Transcript PET in oncology - پزشکی هسته ای دکتر دباغ

‫درمرکزپزشکی هسته ای دکتردباغ – دکترصادقی‬
‫درخدمت شما هستیم‬
‫مشهد‪ ،‬مالصدرا ‪ ، 11‬پالک ‪1/4‬‬
‫‪www.DSNMC.ir‬‬
‫‪Tel:+98(51) 38411524; +98(51)38472927‬‬
Nuclear Medicine
In
Oncology
(Brief)
V. R. Dabbagh Kakhki, M.D.
Nuclear Medicine Specialist
Associate Professor
DSNMC
Nuclear Medicine Research Center (NMRC; MUMS)
www.DSNMC.ir
www.mums.ac.ir/nmrc
Basic
Bone ?
Nuclear Medicine
Tumoral agents
CNS
and…..
SPECT
•Bone Scan
+ SPECT
•Ga- 67 Scan
+ SPECT
•Tc99m-RBC Liver Scan + SPECT
•Tc99m –MIBI Brain
SPECT
•Tl-201 Brain
SPECT
•DMSA(V) Scan +
SPECT
Oncology: Nuclear Medicine

Diagnosis


Staging



Important for proper therapy
Response to Therapy
Follow-up


Specific or non-specific
Early detection of recurrens
Treatment

Specific or non-specific
Diagnostic radiopharmaceuticals

Non-specific agents

PET or PET-CT


F-18 FDG-PET
Planar, SPECT or SPECT-CT
Diphosphonates – bone scan
 Ga-67 citrate
 MIBI
 Tl-201
 DMSA(V)

Diagnostic radiopharmaceuticals


Specific – binds directly to special tumor antigens
or receptors or are accumulated by special
metabolic pathway
PET or PET/CT - no commercially available
 11C-HED

Planar, SPECT or SPECT/CT
MIBG
 I-131
 111In/Tc99m- Octreotide
 MoAb : labelled with In-111, I-123/131 or Tc-99m

Bone Scan
99mTc-MDP
Bone Scan

Clinical applications
Sensitive
But not Specific
Bone metastases,
 Primary bone tumors,
 Trauma and fractures, Stress fractures,
 Osteonecrosis,
 osteomyelitis,
 Prosthesis evaluation,
 Metabolic bone disease,
 Arthritis,

Bone scan

Scan pattern
Increased Uptake
 Defect - cold lesion
 Flare phenomenon – Increased uptake and number of
lesions in the case of effective therapy
 Super-scan (spread malignancies) - diffusely increased
uptake

Rib Fractures
Osteosarcoma
A 16-year-old boy with
pain in the upper left
tibia diagnosed as
primary osteogenic
sarcoma
of the left femur
Bone scan reveals
disseminated bone and
lung metastases.
Bone scan – multiple metastases
Lung cancer – cold lesion
Bone scan - prostate cancer
progression
Bone Metastases
Superscan: Disseminated bone metastases secondary to prostatic
cancer
Bone Scan
PRIMARY MALIGNANT BONE DISEASE
Assessment of
extension of the lesions or metastatic involvement





Osteosarcoma
Ewing Sarcoma
Chondrosarcoma
Multiple Myeloma
Rhabdomyosarcoma
Ewing Sarcoma
Ga-67 scan

Clinical indications

Lymphoma

staging and monitoring effect of therapy
Melanoma
 Lung cancer
 Hepatoma

Ccombination with other imaging modalities
(SPECT/CT)
Ga-67; a cornerstone in functional
imaging of lymphoma

Role; Diagnostic and prognostic data
 Staging
 Monitoring response to treatment
 Differentiate between fibrotic or necrotic tissues from viable
lymphoma in a residual mass
 Early diagnosis of recurrence
 Predicting outcome
 18F-FDG
PET; gradually replacing GS
Gallium Scan

SPECT

A baseline examination before treatment

intense Ga avidity: small, non-cleaved cell lymphoma (lesion
sens:89%)
Clinical History:
20-year-old, three weeks post
partum with anterior
mediastinal mass. Findings:
Gallium scan at shows
mediastinal adenopathy and
bilateral breast uptake.
Diagnosis: Hodgkin's
Lymphoma .The breast
uptake represents benign
uptake secondary to lactation.
Ga-SPECT/CT in a patient with
showing a residual mass on CT
after treatment. Abnormal 67Ga
uptake is demonstrated in the
corresponding residual CT
abnormality, indicating the
presence of residual viable tumor
tissue
Rapid Response
to treatment
Baseline GS
GS after one cycle of
chemotherapy
Tl-201 and Tc99-MIBI

Brain Tumors

Sarcoma

Breast Imaging
Passive
diffusion
99mTc
MIBI
ΔΨc
+
+
-
99mTc
Mitochondria
--
-
ΔΨm
MIBI
+ +
+
Nucleus
Passive
diffusion
99mTc
MIBI
ΔΨc
+
+
99mTc
Mitochondria
--
-
Nucleus
ΔΨm
MIBI
-
+ +
+
MDR Proteins
Active Efflux
Brain Tumors

F-18 FDG PET
Grading
Prognosis
Tumor recurrence
Radiation necrosis
Tumor viability

Tl-201

Tc99m Sestamibi (choroid plexus uptake)
SPECT
Brain tumor
Brain tumor
FDG PET – brain tumor post th
two foci on CT, only one viable tumor
Parathyroid Scan:
Tc99m-MIBI Scan + SPECT
Parathyroid adenoma
early
late
Specific methods

Binding to receptors or antigens
MIBG – pheochromocytoma, neuroblastoma in
children
 Octreoscan – neuroendocrine tumors
 I-131 – thyroid cancer – follow-up and treatment

MIBG SCINTIGRAPHY
MIBG: Clinical application
Adrenal medullary hyperplasia
 Pheochromocytoma: 90% sensitive and
even more specific(95-99%)
 Paragangliomas
 It can show metastatic lesions very
effectively
 Neuroblastoma

11C-
Hydroxyephedrine
similar to MIBG
SPECT/CT carcinoid
OctreoScan+ SPECT
PET in oncology:
General aspects(18FDG)
Cell membrane
18FDG
Glucose
18FDG
hexokinase
18FDG-6-P
Glucose
Glucose-6-P
Metabolites of Glucose
FDG PET

For several tumors



Mainly lymphomas, lung cancers, melanoma,
colorectal cancers and others
Not suitable for prostate cancer
At least 1 w post chemo, 3 m radiotherapy
 18FDG
PET in oncology:
can be used for:
Focal lesions (malignancy potential)
 Staging
 Monitoring response to therapy
 Prognosis
 Evaluation of tumor recurrence

PET in oncology:
Breast cancer (Staging)
A 44 year old female with an
axillary nodule proved to be
carcinoma on biopsy. A FDG
PET exam was then
performed and revealed
extensive metastases to axillary
and supraclavicular lymph
nodes, as well as the primary
lesion in the right breast (black
arrow)
PET in oncology:
Colon cancer (Recurrent cancer)
A patient with a history
of colon cancer,
evaluated for two
pulmonary nodules.
The FDG PET
demonstrated uptake in
the pulmonary nodules
(not shown) and also
revealed diffuse
omental metastases
PET in oncology:
Melanoma (Staging)
A 71 year old male with a history
of melanoma on the left
shoulder.On CT, the abdomen
had been interpreted as negative.
The FDG PET exam revealed
extensive metastatic disease
throughout the body.
PET------PET/CT
FDG PET
Tumor of unknown origin
Pharyngeal cancer
PET:100 %
CT:
0 %
Stomach cancer
PET: 80 %
CT: 20 %
Stomach cancer
PET: 60 %
CT: 40 %
Stomach cancer
PET: 40 %
CT: 60 %
Stomach cancer
PET: 20 %
CT: 80 %
Stomach cancer
PET: 0 %
CT: 100 %
Stomach cancer
18FDG-PET
and PET/CT
Lung Cancer









Solitary pulmonary nodule
Diagnosis of primary lung cancer
Staging
Therapy Planning
Monitoring of therapy
Detection of recurrence
Ideal site for possible tissue diagnosis
Prediction of prognosis.
PET/CT has the best of both worlds of metabolic and
anatomic imaging and may provide optimal disease
assessment.
18FDG-PET
and PET/CT
Solitary Pulmonary Nodule
The negative predictive power of PET is sufficiently
high to avoid biopsy .
 If FDG-PET is negative for lesions > 7 mm diameter,
then the process is most likely benign, and may be
followed with serial surveillance.



When FDG-PET is positive then diagnostic and
definitive treatment may be instituted


PET/CT :more useful than PET in determining the T stage and in
assessing the presence of mediastinal or chest wall invasion
PET was significantly more accurate than CT or MRI in identifying
nodal metastasis with


An accuracy of 81% to 96%
PET/CT : even higher diagnostic accuracy than either CT or PET
alone with a sensitivity of 89% and specificity of 94% and an overall
diagnostic accuracy of 93% .
18FDG-PET
& PET/CT
LC Staging: Distant Metastasis (M)
 In
brain and genitourinary system, PET is less
accurate in identifying malignancy.
 As
the brain is common site for metastatic lung
cancer, CT or MRI recommended.
PET in oncology:
Bronchogenic carcinoma (Staging)
A patient had a left lung
NSCLC . There was no
uptake of tracer within the
hila or mediastinum to
suggest nodal metastases,
however, unsuspected
bone metastases were
found in the right
humerus and right hip
(black arrows).
PET in oncology:
Bronchogenic carcinoma (Staging)
Uptake within the
patients primary lung
cancer can be seen
within the right chest.
Uptake within the
bilateral adrenal glands
(black arrows)
confirmed the
presence of adrenal
metastases.
HL and a negative initial BMB but pathological focal marrow FDG uptake in the
mid- and lower lumbar spine, sacrum and left ischium (arrows).
A grade 3 follicular lymphoma and a negative initial bone marrow biopsy of the
iliac crest.
PET slices show pathological marrow uptake in the sternum (small arrows).
which was confirmed histologically.
There is also lymph node involvement of the right hilum
(large arrow).
GS in a patient with high grade
NHL and BM transplantation.
He presented with a palpable
spleen, fever, dyspnea and
pancytopenia. The MRI
showed findings most
consistent with multiple
peripheral splenic infarcts,
increasing splenomegaly and
no change in multiple small
retroperitoneal LNs.
Complete response and good prognosis of HL.
(A) Baseline PET: Abnormal FDG uptake in sites of lymphadenopathy in the left supraclavicular region, the right axilla, the mediastinum bilaterally, the left lung hilum, and
the porta hepatis region.
(B) Repeat FDG-PET, performed after one cycle of chemotherapy, is negative.
NHL: Assessment of partial response,
prediction of poor outcome, and
detection of recurrence.
(A) Baseline : multiple areas of
abnormal FDG uptake in sites of
mesenteric and retroperitoneal
adenopathy.
(B) Repeat FDG-PET performed after
two cycles of chemotherapy shows
residual but less prominent
abnormal FDG uptake in abdominal
sites indicating partial response.
(C) FDG-PET at the end of treatment is
negative indicating that complete
response was achieved.
(D) Routine follow-up FDG-PET at 4
months of remission shows
recurrent disease inabdominal sites.
Stage IIA high-grade NHL.
Baseline:Highly hypermetabolic lymph nodes in the left axillary and cervical areas
PET performed after 3 courses of chemotherapy shows a complete metabolic response.
The patient is in complete clinical remission 6 months after completing the treatment.
HD :
A: Baseline FDG PET:Multiple foci of increased activity in cervical and mediastinal areas
as well as right hilar and lung infiltration.
B: FDG PET performed after 2 cycles of polychemotherapy indicates residual 18F-FDG
uptake in a right cervical lymph node.
C: Treatment failure was observed at the end of treatment.
Lymphoma (Residual mass post-therapy)
A patient received
chemotherapy for lymphoma.
There was a residual left neck
mass following completion of
therapy. A FDG PET exam
revealed persistent metabolic
activity within the mass
concerning for residual tumor.
FDG-PET or PET/CT at diagnosis
Negative
No more follow-up
scans
Positive scan
HD and NHL
Positive
Repeat PET or PET/CT during therapy
Negative: Further installed treatment and
repeat scan at the end of therapy
Consider more
Negative scan ,
aggressive therapy
NHL ,HD stage ΙΙΙ and ΙV
Repeat scan after secondary
treatment and before
transplantation
1 year follow-up scans
mandatory
Negative scan
HD stage Ι and ΙΙ
Follow-up scans only
within clinical suspicion