FDG PET-CT in Oncology part 1

These slides involve the basic knowledge for using F-18 FDG PET/CT in oncology.

Transcript

1. Jiraporn Sriprapaporn Nuclear Medicine Siriraj Hospital PET/CT in Oncology Jiraporn_PET/CT Onco 2020 19-10-2020
2. Jiraporn_PET/CT Onco 2020 Basic of PET/CT imaging in oncology Overview about PET & PET/CT Introduction PET, PET/CT scanners PET radiopharmaceuticals : F-18 FDG*** Mechanism of F-18 FDG uptake Principle of F-18 FDG PET-CT imaging Radiation dose from PET/CT Clinical indications Reimbursement in Thailand Procedure Guideline for F-18 FDG imaging (SNMM)  Patient preparation  Patient information  Technique  Interpretation: Normal Normal variants Artifacts & pitfalls (false positive & false negative)
3. Jiraporn_PET/CT Onco 2020 Overview about PET & PET/CT  Introduction  PET, PET/CT scanners  PET radionuclides/ radiopharmaceuticals: F-18 FDG***  Mechanism of F-18 FDG uptake  Principle of F-18 FDG PET-CT imaging  Radiation dose
4. Jiraporn_PET/CT Onco 2020 Jiraporn_PET/CT Onco 2020 Introduction  PET = Positron Emission Tomography  Evaluation of in-vivo metabolic imaging, by using positron emitters.
5. Jiraporn_PET/CT Onco 2020 1952 1972 1973 1975 1977 1980 1998 2 001 •Edward J. Hoffman •Michel M. Ter- Pogossian •Michael E. Phelps Development of Instrument Jiraporn_PET/CT Onco 2020
6. Jiraporn_PET/CT Onco 2020 PET-CT in Oncology: Advantages  PET & CT imaging  metabolic & anatomic information  Whole-body evaluation  High sensitivity  High resolution imaging  Good patient tolerance  Suitable for repeated imaging Normal vs Pathologic CT in PET/CT is used for • Image localization and • Attenuation correction of PET data
7. Jiraporn_PET/CT Onco 2020 PET/CT Centers in Thailand  1st Watanosot Hosp: PHILIPS Gemini GXL 16SL, GSO [Oct 2005]+CYC, SIEMENS flow motion  2nd Chulabhorn cancer center: SIEMENS Biograph 16, LSO [2006]+ CYC, SIEMENS Digital PET/CT Biograph Vision [2019]- Flow motion, 30% time reduction  3rd Chulalongkorn Hospital: SIEMENS Biograph 16, LSO  4th Siriraj Hospital- GE Discovery STE 16, BGO [November 2006], GE Discovery MI 16, LBS [2020]  5th Bumrungrad Hosp: SIEMENS Biograph TruePoint 64, LSO [18-6-08]  6th at Ramathibodi Hospital-PHILIPS Gemini TF, 64 SL LYSO [May 2011]  SiPH: GE Discovery 690 16 SL, LYSO [Dec 2012]+CYC  Khonkaen U.: GE Discovery 690 16 SL, LYSO  Chieng-mai U. Biograph 128 mCT, LSO [22 May 2014]+CYC  Songklha U.: PHILIPS Vereos 64/128 LYSO (digital PET/CT-DPC)+ CYC 2 1 3 *CYC = Cyclotron
8. Jiraporn_PET/CT Onco 2020 4 Factors Facilitate Widespread Use of FDG PET-CT Imaging 1.The development of PET scanners with a large field of view for whole-body scanning;  great impact for the detection of distant metastatic sites in cancer patients. 2.The commercial availability of F-18 FDG for hospitals that do not have a cyclotron. 3.The introduction of a PET camera and a CT scanner into a single setting (integrated PET/CT). 4.The approval of reimbursement for PET/CT using F-18 FDG for most oncologic studies. Endo K et al. 2006
9. Jiraporn_PET/CT Onco 2020 PET/CT Clinical Applications
10. Jiraporn_PET/CT Onco 2020 Introduction
11. Jiraporn_PET/CT Onco 2020 Values of PET  Permits cost-effective, whole-body metastatic survey.  one-stop exam !  Avoids biopsy for low-grade tumors.  Avoids unnecessary or futile surgery.  Permits early change in course of ineffective CMT.  Permits noninvasive differentiation of active tumors from postRx fibrosis.
12. Jiraporn_PET/CT Onco 2020 Overview about PET & PET/CT  Introduction  PET, PET/CT scanners  PET radionuclides/ radiopharmaceuticals: F-18 FDG***  Mechanism of F-18 FDG uptake  Principle of F-18 FDG PET-CT imaging  Radiation dose
13. Jiraporn_PET/CT Onco 2020 Instrument  1952  The first gamma camera by Hal Anger  1972  The first CT scanner was invented by British engineer Godfrey Hounsfield of EMI Laboratories, England and by South Africa-born physicist Allan Cormack of Tufts University, Massachusetts. (Hounsfield and Cormack were later awarded the Nobel Prize)  1973 The first PET camera was built for human studies by Edward Hoffman, Michael M. Ter-Pogossian, and Michael E. Phelps at Washington University  1975  The first commercial PET scanner  1977  The first whole-body PET scanner  1977  The first MRI for human body was produced by Raymond Damadian, a physician at State University of New York (SUNY) Brooklyn,.  1980  The first commercial MRI in March 1980 (Melville Company, NY).  1998  The first PET/CT prototype  2001  The first commercial PET/CT scan •Edward J. Hoffman •Michel M. Ter- Pogossian •Michael E. Phelps
14. Jiraporn_PET/CT Onco 2020 1952 1972 1973 1975 1977 1980 1998 2 001 •Edward J. Hoffman •Michel M. Ter- Pogossian •Michael E. Phelps Development of Instrument
15. Jiraporn_PET/CT Onco 2020  1998  The 1st prototype PET/CT scanner was invented by Dr. Ron Nutt and Dr. David Townsend  1999  PET/CT was approved by FDA in Oct 1999.  Medical Inventions of the year 2000 by Time Magazine  2001, PET/CT = ”Product of the Year” by Frost and Sullivan.  2001  commercially available The U.S. Food and Drug Administration approved the combined PET/CT scanner in October 1999.
16. Jiraporn_PET/CT Onco 2020 Suggested Reading Semin Ultrasound CT MR. 2008 Aug;29(4):232-5.
17. Jiraporn_PET/CT Onco 2020 PET SCANNERS  Dedicated PET Scan  Dual-head coincidence PET scan  PET/CT scan (2001)  PET/MRI (SNM Meeting 2007, FDA approved in 6/2011)
18. Jiraporn_PET/CT Onco 2020 3 vendors* SIEMENS PHILIPS GE Healthcare Hitachi Medical Toshiba
19. Jiraporn_PET/CT Onco 2020 Modern PET-CT Scanners
20. Jiraporn_PET/CT Onco 2020 New PET/CT system @ นวมินทร์ ชั้น 4
21. Jiraporn_PET/CT Onco 2020 Table 11.2 Properties of scintillation crystals used in positron emission tomographic (PET) scanners Properties/Crystals NaI(Tl) BGO GSO:Ce LSO:Ce LYSO:Ce Density (gm/cm3) 3.67 7.13 6.7 7.4 7.1 Effective atomic number (Z) 51 74 59 66 64 Linear attenuation coefficient (1/cm) 0.34 0.92 0.62 0.87 0.86 Light yield (% NaI[Tl]) 100 15 30 75 75 Decay time (ns) 230 300 65–60 40 41 Emission maximum (nm) 410 480 440 420 420 Hygroscopic Yes No No No No Photoelectric effect (%) 17 40 25 32 33 Refractive Index 1.85 2.15 1.85 1.82 1.81 Basic Sciences of Nuclear Medicine By Magdy Khalil, Springer 2011
22. Jiraporn_PET/CT Onco 2020 Overview about PET & PET/CT  Introduction  PET, PET/CT scanners  PET radionuclides/ radiopharmaceuticals: F-18 FDG***  Mechanism of F-18 FDG uptake  Principle of F-18 FDG PET-CT imaging  Radiation dose
23. Jiraporn_PET/CT Onco 2020 PET Radionuclides  Positron-emitting radionuclides (emit positron (e+) from Nu (p excess)  Relatively short half-lives and high radiation energies (compared to general NM imaging)  Produced by cyclotron* or generators
24. Jiraporn_PET/CT Onco 2020 Principal Positron Emitters Radionuclides Production Physical T1/2 C-11 Cyclotron 20 min N-13 Cyclotron 10 min O-15 Cyclotron 2 min F-18 Cyclotron 110 min Ga-68 Generator 68 min Rb-82 Generator 75 sec
25. Jiraporn_PET/CT Onco 2020 Production of PET Radionuclides  11C 14N(p,a)11C  13N 16O(p,a)13N  15O  15N(p,n)15O, 14N(d,n)15O  18F  18O(p,n)18F, 16O (3He,p) 18F, 20Ne (d,x)18F  82Rb  82Sr/82Rb generator T 1/2 =1.52 min. [82Sr T 1/2 = 25 days]  68Ga  68Ge/68Ga generator T 1/2 = 68 min. [68Ge T 1/2 = 270.8 days]  124I  124Te(p,n)124I T 1/2 =4.16 days 18O enriched water
26. Jiraporn_PET/CT Onco 2020 F-18 Production  O-18 (p,n) F-18  F-19 (d,t) F-18  F-19 (n,2n) F-18  Ne-20 (d,a) F-18  O-16 (He3,p) F-18  O-16 (t,n) F-18
27. Jiraporn_PET/CT Onco 2020 Physical Properties of PET Radionuclides Vallabhajosula S, SNM 2011
28. Jiraporn_PET/CT Onco 2020 Development of F-18 FDG  Alfred P. Wolf, a chemist [GER] at Brookhaven National Laboratory known as the father of organic radiochemistry, a field that links medicine and chemistry.  In 1976, Wolf and colleagues developed and used a radiotracer called F-18 fluorodeoxyglucose to generate the first functional map of the human brain at work. Tatsuo Ido F-18 FDG is the most commonly used tracer for PET/CT scanning, received FDA approval for cancer imaging in 2000 & for all cancer type in 2005
29. Jiraporn_PET/CT Onco 2020 F-18 FDG  F-18 FDG (F-18-2-fluoro-2-deoxy-D-glucose) or fluorodeoxyglucose (glucose analogue)  Replace OH group to be F-18  Measure glucose metabolism
30. Jiraporn_PET/CT Onco 2020 FDA-Approved PET Radiopharmaceuticals Radiopharms Year of approval Clinical Indication F-18 Fluoride 1972 Bone imaging Rb-82 1992 Myocardial perfusion F-18 FDG 1994 Epileptic foci F-18 Fluoride 2000 Bone Imaging N-13 NH3 2000 Myocardial perfusion F-18 FDG 2000 Myocardial glucose metabolism Tumor glucose metabolism F-18 FDG 2005 Alzheimer’s disease (AD) and Fronto-temporal dementia (FTD)
31. Jiraporn_PET/CT Onco 2020 Overview about PET & PET/CT  Introduction  PET, PET/CT scanners  PET radionuclides/ radiopharmaceuticals: F-18 FDG***  Mechanism of F-18 FDG uptake  Principle of F-18 FDG PET-CT imaging  Radiation dose
32. Jiraporn_PET/CT Onco 2020 F-18 FDG  F-18 FDG (F18-2-fluoro-2-deoxy-D-glucose) or fluorodeoxyglucose (Glucose analogue)  Glucose metabolism  FDG enters the cells using the same pathway as glucose (glucose transporter proteins, GLUT) [R23: Mochizuki T, et al. JNM 2001] but is not used in glycolysis and is metabolically trapped inside the cells after phophorylation (FDG- 6-phosphate).  FDG is excreted in large quantities by kidneys unlike glucose.
33. Jiraporn_PET/CT Onco 2020 Jiraporn_PET/CT Onco 2020 FDG Metabolism Enz1 = Hexokinase – Phosphorylation GLUT = Glucose transpoter Enz2= Glucose-6-phosphatase Tumor cells  higher glycolytic rate than normal tissue. 1 1 2 2 Glycolysis Glycolysis GLUT GLUT G-6-P isomerase (Buck AK JNM 2004)
34. Jiraporn_PET/CT Onco 2020 Glucose Transporters
35. Jiraporn_PET/CT Onco 2020 Mechanism of F-18 FDG Uptake Malignant cells have increased glucose utilization due to  Over expression of membrane glucose transporter receptors, especially GLUT-1 and GLUT-3 on surface of tumor cells.  Increased hexokinase activity  Decreased level of glucose-6-phosphatase
36. Jiraporn_PET/CT Onco 2020 Overview about PET & PET/CT  Introduction  PET, PET/CT scanners  PET radionuclides/ radiopharmaceuticals: F-18 FDG***  Mechanism of F-18 FDG uptake  Principle of F-18 FDG PET-CT imaging
37. Jiraporn_PET/CT Onco 2020 Principle of PET Imaging  Detecting (indirectly) positron emission via the detection of both annihilation photons (511 keV) that occur and hit opposite detectors simultaneously (within coincidence time window ~ 10 ns)  Spatial resolution ~ 4-5 mm FWHM, new system  2-3 mm. Annihilation
38. Jiraporn_PET/CT Onco 2020 Types of Coincidence Detection
39. Jiraporn_PET/CT Onco 2020 Positron Range & Image Resolution  The distance that the positron will travel in tissue before annihilation depends on the energy of the positron,  this distance being about 1 mm in the case of the positrons emitted by F-18 and about 1.5 mm in the case of O-15. Isotope Half-life (min) Maximum positron E (MeV) Positron range in water (FWHM- mm) Production method 11C 20.3 0.96 1.1 cyclotron 13N 9.97 1.19 1.4 cyclotron 15O 2.03 1.70 1.5 cyclotron 18F 109.8 0.64 1.0 cyclotron 68Ga 67.8 1.89 1.7 generator 82Rb 1.26 3.15 1.7 generator http://depts.washington.edu/nucmed/IRL/pet_intro/intro_src/section2.html
40. Jiraporn_PET/CT Onco 2020 Steps for PET-CT Imaging  Production of positron-emitting Rdn.  Labeling a selected compound with a positron-emitting Rdn.  Administration into a patient (IV, inhalation)  Imaging the patient  Reconstruction & display (Quantitation) PET IMAGING CYCLOTRON PET-CT IMAGES PET-CT SCANNER RADIOPHARM PATIENT
41. Jiraporn_PET/CT Onco 2020 PET-CT Imaging CT PET  Scout CT-Topogram  CT-low mA  PET-NAC  PET-AC  Fused PET(AC) +CT AC = Attenuation Correction
42. Jiraporn_PET/CT Onco 2020 Sequences of PET/CT imaging  Topogram (Scout CT)  CT scan- skull base to midthigh  PET scan (NAC)  PET scan (AC)- reconstruction  PET/CT image fusion  MIP image (maximal intensity projection) 3 planes MIP: is a volume rendering method for 3D data that projects in the visualization plane the voxels with maximum intensity MIP
43. Jiraporn_PET/CT Onco 2020 Topogram Sequences of PET/CT imaging
44. Jiraporn_PET/CT Onco 2020 Estimated Radiation Dose  About 50% of F-18 FDG is excreted in the urine at 2 hrs  Estimated rad dose at bladder wall is the highest organ,. [Oehr et al. 2004]  1 rad for each chest/abd/pelvic CT scan. The Essentials:  Dose rate of F-18 = 6 folds Tc-99m  Effective dose 1 mSv/mCi F-18 FDG  F-18 FDG accumulates in breast tissue but not significantly secreted into breast milk, withdraw breast feeding for 8 hrs. to reduce rad to the infant.[close contact]
45. Jiraporn_PET/CT Onco 2020  18F-FDG PET/CT examination at King Chulalongkorn Memorial Hospital  PET/CT system, LSO HI-REZ, CTI/Siemens Medical System  FDG is 5.55 MBq/kg; CT 120 kVp, current varied  The average whole-body effective doses from PET and CT were 4.40 ± 0.61 and 14.45 ± 2.82 mSv, respectively, resulting in the total patient dose of 18.85 mSv. http://rpd.oxfordjournals.org/content/141/1/50.full Radiat Prot Dosimetry (2010) 141 (1): 50-55. The determination of patient dose from 18F-FDG PET/CT examination
46. Jiraporn_PET/CT Onco 2020 Indications for 18F-FDG PET/CT Oncologic indications A. Differentiating benign from malignant lesions B. Searching for an unknown primary tumor C. Staging known malignancies D. Monitoring the effect of therapy on known malignancies E. Determining whether residual abnormalities after treatment represent residual tumor or posttreatment fibrosis F. Detecting tumor recurrence, especially in the presence of elevated tumor markers G. Selecting site for biopsy H. Guiding radiation therapy planning Nononcologic applications A. Infection B. Atherosclerosis Note: 18F-FDG is not equally effective for all malignancies, but other tracers are available  Well differentiated cancer or low-grade malignancy  low FDG uptake  Poorly diff cancer or high-grade malignancy  high FDG uptake
47. Jiraporn_PET/CT Onco 2020 F-18 FDG PET/CT Reimbursement in Thailand Version 1.0  Lung cancer-NSCLC for staging  Colorectal cancer for restaging (suspected tumor recurrence) Version 2.0  Lymphoma  Esophageal cancer  Uterine cervical cancer  Thyroid cancer_DTC
48. Jiraporn_PET/CT Onco 2020 Type of cancer Indications* 1. Non-small cell lung cancer Initial staging 2. Colorectal cancer Detect tumor recurrence 3. Lymphoma Staging & Interim 4. Esophageal cancer Staging, before RT 5. Uterine cervical cancer Prior to pelvic exenteration 6. Thyroid cancer_DTC Detect tumor recurrence Ne w F-18 FDG PET/CT Reimbursement Valid from 1 Oct 2019 *หมายเหตุ: ตามรายละเอียดที่กรมบัญชีกลางระบุ
49. Jiraporn_PET/CT Onco 2020
50. Jiraporn_PET/CT Onco 2020
51. Jiraporn_PET/CT Onco 2020
52. Jiraporn_PET/CT Onco 2020 PET/CT: Procedure Guidelines  SNM guideline  EANM guideline 2006 2015 TO BE CONTINUED