1. PET-CT Fusion Imaging and SUV Assessment Using MIMvista (Resisting RECIST) Pete Anderson MD, PhD Professor, Pediatrics pmanders@mdanderson.org Pete Anderson MD, PhD Professor, Pediatrics pmanders@mdanderson.org

2. Passive vs Active role “SCANXIETY”“SCANXIETY” visual images available before reportvisual images available before report Look at most scans yourselfLook at most scans yourself Information today will empower you to get SUV data from any location in the body yourself!Information today will empower you to get SUV data from any location in the body yourself! “SCANXIETY”“SCANXIETY” visual images available before reportvisual images available before report Look at most scans yourselfLook at most scans yourself Information today will empower you to get SUV data from any location in the body yourself!Information today will empower you to get SUV data from any location in the body yourself!

3. PET-CT Imaging Standard Uptake Value (SUV)Standard Uptake Value (SUV) FDG is the prototype : “ I Have A DREAM”FDG is the prototype : “ I Have A DREAM” Sensitive means to document responsesSensitive means to document responses Numeric data from PET-CT using MimvistaNumeric data from PET-CT using Mimvista Downloading of DICOM images from QC CD for central review (e.g. SARC studies)Downloading of DICOM images from QC CD for central review (e.g. SARC studies) Standard Uptake Value (SUV)Standard Uptake Value (SUV) FDG is the prototype : “ I Have A DREAM”FDG is the prototype : “ I Have A DREAM” Sensitive means to document responsesSensitive means to document responses Numeric data from PET-CT using MimvistaNumeric data from PET-CT using Mimvista Downloading of DICOM images from QC CD for central review (e.g. SARC studies)Downloading of DICOM images from QC CD for central review (e.g. SARC studies)

4. Assessing Response of Sarcomas- NOT Always Easy Clinical: pain improved, alkaline phosphatase and/or LDH better, exam better functionClinical: pain improved, alkaline phosphatase and/or LDH better, exam better function Imaging: shrinkage on CT (Choi) and MRIImaging: shrinkage on CT (Choi) and MRI Osteosarcoma: bone scan changes very slowly and can even increase if some calcification associated with healing occursOsteosarcoma: bone scan changes very slowly and can even increase if some calcification associated with healing occurs Sometimes “more” or “worse” lung metastases are just increased calcificationSometimes “more” or “worse” lung metastases are just increased calcification Clinical: pain improved, alkaline phosphatase and/or LDH better, exam better functionClinical: pain improved, alkaline phosphatase and/or LDH better, exam better function Imaging: shrinkage on CT (Choi) and MRIImaging: shrinkage on CT (Choi) and MRI Osteosarcoma: bone scan changes very slowly and can even increase if some calcification associated with healing occursOsteosarcoma: bone scan changes very slowly and can even increase if some calcification associated with healing occurs Sometimes “more” or “worse” lung metastases are just increased calcificationSometimes “more” or “worse” lung metastases are just increased calcification

5. RECIST (Response Evaluation Criteria in Solid Tumors) 30% decrease in sum of longest diameter of target lesion(s): PR30% decrease in sum of longest diameter of target lesion(s): PR PROG >20%PROG >20% CR (complete disappearance)- unusualCR (complete disappearance)- unusual Most: stable (but patient seems better!)Most: stable (but patient seems better!) Ignores stromal or bone componentsIgnores stromal or bone components 30% decrease in sum of longest diameter of target lesion(s): PR30% decrease in sum of longest diameter of target lesion(s): PR PROG >20%PROG >20% CR (complete disappearance)- unusualCR (complete disappearance)- unusual Most: stable (but patient seems better!)Most: stable (but patient seems better!) Ignores stromal or bone componentsIgnores stromal or bone components

6. PET-CT Imaging: A Reality Check for the Both Clinician and Patient Is the ongoing or proposed treatment worth the toxicity (chemo) or morbidity *Surgery/RTIs the ongoing or proposed treatment worth the toxicity (chemo) or morbidity *Surgery/RT Any disease elsewhere?Any disease elsewhere? 3-D imaging: “Seeing is believing”3-D imaging: “Seeing is believing” Helps set priority of intervention(s) such as local control vs chemotherapyHelps set priority of intervention(s) such as local control vs chemotherapy Is the ongoing or proposed treatment worth the toxicity (chemo) or morbidity *Surgery/RTIs the ongoing or proposed treatment worth the toxicity (chemo) or morbidity *Surgery/RT Any disease elsewhere?Any disease elsewhere? 3-D imaging: “Seeing is believing”3-D imaging: “Seeing is believing” Helps set priority of intervention(s) such as local control vs chemotherapyHelps set priority of intervention(s) such as local control vs chemotherapy

7. MIMvista PET-CT Fusion Images First-hand info about tumor locationFirst-hand info about tumor location FUSION images allow clinician to determine where highest FDG uptake is in-around- near a target lesion. YOU get the SUV!FUSION images allow clinician to determine where highest FDG uptake is in-around- near a target lesion. YOU get the SUV! VISUAL PICTURE and numeric data of where there is active tumorVISUAL PICTURE and numeric data of where there is active tumor LOCAL Control strategy (surgery RT, RFA), more chemotherapy, or just follow-up after therapy (esp RT) – “at a glance”LOCAL Control strategy (surgery RT, RFA), more chemotherapy, or just follow-up after therapy (esp RT) – “at a glance” First-hand info about tumor locationFirst-hand info about tumor location FUSION images allow clinician to determine where highest FDG uptake is in-around- near a target lesion. YOU get the SUV!FUSION images allow clinician to determine where highest FDG uptake is in-around- near a target lesion. YOU get the SUV! VISUAL PICTURE and numeric data of where there is active tumorVISUAL PICTURE and numeric data of where there is active tumor LOCAL Control strategy (surgery RT, RFA), more chemotherapy, or just follow-up after therapy (esp RT) – “at a glance”LOCAL Control strategy (surgery RT, RFA), more chemotherapy, or just follow-up after therapy (esp RT) – “at a glance”

8. MIMvista Color Fusion Images MIMvista for desktop PC (Cleveland OH (MIMvista for desktop PC (Cleveland OH (www.mimvista.com) Right click on image (e.g. in MD Anderson ClinicStation or other)Right click on image (e.g. in MD Anderson ClinicStation or other) DICOM images are downloaded into the MIMvista program (~1-2 min)DICOM images are downloaded into the MIMvista program (~1-2 min) Displays fusion images for YOUR analysisDisplays fusion images for YOUR analysis MIMvista for desktop PC (Cleveland OH (MIMvista for desktop PC (Cleveland OH (www.mimvista.com) Right click on image (e.g. in MD Anderson ClinicStation or other)Right click on image (e.g. in MD Anderson ClinicStation or other) DICOM images are downloaded into the MIMvista program (~1-2 min)DICOM images are downloaded into the MIMvista program (~1-2 min) Displays fusion images for YOUR analysisDisplays fusion images for YOUR analysis

9. MIMvista Display Top (PET)Top (PET) MiddleMiddle –(PET-CT FUSION) Bottom: CTBottom: CT Top (PET)Top (PET) MiddleMiddle –(PET-CT FUSION) Bottom: CTBottom: CT Scroll to adjust PET vs CT fusion SUV displayed where click the arrow on coronal, sagittal, or transverse planes Can capture file to clipboard for power point and forwarding

10. More CT More PET Same Lesion

11. SUV on a Fusion Image - anywhere you point the mouse All areas of tumor not alike: heterogeneity of edges of tumor vs middle of tumorAll areas of tumor not alike: heterogeneity of edges of tumor vs middle of tumor Areas near or in vital structures (e.g. spine, mediastinum, liver, chest wall)Areas near or in vital structures (e.g. spine, mediastinum, liver, chest wall) Ossified lesions may have small “islands” of intense FDG uptake (incomplete response to chemotherapy, focal relapse)Ossified lesions may have small “islands” of intense FDG uptake (incomplete response to chemotherapy, focal relapse) All areas of tumor not alike: heterogeneity of edges of tumor vs middle of tumorAll areas of tumor not alike: heterogeneity of edges of tumor vs middle of tumor Areas near or in vital structures (e.g. spine, mediastinum, liver, chest wall)Areas near or in vital structures (e.g. spine, mediastinum, liver, chest wall) Ossified lesions may have small “islands” of intense FDG uptake (incomplete response to chemotherapy, focal relapse)Ossified lesions may have small “islands” of intense FDG uptake (incomplete response to chemotherapy, focal relapse)

12. Indicator (Target) Lesion More PR than RECIST (Mahajan SIOP) More PR than RECIST (Mahajan SIOP) –RT of OS 0/8 by RECIST –6/8 improved SUV on PET-CT PET-CT may allow better F/U after RT + chemoPET-CT may allow better F/U after RT + chemo More PR than RECIST (Mahajan SIOP) More PR than RECIST (Mahajan SIOP) –RT of OS 0/8 by RECIST –6/8 improved SUV on PET-CT PET-CT may allow better F/U after RT + chemoPET-CT may allow better F/U after RT + chemo

13. MIMvista PET-CT Fusion Examples OsteosarcomaOsteosarcoma EwingsEwings OsteosarcomaOsteosarcoma EwingsEwings

14. Chest Wall Osteosarcoma: Progression after HD-Ifosfamide L pleural/chest wall disease unresectable

15. CT after Doxil +Avastin: Ossification Was 7 Now 4 (pleural Effusion better)

16. PET: Avid Hmmmm……

18. PET-CT Fusion: SUV less SUV was >5

19. Local Control: Samarium + RT Samarium scan and RT plan

20. After Samarium +RT (SUV less; No new lesions)

21. No longer next to heart s/p RT Continues on L-MTP-PE (Junovan) CIND “stable” by RECIST Better on PET-CT

22. Osteosarcoma of Ilium + Sacrum Excellent function, no pain 8 months s/p Proton RT now NED s/p staged thorocotomies:? “CR” on PET-CT

23. Osteosarcoma: Pelvic sidewall RFA- pain gone, no progression at this site; attends High School - Will follow with bone scan and PET-CT

24. Metastatic Osteosarcoma: Identification of Active Primary SUV 5.9 Bone scan not avid Where PET was avid

25. PET- “avid” +bone scan, too PET-CT showed local recurrence (posterior-lateral SUV 8.1= tumor) Artifact on MRI and CT s/p limb salvage

26. Local Recurrence: Fusion Image

27. Right Hilar Osteosarcoma (RT w/o chemo, then chemo-- not enough : now needs surgery)

28. Osteosarcoma s/p Pneumonectomy Stable – Low SUV in R thorax; continues off all therapy

29. Response Quality: 1 Year after Samarium- Tumor Islands Active “islands” also seen in primary extremity lesions

30. Osteosarcoma of Sacrum Clinical Response S/P HD-Ifos and RT (pain gone and NO symptoms x1 yr)

31. Osteosarcoma Relapse- Sacrum (SUV 5.4 at start of HDIFOS )

32. Sacral Osteosarcoma (SUV 1.9 s/p IFOS) NO change in size on CT; slightly less avid on bone scan Pain gone + clinical response to HD-IFOS

33. EWS- s/p 3 cycles TMZ + Irinotecan Began short of breath with massive disease- clinically much better

34. Stopped TMZ + Irinotecan : Relapse Given RT, this lesion ok. Stopped Rx again. Increase LUL nodule

35. EWS: Clinical Response Now Off TMZ + irinotecan X 5 months

36. Summary MIMvista PET-CT fusion can provide same-day visual information to clinicians and patients about FDG metabolic activityMIMvista PET-CT fusion can provide same-day visual information to clinicians and patients about FDG metabolic activity PET-CT can now be used in the clinic for to capture numeric response data (SUV)PET-CT can now be used in the clinic for to capture numeric response data (SUV) SUV obtained-anywhere you clickSUV obtained-anywhere you click Additional data possible (tumor volumes)Additional data possible (tumor volumes) Image capture and sharing possibleImage capture and sharing possible MIMvista PET-CT fusion can provide same-day visual information to clinicians and patients about FDG metabolic activityMIMvista PET-CT fusion can provide same-day visual information to clinicians and patients about FDG metabolic activity PET-CT can now be used in the clinic for to capture numeric response data (SUV)PET-CT can now be used in the clinic for to capture numeric response data (SUV) SUV obtained-anywhere you clickSUV obtained-anywhere you click Additional data possible (tumor volumes)Additional data possible (tumor volumes) Image capture and sharing possibleImage capture and sharing possible

37. Conclusion MIMvista information can help YOU to communicate better -with patients, families, referring physicians, surgeons, radiotherapistsMIMvista information can help YOU to communicate better -with patients, families, referring physicians, surgeons, radiotherapists Response data? SARC to determine Response data? SARC to determine COLOR fusion images with numeric data provides best of both worlds in the clinicCOLOR fusion images with numeric data provides best of both worlds in the clinic –Response + numbers “at a glance” MIMvista information can help YOU to communicate better -with patients, families, referring physicians, surgeons, radiotherapistsMIMvista information can help YOU to communicate better -with patients, families, referring physicians, surgeons, radiotherapists Response data? SARC to determine Response data? SARC to determine COLOR fusion images with numeric data provides best of both worlds in the clinicCOLOR fusion images with numeric data provides best of both worlds in the clinic –Response + numbers “at a glance”

38. THANKS! Questions? pmanders@mdanderson.org