FDG PET and PET-CT for GI Malignancies: Colorectal cancer

FDG PET and PETFDG PET and PET--CT for GI Malignancies:CT for GI Malignancies:Colorectal cancerColorectal cancer

Hepatobiliary malignanciesHepatobiliary malignanciesPancreatic cancerPancreatic cancer

Esophageal and Gastric cancerEsophageal and Gastric cancer

Dominique Delbeke, MD, PhDDominique Delbeke, MD, PhDVanderbilt University Medical CenterVanderbilt University Medical Center

Nashville, TNNashville, TN

VUMC PET Conference August 2009VUMC PET Conference August 2009

AbdelAbdel--NabiNabi et al. Radiology 1998;206:755et al. Radiology 1998;206:755--760.760.MukaiMukai et al. Oncology Reports 2000;7:85et al. Oncology Reports 2000;7:85--87.87.KantorovaKantorova I et al. J I et al. J NuclNucl Med 2003;44:1784Med 2003;44:1784--1788.1788.

FDG PET in the Initial Evaluation of Colorectal carcinomaFDG PET in the Initial Evaluation of Colorectal carcinoma

There are ~133,200 new cases/year in the US.There are ~133,200 new cases/year in the US.Diagnosis based on colonoscopy Diagnosis based on colonoscopy Preoperative staging: Preoperative staging: intraoperativelyintraoperativelyPreoperative staging with FDG PET:Preoperative staging with FDG PET:

Good sensitivity for detection of primaries, F+ Good sensitivity for detection of primaries, F+ inflammatory bowel disease inflammatory bowel disease Poor performance for regional LN involvementPoor performance for regional LN involvementBetter sensitivity and specificity than CT for Better sensitivity and specificity than CT for detection of hepatic metastasesdetection of hepatic metastases

65 year65 year--old patient presenting for initial staging of colon cancerold patient presenting for initial staging of colon cancer

A 45 year old female presented with liver metastases of UPA 45 year old female presented with liver metastases of UP

From Delbeke D et al. From Delbeke D et al. SeminSemin Nucl Med 2004;34(3):209Nucl Med 2004;34(3):209--223.223.

Incidental FDG uptake in GI tract on PET/CTIncidental FDG uptake in GI tract on PET/CT1,750 WB PET performed for evaluation of known or suspected 1,750 WB PET performed for evaluation of known or suspected malignanciesmalignancies

Results: Incidental focal FDG uptake: 3.3% of unexpected foci (Results: Incidental focal FDG uptake: 3.3% of unexpected foci (58 in 53 58 in 53 patients)patients)42 pathologically confirmed42 pathologically confirmed

Incidence of unexpected proven tumors = 1.7%: Incidence of unexpected proven tumors = 1.7%: 18 colonic adenomas and 3 carcinomas18 colonic adenomas and 3 carcinomas

3,281 patients (20013,281 patients (2001--2003)2003)Results: Results: Incidental GI uptake: 3%Incidental GI uptake: 3% (98/3,281)(98/3,281)

Histopathology: 69/98 patientsHistopathology: 69/98 patientsCancer: 19% (13/69)Cancer: 19% (13/69)Precancerous lesions: 42% (29/69)Precancerous lesions: 42% (29/69)Benign and inflammatory: 25% (18/69)Benign and inflammatory: 25% (18/69)

1,716 patients 1,716 patients Results: Results: Incidental GI uptake: 2.6%Incidental GI uptake: 2.6% (45/1,716)(45/1,716)

Colonoscopy: 20/45Colonoscopy: 20/45Advanced neoplasms: 65% (13/20)Advanced neoplasms: 65% (13/20)

Agress H et al. Radiology 2004;230(2):417Agress H et al. Radiology 2004;230(2):417--422422KamelKamel EM et al. J EM et al. J NuclNucl Med 2004;45:1804Med 2004;45:1804--1810.1810.GutmanGutman F et al. Am J F et al. Am J RoentgenolRoentgenol 2005;185:4952005;185:495--500.500.

Detection of Recurrent Colorectal CarcinomaDetection of Recurrent Colorectal Carcinoma

70% are resected with curative intent 1/3 have recurrence 70% are resected with curative intent 1/3 have recurrence within 2 years. within 2 years.

25% have recurrence to one site and are potentially 25% have recurrence to one site and are potentially curable by surgical resection .curable by surgical resection .

Conventional methods for detection of recurrence:Conventional methods for detection of recurrence:CEA levels: Only ~2/3 of patients have elevated and it CEA levels: Only ~2/3 of patients have elevated and it

does not localize.does not localize.CT: suboptimal for CT: suboptimal for

Metastases in the peritoneum, mesentery, LNMetastases in the peritoneum, mesentery, LNDifferentiation of postDifferentiation of post--treatment changes from treatment changes from

recurrence.recurrence.Barium enema: local recurrence only (accuracy 80%).Barium enema: local recurrence only (accuracy 80%).

FDG PET for Detection of Recurrent Colorectal CarcinomaFDG PET for Detection of Recurrent Colorectal Carcinoma

Sensitivity of FDG PET is ~ 90% and specificity > 70%, both > toSensitivity of FDG PET is ~ 90% and specificity > 70%, both > to CTCT

100%100%95%95%Local recurLocal recur2929Strauss 89Strauss 89

61%61%87%87%PelvisPelvis

69%69%100%100%LiverLiver4141Johnson 01Johnson 0172%72%91%91%90%90%98%98%All sitesAll sites100100StaibStaib 0000

71%71%100%100%100%100%LiverLiver2828Zhuang 00Zhuang 0058%58%Mucinous +Mucinous +92%92%Mucinous Mucinous --105105WhitefordWhiteford

50%50%78%78%79%79%93%93%All sitesAll sitesValk 99Valk 9980%80%52%52%100%100%95%95%LiverLiver80%80%52%52%100%100%91%91%Local recurLocal recurOgunbiyOgunbiy 979771%71%74%74%92%92%100%100%Other sitesOther sites78%78%81%81%92%92%91%91%LiverLiver6161Delbeke 97Delbeke 9758%58%86%86%100%100%90%90%LiverLiver2424Vitola 96Vitola 96

CT SpecCT SpecCT CT SensSensPET PET SpecSpec

PET PET SensSens

SitesSitesNo No patientspatients

ReferenceReference

FDG PET for Detection of Recurrent Colorectal CancerFDG PET for Detection of Recurrent Colorectal Cancer

MetaMeta--Analysis: 11 studies and 577 patients analyzed on Analysis: 11 studies and 577 patients analyzed on a patienta patient--basis:basis:

Sensitivity: Sensitivity: 97%97%Specificity: Specificity: 75%75%

higher for local recurrence and hepatic metastases (>95%)higher for local recurrence and hepatic metastases (>95%)Change of management was Change of management was 29%.29%.

Summary of the literature for evaluation of recurrence:Summary of the literature for evaluation of recurrence:Sensitivity: PET Sensitivity: PET 94%,94%, CT 79% (2244 patients studies)CT 79% (2244 patients studies)Specificity: PET Specificity: PET 87%,87%, CT 73% (2244 patients studies)CT 73% (2244 patients studies)Change in management: Change in management: 32%32% (915 patients studies)(915 patients studies)

HuenerHuener RH et al. J Nucl Med 2000;41:1177RH et al. J Nucl Med 2000;41:1177--1189.1189.Gambhir SS et al. J Nucl Med 2001;42(suppl):9SGambhir SS et al. J Nucl Med 2001;42(suppl):9S--12S.12S.

FDG PET for Detection of Local FDG PET for Detection of Local Recurrence of Colorectal CarcinomaRecurrence of Colorectal Carcinoma

YearYearNo of No of PatientsPatients

AccuracyAccuracyPETPET

AccuracAccuracy CTy CT

Strauss Strauss 19891989 2929 100%100% EE

Ito Ito 19921992 1515 100%100% EE

Falk Falk 19941994 16 16 93%93% 60%60%

Beets Beets 19941994 8 / 358 / 35 63% *63% * EE

SchiepersSchiepers 19951995 7676 95%95% 65%65%

OgunbiyiOgunbiyi 19971997 21/5821/58 90%90% 48%48%

Schiepers et al. Eur J Clin Oncol 1995;21:517-522.

63 year63 year--old male with history of colon cancer presented with old male with history of colon cancer presented with rising CEA levelsrising CEA levels

Diagnosis: Local recurrenceDiagnosis: Local recurrence

From Delbeke D et al. From Delbeke D et al. SeminSemin Nucl Med 2004;34(3)209Nucl Med 2004;34(3)209--223.223.

A 61A 61--yearyear--old female with a history of colon cancer old female with a history of colon cancer presented with suspected local recurrencepresented with suspected local recurrence

A 61A 61--yearyear--old female with a history of colon cancer old female with a history of colon cancer presented with suspected local recurrencepresented with suspected local recurrence

Diagnosis:Diagnosis:1)1) Local Local

recurrencerecurrence2)2) Metastasis Metastasis

in left in left presacral LNpresacral LN

Comparison FDG PET/multiphase CT and Comparison FDG PET/multiphase CT and intraoperative US for Detection of Hepatic Metastasesintraoperative US for Detection of Hepatic Metastases

131 patients selected for hepatic resection of colorectal 131 patients selected for hepatic resection of colorectal liver metastases: 363 liver metastases were identifiedliver metastases: 363 liver metastases were identifiedSensitivity for detection:Sensitivity for detection:

63 lesions < 10 mm: 63 lesions < 10 mm: CT CT PET 16% PET 16% 172 lesions 10172 lesions 10--20 mm: CT 72% 20 mm: CT 72% PET 75%PET 75%128 lesions > 20 mm:128 lesions > 20 mm: CT 97% CT 97% PET 95%PET 95%AllAll CT 71% CT 71% PET 72%PET 72%Both CT and PET missed ~ 30% smaller lesions resulting in Both CT and PET missed ~ 30% smaller lesions resulting in change in management in 7% (9/131) patientschange in management in 7% (9/131) patients

WieringWiering B et al. Ann B et al. Ann SurgSurg Oncol 2007;14(2):818Oncol 2007;14(2):818--2626

FDG PET, CT and MRI for Detection of Colorectal FDG PET, CT and MRI for Detection of Colorectal Hepatic Metastases: MetaHepatic Metastases: Meta--analysisanalysis

MetaMeta--analysis comparing nonanalysis comparing non--invasive methodsinvasive methods61/165 data sets were included61/165 data sets were included

Sensitivity for detection of liver metastases: Sensitivity for detection of liver metastases: PatientPatient LesionLesion Lesions>1 cmLesions>1 cm

CTCT--non helical: non helical: 60%60% 52%52% 74%74%

CTCT--helical: helical: 6565%% 64%64% 74%74%MR no GadMR no Gad 76%76% 66%66% 65%65%MR GadMR Gad 69%69%MR SPIOMR SPIO 90%90%PET: PET: 95%95% 76%76%

BipatBipat S, S, vanLeeuwenvanLeeuwen MS, MS, ComansComans EF et al. Radiology 2005;237:123EF et al. Radiology 2005;237:123--131. 131.

FDG PET for Detection of Extrahepatic FDG PET for Detection of Extrahepatic MetastasesMetastases

Study of over 155 patients analyzed by sites Study of over 155 patients analyzed by sites of lesions: of lesions:

Sensitivity: FDG PET > CTSensitivity: FDG PET > CT for all locations, for all locations, except the lungs where the two modalities are except the lungs where the two modalities are equivalent.equivalent.

FDG PET particularly helpful for abdomen, FDG PET particularly helpful for abdomen, pelvis and retroperitoneumpelvis and retroperitoneum

Specificity: FDG PET > CTSpecificity: FDG PET > CT at all sites, except at all sites, except the retroperitoneumthe retroperitoneum

Valk PE et al. Arch Valk PE et al. Arch SurgSurg 1999;134:5031999;134:503--511.511.

A 37A 37--yearyear--old female with a history of metastatic colon old female with a history of metastatic colon cancer to the liver s/p colectomy and hepatic resection cancer to the liver s/p colectomy and hepatic resection presented for restagingpresented for restaging

Diagnosis: Diagnosis: Multiple Multiple metastatic foci in metastatic foci in abdomen abdomen

From Delbeke D. Diagnostic Imaging 2004.From Delbeke D. Diagnostic Imaging 2004.

FDG PET for Detection of Metastases in Patients FDG PET for Detection of Metastases in Patients with Rising CEA levels and Normal Workwith Rising CEA levels and Normal Work--upup

100%100%79%79%434320012001FlamenFlamen83%83%94%94%727220002000MaldonadoMaldonado92%92%90%90%323219991999Valk Valk 100%100%77%77%222219981998FlanaganFlanagan

SpecificitySpecificitySensitivitSensitivityy

No patientsNo patientsYearYearReferenceReference

When the conventional workWhen the conventional work--up is negative (including CT), FDG up is negative (including CT), FDG PET demonstrates tumor in 84%PET demonstrates tumor in 84% (142/169) of the patients.(142/169) of the patients.PET allowed surgical resection in 26% of patientsPET allowed surgical resection in 26% of patients

Flanagan FL et al. Ann Flanagan FL et al. Ann SurgSurg 1998;227:3191998;227:319--323.323.Valk PE et al. Arch Valk PE et al. Arch SurgSurg 1999;134:5031999;134:503--511.511.Maldonado A et al. Clin Pos Imaging 2000;3:170.Maldonado A et al. Clin Pos Imaging 2000;3:170.FlamenFlamen P et al. P et al. EurEur J Cancer 2001;37:862J Cancer 2001;37:862--869.869.

4444--yearyear--old man with a history of colon ca with rising CEA levold man with a history of colon ca with rising CEA lev

From: Delbeke D et al (From: Delbeke D et al (edseds): ): ““Practical FDG Imaging: A teaching FilePractical FDG Imaging: A teaching File”” SpringerSpringer--VerlagVerlag 2002.2002.

Clinical Impact of FDG PET in Colorectal CancerClinical Impact of FDG PET in Colorectal Cancer

14% (6/43)14% (6/43)23% (10/43)23% (10/43)4343Strasberg 01*Strasberg 01*65% (66/102)65% (66/102)102102KalffKalff 000061% (61/100)61% (61/100)95%95%100100StaibStaib 000021% (16/71)21% (16/71)21% (16/71)21% (16/71)7171ImdhalImdhal 000020% (21/10320% (21/10315% (9/60)15% (9/60)103103FlamenFlamen 999934% (17/73)34% (17/73)36% (35/96)36% (35/96)155155Valk 99Valk 9944% (10/23)44% (10/23)2323OgunbiyiOgunbiyi 979728% (17/61)28% (17/61)28% (17/61)28% (17/61)92%92%6161Delbeke 97Delbeke 9732% (11/34)32% (11/34)3434Lai 96Lai 96

13% (10/76)13% (10/76)9595--98%98%7676SchiepersSchiepers 959540%(14/35)40%(14/35)3535Beets 94Beets 94

Clinical Clinical Impact Impact

Unsuspected Unsuspected PET accuracyPET accuracyNo patientsNo patientsReferenceReference

TotalTotal 803803 25% (108/441) 36% (238/645)25% (108/441) 36% (238/645)

Impact of FDG PET in the Management of Impact of FDG PET in the Management of Colorectal Hepatic Metastases: MetaColorectal Hepatic Metastases: Meta--analysisanalysis

Pooled Sensitivity and Specificity of FDG PET Pooled Sensitivity and Specificity of FDG PET and CT from studies in patients evaluated for and CT from studies in patients evaluated for hepatic resection:hepatic resection:

Hepatic metastases:Hepatic metastases:Sensitivity: PET 88%Sensitivity: PET 88% CT 82%CT 82%Specificity: PET 96%Specificity: PET 96% CT 84%CT 84%

ExtrahepaticExtrahepatic metastases:metastases:Sensitivity: PET 91%Sensitivity: PET 91% CT 61%CT 61%Specificity: PET 95%Specificity: PET 95% CT 91%CT 91%

Change in management: 31% (range 20Change in management: 31% (range 20--58%)58%)

WieringWiering B et al. Cancer 2005;104:2658B et al. Cancer 2005;104:2658--2670.2670.

Clinical Impact of FDG PET in Patients with Clinical Impact of FDG PET in Patients with Colorectal Carcinoma: Survival dataColorectal Carcinoma: Survival data

Survival at 3 yearsSurvival at 3 years of patients with FDG of patients with FDG PET: PET: 77%77% (higher than historical series).(higher than historical series).Survival at 5 yearsSurvival at 5 years of patients with hepatic of patients with hepatic metastases preoperatively staged with:metastases preoperatively staged with:

CIM (19 studies with 6,019): 30%CIM (19 studies with 6,019): 30%FDG PET (100 patients): FDG PET (100 patients): 58%58%

Contribution: Detection of occult disease Contribution: Detection of occult disease and reduction of futile surgeriesand reduction of futile surgeries

••Strasberg SM et al. Ann Strasberg SM et al. Ann SurgSurg 2001;233:320.2001;233:320.••Fernandez FG et al. Ann Fernandez FG et al. Ann SurgSurg 2004;240 (3):4382004;240 (3):438--447447

Impact of PET/CT on Radiation TherapyImpact of PET/CT on Radiation Therapy

39 patients with various solid tumors39 patients with various solid tumorsComparison GTV delineated on CT Comparison GTV delineated on CT vsvs with PET overlaywith PET overlayPET changed GTV in 56% of patientsPET changed GTV in 56% of patients

GTV increased by 25% or more because of PET:GTV increased by 25% or more because of PET:17% of patients with H&N tumors and lung cancer17% of patients with H&N tumors and lung cancer33% of patients with cancer of the pelvis33% of patients with cancer of the pelvis

GTV was reduced by 25% or more because of PET:GTV was reduced by 25% or more because of PET:33% of patients with H&N tumors33% of patients with H&N tumors67% of patients with lung cancer67% of patients with lung cancer19% of patients with cancer of the pelvis19% of patients with cancer of the pelvis

Delineation variabilityDelineation variability decreased: decreased: mean mean volvol difference of difference of 25 cm25 cm33 to 9 cmto 9 cm3.3.

Change treatment from Change treatment from curative to palliative: curative to palliative: 16% patients16% patients

CiernikCiernik F, F, DizendorfDizendorf E, E, BaumertBaumert BG, et al. BG, et al. IntInt J Radiation Oncol J Radiation Oncol BiolBiol Phys;2003;57:853Phys;2003;57:853--863.863.

Colorectal cancer: FDG PET versus PET/CTColorectal cancer: FDG PET versus PET/CT

45 patients: retrospective review45 patients: retrospective reviewStandard of reference: Interpretation by a panel Standard of reference: Interpretation by a panel of expertsof expertsIncremental diagnostic value of PETIncremental diagnostic value of PET--CT:CT:

Equivocal: decrease by 50%Equivocal: decrease by 50%Characterization: increase by 30%Characterization: increase by 30%Definite localization: increase by 25%Definite localization: increase by 25%No significant change in sensitivity and specificityNo significant change in sensitivity and specificityCorrect staging increased from 78% to 89%Correct staging increased from 78% to 89%

Cohade C et al. J Nucl Med 2003;44:1797Cohade C et al. J Nucl Med 2003;44:1797--1803.1803.SchoderSchoder H et al. J Nucl Med 2004;45 (H et al. J Nucl Med 2004;45 (SupplSuppl): 72S.): 72S.

ContrastContrast--enhanced CT versus PET/CTenhanced CT versus PET/CT76 patients referred for resection of hepatic metastases76 patients referred for resection of hepatic metastasesHepatic metastasesHepatic metastases: :

Sensitivity: Sensitivity: 95% (CT) = 91% (PET/CT)95% (CT) = 91% (PET/CT)PET better for hepatic recurrence with specificity of 100% PET better for hepatic recurrence with specificity of 100% compared to 50% for CTcompared to 50% for CT

Local recurrenceLocal recurrence: : Sensitivity: 53% (CT) < Sensitivity: 53% (CT) < 93% (PET/CT)93% (PET/CT)

ExtrahepaticExtrahepatic metastasesmetastases::Sensitivity: 64% (CT) < Sensitivity: 64% (CT) < 89% (PET/CT)89% (PET/CT)

Impact on management for PET/CT: 21% of patientsImpact on management for PET/CT: 21% of patientsPET/CT falsePET/CT false--negative: negative:

Lesions < 5 mmLesions < 5 mmChemotherapy during month before PET/CT Chemotherapy during month before PET/CT

SelznerSelzner M et al. Ann M et al. Ann SurgSurg 2004;240:10272004;240:1027--10341034

PET/PET/ceCTceCT vsvs PET/non PET/non ceCTceCT54 patients referred for restaging54 patients referred for restaging

PET/non PET/non ceCTceCT > > ceCTceCT in 50% patientsin 50% patientsChanged therapy in 5 patientsChanged therapy in 5 patientsDue to detection of additional lesionsDue to detection of additional lesions

PET/PET/ceCTceCT > PET/non > PET/non ceCTceCT in 72% patientsin 72% patientsChanged therapy in 23 patientsChanged therapy in 23 patientsMainly due to correct segmental localization of liver Mainly due to correct segmental localization of liver metastasesmetastases

53 patients referred for nodal staging of rectal cancer53 patients referred for nodal staging of rectal cancerAccuracy PET/Accuracy PET/ceCTceCT (79%) > PET/non (79%) > PET/non ceCTceCT (70%) but not (70%) but not statistically significantstatistically significantMore accurate for More accurate for pararectalpararectal, internal iliac and , internal iliac and obturatorobturator LNLN

SoykaSoyka JD et al. J JD et al. J NuclNucl Med 2008;49(3):354Med 2008;49(3):354--361361TateishiTateishi U et al. EJNMMI 2007:34(10):1627U et al. EJNMMI 2007:34(10):1627--16341634

Systematic Review: Monitoring and Systematic Review: Monitoring and Predicting Response to TherapyPredicting Response to Therapy

Chemotherapy response monitoring in advanced Chemotherapy response monitoring in advanced colorectal cancer: 5 studies/127 patientscolorectal cancer: 5 studies/127 patients

FDG PET is a good predictor of outcomeFDG PET is a good predictor of outcomeMonitoring responses after local ablative therapy of Monitoring responses after local ablative therapy of liver metastases: 4 studies/131 patientsliver metastases: 4 studies/131 patients

FDG PET can detect earlier than CT incomplete ablation or FDG PET can detect earlier than CT incomplete ablation or recurrencerecurrence

Radiotherapy and multimodality treatment response Radiotherapy and multimodality treatment response evaluation in primary rectal cancer: 19 studies/603 evaluation in primary rectal cancer: 19 studies/603 patientspatients

FDG PET predicted therapy outcome better than FDG PET predicted therapy outcome better than endorectalendorectalUS, CT and MRIUS, CT and MRIFDG PET detect recurrence after XRT: more accurate after 6 FDG PET detect recurrence after XRT: more accurate after 6 months: sensitivity 84%, specificity 88%months: sensitivity 84%, specificity 88%

De De GeusGeus--OeiOei LF et al. JNM 2009;50:43SLF et al. JNM 2009;50:43S--54S.54S.**HaberkornHaberkorn et al. J et al. J NuclNucl Med 1991;32:1485Med 1991;32:1485--1490.1490.

FDG PET for Colorectal Cancer: Monitoring TherapyFDG PET for Colorectal Cancer: Monitoring Therapy

Hepatic metastasesHepatic metastasesChemotherapyChemotherapy##: :

FDG PET can detect nonFDG PET can detect non--responders 4responders 4--5 weeks 5 weeks into chemotherapy with 5into chemotherapy with 5--FUFUThe degree of histological response: PET > CT.The degree of histological response: PET > CT.Good prediction of longGood prediction of long--term outcome (42 mo): term outcome (42 mo):

Recurrence free: Decrease SUV= mean 69%Recurrence free: Decrease SUV= mean 69%Recurrence: Decrease SUV = mean 37%Recurrence: Decrease SUV = mean 37%

*Strauss et al. Radiology 1992;182:549*Strauss et al. Radiology 1992;182:549--552.552.**HaberkornHaberkorn et al. J et al. J NuclNucl Med 1991;32:1485Med 1991;32:1485--1490.1490.Moore HG et al. J Am Moore HG et al. J Am CollColl SurgSurg 2003;197 (1): 222003;197 (1): 22--28.28.

#Findlay et #Findlay et al.Jal.J Clin Oncol;1996;14:700Clin Oncol;1996;14:700--708.708.##GuillemGuillem J et al. J et al. DisDis Colon Rectum 2000;43:18Colon Rectum 2000;43:18--24.24.GuillemGuillem JG et al. J Am JG et al. J Am CollColl surgsurg 2004;199:12004;199:1--7.7.

Patients who underwent hepatic resection immediately or after Patients who underwent hepatic resection immediately or after downstagingdownstaging with 5FU/Folfox/Folfiriwith 5FU/Folfox/Folfiri--based chemotherapybased chemotherapy

Group 1 (27 patients): immediate resectionGroup 1 (27 patients): immediate resectionGroup 2 (48 patients): Group 2 (48 patients): preoppreop neoadjuvant chemoneoadjuvant chemoFDG PET at least 2 weeks after last chemoFDG PET at least 2 weeks after last chemoSensitivity for detection of metastases:Sensitivity for detection of metastases:

FDG PETFDG PET: Group 1 (93%) > : Group 1 (93%) > Group 2 (49%)Group 2 (49%)CT: CT: Group 1 (87.5%) > Group 2 (65%)Group 1 (87.5%) > Group 2 (65%)

Conclusions:Conclusions:PET and CT have a lower sensitivity for detection of PET and CT have a lower sensitivity for detection of hepatic metastases after neoadjuvant chemotherapyhepatic metastases after neoadjuvant chemotherapyCT is slightly more sensitive than FDG PETCT is slightly more sensitive than FDG PET

FDG PET for Colorectal Cancer:FDG PET for Colorectal Cancer:Detection of hepatic metastases after neoadjuvant Detection of hepatic metastases after neoadjuvant

chemotherapychemotherapy

LubeszkyLubeszky N et al. J N et al. J GastrointestGastrointest SurgSurg 2007;11:4722007;11:472--478478

FDG PET for Monitoring Regional Therapy to FDG PET for Monitoring Regional Therapy to the Liverthe Liver

Hepatic metastases:Hepatic metastases:ChemoembolizationChemoembolizationRFA and cryosurgeryRFA and cryosurgery9090YY--microspheresmicrospheres

Findlay et Findlay et al.Jal.J Clin Oncol;1996;14:700Clin Oncol;1996;14:700--708.708.GuillemGuillem J et al. J et al. DisDis Colon Rectum 2000;43:18Colon Rectum 2000;43:18--2424LangenhoffLangenhoff BS et al. J Clin Oncol 2002;20:4453BS et al. J Clin Oncol 2002;20:4453--4458.4458.DonckierDonckier et al. J et al. J SurgSurg Oncol 2003;84:215Oncol 2003;84:215--223.223.Anderson GS et al. Clin Nucl Med 2003;28:192Anderson GS et al. Clin Nucl Med 2003;28:192--197197

PrePre--therapytherapy PostPost--therapytherapy

CTCT

FDG PETFDG PET

From Vitola JV et al. Cancer 1996;78:2216-2222.

Torizuka et al. J Nucl Med 1994;35:1965-1969.

Monitoring Response to ChemoembolizationMonitoring Response to ChemoembolizationFDG PET better than lipiodol retention on CTFDG PET better than lipiodol retention on CTChange in FDG uptake correlate with the change in tumor markersChange in FDG uptake correlate with the change in tumor markers

Residual tumorResidual tumor

Transmission CTTransmission CT

Contrasted CTContrasted CT

FDG PET for Monitoring Therapy with RFAFDG PET for Monitoring Therapy with RFA38 year38 year--old with old with colon cancer who colon cancer who underwent RFA of underwent RFA of a liver metastasis 4 a liver metastasis 4 months earliermonths earlier

Recurrence at RFA siteRecurrence at RFA siteFrom Delbeke D. From Delbeke D. SeminSemin Nucl Med 2004;34:209Nucl Med 2004;34:209--223.223.

Barker DW et al. AJR 2005;184:1096Barker DW et al. AJR 2005;184:1096--1102.1102.Barker DW et al. AJR 2005;184:1096Barker DW et al. AJR 2005;184:1096--1102.1102.

52 year52 year--old with hepatic metastasis from pancreatic cancer old with hepatic metastasis from pancreatic cancer s/ps/p RFARFA

CTCT FDG PETFDG PET

Nodular enhancementNodular enhancement FDG FDG --avidavid

Immediately after RFA:Immediately after RFA:Peripheral enhancementPeripheral enhancement

15 months after RFA: 15 months after RFA: recurrencerecurrencePET guided needle PET guided needle placement for subsequent placement for subsequent RFARFA

Conclusions: FDG PET for Colorectal CarcinomaConclusions: FDG PET for Colorectal Carcinoma

Diagnosis: Incidental focal uptake in GI tract: ~ 30Diagnosis: Incidental focal uptake in GI tract: ~ 30--50% 50% are malignantare malignantDetection of recurrence:Detection of recurrence:

Presurgical tumor N and M stagingPresurgical tumor N and M stagingUnsuspected metastases: high rate of detection Unsuspected metastases: high rate of detection ExtrahepaticExtrahepatic metatasesmetatases: PET>CT: PET>CT

Rising CEA levels in the absence of a known source.Rising CEA levels in the absence of a known source.Equivocal lesionsEquivocal lesions on other imaging modalities, for example:on other imaging modalities, for example:

Evaluation of postsurgical sitesEvaluation of postsurgical sitesIndeterminate pulmonary nodules, hepatic lesions lymph Indeterminate pulmonary nodules, hepatic lesions lymph nodesnodes

Change in management:Change in management: ~ 30% of patients~ 30% of patients

Conclusions: PET/CT for Hepatic Metastases from Conclusions: PET/CT for Hepatic Metastases from Colorectal CancerColorectal Cancer

FDG PET/CT for detection of hepatic metastasesFDG PET/CT for detection of hepatic metastases::Sensitivity (patient): ~ 90% range > MR no Gad> Sensitivity (patient): ~ 90% range > MR no Gad> ceCTceCTSensitivity (lesion): ~ 75% range > MR no Gad > Sensitivity (lesion): ~ 75% range > MR no Gad > ceCTceCT

MR with SPIO: ~90%MR with SPIO: ~90%False False --: :

small size (< 2 cm)small size (< 2 cm)mucinous primarymucinous primaryhyperglycemiahyperglycemia

For recurrence: specificity FDG PET/CT (~90%) >>ceCT(~50%)For recurrence: specificity FDG PET/CT (~90%) >>ceCT(~50%)FDG PET/FDG PET/ceCTceCT> FDG PET/non > FDG PET/non ceCTceCT for segmental localizationfor segmental localization

After chemotherapyAfter chemotherapy::Decrease FDG T/L and SUV can identify responders 4Decrease FDG T/L and SUV can identify responders 4--5 5 weeks into therapyweeks into therapySensitivity for detection of residual tumor after chemotherapy:Sensitivity for detection of residual tumor after chemotherapy:

FDG PET: ~ 50%FDG PET: ~ 50%--60%60%CT: ~60CT: ~60--90%90%

Esophageal CancerEsophageal Cancer

Prospective study of 74 patients comparing FDG PET, Prospective study of 74 patients comparing FDG PET, CT and EUS:CT and EUS:

SensSens: 41%: 41%Spec: 83%Spec: 83%

CTCT


CT+EUSCT+EUS



Stage IVStage IV



LocoLoco--regionalregionalLNLN

SensSens: 95%: 95%PrimaryPrimary

EUSEUSFDG PETFDG PET

FlamenFlamen P et al. J Clin Oncol 2000;18:3202P et al. J Clin Oncol 2000;18:3202--3210.3210.Van Van WestreenenWestreenen HL et al. J HL et al. J clinclin oncoloncol 2004;22:38052004;22:3805--3812 (review).3812 (review).

Esophageal Cancer: Effectiveness of Esophageal Cancer: Effectiveness of strategies:strategies:

Comparison 6 strategies:Comparison 6 strategies:CT aloneCT aloneCT + EUS with FNACT + EUS with FNACT + thoracoscopy and laparoscopy (TL)CT + thoracoscopy and laparoscopy (TL)CT + EUS with FNA + TLCT + EUS with FNA + TLCT + PET +EUS with FNACT + PET +EUS with FNAPET + EUS with FNA: most effectivePET + EUS with FNA: most effective

Parameters incorporated:Parameters incorporated:Prevalence of local, regional and distant diseasePrevalence of local, regional and distant diseaseLife expectanciesLife expectanciesCost associated with therapyCost associated with therapyProbability of death for patientsProbability of death for patients undergoing TL and those undergoing TL and those undergoing resectionundergoing resection

Wallace et Wallace et al.Annal.Ann ThoracThorac SurgSurg 2002;74:10262002;74:1026--1032.1032.

80 year80 year--old man referred for initial staging of esophageal cancerold man referred for initial staging of esophageal cancer

From Habibian MR, Delbeke D et al (From Habibian MR, Delbeke D et al (edseds): Nuclear Medicine Imaging: A Teaching File, Lippincott 2): Nuclear Medicine Imaging: A Teaching File, Lippincott 2ndnd ed, 2008ed, 2008

57 year old male diagnosed with esophageal cancer in 57 year old male diagnosed with esophageal cancer in July and treated with July and treated with chemoradiationchemoradiation completed two completed two weeks before his followweeks before his follow--up PET scanup PET scan

July 29July 29 Oct 19Oct 19

From Delbeke D, SNM LLSAP program, module GI malignancies, 2006From Delbeke D, SNM LLSAP program, module GI malignancies, 2006

Gastric Cancer: FDG PETGastric Cancer: FDG PET

95% are adenocarcinomas 95% are adenocarcinomas Often associated with H. Pylori infectionOften associated with H. Pylori infectionIntestinal type: forms glandIntestinal type: forms gland--type structures and affects the type structures and affects the elderlyelderlyDiffuse type: poorly differentiated, lacks glandular structuresDiffuse type: poorly differentiated, lacks glandular structuresand has genetic predispositionand has genetic predisposition

FDG PET: controversialFDG PET: controversialLess sensitive for detection of diffuse type with high mucin Less sensitive for detection of diffuse type with high mucin contentcontentPhysiologic/inflammatory background uptakePhysiologic/inflammatory background uptake

Stahl A et al. Stahl A et al. EurEur J Nucl Med 2003;30:288J Nucl Med 2003;30:288--295.295.MochikiMochiki E et al. World J E et al. World J SurgSurg 2004;28:2472004;28:247--253253Yoshioka T et al. J Nucl Med 2003;44:690Yoshioka T et al. J Nucl Med 2003;44:690--699.699.

Frequent diagnosis at advance stage (III and IV): Frequent diagnosis at advance stage (III and IV): Poor survivalPoor survival

Prediction of response to induction therapy is critical to Prediction of response to induction therapy is critical to identify surgical candidates identify surgical candidates

FDG can predict histological response early and after completionFDG can predict histological response early and after completionof neoadjuvant therapyof neoadjuvant therapy

Example: Gastric cancer: 44 patients, 2 weeks after initiation Example: Gastric cancer: 44 patients, 2 weeks after initiation of therapy, decreased uptake > 35% as criterion *of therapy, decreased uptake > 35% as criterion *

Good responders have improved survival after surgeryGood responders have improved survival after surgery

FDG PET for Esophageal and Gastric Cancer:FDG PET for Esophageal and Gastric Cancer:Monitoring TherapyMonitoring Therapy

Weber WA et al. J Clin Oncol 2001;19:3058Weber WA et al. J Clin Oncol 2001;19:3058--3065.3065.FlamenFlamen P et al. Ann Oncol 2002;13:361P et al. Ann Oncol 2002;13:361--368.368.Kato H et al. Am J Kato H et al. Am J SurgSurg 2002;184:2792002;184:279--283. 283. Downey RJ et al. J Clin Oncol 2003;21:428Downey RJ et al. J Clin Oncol 2003;21:428--432.432.Wider HA et al. J Clin Oncol 2004;22(1):900Wider HA et al. J Clin Oncol 2004;22(1):900--908.908.**OttOtt K et al. J Clin Oncol 2003;21(24):4604K et al. J Clin Oncol 2003;21(24):4604--4610.4610.

FDG PET for Pancreatic CarcinomaFDG PET for Pancreatic CarcinomaDiagnosisDiagnosis

Summary of literature 2001:Summary of literature 2001:Sensitivity: 94% (n = 293), Specificity: 90% (n = 281)Sensitivity: 94% (n = 293), Specificity: 90% (n = 281)Change in management: 50%Change in management: 50% (26 patients studies)(26 patients studies)

Retrospective study (n = 65)Retrospective study (n = 65)Sensitivity and specificity : Sensitivity and specificity : FDG PET FDG PET 9191--95% 95% vsvs CT CT 65% 65% Especially helpful when no definite mass on CT or in Especially helpful when no definite mass on CT or in whom whom FNAsFNAs are nonare non--diagnosticdiagnosticChange in management: 41% of patientsChange in management: 41% of patients

Staging (especially M) by detecting CTStaging (especially M) by detecting CT--occult metastases.occult metastases.Detection of recurrenceDetection of recurrenceMonitoring therapyMonitoring therapyGambhir SS et al. J Nucl Med 2001;42(suppl):50SGambhir SS et al. J Nucl Med 2001;42(suppl):50S--52S.52S.Delbeke D et al. J Nucl Med 1999;40:1784Delbeke D et al. J Nucl Med 1999;40:1784--1792.1792.Rose DM et al. Annals of Rose DM et al. Annals of SurgSurg 1998;229:7291998;229:729--738.738.

FDG PET versus EUS for the Diagnosis and FDG PET versus EUS for the Diagnosis and Staging Pancreatic Cancer (35 patients)Staging Pancreatic Cancer (35 patients)

Diagnosis:Diagnosis:Sensitivity: EUS (93%) > FDG PET (87%) > CT Sensitivity: EUS (93%) > FDG PET (87%) > CT (53%).(53%).EUSEUS--guided FNA allowed tissue diagnosis in 67% guided FNA allowed tissue diagnosis in 67% of the patients.of the patients.

T staging: EUS was more sensitive than CT to T staging: EUS was more sensitive than CT to evaluate vascular invasion of the portal and superior evaluate vascular invasion of the portal and superior mesenteric veins.mesenteric veins.M staging:M staging:

FDG PET detected distant metastases in 7 of 9 FDG PET detected distant metastases in 7 of 9 proven metastases, 4 of which were missed by CTproven metastases, 4 of which were missed by CT

Mertz HR et al. Mertz HR et al. GastrointestGastrointest EndoscEndosc 2000;52:3672000;52:367--371.371.

CT Postsurgical changesCT Postsurgical changesPET Recurrent pancreatic CaPET Recurrent pancreatic Ca

44 year44 year--old male old male s/p Whipple for s/p Whipple for pancreatic cancer pancreatic cancer 8 months earlier8 months earlier

FDG PET in the Differential FDG PET in the Differential Diagnosis of Pancreatic Cancer Diagnosis of Pancreatic Cancer

Prospective study of 106 patients with pancreatic Prospective study of 106 patients with pancreatic masses suspicious for pancreatic carcinomamasses suspicious for pancreatic carcinoma

AllAll NlNl GlycemiaGlycemia DMDMMalignantMalignant 63/7463/74 46/4746/47 17/2717/27BenignBenign 27/3227/32 21/2521/25 6/76/7SensitivitySensitivity 85%85% 98%98% 63%63%SpecificitySpecificity 84%84% 84%84% 86%86%AccuracyAccuracy 85%85% 93%93% 68%68%

Zimny et al. EJNM 1997;24:678Zimny et al. EJNM 1997;24:678--682 682

Acute pancreatitisAcute pancreatitisShould CRP be checked?Should CRP be checked?

Abdominal pain & obstructive Abdominal pain & obstructive jaundicejaundice

68%68%50%50%83%83%nml nml glycemiaglycemia, , ↑↑CRPCRP

53%53%86%86%30%30%↑↑ glycemiaglycemia, nml , nml CRPCRP

88%88%87%87%88%88%nml nml glycemiaglycemia, nml , nml CRPCRP

AccAccSpecSpecSensSensn = 159n = 159

DiederichsDiederichs et al. Pancreas 2000; 20: 109et al. Pancreas 2000; 20: 109From Delbeke D, SNM LLSAP From Delbeke D, SNM LLSAP program, module GI malignancies, program, module GI malignancies, 20062006

FDG PET Detects Pancreatic Carcinoma FDG PET Detects Pancreatic Carcinoma in Chronic Pancreatitis in Chronic Pancreatitis

Patients with longPatients with long--standing chronic pancreatitis have a standing chronic pancreatitis have a 1515--fold greater risk of pancreatic carcinoma: fold greater risk of pancreatic carcinoma: FDG PET NPV = 87%FDG PET NPV = 87%

CPCP CACA CP + CACP + CAPET TPPET TP 00 2424 55PET FPPET FP 1010 00 00PET TNPET TN 6767 00 00PET FNPET FN 00 22 11

FP: 3 mild, one stent, 1 infected pseudocyst, 2 acute FP: 3 mild, one stent, 1 infected pseudocyst, 2 acute inflammation at surgery, and 3 w/ probable acute inflammation at surgery, and 3 w/ probable acute inflammationinflammation

Mariette et al. Eur J Nucl Med 2005; 32: 399 .Mariette et al. Eur J Nucl Med 2005; 32: 399 .Van Van KouwenKouwen M et al. M et al. EurEur J Med J Med ImagImag 2005;32:3992005;32:399--404.404.

Differentiating Malignant from Benign Differentiating Malignant from Benign Pancreatic Cysts Pancreatic Cysts

*Prospective study of 50 patients with suspected *Prospective study of 50 patients with suspected cystic pancreatic tumors or intraductal papillary cystic pancreatic tumors or intraductal papillary mucinous tumors (IPMT)mucinous tumors (IPMT)

FDG PETFDG PETMalignantMalignant 16/17* 24/30**16/17* 24/30**BenignBenign 31/3331/33 18/2218/22SensitivitySensitivity 94%94% 80%80%SpecificitySpecificity 94%94% 82%82%

*Sperti et al. J GI Surg 2005; 9: 22 *Sperti et al. J GI Surg 2005; 9: 22

**Hara et al. J Nucl Med 2005; 46: 220P **Hara et al. J Nucl Med 2005; 46: 220P

FDG PET for the Diagnosis ofFDG PET for the Diagnosis ofPancreatic CarcinomaPancreatic Carcinoma

In 2000, the European Consensus In 2000, the European Consensus designated FDG PET as an established designated FDG PET as an established indication for differentiation of benign and indication for differentiation of benign and malignant pancreatic massesmalignant pancreatic masses

Reske. Eur J Nucl Med 2001; 28: 1707 Reske. Eur J Nucl Med 2001; 28: 1707

FDG PET for Hepatocellular CarcinomaFDG PET for Hepatocellular Carcinoma

Study of 91 patients (n=67 for initial staging)Study of 91 patients (n=67 for initial staging)Sensitivity: 64%Sensitivity: 64% (43/67) FDG(43/67) FDG--avid.avid.Change in management: 28% (26/91) Change in management: 28% (26/91)

By guiding biopsy (n= 1)By guiding biopsy (n= 1)By identifying skeletal metastases (n = 8)By identifying skeletal metastases (n = 8)By guiding additional regional therapy (n = 15)By guiding additional regional therapy (n = 15)By detecting recurrence (n = 2)By detecting recurrence (n = 2)

Summary of the literature for staging:Summary of the literature for staging:Sensitivity: 77% ( n = 292), Sensitivity: 77% ( n = 292), Specificity: 97% (n = 249)Specificity: 97% (n = 249)Change in management: 60% (20 patients studies)Change in management: 60% (20 patients studies)

WudelWudel LJ et al: American Surgeon 2003;69:117LJ et al: American Surgeon 2003;69:117--126.126.Gambhir SS et al. J Nucl Med 2001;42(suppl):44SGambhir SS et al. J Nucl Med 2001;42(suppl):44S--45S.45S.

Cell membrane Cell membrane and capillaryand capillary

GlucoseGlucose Glucose-6-PGlucose-6-PGlucoseGlucose

GlycogenGlycogen

HH22O + COO + CO

22

HexokinaseHexokinase

FDGFDG FDGFDG FDG-6-PFDG-6-P

HexokinaseHexokinase

Pentose-PPentose-P

7777--years old male years old male with cirrhosis, a with cirrhosis, a large hepatic lesion large hepatic lesion and elevated AFPand elevated AFP

Diagnosis:Diagnosis:1)1) HCC proven HCC proven

by biopsyby biopsy2)2) Metastatic Metastatic

lung nodulelung nodule

From Delbeke D. HPB 2005;7:166From Delbeke D. HPB 2005;7:166--179.179.

7777--years old years old male with male with cirrhosis, a large cirrhosis, a large hepatic lesion hepatic lesion and elevated and elevated AFPAFP

Diagnosis:Diagnosis:1)1) HCC proven HCC proven

by biopsyby biopsy2)2) Metastatic Metastatic

coeliac LNcoeliac LN

From Delbeke D. HPB 2005;7:166From Delbeke D. HPB 2005;7:166--179.179.

FDG PET Imaging for Hepatocellular CarcinomaFDG PET Imaging for Hepatocellular CarcinomaConclusionsConclusions

Approximately 2/3 of HCC accumulate FDG:Approximately 2/3 of HCC accumulate FDG:For these patients with FDGFor these patients with FDG--avid HCC, FDG PET avid HCC, FDG PET imaging is helpful for staging and monitoring imaging is helpful for staging and monitoring therapy.therapy.

Approximately 1/3 of HCC are false negative Approximately 1/3 of HCC are false negative on FDG imaging:on FDG imaging:

Therefore, FDG imaging is not recommended for Therefore, FDG imaging is not recommended for evaluation of focal lesions in patients with chronic evaluation of focal lesions in patients with chronic hepatitis or for screening for HCC in a population hepatitis or for screening for HCC in a population at increased risk.at increased risk.

FDG PET findings affected the management of FDG PET findings affected the management of 28% (26/91) of patients in a retrospective study.28% (26/91) of patients in a retrospective study.

Hepatocellular Carcinoma: Hepatocellular Carcinoma: 1111CC--acetateacetate57 patients with various hepatobiliary tumors57 patients with various hepatobiliary tumorsHCC (n = 32): both + in 34% of patientsHCC (n = 32): both + in 34% of patients

Sensitivity FDG: 47% average (poorly differentiated)Sensitivity FDG: 47% average (poorly differentiated)Sensitivity Sensitivity 1111CC--acetate: 87% (wellacetate: 87% (well--differentiated)differentiated)Combined sensitivity: 100%Combined sensitivity: 100%

Other malignant and benign tumors were Other malignant and benign tumors were 1111CC--acetate acetate negativenegativeBoth tracers appear complimentaryBoth tracers appear complimentary::

FDG +, FDG +, 1111CC--acetate + : favor HCCacetate + : favor HCCFDG +, FDG +, 1111CC--acetate acetate -- : favor another malignancy: favor another malignancyBoth Both -- : benign: benign Ho CL et al. J Nucl Med 2002;44:213Ho CL et al. J Nucl Med 2002;44:213--221221

Ho CL et al. J Ho CL et al. J NuclNucl Med 2007;48:902Med 2007;48:902--909909

1818FF--FDGFDG 1111CC--acetateacetate

JD #3 1/6/07JD #3 1/6/0756 56 yomyomMod diff HCCMod diff HCCAFP 12,000AFP 12,000Initial stagingInitial stagingDied 5/23/07Died 5/23/07

FDG and acetate FDG and acetate show different show different metastasesmetastases

Cholangiocarcinoma (n = 36):Cholangiocarcinoma (n = 36):Nodular type (> 5Nodular type (> 5--10 mm in size): Sensitivity 85%10 mm in size): Sensitivity 85%

Occasionally, FDG PET helped identify a nodular CCC Occasionally, FDG PET helped identify a nodular CCC (diagnosed pathologically) and equivocal on CT.(diagnosed pathologically) and equivocal on CT.Helpful for staging, detection of recurrence.Helpful for staging, detection of recurrence.

Infiltrating type: Poor sensitivity 18% (probably due to the Infiltrating type: Poor sensitivity 18% (probably due to the lack of cell density)lack of cell density)

Gallbladder cancer (n=14): sensitivity 78%Gallbladder cancer (n=14): sensitivity 78%Impact on therapy: 30% of patients with Impact on therapy: 30% of patients with cholangiocarcinomacholangiocarcinoma

FDG PET for Cholangiocarcinoma and GB cancerFDG PET for Cholangiocarcinoma and GB cancer

Anderson CD et al. J Anderson CD et al. J GastrointestGastrointest SurgSurg 2004;8:902004;8:90--97.97.

57 year57 year--old male old male s/ps/p R lobectomy for cholangiocarcinomaR lobectomy for cholangiocarcinoma

Diagnosis: Diagnosis: Recurrence at Recurrence at margin of margin of resection resection

Diagnosis: Recurrent GB carcinomaDiagnosis: Recurrent GB carcinoma

63 year63 year--old male with a history of GB cancer 3 years earlier old male with a history of GB cancer 3 years earlier treated with surgerytreated with surgery

From Anderson CD et al. J From Anderson CD et al. J GastrointestGastrointest SurgSurg 2004;8:902004;8:90--97.97.

Sources of False +/Sources of False +/-- InterpretationsInterpretationsF+: InflammationF+: Inflammation

TherapyTherapy--relatedrelatedOstomiesOstomies, , Drainage tubes, Drainage tubes, Stents (percutaneous more Stents (percutaneous more common), common), Radiation therapy , Radiation therapy ,

TraumaTraumaInfectionInfection

Abscesses, Abscesses, Acute cholecystitis, Acute cholecystitis, Acute cholangitis, Acute cholangitis, Acute pancreatitis (chronic Acute pancreatitis (chronic pancreatitis but uncommon), pancreatitis but uncommon), nflammatorynflammatory bowel disease, bowel disease, iverticulitisiverticulitis

Granulomatous disease: TB, Granulomatous disease: TB, fungifungi

False negative include:False negative include:Small lesions (<5Small lesions (<5--10 mm, i.e. ampullary carcinomas, 10 mm, i.e. ampullary carcinomas, miliary carcinomatosis)miliary carcinomatosis)Low cellular densityLow cellular density

Tumors of the infiltrating type (cholangiocarcinomas) Tumors of the infiltrating type (cholangiocarcinomas) Tumors with large mucinous components Tumors with large mucinous components Tumor necrosis Tumor necrosis

Some low grade tumors: Lymphoma, sarcoma,Some low grade tumors: Lymphoma, sarcoma,……Low sensitivity: ~ 50Low sensitivity: ~ 50--80%80%

GU: Prostate, Renal cellGU: Prostate, Renal cellGYN: Ovarian (mucinous, miliary spread)GYN: Ovarian (mucinous, miliary spread)HepatocellularHepatocellularDifferentiated neuroendocrineDifferentiated neuroendocrineBronchioalveolarBronchioalveolar

Hyperglycemia and/or insulinHyperglycemia and/or insulin less than 3 H prior to FDGless than 3 H prior to FDG

Sources of False +/Sources of False +/-- InterpretationsInterpretations

FDG PET and PET/CT for GI MalignanciesFDG PET and PET/CT for GI MalignanciesEsophageal cancer:Esophageal cancer:

N and M staging N and M staging Monitoring therapyMonitoring therapy

Gastric cancerGastric cancer::Less sensitive for detection of diffuse type with high mucin conLess sensitive for detection of diffuse type with high mucin contenttentPhysiologic/inflammatory background uptakePhysiologic/inflammatory background uptake

Pancreatic cancer:Pancreatic cancer:For diagnosis:For diagnosis:

In patients in whom CT/EUS fails to identify a massIn patients in whom CT/EUS fails to identify a massIn patients in whom FNA biopsy is nonIn patients in whom FNA biopsy is non--diagnosticdiagnosticIn patients with chronic pancreatitis or cystic lesionsIn patients with chronic pancreatitis or cystic lesions

For staging and detecting recurrence (restaging)For staging and detecting recurrence (restaging)HCCHCC: low sensitivity (50: low sensitivity (50--70%) but impact on management 70%) but impact on management of 30% of patientsof 30% of patientsCholangiocarcinomaCholangiocarcinoma: high sensitivity for nodular type but : high sensitivity for nodular type but low for infiltrating typelow for infiltrating typeNeuroendocrine tumorsNeuroendocrine tumors: limited role : limited role

FDG PET and PET/CT: Impact on ManagementFDG PET and PET/CT: Impact on Management

Diagnostic AccuracyDiagnostic AccuracyFDG PETFDG PET: superior diagnostic accuracy than conventional : superior diagnostic accuracy than conventional imaging for staging and restaging FDGimaging for staging and restaging FDG--avid malignanciesavid malignanciesPET/CTPET/CT: incremental impact on diagnostic accuracy: : incremental impact on diagnostic accuracy: 4040--50%50%patientspatients

Discriminating metastatic from physiologic fociDiscriminating metastatic from physiologic fociImproving lesions detection on both PET and CTImproving lesions detection on both PET and CTLocalizing precisely metastatic fociLocalizing precisely metastatic foci

Impact on ManagementImpact on Management::FDG PETFDG PET: ~: ~30%30% patients (range 10%patients (range 10%--60%)60%)PET/CTPET/CT: incremental impact on Patient: incremental impact on Patient’’s management: s management: 1010--20%20%patients, includingpatients, including

Planning radiation therapy Planning radiation therapy Guiding biopsies.Guiding biopsies.

Supplement to JNM;2001:42: May 2001, Guest editor: Supplement to JNM;2001:42: May 2001, Guest editor: SajivSajiv S. GambhirS. GambhirSupplement to JNM;2004;45: January 2004, Guest editor: Johannes Supplement to JNM;2004;45: January 2004, Guest editor: Johannes CzerninCzernin

Podoloff DA et al. J Podoloff DA et al. J NatlNatlComprCompr CancCanc NetwNetw2007;May;5 2007;May;5 SupplSuppl 1: 1: S1S1--S22.S22.

Breast cancerBreast cancerColorectal cancerColorectal cancerLung cancerLung cancerLymphomaLymphoma

www.nccn.orgwww.nccn.org

PET/CT in NCCN Practice GuidelinesPET/CT in NCCN Practice GuidelinesSummary of Recommendations: Colorectal Summary of Recommendations: Colorectal

CancerCancer

Recommended:Recommended:Initial staging if initial studies are equivocal for metastatic Initial staging if initial studies are equivocal for metastatic diseasediseaseRising CEA levels or suspicious symptoms unless other Rising CEA levels or suspicious symptoms unless other imaging is diagnosticimaging is diagnosticRestaging if curative resection is consideredRestaging if curative resection is considered

Not indicated:Not indicated:Restaging after non surgical treatment of metastatic diseaseRestaging after non surgical treatment of metastatic diseasePostPost--treatment surveillancetreatment surveillance

www.nccn.orgwww.nccn.org

PET/CT in NCCN Practice GuidelinesPET/CT in NCCN Practice GuidelinesSummary of Recommendations: OtherSummary of Recommendations: Other

Esophageal:Esophageal:At Initial staging if no distant metastases demonstrated by At Initial staging if no distant metastases demonstrated by other imagingother imagingTo monitor therapy after neoadjuvant therapyTo monitor therapy after neoadjuvant therapy

Thank you!Thank you!

Documents

FDG PET and PET-CT for GI Malignancies: Colorectal cancer