Coloncancerand livermetastases NuclearmedicinePET/CT · Surgery, Chemo3 yearsago RisingCEA....

ColonColon cancercancer and and liverliver metastasesmetastasesNuclearNuclear medicinemedicine PET/CTPET/CT

Thomas F. Thomas F. HanyHany MDMD

Division of Nuclear Medicine, University Hospital Zurich

PositronPositron Emission Emission TomographyTomography


Most Most usedused tracertracer

FluorFluor--18 18 –– deoxyglucosedeoxyglucose = FDG= FDG

HalfHalf--lifelife--timetime: 110 : 110 minutesminutes, , iviv injectioninjection


PositronPositron--EmissionEmission--TomographyTomography

DataData--acquisitionacquisition 55 55 minutesminutes


ExampleExample LungcancerLungcancer


PET PET alonealone interpretationinterpretation


WhatWhat isis PET/CT ?PET/CT ?

KinahanKinahan PE, Townsend DW, Beyer T, PE, Townsend DW, Beyer T, SashinSashin D. Attenuation correction for a combined 3D PET/CT D. Attenuation correction for a combined 3D PET/CT scanner. scanner.

Med Phys. 1998 Oct;25(10):2046Med Phys. 1998 Oct;25(10):2046--53. 53.


4 4 –– 64 64 sliceslice MSCTMSCT

fullringfullring--detectordetector PETPETLutetiumLutetium-- oror Germanium Germanium basedbased crystalcrystal materialmaterial

InIn--Line PETLine PET--CT systemCT system


TechnicalTechnical considerationconsideration PET/CTPET/CTHanyHany et al. et al. Radiology 2002; 225(2):575Radiology 2002; 225(2):575--8181

emmissiomemmissiom image image withwith CTCT--attenuationattenuation correctioncorrection

time time savingsaving 30%30%

AC AC withwith 5 5 mAsmAs sufficientsufficient) ) (20(20‘‘‘‘ / / examexam))


IntravenousIntravenous ceCTceCT forfor attenuationattenuation correctioncorrection

No No statisticallystatistically oror clinicallyclinically significantsignificant spuriouslyspuriously elevatedelevated SUV SUV levellevel thatthat mightmightpotentiallypotentially interfereinterfere withwith thethe diagnosticdiagnostic valuevalue of PET/CT was of PET/CT was identifiedidentified as a as a resultresult of of thethe applicationapplication of of intravenousintravenous iodinatediodinated contrastcontrast..

YauYau YY, Chan WS, Tam YM, Vernon P, Wong S, YY, Chan WS, Tam YM, Vernon P, Wong S, CoelCoel M, Chu SK. Application ofM, Chu SK. Application of intravenous contrast in intravenous contrast in PET/CT: does it really introduce significant attenuation correctPET/CT: does it really introduce significant attenuation correction error? J ion error? J NuclNucl Med. 2005 Med. 2005 Feb;46(2):283Feb;46(2):283--9191


TechnicalTechnical innovationinnovation: : fullyfully 3D 3D reconstructionreconstruction: fast...: fast...

18 min18 min 9 min9 min 9 min9 min2D2D 3D 3D fullyfully 3D3D


InIn--Line PETLine PET--CT systemCT system

44--1616--64 64 rowrow MSCTMSCT

fullringfullring--detectordetector PETPETBGO, LSO, LYSOBGO, LSO, LYSO


LowLow dose CT 140 kV/40mAsdose CT 140 kV/40mAs

Total acquisition time= 10 sec (64-slice PET/CT

breathbreath-- holdholdexpirationexpiration

normal

normal


PET PET DataData acquisitionacquisition protocolprotocol

PET7 cradle pos7x2 minNon-breath-hold


cePETcePET/CT/CT


PrimaryPrimary stagingstaging colorectalcolorectal cancercancer

3rd 3rd mostmost tumortumor, 5% in , 5% in thethe overalloverall populationpopulation, , colonoskopycolonoskopy, US, CT, US, CT

DataData in PET in PET forfor initialinitial stagingstaging ((onlyonly fewfew studiesstudies))high high sensitivitysensitivity dectectiondectection of of thethe primaryprimary tumortumorlowlow sensitivitysensitivity lymphlymph nodenode stagingstaginghigh high sensitivitysensitivity dectectiondectection distantdistant metastasesmetastases

Abdel-Nabi et al: Staging of primary colorectal carcinomas with fluorine-18 fluorodeoxyglucosewhole-body PET: Correlation with histopathologic andCT findings. Radiology 206:755-760, 1998


PrimaryPrimary stagingstaging of CRCof CRC


StagingStaging includingincluding PET/CT & PET/CT & colonographycolonography




VenousVenous/ / lymphaticlymphatic drainagedrainage


PrimaryPrimary stagingstaging withwith iviv ceCTceCT


ColonColon

Inferior mesenteric nodes

Superiormesenteric nodes


PrimaryPrimary stagingstaging withwith iviv ceCTceCT


RecurrentRecurrent diseasedisease in PETin PET

FDGFDG--PET to predict those patients who benefit from PET to predict those patients who benefit from laparotomylaparotomy

Libutti SK et al. Ann Surg Oncol. 2001 Dec;8(10):779-86.

WhatWhat isis thethe valuevalue of PET/CT?of PET/CT?


PET vs. PET/CTPET vs. PET/CT

reducedreduced frequencyfrequency of equivocal and probable of equivocal and probable lesion characterization by 50% (50 to 25) lesion characterization by 50% (50 to 25) with PET/CTwith PET/CT

increased frequencyincreased frequency of definite lesionof definite lesioncharactericharacteri--zationzation by 30% (84by 30% (84 to 109) with to 109) with PET/CTPET/CT

increasedincreased number of definite locations with number of definite locations with PET/CTPET/CT by 25% (92 to 115). by 25% (92 to 115).

Overall correct staging increasedOverall correct staging increased from 78% to from 78% to 89% with PET/CT89% with PET/CT

CohadeCohade C C et al. et al. Direct comparison of (18)FDirect comparison of (18)F--FDG PET FDG PET and PET/CT in patients with colorectal carcinomaand PET/CT in patients with colorectal carcinoma J J NuclNucl Med. 2003 Nov;44(11):1797Med. 2003 Nov;44(11):1797--803.803.


CT vs. PET/CTCT vs. PET/CT

TheThe differencedifferencebetweenbetween PET/CT and PET/CT and thethe combinedcombined PET/CT PET/CT withwith dedicateddedicated CT CT interpretationinterpretation withwithrespectrespect to to accuracyaccuracy was was statisticallystatistically significantsignificant (p (p

< 0.05).< 0.05).Kamel IR et al. Kamel IR et al. IncrementalIncremental valuevalue of CT in of CT in

PET/CT of PET/CT of patientspatients withwith colorectalcolorectalcarcinomacarcinoma. . AbdomAbdom ImagingImaging. 2004 . 2004 NovNov--Dec;29(6):663Dec;29(6):663--88


PET/CT vs. PET/CT vs. ceCTceCT

ReferralReferral forfor surgerysurgery of of suspectedsuspected liverliver metastasesmetastases7676 patientspatients (52 m, 24 w) 63 (52 m, 24 w) 63 yearsyears (35 (35 -- 78)78)comparisoncomparison PET/CT PET/CT withwith ceCTceCT

intraintra/ extra / extra hepatchepatc metastasesmetastasesLocalLocal recurrencerecurrence



LiverLiver metastasesmetastases ((sensitivitysensitivity))ceCTceCT 95%, PET/CT 91%95%, PET/CT 91%

IntraIntra--hepatichepatic recurrencerecurrence afterafter liversurgeryliversurgery ((specificityspecificity))ceCTceCT 50%, PET/CT 100%50%, PET/CT 100%

LocalLocal recurrencerecurrence ((sensitivitysensitivity))ceCTceCT 53 %, PET/CT 93 %53 %, PET/CT 93 %

ExtraExtra-- hepatichepatic diseasedisease ((sensitivitysensitivity))ceCTceCT 64 %, PET/CT 89 %64 %, PET/CT 89 %

Additional Additional findingsfindings in PET/CT in PET/CT changedchanged managementmanagement in 21%in 21%

Selzner M, Hany TF, Wildbrett P, McCormack L, Kadry Z, Clavien PA.

Ann Surg. 2004 Dec;240(6):1027-34


MetastasisMetastasis in in ceCTceCT notnot visiblevisible: : rarityrarity









Ann Surg. 2004 Dec;240(6):1027-34


LocalLocal hepatichepatic recurrencerecurrence









Ann Surg. 2004 Dec;240(6):1027-34


cePETcePET/CT/CT


ResultsResults ceCT vs. ceCT vs. nonnon--cePETcePET/CT/CT

50 patients

23 patients (46%)27 patients (54%)

Inconclusive ceCT

yes no


ResultsResults ceCT vs. ceCT vs. nonnon--cePETcePET/CT II/CT II

18 patients 7 patients


27 inconclusive patients

1 false positive

Change of therapymanagement

noyes

yes no

1 false negative

false information

Additional information in non-cePET/CT


CeCT inconclusive CeCT inconclusive –– therapytherapy changechange

Male 64 Male 64 yearsyearsSigmoidSigmoid Ca T3 N1 M0 Ca T3 N1 M0

SurgerySurgery, , ChemoChemo 3 3 yearsyears agoagoRisingRising CEACEA


ResultsResults ceCT vs. ceCT vs. nonnon--cePETcePET/CT III/CT III



23 conclusive patients

no

yes


Additional information bynon-cePET/CT

yes

no

2 patient false negative

false information


CeCT CeCT conclusiveconclusive –– therapytherapy changechange


SurgerySurgery, , ChemoChemo 1 1 yearyear agoagoSuspicionSuspicion forfor livermetlivermet in USin US


ResultsResults nonnon--cePETcePET/CT vs. cePET/CT/CT vs. cePET/CT

50 patients



no

noyes

yes

Additional informationby cePET/CT



Ce PET/CT Ce PET/CT –– therapytherapy changechange

FemaleFemale 58 58 yearsyearsSigmoidSigmoid Ca T3 N2 M0 Ca T3 N2 M0



CeCTCeCT inconclusiveinconclusive




ResultsResults nonnon--cePETcePET/CT vs. /CT vs. cePETcePET/CT/CT

50 patients



no

noyes

yes

Additional informationby cePET/CT



RectalRectal cancercancer –– mesorectalmesorectal fasciafascia


PET PET responseresponse predictspredicts coursecourse of of diseasedisease


LivermetastasesLivermetastases

CommonCommon-- ColorectalColorectal cancercancer-- PancreaticPancreatic cancercancer-- BreastBreast cancercancer-- Bronchial Bronchial carcinomacarcinoma

RareRare-- NeuroendocrineNeuroendocrine cancerscancers ((PancreasPancreas, GIT), GIT)-- GISTGIST-- UROURO-- GYNGYN-- ENTENT


LivermetastasesLivermetastases


MRIMRI


FDGFDG--PET/CT negative !PET/CT negative !


NonNon--functioning pancreatic islet cell functioning pancreatic islet cell tumortumorNonNon--functioning pancreatic islet cell tumorsfunctioning pancreatic islet cell tumors-- third most common tumors of the pancreas. third most common tumors of the pancreas. -- usually largeusually large cause symptoms by mass effectcause symptoms by mass effect-- 20% calcified20% calcified-- especially especially hypervascularhypervascular at angiographyat angiography-- clearly less aggressive than clearly less aggressive than adenocarcinomasadenocarcinomas of of

the pancreasthe pancreas-- ChromograninChromogranin--A blood testing is a valuable A blood testing is a valuable

diagnostic laboratory parameter for disease diagnostic laboratory parameter for disease progressionprogression


OctreotideOctreotide planarplanar/SPECT/SPECT


ProblemsolvingProblemsolving withwith FDGFDG--PET/CT (?)PET/CT (?)

TwoTwo situationssituations

AA-- unclearunclear liverliver lesionlesion, , youyou wouldwould likelike to to knowknow whatwhat itit isis–– just do a FDGjust do a FDG--PET/CTPET/CT

BB-- stagingstaging of a of a knowknow oncologicaloncological diseasedisease byby FDGFDG--PET/CTPET/CT


UnclearUnclear liverliver lesionlesion

FDGFDG--PET/CT PET/CT doesdoes notnot playplay a a rolerole unlessunless a a previouspreviousdiseasedisease isis knownknown ((e.ge.g. . colorectalcolorectal cancercancer, , breastbreast etc.)etc.)

FirstFirst--lineline: : ceCT,MRIceCT,MRI, , histologyhistology

PET/CT PET/CT isis notnot


PancreaticPancreatic cancercancer withwith liverliver metsmets


BreastBreast cancercancer withwith liverliver metmet


LiverLiver metastasesmetastases


LiverLiver metastasesmetastases ENT ENT -- cancercancer


MelanomaMelanoma of of thethe retinaretina 20 20 yearsyears agoago


IndicationsIndications forfor livermetastaseslivermetastases and PET/CTand PET/CT

CommonCommon-- ColorectalColorectal cancercancer goodgood-- PancreaticPancreatic cancercancer good (good (onlyonly exocrineexocrine))-- BreastBreast cancercancer goodgood-- Bronchial Bronchial carcinomacarcinoma goodgood

RareRare-- NeuroendocrineNeuroendocrine cancerscancers ((PancreasPancreas, GIT), GIT) no no gogo!!-- GISTGIST goodgood-- URO, URO, prostateprostate no no gogo-- OBOB--GYNGYN +/+/---- ENTENT goodgood

Major Major indicationindication::additional additional extrahepaticextrahepatic diseasedisease beforebefore surgerysurgeryLocalisationLocalisation of of lesionslesions in in thethe liverliver


Basic considerations: treatment responseBasic considerations: treatment response

[[1818F]F]--fluorodeoxyglucose (FDG)fluorodeoxyglucose (FDG)

Tumor tissue:Tumor tissue:glucoseglucose--66--phosphatase (Gphosphatase (G--66--P) P) ↓↓hexokinasehexokinase (HK) (HK) ↑↑transmembranetransmembrane glucose transporters glucose transporters ↑↑FDG FDG ↑↑ ↑↑: : tumourtumour viability / proliferation rateviability / proliferation rate

After therapy: After therapy: FDG uptake FDG uptake ↓↓reduction in tumor cell viability/ number of viable tumor cellsreduction in tumor cell viability/ number of viable tumor cells


before 7 days after


ButBut......


FollowFollow--upup afterafter chemochemo--therapytherapy in a in a patientpatient withwithknownknown liverliver metastasesmetastases (?!)(?!)


TherapyTherapy responseresponse assessmentassessment

-- May May indicateindicate ifif chemotherapychemotherapy was was successfulsuccessful-- Time point of Time point of imagingimaging crucialcrucial-- MetastasesMetastases maymay bebe FDGFDG--negativnegativ duedue to good to good responseresponse

-- PerformPerform PET/CT PET/CT beforebefore and and afterafter chemochemo-- thxthx-- ChemoChemo maymay produceproduce falsefalse--negativenegative PET/CT PET/CT findingsfindings in in

good good respondersresponders !!

FDGFDG--PET/CT PET/CT isis thethe modalitymodality of of choicechoice in in therapytherapy responseresponseassessmentassessment


FollowFollow--upup afterafter chemochemo--therapytherapy


StagingStaging CRCCRC


PET PET alonealone interpretationinterpretation .... .... afterafter treatmenttreatment


RestagingRestaging -- StepStep 1: PET/CT1: PET/CT


StepStep 2: 2: CTCT--PerfusionPerfusion –– freefree breathingbreathing (40 sec)(40 sec)


StepStep 2: 2: CTCT--PerfusionPerfusion –– freefree breathingbreathing (40 sec)(40 sec)


StepStep 3: 3: ContrastContrast--enhancedenhanced PE/CT (PE/CT (delaydelay 70 sec)70 sec)

+ =


LiverLiver metastasismetastasis




F18F18--DOPA: DOPA: nonnon--functioningfunctioning neuroendocrineneuroendocrinetumortumor


F18F18--DOPADOPA

Becherer et al. Imaging of advanced neuroendocrine tumors with (18)F DOPA-PET. JNM 2004, 45(7):1161-7

Koopmanns et al. Staging of carcinoid tumours with 18F-DOPA PET: a prospective, diagnostic accuracy study.Lancet Oncol. 2006 Sep;7(9):728-34.

-FDG uptake in neuro-endocrine tumours dependson tumour entity, therapy, grading…

-18F-DOPA PE/CT canhelp for particularneuroendocrine tumours

-Can be of help fordifferentiation compared to arterial enhancing lesions


CAT CAT scanscan and PET and PET scanscan


PreliminaryPreliminary conclusionsconclusions

BetterBetter patientpatient selectionselection withwith PET/CT PET/CT

PET/CT + PET/CT + standardstandard stagingstaging areare superiorsuperior to to standardstandardstagingstaging alonealone

PET/CT PET/CT impactsimpacts on on thethe oncologiconcologic managementmanagement of of CRC CRC liverliver metastasesmetastases and and pancreaticpancreatic cancercancer

High PPV High PPV forfor pancreaticpancreatic cancercancer byby PET/CTPET/CTNew New applicationapplication: F18: F18--DOPA DOPA forfor NEPT NEPT

BUT:BUT:PET/CT PET/CT isis notnot a a primaryprimary diagnosticdiagnostic tooltool !!

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Coloncancerand livermetastases NuclearmedicinePET/CT · Surgery, Chemo3 yearsago RisingCEA....

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