14/09/2013 FDG PET PET-CT = FDG PET-CT. = Metabolism. Anatometabolic Imaging. = Anatomy. Nuclear Medicine in the Era of Hybrid Imaging

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1 Nuclear Medicine in the Era of Hybrid Imaging Focus on a New SPECT-CT Device : HWK-4 Tarik Belhocine, MD, Ph.D Nuclear Medicine = SPECT = Functional Imaging Function Radiology = Morphological Imaging Anatomy Anatomy 18 FDG PET = Metabolic Imaging = Molecular Imaging Function Hybrid Imaging SPECT-CT SPECT-MRI PET-MRI PET-CT PET-CT Hardware Fusion SPECT-CT Hybrid Imaging SPECT-CT-VCT PET-CT-VCT Software Fusion PET-MRI SPECT-MRI 2006 SNM Highlights by HN Wagner 18 FDG PET-CT Nuclear Medicine Radiology 18 FDG PET = Metabolism Hybrid Imaging PET-CT = Anatometabolic Imaging Radiotherapy CT = Anatomy 1

2 In Today s Clinical Oncology Whole-Body 18 FDG PET = Standard of Care New Trends in Clinical Oncology : From PET to PET-CT Multiple Myeloma Int J Oncology Belhocine et al PET PET-CT CT FDG PET-CT : Principe PET/CT vs. PET PET PET-CT PET-CT Discovery LS PET-CT biograph 16 PET-CT Discovery ST PET-CT GEMINI Duration +/- 60 min min AC 68 Ge or 137 Cs CT Transmission Duration +/- 30 min < 1 min Detection Good Good + Anatomic localization Clinical value (in course) 2

3 Lymphomatous Nodule Peritoneal Implant Brown Adipose Tissue < 1cm Para-Aortic Mets Bowel Focal Activity Supra-Clavicular LN Cervical Cancer Cervical Cancer Courtesy from PW Grigsby - MIR PET-CT Guided Radiation Treatment Planning Brain Tumors 1. Brain = Rigid organ no subject to motion 2. Brain MRI = Gold Standard 3. Brain MRI = Limitations for Rec vs. Necrosis 4. PET = Excellent for Viability Assessment Head and Neck Cancer : PET-CT Sofware Fusion for definition of GTV PET-MRI or SPECT-MRI Software Fusion 1. Tumor Viability / Extent / Heterogenity 2. Treatment Planning Scarfone C JNM

4 Dedicated Brain Software Fusion - Hermes Brain PET-MRI MRI PET-MRI 18 FDG PET PET-MRI Software Fusion Borgwardt L JCO Dosimetry Planning of RadioSurgery in Brain Tumors with PET-MRI Definition of Target Tumor Volumes in Brain Tumors with PET-MRI 18 FDG PET-MRI : Anaplastic Oligoastrocytom 11 C PET-MRI : ACTH Pituitary Adenoma Levivier et al. JNM 2004 Levivier et al. JNM 2004 PET-CT Fusion In Cardiology PET-CTA Fusion In Cardiology Attenuation Correction Schwaiger JNM Anatomy + Function Schwaiger JNM

5 PET-CTA Fusion In Cardiology PET-CTA Fusion In Cardiology Anatomy + Function Di Carli QJNMI Anatomy + Function Di Carli QJNMI PET-CT imaging of Atherosclerosis Tatsumi Radiology Rudd Circulation Is There a Rationale for Hybrid Imaging beyond PET-CT? 1- PET-CT is not available everywhere 2- PET-CT is not reimbursed everywhere 3- Non-oncological diseases are most often explored with SPECT Bone Diseases (Benign or Malignant) Sentinel Lymph Node Detection Liver Hemangioma, Splenosis Hyperparthyroidism 4-18 FDG PET or PET-CT is not useful for all oncological diseases : Neuro-Endocrine Tumours Differentiated Thyroid Cancers Prostate Cancer 5- RI Diagnosis/Therapy are still performed with SPECT tracers : ProstaScint I-based Therapy (Lipiodol, Bexxar) SPECT-CT Image of the Year SNM

6 SPECT-CT Definitions SPECT-CT : X-ray tube mounted in the SPECT gantry 1- Anatomic and Functional imaging 2- CT-based attenuation correction Technion Institute of Technology (Haifa, Israel)) Co-Image of the Year SNM 2006 SPECT-CT Systems Siemens GEMS : Infinia-Hawkeye 1, 4 slice SPECT-CT Symbia PET-CT biograph 16 Philips : Precedence 2, 6 slice Philips Siemens : Symbia T 6, 16 slice SPECT-CT Precedence PET-CT GEMINI Overview on London Experience on HWK-4 Infinia-Hawkeye 4 : Features * Infinia-Hawkeye 4 = 1 st SPECT-CT in North America = 3rd SPECT-CT Worldwide * Installation in SSH = March 2006 * Operation in routine = April 2006 * Dual Head Gamma Camera * Low Dose MSCT : to 2.5 ma or 140 kv - Slice Width = 5 mm - 4 slices mm * Sept : > 400 SPECT-CT Studies HWK-4 - GEMS - MFOV = 450 +/- 5 mm - WFOV = 565 mm - Helical or Axial Mode 6

7 Clinical Indications Cardiac Studies ( 99m Tc-MIBI, 201 Tl) - Known or Suspected CAD Non-Cardiac Studies - Thyroid - Parathyroid - MIBG (NET) - Octreoscan (NET) - 67 Ga (Lymphoma ++) - WBC (Crohn s disease, OM) - RBC (Liver Hemangiomas ++, Splenosis) - ProstaScint (Rise of PSA) - Bone Scans - Brain Studies - Bexxar and Lipiodol (Posttherapy) Synthesis SPECT-CT Anatomy Phy vs. Patho AC PTH /? RBC /? WBC Octreoscan MIBG Bone scan (B vs. M) I ProstaScint Ga SLN Brain Scan Cardiac Scan

8 Clinical Cardiac Studies IRNC : Probably Normal IRAC No QC : Falsely Abnormal IRAC QC : Definitely Normal 70 consecutive patients 27 F / 43 M Mean age = 62.5 y ± 13.5 Mean BMI = ± : Dipyridamole + Submax Bicycle Exercice 4 : Max Bicycle Exercice 3 : Dipyridamole + Handgrip Exercice Pretest Likelihood of CAD (Diamond & Forester Tables) % = High Pretest LH % = Intermediate Pretest LH % = Low Pretest LH Known CAD = 23% 140 SPECT-CT : Rest non-gated MIBI + Stress Gated MIBI 65% = 2.5 ma % = 1.0 ma Non-Cardiac Studies Definitely normal Probably normal Equiv ocal Probably abnormal Definitely abnormal 1- Anatomic Localization 2- Physiology vs. Pathology 3- Attenuation Correction More confident interpretation Detection of unsuspected lesions Avoidance of further studies SPECT-CT : PTH Primary Hyperparathyroidism 17 patients : Primary or Persistent HPT Surgico-pathological correlations still in course SPECT-CT clearly positive = 10 / 17 SPECT-CT non contributive = 4 = MNG SPECT-CT negative = 2 * Advantages : D Anatomic Localisation Ectopic glands SPECT Indication 8

9 SPECT-CT : Red Blood Cell 9 patients : LH, SH, Sp, FNH Usefulness = 100% = Anatomic Correlation Accurate localisation of foci Vascular (Ao, IH) # Pathological SPECT-CT > SPECT alone > CT alone RBC : Liver Hemangioma? Limitations : * Small foci < 1cm * Sub-optimal CT : Respiratory motion artifacts SLN Detection SPECT-CT : ProstaScint 10 patients = Previously treated for Prostate Kc = PT; 3 = RT; 1 = CR; 1 = HM; 1 = CT Mean PSA = 2.3 ng/ml (<1 6.72) Bone Scan negative = 5 Diagnostic CT negative = 3 ProstaScint + = 8 / 10 = 80% = Prostate Bed recurrence = Extra-Prostate recurrence = LN + SPECT-CT > SPECT = Anatomy + AC Limitations = 1 FOV = 1 hour! Left prostate lobe ProstaScint Left obturator LN SPECT-CT : WBC 11 patients : suspicion of active Crohn s Disease : suspicion of osteomyelitis (Diabetic foot) CD : 8 + / 3 OM : 3 + * SPECT-CT Added-Value : --- Anatomic localisation (colon extension / Bone vs. Soft T) --- Detection of fistula --- Physio (99mTc intra-luminal leakage) vs. Patho --- CT findings (wall thickening, lumen narrowing) 9

10 SPECT-CT : 67Ga 25 patients : Lymphoma (HL-NHL) : Staging ReStaging Infection : Spine (1) Neck (1) Abdo (1) Inflammation : Brain (LED) Lymphoma : 16 + / 5 Infection/Inflammation : 2 + / 2 -- Accurate anatomic localisation (LNs) -- Detection of additional foci vs. Planar WB (Upstaging) -- Phy vs. Patho : Abdomen +++ Ccl: More confident interpretation SPECT-CT : Bone Scans 51 patients : Kcs (Prostate, Breast, Lung, Rectal, Cervix) No Kcs (LBP, Joint pains, Infection) Evolution Bone Scan 39 patients (76%) : WB SPECT-CT Evolution acquisition ( 2 FOVs ---- Spine) < 30 min 100% : Evolution Reconst. = Resolution Recovery CT Quality (Radiologist Thanks to Dr. Ghita) : Good (92%) Acceptable (6%) Poor (2%) Detection of OB/OL mets vs. DGD (OA OP) Detection of soft tissue abnormalities (Lung Tmr Pleural effusion - Liver Mets Med LNs) : 20% Faster or Final Diagnosis in Kc = 42 patients = 82% Definition of Further work-up for non-kc = MRI (AVN, Infarct, DDD, Hernia, Enchondroma) or Bone Marrow involvement 10

11 Limitation documented with HWK-4 : Whole-body in Oncology Perspectives with SPECT-CT HWK-4 1- AC + SC + Resolution Recovery 2- Volumetric Quantification --- SUV scores 3- Pre-therapy and Pos-therapy Dosimetry WB + SPECT-CT : 2 H 30 min on the table! PET-CT : 30 min on the table! Bone Evolution : Acquisition and Reconstruction < 30 min - ProstaScint 67Ga, MIBG, OctreoS - Cardiac Studies WB SPECT-CT 30 min WB PET-CT SPECT-CT Posttherapy Hybrid Imaging PET-CT World SPECT-CT World 131I-Bexxar : Lymphoma 131I-Lipiodol : Liver Mets Tracer availability Cost-effectiveness Clinical suitability Radiation Dose issues Medicare issues 11

12 Conclusion 1- PET-CT : Best Example of Hybrid Imaging Nuclear Oncology 2- SPECT-CT : New Impetus in Conventional Nuclear Medicine 3- Perspectives in Pre-Clinical and Clinical Research 4- Pending questions : * Place of SPECT-CT vis-à-vis PET-CT * SPECT-CT? or CT-SPECT? * Software or Hardware Fusion? * Technical expertise or Psychological disposition? Image of the Month EJNMMI

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