Role of DE-CT in Oncology
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1 Role of DE-CT in Oncology Dushyant Sahani, M.D Director of CT Associate Professor of Radiology Massachusetts General Hospital Harvard Medical School
2 Disclosure Research Grant Support from GE Healthcare Consultant, Bracco Diagnostics
3 Staging Volume Size Viability DE-CT Oncology Imaging Density Function
4 Molecular Targeted Therapy for Cancer Surface receptor: EGFR, VEGFR, FGFR Ras-FT BCR-ABL AURORA Angiogeni c Factors VGEF FGF IGF IL-8 Endotheli n Integrin Serine Protease P53 Survivin E2F BCL-2 GNRH Sulfatase Episoline Transferas Growth signal transduction Tumor angiogenesis Tumor invasion Cell cycle apoptosis Hormones & others
5 Mechanistic Antiangiogenic Effects in Malignancy Investigating Anti-angiogenesis and the vascular normalization hypothesis High IFP, Low po2 High permiability Poor Perfusion Lower IFP, Higher po2 Lower permiability Better perfusion and delivery No Perfusion Necrosis Jain, Science :61
6 DECT Spectrum Monochromatic VNC MD Water MD Iodine Iodine map Effective Z Exploitation of contrast Replacement to unenhanced CT Material differentiation and replacement to unenhanced CT Material differentiation, qualitative and quantitative iodine uptake assessment Assessment of iodine uptake both qualitative and quantitatively Material differentiation based on effective atomic number
7 Low kev: Improved Detection 140 kv 70 kev 50 kev 50keV Mono MD Iodine
8 Characterization
9 Characterization CECT MD iodine Iodine map * * *
10 Small cyst Mass Characterization TNC CECT TNC CEC T MD Iodine Iodine map Renal mass Hyperdense cyst
11 Characterization DWI MRI CEC T * * Iodine map
12 IMPROVED CHARACTERIZATION: CTU TNC I+ MD-iodine 85 year old with gross hematuria
13 Treatment Plan and Delivery Indication Liver perfusion abnormality 70 kev 50 kev MD Iodine Differential enhancement better seen on MD Iodine image CT Enterography MD Iodine and lower kev MC images accentuates bowel wall enhancement
14 50 kev Improved CM Attenuation Virtual Monochromatic Images 70 kev 90 kev 110 kev 120 kvp
15 Treatment Planning CECT 50 kev Iodine map Adenocarcinoma of the pancreas: Hypoattenuating lesion in the tail of the pancreas (arrow) with margins unclearly defined in CECT image. The VMC image at 50 kev and iodine map can better define the margins of the lesion as well as its relationship with vessels, contributing to a better treatment planning.
16 Perfusion CT Characterization Biology Angiogenesis Necrosis Recurrence Tumor Grade Soft Tissues Lymph Nodes Pancreas Prostate Lung Nodule Angiogenesis Liver Challenges Pelvis Lung Limited coverage Standardization Kinetic modeling Radiation Dose
17 Oncologic Imaging: FDG-PET Paradigm SUVs Baseline 1 month 16 months Biomarker Expectations Quantitative Reproducible Robust Coverage Applicable in clinical trials Demetri et al N Engl J Med 347: , 2002
18 Iodine (perfusion) Imaging Qualitative Quantitative RM mg/cc RP mc/cc
19 Oncology Therapy Monitoring like PET imaging Iodine map Color overlay image PET Comparison of Iodine maps and color overlay images with PET and a possibility of developing PET-Iodine map and PET-Color overlay fusion images.
20 Therapy Monitoring Indication CECT Iodine map TNC post RF ablation RCC Renal mass
21 Patient with HCC post RFA and TACE. 9/ / mg/cc 0.1 mg/cc 0.1 mg/cc
22 Therapy Monitoring Indication CECT MD Iodine TNC Liver post RF ablation HCC. MD Iodine help assessment of local recurrence. Hemorrhage Vs enhancement in RF bed better differentiated on MD Iodine Post RF ablation RCC. Assessment of local recurrence. Patient with lung CA and metastatic mediastinal lymphnode on antiangiogenic treatment. Iodine map can complement PET & Perfusion CT in assessing treatment response CTp MD Iodine PET SUV 1.8 BF ml/gm Iodine uptake 2.1mg/cc
23 Base line Post BVZ Treatment completion Contrast enhanced CT (RECIST) Contrast enhanced CT (RECIST) Contrast enhanced CT (RECIST) FDG PET Mean SUV 7.62 FDG PET Mean SUV 4.01 FDG PET Mean SUV 2.1
24 Challenges Optimal phase for DE scanning Later arterial/portal or multi Work-flow scan and interpretation Reproducibility Validation Response Criteria Radiation Dose
25 Summary DE-CT offers potential benefits (morphology + Function) For improved lesion detection and staging Response assessment at micro vascular level along with morphologic 2D and 3D methods Protocol customization To enable relevant tumor vascular physiology data Radiation dose optimization Work-flow challenges Validation
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