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Clinical Indications for
   PET.CT Imaging
      in Urology
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
Normal PET/CT
Abnormal PET/CT
Prostate Cancer
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
PET/CT in Prostate Cancer:
Conclusions
●
    Workup: in selected patients only
●
    Restaging in pts with PSA relapse
       ●
           Nodal disease
       ●
           Osseous disease
       ●
           Dual FDG / NaF imaging
Renal Cell Carcinoma
PET/CT in Renal Cell
Carcinoma
●
    FDG excreted by the urinary tract
●
    Indications
       ●
           Staging high risk patients for metastatic
            disease
       ●
           When other imaging is non-diagnostic
Research Studies
PET/CT vs Bone Scan - 1
●
    44 pts with high risk prostate cancer
              ●
                  Gleson score >= 8 or PSA >= 20 ng/mL

●
    Prevalence: 52% with bony mets
●
    Gold Standard
              ●
                  All imaging results including MRI & CT
              ●
                  Biopsy in selected cases
              ●
                  Clinical follow-up
Even-Sapir E, Metser U, Mishani E, Lievshitz G, Lerman H, Leibovitch I. The detection of bone metastases
in patients with high-risk prostate cancer: 99mTc-MDP Planar bone scintigraphy, single- and multi-field-of-
view SPECT, 18F-fluoride PET, and 18F-fluoride PET/CT. J Nucl Med. 2006 Feb;47(2):287-97.
PET/CT vs Bone Scan - 2

   ●
       Agreement: 22/42 (52%)
   ●
       MDP understaged 13/42 (31%)
   ●
       MDP overstaged 7/42 (17%)




Even-Sapir E, Metser U, Mishani E, Lievshitz G, Lerman H, Leibovitch I. The detection of bone metastases
in patients with high-risk prostate cancer: 99mTc-MDP Planar bone scintigraphy, single- and multi-field-of-
view SPECT, 18F-fluoride PET, and 18F-fluoride PET/CT. J Nucl Med. 2006 Feb;47(2):287-97.
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.
Thank You!

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Arab Health 2011: PET/CT Imaging in Urology

  • 1. Clinical Indications for PET.CT Imaging in Urology 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
  • 13. 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
  • 14. PET/CT vs SPECT http://www.cms.gov/mcd/publiccomment_popup.asp?comment_id=19917
  • 16. PET/CT in Prostate Cancer: Conclusions ● Workup: in selected patients only ● Restaging in pts with PSA relapse ● Nodal disease ● Osseous disease ● Dual FDG / NaF imaging
  • 18. PET/CT in Renal Cell Carcinoma ● FDG excreted by the urinary tract ● Indications ● Staging high risk patients for metastatic disease ● When other imaging is non-diagnostic
  • 20. PET/CT vs Bone Scan - 1 ● 44 pts with high risk prostate cancer ● Gleson score >= 8 or PSA >= 20 ng/mL ● Prevalence: 52% with bony mets ● Gold Standard ● All imaging results including MRI & CT ● Biopsy in selected cases ● Clinical follow-up Even-Sapir E, Metser U, Mishani E, Lievshitz G, Lerman H, Leibovitch I. The detection of bone metastases in patients with high-risk prostate cancer: 99mTc-MDP Planar bone scintigraphy, single- and multi-field-of- view SPECT, 18F-fluoride PET, and 18F-fluoride PET/CT. J Nucl Med. 2006 Feb;47(2):287-97.
  • 21. PET/CT vs Bone Scan - 2 ● Agreement: 22/42 (52%) ● MDP understaged 13/42 (31%) ● MDP overstaged 7/42 (17%) Even-Sapir E, Metser U, Mishani E, Lievshitz G, Lerman H, Leibovitch I. The detection of bone metastases in patients with high-risk prostate cancer: 99mTc-MDP Planar bone scintigraphy, single- and multi-field-of- view SPECT, 18F-fluoride PET, and 18F-fluoride PET/CT. J Nucl Med. 2006 Feb;47(2):287-97.
  • 22. 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.