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George Segall, M.D.

Stanford University. PET/CT in Oncology. George Segall, M.D. Evolution of Technology. CT. PET/CT. PET. 2001. 2000. 1973. Imaging Protocol. Patient - Fast 4 hrs prior to exam - Inject tracer - Start scan 60 min later. CT - Topogram (scout) - CT scan (1 min). PET

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George Segall, M.D.

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  1. Stanford University PET/CT in Oncology George Segall, M.D.

  2. Evolution of Technology CT PET/CT PET 2001 2000 1973

  3. Imaging Protocol Patient - Fast 4 hrs prior to exam - Inject tracer - Start scan 60 min later CT - Topogram (scout) - CT scan (1 min) PET - Brain (10 min) - Heart (10 min) - Body (20 min) <130

  4. Glucose Glucose Glucose-6-P Plasma Cell FDG FDG FDG-6-P PET Tracer: FDG 18F-fluorodeoxyglucose (FDG) is taken up by cells proportionate to their metabolic rates

  5. PET CT FDG Bed 15 mCi 1 min PET/CT CT (1 min) KVs mAs Slice 130 kV 75 mA 5 mm H.S., 077-64-28

  6. What Are the Advantages of PET/CT? Advantages of CT • high spatial resolution Advantages of PET • better lesion characterization • enhanced lesion detection

  7. Applications of PET-CT Heart 5% Brain 5% • perfusion • epilepsy • viability • tumor Body 90% 76% • dementia 1.5 million exams performed annually • tumor • infection • bone

  8. PET - CT in Tumor Imaging • Detect radiographically occult lesions • • Characterize radiographic abnormalities • • Evaluate extent of disease • • Evaluate response to therapy

  9. Normal PET - CT Body Scan

  10. CT PET/CT Normal PET/CT scan PET

  11. Abnormal PET - CT Body Scan

  12. Medicare Approved Indications for PET-CT Diagnosis, Staging, and Restaging (unless otherwise indicated) • Head & Neck • Thyroid • Breast • Lung • Esophagus • Colon & Rectum • Cervix • Lymphoma • Melanoma • Other Cancers follicular: I -131 neg, Tg >10 ng/dL not breast masses or regional nodes only non-small cell CT/MRI neg for extra-pelvic mets not regional nodes when enrolled in NOPR

  13. National Oncologic PET Registry http://www.cancerpetregistry.org Sponsored by AMI and managed by ACR for CMS April 15, 2008 1,728 facilities - 74,541 scans since May 2006

  14. National Oncologic PET Registry http://www.cancerpetregistry.org Pre PET/CT Form • Indication for PET/CT • Cancer type and extent • Management plan Post PET/CT Form • Change in assessment of extent of disease • Change in management plan

  15. National Comprehensive Cancer Network Practice Guidelines in Oncology Acute Myeloid Leukemia Bladder Cancer Bone Cancer Breast Cancer Central Nervous System Tumors Cervical Cancer Chronic Myelogenous Leukemia Colorectal Cancer Esophageal Cancer Gastric Cancer Head and Neck Cancer Hepatobiliary Cancer Hodgkin’s Disease Kidney Cancer Melanoma Myelodysplastic Syndromes Multiple Myeloma Neuroendocrine Tumors Non Hodgkin’s Lymphoma Non-Small Cell Lung Cancer Occult Primary Cancer Ovarian Cancer Pancreatic Cancer Prostate Cancer Soft Tissue Sarcoma Skin Cancer (except Melanoma) Small Cell Lung Cancer Testicular Cancer Thyroid Cancer Uterine Cancer

  16. National Comprehensive Cancer Network Practice Guidelines in Oncology • Bone Cancer • Breast Cancer • Cervical Cancer • Colorectal Cancer • Esophageal Cancer • Head and Neck Cancer • Hodgkin’s Disease • Melanoma Multiple Myeloma Non Hodgkin’s Lymphoma Non-Small Cell Lung Cancer Occult Primary Cancer Ovarian Cancer Soft Tissue Sarcoma Small Cell Lung Cancer Testicular Cancer Thyroid Cancer

  17. Lesion Characterization 47 year old man with multiple trauma from a MVA who was incidentally discovered to have a pulmonary nodule

  18. Lesion Characterization 84 year old man with chronic cough found to have a 13 mm nodule on CXR

  19. Enhanced Detection 73 year old woman s/p resection for colon cancer, rising CEA level and negative CT

  20. Enhanced Detection

  21. Enhanced Detection 70 y/o male with H&N cancer

  22. Enhanced Detection I-131 FDG PET 47 year old man with biopsy proven recurrent thyroid cancer 3 months after thyroidectomy

  23. Unknown Primary 68 year old man who presented with right neck mass

  24. Staging 49 year old man with new lung cancer

  25. Recurrent Disease 64 year old man s/p laryngectomy, now has dysphagia

  26. Monitoring Response 63 year old man stage 3A lung cancer, has received 4 cycles of chemotherapy

  27. CT + PET/CT vs PET/ CT • Standard CT followed by PET/CT if needed MOST CASES • PET/CT SOME CASES CT component can be low resolution or optimized

  28. Problems and Pitfalls • False negative findings Tumor histology Lesions smaller than 8 mm Diabetes/Non-fasting patients • False positive findings Normal physiology Granulomas and other infections Adenomas

  29. Standard CT PET/CT 56 year man with HCV, end stage liver disease, and presumed hepatoma

  30. Physiologic Uptake: Brown Fat

  31. Infection 68 year old man with solitary lung nodule. Biopsy: aspergillosis

  32. Granulomatous Disease 62 year old man with hilar and mediastinal adenopathy. Biopsy: sarcoidosis

  33. Adenoma 82 year old man with wt loss and liver masses

  34. Adenoma 82 year old man with wt loss and liver masses

  35. Clinical Impact of PET/CT • More accurate diagnosis • Avoidance of unnecessary tests, and (potentially) harmful procedures • Better treatment or management

  36. National Oncologic PET Registry http://www.cancerpetregistry.org 36.5% change in decision to treat or not treat

  37. Conclusions 1. CT is the first imaging test of choice in most cases 2. PET - CT is more accurate than CT alone • Characterizing lesions difficult to biopsy • Detecting occult cancer • Determining extent of cancer and response to therapy 3. PET - CT changes management 36%

  38. Why PET-CT?

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