U"lity of Screening and Surveillance Using Nuclear Medicine Methodology. (Lung Cancer) Michael M. Graham, PhD, MD University of Iowa

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1 U"lity of Screening and Surveillance Using Nuclear Medicine Methodology (Lung Cancer) Michael M. Graham, PhD, MD University of Iowa

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3 American Cancer Society IniBal Guideline Clinicians with access to high- volume, high- quality lung cancer screening and treatment centers should inibate a discussion about screening with apparently healthy pabents aged 55 years to 74 years who have at least a 30 pack- year smoking history and who currently smoke or have quit within the past 15 years. March, 2013

4 National Lung Screening Trial Research Team, Aberle DR, et al. Reduced lung-cancer mortality with low-dose CT screening. N Engl J Med. 2011; 365:395.

5 National Lung Screening Trial Research Team, Aberle DR, et al. Reduced lung-cancer mortality with low-dose CT screening. N Engl J Med. 2011; 365:395.

6 National Lung Screening Trial Research Team, Aberle DR, et al. Reduced lung-cancer mortality with low-dose CT screening. N Engl J Med. 2011; 365:395. NLST Low-Dose CT Sens=93.1% Spec=76.5% PPV = 3.8% NPV = 99.9% N= ,146 = 0.68

7 Prac"cal Problems How many subjects will be screened? Will there be reimbursement? How should follow- up studies be done? What is the role of FDG PET- CT in follow- up?

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18 128 Yi CA, Lee KS, Kim BT, Choi JY, Kwon OJ, Kim H, Shim YM, Chung MJ. Tissue characteriza"on of solitary pulmonary nodule: compara"ve study between helical dynamic CT and integrated PET/CT. J Nucl Med Mar;47(3): N= 199

19 129 Christensen JA, Nathan MA, Mullan BP, Hartman TE, Swensen SJ, Lowe VJ. Characteriza"on of the solitary pulmonary nodule: 18F- FDG PET versus nodule- enhancement CT. AJR Am J Roentgenol Nov;187(5): N= 42 Original dictated report SUV > 2.5

20 130 Schillaci O, Travascio L, Bolacchi F, Calabria F, Bruni C, Cicciò C, Guazzaroni M, Orlacchio A, Simoned G. Accuracy of early and delayed FDG PET- CT and of contrast- enhanced CT in the evalua"on of lung nodules: a preliminary study on 30 pa"ents. Radiol Med Sep;114(6): N=30 Early = 50 min Late = 90 min

21 131 Bastarrika G, García- Velloso MJ, Lozano MD, Montes U, Torre W, Spiteri N, Campo A, Seijo L, Alcaide AB, Pueyo J, Cano D, Vivas I, Cosín O, Domínguez P, Serra P, Richter JA, Montuenga L, Zulueta JJ. Early lung cancer detec"on using spiral CT and PET. Am J Respir Crit Care Med v171(12): FDG PET for Nodules > 7mm PosiBve = 11 NegaBve = 14 N=25 SensiBvity: 69% (95% CI, 41 89) Specificity: 91% (95% CI, 63 99) PPV: 90% (95% CI, 57 98) NPV: 71% (95% CI, 52 85)

22 132 Fletcher JW, Kymes SM, Gould M, Alazraki N, Coleman RE, Lowe VJ, Marn C, Segall G, Thet LA, Lee K; VA SNAP Coopera"ve Studies Group. A comparison of the diagnos"c accuracy of 18F- FDG PET and CT in the characteriza"on of solitary pulmonary nodules. J Nucl Med Feb;49(2): N = 344 SensiBvity = 91.7% (95% CI, 86.6% 95.0%) Specificity = 82.3% (95% CI, 75.4% 87.6%)

23 133 Ashraf H, Dirksen A, Loi A, Bertelsen AK, Bach KS, Hansen H, Pedersen JH, Mortensen J. Combined use of PET and volume doubling "me in lung cancer screening with low- dose CT scanning. Thorax Apr;66(4): Criteria for PosiBvity Volume Doubling Time < 1 year N=54 PET uptake > background and = or > mediasbnum

24 134 Ohno Y, Koyama H, Matsumoto K, Onishi Y, Takenaka D, Fujisawa Y, Yoshikawa T, Konishi M, Maniwa Y, Nishimura Y, Ito T, Sugimura K. Differen"a"on of malignant and benign pulmonary nodules with quan"ta"ve first- pass 320- detector row perfusion CT versus FDG PET/CT. Radiology. 2011;v258: BV PP = blood volume calculated with Patlak plot model EF PP = extracbon fracbon calculated with Patlak plot model PF MS = perfusion calculated with maximum slope model N=76

25 Veronesi, G et al. Difficulties encountered managing nodules detected during a computed tomography lung cancer screening program. J Thorac Cardiovasc Surg 2008;136:611 Positive PET definition: SUVmax > 1.5

26 Hypothetical Sequential Low-dose CT followed by FDG PET-CT Low- dose CT PPV = 3.7% PET - CT PPV = 23% High risk subjects (11 TP) Low Dose CT PosiBve CT results (10 TP) FDG PET - CT PosiBve PET results (9 TP) + Biopsy/Surgery

27 Defini"ve PET- CT Guidelines are Needed Emphasis on standardizabon of pabent preparabon, image acquisibon, image reconstrucbon and quality control. InterpretaBon criteria: FDG PET is generally assessed using visual criteria (in the context of oncology, looking for a focally increased uptake that may be compabble with malignancy in the clinical context.

28 NCCN Sugges"on

29 Conclusions We are likely to see an increasing number of SPNs for FDG PET- CT imaging. We need consistent methodology and consistent reading criteria. We need to work with pulmonologists, oncologists, and radiologists to define the role of FDG PET- CT in follow- up of SPNs. Do we need to publish a cost- effecbveness paper?

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