An Introduction to PET Imaging in Oncology
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1 January 2002 An Introduction to PET Imaging in Oncology Janet McLaren, Harvard Medical School Year III
2 Basics of PET Principle of Physiologic Imaging: Allows in vivo visualization of structures by their ability to concentrate specific labeled molecules Most commonly used compound: fluorodeoxyglucose (FDG) Past use had been limited due to cost of dedicated PET scanners and the difficulty in obtaining isotopes Recent advances have made PET more feasible: Modification of dual head gamma camera SPECT systems Increase in availability of isotopes 2
3 FDG: The Compound CH 2 OH O 2-deoxy-2-( 18 F)fluoro-D-glucose 18 F: positron-emitting isotope of fluorine Metabolically active cells utilize more glucose than other tissues and therefore uptake more FDG FDG is phosphorylated by hexokinase upon entry into the cell but cannot undergo further glycolytic reactions Dephosphorylation of the compound is slow, limiting transport out of the cell HO OH OH [ 18 F] FDG 3
4 FDG: The Isotope CH 2 OH O HO OH OH 18 F: emits positrons as it decays Positrons travel until they collide with an electron This collision produces two electromagnetic pulses of 511 kev that are detected by the PET detectors [ 18 F] FDG (+) Signal can be quantified: SUV (standardized uptake value) SUV > 2.5 generally used to indicate increased uptake 4
5 Applications Oncology Diagnosis: benign vs. malignant process Staging Post-therapy evaluation: response to tx or to identify recurrence PET is approved for imaging of lung, lymphoma, colon and melanoma cancers Assessment of Cardiac Viability Used to evaluate myocardial perfusion and viability CNS Functional analysis 5
6 Oncologic Imaging FDG identifies hypermetabolic cells: Malignancy Infection Inflammation FDG false (-)s, specific to malignancy: Small tumor size Relatively low tumor metabolic activity (i.e. welldifferentiated tumors, including bronchoalveolar) Hyperglycemia: dilutes uptake of FDG 6
7 PET and the SPN 130,000 new Solitary Pulmonary Nodules (SPN)/year 40% of non-calcified SPN seen on CXR are benign A significant number of these remain indeterminate after CT Transthoracic FNA: high false (-) rate, diagnosis obtained in less than 50% of patients PET: Sensitivity and specificity of 95% and 81% for detecting malignancy PET Imaging is for patients who will have treatment planned according to PET results, i.e. thoracotomy or f/u 7
8 PET and the DDx of a SPN DDx: Benign Tumor Malignant Tumor Metastatic Tumor Round pneumonia A/V malformation Rheumatoid Nodule SUV >2.5 Narrowed DDx: Cancer Cancer Cancer Granuloma Granuloma/Rheumatoid From BrighamRad Teaching Cases: From Metro Region PET Center: SPN Case Study 8
9 Oncologic Applications of PET: Diagnosis Staging Follow-up Post-surgical Response to chemo/rt Utility of PET in each of these areas varies among the different types of cancers From GE Medical Systems 9
10 Patient #1: SPN Nodule 84 year-old man with a solitary pulmonary nodule found on routine CXR. Nodule was followed by CT for 2 years and found to be stable. A few years later, PET became available for SPN evaluation. Courtesy of Dr. Vincent Chan, BIDMC 10
11 Patient #1: SPN A PET Scan showed the nodule to have increased activity The nodule was biopsied and found to be an adenocarcinoma Courtesy of Dr. Vincent Chan, BIDMC 11
12 Patient #1: SPN Lung CA Diagnosis PET can diagnose lesions deemed indeterminate by CT and thus is invaluable in the work-up of a SPN Staging In patients with known NSCLC, PET provides significant staging and prognostic information CT vs PET in assessment of nodal status 1999 Study: PET changed tx in 37% of cases Appropriate use of PET in the work-up of a SPN will prevent unnecessary operations and may prove to be cost effective 12
13 Patient #2: Breast Cancer 58 year-old woman presented with a breast mass after many years without clinical care This mammogram was obtained Diagnosed with inflammatory breast cancer The patient was referred to Nuclear Medicine for staging From Southern Illinois University School of Medicine ( 13
14 Patient #2: Breast Cancer PET Scan findings: Primary Left Breast Mass Mets to the Left Axilla LNs Met to the Liver movie Courtesy of Dr. Vincent Chan, BIDMC 14
15 Patient #2: Breast Cancer Diagnosis Most breast cancer is detected by mammo or PE PET can be used for equivocal lesions to avoid biopsy, or in patients with prior surgery or implants Staging Sentinel Node Biopsy remains the preferred method of detecting axillary node metastsis PET plays a useful role in identifying distant metastases Shown superior to bone scan in detecting osteolytic lesions Follow-Up Limited data show PET can be used to monitor response to chemo as early as 8 days into treatment 15
16 Patient #3: Melanoma 35 year-old man presented with a lesion on his back On excision, the lesion was found to be invasive melanoma Patient was referred to Nuclear Medicine for staging Courtesy of Dr. Vincent Chan, BIDMC 16
17 Patient #3: Melanoma PET Scan showed high activity in the left axilla and in a small area of the upper mediastinum Courtesy of Dr. Vincent Chan, BIDMC 17
18 Patient #3: Melanoma The increased activity in the upper mediastinum was thought to be artifact The patient was treated with surgical excision of the left axillary lymph nodes Courtesy of Dr. Vincent Chan, BIDMC 18
19 Normal brain uptake Patient #3: Melanoma Healing tissue 6 months later the patient returned for follow-up The follow-up PET Scan revealed growth of the upper mediastinal mass The mass was excised and confirmed to be metastatic melanoma Courtesy of Dr. Vincent Chan, BIDMC 19
20 Patient #3: Melanoma Staging Sentinel Node Biopsy remains the preferred method of determining regional lymphatic spread PET is preferred and superior to CT and MRI for identifying distant metastatic lesions Data: sensitivity and specificity of 94% and 83% for PET vs. 55% and 84% for CT PET is very useful in identification and staging of cancers that metastasize widely or in an unpredictable manner (e.g. melanoma, lymphoma, head and neck cancer ) 20
21 Patient #4 78 year old female S/p colectomy and partial hepatectomy for metastatic colon CA seven years prior Rising CEA (10.0) Courtesy of Dr. Vincent Chan, BIDMC 21
22 Patient #4: Colon CA Abdominal CT findings: Courtesy of Dr. Vincent Chan, BIDMC Seroma Rib end? 22
23 Patient #4: Colon CA? Rib end 23 Courtesy of Dr. Vincent Chan, BIDMC
24 Patient #4: Colon CA As Abdominal CT was inconclusive, the patient was referred to Nuclear Medicine for a PET Scan. Courtesy of Dr. Vincent Chan, BIDMC 24
25 Patient #4: Colon CA PET Scan revealed uptake in the chest wall scar, consistent with seeding during removal of the liver metastasis and recurrence. Courtesy of Dr. Vincent Chan, BIDMC 25
26 Patient #4: Colon CA PET Imaging of the pelvis revealed another site of recurrence at the removal site of the primary tumor. Courtesy of Dr. Vincent Chan, BIDMC 26
27 Patient #4: Colon CA PET Imaging of the pelvis revealed another site of recurrence at the removal site of the primary tumor. Courtesy of Dr. Vincent Chan, BIDMC 27
28 Patient #4: Colon CA Diagnosis Highly sensitive in identifying colonic lesions, but not very specific (100% and 43%) Staging Good for evaluating distant metastases; lymph nodes to close to primary tumor to see Follow-up CTs are difficult to evaluate in the post-op patient due to fibrosis and distorted anatomy PET Scans are very useful in follow-up patients by identifying recurrent lesions in areas of scar tissue 28
29 Keeping a DDx FDG identifies hypermetabolic cells Malignancy Infection Inflammation 29
30 Lets review some positive PET scans that were NOT due to malignancy 30
31 Patient #5 60 year old female Referred for evaluation of a SPN in the right upper lobe? RV LV Cross-section at T9 level Courtesy of Dr. Vincent Chan, BIDMC 31
32 Patient #5 Courtesy of Dr. Vincent Chan, BIDMC 32
33 Patient #5 Hiatal Hernia Increased metabolic activity from inflammation Courtesy of Dr. Vincent Chan, BIDMC 33
34 Patient #6 41 year-old man History of hepatocellular carcinoma Chevron Incision Increased metabolic activity of healing tissue Courtesy of Dr. Vincent Chan, BIDMC 34
35 Summary PET is one of the most exciting fields in modern Nuclear Medicine When used in correlation with anatomic imaging, PET can provide important physiologic information The modality has become very useful in the diagnosis, staging, and follow-up of oncologic disease Great opportunity for advances in PET imaging: isotopes tailored for specific cancers new detectors to improve image resolution 35
36 Acknowledgements Vincent Chan, MD and the Nuclear Medicine Department of the BIDMC Pamela Lepkowski Larry Barbaras and Cara Lyn D amour, our Webmasters 36
37 References Bar-Shalom R, Valdivia AY, Blaufox MD. PET Imaging in Oncology. Sem Nuc Med 2000; 30(3): Bax JJ, Patton JA, Poldermans D, Elhendy A, and Sandler MP. 18- Fluorodeoxyglucose imaging with Positron Emission Tomography and Single Photon Emission Computed Tomography: Cardiac Applications. Sem Nuc Med 2000; 30(4): Delbeke D, Martin WH. Positron Emission Tomography Imaging in Oncology. RadClinNA2001 Sept; 39(5): Saunders CA, Dussek JE, O'Doherty MJ, Maisey MN. Evaluation of fluorine-18- fluorodeoxyglucose whole body positron emission tomography imaging in the staging of lung cancer. Annals of Thoracic Surgery1999 Mar; 67(3): Schwartz B and Udelson JE. Assessment of myocardial viability by nuclear imaging in coronary heart disease. Up-to-Date version 9.3, Stark P. Computed Tomography and Positron Emission Tomographic scanning of pulmonary nodules. Up-to-Date version 9.3,
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