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PET-CT Fusion Imaging and SUV Assessment Using MIMvista (Resisting RECIST). Pete Anderson MD, PhD Professor, Pediatrics Passive vs Active role. “SCANXIETY” visual images available before report Look at most scans yourself

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PET-CT Fusion Imaging and SUV Assessment Using MIMvista (Resisting RECIST)

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    1. PET-CT Fusion Imagingand SUV AssessmentUsing MIMvista (Resisting RECIST) Pete Anderson MD, PhD Professor, Pediatrics

    2. Passive vs Active role • “SCANXIETY” • visual images available before report • Look at most scans yourself • Information today will empower you to get SUV data from any location in the body yourself!

    3. PET-CT Imaging • Standard Uptake Value (SUV) • FDG is the prototype : “ I Have A DREAM” • Sensitive means to document responses • Numeric data from PET-CT using Mimvista • Downloading of DICOM images from QC CD for central review (e.g. SARC studies)

    4. Assessing Response of Sarcomas- NOT Always Easy • Clinical: pain improved, alkaline phosphatase and/or LDH better, exam better function • Imaging: shrinkage on CT (Choi) and MRI • Osteosarcoma: bone scan changes very slowly and can even increase if some calcification associated with healing occurs • Sometimes “more” or “worse” lung metastases are just increased calcification

    5. RECIST (Response Evaluation Criteria in Solid Tumors) • 30% decrease in sum of longest diameter of target lesion(s): PR • PROG >20% • CR (complete disappearance)- unusual • Most: stable (but patient seems better!) • Ignores stromal or bone components

    6. PET-CT Imaging: A Reality Check for the Both Clinician and Patient • Is the ongoing or proposed treatment worth the toxicity (chemo) or morbidity *Surgery/RT • Any disease elsewhere? • 3-D imaging: “Seeing is believing” • Helps set priority of intervention(s) such as local control vs chemotherapy

    7. MIMvista PET-CT Fusion Images • First-hand info about tumor location • FUSION images allow clinician to determine where highest FDG uptake is in-around-near a target lesion. YOU get the SUV! • VISUAL PICTURE and numeric data of where there is active tumor • LOCAL Control strategy (surgery RT, RFA), more chemotherapy , or just follow-up after therapy (esp RT) – “at a glance”

    8. MIMvista Color Fusion Images • MIMvista for desktop PC (Cleveland OH ( • Right click on image (e.g. in MD Anderson ClinicStation or other) • DICOM images are downloaded into the MIMvista program (~1-2 min) • Displays fusion images for YOUR analysis

    9. Top (PET) Middle (PET-CT FUSION) Bottom: CT Scroll to adjust PET vs CT fusion SUV displayed where click the arrow on coronal, sagittal, or transverse planes Can capture file to clipboard for power point and forwarding MIMvista Display

    10. Same Lesion More PET More CT

    11. SUV on a Fusion Image - anywhere you point the mouse • All areas of tumor not alike: heterogeneity of edges of tumor vs middle of tumor • Areas near or in vital structures (e.g. spine, mediastinum, liver, chest wall) • Ossified lesions may have small “islands” of intense FDG uptake (incomplete response to chemotherapy, focal relapse)

    12. Indicator (Target) Lesion • More PR than RECIST (Mahajan SIOP) • RT of OS 0/8 by RECIST • 6/8 improved SUV on PET-CT • PET-CT may allow better F/U after RT + chemo

    13. MIMvista PET-CT Fusion Examples • Osteosarcoma • Ewings

    14. Chest Wall Osteosarcoma: Progression after HD-Ifosfamide L pleural/chest wall disease unresectable

    15. CT after Doxil +Avastin: Ossification Was 7 Now 4 (pleural Effusion better)

    16. PET: Avid Hmmmm……

    17. PET-CT Fusion: SUV less SUV was >5

    18. Local Control: Samarium + RT Samarium scan and RT plan

    19. After Samarium +RT(SUV less; No new lesions)

    20. No longer next to heart s/p RT Continues on L-MTP-PE (Junovan) CIND “stable” by RECIST Better on PET-CT

    21. Osteosarcoma of Ilium + Sacrum Excellent function, no pain 8 months s/p Proton RT now NED s/p staged thorocotomies:? “CR” on PET-CT

    22. Osteosarcoma: Pelvic sidewall RFA- pain gone, no progression at this site; attends High School - Will follow with bone scan and PET-CT

    23. Metastatic Osteosarcoma:Identification of Active Primary SUV 5.9 Bone scan not avid Where PET was avid

    24. PET- “avid” +bone scan, too PET-CT showed local recurrence (posterior-lateral SUV 8.1= tumor) Artifact on MRI and CT s/p limb salvage

    25. Local Recurrence: Fusion Image

    26. Right Hilar Osteosarcoma (RT w/o chemo, then chemo-- not enough : now needs surgery)

    27. Osteosarcoma s/p Pneumonectomy Stable – Low SUV in R thorax; continues off all therapy

    28. Response Quality: 1 Year after Samarium- Tumor Islands Active “islands” also seen in primary extremity lesions

    29. Osteosarcoma of Sacrum Clinical Response S/P HD-Ifos and RT (pain gone and NO symptoms x1 yr)

    30. Osteosarcoma Relapse- Sacrum (SUV 5.4 at start of HDIFOS )

    31. Sacral Osteosarcoma (SUV 1.9 s/p IFOS) NO change in size on CT; slightly less avid on bone scan Pain gone + clinical response to HD-IFOS

    32. EWS- s/p 3 cycles TMZ + Irinotecan Began short of breath with massive disease- clinically much better

    33. Stopped TMZ + Irinotecan : Relapse Given RT, this lesion ok. Stopped Rx again. Increase LUL nodule

    34. EWS: Clinical Response Now Off TMZ + irinotecan X 5 months

    35. Summary • MIMvista PET-CT fusion can provide same-day visual information to clinicians and patients about FDG metabolic activity • PET-CT can now be used in the clinic for to capture numeric response data (SUV) • SUV obtained-anywhere you click • Additional data possible (tumor volumes) • Image capture and sharing possible

    36. Conclusion • MIMvista information can help YOU to communicate better -with patients, families, referring physicians, surgeons, radiotherapists • Response data? SARC to determine • COLORfusion images with numeric data provides best of both worlds in the clinic • Response + numbers “at a glance”

    37. THANKS!Questions?