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Gino Pepe Medicina Nucleare – PET H.SanRaffaele IRCCS - Milano

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

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Gino Pepe Medicina Nucleare – PET H.SanRaffaele IRCCS - Milano

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

  2. [18F]FDG-PET

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

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

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

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

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

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

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

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

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

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

  13. Standardized Uptake Value = SUV • SUVBW = Ct/(ID/BW) = (kBq/ml) / (MBq/Kg) • SUVLBM = Ct/(ID/LBM) = (kBq/ml) / (MBq/Kg) • LBM uomini =1.1 * W - 128 *(W/h)2 • LBM donne = 1.07 * W - 148 *(W/h)2 • SUVBSA = Ct/(ID/BSA) = (kBq/ml) / (MBq/m2) • BSA = 0.007184 * W 0.425 * h 0.725

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

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

  16. [18F]FDG PET Lung cancer is hypermetabolic A SPN with SUV more than 2.5 is considered to be malignant No difference between visual vs. quantitative analysis Sens Spec PPV NPV Acc • Visual 100 69 90 100 92 • SUV 96 69 90 85 89 Hain SF et al. Eur J Nucl Med 2001

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

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

  19. Accuracy of PET with [18F]FDG in SPN or Pulmonary Opacity Authors Sensitivity Specificity Accuracy 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% - Hickeson (2002) (using PET-CT)97% 82%92%

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

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

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

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

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

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

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

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

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

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

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

  31. VALUTAZIONE DELLA RISPOSTA ALLA TERAPIA con PET e [18F]FDG NEL TUMORE POLMONARE 113 pazienti con neoplasia polmonare NSC trattati con chemio o radiochemioterapia 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 nell’85% dei pz con PET - dopo terapia Patz et al AJR, 2000

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

  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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