در مرکز پزشکی هسته ای دکتر دباغ – دکتر صادقی در خدمت شما هستیم

1. در مرکز پزشکی هسته ای دکتر دباغ – دکتر صادقی در خدمت شما هستیم مشهد، ملاصدرا 11 ، پلاک 1/4 www.DSNMC.ir Tel:+98(51) 38411524; +98(51)38472927

2. Nuclear Medicine In Oncology (Brief) V. R. Dabbagh Kakhki, M.D. Nuclear Medicine Specialist Associate Professor DSNMC Nuclear Medicine Research Center (NMRC; MUMS) www.DSNMC.ir www.mums.ac.ir/nmrc

3. Bone ? Basic Nuclear Medicine CNS and….. Tumoral agents

4. SPECT • Bone Scan + SPECT • Ga- 67 Scan + SPECT • Tc99m-RBC Liver Scan + SPECT • Tc99m –MIBI Brain SPECT • Tl-201 Brain SPECT • DMSA(V) Scan + SPECT

5. Oncology: Nuclear Medicine • Diagnosis • Specific or non-specific • Staging • Important for proper therapy • Response to Therapy • Follow-up • Early detection of recurrens • Treatment • Specific or non-specific

6. Diagnostic radiopharmaceuticals • Non-specific agents • PET or PET-CT • F-18 FDG-PET • Planar, SPECT or SPECT-CT • Diphosphonates – bone scan • Ga-67 citrate • MIBI • Tl-201 • DMSA(V)

7. Diagnostic radiopharmaceuticals • Specific – binds directly to special tumor antigens or receptors or are accumulated by special metabolic pathway • PET or PET/CT - no commercially available • 11C-HED • Planar, SPECT or SPECT/CT • MIBG • I-131 • 111In/Tc99m- Octreotide • MoAb : labelled with In-111, I-123/131 or Tc-99m

8. Bone Scan 99mTc-MDP

9. Bone Scan • Clinical applications • Bone metastases, • Primary bone tumors, • Trauma and fractures, Stress fractures, • Osteonecrosis, • osteomyelitis, • Prosthesis evaluation, • Metabolic bone disease, • Arthritis, Sensitive But not Specific

10. Bone scan • Scan pattern • Increased Uptake • Defect - cold lesion • Flare phenomenon – Increased uptake and number of lesions in the case of effective therapy • Super-scan (spread malignancies) - diffusely increased uptake

12. Rib Fractures

13. Osteosarcoma A 16-year-old boy with pain in the upper left tibia diagnosed as primary osteogenic sarcoma of the left femur Bone scan reveals disseminated bone and lung metastases.

15. Bone scan – multiple metastases

16. Lung cancer – cold lesion

17. Bone scan - prostate cancerprogression

18. Bone Metastases Superscan:Disseminated bone metastases secondary to prostatic cancer

19. Bone Scan PRIMARY MALIGNANT BONE DISEASE • Osteosarcoma • Ewing Sarcoma • Chondrosarcoma • Multiple Myeloma • Rhabdomyosarcoma Assessment of extension of the lesions or metastatic involvement

20. Ewing Sarcoma

21. Ga-67 scan • Clinical indications • Lymphoma • staging and monitoring effect of therapy • Melanoma • Lung cancer • Hepatoma Ccombination with other imaging modalities (SPECT/CT)

22. Ga-67; a cornerstone in functional imaging of lymphoma • Role; Diagnostic and prognostic data • Staging • Monitoring response to treatment • Differentiate between fibrotic or necrotic tissues from viable lymphoma in a residual mass • Early diagnosis of recurrence • Predicting outcome • 18F-FDG PET; gradually replacing GS

23. Gallium Scan • SPECT • A baseline examination before treatment • intense Ga avidity: small, non-cleaved cell lymphoma (lesion sens:89%)

24. Clinical History: 20-year-old, three weeks post partum with anterior mediastinal mass. Findings: Gallium scan at shows mediastinal adenopathy and bilateral breast uptake. Diagnosis: Hodgkin's Lymphoma .The breast uptake represents benign uptake secondary to lactation.

25. Ga-SPECT/CT in a patient with showing a residual mass on CT after treatment. Abnormal 67Ga uptake is demonstrated in the corresponding residual CT abnormality, indicating the presence of residual viable tumor tissue

26. Rapid Response to treatment GS after one cycle of chemotherapy Baseline GS

27. Tl-201 and Tc99-MIBI • Brain Tumors • Sarcoma • Breast Imaging

28. Mitochondria - - Nucleus - - - 99mTc - ΔΨm ΔΨc + MIBI Passive diffusion + - - 99mTc + - + + MIBI

29. Mitochondria - - Nucleus - - - 99mTc - ΔΨm ΔΨc + MIBI Passive diffusion + - - 99mTc MDR Proteins + - + + MIBI Active Efflux

30. Brain Tumors • F-18 FDG PET Grading Prognosis Tumor recurrence • Tl-201 Radiation necrosis Tumor viability • Tc99m Sestamibi (choroid plexus uptake) SPECT

31. Brain tumor

33. Brain tumor

34. FDG PET – brain tumor post thtwo foci on CT, only one viable tumor

35. Parathyroid Scan:Tc99m-MIBI Scan + SPECTParathyroid adenoma early late

36. Specific methods • Binding to receptors or antigens • MIBG – pheochromocytoma, neuroblastoma in children • Octreoscan – neuroendocrine tumors • I-131 – thyroid cancer – follow-up and treatment

37. MIBG SCINTIGRAPHY

38. MIBG: Clinical application • Adrenal medullary hyperplasia • Pheochromocytoma: 90% sensitive and even more specific(95-99%) • Paragangliomas • It can show metastatic lesions very effectively • Neuroblastoma

41. 11C- Hydroxyephedrinesimilar to MIBG

42. SPECT/CT carcinoid OctreoScan+ SPECT

43. 18FDG Glucose 18FDG Glucose hexokinase 18FDG-6-P Glucose-6-P Metabolites of Glucose PET in oncology:General aspects(18FDG) Cell membrane

44. FDG PET • For several tumors • Mainly lymphomas, lung cancers, melanoma, colorectal cancers and others • Not suitable for prostate cancer • At least 1 w post chemo, 3 m radiotherapy

45. PET in oncology: • 18FDG can be used for: • Focal lesions (malignancy potential) • Staging • Monitoring response to therapy • Prognosis • Evaluation of tumor recurrence

46. PET in oncology:Breast cancer (Staging) A 44 year old female with an axillary nodule proved to be carcinoma on biopsy. A FDG PET exam was then performed and revealed extensive metastases to axillary and supraclavicular lymph nodes, as well as the primary lesion in the right breast (black arrow)

47. PET in oncology:Colon cancer (Recurrent cancer) A patient with a history of colon cancer, evaluated for two pulmonary nodules. The FDG PET demonstrated uptake in the pulmonary nodules (not shown) and also revealed diffuse omental metastases

48. PET in oncology:Melanoma (Staging) A 71 year old male with a history of melanoma on the left shoulder.On CT, the abdomen had been interpreted as negative. The FDG PET exam revealed extensive metastatic disease throughout the body.

49. PET------PET/CT

50. FDG PET Tumor of unknown origin Pharyngeal cancer