Clinical PET Oncology :Clinical PET Oncology Presented By: Alex Ramos


Objectives :Objectives Introduction to PET F18-FDG Metabolism Patient Preparation/Injection Patient History PET Scan Acquisition types Variations in Localization Pet Oncology Applications


Introduction to PET :Introduction to PET One of the most effective diagnostic tools in Nuclear Medicine Better Resolution (Faster and more numerous crystals) PET/CT use for anatomic correlation Evaluate the body at the cellular level More accurate in identifying and staging disease Powerful and valuable oncological imaging tool


F18-FDG Metabolism :F18-FDG Metabolism Chemical structure very similar to naturally occurring glucose Important because many cancer cells use glucose at higher rates than normal cells Hexokinase - Glucose breakdown; glycolosis Noninvasively image malignant tumors Once inside the cell, cannot be broken down further so FDG is trapped Localization Process


F18-FDG :F18-FDG Intracellular activity varies with different types of cancers Disadvantage Normal and noncancerous conditions (infection, inflammation, healing tissues, atelactasis, muscular activity also increase FDG utilization Those cancers that utilize FDG at the same rate as normal tissues are of greatest concern These may go unnoticed and possibly untreated


Patient Preparation/Injection :Patient Preparation/Injection FDG is sensitive to small changes in tissue metabolism Important to have patient remain resting prior to, during, and after injection Refrain from talking NPO – 4 to 6 hours Lowers peripheral blood glucose Measure blood level (glucometer) Ideally <120 mg/dln however no upper limit established Explain the whole procedure and answer questions


Patient History :Patient History Should include information about: Height and Weight Fasting state (fatty/ glucose metabolism) Medications (may cause pharmacologic vigilance) Diabetes, if so, any medication for that? Pregnancy; Breastfeeding Surgeries Prior chemotherapy and/or radiotherapy results of any imaging procedures Anything revelant to the study


Considerations :Considerations Some patients will be imaged pre- and post- chemotherapy that reduces peripheral glucose level Insulin reduces level but not used within 2 hours of pre-injection High peripheral glucose levels will cause tumor uptake to be non-homogenous lack of insulin, insulin resistance, or extracellular glucose competition Diabetes Mellitus- Patients must have snacks and insulin shots


Considerations Cont’d :Considerations Cont’d Know whether the patient is an inpatient or outpatient Valuable because time could be lost looking for necessary items such as Oxygen tanks, etc. Timing is essential (110 minute half-life) Patient on liquid diet (total parenteral nutrition, dextrose solution) Discontinue for 6-8 hours pre-injection


F18-FDG :F18-FDG Normal adult dose 10-20 mCi F-18 FDG, average is 10 mCi Pediatric 150 µCi/kg Three way stopcock used Flush with 20-30 ml Saline Increased update time increases the (tumor: soft tissue) ratio Patient void prior exam


PET Scan Acquisition :PET Scan Acquisition Performed several ways Limited-area scanning Dynamic imaging Total body (base of skull to mid-thigh) Benign and inflammatory processes often decrease FDG concentration with time, while malignant tissue continues to increase uptake over time Dual-Time Point imaging is used for differentiation


Imaging :Imaging Limited-Area Used when indications necessitate evaluation of a specific area Multiple beds (3-5) Solitary pulmonary nodules (discovered on CT) Dynamic Continuous in a single-bed position Known location of lesion or tumor Whole-body Most common From the base of the skull to mid-thigh More than 10 bed positions


Patient Position and Comfort :Patient Position and Comfort Use pillows, patient in supine or recumbent position Spongy pillow for knee support Know Specific Table weight limit Arms above head unless otherwise noted Overlapping of Bed positions 3 minute transmission scan per bed position PET/CT


Normal Whole-Body FDG Distribution :Normal Whole-Body FDG Distribution Most common sites Brain Liver Kidneys Bladder Sites with Variable activities Salivary Thyroid Heart Thymus Spleen Stomach Bowel (especially the colon) Muscles


Variations in Localization :Variations in Localization Purpose Only experienced, focused histories, physical exams, additional imaging modalities, biopsies, or surgery can accurately determine what is ( or is not) a normal variation Myocardial activity is the most noticeable normal variation Two sets of normal variations Brown fat activity GI tract; colon


Pet Oncology Applications :Pet Oncology Applications Effective in a wide variety of cancers Solitary Pulmonary Nodule Non-Small-Cell Lung Cancer Chest Malignancies (Mesothelioma) Melanoma Lymphoma Myeloma Colorectal Cancer Head and Neck Cancer Esophageal Cancer Breast Cancer Brain Cancer Prostate Cancer Cervical Cancer Ovarian Cancer Testicular Cancer Thyroid Cancer Pancreatic Cancer


Solitary Pulmonary Nodule :Solitary Pulmonary Nodule Lung cancer is the leading cause of Cancerous death Chest CT is used to discover lung cancer in early stages Both Benign and Malignant conditions can result in lung nodules Biopsies may not be so useful Invasive Expensive No diagnostic findings Lesions with no FDG activity almost always are benign Dual Time Point Imaging used


Solitary Pulmonary Nodule :Solitary Pulmonary Nodule


Non-Small-Cell Lung Cancer :Non-Small-Cell Lung Cancer Tumor Staging Determines whether or not a patients shall proceed on of the following: Invasive biopsy Undergo Curative surgery Undergo noninvasive (chemo-, radio- therapies or both.)


Non-Small-Cell Lung Cancer :Non-Small-Cell Lung Cancer


Other Chest Malignancies :Other Chest Malignancies Small-Cell Cancer (15% to 20% of all lung cancer) PET cannot differentiate SCLC from NSCLC Two Stages Limited Extensive


Melanoma :Melanoma 7,700 people die from Melanoma each year in the U.S. alone Determining factors of survival: Tumor thickness Depth of invasion Tumor location Presence of metastasis (dramatic decrease) Avidly utilizes FDG Occurs anywhere Melanocytes are found (Skin, eyes, GI tract, etc.)


Melanoma :Melanoma


Lymphoma :Lymphoma Almost 5% of all cancers in the U.S. are lymphomas Divided into two broad Categories: Hodgkin’s Disease Non-Hodgkin’s Lymphoma Usually involves the upper Mediastinum Therapy depends on the stage of the disease NHL metastasizes more widely throughout the lymphatic's Great localization of FDG good for imaging Hormone Therapy may be an option for Treatment


Lymphoma :Lymphoma


Myeloma :Myeloma Begins in the marrow When B-lymphocytes forma a mass in the marrow Referred to as Plasmacytoma If a single mass or tumor is detected outside Common in men and rarely occurs under age 50. Main form of treatment is chemotherapy


Myeloma :Myeloma


Head and Neck Cancer :Head and Neck Cancer Good FDG localization Determining survival: Location of tumor Metastasis Lymph node metastasis(dramatic decrease) Wait at least 1-3 months post Radiation Therapy Causes altered biodistribution of FDG


Head and Neck Cancer :Head and Neck Cancer


Esophageal Cancer :Esophageal Cancer 13,570 deaths annually in the U.S. The origin is still not completely understood When cancer is present, normal function and anatomic structure become compromised As early as 2001, PET imaging was approved for esophageal cancer


Esophageal Cancer :Esophageal Cancer


Breast Cancer :Breast Cancer Ranks as the number one Malignant tumor in women 40,870 people will die annually from the disease Prognostic Factors Extent of axillary metastasis Other lymph-node metastasis Therapy heavily relies on accurate staging PET can best demonstrate response to therapy


Breast Cancer :Breast Cancer


Brain Cancer :Brain Cancer Most tumors in the brain are classified as secondary tumors Develop from primary lung or breast cancer Gliomas are the most common Because the brain has an affinity for FDG, tumors that are primary or metastasized can be, and are, missed F-18 ACBC ( Synthetic Amino Acid) localizes in the brain tumor more efficiently MRI studies may be relevant


Brain Cancer :Brain Cancer


Prostate Cancer :Prostate Cancer Occurs in men older than age 50 and significantly increase after age 65 FDG does not detect the presence of local disease or distant metastases very well Bone scintigraphy is more valuable in this case Labs Rising (PSA)Prostate specific Antigen Greater than 4 nanograms Bladder may be imaged first in a dynamic, moving towards the skull


Prostate Cancer :Prostate Cancer


Ovarian Cancer :Ovarian Cancer 3,700 women will die of the disease annually in the U.S. Risk factors HPV (Human Papilloma Virus) Age Sexual History Smoking Oral Contraceptives PET is an important tool in initial staging


Ovarian Cancer :Ovarian Cancer Fairly common and often deadly Correct diagnosis is only available in late-stages Patient may be asymptomatic Chemotherapy is the most common form of treatment 5 year survival rate (>90%)


Ovarian Cancer :Ovarian Cancer


Testicular Cancer :Testicular Cancer Two major categories Seminomas (50%) Non- Seminomas (50%) Treatment consists of: Surgery, Chemotherapy, Radiation Therapy Good uptake of FDG Must know the various tumors being evaluated and understand that they may have different Uptake values


Testicular cancer w/(Pulmonary Mets) :Testicular cancer w/(Pulmonary Mets)


Thyroid Cancer :Thyroid Cancer Two main types Follicular cell tumors C-cell tumors Follicular cells make thyroid hormone C-cells for calcitonin Metastases to Thyroid can occur from lung, Breast, Brain and kidney cancers Aggressive, anaplastic tumors can be FDG negative Well-differentiated tumors can be positive


Thyroid Cancer :Thyroid Cancer


Pancreatic Cancer :Pancreatic Cancer 5-year survival rate A silent killer due to the difficulty in diagnosing in early stages Delineating acute inflammation from disease can be a limitation in pancreatic imaging 60% to 70% of the time, tumors are found in the head of the pancreas


Pancreatic Cancer :Pancreatic Cancer


Summary :Summary PET Localization Glucose breakdown; glycolosis PET Noninvasively allows imaging of malignant tumors Normal and noncancerous conditions (infection, inflammation, healing tissues, atelactasis, muscular activity also increase FDG utilization Patient Prep NPO – 4 to 6 hours, refrain from strenuous activity, glucose levels.


Summary :Summary Most common FDG localization sites Brain Liver Kidneys Bladder Acquisition Performed several ways Limited-area scanning Dynamic imaging Total body (base of skull to mid-thigh)


Questions :Questions What is the method of Localization for F-18 FDG? Name some advantages of PET and PET/CT List Advantages and Disadvantages in the use of F-18 FDG Name 3 PET imaging acquisitions modes Why is it important that a Technologist provide accurate results in all PET studies?


Questions :Questions Explain why is dual time point imaging is a part of PET oncology and discuss its importance? What is the leading cause of cancerous death? T/F - PET can differentiate SCLC from NSCLC Lymphoma are divided into what two categories? Most Brain tumors are primary or secondary malignancies?


Answers :Answers Glucose Metabolism (glycolosis) Adv.(Remove overlying structures, anatomic correlation), Adv.(Specificity, Great photon flux, high energy, etc.) Disadv.(Malignant tumors may be normalized due to metabolism rate) Dynamic, Whole body, Limited-Area Scan results may determine treatment, and treatment ranges widely in price


Answers :Answers Dual time point may differentiate between inflammation/cyst and Carcinoma Lung Cancer False, no it cannot differentiate Hodgkin’s and Non-Hodgkin’s Most brain tumors are secondary metastases


References :References Christian, Paul E. BS,CNMT,PET Nuclear Medicine and PET/CT Saha, Gopal. Physics and Radiobiology of Nuclear Medicine. Third Ed.. NYC: Springer, 2006. Shackett, Pete. NMT: Procedures and Quick reference. 2nd Ed.. Baltimore: 2008.


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