Imaging of Neuroendocrine Tumors and Obstacles to Diagnosis - Internet Articles

7/30/2019 Imaging of Neuroendocrine Tumors and Obstacles to Diagnosis - Internet Articles

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ImagingofNeuroendocrineTumors

and

Obstaclesto

Diagnosis

EricLiu,M.D.

VanderbiltNeuroendocrineCenter

DivisionofSurgicalOncologyandEndocrineSurgery

DepartmentofSurgery

Vanderbilt

University

Medical

Center


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Overview

BackgroundonNeuroendocrine

CrossSectional

Imaging

NuclearImaging

NewImagingTechniques

FollowupImaging

Choosingtherightimagingtechnique

Obstaclesto

Diagnosis


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Basicsof

Neuroendocrine

Cells

Foundinbronchial,gastroenteropancreatic

tract

Secretehormones

Serotonin

VIP Insulin Somatostatin

Gastrin Histamine

Glucagon

ExpressSOMATOSTATINRECEPTORS

Liu and Oberg, Endo Meta Clin N Am, 39(4):697-71, 2010


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Terminology Carcinoid

APUDoma IsletCellTumors

Neuroendocrinecarcinoma

Modlin et al, Hum Pathol 12:1440-51, 2004


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Definitions

Carcinoidslow growing tumor of the GI and bronchial tractsthat derives from enterochromaffin cells that

frequently secrete serotoninNeuroendocrine Tumorstumors derived from GI endocrine cells that can

secrete many hormonesInsulin glucagon gastrin VIP

Express somatostatin receptor

SiegfriedOberndorfer


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Incidence of neuroendocrine

tumors

2.55.0/100,000

inhabitants

Modlin, I. M. et al. J. Natl. Cancer Inst. 2008 100:1282-1289; doi:10.1093/ nci /d n275


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tumors2.55.0/100000inhabitants

Modlin, I. M. et al. J. Natl. Cancer Inst. 2008 100:1282-1289; doi:10.1093/ nci /d n275


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GEPNET

~75%

Lung

Smallintestine

Rectum


tumorsSurveillance,EpidemiologyandEndResults(SEER),USpopulation19742005

Yaoetal.,JCO,2005. Modlinetal.,LancetOncol.2008


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0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1

0 12 24 36 48 60 72 84 96 108 120

Survivalprobability

Survival time (months)

1988-99 n=892 SEER data base. Median survival 37 mo

1973-87 n=787 SEER data base. Median survival 17 mo

1974-2004 SEER. Median survival 33 mo

Survivalof

patients

with

metastatic

carcinoid

Yaoetal.,JCO,2005.


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SurvivalChangesBasedonLocation

andDifferentiation

Well/ModeratelyDifferentiated PoorlyDifferentiated

Yaoetal,JCO,2005.


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ClinicalPresentations

Carcinoid:diarrhea,flushing,abdominal

cramping Insulinoma: WhipplesTriad

Glucagonoma: diabetes,anemia,diarrhea,

necrolyticmigratory

erythema

Gastrinoma(ZES):resistantulcers,abdominalpain,diarrhea

VIPoma(WDHA,

VMS):

watery

diarrhea,

hypokalemia,achlorhydria,vasodilation


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BiochemicalTesting

Hormonelevels

5HIAA

Gastrin

Insulin/C

peptide/Proinsulin Glucagon

VIP

Serotonin Andothers

Biomarkers

ChromograninA

ChromograninB

Pancreastatin

Neuronspecific

enolase

Ghrelin

PancreaticPolypeptide

SubstanceP

Andmore


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TheImportance

of

Imaging

Diagnosis

Incidentalfinding

Stagingformetastaticdisease

Determinationofresectability

Followup

Diseaseprogression

Symptomatology


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TheImportanceofImaging

Resectionofprimary7.4vs.4.0years;p


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PathologicalClassification

of

NETs

Histology WellDifferentiated Moderately Poorly

Appearance Uniform Pleomorphism

Prognosis Good Intermediate Poor

MitoticRate 10

Ki67 20%

Necrosis Absent Present


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Ultrasound LowCost

HighResolution

ExaminationoftheLiverandBiliary

USER DEPENDENT

Best when attached to an endoscope orbiopsy needle


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Imagefromhttp://www.hopkinscoloncancercenter.org


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Sundin etal,2009


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ComputedTomography

(CT)

Workhorse

Readilyavailable

Fast

CTAbdomen

liver

and

pancreas

protocol

CTNeckandChest


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ScanningProtocols

64

slice

MDCT

PancreasProtocol

Slices13mm

OralContrast(negativecontrast)

LateArterialPhase(25

30sec)

PancreaticPhase(40sec)

VenousPhase(7090sec)

BolusTracking

LiverProtocol

Slices3mm

OralContrast

Noncontrast

ArterialPhase(1525sec)

LateArterialPhase(2530sec)

Venous

Phase

(70

90

sec)

BolusTracking


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Sensitivityand

Specificity

of

CT

Sundin etal,2009


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Featuresof

NETs

on

CT

Mass

Relationshipto

structures

Calcifications

Lymphnode

metastases

LiverMetastases

Carcinomatosis


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RadiationExposure


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MagneticResonance

Imaging

SpecificOrganSystem

Liver Pancreas

Bones

Pelvis ContrastAgents

Gadolinium

EOVIST/PRIMAVIST MRCholangiogram


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MRProtocols

T1weighted(fatbright,waterdark)

T2weighted

(fat

dark,

water

bright)

ContrastEnhancedforvasculature

(Gadolinium) LiverParenchyma

Gadoxetate(Eovist/Primovist)

DuctalSystem


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Appearanceof

NET

on

MRI

T1lowsignal

T2high

signal

Goodforsmalllesions

Sundin etal,2009


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CTvs.

MRI

MRImaypickup~20%morelesions

Giesel etal,2011,Dromain,etal,2005


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FunctionalImaging

ColorPictures

Describe

Biology

Octreoscan 111InPentetreotide131

I/123

I

MIBG18FDGPET11CHTP

18

FDOPA68GaDOTATATE


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Octreoscan SinglePhotonEmissionTomography(SPECT)

ImagesSomatostatin

Receptor

Octreotidepeptidechelatedto111Indium

Inject185

222

MBq

FourHourScan

24hourscan


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Octreoscan


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Octreoscan


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Octreoscan


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Octreoscan


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Octreoscan


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Kwekeboom,etal,2009.

/


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metaiodobenzylguanidine

123/131IMIBG

Pheochromocytoma

Neuroblastoma

Paraganglioma

Sensitivity8288%

Specificity82

24%

Wisemanet

al,

2009


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FDGPET

Tends to accumulate in poorly differentiated tumors

Pasquali, World J Surg, 1998

Adamsetal,EJNM,1998


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11CHTP

PET

Orlefors etal,2005


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18

F

DOPA

PET

Koopmansetal,2008.

68Gallium DOTATATEPET


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Patientwastoldshehadonlytwolesionsby

CT,MRI,octreoscan

Otherpeptides:

DOTATATE

DOTATOC

DOTANOC


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Direct

Comparison

CT

vs.

MRI

vs.

SRS

Dromain etal,JCO,2005

21%betterthanCT

93%better

than

SRS


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STRONGSSTR2Staining

WEAKSSTR2Staining


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Direct

Comparison

CT

vs.

MR

vs.

PET

Giesel etal,EJR,2012.

CT ArterialPhase CT PortalPhase

MRIwithcontrast PET 68GaDOTATOC


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CT

vs.

MRI

Giesel etal,EJR,2012.


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Effective

Imaging

Modlin, 2007


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ChoosingtheRightImagingTechnique

CT resolution

MRI sensitivityinorgans

Ultrasound

biopsyOctreoscan SSTR/Distant

FDGPET

PDNEC


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Follow

up

Imaging EarlyStages: 36months

LateStages:

12

24

months

ChangesinTumorMarkers

Changesin

Symptoms


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Obstaclesin

the

diagnosis

for

the

clinician

Whatdo

these

markers

mean?

Whendoyoustartthehunt?

How

far

do

you

go? WhatifIcantfindit?

WhatifImissit?

Vinik etal,

2010


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GUIDELINESNORTHAMERICANNEUROENDOCRINETUMOR

SOCIETY(2010)

www.nanets.net

EUROPEANNEUROENDOCRINETUMORSOCIETY

(2009)

www.enets.org

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Imaging of Neuroendocrine Tumors and Obstacles to Diagnosis - Internet Articles

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