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PET.CT in Chest Imaging


Thomas F. Heston, MD, FACNM, FASNC, FAAFP
Why PET/CT Works:
The Warburg Effect
●
    Normal Cells
       ●
           Low rate of glycolysis
       ●
           Aerobic metabolism

●
    Most Cancer Cells
       ●
           High rate of glycolysis
       ●
           Anaerobic metabolism
Imaging Glycolysis: 18-F FDG
Imaging the glycolisis: Positron Emission Tomography


                                     511 γ




                                     e+
                                     e-




                                     511 γ
Imaging the Warburg Effect: Why it Works
The Warburg Effect: Cancer Types
●
    Nearly all solid tissue tumors
       ●
           Lung
       ●
           Colon
       ●
           Breast

●
    Notable Exceptions
       ●
           Slow growth: prostate cancer (use 18F-fluoride)
       ●
           Mucinous: BAC
       ●
           Early Disease: tumors < 0.5 cm
18-F FDG PET/CT Works Because:

●
    Tumor cells have increased glycolysis
●
    O-18 enriched water bombarded by protons
      ---> F-18 ---> 18F-FDG
●
    FDG hits a metabolic dead end
●
    PET images 18F positron emissions
●
    CT allows anatomic localization
Imaging the Warburg Effect: Normal vs Abnormal
Case Studies
Case #1: SCLC

●
    71 yr F with SCLC.
●
    Conventional staging
       ●
           Lung tumor
       ●
           Suggestive left lung nodes
       ●
           Suggestive liver metastases
Used with permission: Mike Medeiros, Chief Technologist, Western Washington Oncology, Lacey, WA
Used with Permission: Mike Medeiros, Chief Technologist, Western Washington Oncology, Lacey, WA
Case #1: How PET Helped
●
    PET/CT Findings
       ●
           Identified unknown contralateral disease
       ●
           Identified unknown skeletal metastases
       ●
           Conclusively identified “suggestive” findings
            on CT as metastatic disease

●
    Conclusion: FDG PET/CT important in
     staging SCLC
Case #2: Lung Mass
●
    77 yo F with remote hx of TB
●
    Conventional imaging (CT) noted the
     lung mass and indeterminate liver
     lesions
●
    An FDG PET scan was then performed
Case #2: CT Scan




Used with permission: Dr. Gabriel Soudry, petcases.com
Case #2: PET Scan

                                                         Normal FDG
                                                         uptake with no
                                                         evidence of
                                                         malignancy




Used with permission: Dr. Gabriel Soudry, petcases.com
Case #2: How PET Helped

●
    On the basis of the PET scan and
     clinical circumstances, no further
     testing was performed and invasive
     procedures avoided.
Case #2: Evidence Base

●
    Meta-analysis of 1474 pulmonary
     lesions
●
    FDG PET sensitivity 96.8%
●
    High negative predictive value


        Reference: JAMA 2001;285:914-924
Case #3: Lung Nodule

●
    77 yo F being followed with serial CT
     for a lung nodule
●
    CT Findings
       ●
           Initial: 6mm nodule
       ●
           6 mo follow-up: 6mm nodule
       ●
           No other abnormalities identified

●
    PET Scan then performed
Case #3: CT Findings
                                                         Baseline




                                                         6-mo f/u




Used with permission: Dr. Gabriel Soudry, petcases.com
PET Scan:

                                                         a) FDG avid nodule

                                                         b) Large hilar FDG
                                                         avid mass which
                                                         was only seen
                                                         retrospectively on
                                                         CT




Used with permission: Dr. Gabriel Soudry, petcases.com
Case #3: How PET Helped

●
    PET outperformed wait & watch
●
    No FNA of nodule necessary
       ●
           FNA: low yield for a 6 mm nodule
       ●
           FNA: high false negative rate
       ●
           FNA: added morbidity
Case #3: Evidence Base

  ●
      PET Sens 97% and Spec 78% (1)
  ●
      PET often alters management
       compared to CT (2)
          ●
              41% upstaged
          ●
              20% downstaged

References: (1) JAMA 2001;285:914-924,   (2) N Engl J Med
2000;343:254-61
PET/CT Bone Scans
F-18 NaF vs Tc-99m MDP

●
    PET/CT more accurate
       ●
           Sensitivity: 90% vs 80%
       ●
           Specificity: 95%+ vs 90%

●
    PET/CT more comfortable
       ●
           Shorter uptake time
       ●
           Shorter scan time
PET/CT vs SPECT




 http://www.cms.gov/mcd/publiccomment_popup.asp?comment_id=19917
Dual Tracer Acquisition
Research Studies
Staging NSCLC by PET
            Ann Thorac Surg 1995;60:1573


●
    99 patients: 67 for staging NSCLC and 32 with a
      nodule subsequently determined to be NSCLC
●
    Unexpected distant metastatic disease in 11
●
    CT false-positive for metastatic disease in 18
●
    Conclusion: FDG PET plays an important role in
      staging NSCLC
Detection of Unexpected Extrathoracic
       Metastases in NSCLC With PET
     Langenbecks Arch Chir Suppl Kongressbd. 1998;115:1264-7


●
    100 patients with stage IIIa or less NSC lung
      cancer by conventional imaging
●
    Unexpected distant metastatic disease in 13
●
    Conclusion: FDG PET plays an important role in
      staging NSCLC
FDG PET in Staging Lung Cancer
           Ann Thorac Surg 1999;67:790-797


• 97 NSCLC patients under consideration for surgery

• PET found that 16/97 patients had unexpected
    distant metastatic disease

• PET results altered management in 35/97

• CONCLUSION: FDG PET plays an important role in
    appropriately staging NSCLC patients
Preoperative Staging of NSCLC With PET
         NEJM Volume 343:254-261 July 27, 2000


• 102 patients with suspected resectable NSCLC

• unexpected distant metastatic disease was found in
    11/102

• PET altered cancer stage in 62/102

• CONCLUSION: FDG PET plays an important role in
    appropriately staging NSCLC patients
Clinical Impact of FDG PET in NSCLC
           J Clin Oncol. 2001 Jan 1;19(1):111-8


• prospective trial of 105 NSCLC patients

• 12 patients considered inoperable were downstaged

• 27 patients were upstaged to palliative treatment

• PET changed therapy in 67% of patients

• CONCLUSION: FDG PET plays an important role in
    appropriately staging NSCLC patients
Detecting Unsuspected Distant Metastases
     by PET in Apparent Stage III NSCLC
    Int J Radiat Oncol Biol Phys. 2001 Jun 1;50(2):287-93


• 137 NSCLC patients

• Unexpected distant metastatic disease found in
    32/137

• CONCLUSION: FDG PET plays an important role in
    appropriately staging NSCLC patients
CONCLUSION
• FDG PET improves surgical outcomes by
    decreasing the futile thoracotomy rate

     – FDG PET identifies unexpected metastatic
        disease in 10% to 20% of NSCLC patients

     – FDG PET is the most sensitive, specific, and
        accurate imaging modality to stage the
        mediastinum

• FDG PET is both downstages and upstages NSCLC
QUESTIONS

• When should a less sensitive, less specific,
   less accurate test be preferable to a
   more sensitive, more specific, more
   accurate test? (CT versus PET)

• Don’t all patients with NSCLC deserve the
   most accurate staging possible?
CONCLUSIONS

• For the SPN

    – FDG PET allows a faster decision on
       whether to follow by serial CT scans
       or to proceed to invasive diagnosis

    – FDG PET is the most sensitive,
       specific, and accurate imaging test
       available
CONCLUSIONS

• For confirmed or suspected NSCLC

    – FDG PET has been shown in multiple
       studies to identify unsuspected
       distant metastatic disease in 10% to
       20%

    – FDG PET is more sensitive, specific,
       and accurate in staging the
       mediastinum compared to CT
FDG PET/CT vs MDP Bone Scan - 1

●
    70 pts with a variety of cancers with bone mets
●
    Per Patient Basis: PET/CT 97% vs BS 86% sensitivity
●
    Per Lesion Basis: PET/CT 92% vs BS 70% sensitivity
●
    Incidental Findings: in 24 patients, organ metastases
       were found and in 7/7 pts with unknown primary, the
       primary was found


Ozülker T, Küçüköz Uzun A, Ozülker F, Ozpaçac T. Comparison of (18)F-FDG-PET/CT with (99m)Tc-MDP
bone scintigraphy for the detection of bone metastases in cancer patients. Nucl Med Commun. 2010
Jun;31(6):597-603.
FDG PET/CT vs MDP Bone Scan - 2




                  MDP - Equivocal                              PET/CT - Definite
Ozülker T, Küçüköz Uzun A, Ozülker F, Ozpaçac T. Comparison of (18)F-FDG-PET/CT with (99m)Tc-MDP
bone scintigraphy for the detection of bone metastases in cancer patients. Nucl Med Commun. 2010
Jun;31(6):597-603.
Clinical Guidelines
2007: American College Chest
Surgeons
●
    SPN: yes
●
    NSCLC: yes for patients being treated
     with curative intent
2008: JNM Consensus Panel

●
    Diagnosis of SPN: yes
●
    Staging NSCLC: yes
●
    Staging SCLC: uncertain
●
    Restaging: no opinion
2009: Irish Thoracic Society

●
    Any time resection is being
     considered
●
    Characterization of pulmonary
     nodules (selected cases)
2010: NCCN

●
    SPN: yes
●
    NSCLC Staging: yes
●
    Radiation Therapy Planning: yes
Questions?


    Tawam Molecular Imaging Centre
Thank You!

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Arab Health 2011: PET/CT in Chest Imaging

  • 1. PET.CT in Chest Imaging Thomas F. Heston, MD, FACNM, FASNC, FAAFP
  • 2. Why PET/CT Works: The Warburg Effect ● Normal Cells ● Low rate of glycolysis ● Aerobic metabolism ● Most Cancer Cells ● High rate of glycolysis ● Anaerobic metabolism
  • 4. Imaging the glycolisis: Positron Emission Tomography 511 γ e+ e- 511 γ
  • 5. Imaging the Warburg Effect: Why it Works
  • 6. The Warburg Effect: Cancer Types ● Nearly all solid tissue tumors ● Lung ● Colon ● Breast ● Notable Exceptions ● Slow growth: prostate cancer (use 18F-fluoride) ● Mucinous: BAC ● Early Disease: tumors < 0.5 cm
  • 7.
  • 8. 18-F FDG PET/CT Works Because: ● Tumor cells have increased glycolysis ● O-18 enriched water bombarded by protons ---> F-18 ---> 18F-FDG ● FDG hits a metabolic dead end ● PET images 18F positron emissions ● CT allows anatomic localization
  • 9. Imaging the Warburg Effect: Normal vs Abnormal
  • 11. Case #1: SCLC ● 71 yr F with SCLC. ● Conventional staging ● Lung tumor ● Suggestive left lung nodes ● Suggestive liver metastases
  • 12. Used with permission: Mike Medeiros, Chief Technologist, Western Washington Oncology, Lacey, WA
  • 13. Used with Permission: Mike Medeiros, Chief Technologist, Western Washington Oncology, Lacey, WA
  • 14. Case #1: How PET Helped ● PET/CT Findings ● Identified unknown contralateral disease ● Identified unknown skeletal metastases ● Conclusively identified “suggestive” findings on CT as metastatic disease ● Conclusion: FDG PET/CT important in staging SCLC
  • 15. Case #2: Lung Mass ● 77 yo F with remote hx of TB ● Conventional imaging (CT) noted the lung mass and indeterminate liver lesions ● An FDG PET scan was then performed
  • 16. Case #2: CT Scan Used with permission: Dr. Gabriel Soudry, petcases.com
  • 17. Case #2: PET Scan Normal FDG uptake with no evidence of malignancy Used with permission: Dr. Gabriel Soudry, petcases.com
  • 18. Case #2: How PET Helped ● On the basis of the PET scan and clinical circumstances, no further testing was performed and invasive procedures avoided.
  • 19. Case #2: Evidence Base ● Meta-analysis of 1474 pulmonary lesions ● FDG PET sensitivity 96.8% ● High negative predictive value Reference: JAMA 2001;285:914-924
  • 20. Case #3: Lung Nodule ● 77 yo F being followed with serial CT for a lung nodule ● CT Findings ● Initial: 6mm nodule ● 6 mo follow-up: 6mm nodule ● No other abnormalities identified ● PET Scan then performed
  • 21. Case #3: CT Findings Baseline 6-mo f/u Used with permission: Dr. Gabriel Soudry, petcases.com
  • 22. PET Scan: a) FDG avid nodule b) Large hilar FDG avid mass which was only seen retrospectively on CT Used with permission: Dr. Gabriel Soudry, petcases.com
  • 23. Case #3: How PET Helped ● PET outperformed wait & watch ● No FNA of nodule necessary ● FNA: low yield for a 6 mm nodule ● FNA: high false negative rate ● FNA: added morbidity
  • 24. Case #3: Evidence Base ● PET Sens 97% and Spec 78% (1) ● PET often alters management compared to CT (2) ● 41% upstaged ● 20% downstaged References: (1) JAMA 2001;285:914-924, (2) N Engl J Med 2000;343:254-61
  • 26. F-18 NaF vs Tc-99m MDP ● PET/CT more accurate ● Sensitivity: 90% vs 80% ● Specificity: 95%+ vs 90% ● PET/CT more comfortable ● Shorter uptake time ● Shorter scan time
  • 27. PET/CT vs SPECT http://www.cms.gov/mcd/publiccomment_popup.asp?comment_id=19917
  • 30. Staging NSCLC by PET Ann Thorac Surg 1995;60:1573 ● 99 patients: 67 for staging NSCLC and 32 with a nodule subsequently determined to be NSCLC ● Unexpected distant metastatic disease in 11 ● CT false-positive for metastatic disease in 18 ● Conclusion: FDG PET plays an important role in staging NSCLC
  • 31. Detection of Unexpected Extrathoracic Metastases in NSCLC With PET Langenbecks Arch Chir Suppl Kongressbd. 1998;115:1264-7 ● 100 patients with stage IIIa or less NSC lung cancer by conventional imaging ● Unexpected distant metastatic disease in 13 ● Conclusion: FDG PET plays an important role in staging NSCLC
  • 32. FDG PET in Staging Lung Cancer Ann Thorac Surg 1999;67:790-797 • 97 NSCLC patients under consideration for surgery • PET found that 16/97 patients had unexpected distant metastatic disease • PET results altered management in 35/97 • CONCLUSION: FDG PET plays an important role in appropriately staging NSCLC patients
  • 33. Preoperative Staging of NSCLC With PET NEJM Volume 343:254-261 July 27, 2000 • 102 patients with suspected resectable NSCLC • unexpected distant metastatic disease was found in 11/102 • PET altered cancer stage in 62/102 • CONCLUSION: FDG PET plays an important role in appropriately staging NSCLC patients
  • 34. Clinical Impact of FDG PET in NSCLC J Clin Oncol. 2001 Jan 1;19(1):111-8 • prospective trial of 105 NSCLC patients • 12 patients considered inoperable were downstaged • 27 patients were upstaged to palliative treatment • PET changed therapy in 67% of patients • CONCLUSION: FDG PET plays an important role in appropriately staging NSCLC patients
  • 35. Detecting Unsuspected Distant Metastases by PET in Apparent Stage III NSCLC Int J Radiat Oncol Biol Phys. 2001 Jun 1;50(2):287-93 • 137 NSCLC patients • Unexpected distant metastatic disease found in 32/137 • CONCLUSION: FDG PET plays an important role in appropriately staging NSCLC patients
  • 36. CONCLUSION • FDG PET improves surgical outcomes by decreasing the futile thoracotomy rate – FDG PET identifies unexpected metastatic disease in 10% to 20% of NSCLC patients – FDG PET is the most sensitive, specific, and accurate imaging modality to stage the mediastinum • FDG PET is both downstages and upstages NSCLC
  • 37. QUESTIONS • When should a less sensitive, less specific, less accurate test be preferable to a more sensitive, more specific, more accurate test? (CT versus PET) • Don’t all patients with NSCLC deserve the most accurate staging possible?
  • 38. CONCLUSIONS • For the SPN – FDG PET allows a faster decision on whether to follow by serial CT scans or to proceed to invasive diagnosis – FDG PET is the most sensitive, specific, and accurate imaging test available
  • 39. CONCLUSIONS • For confirmed or suspected NSCLC – FDG PET has been shown in multiple studies to identify unsuspected distant metastatic disease in 10% to 20% – FDG PET is more sensitive, specific, and accurate in staging the mediastinum compared to CT
  • 40. FDG PET/CT vs MDP Bone Scan - 1 ● 70 pts with a variety of cancers with bone mets ● Per Patient Basis: PET/CT 97% vs BS 86% sensitivity ● Per Lesion Basis: PET/CT 92% vs BS 70% sensitivity ● Incidental Findings: in 24 patients, organ metastases were found and in 7/7 pts with unknown primary, the primary was found Ozülker T, Küçüköz Uzun A, Ozülker F, Ozpaçac T. Comparison of (18)F-FDG-PET/CT with (99m)Tc-MDP bone scintigraphy for the detection of bone metastases in cancer patients. Nucl Med Commun. 2010 Jun;31(6):597-603.
  • 41. FDG PET/CT vs MDP Bone Scan - 2 MDP - Equivocal PET/CT - Definite Ozülker T, Küçüköz Uzun A, Ozülker F, Ozpaçac T. Comparison of (18)F-FDG-PET/CT with (99m)Tc-MDP bone scintigraphy for the detection of bone metastases in cancer patients. Nucl Med Commun. 2010 Jun;31(6):597-603.
  • 43. 2007: American College Chest Surgeons ● SPN: yes ● NSCLC: yes for patients being treated with curative intent
  • 44. 2008: JNM Consensus Panel ● Diagnosis of SPN: yes ● Staging NSCLC: yes ● Staging SCLC: uncertain ● Restaging: no opinion
  • 45. 2009: Irish Thoracic Society ● Any time resection is being considered ● Characterization of pulmonary nodules (selected cases)
  • 46. 2010: NCCN ● SPN: yes ● NSCLC Staging: yes ● Radiation Therapy Planning: yes
  • 47. Questions? Tawam Molecular Imaging Centre