1. 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

2. 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

3. 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.

4. 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

5. 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

6. 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)

7. Elevated TG/Negative Dosimetry
GS, 29 yo female undergoing rTSH dosimetry testing.
Negative Iodine-131 Whole Body Scans
TG levels =6 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

8. 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

9. Post Rx
I-131
MB763123

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

12. 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.

13. “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

14. 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

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

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

17. 124I-Iodine in Thyroid Cancer
203 cGy/mCi
229 cGy/mCi
125 cGy/mCi
277269

18. 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

19. 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