PET/CT and PET/MR of Cardiac Tumors

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1 PET/CT and PET/MR of Cardiac Tumors Andrew W. Bowman, MD PhD Assistant Professor of Radiology Mayo Clinic Florida NASCI Annual Meeting San Antonio, TX Oct 9, MFMER slide-1

2 Disclosures No financial relationships to disclose No off-label uses will be discussed 2017 MFMER slide-2

3 Learning Objectives Review techniques for cardiac PET Review PET features of normal myocardium, benign and malignant cardiac tumors, and tumor mimics Discuss special PET techniques for cardiac tumors 2017 MFMER slide-3

4 Indications for Cardiac PET Myocardial Perfusion 82 Rb, 13 N Coronary atherosclerotic disease 18 F Inflammatory cardiovascular disease Cardiac tumors 18 F, 68 Ga 18 F 2017 MFMER slide-4

5 18 FDG PET for Cardiac Tumors Diagnosis Staging/restaging disease Monitoring response to therapy 2017 MFMER slide-5

6 How to Perform PET for Cardiac Tumors Similar to traditional 18 FDG PET Attenuation correction may be performed with either CT or MRI Post-processing may be performed to highlight cardiac data 2017 MFMER slide-6

7 FDG Metabolism of the Heart In the nonfasting state: 50-70% of myocardial energy is derived from oxidation of fatty acids Remainder is generated from carbohydrates In the fasting state: Plasma insulin falls, which leads to decreased glucose metabolism in tissues, including the heart Tumor imaging of the heart is therefore optimized when there is decreased myocardial glucose uptake 2017 MFMER slide-7

8 PET Patient Preparation Diet Routine 18 FDG PET Day of exam: NPO 4 hours before scan 24 hours prior: Avoid high carb foods such as pasta, rice, bread, potatoes May eat meats, eggs, cheese, vegetables, salad 2017 MFMER slide-8

9 PET Patient Preparation Diet Cardiac 18 FDG PET Day of exam: NPO 4 hours before scan 24 hours prior: Avoid all carbs, including milk, cheese, vegetables, peanut butter, beans, fruit, pasta, rice, bread, potatoes May eat meats, eggs, hot dogs 2017 MFMER slide-9

10 Suboptimal increased cardiac glucose metabolism Optimized cardiac glucose metabolism 2017 MFMER slide-10

11 Normal Myocardial 18 FDG Activity Variable, depends on level of myocardial glucose uptake Relatively homogeneous throughout normal LV myocardium, but may be more intense at the base FDG activity in the atria is associated with A-fib FDG activity may diffusely increase if there is chamber enlargement Normal pericardium should have no FDG activity 2017 MFMER slide-11

12 PET Features of Cardiac Tumors FDG PET activity of the mass depends on the mass Both primary and secondary malignant cardiac tumors tend to be hypermetabolic Benign masses typically demonstrate much less metabolic activity, though may still be considered hypermetabolic (SUV max > 2.5) 2017 MFMER slide-12

13 SUV max 3.5 J Nucl Med 2012;53: MFMER slide-13

14 PET/CT 2017 MFMER slide-14

15 PET/CT Physiologic Activity 2017 MFMER slide-15

16 8/17 6/17 Normal 18 FDG cardiac activity 2017 MFMER slide-16

17 Physiologic activity in A-fib 2017 MFMER slide-17

18 Cardiac amyloid 2017 MFMER slide-18

19 PET/CT Malignant Tumors 2017 MFMER slide-19

20 Metastatic lung cancer 2017 MFMER slide-20

21 2017 MFMER slide-21

22 Metastatic melanoma 2017 MFMER slide-22

23 2017 MFMER slide-23

24 Metastatic Cholangiocarcinoma 2017 MFMER slide-24

25 2017 MFMER slide-25

26 Metastatic angiosarcoma 2017 MFMER slide-26

27 Lymphoma 2017 MFMER slide-27

28 2017 MFMER slide-28

29 Primary pericardial mesothelioma 2017 MFMER slide-29

30 Neuroendocrine Tumor PET Imaging Somatostatin receptors are overexpressed in neuroendocrine tumors 68 Ga Dotatate is a somatostatin analog, binds to somatostatin receptors 68 Ga Dotatate PET is more sensitive for NET than Octreoscan J Nucl Med 2016;57: MFMER slide-30

31 2017 MFMER slide-31

32 18 FDG PET Metastatic Carcinoid 2017 MFMER slide-32

33 PET/CT Benign Tumors 2017 MFMER slide-33

34 2017 MFMER slide-34

35 LA myxoma 2017 MFMER slide-35

36 2017 MFMER slide-36

37 LA thrombus 2017 MFMER slide-37

38 PET/CT Tumor Mimics 2017 MFMER slide-38

39 Brown fat in lipomatous hypertrophy of interatrial septum 2017 MFMER slide-39

40 2017 MFMER slide-40

41 Cardiac sarcoidosis 2017 MFMER slide-41

42 2017 MFMER slide-42

43 Erdheim-Chester disease 2017 MFMER slide-43

44 PET/MR 2017 MFMER slide-44

45 J Nucl Med 2015;56: MFMER slide-45

46 J Nucl Med 2015;56: MFMER slide-46

47 2017 MFMER slide-47

48 R lung cancer with LA invasion 2017 MFMER slide-48

49 2017 MFMER slide-49

50 L lung cancer with LA invasion 2017 MFMER slide-50

51 2017 MFMER slide-51

52 2017 MFMER slide-52

53 Sclerosed epithelioid fibrosarcoma 2017 MFMER slide-53

54 Courtesy of Felix Nensa, Essen, Germany Lung cancer invading LA with thrombus 2017 MFMER slide-54

55 Summary In conjunction with other imaging findings, PET is helpful in distinguishing between benign and malignant cardiac tumors Patient preparation (pre-scan diet) is critical for optimum 18 FDG PET imaging of the heart Newer PET radiopharmaceuticals can improve the evaluation of cardiac malignancies 2017 MFMER slide-55

56 Thank You!! 2017 MFMER slide-56

PATIENT INSTRUCTION. Extensive myocardial metabolic PET/CT NUCLEAR MEDICINE. Appointment time. Preparation for examination

PATIENT INSTRUCTION. Extensive myocardial metabolic PET/CT NUCLEAR MEDICINE. Appointment time. Preparation for examination Extensive myocardial metabolic PET/CT Appointment time You have been scheduled for PET-CT scan. The appointment will take 2-4 hours, of which part will be spent in bed rest. Imaging time is about 30 minutes.