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Hybrid imaging in head & NecK Tumors
Raffaele Giubbini
Chair of Nuclear Medicine and Nuclear Medicine Unit
University and Spedali Civili – Brescia, Italy
Metabolic rationale – Staging/Restaging/FU TNM
Rationale for metabolic/functional
imaging in therapy response evaluation
International Journal of Oncology 33: 443-452, 2008
SUV = 20 SUV = 1
tessue concentration (Bq/g)
SUV = -----------------------------------------------------
injected dose (activity Bq) / weight (g)
- Qualitative
- Semiquantitative
- Quantitative
ASSESSMENT OF THERAPY RESPONSE
TIMING OF POST-THERAPY PET/CT
EVALUATION
Response after end of therapy:
• 15-20 DAYS AFTER CHEMOTHERAPY
• 3 MONTHS/12-14weeks AFTER RT (?)
• (1-6) MONTHS AFTER SURGERY
Early response:
• after 1-2 CMT cycles
Advanced
Oropharynx SCC
Staging T N M
Therapy
monitoring CMT RT
Follow-up T N M
Advanced
Larynx
Advanced
Hypopharynx
Staging T N M
Therapy
monitoring CMT RT
Follow-up T N M
Staging T N M
Therapy
monitoring CMT RT
Follow-up T N M
All
Head
Neck
Advanced
Oropharynx SCC
Staging T N M
Therapy
monitoring CMT RT
Follow-up T N M
Advanced
Larynx
Advanced
Hypopharynx
Staging T N M
Therapy
monitoring CMT RT
Follow-up T N M
Staging T N M
Therapy
monitoring CMT RT
Follow-up T N M
All
Head
Neck
*Surgery group: surgery + RT
*RT group: RT+CMT
Advanced
Oropharynx SCC
Staging T N M
Therapy
monitoring CMT RT
Follow-up T N M
Advanced
Larynx
Advanced
Hypopharynx
Staging T N M
Therapy
monitoring CMT RT
Follow-up T N M
Staging T N M
Therapy
monitoring CMT RT
Follow-up T N M
All
Head
Neck
• 46 yr, male heavy smoker.
• August 09: left trigeminal neuralgia:
avulsion of 28 and 38, no relief.
• DentaScan was performed
: L.R., 56 y, F
–May 2009 evidence of LC mets
–At clinical inspection lesion at the base
of tongue
–Biopsy consistent with SCC
–RM for T e N staging
morphology &
microstructural information
L.R., 56 y, F
PET 1, 11.05.2009: Staging
clear evidence of primary lesion and of LC
mets; no distant mets.
PET-CT 4/09/2009 - RM
20/8/2009
Caso 1: L.R., 56 aa, F
PET 2, 04.09.2009: F:U: study after RC
therapy
minimal perilesional uptake (RT) and
minimal Ln uptake to be re-checked
after 2-3 months.
L.R., 56 y, F
PET 3, 27.11.2009: Follow up
“… moderate uptake in a Right LN
between 2° and 3° level, consistent
with local persistence of disease.”
RM 26/11/2009 e PET-TC
27/11/2009
a posteriori !!
L.R., 56 y, F
PET 4, 07.10.2010: Follow up
“… severe and patchy uptake of the tracer
in a bulky lesion behind the ramus of the
mandible .............”
Denta Scan
(09/2009)
• Oct 2009: MSCT is performed under
the advice of a ENT physician
14 Oct 2009: pre-op CXR
– 16 Oct 09 endoscopic sinus surgery: inflammatory
material, maxillary osteitis
– 21 Oct 09 BK neg ; BAL neg
transbronchial biopsy: consistent with
adenocarcinoma
– 25 Oct 09 worsening of facial pain with onset of
diplopia
27 Oct 09 15 Oct 09
PET-CT scan
28 Oct 09 MRI
28 Oct 09 MRI
28 Oct 09 MRI
what is your diagnosis?
• odontogenic sinusitis + lung
adenocarcinoma
• chronic invasive mycosis + lung
adenocarcinoma
• metastasis from lung adenocarcinoma
• other
15/11/09 14/10/09 23/11/09
UL lobectomy: wegener granulomatosis
Advanced
Oropharynx SCC
Staging T N M
Therapy
monitoring CMT RT
Follow-up T N M
Advanced
Larynx
Advanced
Hypopharynx
Staging T N M
Therapy
monitoring CMT RT
Follow-up T N M
Staging T N M
Therapy
monitoring CMT RT
Follow-up T N M
All
Head
Neck
After Therapy After Therapy
DE, f, 61y
• 1998. RT for SCC post-lat wall of right
pyriform sinus (T2 N0 M0).
• (1998-2007) Multiple small SCC of left tonsil
• 1/2009 worsening in dysphonia. Endoscopy:
no sign of SCC, multiple areas of
leucoplachia (NBI). neg biopsies.
• 2/2009 dysphonia persists.
• negative MR
• PET/CT
e
DE, f, 61y
• 1998. RT for SCC post-lat wall of right pyriform
sinus (T2 N0 M0).
• (1998-2007) Multiple small SCC of lect tonsil
• 1/2009 worsening in dysphonia. Endoscopy: no
sign of SCC, multiple areas of leucoplachia
(NBI). neg biopsies.
• 2/2009 dysphonia persists.
• negative MR
• PET/CT positive glottis and left pyriform sinus.
• Multiple biopsie
Advanced
Oropharynx SCC
Staging T N M
Therapy
monitoring CMT RT
Follow-up T N M
Advanced
Larynx
Advanced
Hypopharynx
Staging T N M
Therapy
monitoring CMT RT
Follow-up T N M
Staging T N M
Therapy
monitoring CMT RT
Follow-up T N M
Staging T N M
Therapy
monitoring CMT RT
Follow-up T N M
All
Head
Neck
n.s.
(N-staging)
• Studies on post-therapy F18-FDG PET or PET/CT include heterogeneous patients populations (different selection criteria, diseases sites, treatment strategies and protocols, different technology PET vs PET/CT and different timing), came from retrospective analyses
• SUV cannot reliably differentiate residual cancer and inflammation
• 12 weeks are the optimal time point for post-RT assessment
• Interim PET/CT after 1 or 2 cycles is useful for the assessment of treatment response after induction chemotherapy (despite limited data are available)
• Other tracers as F18-FLT and hypoxia tracer F18-FMISO are under investigation and seem promising
Lung
MM
Conclusions (1)
• CT and MRI are pivotal diagnostic tools in head and neck cancer evaluation, for staging, restaging, therapy monitoring and follow-up.
• F18-FDG (and aminoacids 11C-TYR, 11C-MET) PET/CT are feasible, useful and accurate tools in evaluating head and neck cancer. Large trials are needed to establish their definitive role.
• Quality improvement: “LSO” and “Time of flight”
• The most useful results which allow a change in management of patients modifying therapy plan is restaging, differentiation between residual or persistent diseases after chemotherapy or radiotherapy and identify pts who might respond to Chemo-RT.
• Tumor stage could be more accurately determined using F18-FDG-PET/CT, in particular in lymphnodes and distant metastases evaluation.
• Conformal radiotherapy (3D-CRT) and intensity modulated radiation therapy (IMRT) are significantly modified by F18-FDG-PET/CT in volume delineations.
Conclusions (2)
Thank you for your attention !
