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Advances in Nuclear Medicine and Advances in Nuclear Medicine and its Impact on Diagnosis and its Impact on Diagnosis and Management of GI CancersManagement of GI Cancers
Medhat Osman, MD PhDMedhat Osman, MD PhD
Philip Alderson, MDPhilip Alderson, MD
2007 Estimated US Cancer 2007 Estimated US Cancer CasesCases**
*Excludes basal and squamous cell skin cancers and in situ carcinomas except urinary bladder.Source: American Cancer Society, 2007.
Men766,860
Women678,060 26%26% BreastBreast
15%15% Lung & bronchusLung & bronchus
11%11% Colon & rectumColon & rectum
6%6% Uterine corpus Uterine corpus
4%4% Non-Hodgkin Non-Hodgkin
lymphoma lymphoma
4%4% Melanoma of skinMelanoma of skin
4% Thyroid4% Thyroid
3%3% OvaryOvary
3%3% KidneyKidney
3%3% LeukemiaLeukemia
21%21% All Other SitesAll Other Sites
ProstateProstate
29%29%
Lung & bronchusLung & bronchus
15%15%
Colon & rectumColon & rectum
10%10%
Urinary bladderUrinary bladder
7%7%
Non-Hodgkin Non-Hodgkin
4% 4%
lymphomalymphoma
Melanoma of skinMelanoma of skin
4%4%
KidneyKidney
4%4%
Leukemia Leukemia
3%3%
Oral cavityOral cavity
3%3%
PancreasPancreas
2%2%
All Other SitesAll Other Sites
19%19%
2007 Estimated US Cancer 2007 Estimated US Cancer DeathsDeaths**
ONS=Other nervous system.Source: American Cancer Society, 2007.
Men289,550
Women270,100 26%26% Lung & bronchusLung & bronchus
15%15% BreastBreast
10%10% Colon & rectumColon & rectum
6%6% PancreasPancreas
6%6% OvaryOvary
4%4% LeukemiaLeukemia
3%3% Non-HodgkinNon-Hodgkin lymphoma lymphoma
3%3% Uterine corpusUterine corpus
2%2% Brain/ONSBrain/ONS
2%2% Liver & intrahepatic Liver & intrahepaticbile ductbile duct
23% All other sites23% All other sites
Lung & bronchusLung & bronchus 31%31%
ProstateProstate 9%9%
Colon & rectum Colon & rectum 9%9%
PancreasPancreas 6%6%
LeukemiaLeukemia 4%4%
Liver & intrahepaticLiver & intrahepatic 4%4%bile ductbile duct
EsophagusEsophagus 4%4%
Urinary bladderUrinary bladder 3% 3%
Non-Hodgkin 3% Non-Hodgkin 3% lymphoma lymphoma
KidneyKidney 3%3%
All other sites 24%All other sites 24%
Lifetime Probability of Developing Lifetime Probability of Developing Cancer, by Site, Women, 2001-2003Cancer, 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
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
* For those free of cancer at beginning of age interval. Based on cancer cases diagnosed during 2001 to 2003.
* 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 Lifetime Probability of Developing Cancer, by Site, Men, 2001-2003Cancer, by Site, Men, 2001-2003**
Site Risk
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
Basic QuestionsBasic Questions
Is it cancer?Is it cancer? Is it localized ?Is it localized ? How to treat?How to treat? Is treatment working?Is treatment working? Is more treatment needed?Is more treatment needed?
Limitations of Anatomic Imaging Limitations of Anatomic Imaging Tumor diagnosisTumor diagnosis Disease stagingDisease staging Therapeutic response & disease recurrenceTherapeutic response & disease recurrence Radiation exposureRadiation exposure
– Annual background: 3 mSv Annual background: 3 mSv – Chest PA : 0.02 mSvChest PA : 0.02 mSv– Screeing Mammogram: 0.4 mSvScreeing Mammogram: 0.4 mSv– CT CT
» Chest: 8-18 mSvChest: 8-18 mSv» Abdomen: 3.5- 25 mSvAbdomen: 3.5- 25 mSv» Pelvis: 3.3-10 mSv Pelvis: 3.3-10 mSv
Mettler FA, et al. Radiology 2008:248 (1):254-263
Benefits of PET ImagingBenefits of PET Imaging
Improved diagnostic specificityImproved diagnostic specificity Improved tumor stagingImproved tumor staging Improved monitoring of response to therapyImproved monitoring of response to therapy Improved monitoring of disease recurrenceImproved monitoring of disease recurrence
Limitations of PET ImagingLimitations of PET Imaging
False-positiveFalse-positive False-negativeFalse-negative Limited spatial resolutionLimited spatial resolution Inability to pinpoint tumor locationInability to pinpoint tumor location Two hours per study!Two hours per study!
Positron Emission TomographyPositron Emission Tomography
Advantages of PET-CT ScannerAdvantages of PET-CT Scanner
Whole-body staging in one examWhole-body staging in one exam Nearly simultaneous acquisition of PET and Nearly simultaneous acquisition of PET and
CT imagesCT images Improved anatomic lesion localizationImproved anatomic lesion localization Shorter PET image acquisitionShorter PET image acquisition Lower radiation exposureLower radiation exposure
– Whole body PET/CT at SLU: < 20 mSv Whole body PET/CT at SLU: < 20 mSv – Chest, abdomen and pelvic CT: 14.8-53 mSvChest, abdomen and pelvic CT: 14.8-53 mSv
COLORECTAL CARCINOMACOLORECTAL CARCINOMA Initial Diagnosis Initial Diagnosis
Sensitivity: 85%Sensitivity: 85% Specificity: 67%Specificity: 67%
Facey K, et al. NHS. R&D Programme: July 2004
Colorectal Liver MetastasesColorectal Liver Metastases
Wiering B, et al. Cancer 2005:104:2658-2670
SensitivitySensitivity SpecificitySpecificity
PETPET 88%88% 96%96%
ceCTceCT 83%83% 84%84%
Colorectal Liver Metastases; Colorectal Liver Metastases; on a per-lesion basison a per-lesion basis
Bipat S, et al. Radiology. 2005:273:123-131
SensitivitySensitivity
PETPET 76%76%
ceCTceCT 64%64%
MRI (1.5-T)MRI (1.5-T) 64%64%
Extrahepatic LesionsExtrahepatic Lesions
Wiering B, et al. Cancer. 2005:104:2658-2670
SensitivitySensitivity SpecificitySpecificity
PETPET 92%92% 95%95%
ceCTceCT 61%61% 91%91%
PET Changes Management and Improves PET Changes Management and Improves Prognostic Stratification in Patients with Prognostic Stratification in Patients with
Recurrent Colorectal Cancer: Results of a Recurrent Colorectal Cancer: Results of a Multicenter Prospective StudyMulticenter Prospective Study
65.6% of patients with residual structural lesion 65.6% of patients with residual structural lesion suggestive of recurrencesuggestive of recurrence
49% of patients with potentially resectable pulmonary 49% of patients with potentially resectable pulmonary or hepatic metastasesor hepatic metastases
Scott AM, et al. J Nuc Med. 2008;49:1451-1457
63-yo with prostate ca, s/p 63-yo with prostate ca, s/p prostatectomy prostatectomy
Pre XRT colonoscopy Pre XRT colonoscopy revealed rectal massrevealed rectal mass
Biopsy: rectal cancer Biopsy: rectal cancer Abd ceCT: no metsAbd ceCT: no mets PET/CT for stagingPET/CT for staging
ESOPHAGEAL CANCERESOPHAGEAL CANCER Initial Diagnosis Initial Diagnosis
PET is more accurate than conventional PET is more accurate than conventional imaging modalitiesimaging modalities
The overall incremental value of PET The overall incremental value of PET compared to CT with regard to staging compared to CT with regard to staging accuracy was 14%accuracy was 14%
Kato H, et al. Cancer. 2005:103:148-156
Detection of Metastases:Detection of Metastases:
LocalLocal– Sensitivity: 52%Sensitivity: 52%– Specificity: 84%Specificity: 84%
Distant Distant – Sensitivity: 67%Sensitivity: 67%– Specificity: 97%Specificity: 97%
Facey K, et al. NHS. R&D Programme: July 2004Von Westreenen NH, et al. J Clin Oncol. 2004;22:3850-3812
65-yo M with history of 65-yo M with history of laryngeal ca, s/p XRTlaryngeal ca, s/p XRT
Recent dx of esophageal ca Recent dx of esophageal ca ceCT: no metsceCT: no mets PET/CT for stagingPET/CT for staging
PANCREATIC CANCER;PANCREATIC CANCER;Differentiating Benign From Differentiating Benign From
Malignant LesionsMalignant Lesions
Orlando LA, et al. Aliment Pharmacol Ther. 2004;20:1063-1070
SensitivitySensitivity SpecificitySpecificity
PET/CTPET/CT 71% - 100%71% - 100% 53% - 100%53% - 100%
ceCTceCT 53% - 100%53% - 100% 0% - 100%0% - 100%
54-yo M with jaundice54-yo M with jaundice ceCT: pancreatic mass with ceCT: pancreatic mass with
no metastasesno metastases Biopsy: pancreatic CaBiopsy: pancreatic Ca PET/CT for stagingPET/CT for staging
Male, age 66Male, age 66 Former smokerFormer smoker New LUL massNew LUL mass PET/CT for diagnosis and PET/CT for diagnosis and
stagingstaging
ADVANCESADVANCES
New scannersNew scanners New tracersNew tracers Open coverageOpen coverage
GEMINI TFGEMINI TF PET/CT scanner PET/CT scanner with TruFlight technologywith TruFlight technology
A B C D E
“WHOLE-BODY” FOV VARIATIONS
S Huston, M M Osman, SNM05S Huston, M M Osman, SNM05
Added Value of True Whole-Body Added Value of True Whole-Body Over Limited Whole-Body FDG Over Limited Whole-Body FDG
PET/CT in Cancer PatientsPET/CT in Cancer Patients
ResultsResults
20/ 500 (4%) of patients had new, previously 20/ 500 (4%) of patients had new, previously unidentified cancerous lesions outside LWB FOVunidentified cancerous lesions outside LWB FOV
Detection of malignancy outside LWB resulted in Detection of malignancy outside LWB resulted in changed in management in 13 (65%) and staging in changed in management in 13 (65%) and staging in 11 (55%) of those 20 patients11 (55%) of those 20 patients
Of those 20, 5/500 (1%) patients had their only Of those 20, 5/500 (1%) patients had their only malignant lesion outside the LWB FOVmalignant lesion outside the LWB FOV
Osman MM, et al. SNM. 2006
PET/CTPET/CT
PET/MR
F-18 FLT PETF-18 FLT PET
Imaging Gastric Cancer with PET Imaging Gastric Cancer with PET and the Radiotracers and the Radiotracers 1818F-FLT and F-FLT and 1818F-FDG: A Comparative AnalysisF-FDG: A Comparative Analysis
Hermann, et al. J Nuc Med. 2007;48:1945-1950
Sensitivity and Uptake of Sensitivity and Uptake of 1818F-FLT &F-FLT &1818F-FDG in F-FDG in Gastric CancerGastric Cancer
Imaging gastric cancer with proliferation Imaging gastric cancer with proliferation marker marker 1818F-FLT is feasibleF-FLT is feasible
1818F-FLT was more sensitive than F-FLT was more sensitive than 1818F-FDG, F-FDG, especially in tumors presenting with no/low especially in tumors presenting with no/low 1818F-FDG uptakeF-FDG uptake
Detection of HCC Using Detection of HCC Using 1111C-Choline: C-Choline: Comparison withComparison with1818F-FDGF-FDG
ceCT 11C-Choline 18F-FDG
Detection of HCC:Detection of HCC:1818C-Choline vsC-Choline vs1818F-FDG F-FDG
1111C-Choline had a better detection rate compared had a better detection rate compared to to 1818F-FDG for a moderately differentiated HCC F-FDG for a moderately differentiated HCC lesions but not for poorly differentiated lesionslesions but not for poorly differentiated lesions
1818F-FDG produce the opposite results 1111C-Choline is a potential tracer to complement is a potential tracer to complement1818F-F-
FDG in the detection of HCC lesions FDG in the detection of HCC lesions
Yamamoto Y, et al. J Nuc Med. 2008;49:1245-1248
PET/CT: THE MOST IMPORTNAT PET/CT: THE MOST IMPORTNAT CANCER IMAGING MODALITY CANCER IMAGING MODALITY
NOPR 08 UPDATENOPR 08 UPDATE >1500 facilities contributed data from >23,000 patients>1500 facilities contributed data from >23,000 patients FDG-PET changed treatment in 36.5% FDG-PET changed treatment in 36.5%
JCO, published online March 24, 2008