Steven M. Larson, M.D. Memorial Sloan Kettering Cancer Center PET in Endocrine Response Neoplasms: Thyroid, Prostate and Breast Cancer Steven M. Larson, M.D. Memorial Sloan Kettering Cancer Center

Molecular Imaging and Targeted Radiotherapy: Key Collaborators @MSKCC Akhurst T; Blasberg R; Ballangrud A; Cheung NKV; Divgi C; Erdi A; Erdi Y; Finn R, Fong Y, Guillem J; Hamacher K; Heelan R; Humm J.; Hricak H; Jurcic J; Kalaigian J; Kelly WK; Koehne G; Koutcher J; Ling C; Liebel S; Ma D; Macapinlac H; Mehta B; McDevitt M; Nunez R; O’Donoghue J; O’Reilly R; Old L; Pentlow K; Robbins R, Scheinberg D., Scher H; Sgouros G; Sheh H; Slovin S; Tjuvavev Y; Turlakow, A; Welt S; Yeung H; Zanzonico P

Detecting Tumor: Strategy We detect the living chemistry of the tumor with biomedical tracers (e.g.FDG, a form of glucose) PET imaging is a sensitive diagnostic test that can read these chemical signals that come from a living tumor.

Diagnostic Testing in Thyroid Ca Blood tests: TSH, T4, TG Diagnostic Imaging Tests Ultrasound Thyroid Scintigraphy (99mTc, 123I) MRI Spiral CT Whole Body 131I/123I Testing (+/- Thyrogen) PET* (FDG, Iodine-124 ) *An important complement to other tests

Natural History of Thyroid Ca Death Of Disease 15% 5% * Nodule Evaluation: No Cancer Diagnosis Clinically Localized Disease Rising TG no known site * Clinical Metastases: stable * Clinical Metastases: Progressive 85% *PET Improves Care CURE Normal Life Span

What Does PET Tell Us about Thyroid Cancer Clinical Setting PET Question Rising Tg Known metastases Stable ? Progressive/RX I-131 Rx Where is tumor? Should it be Rx’ed How Extensive Aggressive/Prognosis? Response to Rx Will Rx help (124I)

Elevated TG/Negative Dosimetry GS, 29 yo female undergoing rTSH dosimetry testing. Negative Iodine-131 Whole Body Scans TG levels =6 ng/ml @ 72 hr.s after Thyrogen PET-FDG scan shows R. Cervical lymph node US guided biopsy reveals papillary Ca Rx with 200 mCi of I-131

Thyroid Ca 360317 9 February 2000: Neg. I-131 Dosimetry, post rTSH TG=6 : Where is the tumor? PET FDG I-131 Post-Rx Transaxial Coronal Sagittal Anterior 17 February 2000 3 March 2000 21 February 2000 US guided FNA R. neck “Positive..Papillary Ca..Thyroid Primary

Post Rx I-131 MB763123

Post Therapy Scan (anterior) FDG-PET Coronal-1 FDG-PET Coronal-2 B1 B2 B3 Figure 2

Prognostic Value of FDG-PET Conclusions FDG PET scanning can identify a subset of thyroid cancer patients who have more aggressive tumors Patients with FDG-avid tumor volumes greater than 125 ml have markedly reduced survival times.

“b+ /b- Pairs” Important to Targeted Therapies @ MSKCC b+ Tracer 124I-Iodide 124I-IUDR 124I-FAIU 124I-A33, huM195 86Y-MX35,huM195 b- ,EC Therapeutic 131I-Iodide 125,131I-IUDR 131,125,123I-FAIU 125,131I-A33, huM195 90Y-MX35,huM195

124I-Dosimetry in Metastases PK, 53 yo white male with numerous pulmonary nodules discovered on routine CXR, while being W/U for prostate Ca 4/28/00 Papillary thyroid Ca, moderately differentiated, locally invasive, 2.0 cm in diameter, with 13/23 lymph nodes Refered for Dosimetry 7/2000

THYROID CA 277269 CXR PA . LT. 4/25/2000

THYROID CA 277269 PET-FDG PET-124I 6/20/2000 7/5/2000

124I-Iodine in Thyroid Cancer 203 cGy/mCi 229 cGy/mCi 125 cGy/mCi 277269

PET in Thyroid Cancer: Reading the Biochemical Signals Staging. Extent of Aggressive Ca for optimal treatment planning Prognosis: high-risk (FDG positive) and low-risk (FDG negative) Dosimetry. Individual lesions with 124I Response. Predict susceptibility to treatment and monitor treatment effect

Thyroid Dosimetry 124I and 131I give identical results in whole body and blood clearance 124I can be used to measure tumor specific dosimetry Tumor dose may vary by a factor of 4 or more in the tumor