560 likes | 763 Views
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%
E N D
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* 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.
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.
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
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
Basic Questions • Is it cancer? • Is it localized ? • How to treat? • Is treatment working? • Is more treatment needed?
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
Benefits of PET Imaging • Improved diagnostic specificity • Improved tumor staging • Improved monitoring of response to therapy • Improved monitoring of disease recurrence
Limitations of PET Imaging • False-positive • False-negative • Limited spatial resolution • Inability to pinpoint tumor location • Two hours per study!
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
COLORECTAL CARCINOMA Initial Diagnosis • Sensitivity: 85% • Specificity: 67% Facey K, et al. NHS. R&D Programme: July 2004
Colorectal Liver Metastases Wiering B, et al. Cancer 2005:104:2658-2670
Colorectal Liver Metastases; on a per-lesion basis Bipat S, et al. Radiology. 2005:273:123-131
Extrahepatic Lesions Wiering B, et al. Cancer. 2005:104:2658-2670
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
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
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
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
65-yo M with history of laryngeal ca, s/p XRT • Recent dx of esophageal ca • ceCT: no mets • PET/CT for staging
PANCREATIC CANCER;Differentiating Benign From Malignant Lesions Orlando LA, et al. Aliment Pharmacol Ther. 2004;20:1063-1070
54-yo M with jaundice • ceCT: pancreatic mass with no metastases • Biopsy: pancreatic Ca • PET/CT for staging
Male, age 66 • Former smoker • New LUL mass • PET/CT for diagnosis and staging
ADVANCES • New scanners • New tracers • Open coverage
“WHOLE-BODY” FOV VARIATIONS S Huston, M M Osman, SNM05 A B C D E
Added Value of True Whole-Body Over Limited Whole-Body FDG PET/CT in Cancer Patients
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
PET/CT PET/MR
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