ĐĎॹá>ţ˙ _aţ˙˙˙^˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙ěĽÁq` đż bjbjqPqP .>::ć%˙˙˙˙˙˙¤       Ć?Ć?Ć?8ţ?@\łGś‚@‚@"¤@¤@¤@¤@¤@¤@2G4G4G4G4G4G4G$iHhŃJnXG ‡A¤@¤@‡A‡AXG  ¤@¤@mGĂEĂEĂE‡Al ¤@ ¤@2GĂE‡A2GĂEĂEFń  G¤@v@ €ÇüœÇĆ?óBdňF2GƒG0łGúF?KWC?KG?K G0¤@"Ć@ĂEŢ@ň@•¤@¤@¤@XGXGkEX¤@¤@¤@łG‡A‡A‡A‡A¤"Â&Â&      ˙˙˙˙  Advanced Radiotherapy Consulting Clinical PET Oncology FDG F-18 Nonphysiologic Chemical Structure Similar to that of naturally occurring glucose FDG & Cancer Cells Cancer cells use glucose at faster rate Greater affinity for glucose (membrane transport proteins) Intracellular enzymes are more active than normal FDG & Cancer Cells Varies with the types of cancer Uptake increases with more aggressive tumors Increase Glucose Diffusion Increase rates of glucose phosphorylation Greater FDG accumulation FDG: Problems with Uptake Infection Inflamation Atclectasis Healing Tissues Muscular Activity FDG: Issues Cancer cells that uptake = normal Cancer remains hidden Cancer goes unnoticed Patient Prep / Injection Do Not Exercise (< 24 hours) 10mCi – 20mCi Injection 20ml-30ml saline flush to ensure no iniltration Rest for 45-90 min Patient Prep / Injection Fast for 4-6 hours Want <120mg/dl peripheral blood glucose level No insulin (<2 hours) Increase time, Increase Tumor uptake, Decrease Soft Tissue PET Scan Acquisition Limited Area Scanning: 1 BED Dynamic Imaging: 1 BED (several times) Whole Body Imaging: 7 BEDs Total Body Imaging: 10 BED ETTE Acquistion Emission Transmission Move Table Transmission Emission Normal Tissue Intense Uptake Brain Liver Kidneys Bladder Variable Activity: Organs Salivary Glands Thyroid Heart Thymus Spleen Esophagus Stomach Bowel Endometrium Bone Marrow Muscles Testicles Normal Variations in FDG Localization Myocardial Activity Thyroid Extra-Ocular Muscles Muscular Activities Fat Activity Large Bowel PET Oncology Applications Lung Nodules NSCLC Melanoma Lymphoma Colorectal Head/Neck Breast Brain Prostate Ovarian Thyroid Lung Nodules Increase Uptake: Suggests Malignancy Benign Areas show Uptake Fungal Infection, Pneumonia, Tuberculosis Lung Nodules Note intense uptake Motion Issues Normal Tissue Uptake Positron Emission Tomography Mediastinal lymph node metastasis can be detected with: Sensitivity: 90 % (CT: 75 %) Specificity: 90 % (CT: 66 %) (Ref Chao) Lung Cancer NSCLC PET is superior to CT and MRI for showing nodal involvement Difficult to distinguish between benign and malignant disease (SUVs are the same) NSCLC Melanoma Melanoma may be aggressive and show intense uptake May be difficult to assess small surface skin metastases (faint images) Lymphoma Lymphoma actively accumulate FDG PET, unlike MRI and CT, can discriminate between scar tissue versus active disease Used to assess response to treatment by comparing pre and post treatment scans Lymphoma Colorectal Cancer Cancers frequently metastasize to liver Whole body PET accurately assessing liver involvement and distant mestastasis Head/Neck Cancers PET is superior to CT and MRI for lymph node analysis H/N Cancer staging is very dependent on nodal status Uptake by normal organs must be adequately addressed Post Treatment Imaging should be done > 1month after treatment due to the inflammatory response of tissues caused by radiation therapy Head/Neck Whole Body PET Normal Tissue Uptake Arm Positioning Head/Neck Imaging: PET Staging & Diagnosis Studies are indicating that PET may be more sensitive and specific in evaluating HNSCC lymphatic metastasis compared with CT and MRI. Sensitivity: PET (90%) CT (82%) Sensitivity: PET (90%) MRI (80%) Specificity: PET (94%) CT (85%) Specificity: PET (94%) MRI (79%) Ref Chao Head/Neck Imaging: PET Detection of Recurrence Post Surgery, Primary Chemo, and Irradiation, Identification of Tumor Response is Difficult PET is Superior in Identifying Recurrence Time After Irradiation may be between 2 months – 4 months 1 month post treatment PET Evaluation may lead to high false negatives Head/Neck Imaging: PET Assessing Real Time Treatment Response Early studies may show the role of PET evaluation during course of treatment FDG uptake variation may be due to normal tissue inflammatory response FDG uptake increases up to 5 Gy – 10 Gy, then shows decrease Breast Cancer PET is good for assessing axillary and mediastinal lymph nodes PET is not good for assessing micrometastases PET is good for assessing local reoccurences PET can be used to assess tumor response This may be used as a tool to address appropriate treatment options Breast Opposite Side of Primary Disease Changes Staging Breast Primary Uptake Nodal Uptake Liver Mets Uptake Brain Cancer PET is not used as a screening tool PET helps differentiate residual tumor from radiation necrosis Prostate Cancer PET may be used for assessing distant metastais Bladder may mask uptake in the Prostate A different radiopharmaceutical is needed Prostate Ovarian Cancer Ovarian Cancer Spread can be vast and PET can serve as a screening tool Well differentiated tumors may have normal uptake Metastasis may be difficult if area is close to the liver, spleen, or colon Issues: Radiation Oncology 1. Defines Staging (TNM) 2. Target Delineation 3. Field Placement 4. Monitoring SUV Standard Uptake Value Quantitative Measure of Glucose Metabolism Avg Voxel Value within an ROI Relative to Individual Patient Tumor and Response Malignant vs Benign SUV Limitations Definition of ROI Tumor Heterogeneity: Necrosis Tumor Volume changes with Time Small Tumors (size and resolution) SUV and Target Delineation Limits defined SUV of ROI base values Region determined by PET Borders determined by CT Calibrated Methods for scanners Summary PET is superior for lymphatics Need for New PET isotopes Need for SUV standardization Motion artifacts should be addressed False positives need addressed     PAGE  PAGE 1 =>Cš­A B C U V    ` a k l m n o p ~ Ě Í Î ç _ y ! ƒ ž Ÿ   ° Ç Ň ç č ň ó  + , - H ľ ś ˇ Ý :;<VŽˇÄ.;qrs‘ś¸Á<=F  œüřđéđéüâđÚéüâđéüřÖŇÖřâđéüËđéđéüËđéÖüËđéđéüÖËđéüËđéüËđéüËđéÖéđéđéüËđéđéÖđéÖđéüËđé hSTŻh^~÷h‹aŰh^~÷h‹aŰhÁ@~>* hSTŻhÁ@~ hSTŻhSTŻh‹aŰhSTŻ>*hÁ@~hSTŻP<=CHW™š­Ő B C V v Ł ž č    ' 3 ? ýřëřřăăăřřăăăŢřăăăăăŢřăăăgdÁ@~ & FgdSTŻ &dPĆ˙gdSTŻgdSTŻć ţţ? 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