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Advances in Nuclear Medicine and its Impact on Diagnosis and Management of GI Cancers

Advances in Nuclear Medicine and its Impact on Diagnosis and Management of GI Cancers. Medhat Osman, MD PhD Philip Alderson, MD. 2007 Estimated US Cancer Cases *. Men 766,860. Women 678,060. Prostate 29% Lung & bronchus 15% Colon & rectum 10% Urinary bladder 7% Non-Hodgkin 4%

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Advances in Nuclear Medicine and its Impact on Diagnosis and Management of GI Cancers

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  1. Advances in Nuclear Medicine and its Impact on Diagnosis and Management of GI Cancers Medhat Osman, MD PhD Philip Alderson, MD

  2. 2007 Estimated US Cancer Cases* Men766,860 Women678,060 Prostate 29% Lung & bronchus 15% Colon & rectum 10% Urinary bladder 7% Non-Hodgkin 4% lymphoma Melanoma of skin 4% Kidney 4% Leukemia 3% Oral cavity 3% Pancreas 2% All Other Sites 19% 26% Breast 15% Lung & bronchus 11% Colon & rectum 6% Uterine corpus 4% Non-Hodgkin lymphoma 4% Melanoma of skin 4% Thyroid 3% Ovary 3% Kidney 3% Leukemia 21% All Other Sites *Excludes basal and squamous cell skin cancers and in situ carcinomas except urinary bladder. Source: American Cancer Society, 2007.

  3. 2007 Estimated US Cancer Deaths* Men289,550 Women270,100 Lung & bronchus 31% Prostate 9% Colon & rectum 9% Pancreas 6% Leukemia 4% Liver & intrahepatic 4%bile duct Esophagus 4% Urinary bladder 3% Non-Hodgkin 3% lymphoma Kidney 3% All other sites 24% 26% Lung & bronchus 15% Breast 10% Colon & rectum 6% Pancreas 6% Ovary 4% Leukemia 3% Non-Hodgkin lymphoma 3% Uterine corpus 2% Brain/ONS 2% Liver & intrahepatic bile duct 23% All other sites ONS=Other nervous system. Source: American Cancer Society, 2007.

  4. Lifetime Probability of Developing Cancer, by Site, Women, 2001-2003* Site Risk All sites† 1 in 3 Breast 1 in 8 Lung & bronchus 1 in 16 Colon & rectum 1 in 19 Uterine corpus 1 in 40 Non-Hodgkin lymphoma 1 in 55 Ovary 1 in 69 Melanoma 1 in 73 Pancreas 1 in 79 Urinary bladder‡ 1 in 87 Uterine cervix 1 in 138 * For those free of cancer at beginning of age interval. Based on cancer cases diagnosed during 2001 to 2003. Source: DevCan: Probability of Developing or Dying of Cancer Software, Version 6.1.1 Statistical Research and Applications Branch, NCI, 2006. http://srab.cancer.gov/devcan

  5. Lifetime Probability of Developing Cancer, by Site, Men, 2001-2003* Risk Site All sites† 1 in 2 Prostate 1 in 6 Lung and bronchus 1 in 12 Colon and rectum 1 in 17 Urinary bladder‡ 1 in 28 Non-Hodgkin lymphoma 1 in 47 Melanoma 1 in 49 Kidney 1 in 61 Leukemia 1 in 67 Oral Cavity 1 in 72 Stomach 1 in 89 * For those free of cancer at beginning of age interval. Based on cancer cases diagnosed during 2001 to 2003. Source: DevCan: Probability of Developing or Dying of Cancer Software, Version 6.1.1 Statistical Research and Applications Branch, NCI, 2006. http://srab.cancer.gov/devcan

  6. Basic Questions • Is it cancer? • Is it localized ? • How to treat? • Is treatment working? • Is more treatment needed?

  7. Limitations of Anatomic Imaging • Tumor diagnosis • Disease staging • Therapeutic response & disease recurrence • Radiation exposure • Annual background: 3 mSv • Chest PA : 0.02 mSv • Screeing Mammogram: 0.4 mSv • CT • Chest: 8-18 mSv • Abdomen: 3.5- 25 mSv • Pelvis: 3.3-10 mSv Mettler FA, et al. Radiology 2008:248 (1):254-263

  8. Benefits of PET Imaging • Improved diagnostic specificity • Improved tumor staging • Improved monitoring of response to therapy • Improved monitoring of disease recurrence

  9. Limitations of PET Imaging • False-positive • False-negative • Limited spatial resolution • Inability to pinpoint tumor location • Two hours per study!

  10. Positron Emission Tomography

  11. Advantages of PET-CT Scanner • Whole-body staging in one exam • Nearly simultaneous acquisition of PET and CT images • Improved anatomic lesion localization • Shorter PET image acquisition • Lower radiation exposure • Whole body PET/CT at SLU: < 20 mSv • Chest, abdomen and pelvic CT: 14.8-53 mSv

  12. COLORECTAL CARCINOMA Initial Diagnosis • Sensitivity: 85% • Specificity: 67% Facey K, et al. NHS. R&D Programme: July 2004

  13. Colorectal Liver Metastases Wiering B, et al. Cancer 2005:104:2658-2670

  14. Colorectal Liver Metastases; on a per-lesion basis Bipat S, et al. Radiology. 2005:273:123-131

  15. Extrahepatic Lesions Wiering B, et al. Cancer. 2005:104:2658-2670

  16. PET Changes Management and Improves Prognostic Stratification in Patients with Recurrent Colorectal Cancer: Results of a Multicenter Prospective Study • 65.6% of patients with residual structural lesion suggestive of recurrence • 49% of patients with potentially resectable pulmonary or hepatic metastases Scott AM, et al. J Nuc Med. 2008;49:1451-1457

  17. 63-yo with prostate ca, s/p prostatectomy • Pre XRT colonoscopy revealed rectal mass • Biopsy: rectal cancer • Abd ceCT: no mets • PET/CT for staging

  18. ESOPHAGEAL CANCER Initial Diagnosis • PET is more accurate than conventional imaging modalities • The overall incremental value of PET compared to CT with regard to staging accuracy was 14% Kato H, et al. Cancer. 2005:103:148-156

  19. Detection of Metastases: • Local • Sensitivity: 52% • Specificity: 84% • Distant • Sensitivity: 67% • Specificity: 97% Facey K, et al. NHS. R&D Programme: July 2004 Von Westreenen NH, et al. J Clin Oncol. 2004;22:3850-3812

  20. 65-yo M with history of laryngeal ca, s/p XRT • Recent dx of esophageal ca • ceCT: no mets • PET/CT for staging

  21. PANCREATIC CANCER;Differentiating Benign From Malignant Lesions Orlando LA, et al. Aliment Pharmacol Ther. 2004;20:1063-1070

  22. 54-yo M with jaundice • ceCT: pancreatic mass with no metastases • Biopsy: pancreatic Ca • PET/CT for staging

  23. Male, age 66 • Former smoker • New LUL mass • PET/CT for diagnosis and staging

  24. ADVANCES • New scanners • New tracers • Open coverage

  25. GEMINI TFPET/CT scanner with TruFlight technology

  26. “WHOLE-BODY” FOV VARIATIONS S Huston, M M Osman, SNM05 A B C D E

  27. Added Value of True Whole-Body Over Limited Whole-Body FDG PET/CT in Cancer Patients

  28. Results • 20/ 500 (4%) of patients had new, previously unidentified cancerous lesions outside LWB FOV • Detection of malignancy outside LWB resulted in changed in management in 13 (65%) and staging in 11 (55%) of those 20 patients • Of those 20, 5/500 (1%) patients had their only malignant lesion outside the LWB FOV Osman MM, et al. SNM. 2006

  29. PET/CT PET/MR

  30. F-18 FLT PET

  31. Imaging Gastric Cancer with PET and the Radiotracers 18F-FLT and 18F-FDG: A Comparative Analysis Hermann, et al. J Nuc Med. 2007;48:1945-1950

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