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Functional Imaging with PET for Sarcoma

Functional Imaging with PET for Sarcoma. Rodney Hicks, MD, FRACP Director, Centre for Molecular Imaging. Guy Toner, MD, FRACP Director, Medical Oncology. The Peter MacCallum Cancer Centre, Melbourne, Australia. Functional Imaging with PET in Sarcoma Potential Applications.

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Functional Imaging with PET for Sarcoma

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  1. Functional Imaging with PET for Sarcoma Rodney Hicks, MD, FRACP Director, Centre for Molecular Imaging Guy Toner, MD, FRACP Director, Medical Oncology The Peter MacCallum CancerCentre, Melbourne, Australia

  2. Functional Imaging with PET in SarcomaPotential Applications • Benign versus malignant • Grading • Biopsy guidance • Staging • Therapeutic monitoring • Restaging ( local recurrence)

  3. Functional Imaging with PET in SarcomaPotential Applications • Benign versus malignant • Grading • Biopsy guidance • Staging • Therapeutic monitoring • Restaging ( local recurrence)

  4. PET in SarcomaApplications – Tumour Grading Grade vs SUV (By percentile) n = 89 25% 50% 75% BEN 1.5 3.8 6.9 G1 1.55 2.65 4.11 G2 3.40 6.05 10.25 G3 4.22 6.85 19.35 Folpe AL et al. Clin Cancer Res 2000; 6: 1279-1287

  5. PET in SarcomaApplications – Tumour Grading p7003s0 • Right gluteal malignant fibrous histiocytoma • Very high SUV • Widely disseminated metastases at 12 months

  6. PET in SarcomaApplications – Tumour Grading p6694s0 • Pelvic spindle cell sarcoma • Neoadjuvant Rx then resected at 3 months • No recurrence at 12 months

  7. Functional Imaging with PET in SarcomaPotential Applications • Benign versus malignant • Grading • Biopsy guidance • Staging • Therapeutic monitoring • Restaging ( local recurrence)

  8. PET in SarcomaApplications – Biopsy Guidance • Large left thigh mass with MRI features consistent with liposarcoma • Biopsy guided to highest metabolic region confirmed high grade tumour • Multiple subcutaneous metastases also detected by PET p6826s0

  9. Functional Imaging with PET in SarcomaPotential Applications • Benign versus malignant • Grading • Biopsy guidance • Staging • Therapeutic monitoring • Restaging ( local recurrence)

  10. PET in SarcomaApplications - Staging • CT is superior to stand-alone FDG PET for detecting lung mets (1,2) • PET can identify false positive CT masses • NPV is proportional to uptake in primary tumor • FDG PET has higher sensitivity than CT for soft tissue metastases (2) • Whole-body FDG PET may be superior to bone scan for bone metastases (3) 1. Franzius C et al Ann Oncol 2001; 12:479-486 2. Lucas JD et al J Bone Joint Surg Br 1998; 80:441-447 3. Franzius C et al Eur J Nucl Med 2000; 27:1305-1311

  11. PET in SarcomaApplications – Suspected Local Recurrence • FDG-PET is not disabled by metal susceptibility or metal beam hardening artefacts • Multiple studies indicating good accuracy of FDG PET for detecting late local recurrence Franzius C et al Ann Oncol 2002;13:157-160 Garcia R et al J Nucl Med 1996; 37:1476-1479 el Zeftawy H et al Cancer Biother Radiopharm 2001; 16:37-46 Bredella M et al AJR 2002; 179:1145-1150 Johnson GR et al Clin Nucl Med 2003; 28:815-820

  12. Functional Imaging with PET in SarcomaPotential Applications • Benign versus malignant • Grading • Biopsy guidance • Staging • Therapeutic monitoring • Restaging ( local recurrence)

  13. FDG PET in Lung Cancer Therapeutic Monitoring • Survival by PET response in 88 patients receiving radical radiotherapy Mac Manus et al, J Clin Oncol 2003

  14. PET in SarcomaApplications – Therapeutic Monitoring Baseline Post-Chemo Projection Images PET Fused PET-CT • Osteosarcoma of the left femur treatment with neoadjuvant chemotherapy • Near complete metabolic response p8455s0s1

  15. Clinical Trial Proposal PET PET

  16. Clinical Trial Proposal PET PET PET PET

  17. Study Design Week -1 0 2 4 6 8 10 12 Screen SU11248 50mg po qd Break SU11248 50mg po qd Break All Patients (30-40 planned): Response (RECIST)     FDG PET    PK/PD  10 patients per group:    FLT PET     Miso PET    15O-Water PET   Biopsy

  18. Two Types of Response 2-Central Necrosis 1-Shrinkage Week0 Week0 Week12 Week32

  19. Biologic & Anti-Tumor Activity FDG PET FLT PET Week 0 Week 2 Week 12

  20. Pre- Treatment Week 24

  21. PET For Therapeutic MonitoringSerial FDG Imaging Baseline FDG PET SU-11248-pt-014 Week 2 FDG PET • Metastatic malignant melanoma • Mixed metabolic response - CMR in right chest wall lesion • Had 10 days of drug, 6 day break and on drug at 50% dose

  22. PET For Therapeutic MonitoringSerial FDG Imaging Baseline FDG PET SU-11248-pt-014 Week 4 FDG PET • Metastatic malignant melanoma • Rapid clinical and FDG progression on reduced dose due to toxicity

  23. Functional Imaging with PET in SarcomaPotential Applications - Conclusions • Grading & Benign versus Malignant • provides useful complementary information • must be considered in context of clinical picture • chondroid matrix and sclerosing liposarcoma may produce false negative result • further studies required to determine if independently prognostic • Biopsy guidance • very valuable, particularly PET/CT

  24. Functional Imaging with PET in SarcomaPotential Applications - Conclusions • Staging & re-staging • useful whole-body screen • NPV proportional to uptake in primary tumor • helpful in assessing possible local recurrence • Therapeutic monitoring • potentially of enormous clinical value • changes evident rapidly (weeks) • further studies required to improve quantification of response • potential advantages for alternative tracers e.g. FLT

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