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NEW DEVELOPMENTS IN IMAGING IN MEDICINE SYMPOSIUM OF THE LATIN AMERICAN SECTION AMERICAN NUCLEAR SOCIETY

NEW DEVELOPMENTS IN IMAGING IN MEDICINE SYMPOSIUM OF THE LATIN AMERICAN SECTION AMERICAN NUCLEAR SOCIETY. Rio de Janeiro June 13 – 16, 2005. PET/CT: A New Standard for Oncologic Imaging in Brazil Edwaldo E. Camargo, M.D. Nuclear Medicine Division Sirio-Libanes Hospital

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NEW DEVELOPMENTS IN IMAGING IN MEDICINE SYMPOSIUM OF THE LATIN AMERICAN SECTION AMERICAN NUCLEAR SOCIETY

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  1. NEW DEVELOPMENTS IN IMAGING IN MEDICINESYMPOSIUM OF THE LATIN AMERICAN SECTIONAMERICAN NUCLEAR SOCIETY Rio de Janeiro June 13 – 16, 2005 PET/CT: A New Standard for Oncologic Imaging in Brazil Edwaldo E. Camargo, M.D. Nuclear Medicine Division Sirio-Libanes Hospital Sao Paulo, Brazil

  2. PET/CT in Brazil: a New Standard • Current Dilemma Insufficient 18F-FDG to justify PET/CT scanners vs Abundant positron emitters (baby cyclotrons) State Monopoly vs Free Enterprise

  3. PET/CT in Brazil: a New Standard • Cyclotrons Available Today • IEN, Rio de Janeiro (1978) 24 MeV • IPEN, Sao Paulo (1979) 24 MeV • IPEN, Sao Paulo (1998) 30 MeV • IEN, Rio de Janeiro (2003) 11 MeV • Possible Additional Cyclotrons • Recife ? MeV • Belo Horizonte ? MeV • Goiania ? MeV • Porto Alegre ? MeV • Curitiba ? MeV

  4. PET/CT in Brazil: a New Standard • PET/CTs and PETs Available Today Sao Paulo 3 PET/CTs 1 PET Rio de Janeiro 1 PET/CT 1 PET

  5. PET/CT in Brazil: a New Standard • Positron Emitters Production • 18F-FDG, from IPEN, Sao Paulo (4 days/week) • 18F-FDG, from IEN, Rio de Janeiro (? days/week) • Other Emitters? carbon-11 (20 minutes) nitrogen-13 (10 minutes) oxygen-15 (02 minutes)

  6. PET/CT in Brazil: a New Standard • 18F-FDG Distribution • Sao Paulo • Rio de Janeiro • Campinas • Other cities: Brasília?

  7. Rio de Janeiro 375 km 90 km

  8. Recife Goiânia • Campinas

  9. PET/CT in Brazil: a New Standard [F-18]FDG TUMOR VIABILITY [I-131 or I-123] IODIDE GALLIUM-67 THALIUM-201 [Tc-99m] SESTAMIBI [I-131 or I-123] MIBG [In-111] OCTREOTIDE MONOCLONAL ANTIBODIES

  10. PET/CT in Brazil: a New Standard “IT IS NOT POSSIBLE TO PRACTICE CLINICAL ONCOLOGY WITHOUT 18F-FDG” Abass Alavi, M.D. Director, Nuclear Medicine Division University of Pennsylvania, Philadelphia, USA [Jornada Paulista de Radiologia, São Paulo, 2002]

  11. PET/CT in Brazil: a New Standard 18F-FDG, a glucose analog, a tracer of glucose metabolism that is trapped in the cell after conversion to [18F]-FDG6-PO4 by hexokinase. Tissues with high levels of glucose-6-phosphatase such as the liver, kidneys and intestines accumulate [18F]-FDG6-PO4 to a lesser extent.

  12. PET/CT in Brazil: a New Standard GLUCOSE METABOLIC PATHWAYS hexokinase Glucose glucoseglucose-6-phosphate glucose-6-phosphatase hexokinase X 18F-FDG 18F-FDG18F-FDG-6-phosphate glucose-6-phosphatase

  13. BABYCYCLOTRON

  14. PET/CT in Brazil: a New Standard Positron Emitters Radionuclides T ½ Oxygen-15 2 minutes Nitrogen-1310 minutes Carbon-1120 minutes Fluorine-18110 minutes Iodine-1244.2 days

  15. PRINCIPLE OF POSITRON EMISSION TOMOGRAPHY  = 511 keV Positron emitter + 180° -electron  = 511 keV

  16. PET / CTSCANNER

  17. PET/CT Configuration • CT up front • PET moves backwards for maintenance • Single tunnel CT PET

  18. BIOGRAPH® PET/CT • PET: • Detectors: BGO • Crystals per detector block: 64 • Number of detector blocks: 288 • Number of BGO crystals: 18,432 • Transaxial resolution (NEMA 2001):FWHM @ 1cm = 4.5 mm • FWHM @ 10cm=5.6mm • Axial resolution (NEMA 2001): FWHM @ 0cm = 4.2mm      FWHM @ 10cm=5.7mm  • CT:  • Scanning time: 80 s standard • Rotation: 0.8; 1.0; and 1.5 s • Slice width: 1, 2, 3, 5, 8 and10mm • Minimum slice width: 1 mm • High contrast resolution: 0.32 and 0.36 mm

  19. NORMAL JACO 10/03/2004

  20. PET/CT in Brazil: a New Standard • PET/CT • STANDARD UPTAKE VALUE (SUV) • Mean ROI Activity [mCi/ml] • SUV = • Injected Dose [mCi] / Body Weight [g]

  21. Types of Tumors Brain Head and Neck Lung Colorectal, Esophagus, Stomach Breast, Uterus, Ovary Malignant Melanoma Lymphoma Neuroblastoma Kidney, Prostate, Bladder, Seminoma Other PET IN CLINICAL ONCOLOGY

  22. PET/CT in Brazil: a New Standard Since May 30, 2003, we have imaged over 2,200 patients with this approximate distribution: Oncology: 97.0% Neurology: 2.5% Cardiology: 0.4%

  23. PET/CT in Brazil: a New Standard In Oncology, there is the following approximate distribution: G-I tract: 29% Gynecological tumors: 16% Lung: 12% Lymphomas: 9% Malignant melanoma: 6% G-U tumors: 5% Head and neck tumors: 3% Other (includes check-ups): 17%.

  24. PET/CT in Management Change RESTAGING AND MANAGEMENT CHANGE UPSTAGING DOWNSTAGING MANAGEMENT CHANGE M. MELANOMA 43% 21% 64% COLORECTAL 25% 25% 50% NON-HODGKIN 22% 27% 50% HODGKIN 25% 16% 41% BREAST 14% 14% 28% PROSTATE 9% 0% 9%

  25. PET/CT in Management Change ADVANTAGES OF PET/CT OVER PET • PET/CT precisely identifies, localizes and delineates size and extent of a lesion: • >> essential data for surgical and radiation therapy planning • Goerres GW et al. J Nucl Med 2004; 45: 66S-71S

  26. PET/CT in Management Change ACB, 17 y.o. female Hx:Medullary thyroid carcinoma (MEN 2B disease) after total thyroidectomy. Denies chemotherapy and radiation therapy. Generalized bony pain, and high calcitonin levels. CT PET PET/CT

  27. PET/CT in Management Change CT PET PET/CT ACB 01/07/05

  28. PET/CT in Management Change ADVANTAGES OF PET/CT OVER PET (2) • PET/CT identifies other physiologic accumulations: • - brown adipose tissue • - muscles >>increased specificity • Goerres GW et al. J Nucl Med 2004; 45: 66S-71S • Cohade C et al. J Nucl Med 2003; 44: 170-6

  29. Brown Fat Uptake PET/CT in Management Change CT PET PET/CT

  30. Brown Fat Uptake and Solitary Lesion PET/CT in Management Change CT PET PET/CT

  31. Brown Fat Uptake and Diazepam PET/CT in Management Change BEFORE AFTER CT PET PET/CT

  32. PET/CT in Management Change BREAST CARCINOMA • VLRLM, 49 y.o. female • Hx: Left breast cancer for 10 years, with total mastectomy and axillary node dissection. Submitted to chemotherapy and radiotherapy. Developed bone, brain, pleural and peritoneal metastases, but pleural effusion has been negative for malignancy. CA15: 784 (very high) • PET/CT: For staging

  33. BREAST CARCINOMA VRLRM 05/30/03 01:30 PM

  34. VLRLM 05/30/03 1:30PM CT PET PET/CT

  35. PET/CT in Management Change BREAST CARCINOMA • Staging and Management Change 1) These images change staging in up to 36% of patients(28% upstaging, 8% downstaging) 2) Unsuspected lymph nodes or metastases found in up to 20% of patients 3) Management change in up to 58% of patients Yap CC et al. J Nucl Med 2001; 42: 1334-37

  36. PET/CT in Management Change BREAST CARCINOMA • MSFKD, 46 y.o. female • Hx:  Left sided mastectomy 6 years ago, followed by chemotherapy. Three years ago, bony metastases were found and patient was submitted to additional chemotherapy until 1 month ago. Radiation therapy of the sternum was begun and ended last month. She also had a pathologic fracture of the left iliac bone. • PET/CT: For staging

  37. MSFKD 11/07/03 CT PET PET/CT

  38. PET/CT in Management Change BREAST CARCINOMA • Tumor Recurrence 1) Sensitivity of up to 100% for locoregional recurrence 2) Complementary to bone scintigraphy: it is more sensitivefor lytic or marrow lesions, and bone scintigraphy is more sensitive for blastic lesions 3) Shorter survival for patients with pure lytic lesions than for patients with mixed or sclerotic lesions Eubank WB et al. Radiographics 2002; 22: 5-17 Hathaway PB et al. Radiology 1999; 210: 807-14 Cook GJ et al. J Clin Oncol 1998; 16: 3375-79

  39. PET/CT in Management Change COLORECTAL CARCINOMA • FA, 53 y.o. male • Hx: Transverse colon carcinoma operated on in September 2002. Liver metastases demonstrated during workup. Submitted to chemotherapy through February 2003. No radiotherapy. In March, 2003, new surgery and radioablation of 18 liver metastases. In May, 2003, submitted to 131I-lipiodol protocol and intra-arterial chemotherapy. Patient is now doing well. • PET/CT: For investigation of extent of disease

  40. FA 06/06/03 CT PET PET/CT

  41. FA 06/06/03 CT PET PET/CT

  42. PET/CT in Management Change COLORECTAL CARCINOMA • SBK, 57 y.o. male • Hx: Sigmoid colon carcinoma operated on 3 yrs ago, with liver metastases. Radio-ablation of the lesions followed by chemotherapy. CEA is high. • CT (dedicated): Unable to distinguish viable tumor from fibrosis. • PET/CT: To evaluate tumor viability

  43. SBK 04/07/2004 CT PET PET/CT

  44. PET/CT in Management Change COLORECTAL CARCINOMA • Management Change Changed therapy in 68% of patients, especially by demonstrating unknown sites of disease (upstaging). Meta J et al. J Nucl Med 2001; 42: 586-90

  45. PET/CT in Management Change COLORECTAL CARCINOMA • Management Change In 204 oncologic patients (lung, colorectal, stomach, malignant melanoma, breast, kidney, bladder, uterus) the interpretations of CT, PET and PET/CT were compared: PET/CT provided additional data in 49% of them; changed 10% of equivocal lesions to benign and of 5% to malignant; localized precisely tracer uptake in 6% of patients and retrospectively localized lesions in 8%; changed clinical management in 14% of patients. Bar-Shalom R et al., JNucl Med 2003; 44:1200-09

  46. PET/CT in Management Change G-U MALIGNANCIES • Several studies have shown variable results. • Limitations to dedicated PET (non-PET/CT): - marked renal excretion of 18F-FDG poses a problem to identify kidney, ureter, bladder and prostate tumors and lymph nodes closer to the bladder - large amounts of glucose-6-phosphatase, that converts18F-FDG-6-phosphate back into18F-FDG with its excretion from the tumor cell Hain SF, Maisey MN.BJU Int 2003; 92:159-64 Shvarts O et al.Cancer Control 2002; 9: 335-42 Janzen NK et al.Urol Oncol 2003; 21: 317-26 Van der Heijden AG, Witjes JA.Curr Opin Urol 2003; 13: 389-95 De Santis M et al.J Clin Oncol 2004; 22: 1034-39 Hricak H et al.Semin Oncol 2003; 30: 616-34 Nunez R et al.J Nucl Med 2002; 43: 46-55

  47. PET/CT in Management Change PROSTATE CARCINOMA • 18F-FDG uptake is higher in more aggressive tumors and correlates with Gleason scores and to some extent with PSA levels Agus DB et al.Cancer Res 1998; 15; 58:3009-14 Seltzer MA et al.J Urol 1999;162:1322-8 • Limiting factors for detection of primary tumor: - variable uptake according to aggressiveness - high levels of bladder radioactivity - outdated reconstruction techniques Hofer C et al.Eur Urol 1999; 36: 31-5 Effert PJ et al.J Urol 1996; 155: 994-8

  48. PET/CT in Management Change PROSTATE CARCINOMA • CMS, 46 y.o. male • Hx: Prostate adenocarcinoma diagnosed a week ago and since then on hormone therapy. No other therapy has been attempted. • No other imaging studies available. • PET/CT: For therapy decision. • PMH: Hypothyroidism

  49. CT PET PET/CT CMS 03/29/05

  50. AFTER FUROSEMIDE CORONAL SAGITTAL TRANS-AXIAL CT PET PET/CT CMS 03/29/05

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