clinical applications of PET CT

Clinical Application of Positron Emission Tomography/Computed Tomography (PET/CT) : 

Dr Harsh Mahajan, MD Chief Radiologist Mahajan Imaging Centre Department of PET CT Sir Ganga Ram Hospital New Delhi Clinical Application of Positron Emission Tomography/Computed Tomography (PET/CT)

What is PET ?? : 

What is PET ?? Positron Emission Tomography – It’s a noninvasive, 3 – dimensional, metabolic imaging technique that uses a radiopharmaceutical to target a specific physiologic process ( glucose metabolism/ amino acid metabolism/ DNA synthesis) Most widely used pharmaceutical – FDG

Basic Principle of PET CT : 

Basic Principle of PET CT

Integrated PET/CT Imaging Systems : 

Integrated PET/CT Imaging Systems Diagnostic CT Scanner Multislice (2 – 4 slices/rotation originally, now 8,16, …., 64) 0.5 seconds/rotation, helical Scan – 17 seconds/meter

PET CT in Renal Malignancies : 

PET CT in Renal Malignancies

Case : 

Case 49 Y /M Recently diagnosed case of right renal mass on USG PET CT scan for lesion characterisation and to guide for nephrectomy ( ? Partial ?? Radical)

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Upper pole RCC

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Partial nephrectomy for upper pole tumor

Case : 

Case 42 Y /M Recently diagnosed case of right renal mass

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Mild FDG avid RCC, with no locoregional or distant metastasis

Case : 

Case 68 Y /M Recently diagnosed case of left renal mass on routine USG History of one or two episodes of hematuria in the recent past

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Renal mass Multiple mediastinal and abdominal lymph nodes with skeletal metastases

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Renal mass

Case : 

Case 65 Y/M FUC of right RCC, post treatment with residual mediastinal lymph nodes and lung nodules Post 3 cycles of 2nd line chemotherapy PET CT for treatment response evaluation

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FDG avid lung lesion with metastatic lymphadenopathy

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Progressive disease- increased mediastinal LAP

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Progressive disease- increased mediastinal LAP

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Progressive pulmonary lesion

PET CT in Renal malignancies : 

PET CT in Renal malignancies PET CT can specially help in noninvasive evaluation of Bosniak category III and IV renal masses Helpful in the non invasive characterization of malignant potential of small renal masses For loco regional and distant metastasis Sensitivity – 65 – 77% Specificity – 75 – 100 % PPV > 90% Clinical Nephrology 2002

PET CT in Renal Malignancies : 

PET CT in Renal Malignancies Incremental role in restaging rather than primary staging of the disease Staging nodal involvement,detection of recurrence and evaluation of metastatic disease Superior to anatomical imaging for demonstrating changes in metabolic parameters following biological therapy Akhurst T,Ng V V,Larson S M et al 2000,Clin Positron Imag 3:57-65

PET CT in Testicular Malignancies : 

PET CT in Testicular Malignancies

Case : 

Case 24 Y/M known case of right testicular mass with a thoracic mass lesion on chest X ray PET CT for lesion characterization and overall staging of disease.

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FDG avid right testicular mass with metastatic pulmonary lesion

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FDG avid soft tissue with multiple skeletal metastases Soft tissue

Case : 

Case 35 Y/M FUC of seminoma testis, post left orchidectomy and 4 cycles of chemotherapy PET CT for post treatment restaging of disease and response evaluation.

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Mildly FDG avid retroperitoneal Lymph nodes with IVC thrombus

PET CT in Testicular Malignancies : 

PET CT in Testicular Malignancies Primary staging of the testicular cancer (both seminomatous and non seminomatous) 70% sensitivity and 100% specificity (Vs 40% sensitivity and 78% specificity of CT alone) Hain S F et al,2000.Eur J Nucl Med 27:590-594 Evaluation of post chemotherapy residual retroperitoneal masses - 87% sensitivity and 94% specificity (significantly higher than CT and serum tumor markers) Cremerius U et al,1999.J Urology 54:900-904

PET CT in Testicular Malignancies : 

PET CT in Testicular Malignancies PET CT Vs serum tumor markers in suspected recurrence – Comparable PPV with high NPV (90% for PET CT) In patients with raised markers alone PET CT has effected a management change in 57% of cases Hain S F et al,2000.Br J Cancer 83:863-869 Of considerable value in the evaluation of seminomatous lesion >1 cm in size Matured lesions eg. Teratoma has low metabolic rate – May not be FDG avid

PET CT in other urological malignancies : 

PET CT in other urological malignancies

Case : 

Case 80 Y/ M Known case of high grade transitional carcinoma of bladder Underwent CPE, TURP, TURBT PET CT for the evaluation of locoregional and distant metastatic disease

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Recurrence at bladder base with mediastinal lymphadenopathy

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Recurrence at bladder base

Case : 

Case 65 Y /M Known case of high grade urothelial carcinoma Post TURP and radiotherapy in 2007 Complaining of mild decrease in the urinary outflow with nodules in the shaft of the penis PET CT scan for the evaluation of disease status

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Carcinoma urinary bladder with hepatic and penile metastasis

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Multiple hepatic and penile metastases

Case : 

Case 76 Y/ M Known case of transitional carcinoma of penile urethra Status post operative Presented with complaints of recent onset of severe left hip pain

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Sternal and left sacroiliac joint skeletal metastases

PET CT in Urinary bladder carcinoma : 

PET CT in Urinary bladder carcinoma Accurate nodal staging Sensitivity of 67 % and specificity of 86 % for the detection of pelvic lymph node metastasis ( Urologe Annals 1999) Improved detection of osseous and hepatic metastases Differentiating post radiation therapy scar from recurrent tumor Assessment of neoadjuvant therapy response

PET CT in Carcinoma Prostate : 

PET CT in Carcinoma Prostate

Case : 

Case 72 Y/M Being evaluated for multiple site bone pains PSA raised- 119 ng/ml

Mildly FDG avid prostatic mass with indistinct fat planes with bladder : 

Mildly FDG avid prostatic mass with indistinct fat planes with bladder

Mildly FDG avid prostatic mass with indistinct fat planes with bladder : 

Mildly FDG avid prostatic mass with indistinct fat planes with bladder

Case : 

Case 68 Y/M Known case of adenocarcinoma prostate status; post TURP Rising PSA levels

Para hilar ground glass opacity with non FDG avid lung nodules : 

Para hilar ground glass opacity with non FDG avid lung nodules

Case : 

Case 60 Y/M Being evaluated for metastatic mediastinal lymphadenopathy PET CT for disease evaluation and to locate the primary lesion

FDG avid metastatic mediastinal lymphadenopathy : 

FDG avid metastatic mediastinal lymphadenopathy

Multiple FDG avid mediastinal and abdominal lymphadenopathy : 

Multiple FDG avid mediastinal and abdominal lymphadenopathy BAL – Normal, PSA - Normal

Biopsy of FDG avid abdominal lymphadenopathy- adenocarcinoma prostate : 

Biopsy of FDG avid abdominal lymphadenopathy- adenocarcinoma prostate

PET CT in Prostatic Malignancies : 

PET CT in Prostatic Malignancies Diagnosis & initial staging Advanced metastatic disease Recurrent disease Monitoring treatment response Good correlation with serum PSA value Rakesh Kumar MD, Hongming Zhuang MD, PhD and Abass Alavi MD , Radiologic clinics of North America,November 2004

Future PET Radiotracers in GU Malignancies Imaging : 

Future PET Radiotracers in GU Malignancies Imaging 18F-FDG 18F-fluoride 11C-acetate 11C-methionine 11C-choline 18F-fluoroethylcholine 18F-methylcholine 18F-cis-4-L-proline 15O-H2O 18F-fluoromisonidazole

18F Bone Scan : 

18F Bone Scan

Case : 

Case 62Y/M FUC of adenocarcinoma prostate. Status: post TURP with bilateral orchidectomy, now on hormonal therapy Multiple sites bony pain with gradually rising serum PSA (389.4 ng/ml)

18 F Bone Scan in a patient of Prostatic Carcinoma : 

18 F Bone Scan in a patient of Prostatic Carcinoma

Skeletal Metastases in Carcinoma Prostate : 

Skeletal Metastases in Carcinoma Prostate Skeletal metastases occur in about 85% of patients dying of prostate cancer Abnormal bone scan at presentation is associated with higher 2 yr mortality rate (45% compared with 20% for those with normal scan) LUND F, 1994.Br J Urol 56:58-63

18 F PET bone scan : 

18 F PET bone scan Bone scan in all prostate cancer patients with PSA > 10 ng/ml Serial bone scan in established skeletal metastases to evaluate response to therapy 99m Tc MDP and 18 F have comparable specificity but 18 F has higher sensitivity for osteolytic secondaries Shih W J et al,2003.Clin Nuc Med 16:763-766

Thanking You : 

Thanking You