tumor imaging mudr. kateřina táborská. 1.differentiation of benign from malignant lessions...
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TUMOR IMAGINGTUMOR IMAGING
MUDr. Kateřina Táborská
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1. Differentiation of benign from
malignant lessions
2. Staging of malignant disease
3. Differentiation of reccurent malignant
disease from therapy induced changes
4. Monitoring the response to therapy
Objectives of Tumor Imaging
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AGENTS
Choise depends on:
• Mechanism of uptake
• Sensitivity for detection of malignant lesion
• Specificity of uptake
• Sites of normal physiological uptake in the body and routes of excretion
• availability
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Radiopharmaceuticals
Nonspecific affinity for neoplastic tissue, may be used to image a range of tumors in various organs
18F Fluorodeoxyglucose
67Gallium citrate
201Thallium
99m Tc sestamibi
Designed to label specific tumor antigens, receptors
111In Octreoscan
123I MIBG
123/131 I NaI
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Positron Emission TomographyIs rapidly becoming a major diagnostic modality
similar to conventional NM in principle, but it uses diferent radiopharmaceuticals + more complex acquisitions method – better resolution
based on coincidence detection of two gamma rays (511 keV) that originate from annihilation of positron – electron pair
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PET radiopharmaceuticals contain short half-life radionuclides (prepared in cyclotron), that decay, emitting positrons
Radionuclidhalf-life (mins)
RPH metabolic pathway
18F 110 18F-FDGglucose
metabolism
11C 20 11C-methionin protein syntesis
13N 10 13NH3 blood flow
15O 2 15O - H2O blood flow
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18FDG tracer of glucose metabolism
Estimate the rate of glucose utiliation
blood cell
x greater number of Glucose transporter proteins
Elevated levels of intracellular enzymes that support glycolysis
x
Tumor cells demonstrate glucose metabolism
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Physiological distribution of 18 FDG
brain
myocardium
bowel
liver
spleen
excreted by the kidneys
Inflammation specificity
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Examination
1. Patient preparation 6 hours fasting, good hydration2. Check blood glucose level-lower than 8,3 mmol/l3. RP administration – iv.4. Accumuation phase – 60 - 90 minuts5. Whole body scanning 5-7 bed position, emission,
transmission (CT)6. Data processing7. Evaluation
Contraindicaton
pregnancy, hyperglycaemia, inability to lie without movement during acquisition
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Oncology
Lung cancerHead and neck cancerColorectal cancerEsophageal cancerLymphomaMelanomaBreast cancerThyroid cancerCervical cancerPancreatic cancerBrain tumor
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Differentiation of benign from malignant lessions
SOLITARY PULMONARY NODULE(about a third of SPN in patients older than 35yr malignant)
chest x-ray metabolism of FDG CT sputum cytology + - bronchoscopy mediastinum percutaneous needle biopsy distant metastases mediastinoscopy open lung biopsy
Sensitivity 95%, specificity 80% (CT sensitivity 100%, specificity 50%)
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Differentiation of benign from malignant lessions
SOLITARY PULMONARY NODULE
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- Weight lost (15 kg) - CT and endoultrasound suspicion of malignancy- high risk patient undergoing dialysis- PET negative- clinical follow up without progression
Differentiation of benign from malignant lessions
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Staging of malignant disease is essential for treatment (surgery, chemotherapy)
Functional changes preceed anatomical
N,M morpologic imaging is less accurate
dependent on the size - 1 cm in thorax, 1-2 cm abdomen
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Staging of malignant disease : lung cancer
According to CT
T2N0M0
Dision operation
According to PET
T2N0M1
Dision chemotheraphy
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Differentiation of reccurent malignant disease from therapy induced changes
MRI 18FDG
MRI : metastases of lung Ca – frontal region - necrosis? FDG: frontal region ametabolism (necrosis), occipital region hypermetabolism
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Differentiation of reccurent malignant disease from therapy induced changes
Hodgkin‘s lymphoma, KS II A(bulky mediastinum, neckrestaging after 2. cycle of chemotherapy
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Monitoring the response to therapy
Hodgkin‘s lymphoma
before treatment after treatment
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6767Ga citrateGa citrate
lymphomalymphoma
labeled monoclonal antibody (OncoScint, CEA scan)labeled monoclonal antibody (OncoScint, CEA scan)
colorectal, ovarian cancercolorectal, ovarian cancer
99m99mTc MIBI, TETROFOSMIN, DMSA(V)Tc MIBI, TETROFOSMIN, DMSA(V)
thyroid Cathyroid Ca
ALTERNATIVES
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thyroid Cathyroid Ca 99mTc MIBI99mTc MIBI
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99mTc MIBI – parathyroid adenoma99mTc MIBI – parathyroid adenoma
Dual-phase scanDual-phase scan
Accumulation by thyroid and parathyroid tissue in proportion to blood flow and metabolic rate
Activity in normal parathyroid glands is too low to be seen on image, abnormal uptake > 300 mg
Wash out of normal thyroid tissue is faster than from abnormal parathyroid adenomas and hyperplasia
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99mTc MIBI – parathyroid adenoma99mTc MIBI – parathyroid adenoma
Dual-phase scanDual-phase scan
iv.
Early images (10-15 min) delayed images (2 hours)
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NEUROENDOCRINE TUMORS
Derived from pluripotent stem cells or differentiated neuroendocrine cells
• capacity to synthesize hormones/ peptide neurotransmitters
• biogenic amine precursor uptake and decarboxylation (APUDomas)
• intracytoplasmic storage granule on electron microscopy
• express cell surface receptors for somatostatin
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NEUROENDOCRINE TUMORS
paragangioma
neuroblastoma
pheochromocytoma (catecholamine)
carcinoid (serotonin and metabolites)
medullary thyroid cancer (calcitonin)
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NEUROENDOCRINE TUMORS
localisation, characterisation
123123II MIBG 111In OCTREOSCAN
therapy
131I MIBG
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123I-, 131I- METAJODBENZYLGUANIDIN
123123I I T1/2 13 hours, T1/2 13 hours, γγ rays 27, 159, 529 keV rays 27, 159, 529 keV
131131II T ½ 8,04 days, T ½ 8,04 days, ββ, , γγ rays rays
structurally resembles norepinephrineaccumulation in cytoplasmic catecholamine storage granules
adrenal medulla, sympathetic nervous tissue
tumor cells that posses the type-1 amine uptake mechanism
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123I-, 131I- METAJODBENZYLGUANIDIN
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123I-, 131I- METAJODBENZYLGUANIDIN
SENSITIVITY:
Feochromocytoma 80-90 %Carcinoid 50-60 %Paraganglioma 40-60 %MTC 30 %
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123I-, 131I- METAJODBENZYLGUANIDIN
Preparation:
to minimize thyroid uptake (KI, Lugol‘s solution)
Stop drugs that interfere
with MIBG uptake
(catecholamine agonist)
Imaging:
24 h after iv.
medullary thyroid ca
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111In-OCTREOSCAN®
Pentetreotid - somatostatin analog
Somatostatin - neuropeptide (first found in the hypothalamus)
high density of somatostatin receptors
NT, astrocytoma, meningeoma, breast ca, lymphoma
111In T ½ 67h, (γγ rays 171, 245keV)
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111In-OCTREOSCAN®
SENZITIVITY:
Glukagonom 100 %Vipom 88 %Gastrinom 73 %Nesekreční GEP 82 %Feochromocytom > 85 %Karcinoid 86 – 96 %MTC 65 – 70 %Malubuněčný Ca plic 80 – 100 % Inzulinom 46 %
www.snm.org, guideline, II/2001
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111In-OCTREOSCAN®
Imaging :
4-6h, 24 h after iv.
carcinoid
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SENTINEL LYMPH NODE DETECTION
First node in a lymph node bed to which a tumor cell would come if it penetrated into lymphatic fluid
If an sentinel node is tumor free, with 97-98% accuracy, there is no tumor spread to any lymph node
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SENTINEL LYMPH NODE DETECTION
STAGING
PROGNOSIS
breast
prostate
cervix, vulva
melanoma
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SENTINEL LYMPH NODE DETECTION
Radiopharmaceuticals
99mTc albumin colloids (Senti-Scint® 100-600 nm)
EXAMINATION:
on the morning of surgery (1 day before)
aplication
subdermal
intratumoral
peritomoral
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SENTINEL LYMPH NODE DETECTION
EXAMINATION:
Imaging, marked on skin
In the operating room – hand held gamma detecting probe (combination with blue dye)
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CONCLUSION
ADVANTAGES functional information
DISADVANTAGES lack of anatomic precise localisation
SOLUTION
SPECT/CT
PET/CT