1. L'uso della PET nella diagnosi precoce e la valutazione del SUV CT
[18F]FDG PET
L'uso della PET nella diagnosi precoce
e la valutazione del SUV
come indicatore di prognosi
Gino Pepe
Medicina Nucleare – PET H.SanRaffaele IRCCS - Milano

2. [18F]FDG-PET

3. Why [18F]FDG-PET in tumors?

4. Why [18F]FDG-PET in tumors?
Elevated glucose metabolism in tumor

5. Why [18F]FDG-PET in tumors?
Elevated glucose metabolism in tumor
[18F]FDG is a glucose analog

6. Why [18F]FDG-PET in tumors?
Elevated glucose metabolism in tumor
[18F]FDG is a glucose analog
[18F]FDG uptake into viable neoplastic cells

7. [18F]FDG PET: APPLICATION IN LUNG CANCER
Differentiating benign from malignant lesions (SPN)
Staging N and M and re-staging for therapy planning
Predicting and monitoring response to therapy

8. Solitary Pulmonary Nodule (SPN)
Solitary lung lesion < 3 cm in diameter
20% - 40% of SPN are malignant
Initial presentation in 20% - 30% of lung cancer
Coleman et al. J Nuc Med 1999

9. Measure of metabolic activity of SPN
[18F]FDG PET
Measure of metabolic activity of SPN
Visual Analysis
Quantitative analysis CT CT
[18F]FDG PET
[18F]FDG PET
SUV = 7.3

10. Measure of metabolic activity of SPN
[18F]FDG PET
Measure of metabolic activity of SPN
Visual Analysis: nodule activity vs mediastinal blood pool activity
Quantitative analysis CT CT
[18F]FDG PET
[18F]FDG PET
SUV = 7.3

11. Measure of metabolic activity of SPN
[18F]FDG PET
Measure of metabolic activity of SPN
Visual Analysis: nodule activity vs mediastinal blood pool activity
Quantitative analysis CT CT
[18F]FDG PET
[18F]FDG PET
SUV = 7.3

12. Measure of metabolic activity of SPN
[18F]FDG PET
Measure of metabolic activity of SPN
Visual Analysis
Quantitative analysis: SUV (standardized uptake value) CT CT
[18F]FDG PET
[18F]FDG PET
SUV = 7.3

13. Standardized Uptake Value = SUV
SUVBW = Ct/(ID/BW) = (kBq/ml) / (MBq/Kg)
SUVLBM = Ct/(ID/LBM) = (kBq/ml) / (MBq/Kg)
LBM uomini =1.1 * W *(W/h)2
LBM donne = 1.07 * W *(W/h)2
SUVBSA = Ct/(ID/BSA) = (kBq/ml) / (MBq/m2)
BSA = * W * h 0.725

14. Measure of metabolic activity of SPN
[18F]FDG PET
Measure of metabolic activity of SPN
Visual Analysis
Quantitative analysis: SUV (standardized uptake value) CT CT
[18F]FDG PET
[18F]FDG PET
SUV = 7.3

15. Measure of metabolic activity of SPN
[18F]FDG PET
Measure of metabolic activity of SPN
Visual Analysis
Quantitative analysis: SUV (standardized uptake value) CT CT
[18F]FDG PET
[18F]FDG PET
SUV = 7.9
SUV = 7.3

16. Lung cancer is hypermetabolic
[18F]FDG PET
Lung cancer is hypermetabolic
A SPN with SUV more than 2.5 is considered to be malignant
No difference between visual vs. quantitative analysis
Sens Spec PPV NPV Acc
Visual
SUV
Hain SF et al. Eur J Nucl Med 2001

17. CT
[18F]FDG PET
Fused
SPN: 1.2 cm in diameter
HSR - Milano

18. CT
[18F]FDG PET
CT- PET
SPN: 1.4 cm in diameter
HSR - Milano

19. Accuracy of PET with [18F]FDG in SPN or Pulmonary Opacity
Authors Sensitivity Specificity Accuracy
Duhaylongsod (1995) 97% % 92%
Bury (1996) 100% % 96%
Lowe (1998) 98% % 89%
Prauer (1998) 90% % 87%
Graeber (1999) 97% % 92%
Hung (2001) 95% % 86%
Hellwig (2001) (meta-analysis) 96% % -
Gould (2001) (meta-analysis) 97% 78% -
Hickeson (2002) (using PET-CT) 97% % 92%

20. Limitations of FDG-PET for Lung Nodule Characterization: False-positive results
Inflammatory lesions (mainly granulomas)
Tubercolosis
Sarcoidosis
Aspergillosis
Histoplasmosis
Cryptococcosis

21. Limitations of FDG-PET for Lung Nodule Characterization: False-negative results
Small lesion < 5-6 mm
% of viable neoplastic cells in SPN
Lesion Dimension
Histological Type
Hyperglycemia

22. ? CT [18F]FDG PET Fused R. F. 53 aa Lung nodule 4 mm in diameter
HSR - Milano

23. CT
[18F]FDG PET
CT- PET
Z. A. 41 aa
SPN: 4 mm in diameter
HSR - Milano

24. Limitations of FDG-PET for Lung Nodule Characterization: False-negative results
Lesion Dimension
Histological Type
Hyperglycemia
Carcinoid
Pure Bronchioloalveolar Carcinoma (BAC), mucinous ca, neuroendocrine tumor
Well differentiated type

25. CT
[18F]FDG PET
CARCINOID
HSR - Milano

26. CT [18F]FDG PET PET/CT P. G. 68 aa SPN: 10 mm in diameter
Well differentiated tumor
HSR - Milano

27. [18F]FDG PET IN LUNG CANCER SUV and histological type
Mean SUV
BAC (12) 1.3
Well Differentiated (10) 3.1
Moderately differentiated (12) 4.3
Poorly differentiated (4) 5.6
Higashi et al. Nucl Med Comm 2000

28. [18F]FDG PET IN LUNG CANCER FDG uptake in BAC
No [18F]FDG uptake in more than 50% of patients with BAC
85,7% of BAC are negative for Glut-1 (glucose transporter) expression (Higashi 2000)
[18F]FDG-PET FN
A different PET tracer may solve the problem

29. Pure Bronchioloalveolar CarcinomaCT
[11C]Choline PET
[18F]FDG PET
SUV = 1.73
B. A. 65 aa
HSR Milano

30. Limitations of FDG-PET for Lung Nodule Characterization: False-negative results
Lesion Dimension
Histological Type
Hyperglycemia
> 200 mg/dl = PET not performed

31. Mediana di sopravvivenza 12.1 mesi nei pz con PET + dopo terapia
VALUTAZIONE DELLA RISPOSTA ALLA TERAPIA
con PET e [18F]FDG NEL TUMORE POLMONARE
113 pazienti con neoplasia polmonare NSC trattati con chemio o radiochemioterapia
Differenza significativa nella sopravvivenza tra pazienti con PET positiva e pazienti con PET negativa
Mediana di sopravvivenza
12.1 mesi nei pz con PET + dopo terapia
34.2 mesi nell’85% dei pz con PET - dopo terapia
Patz et al AJR, 2000

32. FDG-PET: VALUTAZIONE PRECOCE DELLA RISPOSTA ALLA CHEMIOTERAPIA
57 pazienti in stadio IIIB o IV studiati con PET prima e dopo I° ciclo di chemio
PET Responder (SUV –61%)
PR in 20/28 PET responders (71%)
SD o PD in 26/27 PET non responders (96%)
Weber et al., J Clin Oncol 2003; 21:2651

33. PET in SPN Who: When: Why: Patient with indetermined lung nodule
After a CT study
Why:
Metabolic characterization of indetermined lung nodule (benign vs malignant)