The Role of PET / CT in Lung Cancer Staging
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1 July 2004 The Role of PET / CT in Lung Cancer Staging Vlad Vinarsky, Harvard Medical School Year IV
2 Patient AM HPI: 81 yo F p/w hemoptysis x 1 month LLL lesion on CXR, not responsive to Abx 35 pack-year smoking history, quit 12 years ago Chest CT at OSH revealed a spiculated 3 cm mass in LLL (images not available) Work-Up at BIDMC: Bronchoscopy and tranbronchial biopsy of LLL: Consistent with poorly differentiated, non-small cell carcinoma. PET / CT for lung cancer staging: 2
3 Anatomy of an PET / CT Report 1. PET/CT Modality 2. Use of PET/CT in NSCLC Staging 3
4 The Chemistry of Positron Emission Tomography (PET) The Chemistry 1. Produce a positron-emitting isotope (F-18) 2. Conjugate to Glucose (FDG) 3. IV-FDG 4. PET scan in 1 hour 4
5 PET/CT Report 5
6 The Biology and Physiology of PET Metabolic / Functional Imaging Cancer Cells: high Glc uptake -higher overall metabolism -less FFA metabolism -hypoxic tissue, less reliance on TCA-cycle Physiologic Uptake of FGD in: -brain; myocardium -muscle; liver -kidney, bladder -bone marrow... FDG Trapped in the Cell adapted from 6
7 The Physics of PET / CT (made ridiculously simple) The Physics 1. F-18 emits positrons as it decays 2. Positrons annihilated by electrons in the tissues 3. Two 511 kev photons are emitted in at 180º 4. Photons detected by BGA 7
8 The CT in PET / CT: Attenuation Correction The Advantages of CT: 1. Faster image acquisition (attenuation correction by CT) 2. Improved lesion localization (no published proof). chest wall vs lung. base of lung vs liver. neck vs superior mediastinum. distal esoph (often normal) vs paraesoph node (N2) uptodate.com 8
9 PET / CT SCANNER PET CT adapted from 9
10 Sample PET / CT CT PET, attenuation-corrected FUSION Image Courtesy of Dr. Parker PET; non-corrected 10
11 DDX of an FDG-Avid Area in BONE FALSE POSITIVES 1. Physiologic Uptake 2. Pathology -malignancy -granulomatous disease (fungal infections: coccidiomycosis, histoplasmosis, aspergillosis, TB) -infection -sarcoidosis -inflammation (DJD) FALSE NEGATIVES -some tumors are less FDG-avid (carcinoid, bronchioalveolar) -nodule too small (esp. micromets in LNs) -brain: very high background -hyperglycemia -too much attenuation correction Sensitivity: 95% for >8mm lesion 11
12 Indications for PET / CT Diagnosis: especially SPN Staging: prognosis and avoidance of ineffective surgery and radiation therapy Localization: ability to guide surgical mediastinal bx and XRT Restaging: monitor response to therapy and surveillance after curative tx * * * 12
13 PET/CT Report for Patient AM: 13
14 NSCLC Staging Algorithm uptodate.com 14
15 PET/CT Report: Finding 1 in Patient AM 15
16 Finding 1 in Pt AM: Left Lower Lung Mass (T1) T1 lesion is less than 3cm in diameter and is considered to be easily resectable, being located in the periphery of the lung. SUV: Standardized Uptake Value tracer activity in ROI dose of tracer injected (cut-off SUV>2.5) PACS 16
17 PET/CT Report: Finding 2 in Patient AM 17
18 Finding 2 in Pt AM: FDG-Avid Hilar Node PACS, BIDMC 18
19 Finding 2 in Pt AM: Paraesophageal Node PACS, BIDMC 19
20 FDG-Avid Hilar and Paraesophageal Nodes (N2) uptodate.com 20
21 NSCLC Staging: TNM System 21
22 Patient appears to be Stage IIIa except 22
23 PET/CT Report: Finding 3 in Patient AM 23
24 Finding 3 in Pt AM: Metastatic Disease in the Ileum DDX for FDG-Avid Lesion in Bone -malignancy -Bone Marrow (normal) -inflammation (DJD) -tendonitis / tendon insertion PACS, BIDMC 24
25 Patient AM PET/CT suggested metastatic disease (Stage IV) --> conservative chemotherapy was initiated Technical difficulties with biopsy and MRI of ilium Repeat PET/CT, when aggressive chemo-radiation and surgery were still being considered, showed dramatic progression of cancer with clear bony mets 25
26 Patients AM PET/CT changed patient management by preventing unnecessary chemoradiation and surgery 26
27 Follow-Up PET/CT Courtesy of Dr. Parker 27
28 PET / CT Affects Management of NSCLC Patients NEJM NEJM Bar-Shalom et. al. (2003) study shows impact on treatment of 14% patients Antoch G. et. al. (2003) shows impact on staging in 30% patients and impact on treatment in 19% of patients 28
29 Summary PET/CT Affects Staging and Patient Management in NSCLC Future PET / High-Resolution CT Tumor-specific Radiopharmaceuticals 29
30 Thank You J. Anthony Parker, MD Jeff English, PET/CT Tech Steve Eiger, PhD Pamela Lepkowski Larry Barbaras our Webmaster 30
31 References Antoch G et. al. Non-small cell lung cancer: dual-modality PET/CT in preoperative staging. Radiology 2003 Nov;229(2): Epub 2003 Sep 25 Lardinois D. et. al. Staging of non-small-cell lung cancer with integrated positronemission tomography and computed tomography. N Engl J Med 2003 Jun 19;348(25): Czernin J. and Schelbert H. PET/CT Imaging: Facts, Opinions, Hopes, and Questions J Nucl Med.2004; 45: 1-3. Use of imaging studies in the staging of lung cancer by Paul Stark, MD, uptodate.com Thoracic positron emission tomography by Paul Stark, MD, uptodate.com Let s Play PET
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