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Positron Emission Tomography in Clinical Oncology Chun Ki Kim, M.D. Mount Sinai School of Medicine New York, New York.

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Presentation on theme: "Positron Emission Tomography in Clinical Oncology Chun Ki Kim, M.D. Mount Sinai School of Medicine New York, New York."— Presentation transcript:

1 Positron Emission Tomography in Clinical Oncology Chun Ki Kim, M.D. Mount Sinai School of Medicine New York, New York

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4 Commonly used PET Radiotracers [F-18] FDG- Glucose metabolism [C-11] Methionine- Amino acid transport - Incorporation of amino acid into protein fractions [O-15] Water- Blood flow [N-13] Ammonia- Blood flow Rb-82- Blood flow

5 [C-11] ThymidineTumor cellular proliferation rate [C-11] Aminoisobutyric acidTumor amino acid uptake [F-18] 5-FUPrediction/evaluation of ChemoTx [C-11] TyrosineTumor metabolism [N-13] GlutamateTumor metabolism [C-11] AcetateMyocardial oxidative metabolism [C-11] PalmitateMyocardial fatty acid metabolism [F-18] FluoroDOPADopamine synthesis Many other receptor agentsDopamine, serotonin, opiate etc. Potential PET Radiotracers

6 PET Radiotracer approved by FDA [F-18] FDG(fluoro deoxyglucose)  Malignancy ~  Glucose / FDG uptake

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8 NORMALTUMOR Overexpression of Glucose transporters Higher levels of Hexokinase Down-regulation of Glucose-6-phosphatase Anaerobic glycolysis, less ATP per glucose molecule, more glucose molecules needed for ATP production General increase in metabolism from high growth rates

9  Malignancy  Glucose/FDG uptake

10 Gallium PET

11 Metastatic Thyroid Ca. to Lung, Mediastinum, and Skeleton

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13 General Indications for FDG-PET Tumor Imaging  DDx: Benign versus Malignant  Staging & Restaging  Metastatic work up: Rising tumor markers  Monitoring treatment response  Scar/necrosis/fibrosis vs. Recurrent/residual disease  Grading/Prognosis  Detection of unknown primary

14 New Medicare Coverage Policy for FDG PET Lung Ca (NSC): Dx, Staging & restaging Esophgeal Ca:Dx, Staging & restaging Colorectal Ca:Dx, Staging & restaging Lymphoma:Dx, Staging & restaging Melanoma:Dx, Staging & restaging, Non-covered for evaluating regional nodes Head & Neck Ca:Dx, Staging & restaging

15 Lung Cancer  Dx: Solitary Pulmonary Nodule  Staging  Metastatic work-up

16 Solitary Pulmonary Nodule Incidence detected by CXR: 130,000/year %: Benign 20-40%: Invasive nodule biopsy Resection.

17 CT: an indeterminant LUL nodule.

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19 Efficacy of PET Solitary Pulmonary Nodule Sensitivity = 97% Specificity = 78% (Meta-analysis of >40 articles: Gould et al. JAMA 2001 )

20 False Positives: Active Infection/Inflammation TB Pneumonia Cryptococcosis Histoplasmosis Aspergillosis Inflammatory

21 Staging

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24 60/M: Lung Ca.

25 62y/o Lung Ca. with adrenal mass

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27 Colorectal Cancer: Clinical Indications for PET Imaging  Staging before primary resection?  Detection of Lesions after Primary Resection  Staging before resection of recurrent disease.  Rising CEA in the absence of a known source.  Equivocal/residual lesion on conventional imaging.  Patient is clinically symptomatic, but CEA is normal.  Monitoring treatment response (pre-op & post-op)

28 Staging before resection of recurrent disease

29 63 y/o woman with a H/O Colon Ca. and liver metastases

30 79/M. Resection of Rectal Ca (Dukes B) 4 mos earlier,  CEA, CT: possible local relapse.

31 T1 T2 T1 enhanced F/68 H/O Colon Ca. Rising CEA CT/MRI; multiple cysts

32 Sagittal Transverse Coronal

33 YW: Colon Ca 3/00: (-) CT 5/00: rising CEA 6/00: (+) PET 7/00: CT

34 58/M - S/P Colon Ca Rising CEA Coronal Coronal Transverse

35 58/M - S/P Colon Ca Rising CEA Local recurrence Hemangioma

36 48y/o with Colon Ca. S/P Primary resection. S/P Resection of liver lesion Now with  CEA CT: (-) for mets

37 48y/o with Colon Ca. S/P Primary resection. S/P Resection of liver lesion Now with  CEA CT: (-) for mets

38 N. G. 8/15/00 Colon cancer with a Hx of UC Proven mesenteric carcinomatosis

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40 Huebner et al. J Nucl Med 2000;41:

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42 Colorectal Cancer: A possible algorithm CT evidence of resectable disease in patient suitable for surgery Whole Body PET imaging

43 Colorectal Cancer: A possible algorithm CT evidence of resectable disease in patient suitable for surgery Whole Body PET imaging Further evaluation of CT abnormality All sites negative

44 Colorectal Cancer: A possible algorithm CT evidence of resectable disease in patient suitable for surgery Whole Body PET imaging Further evaluation of CT abnormality Surgery All sites negative PET = CT and other sites negative

45 Colorectal Cancer: A possible algorithm CT evidence of resectable disease in patient suitable for surgery Whole Body PET imaging Further evaluation of CT abnormality Non-surgical management Surgery All sites negative + ve at multiple Sites PET = CT and other sites negative

46 44/F with Colon Ca, S/P primary resection. CT: multiple liver mets and a lung nodule Treated with systemic chemoTx instead of intra-arterial chemoTx. Staging:

47 Colorectal Cancer: Clinical Indications for PET Imaging  Detection of Lesions  Staging before resection of recurrent disease.  Rising CEA in the absence of a known source.  Equivocal/residual lesion on conventional imaging.  Patient is clinically symptomatic, but CEA is normal.  Monitoring treatment response (pre-op & post-op)  Staging before primary resection?

48 S/P ChemoRx

49 Before 2mo after Adjuvant chemo and radioTx Prior to surgery for rectal Ca.

50 Optimal time to scan after treatment?? Uptake may be seen in inflammatory tissue / macrophages. Residual FDG activity after treatment: Not always active tumor 1 month after Chemo. PET findings at 1 mo ~ CT findings at 3 mos Findlay et al. J Clin Oncol 1996 Several months after RT?

51 Lymphoma: Indications for PET Imaging  Dx  Staging  Monitoring treatment response  Recurrence?

52 Evaluation of early therapeutic response: Is treatment effective? FDG uptake represents cell viability.  FDG uptake can be markedly decreased or even completely suppressed after 1 or 2 cycles of chemotherapy  Early determination is important: To avoid the toxicity of ineffective therapy. To allow selection of a new therapeutic regimen.

53 Lymphoma Before After 2 cylcles of Chemo

54 Lymphoma Before After 2 cylcles of Chemo

55 56y/o : Lymphoma

56 Before 1 month after XRT

57 Esophageal/Gastro-esophageal Cancer: Clinical Indications for PET Imaging  Pre-op staging  Monitoring treatment response  Suspected recurrence  Prognostication

58 Esophageal/ Gastro-esophageal Cancer: Clinical Indications for PET Imaging  Pre-op staging  CT: Limited sensitivity  EUS: More accurate for assessing local invasion and regional nodal mets. Limitations: stenosis, celiac, right hepatic lobe, peritoneum

59 ( Choi et al: J Nucl Med 2000) Evaluation of N stage of patients with Esophageal Cancer: 48 patients underwent esohagectomy and lymph node dissection (2 field=35pts, 3 field=13pts)

60 Evaluation of metastases in Esophageal Cancer: CT versus PET CTPET Kole 1998Lymph nodes62%90% Resectability65%88% Choi 2000Lymph nodes78%86% N staging60%83% Luketich 1999Distant mets63%84%

61 Rt. Paratracheal Subcarinal Lt. Gastric Common hepatic & Celiac Rt. Paratracheal Subcarinal Lt. Gastric Common hepatic & Celiac

62 62F: Gastric Ca. S/P Resection CT: Recurrence PET performed to exclude other sites of tumor Ultrasound: confirmed a liver mets Surgery cancelled and the patient treated with Chemo

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64 Gastro-esophageal Cancer: Clinical Indications for PET Imaging  Pre-op staging  Monitoring treatment response  Suspected recurrence  Prognostication

65 Before sagittal coronal After Radiochemo 49M: large squamous esophageal Ca. Echo-endoscopy – an enlarged node

66 Gastro-esophageal Cancer: Clinical Indications for PET Imaging  Pre-op staging  Monitoring treatment response  Suspected recurrence  Prognostication

67 45M: S/P esophagectomy, Patient is clinically asymptomatic  alkaline phosphatase

68 Gastro-esophageal Cancer: Clinical Indications for PET Imaging  Pre-op staging  Monitoring treatment response  Suspected recurrence  Prognostication

69 Surviavl based on initial PET scan identification of distant versus local disease only: (Luketich et al: Ann Thorac Surg 1999;68)

70 Pancreatic Cancer: Potential Indications for PET Imaging  DDx: Chronic pancreatic mass vs. Cancer  Staging: Nodal mets and liver mets.  Monitoring treatment response  Prognostication

71 53/F: Pancreatic mass

72 51F: CT: (1) Mass forming pancreatitis vs Cancer (2) Hepatic Hemangioma vs Metastasis Coronal Sagittal

73 Pancreatic Cancer: DDx: Chronic pancreatic mass vs. Cancer Delbeke et al: J Nucl Med 1999

74 Brain Tumor  Grading  Prognosis/Survival.  Necrosis or Residual disease after radiation therapy?

75 High Grade Low Grade

76 Kim CK et al. J Neuro-Oncol 1991

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78 Thyroid Cancer Thyroglobulin (+) Iodine-131 scan (-)  FDG PET scan is useful.

79 I V M L FDG-PETI-131 Anterior Posterior M 2 Coronal slices

80 62 y/o male S/P Resection of transglottic right laryngeal cancer R/O Recurrence

81 FDG PET Imaging Determination of the site of unknown primary tumor 20~30%

82 Prediction of tumor response to treatment: Will the tumor respond to treatment?  Labeled Estrogen  [F-18] 5-Fluorouracil (5-FU)

83 FDG-PET Tumor Imaging  DDx: Is the lesion benign or malignant?  Staging: Re-staging:  Evaluation of early therapeutic response:  Scar/Necrosis vs recurrent/residual disease after surgery. Scar/Necrosis vs recurrent/residual disease after XRT.  Histologic grading / P rognosis.  Detection of unknown primary.

84 Summary: PET Safe. Shows all the organ systems of the body with one image. Decreases the number of diagnostic (imaging) procedures. Diagnoses disease often before it shows up on other tests. Shows the progress of disease and how the body responds to treatment. Reduces or eliminates ineffective or unnecessary surgical or medical treatments and hospitalization. Significantly reduces multiple medical costs and avoids needless pain to the patient.

85 The influence of blood glucose levels on 18FDG uptake in cancer (Crippa et al. Tumori 1997:83: ) 8 patients - 20 liver metastases on CT PET 1: Fasting (92.4±10.2) All 20 were (+) on PET. PET 2: Glucose infusion (158±13.8) 6/20 undetected, and 10 lesions localized less clearly.

86 70-years-old female smoker CT showed Rt mid lung mass and inhomogeneity throughout the liver

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88 Coronal Sagittal

89 55 y/o woman Dx’ed with colon ca. S/P resection 2 yrs ago CEA level is rising No evidence of recurrence. CT: normal.


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