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© 2007 Cardinal Health. All rights reserved. Marketing PET in Radiation Treatment Planning PET Marketing Forum – Accelerating Practice Growth May 23, 2007.

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Presentation on theme: "© 2007 Cardinal Health. All rights reserved. Marketing PET in Radiation Treatment Planning PET Marketing Forum – Accelerating Practice Growth May 23, 2007."— Presentation transcript:

1 © 2007 Cardinal Health. All rights reserved. Marketing PET in Radiation Treatment Planning PET Marketing Forum – Accelerating Practice Growth May 23, 2007 Dr. Homer Macapinlac Welcome!

2 © 2007 Cardinal Health. All rights reserved. Brought To You By Cardinal Health Part of PET Foundations SM > comprehensive marketing and education program Continuation of 2006 series > advanced topics Recorded presentation and PowerPoint available on > News > Marketing Forumwww.PETFoundations.com Exclusive benefit to Cardinal Health PET customers Continuing this Fall

3 © 2007 Cardinal Health. All rights reserved. Dr. Homer Macapinlac Over 15 years of PET experience Read over 15,000 clinical PET scans MD Anderson Cancer Center MDA Volume > X PET/CTs per month

4 © 2007 Cardinal Health. All rights reserved. Promises, Promises Know your target NSCLC Head and Neck Ca FDG PET is approved for staging No CPT code for FDG PET in RT planning

5 © 2007 Cardinal Health. All rights reserved. Copyright ©2006 American Cancer Society From Jemal, A. et al. CA Cancer J Clin 2006;56:

6 © 2007 Cardinal Health. All rights reserved. Lung Cancer Staging Treatment based on stage Survival correlates with stage Stage 5-Year Survival I60-80% II 5-50% IIIa10-40% IIIb, IV <5%

7 © 2007 Cardinal Health. All rights reserved. FDG PET Improves Staging PET potentially avoided unnecessary thoracotomy in 1 out of 5 patients Reed J et.al. Thorac Cardiovasc Surg. 2003;126(6): Van Tinteren et.al. Lancet 2002; 359: 1388–92 Nodal Stage:Sensitivity/Specificity 85/91% High NPV M1 detection – mean 13% Stage I -7.5%, Stage II - 18%, Stage III – 24% McManus, et.al. I J R O B P 2001;50:287293

8 © 2007 Cardinal Health. All rights reserved.

9 PET/CT Better Than PET Prospective, Blinded, 120 pts PET-CT was more accurate for N2 nodes (96% VS 93%) and N1 nodes (90% VS 80%, p=0.001) PET-CT more sensitive, specific, and >PPV for both N2 and N1 nodes (p < 0.05 for all). PET-CT is significantly more sensitive at the 4R, 5, 7, 10 L and 11 stations and more accurate at the 7 and 11 stations than dedicated PET. Cerfolio et.al. Ann Thorac Surg Sep;78(3): ;

10 © 2007 Cardinal Health. All rights reserved. RT Plan Planned target volume Gross tumor volume Clinical target volume CTV GTV CTV PTV

11 © 2007 Cardinal Health. All rights reserved. Right Lung Left Lung Heart Esophagus Spinal Cord Target Volume (TV) Delineation of GTV & Normal Organs in the Thorax How to reduce NTCP? 3DCRT/IMRT/Proton

12 © 2007 Cardinal Health. All rights reserved. Effect of FDG-PET on Radiation Treatment Volumes in NSCLC Study Year Patients w/ change in RTP Hiffer (1998) 7/15 (46%) Nestle (1999) 12/34 (35%) Munley (1999) 12/35(34%) Vanuystel (2000) 45/73(62%) Giraud (2001) 5/12(42%) McManus (2001)38/102(37%) Erdi (2002) 7/11(64%) Ciernik(2003)18/39(56%)* Brianzoni(2005)11/25(44%)* PET/CT

13 © 2007 Cardinal Health. All rights reserved.

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17 Differences Between PET and CT Scan of 90 cm < 30 sec Spatial resolution < 0.5 mm Temporal resolution < 1 sec CT – 0.5 sec rotation PET Scan of 15 cm for 3 to 6 mins, Spatial resolution ~ 6 mm Temporal resolution ~ breathing cycle Potential Misalignment Between PET and CT Images

18 © 2007 Cardinal Health. All rights reserved. Scout Helical CT End-inspiration (FB) End-expiration (FB) Mid-expiration (BH) X-ray on Misalignment In Breathing States (sec)

19 © 2007 Cardinal Health. All rights reserved. 4D-CT: Pan et.al. Med Phys Feb;31(2): Respiratory Motion Tracking With Retrospective Gating Signal from RPM system X-ray on First couch position Respiratory tracking with Varian RPM optical monitor CT images acquired over complete respiratory cycles Second couch positionThird couch

20 Impact of Respiratory Motion on IMRT 10 Gy 20 Gy 35 Gy 50 Gy 70 Gy Composite Components Dong, Zhang, et al MDACC

21 © 2007 Cardinal Health. All rights reserved. Determining optimal clinical target volume margins on the basis of microscopic extracapsular extension of metastatic nodes in patients with non-small-cell lung cancer. Int J Radiat Oncol Biol Phys Mar 1;67(3): mm CTV margins for pathologic lymph nodes or=20 mm

22 © 2007 Cardinal Health. All rights reserved. Head and Neck CA Sixth Most Common Cancer Worldwide USA: 2% of all cancers, 2% of all deaths Imaging vital for detection, staging and treatment. Early stage curable (T1/2 N0M0) Most w/ nodal mets 45%, M1-10% Second primary – 5% annual rate

23 © 2007 Cardinal Health. All rights reserved.

24 May improve tumor localization Enlarge/reduce/confirm primary tumor target Enlarge/reduce/confirm neck coverage How Could PET/CT Help XRT? May improve treatment selection Whole body staging Biological characterization, heterogeneity May improve response assessment Need for neck dissection Dose/treatment selection

25 Frank SJ et al. (2005) Technology Insight: PET and PET/CT in head and neck tumor staging and radiation therapy planning Nat Clin Pract Oncol 2: 526– /ncponc0322 Figure 1 PET/CT images of a 58-year-old male with squamous cell carcinoma of the right tonsil

26 Frank SJ et al. (2005) Technology Insight: PET and PET/CT in head and neck tumor staging and radiation therapy planning Nat Clin Pract Oncol 2: 526– /ncponc0322 Figure 2 Radiation treatment planning prior to definitive chemoradiation therapy

27 Frank SJ et al. (2005) Technology Insight: PET and PET/CT in head and neck tumor staging and radiation therapy planning Nat Clin Pract Oncol 2: 526– /ncponc0322 Figure 3 Response to definitive chemoradiation therapy after 3 months

28 © 2007 Cardinal Health. All rights reserved. PET/CT Challenges GTV Registration Nature Clin Oncol :2:10: ;2005

29 © 2007 Cardinal Health. All rights reserved. PET/CT ChallengesGTV Thresholding Nature Clin Oncol :2:10: ;2005

30 © 2007 Cardinal Health. All rights reserved. Nodal CTV Delineation 0.5 – 1 cm CTV margins Apisarnthanarax et al. Int J Radiat Oncol Biol Phys. 64:678, 2006

31 © 2007 Cardinal Health. All rights reserved.

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33 Synchronous Primary Cancers References Head Neck and Esophageal – 12% Radiother Oncol Dec;77(3): Screening for Distant mets or secondary primaries with FDG PET – 6% Oral Oncol Mar;42(3):

34 © 2007 Cardinal Health. All rights reserved. New PET Foundations Marketing Tools New PET Foundations Marketing Tools Under Construction RTP Module PowerPoints Case Studies Referring Physician Letter New Service Announcement

35 © 2007 Cardinal Health. All rights reserved. Marketing PET in Radiation Treatment Planning How Did You Like This Session? Please Fill Out The Polling Questions Before You Leave Thank You! Continuing This Fall!


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