Lung Cancer Imaging. Terence Z. Wong, MD,PhD. Department of Radiology Duke University Medical Center Durham, NC 9/9/09

Transcription

1 Lung Cancer Imaging Terence Z. Wong, MD,PhD Department of Radiology Duke University Medical Center Durham, NC 9/9/09

2 Acknowledgements Edward F. Patz, Jr., MD Jenny Hoang, MD Ellen L. Jones, MD, PhD

3 Lung Cancer Epidemiology Imaging applications: Staging Imaging examples and challenges Ongoing developments

4 FIGURE 3 Annual Age-adjusted Cancer Incidence Rates among Males and Females for Selected Cancers, United States, From Jemal, A. et al. CA Cancer J Clin 2009;59: Copyright 2009 American Cancer Society

5 FIGURE 4 Annual Age-adjusted Cancer Death Rates among Males for Selected Cancers, United States, From Jemal, A. et al. CA Cancer J Clin 2009;59: Copyright 2009 American Cancer Society

6 FIGURE 5 Annual Age-adjusted Cancer Death Rates* among Females for Selected Cancers, United States, From Jemal, A. et al. CA Cancer J Clin 2009;59: Copyright 2009 American Cancer Society

7 Lung Cancer Non-small cell lung cancer Adenocarcinoma»Bronchoalveolar carcinoma (BAC) Squamous cell carcinoma Small cell lung carcinoma Other malignancies Neuroendocrine tumors Metastatic disease

8 Tumor Nodes Metastasis

9 2007

10 2009

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13 New Lung Cancer Staging International Staging Committee (ISC) of the International Association for the Study of Lung Cancer (IASLC) (2009): >68k pts with NSCLC >13k pts with SCLC Revised TNM criteria (7 th ed) More accurately reflects prognosis Rami-porta R, et al. Ann Thorac Cardiovasc Surg 15:4-9 (2009)

14 Lung Cancer Staging T1: 3cm T2: T2: >3cm, invades visceral pleura, or associated atelectasis / pneumonitis T3: >7cm, extends into chest wall, diaphragm, mediastinal pleura, pericardium, or <2cm from carina, ipsilateral nodules in same lobe T4: Invasion of heart, great vessels, trachea, esophagus, spine, or with malignant effusion, ipsilateral nodules in different lobe T3: T4:

15 Additional nodule

16 Lung Cancer Staging N0: No nodal involvement N1: Peribronchial, ipsilateral hilum N2: Ipsilateral mediastinal, subcarinal N3: N3: Contralateral mediastinal or hilar nodes, any scalene or supraclavicular nodes

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19 Lung Cancer Staging M0: No distant metastases M1a: M1a: Contralateral nodules, pleural nodules, malignant effusion M1b: Distant metastases M1b:

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24 Lung Cancer Staging Stage I: T1 or T2, N0 Stage II: T1 or T2, N1 Stage IIIa: T3, N0 or N1 T1, T2, or T3, N2 Stage IIIb: : N3 or T4 Stage IV: any M

25 Staging Lung Cancer

26 Staging Lung Cancer: Current Imaging Strategy CXR Thoracic CT (? IV contrast) PET-CT Brain imaging Bone scan

27 Staging Lung Cancer: Imaging Implications PET-CT - PET and CT are complimentary - Bone scan probably unnecessary Brain imaging (MRI)

28 Lung Cancer: Therapy Surgery Localized disease No contralateral metastases Radiation Therapy Locally advanced disease Post-operative Palliative Chemotherapy

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31 Pancoast Tumor

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34 Brochoalveolar Carcinoma

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37 Lymphangiitic Spread

38 Solitary Pulmonary Nodule

39 Adenocarcinoma

40 Solitary Pulmonary Nodule

41 SUV max = 7.2 Histoplasmosis

42 77 yo man with mediastinal adenopathy

43 CT AC FUSED NAC

44 CT AC FUSED NAC

45 Silicosis CT AC FUSED NAC

46 HIV+ patient with mediastinal adenopathy AC Images

47 CT AC FUSED NAC

48 CT AC PCP FUSED NAC

49 Radiation Therapy Changes Necrosis following high dose XRT can be hypermetabolic Hypermetabolism may be due to macrophages May be focal Time course can be variable

50 Pre-XRT

51 2 months post-xrt

52 5 months post-xrt

53 10 months post-xrt

54 XRT changes? recurrence

55 3 mo later Recurrent Tumor

56 81F melanoma of the foot Diffuse pulmonary metastases

57 81F melanoma of the foot

58 81F melanoma of the foot Diffuse pulmonary metastases

59 CT: higher sensitivity for small pulmonary nodules Diffuse pulmonary metastases

60 Ongoing Developments

61 SUV m = 10.5 SUV = 3.6 SUV = 2.7 Adenocarcinoma Wong TZ et al, AJR 2008; 190:

62 SUV m = 8.4 SUV = 1.7 SUV = 1.0 Granulomatous Disease Wong TZ et al, AJR 2008; 190:

63 IMRT Case: Target Outlines CT FDG-PET PET-GTV PET Avid Regions CT-GTV BEV CT-GTV SPECT High Perfusion PET-GTV Low Perfusion M. Miften, DUMC

64 IMRT Dose Distributions Slightly weighted with PET/SPECT Plan A CT-GTV PET-GTV Heavily weighted with PET/SPECT Plan B More critical structures sparing was achieved in Plan B than Plan A at the cost of slightly losing target coverage M. Miften, DUMC

65 Summary: Lung Cancer New Staging Criteria Current imaging studies - PET/CT - single examination - Brain imaging - Bone scan may not be needed Importance of imaging Staging Prognosis Treatment options

66 Works in Progress New PET imaging strategies for diagnosis and therapy planning Hypoxia CuATSM FMISO Proliferation FLT Radiation therapy treatment planning with functional imaging