POSITRON EMISSION TOMOGRAPHY (PET) WITH F-DEOXY …radiology.med.miami.edu/documents/2008PET_General.pdf · 2011. 7. 19. · FDG uptake in the upper esophagus and in the stomach

POSITRON EMISSION TOMOGRAPHY (PET)WITH 18F-DEOXY-GLUCOSE

By George N. Sfakianakis, M.D.Professor of Radiology and Pediatrics October 2008

FDG-PET CLINICAL APPLICATIONS

• TUMORS

Diagnosis, Staging,

Response to Therapy,

Recurrence

• BRAIN

Tumors and Infections,

Epilepsy, Dementias, etc.

• HEART

Myocardial Viability

PET with 18F-DEOXY-GLUCOSE

THE EVOLUTIONNeuro

Cardiac

Tumors

FDG-PET in DEMENTIAS

Normal AZD

EXAMPLE of 18F-DG in NEUROLOGY

REST THALLIUM

FDG PET

STRESS THALLIUM

PERFUSION/METABOLISM MATCH = MYOCARDIAL SCAR

Revascularization is not needed

EXAMPLE of 18F-DG in MYOCARDIAL VIABILITY 1

FDG PET

Short axis slices from the apex (left) to the base of the heart

REST THALLIUM

Revascularization is indicated

PERFUSION/METABOLISM MISMATCH == VIABLE HIBERNATING MYOCARDIUM


MISMATCHES UNDERLINE THE NEED FOR REVASCULARIZATION

In Mismatch, Revascularization Increases SurvivalDiCarli AJC 1994


Gated Cardiac PET Study on the GEMINI

Images courtesy ofDr. Bruce Line

University of Maryland

• Respiratory gating on the GEMINI will use the same input


TISSUE CHARACTERIZATION / STAGING / EFFECT OF THERAPY

EXAMPLE of 18F-DG in TUMOR IMAGING

FDG/PET FOR IMAGING OF TUMORS:

IMPORTANT PUBLICATIONS

EXAMPLE of FDG/PET FOR TUMORS:

The PET showed all lesions c/w tumor. Biopsy: NSCLC PET brain study

PET total body study

Patient with cavitating lung lesion on CT and also a brain lesion.

Small Cell Lung Cancer

EXAMPLE of FDG – PET/CT FOR TUMORS:

FDG PET in LYMPHOMA

FDG/PET FOR IMAGING OF TUMORS:

CLINICAL APPLICATIONS18F-FDG (18F-Fluoro-Deoxy-Glucose) [Tumors/Heart/Brain]18F-FLT (18F-Fluorothymidine) [Tumors]18F-L-DOPA (18F-Des-Oxy-Phenyl-Alanine) [Tumors/Brain]18F-Na [Skeleton]

DEVELOPING18F-Amino-Acids/Hormones18F-FDDNP for tangles and plaques in AD

RESEARCH (11C, 15O, 13N, 18F) Blood Flow / Blood Pool / O2-ExtractionReceptor Distribution ImagingDNA / RNA / Gene Studies

PET TUMOR IMAGINGNEW RADIOPHARMACEUTICALS

THE UM EXPERIENCE

WITH FDG PET AND PET/CT

Tumor of unknown Origin

Initial Diagnosis

Original Staging

Restaging

a) Effect of (Chemo)Therapy

b) Recurrence

A 39yo female presents with RUQ pain

Ultrasonogram showed a right peri-diaphragmatic mass. CT and MRI confirmed the mass.

CT also showed a hilar LN but no other lesions.

Participation 1a

FDG-PET FOR TUMOR OF UNKNOWN ORIGIN

Biopsy of the mass showed adenocarcinoma with a differential including digestive tract as origin.

FDG-PET FOR TUMOR OF UNKNOWN ORIGINParticipation 1b


transaxial cuts

sagittal cuts

coronal cuts

High-intensity focal activity in the known hepatic metastasis

Participation 1c

but also in the left pararenal space c/w primary, colon cancer

Correlation of FDG-PET with the CT of the abdomen

Retrospectively, a mass lesion was present in the perirenal space on the recent CT (colon cancer).

PET CT

Participation 1d


A smoker has a suspicious nodule in the lung (CT).

FDG-PET for lung lesions were among the first applications

Participation 2a

18FDG-PET in LUNG CANCER

Initial Diagnosis

Participation 2b

The study is positive for tumor: a Cavitating Lesion in the lung (NSCLC by biopsy)

Participation 2d18FDG-PET in LUNG CANCER Enters PET / CT

Restaging

The study is positive for tumor: Lesion in the lung with Metastases

A patient with a history of Squamous Cell Cancer of the FaceNot known mets by CT

FDG-PET for staging was performed

Participation 3a

High-intensity FDG accumulation in a supraclavicular Lymph Node.Therefore the patient’s stage is advanced

FDG-PET in HEAD and NECK Ca

Preoperative LN staging

Participation 3b

FDG accumulation in the left vocal chord

FDG-PET in HEAD and NECK Ca Enters PET / CT Restaging

Participation 3c

A patient with biopsy proven Lymphoma

FDG-PET a) for Staging and b) for the Effect of Therapy

Participation 4a

October: Original Staging: Disease Above and Below the Diaphragm

FDG-PET IN LYMPHOMA: STAGINGParticipation 4b

February: Post-Therapy

/ RESTAGING

Residual Disease

FDG-PET IN LYMPHOMA: Enters PET / CT Participation 4c

Initial Staging: Disease Above and Below the Diaphragm

A patient with lung cancer has CNS symptoms

Participation 5a

Brain lesion with activity comparable to the lung lesion

18FDG-PET in metastatic brain lesions

Brain Metastasis from a lung cancer

Participation 5b

A patient with ovarian cancer has deteriorating CNS symptoms s/p radiation therapy of brain mets

The MRI was not diagnostic

Participation 6a

Hyperactive lesion in the middle of radiation necrosis c/w recurrence

18FDG-PET in metastatic brain lesions, s/p radiation

Evaluate for recurrence

Recurrent Brain Metastasis from

an ovarian cancer

Participation 6b

FDG/PET studies differ depending on the grade of the tumor:High grade: visualized

Low grade: not-visualized

Amino acid Imaging (methionine)Visualizes both High and How grade

Participation 7a

Low grade Tumor

High grade Tumor

FDG and Methionine Imaging of Brain TumorsParticipation 7b

A patient with thyroid cancer is reevaluated

Participation 8a

THYROID CANCER: IODINE v/s GLUCOSE

Positive Iodine scan

Many more lesions on the FDG

scan

Participation 8b

Different lesions by the two

different methods

THYROID CANCER: IODINE v/s GLUCOSE Enters PET/CT

Participation 7e

Positive Iodine scan

Positive FDG scan

Different lesions by the two different methods

A patient with cutaneous Melanoma for staging

Participation 8a

Melanoma of the right great toe diagnosed 1mo ago

FDG PET inMELANOMA

(Staging)

PET study showedabdominal lymph nodesconfirmed by CT

Participation 8d

Participation 8e

A patient with history of Melanoma for restaging

FDG PET in MELANOMA (Restaging): Enters PET / CT

PET study showed abdominal lymph nodes confirmed by CT

Participation 8e

A patient with history of colorectal cancer treated, is now evaluated because of increasing CEA

Participation 9a

No lesions were reported on CT originally

FDG-PET IN COLORECTAL CANCER Evaluation for Recurrence

PET: (Transaxial; Bladder level)

Tumor

Tumorbut the PET was positive behind the bladderReview of the CT after PET showed the recurrence

Participation 9d

Participation 9e

FDG PET in COLORECTAL cancer (Staging): Enters PET / CT

primary

Livermetastases

ESOPHAGEAL

Most gastroesophageal cancers are locally advanced at presentation,

undergo neoadjuvant chemoradiation to downstage prior to surgery.

Main role PET/CT is in locally advanced disease.

No consensus re survival benefit, data suggests neoadjuvant therapy is

associated with survival benefit, but this benefit may be outweighed by

poor prognosis of non responders.

Early prediction of response is important, offer alternative therapy to non

responders, it is suggested that progression during ineffective

chemotherapy is one reason for poor survival.

A 59yo male with history of gastric cancer s/p subtotal gastrectomy

CT: LUQ mass

Participation 10a

FDG-PET IN RECURRENT GASTRO-ESOPHAGEAL

CANCER

FDG uptake in the region of the remaining stomach c/w RECURRENCE

Participation 10c

FDG-PET in Restaging GASTRO-ESOPHAGEAL CANCEREnters PET / CT

FDG uptake in the upper esophagus and in the stomach

Participation 10e

Recurrence

GIST

GIST includes leiomyomas, leiomyoblastomas, leiomyosarcomas.

All stain + for C-kit, tyrosine kinase growth factor receptor.

Imatinib mesylate (Gleevec) : selective tyrosine kinase receptor inhibitor, effective when tumors resist conventional chemotherapy.

FDG PET is highly effective in evaluation of treatment response: imatinib causes rapid reduction in FDG uptake in responders, whereas major changes in tumor volume occur later.

Stroobants et al 2003 n = 21, PET at baseline and Day 8,

13 responders (11 CR, 2 PR) Progression free survival at 1 year 92% for PET responders vs 12% PET non responders.

A patient with history of Gastro-Intestinal Stromal Cell tumor is evaluated before and after Chemotherapy

Participation 11a

Clinical Experience is Expanding: GIST: Gastrointestinal Stromal Cell Tumors

GIST includes leiomyomas, leiomyoblastomas, leiomyosarcomas.All stain + for C-kit, tyrosine kinase growth factor receptor.

Before Treatment

Before Treatment

Participation 11b GIST Tumors

Effective Chemotherapy

GIST: Gastrointestinal Stromal Cell TumorsEffect of Chemotherapy

Before Treatment

4 weeks on Treatment

4 weeks on Treatment

Participation 11c

Before Treatment

GIST includes leiomyomas, leiomyoblastomas, leiomyosarcomas.All stain + for C-kit, tyrosine kinase growth factor receptor.

Patient with breast cancer, s/p mastectomypresents with bone pain

Participation 13a

FDG-PET IN BREAST CANCER

Extent of Tumor

Participation 13b


Extent of Tumor

Participation 13c


StagingFDG positive in multiple areas of the bodyincluding liver and skeleton

Extent of Tumor

Participation 13d

Bone Scan negative

FDG-PET IN BREAST CANCER: Enters PET / CTParticipation 13e

Staging:

Re-Staging:

Bone Metastases

Deterioration

FDG PET vs. MDP Bone Scans

Effect of Therapy

Participation 14a

49 yo lady with R. breast cancer, s/p mastectomyis evaluated because of rising Ca 15.3

Participation 14a

Participation 14b

Bone Lesions are visualized better on FDGbefore therapy

THERAPY

Results of therapy are visualized better on FDG/PET

56 yo gentleman with R Lung cancer, s/p resectionis evaluated because of lumbar pain

Participation 15a

Participation 15b

Bone Lesions are visualized better on FDGbefore therapy

surgery

THERAPY

Results of therapy are visualized better on FDG/PET

PET vs. CT

Sensitivity and Specificity

for Tumor

PET in the contemporary medical literature

MESOTHELIOMA

MESOTHELIOMA

WHAT IS FDG-PET AND HOW DOES IT WORK?

18F-Deoxy-Glucose Positron Emission Tomography

(FDG-PET)

is a noninvasive imaging method

for routine patient care

It can evaluate cellular and sub-cellular

Glucose Metabolic Activity semi-quantitatively.

Clinical Need for Positron Emission Tomography:

In many patients,

available imaging modalities cannot provide

-sufficient information for accurate Staging and

-successful Therapy Planning,

-for timely assessment of Response to Treatment

-and early detection of Recurrence of disease.

WHY DO WE NEED PET?

There is a Biological Solution:

Imaging the distribution of biological tracers

(Glucose, Amino Acids, Receptor Ligands etc)

may provide the needed information.

THE PROBLEM OF LABELING

However, labeling these small tracers for imaging

with big Single Photon-Emitting radioisotopes

(like 99mTc, 123I, 111In, used for common scans)

alters their biological properties

(their biological recognition by enzymes etc).

THE MOLECULAR IMAGING ANSWER

G

G

99mTc

GL AA RL

The PET Solution:

Positron emitters (like 18F) can label tracers

without altering their biological recognition.

PET provides unique and much-needed information

but depends on Production and Availability

of appropriate Radiopharmaceuticals

and requires Special Cameras for scanning and

quantitating the distribution of positron emitters.

PET PROVIDES THE NEEDED INFORMATION

GLP

AAP

RLP

• Use Tumor Glucose Uptake

• Label an Altered Glucose Molecule with Fluorine-18


Most Tumors metabolize glucose in excess of normal tissues

(Myocardium and Brain Cortex also metabolize glucose )

FDG-PET in vivo quantitates glucose metabolic activity of

tumors and normal organs, brain and heart

Most current applications are based on Mapping the High

Metabolic Activity (glucose utilization) of tumors/brain/heart


PRINCIPLES OF GLUCOSE (FDG) IMAGING

A. Modify the molecule of

Glucose to 2-Deoxy-Glucose

so that it can be taken up

by the cells, like glucose,

but not metabolized.

B. Label 2-Deoxy-Glucose

with a radioisotope, 18F, which

does not alter its properties

for biochemical recognition.18F-2-Deoxy-Glucose = FDG

18F

PRINCIPLES OF FDG IMAGING

FDG enters the cells and it is phosphorylated like Glucose

FDG is not metabolized and accumulates, thus allowing imaging

glycolysis

2hr after normal meal After 6hr fasting(for myocardial imaging) (for tumor imaging)

NORMAL FDG DISTRIBUTION

• Brain (gray matter)

• Heart

• Testicles

• Kidneys, Ureters, Bladder

• Stomach (and esophagus)

• Bowel

• Brown Fat (cold activated)

• Liver and Spleen

• Bone marrow

• Muscles


.


.

NORMAL FDG; BROWN FAT

• Most Malignant Tumors

• Some Benign Tumors

• Infections (esp. Fungal)

• Inflammations (DJD, Aortitis, Pancreatitis)

• Radiation Reaction (Pneumonitis, Osteitis)

• Activated Bone Marrow

ABNORMAL FDG DISTRIBUTION

Breast Cancer

ABNORMAL FDG DISTRIBUTION

.

ABNORMAL FDG DISTRIBUTION: Bone Marrow Activation

POSITRON EMITION TOMOGARPHY

• THE MOLECULAR PRINCIPLE

• THE PRODUCTION OF POSITRON EMITTERS

• THE IMAGING (PET)\

• THE CLINICAL APPLICATIONS

PROPERTIES OF POSITRON EMITTERS

• CHEMICAL

Can label Metabolic Molecules (Glucose, AA, etc)

• PHYSICAL

Small: Do not alter the Biochemical Properties

of the Metabolic Molecules (Recognition)

Emit Positrons: Need special Cameras (PET-C)

Allow Tomography and Quantitation

Have short half lives: Low Radiation Exposure

• PRODUCTION

Most need Cyclotrons on premises for their production

RADIOPHARMACEUTICALSFOR POSITRON EMISSION TOMOGRAPHY (PET)

Radiopharmaceuticals for PET,

the Positron Emitters, are not readily available

They have very short half lives (seconds), therefore

most need Cyclotrons on premises for their production

Only 18F (half life = 2 hr) can be shipped from afar

For full utilization of PET technology, a cyclotron is

required on premises for production of very short-lived PET

radionuclides, 11C, 13N, 15O (T1/2=5-20min). [18F is an

exemption (T1/2=108min) and can be shipped from afar]

Because of this, only centers with cyclotrons can provide certain patient

services and participate in many cutting-edge research activities

requiring the very short-lived nuclides (and some 18F-labeled

radiopharmaceuticals).

Otherwise PET applications are limited to those performed with

commercially available 18F-Deoxy-Glucose (FDG).

PET AND CYCLOTRON

CYCLOTRON: STRUCTURE AND FUNCTION

Electromagnetic core of the cyclotron for acceleration of charged subatomic particles

acceleration acceleration

Charged particles (p,d) are highly accelerated and hit the target, a stable nucleus; they are incorporated and produce radioisotopes

CYCLOTRON: PRODUCTION OF RADIOISOTOPES

acceleration

target

acceleratedtarget incorporated

chemical manipulation radiopharmaceutical

Radiopharmaceuticals are synthesized in heavily shielded cells,using the newly produced radioactive isotopes

CYCLOTRON:SYNTHESIS OF RADIOPHARMACEUTICALS

chemical manipulation

Small Hospital Cyclotrons are available for clinical production, but did not help

CYCLOTRON:THE BABY CYCLOTRONS

chemical manipulationproduction

POSITRON EMITTING RADIONUCLIDES

POSITRON EMITTERS

A. Ultra Short Half Life Positron Emitters

(15O, 2 min; 13N, 10 min; 11C, 20 min)

Blood Flow, Blood Pool studies

Tissue Metabolism (glucose, amino acids)

Transmitter - Receptor studies

Require a Cyclotron on premises

and a Special Camera (BGO crystal)

Continuous Research Efforts for CNS, Heart, Tumors

POSITRON EMITTERS

B. Short half life Positron Emitters

(18F, 110 min)

Tissue Glucose Metabolism studies (FDG - PET)

Other studies under development (AA, T/R)

Can be shipped from regional cyclotrons (City,State)

Require a Special camera (PET and PET/CT)

18F-Deoxy-Glucose (FDG) is currently widely used

in clinical practice for Tumors, Myocardial Viability, CNS

POSITRON EMITTERS

C. Generator produced Positron Emitters( 82Rb, 1.7 sec; 68Ga, 68 min )

82Rb: Myocardial Perfusion studies

Requires fast camera

With the new PET/CT cameras it is a promising method

PRINCIPLE of POSITRON EMISSION TOMOGRAPHY

b) TIME OF FLIGHTa) COINCIDENCE

EQUIPMENT FOR FDG PET

Dedicated PET Cameras

Ring-Detectors Crystals: NaI/BGOwithout collimators,

use coincidence detection for tomographic imaging

First generation detectors1-2cm resolution

Hybrid SPECT/PET Cameras

Two-detector cameras, Crystals: NaI/BGO

with/without collimators,alternate single photon

and coincidence imaging

Cost-effective solution for some laboratories.

New PET(/CT) Cameras

Ring-Detectors Crystals: LSO/GSOwithout collimators,

use coincidence detection for tomographic imaging

(May combine with CTfor anatomic localization

and specific lesion characterization)

Provides in vivo

3-D Pictorial Information

on regional Tissue Composition, Function,

Metabolism, Chemistry,

(Molecular, RNA/DNA/Gene evaluation)

quantitatively and noninvasive

POSITRON EMISSION TOMOGRAPHY (PET)

MOLECULAR IMAGING

Special Camera for Positron emitters

QUANTITATIVE PET TO INCREASE SPECIFICITYSUV and other units indicating % dose/gram tissue uptake

SUV=9.5

(TUMOR>3)

GSO-based PET systems ALLEGRO™

NEW TECHNOLOGY

LSO: Lutetium Oxy-Ortho-Silicate Lu2SiO5[Ce]

GSO: Gadolinium Oxy-Ortho-Silicate Gd2SiO5[Ce]

New Crystals

Old Crystals

NaI: Sodium Iodide NaI(Tl)

BGO: Bismuth Germanate Bi4Ge3O12

NEWEST TECHNOLOGY

NEW TECHNOLOGY Selected PET Scintillator Basic Characteristics

24%

75%

40 ns

0.87/cm

LSO

25%

15%

300 ns

0.92/cm

BGO

14%10%System energy resolution

35%100% Rel. light output

60 ns240 nsDecay time

0.67/cm0.34/cmStopping power

GSONaI(Tl)

Scintillator characteristics are taken from published papers; system energy resolution is publishedvendors’ data: NaI(Tl)+GSO: ADAC, BGO+LSO: CTI/Siemens.

GSO has the best combination of imaging properties

There is not enough information to characterize the areas of FDG accumulation

Lack of Anatomical Definition

FDG DISTRIBUTION

NORMAL (NON TUMOR) ABNORMAL

• Brain (gray matter)• Heart• Testicles• Kidneys, Ureters, Bladder• Stomach (and esophagus) • Bowel• Brown Fat (cold activated)• Liver and Spleen• Bone marrow• Muscles

• Most Malignant Tumors

• Some Benign Tumors

• Infections (esp. Fungal)

• Inflammations (DJD, Aortitis, Pancreatitis)

• Radiation Reaction (Pneumonitis, Osteitis)

• Activated Bone Marrow

Correlating PET with Anatomical Images

(CT, MRI, Ultrasound, Radiographs, Nuclear Studies)

a) By visual appreciation (as it was done for the cases

in the presentation to follow )

b) By computer methods, fusion of images (as in the

two demonstration cases on the following pages)

c) By sequential acquisition of two studies (as in the

case of PET+CT combined scanners, which acquire

PET and CT of the entire body in sequence)

a) Correlation of FDG-PET with the diagnostic CT(of the abdomen) by VISUAL appreciation

Retrospectively, a mass lesion was present in the perirenal space on the recent CT (colon cancer).

PET CT

b) IMAGE FUSION can combine the images

CT

PET

CT FUSED WITH PET

? ?

c) With Combined PET/CT Scanners

PET

CT

PET/CT fused

c1) Issues concerning Fusion

Mismatch

Correlating PET with anatomical Images(CT, MRI, Ultrasound, Radiographs, Nuclear Studies)

Most of the patients who have PET studies have already had another

imaging study (CT, MRI etc) and findings on PET can be correlated.

PET/CT helps localizing better and easier the lesions and

increases the specificity because it characterizes most lesions

PET/CT involves additional radiation of the entire body and

added expenditure, but clinical experience is indicating that it

significantly improves patient care and it is worth the extra sacrifice.

Keeping the dose of x-rays low (non-diagnostic CT) lowers exposure

Combined PET/CT ScannersGE

N Engl J Med 2003;348:2500-7


PET-CT provided 24 items of additional information

In 20 of 49 patients

Exact Location of LNs 9 pts

Chest Wall Infiltration 3 pts

Mediastinal Invasion 3 pts

Differentiation of Tumor from

Atelectasis/Inflammation 7 pts

Exact Location of Distal Metastasis 2 pts

N Engl J Med 2003;348:2500-7


N Engl J Med 2003;348:2500-7


In the coregistered PET-CT tumor invasion was evident

N Engl J Med 2003;348:2500-7


N Engl J Med 2003;348:2500-7


In the coregistered PET-CT tumor matched a NL size LN

N Engl J Med 2003;348:2500-7

Combined PET/CT ScannersComparison with MRI GE

Antoch G. et al Essen GermanySociety of Magnetic Resonance Meeting July 2003

50 oncology patients

MRI and PET/CT agreed in 33 patients

PET/CT MRI

Pulmonary Lesions 94 (16pts) 58(13pts)

Additional LN Metastasis 8 patients

Additional Other Metastasis 12 patients

Additional Bone Lesions 7 patients

PET IN RADIATION THERAPY PLANNINGFusion of PET with CT

“The use of PET information in the RTx planning process significantly improves outcome and patient care”

R. Thompson

At UMHC the ADAC/PHILIPS program “Pinnacle RTP”

Combined PET/CT Scanners: Attenuation Correction, Germanium v/s CT

300 clinical patients had FDG-PET corrected with Ge and CTIndependent CT and MR used for accurate location of lesions

Mislocalization of 6 lesions in 6 patients (2%) with CT correction

(colon cancer metastatic lesions in the liver were projected on the CT corrected PET as lung lesions, due to respiratory motion)

Osman et al: J Nucl Med 44(2): 240-3, 2003 .

2003 review

FDG-PET IN LUNG CANCER STAGINGDetection of Mediastinal Nodes

Sensitivity Specificity PPV NPV

CT 74% 78% 55% 88%PET side by side CT 59-76% 77-89% 48-62% 84-91%PET/CT registered 71-76% 89-96% 70-86% 90-91%

130 Nodal Stations in the mediastinum and hila by Biopsy

Aquino: J Computed Tomography 27(4);479-84 2003 // Massachusetts Gen.

2003 review

FDG PET

The search for the Best

Combined PET/CT Scanners: GE

DISCOVERY LS (DISCOVERY ST)

Combined PET/CT Scanners: CTI/SIEMENS

CTI = REVEAL, SIEMENS = BIOGRAPH

Combined PET/CT Scanners: ADAC-PHILIPS

CTPET

GEMINI

GEMINI Description

• Single acquisition console - PET and CT control• Separate PET / CT processing capability• Single table• Allegro• Dual-slice CT

Combined PET/CT Scanner Issues

Organ motion– PET/CT mismatch at

liver/lung boundary– Error in attenuation

correction– Imperfect registration

Quantification– No validation of SUV’s

Metal prosthesis etc

FDG PET

Reimbursement

MEDICAREReimbursement

MEDICARE ReimbursementNew additions

• Breast Cancer staging/restaging• Thyroid follicular cancer restaging• (thyroglobulin>10 + negative 131I scan)• 13NH3 for Myocardial Perfusion• Brain FDG for Alzheimer’s

Other indications under evaluation

• Ovarian• Sarcomas• Stomach• Hepatobiliary• Pediatric

Slide Number 1FDG-PET CLINICAL APPLICATIONSSlide Number 3FDG-PET in DEMENTIASSlide Number 5Slide Number 6Slide Number 7Gated Cardiac PET Study on the GEMINITISSUE CHARACTERIZATION / STAGING / EFFECT OF THERAPYSlide Number 10EXAMPLE of FDG/PET FOR TUMORS: Slide Number 12Slide Number 13PET TUMOR IMAGING�NEW RADIOPHARMACEUTICALSTHE UM EXPERIENCE��WITH FDG PET AND PET/CTA 39yo female presents with RUQ pain��Ultrasonogram showed a right peri-diaphragmatic mass. CT and MRI confirmed the mass. �CT also showed a hilar LN but no other lesions.Biopsy of the mass showed adenocarcinoma �with a differential including digestive tract as origin.FDG-PET FOR TUMOR OF UNKNOWN ORIGINCorrelation of FDG-PET with the CT of the abdomenSlide Number 20Slide Number 21Slide Number 22Slide Number 23Slide Number 24Slide Number 25Slide Number 26FDG-PET IN LYMPHOMA: STAGINGFDG-PET IN LYMPHOMA: Enters PET / CT A patient with lung cancer has CNS symptomsSlide Number 30A patient with ovarian cancer has deteriorating CNS symptoms s/p radiation therapy of brain mets�The MRI was not diagnosticSlide Number 32Slide Number 33Slide Number 34A patient with thyroid cancer is reevaluatedTHYROID CANCER: IODINE v/s GLUCOSETHYROID CANCER: IODINE v/s GLUCOSE �Enters PET/CTA patient with cutaneous Melanoma for stagingFDG PET in�MELANOMA�(Staging)A patient with history of Melanoma for restagingFDG PET in MELANOMA (Restaging): Enters PET / CTA patient with history of colorectal cancer treated, is now evaluated because of increasing CEASlide Number 43FDG PET in COLORECTAL cancer (Staging): Enters PET / CTESOPHAGEALA 59yo male with history of gastric cancer �s/p subtotal gastrectomy�CT: LUQ massFDG-PET IN �RECURRENT GASTRO-ESOPHAGEAL CANCERFDG-PET in Restaging GASTRO-ESOPHAGEAL CANCER�Enters PET / CTGISTA patient with history of Gastro-Intestinal Stromal Cell tumor �is evaluated before and after ChemotherapySlide Number 51GIST: Gastrointestinal Stromal Cell Tumors�Effect of ChemotherapyPatient with breast cancer, s/p mastectomy�presents with bone pain �FDG-PET IN BREAST CANCERFDG-PET IN BREAST CANCERFDG-PET IN BREAST CANCERSlide Number 58Slide Number 5949 yo lady with R. breast cancer, s/p mastectomy�is evaluated because of rising Ca 15.3 �Slide Number 6156 yo gentleman with R Lung cancer, s/p resection�is evaluated because of lumbar pain �Slide Number 63Slide Number 64Slide Number 65Slide Number 66Slide Number 67Slide Number 68Slide Number 69Slide Number 70Slide Number 71Slide Number 72Slide Number 73Slide Number 74WHAT IS FDG-PET AND HOW DOES IT WORK?WHY DO WE NEED PET? THE MOLECULAR IMAGING ANSWERPET PROVIDES THE NEEDED INFORMATIONPET PROVIDES THE NEEDED INFORMATIONPET PROVIDES THE NEEDED INFORMATIONPRINCIPLES OF GLUCOSE (FDG) IMAGINGPRINCIPLES OF FDG IMAGINGNORMAL FDG DISTRIBUTIONNORMAL FDG DISTRIBUTIONSlide Number 85Slide Number 86ABNORMAL FDG DISTRIBUTIONSlide Number 88Slide Number 89POSITRON EMITION TOMOGARPHYPROPERTIES OF POSITRON EMITTERSSlide Number 92For full utilization of PET technology, a cyclotron is�required on premises for production of very short-lived PET radionuclides, 11C, 13N, 15O (T1/2=5-20min). [18F is an�exemption (T1/2=108min) and can be shipped from afar]��Because of this, only centers with cyclotrons can provide certain patient services and participate in many cutting-edge research activities requiring the very short-lived nuclides (and some 18F-labeled radiopharmaceuticals).��Otherwise PET applications are limited to those performed with commercially available 18F-Deoxy-Glucose (FDG). �CYCLOTRON: STRUCTURE AND FUNCTIONCYCLOTRON: PRODUCTION OF RADIOISOTOPESCYCLOTRON:�SYNTHESIS OF RADIOPHARMACEUTICALSCYCLOTRON:THE BABY CYCLOTRONS POSITRON EMITTING RADIONUCLIDESPOSITRON EMITTERSPOSITRON EMITTERSPOSITRON EMITTERSPRINCIPLE of POSITRON EMISSION TOMOGRAPHYEQUIPMENT FOR FDG PETSlide Number 104Slide Number 108Slide Number 109NEWEST TECHNOLOGYNEW TECHNOLOGY �Selected PET Scintillator Basic CharacteristicsFDG DISTRIBUTIONSlide Number 113Correlation of FDG-PET with the diagnostic CT� (of the abdomen) by VISUAL appreciationb) IMAGE FUSION can combine the imagesc) With Combined PET/CT Scannersc1) Issues concerning FusionSlide Number 118Combined PET/CT ScannersCombined PET/CT ScannersCombined PET/CT ScannersCombined PET/CT ScannersCombined PET/CT ScannersCombined PET/CT ScannersCombined PET/CT ScannersCombined PET/CT Scanners�Comparison with MRISlide Number 127Combined PET/CT Scanners: �Attenuation Correction, Germanium v/s CT� ��300 clinical patients had FDG-PET corrected with Ge and CT�Independent CT and MR used for accurate location of lesions��Mislocalization of 6 lesions in 6 patients (2%) �with CT correction�(colon cancer metastatic lesions in the liver were projected on �the CT corrected PET as lung lesions, due to respiratory motion)��Osman et al: J Nucl Med 44(2): 240-3, 2003 . FDG-PET IN LUNG CANCER STAGING�Detection of Mediastinal NodesFDG PET��The search for the BestCombined PET/CT Scanners: GECombined PET/CT Scanners: CTI/SIEMENSCombined PET/CT Scanners: ADAC-PHILIPSSlide Number 134Combined PET/CT Scanner IssuesSlide Number 136MEDICARE�Reimbursement��MEDICARE Reimbursement�New additions

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POSITRON EMISSION TOMOGRAPHY (PET) WITH F-DEOXY …radiology.med.miami.edu/documents/2008PET_General.pdf · 2011. 7. 19. · FDG uptake in the upper esophagus and in the stomach