Triangle Edition March 2009 VOL. 11, NO. 2 Wake Radiology integrates PET CT and radiation oncology New facility offers patients new conveniences and consolidates physicians services Wake Radiology Nuclear Medicine Radiologists (L to R) Paul A. Haugan, MD William G. Way, MD Holly J. Burge, MD
Wake Radiology Integrates PET CT and Radiation Therapy New facility provides confidence for physicians and comfort for patients. cover story For patients throughout the Triangle region, Wake Radiology s opening of a PET CT in a private office setting has made access to this important modality faster and easier. A joint venture of Wake Radiology and WakeMed Health and Hospitals, the PET CT center is located in Wake Radiology s Cary offices, 300 Ashville Avenue, near WakeMed Cary Hospital. The center, which opened last December, features many patient comforts including a unique scan room with a wall of windows overlooking a wooded area so patients can enjoy a calm, natural setting while their scanning takes place. By 2010, the number of annual PET studies is expected to surpass 2 million, more than doubling the number of annual PET scans in 2004, according to one estimate. This demonstrates the increased medical utility of PET, which previously have been available solely at regional health centers and hospitals such as UNC, Duke, and Rex. PET CT completes us, says Holly Burge, MD, director of nuclear medicine at Wake Radiology. This technology allows WakeMed and Wake Radiology to offer comprehensive oncology imaging services. Wake Radiology emphasizes patient-friendly, easy access, and the new PET CT center has been designed to that end. When patients go to a typical PET healthcare setting, they may have to park far away, walk a considerable distance, register in one place, and then go to another department for imaging. At Wake Radiology, patients can be dropped off or they can park right in front. They re literally ten steps away from the office. Patients are registered and imaged all in the same suite, Dr. Burge says. If a physician also requests a diagnostic CT, it can be performed on the same machine patients don t have to go to a different department. The suite itself is beautiful and comfortable, which has a very positive impact on our patients. The entire process is designed to be stress-free for our patients and their caregivers. Patients benefit from hometown location The local availability of Wake Radiology s PET CT outpatient center is an immediate benefit to patients, notes Jon-Michael Bruce, MD, of Cary Surgical Specialists. In this era of advanced medicine, responsiveness and communication are keys to patient care, Dr. Bruce says. Having this level of capability at our fingertips, coupled with the excellent service we have traditionally received from the radiologists at Wake Radiology, further augments our ability to care for our patients locally, as opposed to having to refer them to regional centers. There is a comfort level that patients associate with getting care in their own home town. Moreover, the physician can continue to serve as a focal point of care, as opposed to farming out different elements of care to different medical hubs, which may or may not have good lines of communication available or be focused on the continuum of care. Another consideration is availability. Wake Radiology has always been able to accommodate the patient very quickly, so there is no delay in patient care. Having PET readily available improves our level of care. People who get better, quicker, more compassionate care do better than others. Wake Radiology has always been top notch. They have an excellent infrastructure and are responsive, and my patients appreciate that. Our PET CT technologist prepares a patient for her FDG tracer in one of our three comfortable infusion rooms equipped with plasma televisions. Bryan Regan Photography Technologies for the new millennium Wake Radiology s Siemens Biograph 6 TruePoint PET CT scanner represents the most advanced evolution of the first hybrid PET CT imager, a combined technology so revolutionary that Time magazine named it Invention of the Year in 2000. The machinery is a prime example of the whole being greater than the sum of its
parts in this case, the separate technologies of positron emission tomography (PET) and computed tomography (CT). Individually, each had come into common medical use by the last decades of the twentieth century. Then one day in 1992, according to Time, an oncology surgeon happened by when an electrical engineer had the cover off a newly developed PET machine. The result was the combination PET CT, the first medical-imaging device that simultaneously and clearly reveals both anatomical details and metabolic processes within the body, Time said. A PET scan reveals the function of cells. The patient is injected with a tiny amount of a radioactive tracer, fluorodeoxyglucose (FDG). Because cancer cells are highly metabolic, they take up the tracer, lighting up on the scan. CT technology generates a series of x-ray images, or slices, as the equipment rotates around the patient. CT studies provide a sharply focused anatomical map Having this level of capability at our fingertips, coupled with the excellent service we have traditionally received from the radiologists at Wake Radiology, further augments our ability to care for our patients locally, as opposed to having to refer them to regional centers. Jon-Michael Bruce, MD Cary Surgical Specialists of organs and bones. When PET and CT images are overlaid, physicians can identify and precisely locate highly metabolic areas that could be cancerous. The combination of technologies is powerful, practical, and revealing. PET CT studies can locate probable cancer before any other technology finds it. PET CT affords physicians an extra measure of confidence and clarity. Wake Radiology s Julie Newton, PET CT lead technologist with National Oncologic PET Registry Major Studies report PET impacts Treatment for many cancers Two recent studies demonstrate that with PET findings, physicians significantly and consistently modify or change treatment across a wide range of cancers. The studies investigated the impact of PET CT on the intended management of thousands of elderly cancer patients participating in the National Oncologic PET Registry (NOPR). Both studies were led by Bruce E. Hillner, MD, of the Department of Internal Medicine and Massey Cancer Center at Virginia Commonwealth University. A May 2008 study in the Journal of Clinical Oncology showed that physicians changed their intended care for 36.5% of patients based upon PET data, when intended management was either treatment or non-treatment. The study reported, If PET data were not available, the most common pre-pet plan would have been other imaging. In these patients, the post-pet strategies changed to watching in 37% and treatment in 48%. In patients with planned biopsy before PET, biopsy was avoided in approximately 70%. A further study in the December 2008 Journal of Nuclear Medicine assessed the impact of PET for 18 cancer types (change in management of treatment vs. non-treatment). The investigators said, When intended management was classified as treatment or non-treatment, physicians changed their intended management for 38% of cases. The frequencies of changes in management ranged from 48.7% for myeloma to 31.4% for non-melanoma skin cancer. The study concluded, The impact of PET on physicians intended management for patients with known cancer was consistent across cancer types. The table here shows data from Table 7 of this study. Impact of PET on Intended Management for Detection of Suspected Recurrence by Cancer Type Cancer type Percent of cases with change in management* Myeloma 50.9 Ovary 44.5 Primary brain 40.5 Other female genital 39.8 Prostate 39.4 Pancreas 39.3 Uterus 38.8 Small cell lung 38.1 Bladder 36.7 Cervix 35.9 All other 35.1 Connective tissue 34.7 Thyroid 33.2 Kidney 32.4 Stomach 29.3 Total 38.5 *Defined as change from treatment to non-treatment or from non-treatment to treatment. Lead technologist Julie Newton positions a patient for her PET CT scan. Hillner BE, Siegel BA, Shields AF, et al. Relationship between cancer type and impact of PET and PET/CT on intended management: findings of the National Oncologic PET Registry. J Nucl Med. 2008;49(12):1928-1935.
eight years experience, provides an example. Quite frequently in PET CT, we will work up a patient for suspected lung malignancy based on an incidental finding from either a chest x-ray or a CT scan. Although the CT reveals clear anatomy of the area, the PET portion helps determine if the suspected region is malignant without unnecessarily sending the patient for biopsy. PET CT has broad-ranging utility For oncologists, PET CT is of primary use for staging and restaging disease and for monitoring responses to therapies. And because areas of high metabolism light up, PET CT also can reveal incidental findings not previously detected. William G. Way, MD, chief medical officer for Wake Radiology, elaborates. PET allows for more accurate staging of a variety of malignant diseases. It adds valuable metabolic information to the anatomic information that we have used for years as the criteria for staging malignancies. Anatomic characterization relies heavily on size criteria and is not sensitive for the detection of small metastatic deposits. Detection of otherwise unsuspected metastatic disease allows the treating physician to select the most appropriate therapy. PET results can change treatment plans. When malignant disease is shown to be more extensive than originally thought, information from the PET scan may spare the patient unnecessary surgery. Conversely, when the PET scan shows malignant disease to be localized or regional, rather than widely disseminated, this information may allow a surgeon to operate with greater confidence, knowing that tumor resection is potentially curative. In addition, PET can be used effectively to monitor response to therapy. Says Dr. Way, Failure to respond to treatment can be detected earlier with PET, helping determine whether or not a particular treatment regimen is working. If the patient s tumor is not responding as anticipated, the treatment plan can be modified earlier in the course of therapy. PET can also be used to direct biopsies to the portions of a tumor that are the most hypermetabolic. Tumors often have areas of necrosis that may not yield positive results on biopsy. By target- Technologists prepare to scan a patient from the PET CT control room. ing the metabolically active portion of a tumor, one has a better chance of getting a positive tissue diagnosis that can then be used to expedite treatment. There are certain abnormalities on imaging studies, such as CT or MRI (magnetic resonance imaging), says Way, that may lie in a location that is not safe or readily accessible for biopsy and that might require a risky percutaneous biopsy or a more invasive surgical procedure to accurately diagnose. The degree of hypermetabolism of a particular lesion on PET can be used as a measure of the likelihood of malignancy. This information can then be used to justify exposing the patient to the risks of an invasive diagnostic procedure. For example, a solitary pulmonary nodule in a precarious location might be malignant, and documenting the nodule as hypermetabolic on PET prior to biopsy provides sufficient justification for risking collapse of the lung or hemorrhage that might occur with needle biopsy. PET allows for more accurate staging of a variety of malignant diseases. It adds valuable metabolic information to the anatomic information that we have used for years as the criteria for staging malignancies. William G. Way, MD One recent case of interest, Dr. Way added, was a head and neck tumor with PET-positive cervical lymph nodes that were not apparent on physical exam. Another case involved a breast cancer patient with unexpectedly PET-positive ipsilateral (same side) axillary and contralateral (opposite side) internal mammary lymph nodes. In both cases, treatment plans were adjusted to accommodate the unexpected findings. PET CT Is Key to Radiation Treatment Planning PET CT imaging delivers important advantages in radiation treatment planning, explains Scott L. Sailer, MD, co-medical director of Wake Radiology Oncology Services. For certain types of tumors, PET CT is helpful in very accurately targeting areas that need radiation. It also can help distinguish masses seen on a CT as being tumor or not tumor. For instance, I just completed a planning session on a patient who had a PET scan at an area hospital. I had the PET scan on one computer screen and my treatment planning CT scan on another. Since they weren t obtained in exactly the same position, it was a little more difficult to correlate. It is certainly easier now with the option of obtaining a PET CT in the treatment position. The combination of the two technologies is key. An example would be a lung cancer patient who had a collapsed lung, Dr. Sailer says. On a CT scan, it s hard to distinguish what is collapsed lung
about two years ago, and now we re proud to offer this advanced technology to our patients. explains Dr. Sailer. It can be used with any tumor site, but is most commonly used for head and neck cancers, prostate cancer, brain tumors, lung cancer, esophageal cancer, pelvic malignancies, pancreatic cancer, and tumor-bed boosts for breast cancer. The patient can also be monitored during treatment, and treatment can be interrupted immediately if he or she moves too much. Radiation therapists prepare a patient for his prostate cancer radiation treatment using the newly installed ExacTrac IGRT system. and what is tumor. So I will tend to make my fields bigger than they need to be, because it s not clear where the tumor begins and ends. On a PET scan, however, the collapsed lung looks different than a tumor does. So I can easily target the tumor and spare more normal lung tissue. Another recent case, he relates, was a patient who for years had a low-grade lymphoma and recently had a new carcinoma in the groin. We used the PET scan to determine which nodes were carcinoma and which nodes were lymphoma. The nodes enlarged from lymphoma didn t light up like those affected with carcinoma. Treatment was then tailored specifically to the carcinoma-affected area. Image Guided Radiation Therapy Increases Accuracy to within 2 mm Wake Radiology Oncology Services (WROS) is a tightly integrated practice focused on outpatient radiation therapy. Our new ExacTrac image guided radiation therapy (IGRT) enhancement system from BrainLab AG is among the latest examples of our commitment to state-of-the-art technology. The ExacTrac IGRT system enables ultra-precise alignment of radiation beams to within two millimeters or less of a tumor during radiation therapy. Some types of radiation therapy (stereotactic radiosurgery) have used IGRT for many years, but its widespread use only began Radiation therapists Rhonda Weathington and Tracy Grove pose with patient Tom Anderson after his treatment. How ExacTrac Works The patient is pre-positioned either automatically or conventionally on the linear accelerator gurney. IGRT (image guided radiation therapy) provides millimeter precise setup automatically, eliminating time-consuming manual alignment of patient skin markers to room lasers. With ExacTrac, the therapist can position the patient for treatment, leave the room, and confirm setup using IGRT, and the patient is then positioned for treatment precisely. Traditionally, larger treatment margins have been used to compensate for patient positioning or internal movement of the tumor. But the new IGRT system affords more advanced targeting and promises improved patient outcomes. This is a key development in care because day-to-day, tumor and patient position can change slightly during treatment. IGRT provides a way to minimize these changes on each day of treatment. Although radiation therapy in general is delivered with great accuracy, most physicians add extra margin to the treatment plan to ensure that the tumor is not missed, because the patient cannot always be placed in the exact same position every day, Dr. Sailer says. For years, the accuracy of the treatment has been increased by using lasers to set up the patient and by using immobilization devices that help guide the patient into the same position every day. Normally, the accuracy is checked at least once a week using verification x-rays. This new technology increases the accuracy of the delivered treatment and decreases the amount of radiation given to normal tissue. This, in turn, results in lower complication rates. IGRT enhances another advanced procedure that WROS began
offering patients in 1998, three-dimensional conformal radiation therapy (3D-CRT), which allows each beam to be shaped to a 3D image of an individual patient s tumor. For some patients, an extension of 3D-CRT called intensity modulated radiation therapy (IMRT) is used to avoid radiating normal structures that are typically treated with standard 3D-CRT or to safely increase the dose of radiation that would normally be delivered with standard 3D-CRT. With an IMRT map, radiation oncologists can customize treatment to the shape of that unique tumor, preventing unnecessary damage to healthy tissue while focusing intense beams on the cancer. If the dose is increased, there is a greater chance of cure with fewer side effects. IGRT works with these technologies to keep the patient more accurately aligned with the planned treatment. Wake Radiology is committed to meeting the challenges of advancing technology through sub-specialty care in partnership with the area s finest physicians. With our innovative approach in the treatment of cancer offered through PET CT and image guided radiation therapy, Wake Radiology strives to provide the highest level of care for your patients and the confidence you ve come to expect. n PET indications The Centers for Medicare and Medicaid Services (CMS) currently cover the following indications for PET. However, for patients participating in the National Oncologic PET Registry (NOPR), ovarian, pancreatic, small cell lung, testicular cancers, and all other cancers and indications not previously specified are covered under their current coverage with evidence development policy. Indications are documented in the National Coverage Determination, Section 220.6. Clinical Condition Breast cancer Esophageal cancer Colorectal cancer Head & neck cancers Lung cancer Lymphoma Melanoma Solitary pulmonary nodule Thyroid cancer Cervical Coverage (subject to additional guidelines and requirements documented in National Coverage Determination section 220.6) Staging, restaging, and monitoring response to therapy Characterization of indeterminate single pulmonary nodule Restaging Staging as an adjunct to conventional imaging Source: Molecular Imaging LifeNet, <www.mi-lifenet.com> accessed on 01/27/09. In January, CMS proposed for public comment a new, simpler PET coverage framework for oncology patients. According to the Siemens Molecular Imaging LifeNet Web site, the new document proposes that the indications currently covered with evidence development through the [National Oncologic PET Registry] be officially covered by Medicare for initial treatment strategy (formerly diagnosis and staging ), with some exceptions such as prostate cancer. These same indications will only be covered for subsequent treatment strategy scans (formerly restaging and monitoring ) through the NOPR. WR EXPRESS SCHEDULING CONTINUES TO STREAMLINE SCHEDULING 1 number, 14 locations to serve you. ExacTrac is a registered trademark of BrainLab AG. With Wake Radiology s new WR Express Scheduling, scheduling patients throughout the region takes only one call or fax to order any service. As an additional feature, Wake Radiology Express Schedulers will contact referring physicians patients to coordinate the best date, time, and location for their procedures. The practice also offers extended weekday and weekend hours. WR Express Scheduling 919-232-4700 wakerad.com Wake Radiology PET CT Center 300 Ashville Avenue, Suite 180 Cary, NC 27518 Scheduling: 919-232-4700 Wake Radiology Oncology Services 300 Ashville Avenue, Suite 110 Cary, NC 27518 Scheduling: 919-854-4588