Bone Metastasis. Patient Management with PET/CT

Bone Metastasis Patient Management with PET/CT

Bone Metastasis Patient Management with PET/CT OVERVIEW Bone Metastasis is a process in which cancer cells from the original or primary tumor site break away and spread to a bone or bones. This is a result of the tumor cells entering and traveling through the bloodstream or through the lymphatic system. A majority of the cancers cells that break away from a primary tumor will die before spreading to other sites. When cancer spreads to different areas of the body, it is named after the primary tumor site. For example, if a patient has breast cancer that spreads to the bones, it is referred to as breast cancer with bone metastases. 1 Many people with cancer will develop bone metastases during some course of their disease. Common primary tumor sites that can metastasize to the bone include cancers of the breast, prostate, lung, thyroid and kidney. The American Cancer Society estimates that of the 560,000 people who will die of cancer in 2009, approximately 350,000 will have bone metastases. 1 There are two main types of bone metastasis: osteoblastic and osteolytic. Osteoblastic disease occurs when the cancer cells cause increased bone formation resulting in more dense or sclerotic features. It is often associated with prostate cancer tumor types. Osteolytic disease occurs when the cancer cells cause increased bone mineral turnover or resorption resulting in the decrease of the bone density. The weakening of the bone structures results in bone fractures with minimal trauma. Osteolytic disease is often associated with breast cancer tumor types. Most bone metastases will include a mixture of both osteoblastic and osteolytic types as pure bone metastasis is fairly rare. Bone metastasis usually develops in bones located in the body trunk, including the ribs, vertebral spine, sternum and pelvis and can develop in one or numerous areas including the extremities. If the disease has spread to several areas, symptoms can be relieved, but it is hard to cure. 1 In general, metastatic disease can be found by tests either prior to or after the primary cancer has been diagnosed. When metastatic disease is discovered prior to determining the primary tumor site, it is commonly referred to as cancer with an unknown primary. If metastatic disease develops after the primary tumor site has been diagnosed and treated, it is referred to as distant recurrence. 1 Primary bone cancer, which is much different than bone metastases, occurs when the primary cancer originates in the bones. It also occurs less frequently than bone metastases with an estimated 2,500 people being diagnosed and 1,500 people dying from the disease in 2009. 1 2 12

SYMPTOMS According to The American Cancer Society, symptoms of Bone Metastases can include bone pain that increases in severity over time and tends to be worse at night, chronic bone fractures with minimal trauma, spinal cord compression and hypercalcemia (increased calcium levels in the blood). Hypercalcemia symptoms can include constipation, nausea and dehydration. 1 THE AMERICAN CANCER SOCIETY ESTIMATES IN 2009: (Numbers are approximate) 560,000 people who will die of cancer 350,000 people who have bone metastasis 3 12

TREATMENTS TREATMENTS 1 Please note that any information on treatments included herein is not intended as medical advice to replace the expertise and judgement of a cancer care specialist. Also, many treatment options do carry the risk of side effects and should be discussed in detail with cancer care experts. Treatment choices for people with bone metastases depend on many factors including: the primary cancer type, which and how many bones are affected, and any previous treatments. Most treatment regimens are broken down into two ideologies: Treating the primary cancer systemically Systemic Treatments can include: Chemotherapy Hormone Therapy Immunotherapy Radiation Therapy Treating the specific metastatic bone symptoms Treatments can include: Radiopharmaceuticals Help kill cancer cells in the bone structures Assist in relieving bone pain Bisphosphonates Assist in reducing bone pain Assist in slowing down damage to bone from the cancer cells Assist in reducing increased calcium levels Assist in the reduction of bone fractures caused by the cancer Radiation Therapy Preferred choice when the patient has one or two bone metastases present Assist in relieving bone pain Slow down or prevent future bone weakening and/or fracturing Surgery Used to strengthen broken bones that don t heal properly Insert pins, rods, etc. 4 12

THE ROLE OF 18F SODIUM FLUORIDE (NAF) PET OR PET/CT IN BONE METASTASIS The injection 18F NaF was approved by the Food and Drug Administration (FDA) in 1972 as a bone imaging agent to defi ne areas of altered osteogenic activity. 2 Clinical studies have suggested that 18F NaF PET or PET/CT imaging can be of assistance in the management of patient care in bone metastases. When compared to traditional Tc-99m Radionuclide Bone imaging: 18F-labeled Sodium Fluoride (NaF) PET is more accurate than 99mTc-diphosphonate SPECT for identifying both malignant and benign lesions of the skeleton. 3 Combining 18F-fl uoride PET with other imaging, such as CT, can improve the specifi city and overall accuracy of skeletal 18F-fl uoride PET imaging. 3 18F PET scans promise improved imaging quality for both benign and malignant bone disease, with a 25% improvement in sensitivity and specifi city over conventional planar and SPECT bone scans. 4 18F PET is more sensitive than Radionuclide Bone imaging (RNB) in detecting osseous lesions. With RNB, sensitivity in detecting osseous metastases is highly dependent on anatomic localization of these lesions, whereas detection rates of osteoblastic and osteolytic metastases are similar. 5 F-18 PET demonstrates a very early bone reaction when small bone marrow metastases are present, allowing accurate detection of breast cancer bone metastases. This accurate detection has a signifi cant effect on clinical management, compared with the effect on management brought about by detection with conventional bone scanning. 6 PET with 18F-fl uoride demonstrates very high uptake in lytic and sclerotic breast cancer metastases. 7 5 12

PET/CT for BONE METASTASIS Image provided courtesy of Grant FD, Fahey FH, Packard AB, Davis RT, Alavi A, Treves ST. Skeletal PET with 18F- Fluoride: applying new technology to an old tracer. Journal of Nuclear Medicine. 2008 Jan;49(1):68-78. 6 12

18F SODIUM FLUORIDE (NAF) PET OR PET/CT METASTATIC BONE IMAGING TECHNICAL CONSIDERATIONS 8 Patient Preparation No special patient preparation is required Maintain normal diet Ensure hydration - Drink plenty of fl uids prior to their procedure time Take medications as directed by physician Patient Dosage Amount Adult 10 mci dependent on camera manufacturer suggestions Pediatric Range 0.057mCi/kg with a 4mCi maximum Patient Dosage Administration Route Intravenously (IV) PET Image Acquisition Procedure Blood Flow/Blood Pool Images Area of interest should be placed in camera FOV before tracer injection. Scanner acquisition workstation should be setup for proper protocol depending on facility preference. Acquisition should begin immediately after injection of tracer. Delayed Images (Skeletal Phase) Typically occur 60 minutes after tracer injection Range 30 minutes to 4 hours Patient instructed to drink fluids and perform physical activity during uptake period To facilitate clearance of tracer and reduce background activity Facilities should consult with Radiation Safety Offi ce to determine if any patient isolation restrictions are required during the uptake period Patient voids bladder prior to imaging As in Radionuclide Bone Imaging, proper patient positioning is essential for appropriate image quality Patient positioned on table Arms at body side or above head Acquisition protocol similar to FDG Melanoma Protocol Scan range (May require 2 separate acquisitions) From skull vertex to distal extremities including the toes CT scout acquired (similar to FDG PET protocol) CTAC or Transmission Scan acquired (similar to FDG PET protocol) PET emission scan performed 1-5 minutes/bed depending on body habitus, scanner type and/or scanning mode (2D vs. 3D) Post Procedure Patient Instructions Resume normal activities Encourage drinking fl uids. Disclaimer: Please note that this information is provided for educational purposes only. It is not intended to substitute for informed medical advice. The user of this document should not use this information to diagnose or treat a health problem or disease without consulting with a qualifi ed health care provider. 7 12

TARGET PHYSICIAN INFORMATION TARGET PHYSICIAN INFORMATION 18F NaF PET imaging program educators and marketers may wish to focus their efforts on physicians who might be expected, in bone metastatic patient care management, to consider referring their patients for a 18F NaF PET or PET/CT scan, where and when appropriate. Medical Oncologists Inform them that 18F NaF PET Bone imaging can be utilized to stage and restage high risk patients suspected or diagnosed with bone metastases. They should utilize 18F NaF Bone imaging scans in the same manner they utilize Tc-99m MDP or HDP Bone Scans. Radiation Oncologists Inform them that 18F NaF PET Bone imaging can be utilized to stage and restage high risk patients suspected or diagnosed with bone metastases. They should utilize 18F NaF Bone imaging scans in the same manner they utilize Tc-99m MDP or HDP Bone Scans. Surgeons Inform them that 18F NaF PET Bone imaging can be utilized to stage and restage high risk patients suspected or diagnosed with bone metastases. They should utilize 18F NaF Bone imaging scans in the same manner they utilize Tc-99m MDP or HDP Bone Scans. Urologists Inform them that 18F NaF Bone imaging can be utilized to stage and restage high risk prostate cancer patients. They should utilize 18F NaF Bone imaging scans in the same manner they utilize Tc-99m MDP or HDP Bone Scans. 8 12

GLOSSARY OF TERMS GLOSSARY 99mTc-diphosphonate: a Technetium-based radionuclide complex used for bone scans. A gamma-emitting radionuclide imaging agent used primarily in skeletal scintigraphy. Because of its absorption by a variety of tumors, it is useful for the detection of neoplasms. 9 Accuracy: The ability of an imaging test to correctly diagnose a suspected medical condition. 10 Bisphosphonates: In pharmacology, bisphosphonates (also called diphosphonates) are a class of drugs that prevent the loss of bone mass, and are used to treat osteoporosis, bone metastasis, multiple myeloma and other bone diseases. In radiopharmacy, other bisphosphonates, medronate (R1, R2 = H) and oxidronate (R1 = H, R2 = OH) are mixed with radioactive technetium and injected for imaging bone and detecting bone disease. 9 Bone Metastasis: Bone metastasis is cancer that started in another location (especially breast, lung, prostate, thyroid and kidney), and spread to the bones. Metastases are established when a single tumor cell or a clump of cells gain access to the blood stream, reach the bone marrow through blood vessels in Haversian canals, extravasate, multiply and neovascularize. 11 Chemotherapy: Treatment with drugs that kill cancer cells. 12 Hormone therapy: Treatment that adds, blocks, or removes hormones. To slow or stop the growth of certain cancers (such as prostate and breast cancer), synthetic hormones or other drugs may be given to block the body s natural hormones. Also called endocrine therapy, hormonal therapy, and hormone treatment. 12 Hypercalcemia: Hypercalcemia is the term that refers to elevated levels of calcium in the bloodstream. Malignancies, particularly breast and lung cancer, are a common cause of elevated blood calcium. It is estimated that up to 20% of individuals with cancer will develop hypercalcemia at some point in their disease. 12 Immunotherapy: Treatment to boost or restore the ability of the immune system to fi ght cancer, infections, and other diseases. Also used to lessen certain side effects that may be caused by some cancer treatments. Agents used in immunotherapy include monoclonal antibodies, growth factors, and vaccines. These agents may also have a direct antitumor effect. Also called biological response modifi er therapy, biological therapy, biotherapy, and BRM therapy. 12 Lymphatic System: The tissues and organs that produce, store, and carry white blood cells that fi ght infections and other diseases. This system includes the bone marrow, spleen, thymus, lymph nodes, and lymphatic vessels (a network of thin tubes that carry lymph and white blood cells). Lymphatic vessels branch, like blood vessels, into all the tissues of the body. 12 Lytic Bone Metastasis: Destruction of an area of bone due to disease process, such as cancer. 13 Metastasis: The spread of cancer from one part of the body to another. A tumor formed by cells that have spread is called a metastatic tumor or a metastasis. The metastatic tumor contains cells that are like those in the original (primary) tumor. 12 Neoplasm or neoplastic event: An abnormal mass of tissue that results when cells divide more than they should or do not die when they should. Neoplasms may be benign (not cancer), or malignant (cancer). Also called tumor. 12 9 12

GLOSSARY OF TERMS Osteoblastic lesion: Osteoblastic lesions occur when the cancer cells cause increased bone formation resulting in more dense or sclerotic features. They are often associated with prostate cancer tumor types. 12 Osteolytic lesion: Osteolytic lesions occur when the cancer cells cause increased bone mineral turnover or resorption resulting in decrease of the bone density. 12 Primary Tumor: The mass of tumor cells at the original site of the neoplastic event. 12 Radiation Therapy: The use of high-energy radiation from x-rays, gamma rays, neutrons, protons, and other sources to kill cancer cells and shrink tumors. Radiation may come from a machine outside the body (external-beam radiation therapy), or it may come from radioactive material placed in the body near cancer cells (internal radiation therapy). Systemic radiation therapy uses a radioactive substance, such as a radiolabeled monoclonal antibody, that travels in the blood to tissues throughout the body. Also called irradiation and radiotherapy. 12 Radionuclide bone imaging: Nuclear imaging method used to evaluate pathological bone metabolism. The method is used for the detection of bone metastases of malignant tumours, osteomyelitis, joint disorders, stress fractures and other disease entities. 14 Radiopharmaceutical: A radioactive drug used to diagnose or treat disease, including cancer. 12 Specificity: The probability that, given the absence of disease, a normal test result excludes disease. 10 Sensitivity: The probability that, given the presence of disease, an abnormal test result indicates the presence of disease. 10 SPECT bone scans: Diagnostic radionuclide scans completed on a single photon emission computed tomography camera. 15 Spinal Cord Compression: Pressure on the spinal cord that may be caused by a tumor, a spinal fracture, or other conditions. 12 Trabeculae: Any of the intersecting osseous bars occurring in bone. 16 10 12

REIMBURSEMENT & REFERENCES REIMBURSEMENT Please refer to IBA 18F NaF PET Reimbursement Information Sheet, or contact your IBA Molecular Regional Account Executive. REFERENCES 1. American Cancer Society, 2007 Facts, available at: www.cancer.org. Accessed July 1, 2009. 2. Positron Emission Tomography Drug Products; Safety and Effectiveness of Certain PET Drugs for Specifi c Indications (Food & Drug Administration Docket No. OON-0553) Available at: http://www.fda.gov/ohrms/dockets/98fr/cd99111.pdf; Accessed: Sept. 28, 2009. 3. Grant FD, et.al. Skeletal PET with 18F-fl uoride: Applying New Technology to an old Tracer. J Nucl Med 2008 Jan;49(1):68-78. 4. Bridges RL, et.al. An Introduction to Na18F Bone Scintigraphy: Basic Principles, Advanced Imaging Concepts and Case Examples. J Nucl Med Tech 2007;35:64-76. 5. Schirrmeister H, et.al. Sensitivity in Detecting Osseous Lesions Depends on Anatomic Localization: Planar Bone Scintigraphy Versus 18F PET. J Nucl Med 1999 Oct;40(40):1623-9. 6. Schirrmeister H, et.al. Early Detection and Accurate Description of Extent of Metastatic Bone Disease in Breast Cancer with Fluoride Ion and Positron Emission Tomography. J Clin Oncol 1999 August ;17(8):2381. 7. Petren-Mallmin M, et.al. Skeletal Metastases From Breast Cancer: Uptake of 18F-Fluoride Measured with PET in Correlation with CT. Skeletal Radiol 1998;27:72-76. 8. Minerich, SM. 18F Sodium Fluoride Bone PET and PET/CT: Technical Tips. SNMTS Uptake 2009 Sept/Oct; 15(5):2,6-7. 9. Drug Safety and Availability: U.S. Food & Drug Administration; Available at: www.fda.gov/drugs/; Accessed: December 8, 2009. 10. CancerWeb Project (U of Newcastle-New Tyne): Medical Dictionary; Available at: www.cancerweb.ncl.ac.uk. Accessed: Jun 7, 2009. 11. Bone Tumor Information; Henry DeGroot III, M.D., Principal Author; Avaliable at: www.bonetumor.org; Accessed December 15, 2009. 12. National Cancer Institute Dictionary of Cancer Terms; National Institutes of Health; Available at: www.cancer.gov/dictionary/; Accessed: December 8, 2009. 13. Glossary of Terms: Skeletal Wellness Institute for Cancer; Available at: www.swicancer.gov; Accessed: December 16, 2009. 14. Encyclopedia of Medical Imaging; GE Healthcare; 2009; Available at: www.medcyclopaedia.com; Accessed December 16, 2009. 15. Nuclear Medicine Information; RadiologyInfo; American College of Radiology, Radiological Society of North America; Available at: www. radiology.info.org; Accessed: December 17, 2009. 16. MedLinePlus Online Medical Dictionary; U.S. National Library of Medicine; National Institutes of Health; Available at: www.nlm.nih.gov/ medlineplus/mplusdictionary.html; Accessed: Sept 28, 2009. 11 12

Quality + Confidence = Outcomes IBA Molecular believes that personalized medicine lies in the scientifi c equation, Q+C=O, which symbolizes Quality + Confidence = Outcomes. Our reputation for delivering quality products, together with our comprehensive educational offerings enables you to increase confidence in your imaging staff, expanding the impact of nuclear medicine on patient care and outcomes. IBA Molecular North America, Inc. 21000 Atlantic Blvd., Suite 730 Dulles, VA 20166 Toll Free: 1 877 334 3673 Tel.: + 1 703 787 7900 Fax + 1 571 434 0330 IBA Molecular North America, Inc. April 2010 F-18 NaF Reference Booklet 001 IBA 2010 / All Rights Reserved. IBA Molecular Jan 2010 Bone Campaign 001 IBA 2010 / All Rights Reserved This brochure has been printed on environment-friendly paper using soy based inks. E-mail: marketing_us@iba-group.com Copyright IBA 2010. This information is provided courtesy of IBA Molecular North America, Inc. IBA is a registered trademark of IBA SA. Any opinions, fi ndings and conclusions or recommendations expressed in this material are those of the author. The information is designed for educational purposes only and is not engaged in rendering medical advice or professional services. The information provided should not be used for diagnosing or treating a health condition or a disease and is not a substitute for professional medical care. www.iba-molecular.com