Lung Cancer Imaging Terence Z. Wong, MD,PhD Department of Radiology Duke University Medical Center Durham, NC 9/9/09
Acknowledgements Edward F. Patz, Jr., MD Jenny Hoang, MD Ellen L. Jones, MD, PhD
Lung Cancer Epidemiology Imaging applications: Staging Imaging examples and challenges Ongoing developments
FIGURE 3 Annual Age-adjusted Cancer Incidence Rates among Males and Females for Selected Cancers, United States, 1975-2005 From Jemal, A. et al. CA Cancer J Clin 2009;59:225-249. Copyright 2009 American Cancer Society
FIGURE 4 Annual Age-adjusted Cancer Death Rates among Males for Selected Cancers, United States, 1930-2005 From Jemal, A. et al. CA Cancer J Clin 2009;59:225-249. Copyright 2009 American Cancer Society
FIGURE 5 Annual Age-adjusted Cancer Death Rates* among Females for Selected Cancers, United States, 1930-2005 From Jemal, A. et al. CA Cancer J Clin 2009;59:225-249. Copyright 2009 American Cancer Society
Lung Cancer Non-small cell lung cancer Adenocarcinoma»Bronchoalveolar carcinoma (BAC) Squamous cell carcinoma Small cell lung carcinoma Other malignancies Neuroendocrine tumors Metastatic disease
Tumor Nodes Metastasis
2007
2009
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)
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:
Additional nodule
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
Lung Cancer Staging M0: No distant metastases M1a: M1a: Contralateral nodules, pleural nodules, malignant effusion M1b: Distant metastases M1b:
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
Staging Lung Cancer
Staging Lung Cancer: Current Imaging Strategy CXR Thoracic CT (? IV contrast) PET-CT Brain imaging Bone scan
Staging Lung Cancer: Imaging Implications PET-CT - PET and CT are complimentary - Bone scan probably unnecessary Brain imaging (MRI)
Lung Cancer: Therapy Surgery Localized disease No contralateral metastases Radiation Therapy Locally advanced disease Post-operative Palliative Chemotherapy
Pancoast Tumor
Brochoalveolar Carcinoma
Lymphangiitic Spread
Solitary Pulmonary Nodule
Adenocarcinoma
Solitary Pulmonary Nodule
SUV max = 7.2 Histoplasmosis
77 yo man with mediastinal adenopathy
CT AC FUSED NAC
CT AC FUSED NAC
Silicosis CT AC FUSED NAC
HIV+ patient with mediastinal adenopathy AC Images
CT AC FUSED NAC
CT AC PCP FUSED NAC
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
Pre-XRT
2 months post-xrt
5 months post-xrt
10 months post-xrt
XRT changes? recurrence
3 mo later Recurrent Tumor
81F melanoma of the foot Diffuse pulmonary metastases
81F melanoma of the foot
81F melanoma of the foot Diffuse pulmonary metastases
CT: higher sensitivity for small pulmonary nodules Diffuse pulmonary metastases
Ongoing Developments
SUV m = 10.5 SUV = 3.6 SUV = 2.7 Adenocarcinoma Wong TZ et al, AJR 2008; 190:427-432
SUV m = 8.4 SUV = 1.7 SUV = 1.0 Granulomatous Disease Wong TZ et al, AJR 2008; 190:427-432
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
IMRT Dose Distributions Slightly weighted with PET/SPECT Plan A CT-GTV PET-GTV 100 70 50 30 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
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
Works in Progress New PET imaging strategies for diagnosis and therapy planning Hypoxia CuATSM FMISO Proliferation FLT Radiation therapy treatment planning with functional imaging