Nuclear medicine in oncology

Marin

Nuclear
medicine
clinic , INMM
Košice
Nuclear Diagnostics
medicine in
oncology
Therapy (lecture)

Theranostics (lecture)
Nuclear medicine in
Diagnostics
oncology
Diagnostics Therapy
(Shorter life, longer flight) (longer life, shorter flight)
The diffferent emitters, the different images (or even no images)
 NM diagnostics in
oncology

Scintigraphy
PET/CT
(gammacamera)

Planar SPECT (SPECT/CT) 68Ga-DOTA Ga-PSMA Other radiopharmaceuticals........

Bone scan Bone scan

MIBG MIBG

18F-FDG
Parathyroid Parathyroid
Thyroid Thyroid
Sentinel lymphnode Sentinel lymphnode
............ ..........
Gamma-camera PET camera
 Why PET?
 Not only because of better quality of image, but also
because of more specific information about tumor
provided by PET RPh

PET Radiopharmaceuticals provide more specific

information about malignant tissue:

a) Metabolic activity
b) Differentiation of malignant cells
c) Intensity of expression of receptors or antigens, that
are typical for particular tumor)
d) ...
 Why do we use so many
radiopharmaceuticals for PET?

Radiopharmaceutical Isotope Chemical substance Information Examples of indications

18
FDG F fludeoxyglucose metabolic activity Lymphoma, melanoma, adenocarcinoma...
11
Acetate C acetate FDG non-avid tumors HCC, renal cancer
18
FES F fluoroestradiol estrogen receptors Breast and ovarian cancer
18
FET F fluoroetyltyrozine Tumors of CNS
18
FLT F fluorotymidin Early phase of malignant proliferation Early phase of FDG-avid tumors
11
Metionin C metionin Imaging of specific carriers CNS, mainly gliomas
11 18
Cholin C, F cholin Prostate cancer
68 prostatic specific membrane
PSMA Ga PSMA expression in cell membrane Prostate cancer
antigen
18 Increased intracellular transport and Medullar thyroid cancer, neuroblastoma,
DOPA F dihydroxyfenylalanine
decarboxylation in tumor cells pheochromocytoma, NET
11
5-HTP C hydroxytryptofan Serotonergic activity NET
68
DOTA Ga DOTATOC, DOTATATE, DOTANOC Expression of somatostatin receptors NET
18
NAF F Natriumfluorid osteogenesis Like bone scan (bone mts)
18 68 Fibroblasts activating protein
FAPI F, Ga Proliferation Trials – clinical phase III - similar to FDG
inhibitor
.............. ... ....... ........ .......
An optimal RPh doesn´t exist
The most often used PET
rhadiopharmaceuticals

RPh Radionuclide Name Information Indications

lymphoma,
18 metabolic
FDG F fludeoxyglucose melanoma,
activity
adenocarcinoma....

prostatic specific PSMA

68
PSMA Ga membrane expression in Prostate cancer
antigen cell membrane

DOTATOC, Expression of
68 Neuroendocrine
DOTA Ga DOTATATE, somatostatin
tumors
DOTANOC receptors
 Dif dg of malignant and benign lesions

Diagnostic targeting (which lesion is the best one for biopsy? – biopsy guidance)

Therapeutic targeting (helps to target radiotherapy or to find what should be

Nuclear
removed)

Tumor origo ignota (an unknown primary tumour)

medicine Staging (extent of disease)
diagnostics in „Grading“ (low grade versus high grade tumors)
oncology Availability of theranostics

Therapeutic effect assessment

Monitoring (recovery/relaps)
 Dif dg of malignant and benign lesions (Lesion
with equivocal diagnostic conclusion in
Nuclear conventional examinations (US, CT, MRI)

medicine
diagnostics in
oncology
Nuclear Targeting
medicine
diagnostics in
oncology
 Targeting:
Nuclear
medicine 1. Diagnostic targeting
diagnostics in 2. Therapeutic targeting
oncology
Diagnostic targeting
 Which part of the body should be targeted by
specialists from other fields of medicine to be
successful in making a correct diagnosis

 Which lymph node has to be removed for

histology?

 Biopsy guidance - From which part of the

organ to take a tissue sample
(e.g.prostate)
Which
lymph
node
should be
taken for
biopsy?
Which
part of
the organ
should be
taken for
biopsy?
Therapeutic targeting
 Which part of the body should be targeted by
therapy

 Radiotherapy (where are the borders of

tumor? Volume of tumor)

 Exact localization of small tumors (gamma

probe helps to find it)
Therapeutic
targeting
(Radiotherapy
planning)
Sentinel
lymph
node (both
diagnostic and therapeutic
targeting)
 Staging (extent of disease at the
beginning of disease)
Nuclear
medicine
diagnostics in
oncology

Restaging (during the disease)

 Staging

Restaging
 Monitoring (follow-up examinations as a part of monitoring -
recovery/relaps)

Nuclear medicine
diagnostics in
oncology
 2D – whole body bone scan

3D – SPECT/CT of bones
SPECT coronal view
Fused image transverse view

CT coronal view
CT transverse view

Solitary bone metastasis of breast cancer

Prostate cancer – Clinical question: Are there bone mts?
A few days before bone scan patient slipped in bathroom
and hit his chest and pelvis.
Where is pathology?
 after

before

Liposarcoma (before and after surgery)

Relaps of liposarcoma?
Non-FDG avid Soft tissue sarcoma

tumors Indolent lymphoma

(low level of glucose metabolism, low
cellularity, small size) Mucinous carcinoma
NET
Prostate cancer
HCC (hepatocellular carcinoma)
Renal carcinoma
GIST
Uterine cancer
Teratoma
Thyroid cancer
Lung cancer
....
 Soft tissue sarcoma
Non-FDG avid
Indolent lymphoma
tumors
(low level of glucose metabolism, low
cellularity, small size) Mucinous carcinoma
NET

Prostate cancer

HCC (hepatocellular carcinoma)

Renal carcinoma

GIST

Uterine cancer

Teratoma

Thyroid cancer

Lung cancer

....
Main non-oncologic indications of 18FDG-PET/CT:

 Fever of unknown origin

 Vasculitis of big arteries

 Detection of inflammatory acitivity in various diseases (sarcoidosis, interstitial

lung fibrosis etc.)

 Inflammatory complications of vascular grafts

 Some neurological diseases (m.Alzheimer, amyotrofic lateral sclerosis...)

 Epilepsy before surgery

Spondylodiscitis (accumulation of FDG in inflammation)
Therapeutic effect assessment
FDG – therapeutic effect assessment
Bone scan – therapeutic effect assessment?
The same patient after RAT of Th3
  Sensitivity of bone scan in looking for
bone mts in patient with breast cancer is
76% versus 96% in PET. Specificity of both
FDG PET versus BONE SCAN
methods is 95%.

 FDG is a strong tool for assessment of

therapeutic effect on bone mts, because
it reflects metabolic activity of tumor
tissue (diminished during efficient
therapy).
 Bone scan is not appropriate for this
purpose, because it reflects increased
osteoblastic reaction of bone during
efficient therapy (healing metastasis is
substituted by new bone tissue).
Assessment of viability of mts after treatment

SBRT

New mts

After surgery
CT
CT - can you see pathology?
CT
?
Lymphoma (enlarged and hypermetabolic lymph nodes)

CT PET/CT
Therapeutic effect
assessment of  1 = no uptake of FDG above background
lymphomas – Deauville  2 = uptake at an initial site that is less than

score or equal to mediastinum

 3 = uptake at initial site that is greater

than mediastinum but less than or equal
to liver

 4 = uptake at an initial site that is

moderately incresed compared to liver

 5a = uptake markedly increased

compared to the liver

 5b = uptake markedly increased

compared to the liver at any new site
that is possibly related to lymphoma

1,2, 3 = complete response

4,5 = partial response or residual disease or progression of disease
Therapeutic effect  PET:

assessment of
 1 = no uptake of FDG above background
 2 = uptake at an initial site that is less than or
lymphomas – Deauville 
equal to mediastinum
3 = uptake at initial site that is greater than
score mediastinum but less than or equal to liver

 CT:
1. No residual mass or LAP
2. Residual mass or LAP

Inspite of residual mass conclusion is:

Complete metabolic response!!!...

1,2, 3 = complete response

Persisting LAP after treatment...

1,7x2,5 cm

2,1x3,1 cm
Therapeutic effect assessment - lymphoma
 Infiltrated bone marrow?

After treatment
Deauville score 1

Before treatment
Hypermetabolic bone marrow after treatment with growth factors to support the bone marrow
  Imaging of places with high
concentration of prostatic specific
membrane antigen
 High concentration of PSMA in prostate
cancer tissue (primary tumor and mts)
 PSMA occurs not only in prostate, but also
in some other tissues – decrease of
specificity of method (optimal RPh doesn´t exist)

68Ga-PSMA
Which bone metastases seen in CT are living (viable) - 68Ga-PSMA
68Ga-PSMA PET/CT – before and after treatment
68Ga-PSMA PET/CT
PSMA a FDG
 Ability to bind up in SSR (somatostatin receptors)

 Increased number of SSR – in well differentiated neuroendocrine

tumors (NET)

68Ga-DOTA (-TOC, -TATE, -NOC)

68Ga-DOTA v. 99mTc-Tektrotyd
(PET versus SPECT)
NET mts
NET mts?
„Biopsy“
„Biopsy“
Nuclear medicine
diagnostics in „Grading“ (low grade versus high
oncology grade tumors) - prognosis
Flip-flop phenomenon

FLIP FLOP

• High accumulation of RPh1 • No accumulation of RPh1

• No accumulation of RPh2 • High accumulation of RPh2

Flip-flop phenomenon
FLIP
 Well differentiated tumor
 High uptake of RPh1
 No uptake of RPh2
 Good prognosis (lesser
agression of tumor – low
grade)
FLOP
 Dedifferentiated tumor
later (months, years)
 No uptake of RPh1
 High uptake of RPh2
 Poor prognosis (high
grade – very aggressive
tumor)
Example of flip-flop phenomenon

FLIP FLOP
 Well differentiated NET  Dedifferentiation of NET

 High uptake of 68Ga-DOTA  No uptake of 68Ga-DOTA

 No uptake of 18F-FDG  High uptake of 18F-FDG