Kh Taalab IMC

Role of FDG PET In Characterization of Lung Role of FDG PET In Characterization of Lung DiseasesDiseases

Cairo Chest 2014Cairo Chest 2014Khalid Muhammad TaalabKhalid Muhammad Taalab

M.B,B.Ch., M.Sc., M.D. IAEA-M.B,B.Ch., M.Sc., M.D. IAEA-Research Fellowship Research Fellowship

Nuclear MedicineNuclear Medicine

International Medical CenterInternational Medical Center

Indications: FDG PET CT in lung disease

• Cancer

• Infection & inflammation

Normal cells use glucose

GLU

FDG

Glut 1 & 3

GLU

CO2+H20

FDG

hexokinase

FDG-6- phoshate

GLU-6-phoshate

Cancer cells use much glucose

GLU

FDG

Glut 1 & 3

GLU GLU-6-phoshate

CO2+H20

FDG FDG-6- phoshate

Metabolic trapping

(Warburg O. 1930, 129-169)

*

Also high amino acid and nucleic acid use

Fused PET + CTLow dose CT PET

Fused PET + CTCT PET

Anato-metabolic imaging

Indications: PET in pulmonary disease

• Cancer @

– Pulmonary nodules– Staging (NSCLC)

– Relaps and re-staging– Treatment monitoring– SCLC– Mesothelioma

– [Radiation field planning]

@ PET costs covered by US Medicare

Indications: PET in pulmonary disease

• Cancer @

– Pulmonary nodules– Staging (NSCLC)

– Relaps and re-staging– Treatment monitoring– SCLC– Mesothelioma

– [Radiation field planning]

• Infection & inflammation* – Localisation and monitoring

of activity:

– Sarcoidosis– AIDS (opportunistic infections and

malignancy)– Fever of unknown origin– Lung abscess– Tuberculosis, Actinomycosis,

Histoplasmosis, Invasive aspergillosis

– Vasculitis (Wegener, Takayasu..)– Radiation induced inflammation

* = Sem Nucl Med 2002 ;32: 293-321@ PET costs covered by US Medicare

Case: 57 y-o-m with COPD

9 mm nodule found on high-resolution CT

18F-FDG PET

transaxial coronal saggital

attenuation corrected RH - PET / jm (ap)

Diagnosis and staging(PET suggests T1 N0 M0)

Case: 57 y-o-m with COPD

FDG PET for extrathoracic metastasis

• 40% with NSCLC have distant metastases at presentation, most often in the adrenal glands, bones, liver, or brain [Ann Thorac Surg 1996;62:246–250].

• Adrenal glands: 10% of NSCL have enlarged adrenal glands on CT, 2/3 being benign.

PET has high sensitivity (>92%) and specificity (80%–100%) -> reduces number of unnecessary adrenal biopsies.

• Bone: Bone scintigraphy good sensitivity (90%), low specificity (±60%),

PET good sensitivity (90%), but higher specificity (98%) and accuracy (96%).

• Liver: US and/or CT remain the standard imaging techniques for the liver. No good comparisons studies. Additional diagnostic information by PET combined with CT, in the differentiation of hepatic lesions that are indeterminate on conventional imaging.

• Brain: PET low sensitivity (60%) not suited for the detection of brain metastases.

The Oncologist 2004; 9 (6): 633-43

”PET/CT will improve staging in 20- 40 % of lung cancer patients”Lardinois D et al.

N Engl J Med 2003; 348: 2500-7

PET/CT in lung cancer

Cerfolio RJ et al. Ann Thorac Surg 2004; 78: 1017–23

A randomised study in progress in Copenhagen

Bone metastasis with normal CT

Impact of PET in lung cancer

• PET changes stage in 35% of patients (N=894, 16 studies)

– Usually the PET stage is higher than with usual work-up incl. CT• Due to local (N2 eller N3) metastasis or extra-pulmonary metastasis

– ie. operation is unnecessary

– change in therapy to chemotherapy and / or radiation treatment • Semin Nucl Med 2002, 32:240-71

• PET is cost effective in lung cancer– Both for diagnosis of single pulmonary nodules and for Staging

– References: (Gambhir J Clin Oncol 1998; 16: 2113-2125) (Dietlein Eur J Nucl Med 2000; 27: 1441-56) (Gould ARRDCCM 2001) (Plus study)

Increased FDG-PET uptake can be seen inbenign mediastinal adenopathies(Z)

• Granulomatosis and silicosis (Inflammation)– Sarcoidosis– Anthrasilicosis

• Infections– Histoplasmosis, – Tuberculosis (and M avium intracellulare)– Actinomycosis, etc.

• Benign neoplasm (-thymoma, teratoma, swannoma)

• Iatrogenic disorders (Radiation related changes)

(Z) Yet, only a minority with these conditions have a high FDG uptake

Sem Nucl Med 2002;32(4): 293-321

Case stories

TB in a 58-year-old man. (A) chest radiograph shows two nodules (b) coronal FDG PET scan shows increased uptake (solid arrow) in the left upper lobe nodules (SUV 4).

• Radiology 2000 6:117-21

FDG PET in active tuberculosis

Sarcoidosis

Milman N, Mortensen J, Sloth C. Respiration. 2003;70:408-13.

Before treatment:

After inhaled steroid:

After prednisolone:

Localisation of activity in- and outside lungs:

Monitoring:

Newer indications for PET in lung cancer

• Prognostic information from SUV

• Evaluation of treatment effect ->

• PET/CT for planning of radiation field

• Staging and monitoring SCLC ->

• Staging and diagnosis of Mesothelioma

FDG PET for:• Guiding of biopsy• Staging (extrathoracic or contralateral metastasis)

J Nucl Med. 1999 Aug;40(8):1241-5.

Semin Oncol. 2002 Feb;29(1):26-35.

Axial FDG-PET image shows intense uptake (arrow) Axial FDG-PET image shows intense uptake (arrow) in the left upper lobe suggesting a malignant in the left upper lobe suggesting a malignant condition with a maximum standardized uptake condition with a maximum standardized uptake value of 4.3. The pathologic examination reveals value of 4.3. The pathologic examination reveals tuberculoma. Another lesion showing high FDG tuberculoma. Another lesion showing high FDG uptake (arrowhead) is a pulmonary artery.uptake (arrowhead) is a pulmonary artery.

Tuberculous Lymphadenopathy:Tuberculous Lymphadenopathy:

Coronal FDG-PET scan shows high uptake Coronal FDG-PET scan shows high uptake in the same area (arrow).in the same area (arrow).

CryptococcosisCryptococcosisContrast-enhanced CT scan shows a cavitary nodule in Contrast-enhanced CT scan shows a cavitary nodule in

the left lower lobe (the left lower lobe (arrowedarrowed ). ).Transverse section of a whole body PET image shows Transverse section of a whole body PET image shows

increased uptake (increased uptake (arrowedarrowed) in the left lower lobe and a ) in the left lower lobe and a standardized uptake value of 2.6. The lesion is a round standardized uptake value of 2.6. The lesion is a round mass-like lesion unlike the CT findings due to mass-like lesion unlike the CT findings due to respiration artifact.respiration artifact.

Lung abscess:Lung abscess: Axial contrast enhanced CT scans show a Axial contrast enhanced CT scans show a consolidation with air density in the right upper lobe (black consolidation with air density in the right upper lobe (black arrow). Multiple conglomerated mediastinal lymph node arrow). Multiple conglomerated mediastinal lymph node enlargements are also noted (white arrow).enlargements are also noted (white arrow).

Coronal FDG-PET image shows high uptake (arrows) in the Coronal FDG-PET image shows high uptake (arrows) in the right upper lobe. High uptake in the left hilar lymph node right upper lobe. High uptake in the left hilar lymph node (arrowhead) is also noted. Malignancy is suspected in PET scan. (arrowhead) is also noted. Malignancy is suspected in PET scan. Per-cutaneous needle biopsy reveals a lung abscess.Per-cutaneous needle biopsy reveals a lung abscess.

Radiation FibrosisRadiation Fibrosis Axial CT scan shows consolidation in the left Axial CT scan shows consolidation in the left

lower lobe, suggesting lung cancer recurrence.lower lobe, suggesting lung cancer recurrence. Axial PET image shows increased uptake in the Axial PET image shows increased uptake in the

left lower lobe (arrow) which was mistaken for left lower lobe (arrow) which was mistaken for lung cancer recurrence.lung cancer recurrence.

Pneumoconiosis with Combined Massive Pneumoconiosis with Combined Massive FibrosisFibrosis

Progressive massive fibrosis in a 58-year-old male. Progressive massive fibrosis in a 58-year-old male. Coronal FDG-PET image shows increased uptake in Coronal FDG-PET image shows increased uptake in right upper lobe (arrow) and the standardized uptake right upper lobe (arrow) and the standardized uptake value max. of 6.4.value max. of 6.4.

Bronchiolo-alveolar Carcinoma (BAC)Bronchiolo-alveolar Carcinoma (BAC) Axial chest CT images show a low Axial chest CT images show a low

attenuating mass in the left upper lobe.attenuating mass in the left upper lobe.

FDG-PET also shows a hyper-metabolic FDG-PET also shows a hyper-metabolic lesion with a maximum standardized lesion with a maximum standardized uptake value of 3.8 in the left upper lobe.uptake value of 3.8 in the left upper lobe.

Another area of ground-glass opacity is noted in Another area of ground-glass opacity is noted in the right lower lobe.the right lower lobe.

FDG-PET shows no abnormal uptake in this area. FDG-PET shows no abnormal uptake in this area. Both the left upper and right lower lobe lesions Both the left upper and right lower lobe lesions

were bronchioloalveolar carcinomas, mucinous were bronchioloalveolar carcinomas, mucinous type. In the same patient, FDG uptake for each type. In the same patient, FDG uptake for each of the lung lesions was different, and the amount of the lung lesions was different, and the amount mucin in mass may have been the major cause of mucin in mass may have been the major cause of this difference.this difference.

Metastatic Lung Nodule of Extrapulmonary Metastatic Lung Nodule of Extrapulmonary NeoplasmNeoplasm

FDG-PET fusion CT shows a nodular lesion in the right FDG-PET fusion CT shows a nodular lesion in the right lower lung without increased FDG uptake (arrow).lower lung without increased FDG uptake (arrow).

Mucinous adeno-carcinomas of gastrointestinal origin Mucinous adeno-carcinomas of gastrointestinal origin can also show false negative findings in PET scans. can also show false negative findings in PET scans.

Axial CT scan of lung window setting shows a lung Axial CT scan of lung window setting shows a lung nodule metastasis from renal cell carcinoma in the nodule metastasis from renal cell carcinoma in the right middle lobe (arrow).right middle lobe (arrow).

A selected transverse section of whole body-PET A selected transverse section of whole body-PET image shows no demonstrable uptake in the right image shows no demonstrable uptake in the right lung.lung.

Help from a PET-scan

• A positive PET focus indicates malignancy • but needs histological proof (to avoid false positive)• PET or PET/CT guided biopsy possible

• A negative PET focus indicates benignancy – A solitary pulmonary nodule is either benign or very slowly

growing cancer (no or CT control 6-12 months for growth)

– Staging, no metastasis found, refer to operation.

Conclusion• Single Pulmonary Nodules

– Differentiate between benign/malignant indeterminate SPN• if biopsy is difficult / nondiagnostic • confirm benignity with CT follow-up

– the uptake predicts prognosis (high metabolism -> bad prognosis)

• Staging Regional (N) and distant (M) metastases:– Addition of PET improves conventional staging (CT+US+ bone scintigraphy)

– PET changes stage and treatment in ~35 % of patients• Detects unexpected distant metastases in ~14 % • Exclusion of malignancy in ~5 % (can be operated)• Usually a higher stage is found• Avoids unneccesary thoracotomy (in 10-20 %)- Mediastinoscopy can be avoided if PET + CT are normal (in non-central tumors)

- Other indications:- Restaging and treatment monitoring, radiation field planning, SCLC, Mesothelioma

- Localisation & monitoring of infections & inflammatory disorders

INTERNATIONAL MEDICAL CENTERINTERNATIONAL MEDICAL CENTER