Positron Emission Tomography in Lung Cancer

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1 May 19, 2003 Positron Emission Tomography in Lung Cancer Andrew Wang, HMS III

2 Patient DD 53 y/o gentleman presented with worsening dyspnea on exertion for the past two months 30 pack-year smoking Hx and no significant past medical Hx Initially had flu like symptoms but never fully resolved + cough, fever, fatigue (2 months) and night sweats (1 year) - hemoptysis, chest pain, weight changes PA and Left lateral CXRs were obtained 2

3 CXR Air/fluid level air fluid MGH PACS mass 3

4 Chest CT RUL RUL air fluid mass? mass vs hernia MGH PACS 4

5 Clinical Course Chest tube-large empyema Bronchoscopy/biopsy-large soft tissue mass occluding right bronchus intermedius, preliminary path is SCLC. Cancer staging CT- 7.5 X 10.5cm soft tissue mass in the right hilar region. Soft tissue mass in the left posterior mediastinum which may be contiguous with the stomach. 2.1 X 1.5 left adrenal nodule. Head MRI-no mets Bone scan- no bone mets PET for staging as well as assessing left hilar mass and adrenal nodule. Results showed a large right lung mass and left retrocardiac mass, right hilar lymph node mets and 2 left adrenal increased uptake. 5

6 PET Heart tumor tumor? Adrenal met MGH PACS 6

7 Our patient Final pathology: small cell lung cancer. Stage: extensive. Treatment: Systemic chemotherapy Radiation therapy to open occluded right bronchus intermedius PET imaging was unnecessary in this case Question: when is PET indicated in evaluating lung cancer and how is it used? 7

8 Positron Emission Tomography Physics e + + e - γ +γγ Photons (511 kev) leave the annihilation site in opposite direction Simultaneous detection of the photons allow localization of annihilation location Common positron emitters: 11 C, 15 O, 13 N and 18 F. Type of detectors PET-several thousand ring detectors, more signal, better resolution SPECT-retrofitter with coincidence detectors, cheaper PET/CT-more accurate location of cancer 8

9 PET Physiology for imaging of cancers Cancer cells have high metabolism, and rich in hexokinases. Most commonly used molecule for cancer imaging is FDG (2-18 F-2-deoxy-D-glucose) FDG is phosphorylated in the cell. It cannot be degraded nor can be excreted quickly after phosphorylation. FDG labels cells with high metabolism-cancers 9

10 PET Patient preparation Fasting for at least 4 hours Physiologic positives: brain, myocardium, urinary system, recently exercised muscle. False positives: Inflammation and benign neoplasms. False negatives: slow growing tumors-bronchoalveolar carcinoma, carcinoids, prostate cancer, etc. PET is approved for imaging of lung, thyroid, lymphoma, colon and melanoma cancers. PET is not indicated in SCLC (staging is only based on size) and slow growing tumors (low signal) such as bronchoalveolar carcinoma. 10

11 Indications for PET in lung cancer Diagnosis: malignant vs. benign. Especially in the evaluation of solitary pulmonary nodules (SPN) Cancer staging Post-therapy evaluation and recurrence assessment 11

12 SPN Hot nodule Courtesy of Kevin Donohoe, MD BIDMC 130,000 new SPN/year. Majority of SPN are indeterminate by radiographic and CT criteria. Lowe et al reported PET has 92% sensitivity and 90% specificity for 0.7cm-4.0cm nodule. Radiology 202(2): ,1997 Gould et al reported PET has 96.8% sensitivity and 77.8% specificity. JAMA 285(7): ,2001 Standardized uptake value SUV>2.5 is considered malignant. Common false positives are granulomas. 12

13 Cancer Staging tumors Courtesy of Kevin Donohoe, MD BIDMC NSCLC Most accurate, noninvasive method for staging extracranial metastases. Marom et al compared PET vs CT, bone scan and MRI: Overall staging: PET 83%, conventional 65%. Mediastinal lymph nodes: PET 85%, conventional 58%. Bone mets: PET-sensitivity 92%, specificity 99%, PPV 92%, NPV 99%; bone scan -50%, 92%, 50% and 92% respectively. Radiology 212(3): ,

14 Post-therapy therapy Evaluation Courtesy of Daniel Cornfeld, MD BIDMC Lymphoma No disease Before treatment After treatment Bury et al reported PET: 100% sensitivity, 92% specificity, 92% positive predictive value, 100% negative predictive value and 96% diagnostic accuracy; CT: 72%, 95%, 93%, 79%, and 84% respectively. Eur Respir J 14(6):

15 Summary PET is a powerful noninvasive diagnostic tool in lung cancer imaging. It is indicated in evaluation of SPN, staging of NSCLC, and in evaluating treatment effects. It is not indicated in SCLC, and bronchoalveolar cancer. Bone mets should be evaluated with PET, not bone scan in lung cancer. 15

16 References Turkington TG, Coleman RE. Clinical Oncologic Positron Emission Tomography: An introduction. Seminars in Roentgenology 37(2): Hagge RJ, Coleman RE. Positron Emission Tomography: Lung Cancer. Seminars in Roentgenology 37(2): Lowe VJ et al. Pulmonary abnormalities and PET Data analysis : a retrospective study. Radiology 202(2): ,1997 Gould MK et al: Accuracy of positron emission tomography for diagnosis of pulmonary nodules and mass lesions. JAMA 285(7): ,2001 Marom EM et al. Staging non-small cell lung cancer with whole-body PET. Radiology 212(3): ,1999 Bury T et al: Value of FDG-PET in detecting residual or recurrent nonsmall cell lung cancer. Eur Respir J 14(6):

17 Acknowledgements Kevin Donohoe, MD Daniel Cornfeld, MD Pamela Lepkowski Larry Barbaras and Cara Lyn D amour 17

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