P ositron E mission T omography in Clinical Oncology

1. Positron Emission Tomography in Clinical Oncology • Chun Ki Kim, M.D. • Mount Sinai School of Medicine • New York, New York

4. [F-18] FDG - Glucose metabolism [C-11] Methionine - Amino acid transport - Incorporation of amino acid into protein fractions [O-15] Water - Blood flow [N-13] Ammonia - Blood flow Rb-82 - Blood flow Commonly used PET Radiotracers

5. Potential PET Radiotracers • [C-11] Thymidine Tumor cellular proliferation rate • [C-11] Aminoisobutyric acid Tumor amino acid uptake • [F-18] 5-FU Prediction/evaluation of ChemoTx • [C-11] Tyrosine Tumor metabolism • [N-13] Glutamate Tumor metabolism • [C-11] Acetate Myocardial oxidative metabolism • [C-11] Palmitate Myocardial fatty acid metabolism • [F-18] FluoroDOPA Dopamine synthesis • Many other receptor agents Dopamine, serotonin, opiate etc.

6. [F-18] FDG (fluoro deoxyglucose)  Malignancy ~  Glucose / FDG uptake PET Radiotracer approved by FDA

8. NORMAL TUMOR • Overexpression of Glucose transporters • Higher levels of Hexokinase • Down-regulation of Glucose-6-phosphatase • Anaerobic glycolysis, less ATP per glucose molecule, • more glucose molecules needed for ATP production • General increase in metabolism from high growth rates

9. Malignancy  Glucose/FDG uptake

10. Gallium PET

11. Metastatic Thyroid Ca. to Lung, Mediastinum, and Skeleton

13. General Indications for FDG-PET Tumor Imaging • DDx: Benign versus Malignant • Staging & Restaging • Metastatic work up: Rising tumor markers • Monitoring treatment response • Scar/necrosis/fibrosis vs. Recurrent/residual disease • Grading/Prognosis • Detection of unknown primary

14. Lung Ca (NSC): Dx, Staging & restaging Esophgeal Ca: Dx, Staging & restaging Colorectal Ca: Dx, Staging & restaging Lymphoma: Dx, Staging & restaging Melanoma: Dx, Staging & restaging, Non-covered for evaluating regional nodes Head & Neck Ca: Dx, Staging & restaging New Medicare Coverage Policy for FDG PET

15. Lung Cancer • Dx: Solitary Pulmonary Nodule • Staging • Metastatic work-up

16. Solitary Pulmonary Nodule • Incidence detected by CXR: 130,000/year. 50-60%: Benign 20-40%: Invasive nodule biopsy Resection.

17. CT: an indeterminant LUL nodule.

19. Efficacy of PET Solitary Pulmonary Nodule • Sensitivity = 97% • Specificity = 78% (Meta-analysis of >40 articles: Gould et al. JAMA 2001)

20. False Positives: Active Infection/Inflammation TB Pneumonia Cryptococcosis Histoplasmosis Aspergillosis Inflammatory

21. Staging

24. 60/M: Lung Ca.

25. 62y/o Lung Ca. with adrenal mass

27. Colorectal Cancer:Clinical Indications for PET Imaging • Staging before primary resection? • Detection of Lesions after Primary Resection • Staging before resection of recurrent disease. • Rising CEA in the absence of a known source. • Equivocal/residual lesion on conventional imaging. • Patient is clinically symptomatic, but CEA is normal. • Monitoring treatment response (pre-op & post-op)

28. Staging before resection of recurrent disease

29. 63 y/o woman with a H/O Colon Ca. and liver metastases

30. 79/M. Resection of Rectal Ca (Dukes B) 4 mos earlier, CEA, CT: possible local relapse.

31. T1 T2 • F/68 • H/O Colon Ca. • Rising CEA • CT/MRI; multiple cysts T1 enhanced T1 enhanced

32. Sagittal Transverse Coronal

33. YW: Colon Ca • 3/00: (-) CT • 5/00: rising CEA • 6/00: (+) PET • 7/00: CT

34. 58/M - S/P Colon Ca Rising CEA Coronal Coronal Transverse

35. 58/M - S/P Colon Ca Rising CEA Hemangioma Local recurrence

36. 48y/o with Colon Ca. • S/P Primary resection. • S/P Resection of liver • lesion • Now with  CEA • CT: (-) for mets

37. 48y/o with Colon Ca. • S/P Primary resection. • S/P Resection of liver • lesion • Now with  CEA • CT: (-) for mets

38. N. G. 8/15/00 Colon cancer with a Hx of UC Proven mesenteric carcinomatosis

39. 1756441

40. Huebner et al.J Nucl Med 2000;41:1177-1189

41. Huebner et al.J Nucl Med 2000;41:1177-1189

42. Colorectal Cancer: A possible algorithm CT evidence of resectable disease in patient suitable for surgery Whole Body PET imaging

43. Colorectal Cancer: A possible algorithm Further evaluation of CT abnormality All sites negative CT evidence of resectable disease in patient suitable for surgery Whole Body PET imaging

44. Colorectal Cancer: A possible algorithm Further evaluation of CT abnormality All sites negative CT evidence of resectable disease in patient suitable for surgery Whole Body PET imaging PET = CT and other sites negative Surgery

45. Colorectal Cancer: A possible algorithm Further evaluation of CT abnormality All sites negative CT evidence of resectable disease in patient suitable for surgery Whole Body PET imaging PET = CT and other sites negative Surgery + ve at multiple Sites Non-surgical management

46. Staging: 44/F with Colon Ca, S/P primary resection.CT: multiple liver mets and a lung nodule Treated with systemic chemoTx instead of intra-arterial chemoTx.

47. Colorectal Cancer:Clinical Indications for PET Imaging • Detection of Lesions • Staging before resection of recurrent disease. • Rising CEA in the absence of a known source. • Equivocal/residual lesion on conventional imaging. • Patient is clinically symptomatic, but CEA is normal. • Monitoring treatment response (pre-op & post-op) • Staging before primary resection?

48. S/P ChemoRx

49. Before 2mo after Adjuvant chemo and radioTx Prior to surgery for rectal Ca.

50. Residual FDG activity after treatment: Not always active tumor Optimal time to scan after treatment?? Uptake may be seen in inflammatory tissue / macrophages. • 1 month after Chemo. • PET findings at 1 mo ~ CT findings at 3 mos • Findlay et al. J Clin Oncol 1996 • Several months after RT?