간담도 암에서의 PET 의 활용 핵의학과 홍일기

18 F-FDG PET: Warburg effect

hexokinase

Normal Distribution of FDG uptake

Standardized Uptake Value, SUV Tracer Activity in Tissue (ROI) Injected Dose/Patient wt.

False positive and negative findings Inflammation – abscess, sarcoidosis, granuloma, acute fracture, other nonspecific inflammation Benign tumor – pituitary adenoma, meningioma, Warthin's tumor, thyroid adenoma, colonic adenoma, kidney (angiomyolipoma, pericytoma), pheochromocytoma, ovary (thecoma, cystadenoma, endometrial/follicular cyst) Other benign disease – thymic hyperplasia, retroperitoneal fibrosis Low cellularity – necrotic tumor, cystic tumor, mucinous carcinoma, osteoblastic bone metastasis High Glucose-6-phosphatase – W/D hepatocellular carcinoma, W/D renal cell carcinoma Low glycolysis, GLUT expression – W/D thyroid carcinoma, BAC, adenocarcinoma of lung, low-grade tumors False Positive False Negative

Diagnosis Staging Prognosis prediction Treatment Response Recurrence Detection Role of F-18 FDG PET in HCC

18 F-FDG uptake in HCC 55%30%15% P/D W/D

hexokinase Glu-6-phosphatase

Role of F-18 FDG PET in HCC Staging

FDG PET/CT for the detection of extrahepatic metastases from HCC Hepatology Research 2009; 39: 134–142 LungLymph nodeBone

Role of 18 F-FDG PET in Detecting Extrahepatic Metastasis in Pretreatment Staging of HCC Oncology 2007;72:104–110

Role of 18 F-FDG PET in Detecting Extrahepatic Metastasis in Pretreatment Staging of HCC Oncology 2007;72:104–110

Role of 18 F-FDG PET in Detecting Extrahepatic Metastasis in Pretreatment Staging of HCC Oncology 2007;72:104–110

Role of the routine use of chest CT and bone scan in staging workup of HCC J Hepatol 2012

Manifestation of osteolytic lesion on bone scan Manifestation of osteoblastic lesion on bone scan Lytic lesions scan manifestations “HOT” “NORMAL” “COLD” 2 cm, very active reactive tissue & vascularity 2 cm, limited reactive tissue & vasculatiry >2 cm, limited reactive tissue & vasculatiry Active metabolism Indolent metabolism “HOT” “NORMAL”

Treatment Response

Evaluation of Metabolic Characteristics and Viability of Lipiodolized Hepatocellular Carcinomas Using 18 F-FDG PET/CT J Nucl Med 2010; 51:1849–1856

Prognosis prediction Role of F-18 FDG PET in HCC

18 F-FDG Uptake on Positron Emission Tomography as a Prognostic Predictor in Locally Advanced Hepatocellular Carcinoma Cancer 2011;117:4779–87

Prediction of Tumor Recurrence by 18 F-FDG PET in Liver Transplantation for HCC J Nucl Med 2009; 50:682–687 T SUVmax /L SUVmax <1.15 T SUVmax /L SUVmax ≥1.15

Prognostic value of 18 F-FDG PET for hepatocellular carcinoma patients treated with sorafenib Liver international 2011 P = P = Baseline PET, SUVmax cutoff 5.0

Patients With Non–[18F]Fluorodeoxyglucose-Avid Advanced Hepatocellular Carcinoma on Clinical Staging May Achieve Long-Term Recurrence-Free Survival After Liver Transplantation Liver Transpl 18:53-61, 2012 P = 0.002P = 0.001

Recurrence Detection Role of F-18 FDG PET in HCC

Unexplained AFP elevation in pts with suspected recurrence When conventional examinations are normal, FDG- PET is a valuable imaging tool in patients who have rising AFP levels after HCC treatment. FDG-PET whole-body scan also provides an important and valuable imaging study for detecting extrahepatic metastasis. When the multiphasic CT was normal, the 18 F-FDG PET/CT was valuable to reveal intrahepatic tumor recurrence and/or extrahepatic metastases in patients with AFP elevation after interventional therapy for HCC. Anticancer Res Hepatogastroenterology. 2009

Radiotracer beyond F-18 FDG

A Prospective Evaluation of 18 F-FDG and 11 C-Acetate PET/CT for Detection of Primary and Metastatic Hepatocellular Carcinoma M/71, grade 1 M/65, grade 3 18 F-FDG 11 C-acetate J Nucl Med 2008; 49:1912–1921

Dual-Tracer PET/CT Imaging in Evaluation of Metastatic Hepatocellular Carcinoma J Nucl Med 2007; 48:902–909

PET/CT in patients with hepatocellular carcinoma using 18 F- Fluorocholine: preliminary comparison with 18 F-FDG PET/CT 8cm well-differentiated HCC 18 F-Fluorocholine 18 F-FDG Eur J Nucl Med Mol Imaging (2006) 33:1285–1289

Cholangiocarcinoma Diagnostic accuracy depends on Anatomic location intrahepatic > hilar and extrahepatic Growth pattern mass-forming or nodular > ductal infiltrating Pathologic characteristics mucinous tumor primary sclerosing cholangitis, granulomatous disease, abscess

Diagnosis Staging Prognosis prediction Treatment Response Recurrence Detection Role of F-18 FDG PET in HCC

Appendix Clinical significance of the incidental uptake in F-18 FDG PET

Lung ca. staging 614 Incidental uptake 77 (12%) no further w/u 38 further w/u: 39 Biopsy, surgery, endoscopy, f/u False-positive: 19 Benign: 18 Atypical metastatic site (stomach): 1 True-positive: 20 Second primary: 11 Pre-malignant: 9 Lung cancer, 2012