FDG PET and PET-CT for GI Malignancies: Colorectal cancer Hepatobiliary malignancies Pancreatic cancer Esophageal and Gastric cancer

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1 FDG PET and PET-CT for GI Malignancies: Colorectal cancer Hepatobiliary malignancies Pancreatic cancer Esophageal and Gastric cancer Dominique Delbeke, MD, PhD Vanderbilt University Medical Center Nashville, TN VUMC PET Conference August 2009

2 FDG PET in the Initial Evaluation of Colorectal carcinoma There are ~133,200 new cases/year in the US. Diagnosis based on colonoscopy Preoperative staging: intraoperatively Preoperative staging with FDG PET: Good sensitivity for detection of primaries, F+ inflammatory bowel disease Poor performance for regional LN involvement Better sensitivity and specificity than CT for detection of hepatic metastases Abdel-Nabi et al. Radiology 1998;206: Mukai et al. Oncology Reports 2000;7: Kantorova I et al. J Nucl Med 2003;44:

3 65 year-old patient presenting for initial staging of colon cancer

4 A 45 year old female presented with liver metastases of UP From Delbeke D et al. Semin Nucl Med 2004;34(3):

5 Incidental FDG uptake in GI tract on PET/CT 1,750 WB PET performed for evaluation of known or suspected malignancies Results: Incidental focal FDG uptake: 3.3% of unexpected foci (58( in 53 patients) 42 pathologically confirmed Incidence of unexpected proven tumors = 1.7%: 18 colonic adenomas and 3 carcinomas 3,281 patients ( ) 2003) Results: Incidental GI uptake: 3% (98/3,281) Histopathology: 69/98 patients Cancer: 19% (13/69) Precancerous lesions: 42% (29/69) Benign and inflammatory: 25% (18/69) 1,716 patients Results: Incidental GI uptake: 2.6% (45/1,716) Colonoscopy: 20/45 Advanced neoplasms: 65% (13/20) Agress H et al. Radiology 2004;230(2): Kamel EM et al. J Nucl Med 2004;45: Gutman F et al. Am J Roentgenol 2005;185:

6 Detection of Recurrent Colorectal Carcinoma 70% are resected with curative intent 1/3 have recurrence within 2 years. 25% have recurrence to one site and are potentially curable by surgical resection. Conventional methods for detection of recurrence: CEA levels: Only ~2/3 of patients have elevated and it does not localize. CT: suboptimal for Metastases in the peritoneum, mesentery, LN Differentiation of post-treatment treatment changes from recurrence. Barium enema: local recurrence only (accuracy 80%).

7 FDG PET for Detection of Recurrent Colorectal Carcinoma Reference Strauss 89 Vitola 96 Delbeke 97 Ogunbiy 97 Valk 99 Whiteford Zhuang 00 Staib 00 Johnson 01 No patients Sites Local recur Liver Liver Other sites Local recur Liver All sites Mucinous - Mucinous + Liver All sites Liver PET Sens 95% 90% 91% 100% 91% 95% 93% 92% 58% 100% 98% 100% PET Spec 100% 100% 92% 92% 100% 100% 79% 100% 90% 69% CT Sens 86% 81% 74% 52% 52% 78% 71% 91% 58% 78% 71% 80% 80% 50% 72% Pelvis 87% 61% Sensitivity of FDG PET is ~ 90% and specificity > 70%, both > to CT CT Spec

8 FDG PET for Detection of Recurrent Colorectal Cancer Meta-Analysis: 11 studies and 577 patients analyzed on a patient-basis: Sensitivity: 97% Specificity: 75% higher for local recurrence and hepatic metastases (>95%) Change of management was 29%. Summary of the literature for evaluation of recurrence: Sensitivity: PET 94%, CT 79% (2244 patients studies) Specificity: PET 87%, CT 73% (2244 patients studies) Change in management: 32% (915 patients studies) Huener RH et al. J Nucl Med 2000;41: Gambhir SS et al. J Nucl Med 2001;42(suppl):9S-12S. 12S.

9 FDG PET for Detection of Local Recurrence of Colorectal Carcinoma Year No of Patients Accuracy PET Accurac y CT Strauss % E Ito % E Falk % 60% Beets / 35 63% * E Schiepers % 65% Ogunbiyi /58 90% 48% Schiepers et al. Eur J Clin Oncol 1995;21:

10 63 year-old male with history of colon cancer presented with rising CEA levels Diagnosis: Local recurrence From Delbeke D et al. Semin Nucl Med 2004;34(3)

11 A 61-year year-old female with a history of colon cancer presented with suspected local recurrence

12 A 61-year year-old female with a history of colon cancer presented with suspected local recurrence Diagnosis: 1) Local recurrence 2) Metastasis in left presacral LN

13 Comparison FDG PET/multiphase CT and intraoperative US for Detection of Hepatic Metastases 131 patients selected for hepatic resection of colorectal liver metastases: 363 liver metastases were identified Sensitivity for detection: 63 lesions < 10 mm: CT PET 16% 172 lesions mm: CT 72% PET 75% 128 lesions > 20 mm: CT 97% PET 95% All CT 71% PET 72% Both CT and PET missed ~ 30% smaller lesions resulting in change in management in 7% (9/131) patients Wiering B et al. Ann Surg Oncol 2007;14(2):

14 FDG PET, CT and MRI for Detection of Colorectal Hepatic Metastases: Meta-analysis analysis Meta-analysis analysis comparing non-invasive methods 61/165 data sets were included Sensitivity for detection of liver metastases: Patient Lesion Lesions>1 cm CT -non helical: 60% 52% 74% CT-helical: 65% 64% 74% MR no Gad 76% 66% 65% MR Gad 69% MR SPIO 90% PET: 95% 76% Bipat S, vanleeuwen MS, Comans EF et al. Radiology 2005;237:

15 FDG PET for Detection of Extrahepatic Metastases Study of over 155 patients analyzed by sites of lesions: Sensitivity: FDG PET > CT for all locations, except the lungs where the two modalities are equivalent. FDG PET particularly helpful for abdomen, pelvis and retroperitoneum Specificity: FDG PET > CT at all sites, except the retroperitoneum Valk PE et al. Arch Surg 1999;134:

16 A 37-year year-old female with a history of metastatic colon cancer to the liver s/p colectomy and hepatic resection presented for restaging Diagnosis: Multiple metastatic foci in abdomen From Delbeke D. Diagnostic Imaging 2004.

17 FDG PET for Detection of Metastases in Patients with Rising CEA levels and Normal Work-up Reference Flanagan Valk Maldonado Flamen Year No patients Sensitivit y 77% 90% 94% 79% Specificity 100% 92% 83% 100% When the conventional work-up is negative (including CT), FDG PET demonstrates tumor in 84% (142/169) of the patients. PET allowed surgical resection in 26% of patients Flanagan FL et al. Ann Surg 1998;227: Valk PE et al. Arch Surg 1999;134: Maldonado A et al. Clin Pos Imaging 2000;3:170. Flamen P et al. Eur J Cancer 2001;37:

18 44-year year-old man with a history of colon ca with rising CEA lev From: Delbeke D et al (eds( eds): Practical FDG Imaging: A teaching File Springer-Verlag 2002.

19 Clinical Impact of FDG PET in Colorectal Cancer Reference Beets 94 Schiepers 95 Lai 96 Delbeke 97 Ogunbiyi 97 Valk 99 Flamen 99 Imdhal 00 Staib 00 Kalff 00 Strasberg 01* No patients PET accuracy 95-98% 98% 92% 95% Unsuspected 13% (10/76) 28% (17/61) 36% (35/96) 15% (9/60) 21% (16/71) 23% (10/43) Clinical Impact 40%(14/35) 32% (11/34) 28% (17/61) 44% (10/23) 34% (17/73) 20% (21/103 21% (16/71) 61% (61/100) 65% (66/102) 14% (6/43) Total % (108/441) 36% (238/645)

20 Impact of FDG PET in the Management of Colorectal Hepatic Metastases: Meta-analysis analysis Pooled Sensitivity and Specificity of FDG PET and CT from studies in patients evaluated for hepatic resection: Hepatic metastases: Sensitivity: PET 88% CT 82% Specificity: PET 96% CT 84% Extrahepatic metastases: Sensitivity: PET 91% CT 61% Specificity: PET 95% CT 91% Change in management: 31% (range 20-58%) Wiering B et al. Cancer 2005;104:

21 Clinical Impact of FDG PET in Patients with Colorectal Carcinoma: Survival data Survival at 3 years of patients with FDG PET: 77% (higher than historical series). Survival at 5 years of patients with hepatic metastases preoperatively staged with: CIM (19 studies with 6,019): 30% FDG PET (100 patients): 58% Contribution: Detection of occult disease and reduction of futile surgeries Strasberg SM et al. Ann Surg 2001;233:320. Fernandez FG et al. Ann Surg 2004;240 (3):

22 Impact of PET/CT on Radiation Therapy 39 patients with various solid tumors Comparison GTV delineated on CT vs with PET overlay PET changed GTV in 56% of patients GTV increased by 25% or more because of PET: 17% of patients with H&N tumors and lung cancer 33% of patients with cancer of the pelvis GTV was reduced by 25% or more because of PET: 33% of patients with H&N tumors 67% of patients with lung cancer 19% of patients with cancer of the pelvis Delineation variability decreased: mean vol difference of 25 cm 3 to 9 cm 3. Change treatment from curative to palliative: 16% patients Ciernik F, Dizendorf E, Baumert BG, et al. Int J Radiation Oncol Biol Phys;2003;57:

23 Colorectal cancer: FDG PET versus PET/CT 45 patients: retrospective review Standard of reference: Interpretation by a panel of experts Incremental diagnostic value of PET-CT: Equivocal: decrease by 50% Characterization: increase by 30% Definite localization: increase by 25% No significant change in sensitivity and specificity Correct staging increased from 78% to 89% Cohade C et al. J Nucl Med 2003;44: Schoder H et al. J Nucl Med 2004;45 (Suppl( Suppl): 72S.

24 Contrast-enhanced CT versus PET/CT 76 patients referred for resection of hepatic metastases Hepatic metastases: Sensitivity: 95% (CT) = 91% (PET/CT) PET better for hepatic recurrence with specificity of 100% compared to 50% for CT Local recurrence: Sensitivity: 53% (CT) < 93% (PET/CT) Extrahepatic metastases: Sensitivity: 64% (CT) < 89% (PET/CT) Impact on management for PET/CT: 21% of patients PET/CT false-negative: Lesions < 5 mm Chemotherapy during month before PET/CT Selzner M et al. Ann Surg 2004;240:

25 PET/ceCT vs PET/non cect 54 patients referred for restaging PET/non cect > cect in 50% patients Changed therapy in 5 patients Due to detection of additional lesions PET/ceCT > PET/non cect in 72% patients Changed therapy in 23 patients Mainly due to correct segmental localization of liver metastases 53 patients referred for nodal staging of rectal cancer Accuracy PET/ceCT (79%) > PET/non cect (70%) but not statistically significant More accurate for pararectal,, internal iliac and obturator LN Soyka JD et al. J Nucl Med 2008;49(3): Tateishi U et al. EJNMMI 2007:34(10):

26 Systematic Review: Monitoring and Predicting Response to Therapy Chemotherapy response monitoring in advanced colorectal cancer: 5 studies/127 patients FDG PET is a good predictor of outcome Monitoring responses after local ablative therapy of liver metastases: 4 studies/131 patients FDG PET can detect earlier than CT incomplete ablation or recurrence Radiotherapy and multimodality treatment response evaluation in primary rectal cancer: 19 studies/603 patients FDG PET predicted therapy outcome better than endorectal US, CT and MRI FDG PET detect recurrence after XRT: more accurate after 6 months: sensitivity 84%, specificity 88% De Geus-Oei LF et al. JNM 2009;50:43S-54S. 54S. *Haberkorn et al. J Nucl Med 1991;32:

27 FDG PET for Colorectal Cancer: Monitoring Therapy Hepatic metastases Chemotherapy # : FDG PET can detect non-responders weeks into chemotherapy with 5-FU5 The degree of histological response: PET > CT. Good prediction of long-term outcome (42 mo): Recurrence free: Decrease SUV= mean 69% Recurrence: Decrease SUV = mean 37% *Strauss et al. Radiology 1992;182: *Haberkorn et al. J Nucl Med 1991;32: Moore HG et al. J Am Coll Surg 2003;197 (1): #Findlay et al.j Clin Oncol;1996;14: #Guillem J et al. Dis Colon Rectum 2000;43: Guillem JG et al. J Am Coll surg 2004;199:1-7.

28 FDG PET for Colorectal Cancer: Detection of hepatic metastases after neoadjuvant chemotherapy Patients who underwent hepatic resection immediately or after downstaging with 5FU/Folfox/Folfiri-based chemotherapy Group 1 (27 patients): immediate resection Group 2 (48 patients): preop neoadjuvant chemo FDG PET at least 2 weeks after last chemo Sensitivity for detection of metastases: FDG PET: : Group 1 (93%) > Group 2 (49%) CT: Group 1 (87.5%) > Group 2 (65%) Conclusions: PET and CT have a lower sensitivity for detection of hepatic metastases after neoadjuvant chemotherapy CT is slightly more sensitive than FDG PET Lubeszky N et al. J Gastrointest Surg 2007;11:

29 FDG PET for Monitoring Regional Therapy to the Liver Hepatic metastases: Chemoembolization RFA and cryosurgery 90 Y-microspheres Findlay et al.j Clin Oncol;1996;14: Guillem J et al. Dis Colon Rectum 2000;43: Langenhoff BS et al. J Clin Oncol 2002;20: Donckier et al. J Surg Oncol 2003;84: Anderson GS et al. Clin Nucl Med 2003;28:

30 Monitoring Response to Chemoembolization FDG PET better than lipiodol retention on CT Change in FDG uptake correlate with the change in tumor markers Pre-therapy Post-therapy therapy CT FDG PET From Vitola JV et al. Cancer 1996;78: Torizuka et al. J Nucl Med 1994;35: Residual tumor

31 FDG PET for Monitoring Therapy with RFA 38 year-old with colon cancer who underwent RFA of a liver metastasis 4 months earlier Transmission CT From Delbeke D. Semin Nucl Med 2004;34: Contrasted CT Recurrence at RFA site

32 52 year-old with hepatic metastasis from pancreatic cancer s/p RFA Immediately after RFA: CT FDG PET Peripheral enhancement 15 months after RFA: recurrence PET guided needle placement for subsequent RFA Nodular enhancement FDG -avid Barker DW et al. AJR 2005;184:

33 Conclusions: FDG PET for Colorectal Carcinoma Diagnosis: Incidental focal uptake in GI tract: ~ 30-50% are malignant Detection of recurrence: Presurgical tumor N and M staging Unsuspected metastases: high rate of detection Extrahepatic metatases: : PET>CT Rising CEA levels in the absence of a known source. Equivocal lesions on other imaging modalities, for example: Evaluation of postsurgical sites Indeterminate pulmonary nodules, hepatic lesions lymph nodes Change in management: ~ 30% of patients

34 Conclusions: PET/CT for Hepatic Metastases from Colorectal Cancer FDG PET/CT for detection of hepatic metastases: Sensitivity (patient): ~ 90% range > MR no Gad> cect Sensitivity (lesion): ~ 75% range > MR no Gad > cect MR with SPIO: ~90% False -: small size (< 2 cm) mucinous primary hyperglycemia For recurrence: specificity FDG PET/CT (~90%) >>cect(~50%) FDG PET/ceCT cect> > FDG PET/non cect for segmental localization After chemotherapy: Decrease FDG T/L and SUV can identify responders 4-54 weeks into therapy Sensitivity for detection of residual tumor after chemotherapy: FDG PET: ~ 50%-60% CT: ~60-90%

35 Esophageal Cancer Prospective study of 74 patients comparing FDG PET, CT and EUS: FDG PET CT+EUS CT EUS Primary Sens: : 95% Loco- regional LN Stage IV Sens: : 33% Spec: 89% Sens: : 74% Spec: 90% Sens: : 47% Spec: 78% Sens: : 41% Spec: 83% Sens: : 81% Spec: 67% Sens: : 42% Spec: 94% Flamen P et al. J Clin Oncol 2000;18: Van Westreenen HL et al. J clin oncol 2004;22: (review).

36 Esophageal Cancer: Effectiveness of strategies: Comparison 6 strategies: CT alone CT + EUS with FNA CT + thoracoscopy and laparoscopy (TL) CT + EUS with FNA + TL CT + PET +EUS with FNA PET + EUS with FNA: most effective Parameters incorporated: Prevalence of local, regional and distant disease Life expectancies Cost associated with therapy Probability of death for patients undergoing TL and those undergoing resection Wallace et al.ann Thorac Surg 2002;74:

37 80 year-old man referred for initial staging of esophageal cancer From Habibian MR, Delbeke D et al (eds( eds): Nuclear Medicine Imaging: A Teaching File, Lippincott 2 nd ed, 2008

38 57 year old male diagnosed with esophageal cancer in July and treated with chemoradiation completed two weeks before his follow-up PET scan July 29 Oct 19 From Delbeke D, SNM LLSAP program, module GI malignancies, 2006

39 Gastric Cancer: FDG PET 95% are adenocarcinomas Often associated with H. Pylori infection Intestinal type: forms gland-type structures and affects the elderly Diffuse type: poorly differentiated, lacks glandular structures and has genetic predisposition FDG PET: controversial Less sensitive for detection of diffuse type with high mucin content Physiologic/inflammatory background uptake Stahl A et al. Eur J Nucl Med 2003;30: Mochiki E et al. World J Surg 2004;28: Yoshioka T et al. J Nucl Med 2003;44:

40 FDG PET for Esophageal and Gastric Cancer: Monitoring Therapy Frequent diagnosis at advance stage (III and IV): Poor survival Prediction of response to induction therapy is critical to identify surgical candidates FDG can predict histological response early and after completion of neoadjuvant therapy Example: Gastric cancer: 44 patients, 2 weeks after initiation of therapy, decreased uptake > 35% as criterion * Good responders have improved survival after surgery Weber WA et al. J Clin Oncol 2001;19: Flamen P et al. Ann Oncol 2002;13: Kato H et al. Am J Surg 2002;184: Downey RJ et al. J Clin Oncol 2003;21: Wider HA et al. J Clin Oncol 2004;22(1): *Ott K et al. J Clin Oncol 2003;21(24):

41 FDG PET for Pancreatic Carcinoma Diagnosis Summary of literature 2001: Sensitivity: 94% (n = 293), Specificity: 90% (n = 281) Change in management: 50% (26 patients studies) Retrospective study (n = 65) Sensitivity and specificity : FDG PET 91-95% 95% vs CT 65% Especially helpful when no definite mass on CT or in whom FNAs are non-diagnostic Change in management: 41% of patients Staging (especially M) by detecting CT-occult metastases. Detection of recurrence Monitoring therapy Gambhir SS et al. J Nucl Med 2001;42(suppl):50S-52S. 52S. Delbeke D et al. J Nucl Med 1999;40: Rose DM et al. Annals of Surg 1998;229:

42 FDG PET versus EUS for the Diagnosis and Staging Pancreatic Cancer (35 patients) Diagnosis: Sensitivity: EUS (93%) > FDG PET (87%) > CT (53%). EUS-guided FNA allowed tissue diagnosis in 67% of the patients. T staging: EUS was more sensitive than CT to evaluate vascular invasion of the portal and superior mesenteric veins. M staging: FDG PET detected distant metastases in 7 of 9 proven metastases, 4 of which were missed by CT Mertz HR et al. Gastrointest Endosc 2000;52:

43 44 year-old male s/p Whipple for pancreatic cancer 8 months earlier CT Postsurgical changes PET Recurrent pancreatic Ca

44 FDG PET in the Differential Diagnosis of Pancreatic Cancer Prospective study of 106 patients with pancreatic masses suspicious for pancreatic carcinoma All Nl Glycemia DM Malignant 63/74 46/47 17/27 Benign 27/32 21/25 6/7 Sensitivity 85% 98% 63% Specificity 84% 84% 86% Accuracy 85% 93% 68% Zimny et al. EJNM 1997;24:

45 Abdominal pain & obstructive jaundice Acute pancreatitis Should CRP be checked? n = 159 Sens Spec Acc nml glycemia,, nml CRP 88% 87% 88% glycemia,, nml CRP nml glycemia, CRP 30% 83% 86% 50% 53% 68% Diederichs et al. Pancreas 2000; 20: 109 From Delbeke D, SNM LLSAP program, module GI malignancies, 2006

46 FDG PET Detects Pancreatic Carcinoma in Chronic Pancreatitis Patients with long-standing chronic pancreatitis have a 15-fold greater risk of pancreatic carcinoma: FDG PET NPV = 87% CP CA CP + CA PET TP PET FP PET TN PET FN FP: 3 mild, one stent, 1 infected pseudocyst, 2 acute inflammation at surgery, and 3 w/ probable acute inflammation Mariette et al. Eur J Nucl Med 2005; 32: 399. Van Kouwen M et al. Eur J Med Imag 2005;32:

47 Differentiating Malignant from Benign Pancreatic Cysts *Prospective study of 50 patients with suspected cystic pancreatic tumors or intraductal papillary mucinous tumors (IPMT) FDG PET Malignant 16/17* 24/30** Benign 31/33 18/22 Sensitivity 94% 80% Specificity 94% 82% *Sperti et al. J GI Surg 2005; 9: 22 **Hara et al. J Nucl Med 2005; 46: 220P

48 FDG PET for the Diagnosis of Pancreatic Carcinoma In 2000, the European Consensus designated FDG PET as an established indication for differentiation of benign and malignant pancreatic masses Reske. Eur J Nucl Med 2001; 28: 1707

49 FDG PET for Hepatocellular Carcinoma Study of 91 patients (n=67 for initial staging) Sensitivity: 64% (43/67) FDG-avid. Change in management: 28% (26/91) By guiding biopsy (n= 1) By identifying skeletal metastases (n = 8) By guiding additional regional therapy (n = 15) By detecting recurrence (n = 2) Summary of the literature for staging: Sensitivity: 77% ( n = 292), Specificity: 97% (n = 249) Change in management: 60% (20 patients studies) Wudel LJ et al: American Surgeon 2003;69: Gambhir SS et al. J Nucl Med 2001;42(suppl):44S-45S. 45S.

50 Glucose Glycogen Hexokinase Glucose Glucose-6-P Cell membrane and capillary H O 2 + CO 2 Pentose-P FDG FDG Hexokinase FDG-6-P

51 77-years old male with cirrhosis, a large hepatic lesion and elevated AFP Diagnosis: 1) HCC proven by biopsy 2) Metastatic lung nodule From Delbeke D. HPB 2005;7:

52 77-years old male with cirrhosis, a large hepatic lesion and elevated AFP Diagnosis: 1) HCC proven by biopsy 2) Metastatic coeliac LN From Delbeke D. HPB 2005;7:

53 FDG PET Imaging for Hepatocellular Carcinoma Conclusions Approximately 2/3 of HCC accumulate FDG: For these patients with FDG-avid HCC, FDG PET imaging is helpful for staging and monitoring therapy. Approximately 1/3 of HCC are false negative on FDG imaging: Therefore, FDG imaging is not recommended for evaluation of focal lesions in patients with chronic hepatitis or for screening for HCC in a population at increased risk. FDG PET findings affected the management of 28% (26/91) of patients in a retrospective study.

54 Hepatocellular Carcinoma: 11 C-acetate 57 patients with various hepatobiliary tumors HCC (n = 32): both + in 34% of patients Sensitivity FDG: 47% average (poorly differentiated) Sensitivity 11 C-acetate: 87% (well-differentiated) Combined sensitivity: 100% Other malignant and benign tumors were 11 C-acetate negative Both tracers appear complimentary: FDG +, 11 C-acetate + : favor HCC FDG +, 11 C-acetate - : favor another malignancy Both - : benign Ho CL et al. J Nucl Med 2002;44:213 Ho CL et al. J Nucl Med 2002;44: Ho CL et al. J Nucl Med 2007;48:

55 JD #3 1/6/07 56 yom Mod diff HCC AFP 12,000 Initial staging Died 5/23/07 FDG and acetate show different metastases 18 F-FDGFDG 11 C-acetate

56 FDG PET for Cholangiocarcinoma and GB cancer Cholangiocarcinoma (n = 36): Nodular type (> mm in size): Sensitivity 85% Occasionally, FDG PET helped identify a nodular CCC (diagnosed pathologically) and equivocal on CT. Helpful for staging, detection of recurrence. Infiltrating type: Poor sensitivity 18% (probably due to the lack of cell density) Gallbladder cancer (n=14): sensitivity 78% Impact on therapy: 30% of patients with cholangiocarcinoma Anderson CD et al. J Gastrointest Surg 2004;8:

57 57 year-old male s/p R lobectomy for cholangiocarcinoma Diagnosis: Recurrence at margin of resection

58 63 year-old male with a history of GB cancer 3 years earlier treated with surgery Diagnosis: Recurrent GB carcinoma From Anderson CD et al. J Gastrointest Surg 2004;8:

59 Sources of False +/- Interpretations F+: Inflammation Therapy-related related Ostomies, Drainage tubes, Stents (percutaneous more common), Radiation therapy, Trauma Infection Abscesses, Acute cholecystitis, Acute cholangitis, Acute pancreatitis (chronic pancreatitis but uncommon), nflammatory bowel disease, iverticulitis Granulomatous disease: TB, fungi

60 Sources of False +/- Interpretations False negative include: Small lesions (<5-10 mm, i.e. ampullary carcinomas, miliary carcinomatosis) Low cellular density Tumors of the infiltrating type (cholangiocarcinomas) Tumors with large mucinous components Tumor necrosis Some low grade tumors: Lymphoma, sarcoma, Low sensitivity: ~ 50-80% GU: Prostate, Renal cell GYN: Ovarian (mucinous, miliary spread) Hepatocellular Differentiated neuroendocrine Bronchioalveolar Hyperglycemia and/or insulin less than 3 H prior to FDG

61 FDG PET and PET/CT for GI Malignancies Esophageal cancer: N and M staging Monitoring therapy Gastric cancer: Less sensitive for detection of diffuse type with high mucin content Physiologic/inflammatory background uptake Pancreatic cancer: For diagnosis: In patients in whom CT/EUS fails to identify a mass In patients in whom FNA biopsy is non-diagnostic In patients with chronic pancreatitis or cystic lesions For staging and detecting recurrence (restaging) HCC: : low sensitivity (50-70%) but impact on management of 30% of patients Cholangiocarcinoma: : high sensitivity for nodular type but low for infiltrating type Neuroendocrine tumors: : limited role

62 FDG PET and PET/CT: Impact on Management Diagnostic Accuracy FDG PET: : superior diagnostic accuracy than conventional imaging for staging and restaging FDG-avid malignancies PET/CT: : incremental impact on diagnostic accuracy: 40-50% patients Discriminating metastatic from physiologic foci Improving lesions detection on both PET and CT Localizing precisely metastatic foci Impact on Management: FDG PET: : ~30% ~ patients (range 10%-60%) PET/CT: : incremental impact on Patient s s management: 10-20% patients, including Planning radiation therapy Guiding biopsies. Supplement to JNM;2001:42: May 2001, Guest editor: Sajiv S. Gambhir Supplement to JNM;2004;45: January 2004, Guest editor: Johannes Czernin

63 Breast cancer Colorectal cancer Lung cancer Lymphoma Podoloff DA et al. J Natl Compr Canc Netw 2007;May;5 Suppl 1: S1-S22. S22.

64 PET/CT in NCCN Practice Guidelines Summary of Recommendations: Colorectal Cancer Recommended: Initial staging if initial studies are equivocal for metastatic disease Rising CEA levels or suspicious symptoms unless other imaging is diagnostic Restaging if curative resection is considered Not indicated: Restaging after non surgical treatment of metastatic disease Post-treatment treatment surveillance

65 PET/CT in NCCN Practice Guidelines Summary of Recommendations: Other Esophageal: At Initial staging if no distant metastases demonstrated by other imaging To monitor therapy after neoadjuvant therapy

66 Thank you!