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Gino Pepe Medicina Nucleare – PET H.SanRaffaele IRCCS - Milano L'uso della PET nella diagnosi precoce e la valutazione del SUV come indicatore di prognosi.

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Presentation on theme: "Gino Pepe Medicina Nucleare – PET H.SanRaffaele IRCCS - Milano L'uso della PET nella diagnosi precoce e la valutazione del SUV come indicatore di prognosi."— Presentation transcript:

1 Gino Pepe Medicina Nucleare – PET H.SanRaffaele IRCCS - Milano L'uso della PET nella diagnosi precoce e la valutazione del SUV come indicatore di prognosi [ 18 F]FDG PETCT

2 [ 18 F]FDG-PET

3 Why [ 18 F]FDG-PET in tumors?

4 Elevated glucose metabolism in tumor Why [ 18 F]FDG-PET in tumors?

5 Elevated glucose metabolism in tumor [ 18 F]FDG is a glucose analog Why [ 18 F]FDG-PET in tumors?

6 Elevated glucose metabolism in tumor [ 18 F]FDG is a glucose analog [ 18 F]FDG uptake into viable neoplastic cells Why [ 18 F]FDG-PET in tumors?

7 [ 18 F]FDG PET: APPLICATION IN LUNG CANCER n Differentiating benign from malignant lesions (SPN) n Staging N and M and re-staging for therapy planning n Predicting and monitoring response to therapy

8 Solitary Pulmonary Nodule (SPN) n Solitary lung lesion < 3 cm in diameter n 20% - 40% of SPN are malignant n Initial presentation in 20% - 30% of lung cancer Coleman et al. J Nuc Med 1999

9 Visual Analysis Visual Analysis Quantitative analysis Quantitative analysis [ 18 F]FDG PET Measure of metabolic activity of SPN SUV = 7.3 CT[ 18 F]FDG PETCT[ 18 F]FDG PET

10 Visual Analysis: nodule activity vs mediastinal blood pool activity Visual Analysis: nodule activity vs mediastinal blood pool activity Quantitative analysis Quantitative analysis [ 18 F]FDG PET Measure of metabolic activity of SPN SUV = 7.3 CT[ 18 F]FDG PETCT[ 18 F]FDG PET

11 Visual Analysis: nodule activity vs mediastinal blood pool activity Visual Analysis: nodule activity vs mediastinal blood pool activity Quantitative analysis Quantitative analysis [ 18 F]FDG PET Measure of metabolic activity of SPN SUV = 7.3 CT[ 18 F]FDG PETCT[ 18 F]FDG PET

12 Measure of metabolic activity of SPN Visual Analysis Visual Analysis Quantitative analysis: SUV (standardized uptake value) Quantitative analysis: SUV (standardized uptake value) SUV = 7.3 CT[ 18 F]FDG PETCT[ 18 F]FDG PET

13 Standardized Uptake Value = SUV –SUV BW = Ct/(ID/ BW ) = (kBq/ml) / (MBq/Kg) –SUV LBM = Ct/(ID/ LBM ) = (kBq/ml) / (MBq/Kg) LBM uomini =1.1 * W *(W/h) 2 LBM donne = 1.07 * W *(W/h) 2 –SUV BSA = Ct/(ID/ BSA ) = (kBq/ml) / (MBq/m 2 ) BSA = * W * h 0.725

14 [ 18 F]FDG PET Measure of metabolic activity of SPN Visual Analysis Visual Analysis Quantitative analysis: SUV (standardized uptake value) Quantitative analysis: SUV (standardized uptake value) SUV = 7.3 CT[ 18 F]FDG PETCT[ 18 F]FDG PET

15 Measure of metabolic activity of SPN Visual Analysis Visual Analysis Quantitative analysis: SUV (standardized uptake value) Quantitative analysis: SUV (standardized uptake value) SUV = 7.3 CT[ 18 F]FDG PET SUV = 7.9 CT[ 18 F]FDG PET

16 Visual Visual SUV SUV SensSpecPPVNPVAcc Hain SF et al. Eur J Nucl Med 2001 No difference between visual vs. quantitative analysis A SPN with SUV more than 2.5 is considered to be malignant Lung cancer is hypermetabolic

17 CT Fused HSR - Milano [ 18 F]FDG PET SPN: 1.2 cm in diameter

18 HSR - Milano SPN: 1.4 cm in diameter [18F]FDG PETCT CT- PET

19 AuthorsSensitivity SpecificityAccuracy Duhaylongsod (1995)97% 82%92% Bury (1996)100% 88% 96% Lowe (1998)98% 69% 89% Prauer (1998)90% 83% 87% Graeber (1999)97% 89% 92% Hung (2001)95% 50% 86% Hellwig (2001) (meta-analysis)96% 80%- Gould (2001) (meta-analysis)97%78%- (using PET-CT) 97% 82%92% Hickeson (2002) (using PET-CT) 97% 82%92% Accuracy of PET with [ 18 F]FDG in SPN or Pulmonary Opacity

20 Tubercolosis Tubercolosis Sarcoidosis Sarcoidosis Aspergillosis Aspergillosis Histoplasmosis Histoplasmosis Cryptococcosis Cryptococcosis Inflammatory lesions (mainly granulomas) Limitations of FDG-PET for Lung Nodule Characterization: False-positive results

21 Lesion Dimension Lesion Dimension Histological Type Histological Type Hyperglycemia Hyperglycemia Small lesion < 5-6 mm % of viable neoplastic cells in SPN Limitations of FDG-PET for Lung Nodule Characterization: False-negative results

22 [ 18 F]FDG PETCT Fused HSR - Milano R. F. 53 aa Lung nodule 4 mm in diameter ?

23 [18F]FDG PETCT CT- PET HSR - Milano Z. A. 41 aa SPN: 4 mm in diameter

24 Lesion Dimension Lesion Dimension Histological Type Histological Type Hyperglycemia Hyperglycemia Carcinoid Pure Bronchioloalveolar Carcinoma (BAC), mucinous ca, neuroendocrine tumor Well differentiated type Limitations of FDG-PET for Lung Nodule Characterization: False-negative results

25 [ 18 F]FDG PET HSR - Milano CARCINOID CT

26 [18F]FDG PETCT PET/CT HSR - Milano P. G. 68 aa SPN: 10 mm in diameter Well differentiated tumor

27 [ 18 F]FDG PET IN LUNG CANCER SUV and histological type BAC (12) 1.3 BAC (12) 1.3 Well Differentiated (10) 3.1 Well Differentiated (10) 3.1 Moderately differentiated (12) 4.3 Moderately differentiated (12) 4.3 Poorly differentiated (4) 5.6 Poorly differentiated (4) 5.6 Mean SUV Higashi et al. Nucl Med Comm 2000

28 [ 18 F]FDG PET IN LUNG CANCER FDG uptake in BAC No [ 18 F]FDG uptake in more than 50% of patients with BAC 85,7% of BAC are negative for Glut-1 (glucose transporter) expression (Higashi 2000) [ 18 F]FDG-PET FN A different PET tracer may solve the problem

29 Pure Bronchioloalveolar Carcinoma B. A. 65 aa HSR Milano SUV = 1.73 [ 18 F]FDG PETCT[ 11 C]Choline PET

30 Lesion Dimension Lesion Dimension Histological Type Histological Type Hyperglycemia Hyperglycemia > 200 mg/dl = PET not performed Limitations of FDG-PET for Lung Nodule Characterization: False-negative results

31 VALUTAZIONE DELLA RISPOSTA ALLA TERAPIA con PET e [ 18 F]FDG NEL TUMORE POLMONARE 113 pazienti con neoplasia polmonare NSC trattati con chemio o radiochemioterapia Patz et al AJR, 2000 Differenza significativa nella sopravvivenza tra pazienti con PET positiva e pazienti con PET negativa Mediana di sopravvivenza 12.1 mesi nei pz con PET + dopo terapia 34.2 mesi nell85% dei pz con PET - dopo terapia

32 PET Responder ( SUV –61%) Weber et al., J Clin Oncol 2003; 21:2651 FDG-PET: VALUTAZIONE PRECOCE DELLA RISPOSTA ALLA CHEMIOTERAPIA PR in 20/28 PET responders (71%) SD o PD in 26/27 PET non responders (96%) 57 pazienti in stadio IIIB o IV studiati con PET prima e dopo I° ciclo di chemio

33 PET in SPN Who: –Patient with indetermined lung nodule When: –After a CT study Why: –Metabolic characterization of indetermined lung nodule (benign vs malignant)


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