Transcript Geneva slides

TRANSLATING TECHNOLOGY FROM NUCLEAR AND
PARTICLE PHYSICS TO THE CLINIC: ADDRESSING
MEDICAL NEEDS BY DETECTOR KNOW-HOW WITH
A FOCUS ON ORGAN-SPECIFIC IMAGING
Alghero, Sardinia, Italy
September 3rd – 7th, 2014
1
Wide range of topics – 1 –
•
From PawPET to Explorer: different scales of PET
•
Time-of-Flight (TOF) PET
•
PET/CT: clinical applications and limitations
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PET/MR: concept to the clinic
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PET radiotracer modeling in neuroimaging and DD
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The role of the equipment industry: lessons learned
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Molecular imaging in cardiology: lively debate on funding!
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The role of radiotherapy and particle therapy
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In beam therapy monitoring, dosimetry
2
Wide range of topics – 2 –
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Clinical: GI endoscopy and pancreatic cancer
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Clinical: urological disease and prostate cancer
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Clinical: ovarian, endometrial and gynecological cancer
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Prospects for imaging prostate cancer, new tracers
• 18F-choline
and SUV inaccuracies
•
TRUS Tof PET (Group in Poland)
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Detectors for endoTOFPET-US and OB/GYN
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Endoscopy: do we need multimodality? Organ motion
3
Wide range of topics – 3 –
•
Clinical: review of breast imaging and MBI
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Review of surgical imagers
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Review of breast imagers for PET
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Clinical: molecular brain imaging: AD and treatment
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Dedicated brain imaging systems
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Clinical: head and neck imaging
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Dedicated detectors for brain, head and neck?
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SiPMs, timing for TOF, dSiPM and DPC
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Discussion of SiPM versus dSiPM
4
5
6
Lessons we learned from PET/CT
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understand the medical need and significance to healthcare
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expect negative comments and reviews – do not give up
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identify physicians to support and champion the proposal
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work with small entrepreneurial company, not just market-driven
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assemble sufficient funding to complete a clinical prototype
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evaluate prototype clinically in a hospital for access to suitable patients
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ensure that prototype reliability is adequate to support clinical demand
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strong clinician support for the prototype at all times is essential
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be lucky: be in the right place at the right time
7
Ali Shabestani Monfared
Seyed Mohamad Javad Mortazavi
“It is likely that we need more radiation to
improve our longevity”
John Cameron
8
Studies involving low doses and low dose
rates have failed to detect any increased
cancer rate. The baseline cancer rate is
already very high (~42 out of 100 people
will be diagnosed in their lifetime) and it
fluctuates ~40% because of lifestyle and
environmental effects, obscuring the subtle
effects of low level radiation. For low doses
(1 –100 mSv) the predicted elevated risks
are only 1.001 to 1.04 and excess cancer
cases, if present, cannot be detected.
Example: To reliably detect an increase in
cancer from an exposure of 12 mSv would
require a study of ~7,000,000 subjects.
Required number of subjects in study
Sample sizes required to detect an effect
Dose range of
relevance for
medical imaging
Dose (mSv)
Sample size required to detect a significant increase in cancer mortality
Assumes lifetime follow-up
National Research Council (1995) Radiation Dose Reconstruction for Epidemiologic Uses
(Natl. Acad. Press, Washington, DC).
9
The BEIR Report: theoretical models
?
The models:
1. Linear No Threshold
2. Threshold
3. Hormesis
2. Threshold
1. LNT
Biological Effects of
Ionizing Radiation
(BEIR) VII Phase 2 (2007)
Japanese Survivor
Data
3. Hormesis
Potential sources of data:
A.
B.
C.
D.
Environmental Radiation Studies
Occupational Radiation Studies
Medical Radiation Studies
Atomic Bomb Survivor Studies
No scientific data to
distinguish between any
of the models
10
Organ-specific imaging devices: brain
RatCap PET
PET Hat
Non-compliant animal
Compliant sitting patient
Helmet PET
Compliant standing or
moving patient
Normal
AD
Lilly/AVID Amyvid
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Organ-specific imaging devices: breast
Dual-ring MAMMI breast
PET scanner
Field of view
Transaxial:
Axial:
Axial/frame:
Spatial resolution
Radial:
Tangential:
Axial:
Absolute sensitivity
3.6% (250 – 750 keV)
Energy resolution
26%
ClearPEM-Sonic Hôpital Nord, in Marseilles, 2011
170 mm
190 mm
94 mm
1.8 mm
1.7 mm
1.5 mm
12
Organ-specific imaging devices: prostate
Prostate
PET Probe
EndoTOPPET prostate probe
using a dSiPM chip (SPAD array)
• MR compatibility
• biopsy capability
• organ motion
13
Organ motion during imaging and therapy
Treatment plan must account for organ motion
Inter-fraction organ motion
Internal organs may move
considerably from day to
day during treatment
Courtesy JJ Sonke and A Martinez
Use large margins
thus irradiating too
much healthy tissue
Use small margins
with IMRT and risk
missing the target
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EndoTOFPET-US
Ultrasound endoscope with
PET extension positioned inside
stomach and close to pancreas
Possible pancreatic cancer
investigated with ultrasound
endoscope that incorporates
a PET detector
EndoTOPPET external detector
with attachment for a robotic arm
15
PET for assessing response
3.5
3
2
SUV
SUV
2.5
1.5
1
Responder
0.5
0
1
2
3
4
5
6
8
7
6
5
4
3
2
1
0
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Non-responder
1
2
3
Week
4
5
6
7
Week
Probability of survival
A PET/CT scan acquired each week during chemo maps a
decreasing SUV in responders compared to patients who
do not respond, assessing efficacy of treatment.
Tumour
Control region
1.0
0.9
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0.0
Metabolic
Responder
Metabolic
Responders
1
2
Metabolic
Non-responders
Metabolic
Non-Responder
0
10
20
30 40 50 60
Survival (weeks)
70
80
3
Time-activity curves
from sensors over
tumour and normal
tissue regions.
Lucerno sensors placed
over the tumour acquire
time-activity curves.
90
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Early assessment of response
Courtesy: UNC Healthcare System
Breast cancer: Non-responder
SUV
AUC
14/1/13
6.7
499
20/2/13
2.7
534
-60.0%
+7%
Difference
Neo-adjuvant breast cancer patient
shows decreased SUV but increased
AUC from Lucerno scan suggesting
non-response. Patient developed
brain mets two months after scan.
Lymphoma: responder
SUV
AUC
6/7/12
16.7
588
20/8/12
6.4
330
-61.0%
-48%
Difference
Lymphoma patient shows response
from SUV and Lucerno AUC assessed
before 3rd cycle of chemotherapy.
Time (secs)
17
Projection of healthcare expenditure by disease in Australia: 2003 - 2033
Population Growth
Ageing Population
Obesity
Australia’s
Productivity Loss
Source Goss, J., 2008
Diabetes
Mental Illness
150
100
Cardiovascular
Disease
Dementia
B€
Depression
Schizophrenia
Anxiety
Cancer
Joint Disorders
2010
50
0
Developing Countries
Annual cost of mental illness
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