© Copyright 2003 Cardinal Health, Inc. or one of its subsidiaries. All rights reserved.

PET in PET in Colorectal CancerColorectal Cancer

Early detection of diseaseEarly detection of diseasePrecise Staging of Disease ProgressionPrecise Staging of Disease Progression

Accurate Assessment of TherapyAccurate Assessment of Therapy

© Copyright 2003 Cardinal Health, Inc. or one of its subsidiaries. All rights reserved.

Colorectal CancerColorectal Cancer

• Over 150,000 new colorectal cancers/yr, the second most common killer after lung cancer.

• A Malignant transformation of a polyp

• TNM staging is used to plan and assess therapy

• Complete surgical resection is generally required for a cure

• Resection of limited metastatic disease yields improved survival, unlike many cancers

© Copyright 2003 Cardinal Health, Inc. or one of its subsidiaries. All rights reserved.

Colorectal Cancer IndicationsColorectal Cancer Indications

• Diagnosis

• Staging

• Restaging

© Copyright 2003 Cardinal Health, Inc. or one of its subsidiaries. All rights reserved.

Diagnosing Colorectal CancerDiagnosing Colorectal Cancer

History • 54 YOF • Right Upper Quadrant

abdominal pain• CT reveals hepatic metastases

without known primary

PET Findings• 3 Hyper-metabolic foci in the

liver and 1 in the Left Upper Quadrant

Outcome • Splenic flexure colon cancer

and 3 liver mets resected

primary

mets

© Copyright 2003 Cardinal Health, Inc. or one of its subsidiaries. All rights reserved.

PET in Colorectal CancerPET in Colorectal Cancer

• Diagnosis

• Staging

• Restaging

© Copyright 2003 Cardinal Health, Inc. or one of its subsidiaries. All rights reserved.

Staging Colorectal CancerStaging Colorectal Cancer

History • 63 YOM • Large rectal cancer via pre-op evaluation• CT suggest invaded lymph nodes near

the primary

PET Findings• Rectal, multiple pelvic, right inguinal,

and liver abnormalities

Outcome • Aggressive chemotherapy followed by

pelvic XRT• Followed by successful AP (rectal) and

liver resection

Large solitary met

© Copyright 2003 Cardinal Health, Inc. or one of its subsidiaries. All rights reserved.

Pre-operative Staging of Pre-operative Staging of Primary Colorectal CarcinomaPrimary Colorectal Carcinoma

• Study of 48 colorectal cancer patients

• Pre-op PET results compared to results at surgery and follow up

PET CT Liver Mets Detected 88% 38%

• 4 liver mets were detected by PET, but ignored at time of initial surgery.

Presence of mets was confirmed >3 months after surgery

Abdel-Nabi Radiology 1998; 206:755.

© Copyright 2003 Cardinal Health, Inc. or one of its subsidiaries. All rights reserved.

PET in Colorectal CancerPET in Colorectal Cancer

• Diagnosis

• Staging

• Restaging Detecting recurrence

Staging recurrence

Assessing therapy

© Copyright 2003 Cardinal Health, Inc. or one of its subsidiaries. All rights reserved.

Detecting RecurrenceDetecting Recurrence

History • 60 YOM • Colon cancer 2 years ago • Rising CEA• Negative CT findings

PET Findings• Retroperitoneal abnormality

Outcome • Nodal metastasis resected to

confirm PET findings• Adjuvant chemotherapy

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Staging RecurrenceStaging Recurrence

History • 56 YOF • Rectal cancer 14 months ago• Persistently elevated CEA (never

really dropped)

PET Findings• Single liver abnormality

Outcome • Liver met resection• No recurrence

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Staging RecurrenceStaging Recurrence

History • 38 YOF • Sigmoid colon cancer 6 months

ago• Persistent CEA elevation• Pre-op work-up was negative

PET Findings• Single pulmonary, multiple liver

and pericaval abnormalities

Outcome • Biopsy of lung nodule confirmed

mets• Chemotherapy

Nodal met near the primary location

© Copyright 2003 Cardinal Health, Inc. or one of its subsidiaries. All rights reserved.

Detecting Recurrence in Patients Detecting Recurrence in Patients with Increasing CEA Levels with Increasing CEA Levels

• Prospective study of 28 colorectal cancer patients

• PET was compared to 2nd look surgery results

• PET predicted correctly

PET Un-resectable Disease90% Resectable Disease 81%

Libutti SK Ann Surg Onc 2001;8:779

© Copyright 2003 Cardinal Health, Inc. or one of its subsidiaries. All rights reserved.

Why PET?Why PET?

• Recurrent and metastatic colorectal cancer is common (35% within 2 years)

• Early detection of localized disease is possible with PET , when the disease is still resectable

• PET helps avoid surgery in patients with multi-focal and extra-hepatic metastases

© Copyright 2003 Cardinal Health, Inc. or one of its subsidiaries. All rights reserved.

PET in Colorectal CancerPET in Colorectal Cancer

• PET accurately detects local, hepatic and extra-hepatic disease

• PET is superior to all imaging modalities in the restaging of colorectal cancer

• Difficult patient management problems can be solved with the unique information PET provides