm </li></ul><ul><li>negative => wait and see </li></ul><ul><ul><li>clinical-radiological follow-up >1 yr </li></ul></ul><ul><ul><li>no histologic confirmation necessary </li></ul></ul><ul><li>positive => invasive exploration </li></ul>
  37. 45. LUNG CANCER <ul><ul><ul><li>small cell lung cancer (oat cell): 20% </li></ul></ul></ul><ul><ul><ul><li>non small cell lung cancer: 80% </li></ul></ul></ul><ul><ul><ul><ul><li>epidermoid carcinoma: 50% </li></ul></ul></ul></ul><ul><ul><ul><ul><li>adenocarcinoma / bronchioloalveolair ca: 10% / 3% </li></ul></ul></ul></ul><ul><ul><ul><ul><li>large cell carcinoma: 18% </li></ul></ul></ul></ul>Therapy/prognosis depends on TNM stage
  38. 46. LUNG CANCER : II&III STAGING OF NSCLC <ul><ul><ul><li>RX thorax, CT-thorax </li></ul></ul></ul><ul><ul><ul><li>fiber-bronchoscopy and biopsy </li></ul></ul></ul><ul><ul><ul><ul><li>90% + if central ca </li></ul></ul></ul></ul><ul><ul><ul><ul><li>25-35% failure if small and peripheral ca </li></ul></ul></ul></ul><ul><ul><ul><li>TTNA and mediastinoscopy </li></ul></ul></ul><ul><ul><ul><li>blood sample: </li></ul></ul></ul><ul><ul><ul><ul><li>liver tests, CEA, NSE, cortisol, AP, calcium,… </li></ul></ul></ul></ul><ul><ul><ul><li>CT-brain </li></ul></ul></ul><ul><ul><ul><li>ultrasound or CT abdomen: liver? adrenals? </li></ul></ul></ul><ul><ul><ul><li>bone scan </li></ul></ul></ul>
  39. 47. STAGING OF NSCLC : N STAGING
  40. 48. STAGING OF NSCLC <ul><li>Mediastinoscopy invasive and expensive with sensitivity of (only) 87% ... </li></ul><ul><li>Majority of pts with intended curative resection ultimately die of metastatic disease (usually within 2 yrs): understaging… </li></ul><ul><li>Are non invasive techniques capable of screening equally well or better for N2N3 disease? </li></ul><ul><li>Or can they identify patients with M+ better? </li></ul>
  41. 49. NSCLC MEDIASTINAL STAGING <ul><li>Authors n sens spec </li></ul><ul><li>Wahl, 1994 </li></ul><ul><ul><ul><ul><ul><li>12 PET 82 % 81 % </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>CT 64 % 44 % </li></ul></ul></ul></ul></ul><ul><li>Scott, 1994 </li></ul><ul><ul><ul><ul><ul><li>25 PET 66 % 86 % </li></ul></ul></ul></ul></ul><ul><li>Bury, 1995 </li></ul><ul><ul><ul><ul><ul><li>20 PET 90 % 80 % </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>CT 63 % 66 % </li></ul></ul></ul></ul></ul><ul><li>Chin, 1995 </li></ul><ul><ul><ul><ul><ul><li>30 PET 78 % 81 % </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>CT 56 % 87 % </li></ul></ul></ul></ul></ul><ul><li>Sasaki, 1996 </li></ul><ul><ul><ul><ul><ul><li>29 PET 76 % 98 % </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>CT 65 % 87 % </li></ul></ul></ul></ul></ul><ul><li>Bury, 1997 </li></ul><ul><ul><ul><ul><ul><li>109 PET 100% 94 % </li></ul></ul></ul></ul></ul><ul><li>Erasmus, 1997 </li></ul><ul><ul><ul><ul><ul><li>27 PET 100% 80 % </li></ul></ul></ul></ul></ul><ul><li>Vansteenkiste, 1997 </li></ul><ul><ul><ul><ul><ul><li>50 PET (-CT) 67 % 97 % </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>PET (+ CT)93 % 97 % </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>CT 67 % 59 % </li></ul></ul></ul></ul></ul>
  42. 50. STAGING OF NSCLC : N STAGING Van Steenkiste et al, Chest, 1997
  43. 51. STAGING OF NSCLC : N STAGING <ul><li>68 yr old man with hemoptoe </li></ul><ul><li>CT : left upper lobe nodule and enlarged LN in the homo- and heterolateral mediastinum (N3) </li></ul>FDG-PET : high uptake in primary tumour but no focal abnormality in the mediastinum
  44. 52. STAGING OF NSCLC : M STAGING <ul><ul><ul><li>Bone: whole body FDG-PET vs bone scan (EJNM 1998) </li></ul></ul></ul><ul><ul><ul><ul><li>equal sensitivity of 90% </li></ul></ul></ul></ul><ul><ul><ul><ul><li>specificity of 98% versus 61% </li></ul></ul></ul></ul><ul><ul><ul><li>Liver: FDG-PET vs CT : </li></ul></ul></ul><ul><ul><ul><ul><li>sensitivity of 97% vs 93% and </li></ul></ul></ul></ul><ul><ul><ul><ul><li>specificity of 88% vs 75% (Ann Oncol 1998) </li></ul></ul></ul></ul><ul><ul><ul><li>Adrenals: ( Am J Roentg, 1997) </li></ul></ul></ul><ul><ul><ul><ul><li>up to 60% of detected masses are nonmalignant </li></ul></ul></ul></ul><ul><ul><ul><ul><li>biopsy is often required after CT or MRI </li></ul></ul></ul></ul><ul><ul><ul><ul><li>PET sensitivity of 100 % and specificity of 80% </li></ul></ul></ul></ul>
  45. 53. STAGING OF NSCLC : CONCLUSIONS <ul><ul><ul><li>PET negative (very high NPV) => thoracotomy </li></ul></ul></ul><ul><ul><ul><ul><li>mediastinoscopy could be omitted in up to 74% of patients eligible for surgery </li></ul></ul></ul></ul><ul><ul><ul><li>PET N + => confirmation mediastinoscopy </li></ul></ul></ul><ul><ul><ul><ul><li>no potentially curable patients are withdrawn from surgery </li></ul></ul></ul></ul><ul><ul><ul><ul><li>PET only incidentally false negative in minimal N2 disease (stage IIIA) </li></ul></ul></ul></ul><ul><ul><ul><li>Whole body PET for detection of distant metastasis : very high NPV </li></ul></ul></ul>
  46. 55. STAGING MALIGNANT MELANOMA <ul><li>High sensitivity for superficial LN and visceral lesions </li></ul><ul><ul><li>Ideal for follow-up of pts with high risk of recurrence or metastasis, in combination with CT for brain and lungs </li></ul></ul><ul><li>Lower sensitivity for </li></ul><ul><ul><li>Pulmonary lesions </li></ul></ul><ul><ul><li>Small skin lesions </li></ul></ul><ul><ul><li>Miliary involvement of larger organs </li></ul></ul><ul><ul><li>Brain metastasis (contrast) </li></ul></ul><ul><ul><li>Tumor sites with important necrosis </li></ul></ul>
  47. 57. STAGING PANCREAS TUMOR <ul><li>Differential diagnosis between malignancy and chronic pancreatitis : increases diagnostic accuracy as compared to CT and ERCP </li></ul><ul><ul><li>Sens of 88 % and spec of 88 % (Keogan et al, Am J Roentgenol 1998 : n 37) </li></ul></ul><ul><ul><li>Problem acute pancreatitis (Shreve, EJNM 1998) </li></ul></ul><ul><li>Detection of metastasis : </li></ul><ul><ul><li>for hepatic metastasis sens of 70 % and spec of 95 % </li></ul></ul><ul><ul><li>for LN staging sens of 49 % and spec of 63 % </li></ul></ul><ul><ul><li>missing metastasis < 1 cm or poorly localized peritoneal metastatic spread </li></ul></ul><ul><ul><li>( Diederichs et al, Pancreas 2000 : n 159 pts : 89 malignant, 70 benign) </li></ul></ul>
  48. 59. FDG PET: PRACTICALITIES <ul><li>Low glycemia </li></ul><ul><ul><li>Sober > 4 hours , no caloric drinks or glucose infusion </li></ul></ul><ul><li>- overnight fasting for morning scan </li></ul><ul><li>- light breakfast if afternoon scanning </li></ul><ul><ul><li>No glucose containing drinks </li></ul></ul><ul><ul><li>In diabetics : optimal metabolic control : insulin? </li></ul></ul><ul><li>Good hydration : </li></ul><ul><ul><li>0.5 l H2O extra + 20 mg furosemide iv </li></ul></ul><ul><ul><li>background activity + radiation </li></ul></ul><ul><li>Muscle relaxation : </li></ul><ul><ul><li>5-10 mg diazepam po </li></ul></ul>
  49. 60. FDG PET: PRACTICALITIES <ul><li>Complementary anatomical information (CT, MRI) for exact localization of hot spots (N2?N3?; rib vs pleura?) </li></ul><ul><li>Information about </li></ul><ul><ul><li>recent/concurrent surgery (min 3 months), </li></ul></ul><ul><ul><li>chemotherapy (before third cycle) </li></ul></ul><ul><ul><li>radiotherapy (3-4 months) </li></ul></ul><ul><ul><li>medication that stimulates bone marrow (growth factors) </li></ul></ul><ul><li>Bladder catheterisation may be warranted for evaluation of pelvic tumours close to the bladder </li></ul><ul><li>Total time: 2 hours </li></ul>
  50. 62. TOWARDS … <ul><li>N ew indications for the same tumors </li></ul><ul><ul><li>diagnosis, (re)staging of NSLC, colorectal, lymphoma, malignant melanoma </li></ul></ul><ul><ul><li>therapy monitoring early after start chemotherapy </li></ul></ul><ul><li>=> early switch to second line therapy </li></ul><ul><li>2) New tumours </li></ul><ul><ul><li>uterusca, germ cell tumours, osteosarcoma, </li></ul></ul><ul><ul><li>cfr USA : oesophagusca, breastca… </li></ul></ul><ul><li>3) New technology : new detectors, coregistration, etc </li></ul><ul><li>4) New tracers : fluorine chemistry, … </li></ul>
  51. 63. IMAGE FUSION : PET + CT
  52. 64. IMAGE FUSION
  53. 66. BREAST CARCINOMA <ul><li>PET potential </li></ul><ul><ul><li>T DD benign vs. malignant </li></ul></ul><ul><ul><li>N axillary lymph node evaluation </li></ul></ul><ul><ul><li>M distant metastases evaluation </li></ul></ul><ul><ul><li>Therapy monitoring </li></ul></ul><ul><li>T : DD benign vs. malignant </li></ul><ul><ul><li>radiodense breasts </li></ul></ul><ul><ul><li>young, hormone replacement, augmentation </li></ul></ul><ul><ul><li>occult primary lesion (N+) </li></ul></ul><ul><ul><li>multicentric and multifocal disease </li></ul></ul>
  54. 67. BREAST CARCINOMA, T <ul><li>Authors (n pts / benign/malignant) sens% spec% </li></ul><ul><li>Tse, 1992 14 (4/10) 80% 100 % </li></ul><ul><li>Adler, 1993 35 (8/27) 96 % 100 % </li></ul><ul><li>Hoh, 1993 20 (3/17) 88 % 33 % </li></ul><ul><li>Dehdrasti, 1995 22 (8/24) 88 % 100 % </li></ul><ul><li>Avril, 1996 72 (31/41) 92 % 97 % </li></ul><ul><li>Scheidhauer, 1996 30 (7/23) 91 % 86 % </li></ul>
  55. 68. BREAST CARCINOMA <ul><li>N STAGING </li></ul><ul><ul><li>for therapeutic implication & prognostic value </li></ul></ul><ul><li>Presently axillary dissection </li></ul><ul><ul><li>high cost & moderate morbidity </li></ul></ul><ul><li>=> an imaging test that could accurately determine the extent of disease at initial presentation would be of great value </li></ul>
  56. 69. BREAST CARCINOMA, N axillary <ul><li>Authors n sens % spec % </li></ul><ul><li>Wahl, 1991 7 100 % N/A </li></ul><ul><li>Tse, 1992 10 57 % 100 % </li></ul><ul><li>Adler, 1993 20 90 % 100 % </li></ul><ul><li>Hoh, 1993 14 67 % 100 % </li></ul><ul><li>Nieweg, 1993 5 100 % N/A </li></ul><ul><li>Multi-center, 1993 49 96 % 96 % </li></ul><ul><li>Avril, 1996 51 79 % 96 % </li></ul><ul><li>Scheidhauer, 1996 18 100 % 89 % </li></ul><ul><li>Utech, 1996 124 100 % 75 % </li></ul>
  57. 70. BREAST CARCINOMA <ul><li>M+ </li></ul><ul><ul><li>overall sensitivity > 85 % </li></ul></ul><ul><ul><li>positive predictive value 94 % </li></ul></ul><ul><li>Therapy response </li></ul><ul><ul><li>18 FDG decrease following therapy antedates a decrement in tumor size by 1.5-2 months </li></ul></ul><ul><ul><ul><ul><ul><li>Wahl et al., 1993 , J Clin Oncol, n = 11 </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Minn et al., 1989 , Eur J Nucl Med, n = 10 </li></ul></ul></ul></ul></ul>
  58. 71. BREAST CARCINOMA : DIAGNOSIS
  59. 72. BREAST CARCINOMA : NODAL STAGING
  60. 73. BREAST CARCINOMA : METASTASIS ? Bone scan suspicious; MRI doubtful; PET neg (TN)
  61. 74. HEAD AND NECK CANCER : I STAGING <ul><li>Accurate diagnosis of the nodal status of the neck is extremely important for treatment planning and prognosis </li></ul><ul><ul><li>N-stage dependent on localisation & extent of primary tumour </li></ul></ul><ul><ul><li>Clinical staging 15-50% FN as compared to CT/MRI (Curtin et al, Radiology 1998) </li></ul></ul><ul><li>CT NPV 84%, PPV 50%; MRI NPV 79%, PPV 52% </li></ul><ul><ul><li>CT/MRI criteria based on LN volume and inhomogeneity problematic : reactive enlargement vs tumour-infiltrated LN </li></ul></ul><ul><ul><li>quid N0 studies ? </li></ul></ul><ul><li>PET high sens & spec for detecting malignant tissue (primary tumour, LN, second tumour, metastasis) </li></ul><ul><ul><li>FP : inflammation </li></ul></ul><ul><ul><li>FN : micrometastases, resolution </li></ul></ul>
  62. 75. N STAGING: COMPARISON OF FDG PET WITH CONVENTIONAL STAGING <ul><li>Sens. Spec . </li></ul><ul><li>Braams, 1995, n = 60 </li></ul><ul><ul><ul><ul><ul><li>PET 91 % 88 % </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>NMR 36 % 94 % </li></ul></ul></ul></ul></ul><ul><li>Lauderbacher , 1995, n = 22 </li></ul><ul><ul><ul><ul><ul><li>PET 90 % 96 % </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>NMR 78 % 71 % </li></ul></ul></ul></ul></ul><ul><li>Myers , 1998, n = 14 </li></ul><ul><ul><ul><ul><ul><li>PET 78 % 100 % </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>CT 57 % 90 % </li></ul></ul></ul></ul></ul><ul><li>Adams , 1998, n = 60 </li></ul><ul><ul><ul><ul><ul><li>PET 90 % 94 % </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>CT 82 % 85 % </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>NMR 80 % 85 % </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>US 72 % 79 % </li></ul></ul></ul></ul></ul><ul><li>Myers , 1998, n = 12 </li></ul><ul><ul><ul><ul><ul><li>PET 100 % 100 % </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>CT 40 % 88 % </li></ul></ul></ul></ul></ul>
  63. 76. HEAD AND NECK CANCER <ul><li>III EVALUATION OF TREATMENT </li></ul><ul><ul><li>PET becomes negative when tumour response is achieved <=> anatomical imaging (necrosis, fibrosis) </li></ul></ul><ul><ul><li>Early postradiation PET can be FN: waiting for 3-4 months is advised (Rege et al., 1993) </li></ul></ul><ul><ul><li>No such delay period is warranted after chemotherapy => early adaptation of therapy possible (Haberkorn et al, 1993) </li></ul></ul><ul><li>IV EVALUATION OF CUP SYNDROME </li></ul><ul><ul><li>PET useful in detecting occult primary tumours in 30-50 % when anatomic imaging methods are negative ( Kole et al., Cancer 1998; Aasar et al., Radiology 1999; Lassen et al, Eur J Cancer 1999; Safa et al, Cancer J Sci Am 1999) </li></ul></ul><ul><ul><li>Comparative studies needed </li></ul></ul>
  64. 78. HEAD AND NECK CANCER CLINICAL STUDY <ul><li>50 year old woman with left palpable neck mass </li></ul><ul><li>Palpable mass of the tongue found (+ on MRI and PET) </li></ul><ul><li>2 LN both positive on MRI and PET </li></ul>
  65. 79. IMPORTANCE OF METABOLIC PREPARATION

×