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OverviewImage guided biopsies
Current gold standardsPET/CT guided biopsy
ProtocolAdvantages/disadvantagesUtilityFeasibility in Canada
Case Studies
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Biopsy SignificanceIndividualized treatment regimen
Accurate tumor stageDistant mets
Patients in palliative situationsLess aggressive treatmentsBurden vs. quality of life
Cell-typing
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Gold Standards Ultrasound CT
MRI
http://www.clinicalimagingscience.orghttps://iame.com http://radiology.ucla.edu
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Gold Standard Modality Limitation
UltrasoundRetroperitoneal or deep pelvis,
masses surrounded by lung, bone, and/or bowel
CT Contrast is evanescent or valuable only in venous or arterial phase
MRIAbdominal masses require wide or open bore magnet, MR compatible
devices
• Modalities capable of identifying anatomical and structural changes
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PET/CT Guided Biopsy
(Klaeser et al., 2009)
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Effectiveness of PET/CT Guided BiopsyBegan with retrospective fusion
Previously acquired PET or PET/CT images to intraprocedural CT images
Target alignment not optimalNow moved to real-time imaging in the
PET/CT suite
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ProtocolRoutine PET patient prepDiagnostic PET/CT image acquired
Eyes to thighsCan also use 185MBq dose for biopsy
Patient positioning adjusted1 CT bed (15cm) acquired, 1 PET bed (3mins)
acquiredEntry site marked and sterile drapes applied
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ProtocolModerate sedationLocal anesthesiaBiopsy needles in place using unenhanced CT
scansFused with previously obtained PET scan
Biopsy needle placed in massRepeat CT and PET scan to confirm
Cytologist present2 hour observation
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(Shyn, 2013)
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UtilityFrom primary:
Melanoma LungLymphomaBreast
Metastasized to:BoneLiverSoft tissue
Head and NeckEsophagealColonPancreas
AbdomenLymph nodesLung
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PET/CT AdvantagesCan indentify tumors without morphological
changesIf metabolic change has occurred“invisible” in U/S, CT and MRI
Identifies lesions with necrosisAble to identify more aggressive lesionsUptake lasts for hoursFDG not affected by procedure-related
complicationsCost-effectiveness
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Cases Changed Types of Changes
Intramodality 22%
Chemotherapy with palliative
intent instead of curative intent
Intermodality 50%Systemic therapy chosen instead of
surgery
• If case remained unchanged, confidence in decision made was increased
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DisadvantagesOccupancy of PET/CT machine
Room time = 87 mins – 141 minsBiopsy time = 37 mins – 87 mins
Radiation burden to patientRadiation burden to the interventionist Limited resolution
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Dose
PET/CT Guided Biopsy 3.5 – 15.2 mSv
CT Component 54% - 81% of total combined dose
Low-Dose CTs in PET/CT
~ 8.2 mSv
CT Guided Biopsy 6.2 mSv – 23 mSv
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DisadvantagesOccupancy of PET/CT machineRadiation burden to patientRadiation burden to the interventionist
Originating from the patient 10 uSv – 580 uSv @ 12-24 inches from pt.
Limited resolutionLess than 1.2cm in sizeMinimal amounts of metabolically active cells
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Contacted 17 PET sites across Canada• Practicing interventional PET? Known future?• See a need?• Feasible (based on current workload)?
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• Blue = Saw need/feasibility• Red = Required more
information
• White = No need/feasibility• Green = Retrospective
method
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(Werner et al., 2013)
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(Chakraborty et al., 2014)
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ConclusionAiming for patient-centered careInterventional PET/CT offers:
EfficiencyBetter patient managementAccurate & timely diagnosisImproved patient outcomes
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References Chakraborty, P. S., Dhull, V. S., Karunanithi, S., Verma, S., Kumar, R. (2014).
Malignant melanoma with cavitary pulmonary metastasis: Diagnostic dilemma resolved by FDG PET/CT guided biopsy. Indian Journal of Nuclear Medicine, 29(3), 196-197.
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Huang, B., Law, M. W., Khong, P. L. (2009). Whole-body PET/CT scanning: Estimation of radiation dose and cancer risk. Radiology, 251, 166-174.
Klaeser, B., Mueller, M. D., Schmid, R. A., Guevara, C., Krause, T. (2009). PET-CT-guided interventions in the management of FDG-positive lesions in patients suffering from solid malignancies: Initial experiences. European Radiology, 19(7), 1780-1785.
Klaeser, B., Wiskirchen, J., Wartenberg, J., Weitzel, T., Schmid, R. A. (2010). PET/CT-guided biopsies of metabolically active bone lesions: Applications and clinical impact. European Journal of Nuclear Medicine and Molecular Imaging, 37(11), 2027-2036.
Povoski, S. P., Sarolaya, I., & White, W. C. (2009). Comprehensive evaluation of occupational radiation exposure to intraoperative and perioperative personnel from 18F-FDG radioguided surgical procedures. European Journal of Nuclear Medicine and Molecular Imaging, 35, 2026-2034.
Rasmussen, S. N., Holm, H. H., Kristensen, J. K., & Barlebo, H. (1972). Ultrasound-guided liver biopsy. British Medical Journal, 2, 500-502.
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Selzner, M., Hany, T. F., Wildbrett, P., McCormack, L., Kadry, Z., & Clavien, P. A. (2004). Does the novel PET/CT imaging modality impact on the treatment of patients with metastatic colorectal cancer of the liver? Annual Surgical, 240, 1027-1034.
Shyn, P. B. (2013). Interventional positron emission tomography/computed tomography: State-of-the-art. Techniques in Vascular and Interventional Radiology, 16(3), 182-190.
Silverman, S. G., Collick, B. D., & Figueira, M. R. (1995). Interactive MR-guided biopsy in an open-configuration MR imaging system. Radiology, 197, 175-181.
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Tatli, S., Gerbaudo, V. H., Feeley, C. M., Shyn, P. B., Tuncali, K., Silverman, S. G. (2011). PET/CT-guided percutaneous biopsy of abdominal masses: Initial experience. Journal of Vascular and Interventional Radiology, 22(4), 507-514.
Tsalafoutas, I. A., Tsapaki, V., Triantopoulou, C., Gorantonaski, A., & Paplliou, J. (2007). CT-guided interventional procedures without CT fluoroscopy assistance: Patient effective dose and absorbed dose considerations. American Journal of Roentgenology, 188, 1479-1484.
Werner, M. K. (2014). FDG-PET/CT-guided biopsy of bone metastases sets a new course in patient management after extensive imaging and multiple futile biopsies. British Journal of Radiology, 84(999), 65-67.
Wiering, B., Ruers, T. J., Krabbe, P. F., Dekker, H. M. & Oyen, W. J. (2007). Comparison of multiphase CT, FDG-PET and intra-operative ultrasound in patients with colorectal liver metastases selected for surgery. Annual Surgical, 14, 818-826.