Dual-time point 18F-FDG PET/CT scan: is it always working?

Slides:



Advertisements
Similar presentations
Approach to a Patient with Lymphadenopathy
Advertisements

CLINICAL USE OF SPECT-CT IN BREAST & PROSTATE CANCERS
Radiologic Imaging Defines the local extent of a tumor Can be used to stage malignant disease Aids in the diagnosis Monitoring tumor changes after treatment.
PET/CT in Oncology George Segall, M.D. Stanford University.
The Thyroid Incidentaloma
“International Conference on Clinical PET and Molecular Nuclear Medicine” IAEA - IPET 2007 Bangkok, Thailand 10 to 14 November 2007 C. Suarez, R. Pruzzo,
ROLE OF FDG-PET/CT STUDY IN THE DETECTION OF BONE MARROW DISEASE IN PATIENTS WITH AGGRESSIVE NON- HODGKIN LYMPHOMA (NHL) AND HODGKIN LYMPHOMA (HL) Figure.
18F- FDG PET/CT in the Diagnosis of Tumor Thrombosis
In biochemical recurrence after curative treatment of prostate cancer, Choline PET/CT 1- has a detection rate of 10-20% when PSA: 1-2 ng/ml 2- has a detection.
Metastatic involvement (M) M0 - No metastases M1 - Metastases present.
In The Nam of God.
Total Lesion Glycolysis by 18 F-FDG PET/CT a Reliable Predictor of Prognosis in Soft Tissue Sarcoma Ilkyu Han Musculoskeletal Tumor Center, Seoul National.
Brain Scan Imaging MRI, CAT, PET Imaging Interpreting Functions of the Brain through Imaging – Activity Case Study – Professional Sports and Head Trauma.
JHSGR 16 th April 2011 Dr Lee Man Kit Derek.  The value of PET in staging adenocarcinoma (e.g. colorectal cancer) is well established Tomoharu T. et.
Application of Positron Emission Tomography ( PET ) in Colorectal Cancer Dr Chan Wai Keung Department of Surgery Ruttonjee and Tang Shiu Kin Hospitals.
AN INTRODUCTION TO PET-CT SCANNING Ray Murphy Chair – MCCN Partnership Group.
© Copyright 2003 Cardinal Health, Inc. or one of its subsidiaries. All rights reserved. PET in Breast Cancer Early detection of disease Precise Staging.
PET after Chemotherapy in Rhabdomyosarcoma Connective Tissue Oncology Society November 19, 2005 Michelle L. Klem, Leonard H. Wexler, Ravinder Grewal, Heiko.
Steven M. Larson, M.D. Memorial Sloan Kettering Cancer Center
18 F-FET PET Compared with 18 F- FDG PET and CT in Patients with Head and Neck Cancer Present by Intern 羅穎駿 Journal of Nuclear Medicine Vol. 47 No
Update on 18 F-Fluorodeoxyglucose/Positron Emission Tomography and Positron Emission Tomography/ Computed Tomography Imaging of Squamous Head and Neck.
Advances in Nuclear Medicine and its Impact on Diagnosis and Management of GI Cancers Medhat Osman, MD PhD Philip Alderson, MD.
MedPix Medical Image Database COW - Case of the Week Case Contributor: Hugh M Dainer Affiliation: National Capital Consortium.
© Copyright 2003 Cardinal Health, Inc. or one of its subsidiaries. All rights reserved. PET in Colorectal Cancer Early detection of disease Precise Staging.
Integrated PET/CT in Differentiated Thyroid Cancer: Diagnostic Accuracy and Impact on Patient Management J Nucl Med 2006; 47:616–624 報告者 : 蘇惠怡.
The Detection of Bone Metastases in Patients with High-Risk Prostate Cancer: 99 mTc-MDP Planar Bone Scintigraphy, Single- and Multi-Field-of-View SPECT,
Thorax / Lung Basic Science Conference 12/21/2005 J.R. Nitzkorski.
SYB Case 2 By: Amy. History 63 y/o female History of left breast infiltrating duct carcinoma s/p mastectomy in 1996 and chemotherapy ER negative, PR negative,
Right shoulder and chest pain Kate Rubey November 2013.
PET Applications in Oncology
Kh Taalab IMC Role of FDG PET In Characterization of Lung Diseases Cairo Chest 2014 Khalid Muhammad Taalab M.B,B.Ch., M.Sc., M.D. IAEA- Research Fellowship.
Hodgkin’s Lymphoma By: Tonya Weir and Paige Mathias Date: October 13, 2010.
IRIA 67th Annual Conference
Functional Imaging with PET for Sarcoma Rodney Hicks, MD, FRACP Director, Centre for Molecular Imaging Guy Toner, MD, FRACP Director, Medical Oncology.
radio-iodinated metaiodobenzylguanidine (123I-MIBG)
PET in Colorectal Cancer. Indications for FDG PET Rising marker, (-) CT/MRI Nonspecific findings on CT/MRI, recurrence or post treatment changes? Known.
Follow up in Chest Tumors : Value of integrated PET/CT By : Dr. Heba Nabil, MSc Radiology Specialist at Nasser Institute For Research and Treatment.
PET/CT AND PAEDIATRIC ONCOLOGY: A SINGLE CENTRE EXPERIENCE A. Cistaro 1, L. Gastaldo 2, A. Brach del Prever 3, V. Arena 1, E. Pelosi 1, M. Mancini 1 CONCLUSIONS.
FDG PET/CT case report early detection of ovarian cancer NM case conference, chairman: Nan-Jing Peng, MD.
NeoTect Tc99m Depreotide Injection. NeoTect  Approved by the FDA - August 3, 1999  Used in Imaging Pulmonary Masses  Normal activity in high concentrations.
Incidentally find an adrenal tumor on health screening by FDG-PET/CT Nan-Jing Peng, MD Department Nuclear Medicine.
CARATTERIZZAZIONE DI LESIONI DI ORIGINE SCONOSCIUTA SOSPETTE PER LESIONI MALIGNE NEI PAZIENTI PEDIATRICI: POSSIBILE RUOLO DEL 18F-FDG PET/CT A.Cistaro.
1. Clinical Impression? Differentials?. Thyroid Carcinoma commonly manifests as a painless, palpable, solitary thyroid nodule The patient's age at presentation.
Characteristic Dynamic Enhancement Pattern of MR imaging for Malignant Thyroid Tumor XIX Symposium Neuroradiologicum Division of Head & Neck radiology.
Anaplastic thyroid cancer based on ATA guideline for Management of Patients with ATC. Thyroid. 2012;22: R3 이정록.
IMAGING OF INCIDENTAL ADRENAL LESIONS: PRINCIPLES, TECHNIQUES AND ALGORITHMS Giles W.L. Boland Massachusetts General Hospital Harvard Medical School.
Preoperative staging of hilar cholangiocarcinoma by dual-modality PET/CT. DR SIKANDAR YASHODA HOSPITALS HYDERABAD.
간담도 암에서의 PET 의 활용 핵의학과 홍일기. 18 F-FDG PET: Warburg effect.
Background: Malignant pleural mesothelioma (MPM) is a rare and aggressive tumor with a complex growth pattern. Imaging plays a crucial role in diagnosis.
University of Pennsylvania Department of Orthopaedic Surgery Joseph King, Eileen Crawford, Abass Alavi, Arthur Staddon, Lee Hartner, Richard Lackman and.
Metastatic Amelanotic Melanoma
FDG Squamous Cell Carcinoma of Tonsil
Badiee MD SPRING 2017 MULTIMODALITY
PET Applications in Oncology 2015/2016
CT and PET imaging in non-small cell lung cancer
Keith E. Kelly, MD and William H. Culbertson, MD
FDG PET-CT of Genitourinary and Gynecologic Tumors: Overcoming the Challenges of Evaluating the Abdomen and Pelvis  Leslie K. Lee, MD, Aoife Kilcoyne,
Whole Body 18F-FDG PET/CT Imaging Staging of Malignant Melanoma:
Whole-body diffusion-weighted magnetic resonance imaging: Current evidence in oncology and potential role in colorectal cancer staging  Doenja M.J. Lambregts,
Michael Lin, Jenn Hian Koo, David Abi–Hanna 
FDG PET-CT Aids in the Preoperative Assessment of Patients with Newly Diagnosed Thymic Epithelial Malignancies  Marcelo F.K. Benveniste, MD, Cesar A.
Tc99m Depreotide Injection
Harika Tirumani, MBBS, Michael H
The Role of Modern Molecular Imaging Techniques in Gastroenterology
MR-PET of the body: Early experience and insights
Pulmonary nodules discovered on CT scan of the chest
Can FDG-PET reduce the need for mediastinoscopy in potentially resectable nonsmall cell lung cancer?  Kemp H Kernstine, MD, PhD, Kelley A McLaughlin,
Serial imaging before and after immunotherapy among patients with MDM2/4 amplifications (N = 6). Serial imaging before and after immunotherapy among patients.
Axial contrast-enhanced CT demonstrates a myocutaneous fat flap (white arrow) used for reconstruction following resection of a squamous cell carcinoma.
Figure 12a Pitfalls in N staging at CT and PET
Presentation transcript:

Dual-time point 18F-FDG PET/CT scan: is it always working? Dr. Hussein R. S. Farghaly Prince Sultan Military Medical City

Rational of Dual Time Point FDG PET/CT The utility of 18F-fluorodeoxyglucose (FDG) PET/CT is widely used for the management of patients with cancer including several aspects including diagnosis, staging, restaging, monitoring therapeutic intervention and radiotherapy planning. However, FDG is not a tumor specific and accumulates also in the inflammatory lesions. So recently F-18 FDG PET/CT is also used for detection, characterization, and monitoring of patients with infectious and non-infectious inflammatory processes. Because of this non-specific uptake of FDG in benign processes such as inflammation and infection, distinguishing malignant lesions from benign ones can be difficult in some cases. Dual time point (DTP) and delayed FDG-PET imaging protocols were developed to enhance the ability of FDG PET/CT for distinction between malignant and benign lesions. The rational for DTP is that pattern and rate of FDG uptake over time vary considerably between malignant and benign processes.

Uptake of FDG. FDG is a glucose analog that is taken up by metabolically active cells by means of facilitated transport via glucose transporters (Glut) in the cell membrane. In the cell cytoplasm, FDG undergoes phosphorylation to form FDG-6-phosphate (6P), which, unlike glucose, cannot undergo further metabolism and becomes trapped within the cell. N = nucleus.

FDG Uptake in Malignant cell vs. inflammatory cell GLUT FDG Low levels of hexokinase High levels of glucose-6-phosphatase, FDG FDG-6P GLUT FDG FDG FDG-6P High levels of hexokinase low levels of glucose-6-phosphatase The accumulation of FDG within cells is dependant upon two main factors: the number of membrane transporters and the ratio of hexokinase to glucose-6-phosphatase. Both malignant and infl ammatory cells have high concentrations of membrane transporters. The brain and the heart have the highest levels of hexokinase and lower levelsof glucose-6-phosphatase, and generally accumulate FDG. Malignant cells have substantially enhanced glucose transporters (GLUT) on their surface. Malignant cells also express high levels of hexokinase and low levels of glucose-6-phosphatase, which lead to an accumulation of FDG in these cells. As FDG accumulates, the contrast between lesions and the normal surrounding tissue increases. This leads to their prominent visualization of lesions on FDG-PET imaging. In contrast, inflammatory cells have higher levels of glucose-6-phosphatase than malignant cells, and therefore a lower ratio of hexokinase to glucose-6-phosphatase. Consequently, FDG-6-phosphate is rapidly dephosphorylated and cleared from the cell, leading to decreasing concentration of this metabolic product in these cells over time

There is evidence in the recent literature of the clinical usefulness of dual-time-point FDG-PET imaging in a wide variety of malignancies, including those of head and neck, lung, breast, gallbladder, cervix, liver, and in brain tumors. A lesion is likely to be malignant if the standard uptake value increases over time, whereas it is likely to be benign if the standard uptake value is stable or decreases. However; there is also evidence in the literature of limited value of DTP FDG –PET such as in characterization of lung nodules, mediastinal lymph nodes (TB endemic areas), primary esophageal car

Studies showed added value of DTP

Studies showed limited value of DTP

DTP FDG-PET/CT preliminary research in PSMMC In our center we reviewed 60 consecutive patients with cancer (19 women, 41 men) with mean age of 63±10.4 years. All patients suspected to have malignant lesions and investigated by performing whole body PET/CT at 60 minutes and delayed limited PET/CT on areas of interest at 120 minutes after the tracer injection. Visual and semiquantitative analysis was performed on both the early and delayed images. All findings were confirmed by histopathology and/or at least 3 months imaging follow-up (clinical, PET/CT, CT or/and MRI). The result consider true positive (TP) in lesions with increased SUV in delayed image and confirmed to be malignant, false positive (FP) in lesions with increased SUV and confirmed to be benign, true negative (TN) in lesions showed decreased or unchanged SUV and confirmed to be benign and false negative (FN) in lesion showed decreased or unchanged SUV and confirmed to be malignant.

Preliminary Results: The total number of suspicious lesions was 82 (the common lesions were 10 presacral soft tissue lesions in rectal car., 9 lung nodules, 7 hepatic lesions, 8 rectal lesion, , 9 Hodgkin’s disease (HD) lesions, 8 head and neck (H&N) lesions, 7 Non-Hodgkin’s lymphoma (NHL) lesions). 32 lesions were histopathologically confirmed and 50 lesions confirmed based on 3 months imaging follow-up. There were 33 TP lesions, 27 FP, 22 NT and no FN results. The overall sensitivity was 98.5% of DTP FDG PET/CT in detecting suspicious lesions. The specificity was 44.9% in differentiating benign from malignant lesions and the accuracy was 67%. PPV was 55%, NPV 100%.

Preliminary Result cont. All hepatic lesions were TP. Lung nodules showed 5 TP, 2 FP and 2 TN with accuracy 78%. Rectal lesions showed 1 TP, 3 FP and 4 TN with accuracy of 62%. Presacral soft tissue lesions showed 2 TP, 2 FP and 6 TN with accuracy 80%. Mediastinal LN showed accuracy of 33.3%. HD lesions showed accuracy of 78% and NHL lesions showed accuracy of 71%. H&N lesions (LN and suspicious recurrent lesions) showed accuracy 75%

CASES presentation

(A) Early FDG WB PET/CT scan (B) 2 hours limited pelvic PET/CT False Positive DTP FDG PET/CT: 41 years old male patient Known case of papillary thyroid carcinoma with negative I-131 WB scan and elevated TG. FDG PET/CT was done to detect the source of TG. Accidentally there is a FDG avid lesion protruded from the rectal wall (arrows) with maxSUV was 6.2 in the early image (A) and increased to 9.7 in the 2 hours delayed limited pelvic PET/CT with rectal enema (B). Polypectomy was done and pathological examination revealed Tubulovillous adenoma.

(A) Early WB FDG PET/CT Fusion ( sagital. Coronal and axial) (B) 2 hours Delayed limited Chest FDG PET/CT Fusion ( sagital. Coronal and axial) True Positive DTP FDG PET/CT: 46-yr-old female patient known case of breast Ca with pulmonary nodule. FDG PET/CT was done for characterization of the lung nodule. (A) early WB FDG PET/CT showed FDG avid right lung apical density (white arrow) with maxSUV of 3.6 and a left supraclavicular brown fat FDG uptake (red arrow) with maxSUV of 8. (B) 2 hours delayed chest FDG PET/CT showed increased of the maxSUV of the lung lesion to 5.6 and left supraclavicular brown to 9.8. CT guided biopsy and pathological examination from the right apical lesion revealed metastases from breast cancer.

(A) Early WB FDG PET/CT images (B) 2 hours delayed pelvic FDG PET/CT True Negative DTP FDG PET/CT: 56 yrs male patient with cancer rectum, post surgery and chemotherapy, CT showed perirectal soft tissue density, FDG PET/CT done to rule out recurrence. (A) Early WB FDG PET/CT fusion images showed heterogeneous FDG uptake in the perirectal soft tissue density with maxSUV of 4. (B) 2 hours delayed pelvic FDG PET/CT images showed decreased in maxSUV to be 2.3 in the perirectal soft tissue density. Biopsy showed minimal non-specific inflammation with no evidence of malignancy.

CONCULSION: DTP 18F-FDG-PET/CT protocol is not always working. However; promising results was noted in hepatic lesions and presacral soft tissue lesions and to less extent in lung nodules and lymphomatous lesions which need further studies with large patient number to emphasize these results. Also concluded that decrease SUV in delayed image has high NPV.