The role of PET/CT in the management of Gynaecological Malignancies. Dr Patrick Fielding Consultant Radiologist PETIC UHW 19 th November 2010

Transcription

1 The role of PET/CT in the management of Gynaecological Malignancies Dr Patrick Fielding Consultant Radiologist PETIC UHW 19 th November 2010

2 Thank you! ABMU LHB Cheltenham Sept 2010

3 PETIC Partnership Working ALL Wales Centre Expertise

4 Structure The Centre Updates/ pictures A few basics to emphasise PET/CT Gynaecological malignancy (literature based) Cervical Carcinoma Ovarian Carcinoma Current Commissioning policy Suggestions Possible way forward Discussion

5 The centre

6 Requests Contacts Centre Fax: Reporting Room: Centre Phone: /1

7 The scan process: nuclear physics to patient Before the patient arrives!! (5am)

8 Positron emitting radionuclides Radionuclide Half life 18 F 109 mins 11 C 20.4 mins 13 N 10 mins 15 O 2.1 mins

9 Radiochemical Synthesis plant Changing 3 stage cassette radiochemistry QC QC

10 FDG Radioactive sugar

11 Patient Journey Reception Changing/ assessment

12 Injection/uptake rooms Patient Journey

13 Scanner

14 Annihilation coincidence detection

15 Time of flight Time of flight 8hrs 5 mins

16 Time of flight

17 Scanner control room and Reporting area

18 Image presentation

19 What is the SUV? Standardized Uptake Value semiquantitative SUV=measured activity/ patient volume* injected activity Measured activity/expected activity

20 SUV Values Proceed with caution Different protocols Different uptake times Different scanner Different reconstruction algorithms

21 PET/CT in gynaecological Normal appearances malignancies

22 PET/CT in gynaecological malignancies Normal appearances Nucl Med Feb;45(2): Normal and abnormal 18F-FDG endometrial and ovarian uptake in preand postmenopausal patients: assessment by PET/CT. Lerman H, Metser U, Grisaru D, Fishman A, Lievshitz G, Even-Sapir E. Ann Nucl Med : Benign ovarian and endometrial uptake on FDG PET-CT patterns and pitfalls Yiyan Liu

23 Study Design Single centre, Tel-Aviv April to July 2003 All consecutive female patients attending for PET/CT over 3 month period All straightforward menstrual questionnaire Gynae history, contraceptive, HRT 360 total, 75 previous hysterectomy 285 study group Mean age 50.2+/-16.9 Range Nucl Med Feb;45(2): Normal and abnormal 18F-FDG endometrial and ovarian uptake in preand postmenopausal patients: assessment by PET/CT. Lerman H, Metser U, Grisaru D, Fishman A, Lievshitz G, Even-Sapir E.

24 Study Design

25 Endometrial uptake On non contrast CT images, if could see a hypoattenuating stripe then this used otherwise centre of uterus

26 Endometrial uptake: Premenopausal patients

27 Endometrial uptake Premenopausal patients: 4 had IUD 4 COC No sig differences in FDG uptake (few other studies suggest some decrease in uptake with COC and increase with IUD) Amenorrhoea 8 patients 1.9+/- 1.2 similar to post menopausal pts Oligomenorrhoea 19 patients 3.4 +/- 1.2 similar to ovulatory phase pts

28 Endometrial uptake Postmenopausal patients: no gynae malignancy Characteristic No hormonal therapy Hormonal therapy Benign uterine pathology No. of patients SUV SD Range

29 Cervical or endometrial Carcinoma 21 cervical /- 7.3 SUV 5 endometrial /- 9 SUV

30 Ovarian uptake (Increased uptake in ovaries noted in 7 patients with known ovarian malignancy) Seen in 21 premenopausal patients with no gynae malignancy. Of these 15 ovulatory phase 3 oligomenorhoea Ovarian uptake around time ovulation and from corpus luteum cysts well described Of note: No increased FDG uptake was seen in any of the 134 postmenopausal patients with no history of gynaecological malignancy This finding confirmed in subsequent studies significant ovarian uptake in postmenopausal patients considered pathological

31 Ovarian Uptake

32 Benign Uterine tumours

33 Leiomyoma Typical findings Low grade uptake SUV max 2.0 Atypical findings Higher grade uptake SUV 8.5 Premenopausal Luteal phase Degeneration Degenerating fibroid Low grade uptake SUV max 3.9

34 Normal appearances: summary Cyclical uptake of FDG is normal in premenopausal patients in both ovaries and uterus Significant uptake in ovaries in postmenopausal women is considered pathological Benign leiomyomas may show sometimes marked FDG uptake We don t yet have a normal database

35 Carcinoma Cervix

36 Primary staging: Cervical carcinoma

37 Carcinoma Cervix: staging

38 Carcinoma Cervix: staging: MRI 1B1 1B2 11B IIIA IVA

39 Nodal staging: carcinoma cervix Nodes not incorporated to FIGO staging: but significant prognostic and treatment consequences Using standard size only : MRI limited sensitivity (29-86%) DWI MR shows promise in increasing sensitivity

40 Carcinoma of cervix FDG: general Most Cervical carcinomas are avid for FDG Adenocarcinomas are often non FDG avid General view is PET/CT may add to staging in stages IIB to IVB but of little value in stages I to IIA General view is that PET/CT is of value not in the local but in nodal and distant staging

41 Case 1 :Nodal staging Ca cervix DB 40 woman advanced cervical tumour : staging? Remote disease? Nodal status

42 Case 2 Carcinoma cervix: pelvic nodes

43 Nodal staging of Ca Cervix: a metanalysis

44 Nodal staging of Ca Cervix: a Published March 2010 Searches At least 20 patients Histological confirmation 768 studies 41 included 20 data on CT 31 data on MRI 20 data on PET or PET/CT metanalysis

45 ROC Curves: receiver operator characteristics 1 Sensitivity Perfect Q* Any node above 1mm Area under curve Useless 0 1 Any node above Specificity 0 4cm

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47 Ca cervix Modality Sensitivity Specificity CT 50% 92% MRI 56% 91% PET or PET/CT 82% 95%

48 Ca cervix: distant metastases Prospective study 120 patients All FIGO 1B or greater (study also looked at nodal status) Distant Metastases in true positive, 9 false positive 100 considered true negative PPV 63% NPV 100% Sensitivity 100% Specificity 94% Gynecol Oncol Jul;106(1): Epub 2007 May 7. The diagnostic value of PET/CT scanning in patients with cervical cancer: a prospective study. Loft A, Berthelsen AK, Roed H, Ottosen C, Lundvall L, Knudsen J, Nedergaard L, Højgaard L, Engelholm SA.

49 Carcinoma cervix ACR guidelines

50 Prognosis carcinoma cervix

51 Ca cervix prognosis

52 Cervical Carcinoma: recurrence Chemoradiotherapy Exenteration May be options: Careful Staging appropriate prior to major surgery/ chemotherapy etc 55 patients with suspected or confirmed recurrence PET provided additional information and altered management in in 36/55 (65%) J Nucl Med Oct;45(10): Defining the priority of using 18F-FDG PET for recurrent cervical cancer. Yen TC, See LC, Chang TC, Huang KG, Ng KK, Tang SG, Chang YC, Hsueh S, Tsai CS, Hong JH, Lin CT, Chao A, Ma SY, Lin WJ, Fu YK, Fan CC, Lai CH.

53 Carcinoma cervix:? recurrence

54 Carcinoma cervix? recurrence Cystic lesion No increased FDG uptake? Cause: No FDG avid abnormality seen No definite evidence recurrence

55 Recommendations: possible recurrence

56 Carcinoma cervix: summary No obvious value in local staging Evidence of value in assessment of nodal and distant disease (ACR) Prognostic value in monitoring response to radiotherapy Of value in assessment of possible recurrence especially when radical therapy contemplated (SIGN)

57 Carcinoma Ovary

58 Case 4: Ovarian pathology characterisation PS 64 woman. Incidental findings of 9mm lung nodule and indeterminate ovarian/ adenexal mass

59 Carcinoma Ovary: assessment of primary lesions Prospective study 55 patients all scheduled for surgery All PET/CT contrast enhanced CT and TVUS SUV max 3 or more considered malignant 32 ovarian malignancy/ 18 benign at histology Sens Spec NPV PPV Accuracy PET/CT 87% 100% 81% 100% 92% TVUS 90% 61% 78% 80% 80% Nucl Med Commun 2007; 28: Diagnostic accuracy of 18F-FDG PET/CT in characterizing ovarian lesions and staging ovarian cancer: correlation with transvaginal ultrasonography, computed tomography, and histology. Castellucci P, Perrone AM, Picchio M.

60 Carcinoma ovary: staging PET/CT concordance with pathological staging 22/32 patients (69%) CT concordance 17/32 (53%) Of note 4 of the 6 stage IV patients were missed by CT and correctly characterised by PET/CT Liver Pleura Mediastinum Supraclavicular (also correctly identified a patient with ductal breast carcinoma) Nucl Med Commun 2007; 28: Diagnostic accuracy of 18F-FDG PET/CT in characterizing ovarian lesions and staging ovarian cancer: correlation with transvaginal ultrasonography, computed tomography, and histology. Castellucci P, Perrone AM, Picchio M.

61 Carcinoma Ovary staging Notes: lesion size less than 1 cm much less reliable Mucinous tumours tend to have much lower FDG uptake

62 Carcinoma Ovary: restaging Prospective study 70 patients referred to tertiary centre with suspected recurrent ovarian carcinoma NPV 83.3%, PPV 76.9% Specificity 55% sensitivity 93% Provided complementary information to laparoscopy to inform therapy Fagotti a F. Fanfani Treatment Selection Protocol for Recurrent Ovarian Cancer Patients: The Role of FDG-PET/CT and Staging Laparoscopy A. Oncology 2008;75: A

63 Carcinoma ovary: summary Some literature on characterisation of ovarian/ adenexal lesions Evidence of value in staging especially extrapelvic Evidence of value in assessment of possible recurrence

64 Current funding guidelines/ criteria: WHSCC Lung cancer: Colorectal cancer Lymphoma Oesophageal cancer Head and Neck cancer Other Cancer Sites Other cancer sites (including thyroid, melanoma, sarcoma, testicular, brain, spinal cord and unknown primary) where there is difficulty in staging, restaging or assessment of possible recurrence.

65 Suggestions for a way forward Need to continue to work closely Clinical collaboration Research collaboration Establish normal ranges/ database for SUV value in pre and post menopausal women

66 Clinical recommendations Staging scenario: all 3 tumours For problem solving/ equivocal cases where radical treatment is contemplated Restaging/ recurrence For problem solving/ equivocal cases where radical treatment is contemplated Building the case for future agreed indications: case recording

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68 Endometrial Carcinoma

69 Ca endometrium: staging Retrospective study: 32 patients histological diagnosis primary high risk endometrial carcinoma Primary carcinoma detection 29 of 32 patients Sens Spec PPV NPV Accuracy Nodes 57% 100% 100% 86% 89% Distant Mets 100% 96% 88% 100% 97% Conventional imaging suspicious for M1 in 2 patients, PET correctly identified M1 in 7 patients (22%) Nucl Med Commun Jun;31(6): High-grade endometrial cancer: value of [(18)F]FDG PET/CT in preoperative staging. Picchio M, Mangili G, Samanes Gajate AM, De Marzi P, Spinapolice EG, Mapelli P, Giovacchini G, Sigismondi C, Viganò R, Sironi S, Messa C. Department of Nuclear Medicine, San Raffaele Scientific Institute, Milan, Italy. picchio.maria@hsr.it

70 Case 3 Endometrial carcinoma JE 74 woman IIa cervical carcinoma. Pelvic recurrence feb Lung nodules felt to be stable? Co incidendal benign lung nodules

71 Endometrial carcinoma Likely metastatic nodules

72 Spare picts

73 Cyclotron

74 Target reaction 17 8 O +1 1 P 18 9 F

75 FDG and the cancer cell Extracellular compartment Cancer cell GLUT 1 GLUT 1 Hexokinase FDG FDG ( ) FDG-6-PO 4 G-6-PO 4 ase GLUT 1 GLUT 1

76 Case 3: Carcinoma cervix? recurrence SA 56 woman ca cervix Hysterectomy and post op RT. Recurrence vaginal vault Treated with chemotherapy. Recent left adenexal mass, new hydroureteronephrosis