gino pepe medicina nucleare – pet h.sanraffaele irccs - milano l'uso della pet nella diagnosi...
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Gino Pepe
Medicina Nucleare – PET H.SanRaffaele IRCCS - Milano
L'uso della PET nella diagnosi precoce L'uso della PET nella diagnosi precoce
e la valutazione del SUV e la valutazione del SUV
come indicatore di prognosi come indicatore di prognosi
[18F]FDG PETCT
[18F]FDG-PET
Why [18F]FDG-PET in tumors?
Elevated glucose metabolism in tumor
Why [18F]FDG-PET in tumors?
Elevated glucose metabolism in tumor
[18F]FDG is a glucose analog
Why [18F]FDG-PET in tumors?
Elevated glucose metabolism in tumor
[18F]FDG is a glucose analog
[18F]FDG uptake into viable neoplastic cells
Why [18F]FDG-PET in tumors?
[[1818F]FDG PET: APPLICATION IN LUNG CANCERF]FDG PET: APPLICATION IN LUNG CANCER
Differentiating benign from malignant lesions (SPN)
Staging N and M and re-staging for therapy planningStaging N and M and re-staging for therapy planning
Predicting and monitoring response to therapyPredicting and monitoring response to therapy
Solitary Pulmonary Nodule (SPN)Solitary Pulmonary Nodule (SPN)
Solitary lung lesion < 3 cm in diameterSolitary lung lesion < 3 cm in diameter
20% - 40% of SPN are malignant20% - 40% of SPN are malignant
Initial presentation in 20% - 30% of lung cancerInitial presentation in 20% - 30% of lung cancer
Coleman et al. J Nuc Med 1999
Visual AnalysisVisual Analysis
Quantitative analysisQuantitative analysis
[[1818F]FDG PETF]FDG PET
Measure of metabolic activity of SPNMeasure of metabolic activity of SPN
SUV = 7.3
CT [18F]FDG PETCT [18F]FDG PET
Visual Analysis: Visual Analysis: nodule activity vs mediastinal blood pool activitynodule activity vs mediastinal blood pool activity
Quantitative analysisQuantitative analysis
[[1818F]FDG PETF]FDG PET
Measure of metabolic activity of SPNMeasure of metabolic activity of SPN
SUV = 7.3
CT [18F]FDG PETCT [18F]FDG PET
Visual Analysis: Visual Analysis: nodule activity vs mediastinal blood pool activitynodule activity vs mediastinal blood pool activity
Quantitative analysisQuantitative analysis
[[1818F]FDG PETF]FDG PET
Measure of metabolic activity of SPNMeasure of metabolic activity of SPN
SUV = 7.3
CT [18F]FDG PETCT [18F]FDG PET
[[1818F]FDG PETF]FDG PET
Measure of metabolic activity of SPNMeasure of metabolic activity of SPN
Visual AnalysisVisual Analysis
Quantitative analysis: Quantitative analysis: SUV (standardized uptake value)SUV (standardized uptake value)
SUV = 7.3
CT [18F]FDG PETCT [18F]FDG PET
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 - 128 *(W/h)2
• LBM donne = 1.07 * W - 148 *(W/h)2
– SUVBSA = Ct/(ID/BSA) = (kBq/ml) / (MBq/m2)
• BSA = 0.007184 * W 0.425 * h 0.725
[[1818F]FDG PETF]FDG PET
Measure of metabolic activity of SPNMeasure of metabolic activity of SPN
Visual AnalysisVisual Analysis
Quantitative analysis: Quantitative analysis: SUV (standardized uptake value)SUV (standardized uptake value)
SUV = 7.3
CT [18F]FDG PETCT [18F]FDG PET
[[1818F]FDG PETF]FDG PET
Measure of metabolic activity of SPNMeasure of metabolic activity of SPN
Visual AnalysisVisual Analysis
Quantitative analysis: Quantitative analysis: SUV (standardized uptake value)SUV (standardized uptake value)
SUV = 7.3
CT [18F]FDG PET
SUV = 7.9
CT [18F]FDG PET
[[1818F]FDG PETF]FDG PET
VisualVisual 100100 69 69 9090 100100 9292
SUVSUV 96 96 69 69 9090 85 85 8989
SensSens SpecSpec PPVPPV NPVNPV AccAcc
Hain SF et al. Eur J Nucl Med 2001
No difference between visual vs. quantitative analysis
A SPN with SUV more than 2.5 is considered to be malignant
Lung cancer is hypermetabolic
CT
Fused
HSR - Milano
[18F]FDG PET
SPN: 1.2 cm in diameter
HSR - Milano
SPN: 1.4 cm in diameter
[18F]FDG PETCT
CT- PET
AuthorsAuthors SensitivitySensitivity Specificity Specificity AccuracyAccuracy
Duhaylongsod (1995)Duhaylongsod (1995) 97%97% 82% 82% 92%92%
Bury (1996)Bury (1996) 100% 100% 88% 88% 96%96%
Lowe (1998)Lowe (1998) 98% 98% 69% 69% 89%89%
Prauer (1998)Prauer (1998) 90% 90% 83% 83% 87%87%
Graeber (1999)Graeber (1999) 97% 97% 89% 89% 92%92%
Hung (2001)Hung (2001) 95% 95% 50% 50% 86%86%
Hellwig (2001) (meta-analysis)Hellwig (2001) (meta-analysis) 96%96% 80% 80% --
Gould (2001) (meta-analysis)Gould (2001) (meta-analysis) 97%97% 78%78% --
Hickeson (2002) (using PET-CT)(using PET-CT) 97%97% 82% 82% 92%92%
Accuracy of PET with [18F]FDG in SPN or Pulmonary Opacity
TubercolosisTubercolosis
SarcoidosisSarcoidosis
AspergillosisAspergillosis
HistoplasmosisHistoplasmosis
CryptococcosisCryptococcosis
Inflammatory lesions (mainly granulomas)
Limitations of FDG-PET for Lung Nodule Characterization:
False-positive results
Lesion DimensionLesion Dimension
Histological TypeHistological Type
HyperglycemiaHyperglycemia
Small lesion < 5-6 mmSmall lesion < 5-6 mm
% of viable neoplastic cells % of viable neoplastic cells in SPNin SPN
Limitations of FDG-PET for Lung Nodule Characterization:
False-negative results
[18F]FDG PETCT
Fused
HSR - Milano
R. F. 53 aaLung nodule
4 mm in diameter
?
[18F]FDG PETCT
CT- PET
HSR - Milano
Z. A. 41 aaSPN: 4 mm in diameter
Lesion DimensionLesion Dimension
Histological TypeHistological Type
HyperglycemiaHyperglycemia
CarcinoidCarcinoid
Pure Bronchioloalveolar Pure Bronchioloalveolar Carcinoma (BAC), mucinous Carcinoma (BAC), mucinous ca, neuroendocrine tumorca, neuroendocrine tumor
Well differentiated typeWell differentiated type
Limitations of FDG-PET for Lung Nodule Characterization:
False-negative results
[18F]FDG PET
HSR - Milano
CARCINOID
CT
[18F]FDG PETCT
PET/CT
HSR - Milano
P. G. 68 aaSPN: 10 mm in diameterWell differentiated tumor
[[1818F]FDG PET IN LUNG CANCERF]FDG PET IN LUNG CANCER
SUV and histological typeSUV and histological type
BAC BAC (12)(12) 1.31.3
Well Differentiated Well Differentiated (10)(10) 3.13.1
Moderately differentiated Moderately differentiated (12)(12) 4.34.3
Poorly differentiated Poorly differentiated (4)(4) 5.65.6
Mean SUV
Higashi et al. Nucl Med Comm 2000
[[1818F]FDG PET IN LUNG CANCERF]FDG PET IN LUNG CANCER
FDG uptake in BACFDG 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
Pure Bronchioloalveolar Carcinoma
B. A. 65 aaHSR Milano
SUV = 1.73
[18F]FDG PETCT [11C]Choline PET
Lesion DimensionLesion Dimension
Histological TypeHistological Type
HyperglycemiaHyperglycemia > 200 mg/dl = PET not performed> 200 mg/dl = PET not performed
Limitations of FDG-PET for Lung Nodule Characterization:
False-negative results
VALUTAZIONE DELLA RISPOSTA ALLA TERAPIA
con PET e [18F]FDG NEL TUMORE POLMONARE
113 pazienti con neoplasia polmonare NSC trattati con 113 pazienti con neoplasia polmonare NSC trattati con
chemio o radiochemioterapiachemio o radiochemioterapia
Patz et al Patz et al AJR, 2000AJR, 2000
Differenza significativa nella sopravvivenza tra pazienti con PET positiva e pazienti con PET negativa
Mediana di sopravvivenza12.1 mesi nei pz con PET + dopo terapia
34.2 mesi nell’85% dei pz con PET - dopo terapia
PET Responder (SUV –61%)
Weber et al., J Clin Oncol 2003; 21:2651
FDG-PET: VALUTAZIONE PRECOCE DELLA RISPOSTA ALLA CHEMIOTERAPIA
PR in 20/28 PET responders (71%)
SD o PD in 26/27 PET non responders (96%)
57 pazienti in stadio IIIB o IV studiati con PET prima e dopo I° ciclo di chemio
PET in SPN
• Who: – Patient with indetermined lung nodule
• When: – After a CT study
• Why: – Metabolic characterization of indetermined
lung nodule (benign vs malignant)
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