C-methionine PET/CT for tumors of the skull base: Comparison with F-FDG PET/CT

Transcription

1 11 C-methionine PET/CT for tumors of the skull base: Comparison with 18 F-FDG PET/CT Award: Certificate of Merit Poster No.: C-0287 Congress: ECR 2013 Type: Scientific Exhibit Authors: N. Tomura, T. Saginoya, K. Watanabe; Koriyama/JP Keywords: Neoplasia, Staging, PET-CT, Nuclear medicine, Neuroradiology brain, Head and neck DOI: /ecr2013/C-0287 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 49

2 Purpose 18 Positron emission tomography (PET) using F-fluorodeoxyglucose (FDG-PET) has been most frequently used for various malignancies. However, in visualizing head and 11 neck malignancies, sensitivity and specificity rates are not necessarily sufficient. Cmethionine (MET) gives relevant information on amino-acid transport. MET is needed for protein synthesis as a precursor of S-adenosylmethionine that is a precursor to polyamine synthesis. Uptake of 11 C-MET reflects increased transport, transmethylation 11 rate, and protein synthesis of the lesion (1). PET using C-MET (MET-PET) has been used mainly in tumors of the brain. In tumors of the brain after treatment, its usefulness for differentiation between recurrent tumors and radiation necrosis has been reported (2, 3). However, previous reports for tumors in the skull base using MET-PET are scarce (4). In tumors invading the skull base, radiotherapy usually is planned due to inoperability of the tumor. Planning radiotherapy requires exact delineation of the tumor that is determined by CT, MRI, PET, and single photon emission computed tomography (SPECT). After treatment, PET could be an effective tool to evaluate treatment response as well as to detect recurrent tumors. In the present study, clinical value of MET-PET was compared withthat of FDG-PET. Page 2 of 49

3 Methods and Materials PET/CT was used for every patient in the present study. Both FDG-PET/CT and METPET/CT were performed in 24 patients (19 males, 5 females#mean age 57.9±13.0 years old) with tumors of the skull base. They comprised adenoid cystic carcinomas (n=3), squamous cell carcinomas (n=10), osteosarcomas (n=2), olfactory neuroblastomas (n=2), malignant meningiomas (n=2), common meningioma (n=1), chondrosarcoma (n=1), chordoma (n=1), pituitary adenoma (n=1), and malignant melanoma (n=1). In all cases, their pathology was proved by surgery or biopsy before PET/CT. All patients underwent both PET/CTs on the same day (Fig. 1) (5). Fig. 1: Protocol for both PET/CTs using C-11 methionine (MET) and F-18 fluorodeoxy glucose (FDG). References: Radiology, Southern Tohoku Research Institute for Neuroscience, Southern Tohoku General Hospital - Koriyama/JP PET/CT examinations were performed using two different PET/CT units. Full width at half maximum axial spatial resolution was 6-mm with one unit and was 7-mm with another unit. CT was performed using a continuous spiral technique with a 4- or 16-slice spiral CT that had a gantry rotation speed of 0.8 s. CT was performed at 10-, 250-, or 300mAs; 120-KeV; with a section width of or 5.0-mm; and a table feed of , 15.0-, , or 7.5-mm per rotation. No intravenous contrast material was used. After the CT, PET using MET (MET-PET/CT) was performed 20 min after injection of MET. For PET using FDG (FDG-PET/CT), FDG was injected 60 min after MET-PET. FDG-PET/CT was performed 60 min after injection of FDG. The acquisition time was 5- or 10-min per table position. PET images were reconstructed using CT data for attenuation correction and image fusion. Coregistered images were displayed on a workstation. The images were visually and independently reviewed by 2 neuroradiologists who were aware of the pathological diagnoses. The reviewers had access to the both PET/CT images including multiplanar reconstructions on a color-coded monitor. For qualitative analysis, positive uptake was defined as obvious or marked uptake in comparison to the surrounding tissues. The negative uptake was defined as no or neglisible uptake. The interrater agreement between two reviewers calculated using Cohen's kappa. Any initial differences in their interpretations were resolved by the consensus of both reviewers. Page 3 of 49

4 For semiquantitative evaluation, the tumor-to-normal brain uptake ratios (T/N ratios) were calculated by dividing the maximum of standardized uptake value (SUVmax) for the tumor by the SUVmax of the normal contralateral cerebellar hemisphere. Difference in SUVmax between FDG-PET/CT and MET-PET/CT was analyzed for statistical significance by twotailed paired t test. Page 4 of 49

5 Images for this section: Fig. 1: Protocol for both PET/CTs using C-11 methionine (MET) and F-18 fluorodeoxy glucose (FDG). Radiology, Southern Tohoku Research Institute for Neuroscience, Southern Tohoku General Hospital - Koriyama/JP Page 5 of 49

6 Results On qualitative evaluation, the Cohen's kappa was 0.78 for 18 F-FDG images, and 1.00 for 11 C-methionine. The sensitivity for the positive detection of tumor was 87.5% using FDGPET/CT, compared with 100% using MET-PET/CT. MET-PET/CT had a significantly higher T/N ratio than did FDG-PET/CT (2.90±1.28 vs. 1.03±0.57, p < 0.001) (Fig. 2). Fig. 2: T/N ratio of MET-PET/CT and FDG-PET/CT. MET-PET/CT had a significantly higher T/N ratio than did FDG-PET/CT (2.90±1.28 vs. 1.03±0.57, p < 0.001). Page 6 of 49

7 References: Radiology, Southern Tohoku Research Institute for Neuroscience, Southern Tohoku General Hospital - Koriyama/JP Representative cases were displayed in Fig Fig. 3: Squamous cell carcinoma in the left parasellar region. A tumor is showing a perineural extension from the nasopharynx. Contrast-enhanced T1-weighted MR image with fat-saturation shows contrast-enhanced lesion in the left parasellar region (arrow). References: Radiology, Southern Tohoku Research Institute for Neuroscience, Southern Tohoku General Hospital - Koriyama/JP Page 7 of 49

8 Fig. 4: MET-PET/CT of the same case as Fig. 3. MET-PET/CT shows an increased uptake of MET in the lesion. References: Radiology, Southern Tohoku Research Institute for Neuroscience, Southern Tohoku General Hospital - Koriyama/JP Page 8 of 49

9 Fig. 5: FDG-PET/CT of the same case as Fig. 3 and 4. FDG-PET/CT do not definite uptake of FDG. References: Radiology, Southern Tohoku Research Institute for Neuroscience, Southern Tohoku General Hospital - Koriyama/JP Page 9 of 49

10 Fig. 6: Squamous cell carcinoma in the sphenoid sinus and clivus. A tumor in the sphenoid sinus is invading the clivus and the petrous apex. Contrast-enhanced T1weighted MR image with fat-saturation shows contrast-enhanced lesion in the sphenoid sinus and clivus (arrow). References: Radiology, Southern Tohoku Research Institute for Neuroscience, Southern Tohoku General Hospital - Koriyama/JP Page 10 of 49

11 Fig. 7: MET-PET/CT of the same case as Fig. 6. MET-PET/CT shows an increased uptake of MET in the lesion. References: Radiology, Southern Tohoku Research Institute for Neuroscience, Southern Tohoku General Hospital - Koriyama/JP Page 11 of 49

12 Fig. 8: FDG-PET/CT of the same case of Fig. 6 and 7. FDG-PET/CT do not definite uptake of FDG. References: Radiology, Southern Tohoku Research Institute for Neuroscience, Southern Tohoku General Hospital - Koriyama/JP Page 12 of 49

13 Fig. 9: Adenoid cystic carcinoma in the left orbit. CT shows a tumor invading the bony wall of the orbit (arrow). References: Radiology, Southern Tohoku Research Institute for Neuroscience, Southern Tohoku General Hospital - Koriyama/JP Page 13 of 49

14 Fig. 10: CT with bone window of the same case as Fig. 9. CT shows a tumor with destruction of the bony wall of the orbit (arrows). References: Radiology, Southern Tohoku Research Institute for Neuroscience, Southern Tohoku General Hospital - Koriyama/JP Page 14 of 49

15 Fig. 11: MET-PET/CT of the same case as Fig. 9 and 10. MET-PET/CT shows an increased uptake of MET in the lesion. References: Radiology, Southern Tohoku Research Institute for Neuroscience, Southern Tohoku General Hospital - Koriyama/JP Page 15 of 49

16 Fig. 12: FDG-PET/CT of the same case as Fig. 9, 10, and 11. FDG-PET/CT do not definite uptake of FDG. References: Radiology, Southern Tohoku Research Institute for Neuroscience, Southern Tohoku General Hospital - Koriyama/JP Page 16 of 49

17 Fig. 13: Malignant meningioma in the sphenoid bone and petrous bone. Contrastenhanced T1-weighted MR image shows contrast-enhanced lesion in the sphenoid bone and right petrous bone (arrows). References: Radiology, Southern Tohoku Research Institute for Neuroscience, Southern Tohoku General Hospital - Koriyama/JP Page 17 of 49

18 Fig. 14: MET-PET/CT of the same case as Fig. 13. MET-PET/CT shows a remarkable uptake of MET in the lesion. References: Radiology, Southern Tohoku Research Institute for Neuroscience, Southern Tohoku General Hospital - Koriyama/JP Page 18 of 49

19 Fig. 15: FDG-PET/CT of the same case as Fig. 13 and 14. FDG-PET/CT shows slight uptake of FDG. References: Radiology, Southern Tohoku Research Institute for Neuroscience, Southern Tohoku General Hospital - Koriyama/JP Page 19 of 49

20 Fig. 16: Malignant melanoma in the ethmoid sinus. Contrast-enhanced T1-weighted MR image shows a tumor in the ethmoid sinus (arrow). References: Radiology, Southern Tohoku Research Institute for Neuroscience, Southern Tohoku General Hospital - Koriyama/JP Page 20 of 49

21 Fig. 17: MET-PET/CT of the same case as Fig. 16. MET-PET/CT shows an increased uptake of MET. References: Radiology, Southern Tohoku Research Institute for Neuroscience, Southern Tohoku General Hospital - Koriyama/JP Page 21 of 49

22 Fig. 18: FDG-PET/CT of the same case as Fig. 16 and 17. FDG uptake is seen in the ethmoid sinus. References: Radiology, Southern Tohoku Research Institute for Neuroscience, Southern Tohoku General Hospital - Koriyama/JP Inflammatory changes near the tumor were seen in 9 cases. One of those 9 cases represented moderate uptake of both FDG and MET in the inflammatory changes near the tumor (Fig. 19, 20, and 21). Page 22 of 49

23 Fig. 19: Contrast-enhanced T1-weighted MR image of the same case as Fig. 16, 17, and 18. Inflammatory change is seen in the left maxillary sinus (arrows). References: Radiology, Southern Tohoku Research Institute for Neuroscience, Southern Tohoku General Hospital - Koriyama/JP Page 23 of 49

24 Fig. 20: MET-PET/CT of the same case as Fig Increased uptake of MET is seen in the inflammatory change in the left maxillary sinus. References: Radiology, Southern Tohoku Research Institute for Neuroscience, Southern Tohoku General Hospital - Koriyama/JP Page 24 of 49

25 Fig. 21: FDG-PET/CT of the same case as Fig Moderate uptake of FDG is also seen in the inflammatory change in the left maxillary sinus. References: Radiology, Southern Tohoku Research Institute for Neuroscience, Southern Tohoku General Hospital - Koriyama/JP MET-PET/CT showed higher uptake of the mucosa of the nasal cavity and nasopharynx than FDG-PET/CT (Fig. 20). On FDG-PET/CT, high uptake of the normal brain tissue disturbed identifying the tumors near the brain (Fig. 5, 8, and 15). Page 25 of 49

26 Images for this section: Fig. 1: Protocol for both PET/CTs using C-11 methionine (MET) and F-18 fluorodeoxy glucose (FDG). Radiology, Southern Tohoku Research Institute for Neuroscience, Southern Tohoku General Hospital - Koriyama/JP Page 26 of 49

27 Fig. 2: T/N ratio of MET-PET/CT and FDG-PET/CT. MET-PET/CT had a significantly higher T/N ratio than did FDG-PET/CT (2.90±1.28 vs. 1.03±0.57, p < 0.001). Radiology, Southern Tohoku Research Institute for Neuroscience, Southern Tohoku General Hospital - Koriyama/JP Page 27 of 49

28 Fig. 3: Squamous cell carcinoma in the left parasellar region. A tumor is showing a perineural extension from the nasopharynx. Contrast-enhanced T1-weighted MR image with fat-saturation shows contrast-enhanced lesion in the left parasellar region (arrow). Radiology, Southern Tohoku Research Institute for Neuroscience, Southern Tohoku General Hospital - Koriyama/JP Page 28 of 49

29 Fig. 4: MET-PET/CT of the same case as Fig. 3. MET-PET/CT shows an increased uptake of MET in the lesion. Radiology, Southern Tohoku Research Institute for Neuroscience, Southern Tohoku General Hospital - Koriyama/JP Page 29 of 49

30 Fig. 5: FDG-PET/CT of the same case as Fig. 3 and 4. FDG-PET/CT do not definite uptake of FDG. Radiology, Southern Tohoku Research Institute for Neuroscience, Southern Tohoku General Hospital - Koriyama/JP Page 30 of 49

31 Fig. 6: Squamous cell carcinoma in the sphenoid sinus and clivus. A tumor in the sphenoid sinus is invading the clivus and the petrous apex. Contrast-enhanced T1weighted MR image with fat-saturation shows contrast-enhanced lesion in the sphenoid sinus and clivus (arrow). Radiology, Southern Tohoku Research Institute for Neuroscience, Southern Tohoku General Hospital - Koriyama/JP Page 31 of 49

32 Fig. 7: MET-PET/CT of the same case as Fig. 6. MET-PET/CT shows an increased uptake of MET in the lesion. Radiology, Southern Tohoku Research Institute for Neuroscience, Southern Tohoku General Hospital - Koriyama/JP Page 32 of 49

33 Fig. 8: FDG-PET/CT of the same case of Fig. 6 and 7. FDG-PET/CT do not definite uptake of FDG. Radiology, Southern Tohoku Research Institute for Neuroscience, Southern Tohoku General Hospital - Koriyama/JP Page 33 of 49

34 Fig. 9: Adenoid cystic carcinoma in the left orbit. CT shows a tumor invading the bony wall of the orbit (arrow). Radiology, Southern Tohoku Research Institute for Neuroscience, Southern Tohoku General Hospital - Koriyama/JP Page 34 of 49

35 Fig. 10: CT with bone window of the same case as Fig. 9. CT shows a tumor with destruction of the bony wall of the orbit (arrows). Radiology, Southern Tohoku Research Institute for Neuroscience, Southern Tohoku General Hospital - Koriyama/JP Page 35 of 49

36 Fig. 11: MET-PET/CT of the same case as Fig. 9 and 10. MET-PET/CT shows an increased uptake of MET in the lesion. Radiology, Southern Tohoku Research Institute for Neuroscience, Southern Tohoku General Hospital - Koriyama/JP Page 36 of 49

37 Fig. 12: FDG-PET/CT of the same case as Fig. 9, 10, and 11. FDG-PET/CT do not definite uptake of FDG. Radiology, Southern Tohoku Research Institute for Neuroscience, Southern Tohoku General Hospital - Koriyama/JP Page 37 of 49

38 Fig. 13: Malignant meningioma in the sphenoid bone and petrous bone. Contrastenhanced T1-weighted MR image shows contrast-enhanced lesion in the sphenoid bone and right petrous bone (arrows). Radiology, Southern Tohoku Research Institute for Neuroscience, Southern Tohoku General Hospital - Koriyama/JP Page 38 of 49

39 Fig. 14: MET-PET/CT of the same case as Fig. 13. MET-PET/CT shows a remarkable uptake of MET in the lesion. Radiology, Southern Tohoku Research Institute for Neuroscience, Southern Tohoku General Hospital - Koriyama/JP Page 39 of 49

40 Fig. 15: FDG-PET/CT of the same case as Fig. 13 and 14. FDG-PET/CT shows slight uptake of FDG. Radiology, Southern Tohoku Research Institute for Neuroscience, Southern Tohoku General Hospital - Koriyama/JP Page 40 of 49

41 Fig. 16: Malignant melanoma in the ethmoid sinus. Contrast-enhanced T1-weighted MR image shows a tumor in the ethmoid sinus (arrow). Radiology, Southern Tohoku Research Institute for Neuroscience, Southern Tohoku General Hospital - Koriyama/JP Page 41 of 49

42 Fig. 17: MET-PET/CT of the same case as Fig. 16. MET-PET/CT shows an increased uptake of MET. Radiology, Southern Tohoku Research Institute for Neuroscience, Southern Tohoku General Hospital - Koriyama/JP Page 42 of 49

43 Fig. 18: FDG-PET/CT of the same case as Fig. 16 and 17. FDG uptake is seen in the ethmoid sinus. Radiology, Southern Tohoku Research Institute for Neuroscience, Southern Tohoku General Hospital - Koriyama/JP Page 43 of 49

44 Fig. 19: Contrast-enhanced T1-weighted MR image of the same case as Fig. 16, 17, and 18. Inflammatory change is seen in the left maxillary sinus (arrows). Radiology, Southern Tohoku Research Institute for Neuroscience, Southern Tohoku General Hospital - Koriyama/JP Page 44 of 49

45 Fig. 20: MET-PET/CT of the same case as Fig Increased uptake of MET is seen in the inflammatory change in the left maxillary sinus. Radiology, Southern Tohoku Research Institute for Neuroscience, Southern Tohoku General Hospital - Koriyama/JP Page 45 of 49

46 Fig. 21: FDG-PET/CT of the same case as Fig Moderate uptake of FDG is also seen in the inflammatory change in the left maxillary sinus. Radiology, Southern Tohoku Research Institute for Neuroscience, Southern Tohoku General Hospital - Koriyama/JP Page 46 of 49

47 Conclusion MET-PET has been used widely to visualize tumors of the brain. Literature review showed the use of MET in the head and neck tumors (6-10), which was not performed in a large population. The use of MET concerned with tumors at the base of the skull was not found by our literature review. Although MET-PET/CT could show positive uptake in every tumor, FDG-PET/CT did not show obvious uptake in some tumors. In tumors showing positive uptake on both PET-CTs, positive uptake areas on MET-PET/CT were bigger than those on FDG-PET/CTs. Mechanism of uptake of MET is quite different from that of FDG. Twenty of 24 tumors were pathologically malignant. MET uptake is likely to be influenced by amino-acid transport and protein synthesis (1). Compared with FDG-PET, MET-PET has already proved efficient in delineation of brain tumors. In the literature, MET uptake correlates better than FDG uptake with tumor proliferative activity in squamous head and neck cancer cell lines (10). It is quite difficult to determine an exact margin of the tumors at the skull base, but larger areas visualized by accumulated MET-PET may show more exact margin of the tumor compared with FDG-PET. The high uptake of 18 F-FDG in the brain disturbed the PET visualization of tumors at the 11 skull base. C-methionine accumulates in the bone marrow of the skull base, but it did not disturb the visualization of uptake of the tumor in every case. In a case with melanoma in the nasal cavity, both FDG and MET accumulated in the coexisting inflammatory lesions. Although hyperglycemia was not included in the present study, FDG-PET studies will be unreliable in diabetic patients. MET uptake is not influenced by hyperglycemic state. 18 F-FDG uptake of the tumor was not seen in cases with chondrosarcoma, osteosarcoma, and adenoid cystic carcinoma, but tumors. 11 C-methionine did accumulate in their 18 F-FDG may not be useful to image bony tumors such as osteosarcomas. In tumors at the skull base, radiotherapy and / or chemotherapy will be planned because total removal of the tumor will be usually impossible. In our institute, proton therapy has been performed in those tumors at the skull base. Other recent advanced radiotherapy such as intensity modulated radiation therapy (IMRT), gamma knife therapy, and particle beam therapy also requires exact margin of the tumors. Although the present study showed promising results of MET-PET compared with FDG-PET in evaluation of tumors at the skull base, further studies in other evaluations such as treatment response will be required. In conclusion, MET-PET/CT showed higher sensitivity and higher uptake for the tumors at the skull base. Positive uptake areas on MET-PET/CT were bigger than those on FDGPET/CTs. MET-PET/CT is considered to have a superior potential for imaging the tumors of the skull base. Page 47 of 49

48 References 1. Chesnay E, Babin E, Constans JM, et al. Early response to chemotherapy in hypoglossal cancer: assessment with C-methionine PET, correlation with morphologic response, and clinical outcome. J Nucl Med 2003; 44: Okamoto S, Shiga T, Hattori N, et al. Semiquantitative analysis of C-11 methionine PET may distinguish brain tumor recurrence from radiation necrosis even in small lesions. Ann Nucl Med 2011; 25: Saginoya T, Tomura N, Mizuno Y, et al. Differentiation between brain tumor recurrence and radiation necrosis using C-methionine PET. J Medical Imaging Information 2012: 44: Hasebe M, Yoshikawa K, Ohashi S, et al. A study on the prognostic evaluation of carbon ion radiotherapy for head and neck adenocarinoma with C-11 methionine PET. Mol Imaging Biol 2010; 12: Mitsumoto T, Kubota K, Sato T, et al. validation for performing Cmethionine and 18F-FDG-PET studies on the same day. Nucl Med Comm 2012; 33: Leskinen-Kallio S, Nagren K, Lehikoinen P et al. Carbon-11-methionine and PET is an effective method to image head and neck cancer. J Nucl Med 1992; 33: Lindholm P, Leskinen-Kallio S, Minn H, et al. Comparison of fluorine-18fluorodeoxyglucose and carbon-11-methionine in head and neck cancer. J Nucl Med 1993; 34: Lindholm P, Leskinen S, Lapela M. Carbon-11-methionine uptake in squamous cell head and neck cancer. J Nucl Med 1998; 39: Greets X, Daisne JF, Gregoire V, et al. Role of C-methionine positron emission tomography for the delineation of the tumor volume in pharyngolaryngeal squamous cell carcinoma: comparison with FDG-PET and CT. Radiother Oncol 2004; 71: Wedman J, Pruim J, Langendijk JA, et al. Visualization of small glottis 11 laryngeal cancer using methyl-labeled C-methionine positron emission tomography. Oral Oncology 2009; 45: Page 48 of 49

49 Personal Information Noriaki Tomura, M.D., Ph.D. Department of Neuroradiology, Southern Tohoku Research Institute for Neuroscience, Southern Tohoku General Hospital, Koriyama, Fikushima, Japan; Toshiyuki Saginoya, M.D., Ph. D. Department of Radiology, Southern Tohoku Research Institute for Neuroscience, Southern Tohoku General Hospital, Koriyama, Fukushima, Japan; Kazuo Watanabe, M.D., Ph.D. Department of Neurosurgery, Southern Tohoku Research Institute for Neuroscience, Southern Tohoku General Hospital, Koriyama, Fukushima, Japan; Page 49 of 49