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P ositron E mission T omography in Clinical Oncology. Chun Ki Kim, M.D. Mount Sinai School of Medicine New York, New York. [F-18] FDG - Glucose metabolism [C-11] Methionine - Amino acid transport - Incorporation of amino acid into protein fractions
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Positron Emission Tomography in Clinical Oncology • Chun Ki Kim, M.D. • Mount Sinai School of Medicine • New York, New York
[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 Commonly used PET Radiotracers
Potential PET Radiotracers • [C-11] Thymidine Tumor cellular proliferation rate • [C-11] Aminoisobutyric acid Tumor amino acid uptake • [F-18] 5-FU Prediction/evaluation of ChemoTx • [C-11] Tyrosine Tumor metabolism • [N-13] Glutamate Tumor metabolism • [C-11] Acetate Myocardial oxidative metabolism • [C-11] Palmitate Myocardial fatty acid metabolism • [F-18] FluoroDOPA Dopamine synthesis • Many other receptor agents Dopamine, serotonin, opiate etc.
[F-18] FDG (fluoro deoxyglucose) Malignancy ~ Glucose / FDG uptake PET Radiotracer approved by FDA
NORMAL TUMOR • 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
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
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 New Medicare Coverage Policy for FDG PET
Lung Cancer • Dx: Solitary Pulmonary Nodule • Staging • Metastatic work-up
Solitary Pulmonary Nodule • Incidence detected by CXR: 130,000/year. 50-60%: Benign 20-40%: Invasive nodule biopsy Resection.
Efficacy of PET Solitary Pulmonary Nodule • Sensitivity = 97% • Specificity = 78% (Meta-analysis of >40 articles: Gould et al. JAMA 2001)
False Positives: Active Infection/Inflammation TB Pneumonia Cryptococcosis Histoplasmosis Aspergillosis Inflammatory
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)
79/M. Resection of Rectal Ca (Dukes B) 4 mos earlier, CEA, CT: possible local relapse.
T1 T2 • F/68 • H/O Colon Ca. • Rising CEA • CT/MRI; multiple cysts T1 enhanced T1 enhanced
YW: Colon Ca • 3/00: (-) CT • 5/00: rising CEA • 6/00: (+) PET • 7/00: CT
58/M - S/P Colon Ca Rising CEA Coronal Coronal Transverse
58/M - S/P Colon Ca Rising CEA Hemangioma Local recurrence
48y/o with Colon Ca. • S/P Primary resection. • S/P Resection of liver • lesion • Now with CEA • CT: (-) for mets
48y/o with Colon Ca. • S/P Primary resection. • S/P Resection of liver • lesion • Now with CEA • CT: (-) for mets
N. G. 8/15/00 Colon cancer with a Hx of UC Proven mesenteric carcinomatosis
Colorectal Cancer: A possible algorithm CT evidence of resectable disease in patient suitable for surgery Whole Body PET imaging
Colorectal Cancer: A possible algorithm Further evaluation of CT abnormality All sites negative CT evidence of resectable disease in patient suitable for surgery Whole Body PET imaging
Colorectal Cancer: A possible algorithm Further evaluation of CT abnormality All sites negative CT evidence of resectable disease in patient suitable for surgery Whole Body PET imaging PET = CT and other sites negative Surgery
Colorectal Cancer: A possible algorithm Further evaluation of CT abnormality All sites negative CT evidence of resectable disease in patient suitable for surgery Whole Body PET imaging PET = CT and other sites negative Surgery + ve at multiple Sites Non-surgical management
Staging: 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.
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?
Before 2mo after Adjuvant chemo and radioTx Prior to surgery for rectal Ca.
Residual FDG activity after treatment: Not always active tumor Optimal time to scan after treatment?? Uptake may be seen in inflammatory tissue / macrophages. • 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?