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Outline of Presentation. Description of PETPatient preparation / imagingReimbursementClinical studies
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3. PET Molecular imaging
Primary modality for molecular medicine
Research / animal PET
4. Positron Emitting Radionuclides Cyclotron Produced Generator Produced
F-18 : 110 mins Ga-68 : 68 minsC-11 : 20 mins Rb-82 : 76 secsN-13 : 10 mins
O-15 : 2 mins
5. Positron Annihilation
8. F-18 FDG
9. FDG F-18 (cyclotron produced) has 110 min half-life
FDG readily available commercially at most sites
Synthesis units make large quantities reproducibly
10. FDG Competes with serum glucose for accumulation
After phosphorylated, metabolically trapped except in liver where it is dephosphorylated
Tumors have increased concentrations of glucose transporter proteins and/or hexokinase enzymes
11. Patient Preparation Goal is to have low serum glucose and insulin levels
Should be without caloric intake (encourage to drink water) for 4 hrs
Can take medications
Obtain routine serum glucose
12. Imaging Minimum time delay from FDG administration Brain - 30 min Whole-body - 45 min
Brain imaging 1 min acquisition for positioning 3D acquisition for 8 mins calculated attenuation correction
13. Imaging Whole body imaging
5-7 bed positions
4 min. emission, 2.5 min. transmission per bed position
14. PET Reimbursement Complex, evolving process
Dependent on FDA approval of drugs Facilitated by FDAMA (1997)
Reimbursable indications Determined by technology assessment panels of third party payers Process dominated by CMS
15. Medicare Reimbursement Hospitals paid under HOPPS/APC rules
Reimbursement for others set by local carrier
G codes used for billing instead of CPT codes
Effective April 2002, APC technical payment for whole-body PET set at $1850 (including FDG)
Professional reimbursement remains at ~ $80
vs. ~ $186 for CT of chest, abdomen, pelvis
vs. ~ $165 for gated myocardial SPECT
16. Non-Oncologic PETMedicare Coverage Rb-82: myocardial perfusion
FDG: refractory seizure disorder myocardial viability assessment under review: dementia
N-13 ammonia: myocardial perfusion
17. Oncologic PETMedicare Coverage Diagnosis, staging and restaging
Non-small cell lung cancer
Colorectal cancer
Esophageal cancer
Head and Neck cancer
Lymphoma
Melanoma
18. Oncologic PETMedicare Coverage Staging, restaging and treatment monitoring of breast cancer
Thyroid cancer after therapy, TG elevated, I-131 scan negative
19. Cancers Submitted for Coverage Brain tumor
Cervical cancer
Small cell lung cancer
Testicular cancer
Pancreatic cancer
20. Ovarian cancer
GIST
Aggressive prostate cancer
Multiple myeloma Cancers Submitted for Coverage
22. Clinical Indications: 2002 Lung 1024
Lymphoma 542
Melanoma 272
Colorectal 244
Breast 158
Head & Neck 83
Esophagus 74
23. Clinical Indications: 2002 Brain tumor 570
Seizure 62
Other 25
24. rachelrachel
25. FDG-PET: Meta-analysis in Pulmonary Nodules
26. FDG-PET as a Metabolic Biopsy 63 lung lesions - biopsy “unsuccessful” or “too dangerous”
PPV = 90%; NPV = 100% (visual analysis)
False positive results: 2 with mycobacteria infection, 3 resolved over 12 months
Hain et al. Eur J Nucl Med 2001; 28:1336-1340
27. FDG PET in Lung Cancer Uptake (SUV) in the primary mass correlates with median survival
SUV < 10 24.6 months
SUV > 10 11.4 months
SUV > 10, SPN > 3 cm 5.7 month
Ahuja et al. Cancer 1998; 83:918
28. Brown-mcbrid
Brown-mcbrid
29. Mediastinal Staging: Meta-analysis Included 14 PET studies of 514 pts and 29 CT studies of 2226 pts
PET Sensitivity=79%, Specificity=91%
CT Sensitivity=60%, Specificity=77%
Dwamena et al. Radiology 1999;213:503-506
30. Effectiveness of PET in Preoperative Assessment of Patients with Suspected NSCLCThe PLUS Multi-center Trial 188 patients with NSCLC randomized to conventional work-up (CWU) ? PET
Endpoint: futile thoracotomy
benign disease
exploratory thoracotomy only
IIIA (N2) or IIIB disease
relapse or death within 12 months
CWU (n=96): 41% futile thoractomiesCWU + PET (n=92): 21% futile thoracotomiesRelative reduction: 51%; p=0.003
31. The PLUS Multi-center Trial CWU (n=96) CWU + PET (n=92)
No thoracotomy 18 (19%) 32 (35%)
Confirmed N2/N3 10 18
Confirmed distant metastases 1 7
Benign primary lesion 2 3
Other tumor 2 1
Intercurrent disease/refused 3 3
Non-futile thoracotomy 39 (41%) 41 (44%)
Futile thoracotomy 39 (41%) 19 (21%)
Benign 7 2
Exploratory thoracotomy 1 1
IIIA (N2) 6 4
IIIB 6 2
Recurrence/death < 1 yr 19 10
32. Bracey
11/01 - 02/02Bracey
11/01 - 02/02
34. Loftus
Loftus
36. Detection of Hepatic Metastases from Cancers of the GI Tract: Meta-Analysis Used 111 data sets: 9 US, 25 CT, 11 MRI, 9 PET
At a specificity higher than 85%Modality Mean wt sens (CI) US 55 (41, 65) CT 72 (63, 80) MRI 76 (57, 91) PET 90 (80, 97)
37. Boso
Boso
39. Foster
Foster
41. Improving the Performance of PET Scanners Accelerating pace of technical innovation
New scintillation crystals
Lutetium oxyorthosilicate (LSO) [Lu2SiO5(Ce)]
Gadolinium oxyorthosilicate (GSO) [Gd2SiO5(Ce)]
Higher light output and shorter decay time than BGO
Improved NEC = reduced scanning time
New BGO detector design
More sensitive
Faster patient throughput
42. PET/CT
43. PET / CT Patient dosing of FDG
140 uCi / kg (10 – 20 mCi)
Patient imaging
Scout view obtained
CT from external auditory meatus to prox thigh
PET scan acquisition
<150 lbs 2 min / bed position
>150 lbs 3 min / bed position
44. Advantages of PET/CT Shorter scan time
More accurate attenuation correction – better images
Anatomic fusion
48. Integrated PET and CT in Staging Lung Cancer (NEJM 2003;348:2500) Prospective study of 50 patients with proven or suspected NSCLC
Evaluated PET and CT alone, visually correlated PET and CT, and integrated PET-CT for TNM staging
Histology: adeno ca (28), SCC (13), large cell (8), MALT (1-excluded)
49. Integrated PET and CT in Staging Lung Cancer (NEJM 2003;348:2500) PET/CT provided additional information in 20/49 patients
Exact location of lymph nodes (9)
Precise evaluation of chest wall (3) and mediastinal (3) invasion
Differentiation between tumor and inflammation (7)
Exact location of distant metastases (2)
PET/ CT significantly more accurate than others for tumor staging and than PET for nodal staging.
50. Wholebody PET/CT and MRI for Tumor Staging(Antoch, Essen, Submitted) Studied 98 patients with various malignancies.
PET/CT correctly TNM staged 75/98 (77%) pts.
MRI correctly TNM staged 53/98 (54%) pts.
Impact on patient management: PET/CT=12, MRI=2
51. Wholebody PET/CT and MRI for Tumor Staging(Antoch, Essen, Submitted) Accuracy
PET/CT MRI
T stage 34/46 (80%)* 24/46 (52%)
N stage 91/98 (93%)* 77/98 (79%)
M stage 92/98 (94%)* 91/98 (93%)
55. PET in Alzheimer’s Disease Request for coverage
… distinguish patients with AD from other causes of dementia, or assist with early diagnosis in patients with suspected neurodegenerative disease …
56. Criteria for PET in Dementia Progressive decline in cognitive domain and/or cognitive impairment (change from baseline) present for at least 6 months
Not suffering from severe dementia
Making a diagnosis will impact care
57. Dementia Affects 8 % of persons > 65 years
Affects 47 % of persons > 85 years
Alzheimer’s disease accounts for 70 %
58. Rationale for Early Diagnosis of AD Cholinesterase inhibitors delay decline in memory and cognitive function (9-12 months) and need for institutionalization (18 months)
Better planning for future - delays nursing home placement an average of 11 months
59. Conventional Workup of Dementia Lim et al: (J Am Geriatr Soc 1999; 47:564-9) evaluated 134 patients with new onset of symptoms - diagnosis based on follow-up of 3 years.
60. Conventional Workup of Dementia 94 AD, 40 non-AD
Sens Spec
Prob AD 83 55
Prob + Poss AD 85 50
61. Anatomic Imaging in Dementia CT and/or MRI detects unsuspected lesions (strokes and tumors) in approximately 5% of patients
In a 7 center study, less than 30% of patients diagnosed as vascular dementia actually had isolated cerebrovascular disease and 55% had AD on pathological diagnosis (Am J Psychiatr 1995; 152:1476-1484)
62. PET in Dementia Pattern of decreased FDG in AD in parietotemporal cortex sparing basal ganglia, thalamus, cerebellum, brainstem and cortical regions mediating sensory and motor functions.
Extent of hypometabolism correlates with severity of cognitive impairment
May be unilateral early, more symmetric as disease progresses
63. MitchellMitchell
64. PricePrice
65. TaylorTaylor
67. PET and Neuropathologic Correlation Study N Sens Spec
Hoffman (J Nucl Med) 22 88% 67%
Multicenter study (JAMA) 138 94% 73%