Download Hybrid Imaging with PET/CT and with PET/CT and SPECT/CT

Hybrid Imaging with PET/CT and with PET/CT and SPECT/CT
SPECT/CT: : Improving
Improving Therapeutic Decisions
Therapeutic Decisions
American College of Osteopathic Internists
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p
October 14, 2011
San Antonio, Texas
Aaron C. Jessop, MD Assistant Professor
Department of Nuclear Medicine
UT MD Anderson Cancer Center, Houston, Texas
EARLY
PET
EARLY PET
11C-glucose
C glucose
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Courtesy of R.E. Coleman
Early
CT
Early CT
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Complimentary role of Anatomical & Molecular Imaging • Anatomical imaging (CT or MRI): best imaging modalities to evaluate the relationship between organs and vascular structures. structures
• SPECT
SPECT and PET: provide functional images but lack and PET: provide functional images but lack
anatomical landmarks for accurate localization.
• Optimal interpretation and localization is obtained when both are interpreted in conjunction with each other.
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Correlation of Anatomical and Functional IImages
mages
• Visual correlation
• Fusion of images obtained separately using registration software
g
– Straightforward for rigid structures (e.g. brain)
– Problems with non‐rigid structures (e.g. body)
• Breath‐hold versus breathing
• Internal motion of organs
• Position of the patient on the imaging table
• Integrated imaging systems I
di
i
– SPECT/CT – PET/CT
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Integrated PET/CT Imaging System
Benefit of the combined technique:
q
1) Attenuation correction with CT 2) Anatomical localization
PET CT
Attenuation
Att
ti
Correction
Anatomical localization
• 62 year
old male
62 year‐old
male
– Two weeks of abdominal pain
abdominal pain
– CT abdomen
• Retroperitoneal
Retroperitoneal adenopathy
• Hepatic steatosis
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• 62 year
old male
62 year‐old
male
– Two weeks of abdominal pain
abdominal pain
– CT abdomen
• Retroperitoneal
Retroperitoneal adenopathy
• Hepatic steatosis
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Retroperitoneal node biopsy: Metastatic Pancreatic Adenocarcinoma
FDG
PET and PET/CT: Impact on Management
FDG PET and PET/CT: Impact on Management
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y
• Diagnostic Accuracy
– FDG PET: superior diagnostic accuracy than conventional imaging for staging and restaging FDG‐avid
imaging for staging and restaging FDG
avid malignancies
malignancies
– PET/CT: incremental impact on diagnostic accuracy: 40‐50%
40
50% patients
– Discriminating metastatic from physiologic foci
– Improving lesions detection on both PET and CT
– Precise localization of metastatic foci
P i l li ti
f
t t ti f i
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Supplement to JNM;2001:42: May 2001, Guest editor: Sajiv
Supplement to JNM;2001:42: May 2001, Guest editor: Sajiv S. S. Gambhir
Gambhir
Supplement to JNM;2004;45: January 2004, Guest editor: Johannes Czernin
Supplement to JNM;2004;45: January 2004, Guest editor: Johannes Czernin
FDG
PET and PET/CT: Impact on Management
FDG PET and PET/CT: Impact on Management
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• Impact on Management:
– FDG PET: ~30% patients (range 10%‐60%)
– PET/CT: incremental impact on Patient’s management: 10‐20% patients, including
– Planning radiation therapy Planning radiation therapy
– Guiding biopsies.
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Supplement to JNM;2001:42: May 2001, Guest editor: Sajiv
Supplement to JNM;2001:42: May 2001, Guest editor: Sajiv S. S. Gambhir
Gambhir
Supplement to JNM;2004;45: January 2004, Guest editor: Johannes Czernin
Supplement to JNM;2004;45: January 2004, Guest editor: Johannes Czernin
FDG
PET and PET/CT: Impact on Management
FDG PET and PET/CT: Impact on Management
Disease
Process
Author
Year
#
patients
Mixed tumors
Bar-Shalom
2003
204
Modality
Compariso
n
Change of
management
FDG PET/CT
PET alone
14%
10
Mixed tumors
Roman 11
2005
173
FDG PET/CT
PET alone
12.5%
Mixed tumors
Hillner 12
(NOPR)
2008
22,975
,
FDG PET
(16%)
PET/CT (84%)
Referringg
physician
questionnair
e
36.5%
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Delbeke D et al. Semin
Delbeke D et al. Semin Nucl Med 2009;39(3): 308‐
Med 2009;39(3): 308‐40.
NOPR: National Oncologic PET Registry
A Nationwide (US) Collaborative Program: 2006‐2008
• Nationwide prospective registry
• Goal: – Evaluate the impact of PET on physicians plans of patient management
patient management
• Providers:
– Pre‐PET and post‐PET physician questionnaires • condition for reimbursement
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NOPR: Results
Overall Impact on Patient Management
– Diagnosis
Diagnosis, Staging, Restaging, Recurrence
Staging Restaging Recurrence
– Data on 22,975 scans from May 8, 2006 – May 7, 2007
– J Clin Oncol 2008; 26:2155‐61
Impact on Patient Management by Cancer Type
– Staging, Restaging, Recurrence (proven cancer type)
– Data on 40,863 scans from May 8, 2006 – May 7, 2008
– J Nucl Med 2008; 49:1928‐35 J Nucl Med 2008; 49:1928‐35
Treatment Monitoring
– Data on 10,447 scans from May 8, 2006 Data on 10 447 scans from May 8 2006 – Dec 31, 2007
Dec 31 2007
– Cancer, published on‐line Nov 17, 2008
NOPR: Cohort Profile
• First year of NOPR (5/8/06 to
5/7/07)
• 22,975 “consented” cases
from 1,519 facilities
• Technology profile
– 84% PET/CT
– 71% non
non--hospital
– 76% fixed sites
• Indications
–
–
–
–
Diagnosis 24%
Initial Staging 28%
Restaging 24%
Recurrence 24%
Hillner et al., J Clin Oncol 2008;26 (13):2155‐61.
NOPR: National Oncologic PET Registry
Clinical Indication for PET Study (%)
Pre-Pet
PrePlan
Post-PET
PostPlan
Treat
Dx
Staging
Restaging
Recurrence
All
n=5,616
n=6,464
n=5,607
n=5,388
n=22,975
Same
16.0
46.5
15.8
20.4
25.5
Non--Treat
Non
Same
52.9
14.0
48.0
40.7
37.9
Non--Treat
Non
Treat
23.2
31.6
28.6
29.2
28.3
Treat
Non--Treat
Non
7.9
7.9
7.5
9.7
8.2
31.1
31 1
39.5
39 5
36.1
36 1
39.0
39 0
36.5
36 5
Patients with change
g
post--PET (%)
post
PET Changed Intended Management in 36
36.5%
5% of Cases
Hillner et al., J et al., J Clin
Clin Oncol 2008;26 (13):2155‐
2008;26 (13):2155‐61.
Hillner et al., J et al., J Clin
Clin Oncol 2008;26 (13):2155‐
2008;26 (13):2155‐61.
NOPR: PET Impact on Management
by Cancer type (Overall: 38%)
Impact of PET on intended management in the top 10
cancers in the NOPR
Cancer
No of % change in
No.
scans intended treatment
% imagingimagingadjusted impact
Prostate
5,309
35.1
15.0
Ovary
4,509
41.4
16.2
Bladder
3,578
37.9
15.4
Pancreas
a c eas
3,314
3,3
39.0
39 0
14.8
8
Stomach
3,025
36.9
14.5
Small--cell lung
Small
2,983
41.2
13.1
Kidney
2 877
2,877
35.8
35 8
16.0
16 0
Uterus
2,869
36.5
15.1
Myeloma
1,784
48.7
11.5
Connective
Tissue
1,350
36.4
13.6
Hillner B et al. J Nucl Med 2008;49 (12):1928(12):1928-35
Summary Table of Medicare Coverage Policy (US) for FDG PET/CT as of April 2009 Cancer Type
Initial Treatment
Strategy Evaluation
Subsequent Treatment
Strategy Evaluation
Breast
Covered 1
Covered
Cervix
Covered 2/ CED
Covered
Colorectal
Covered
Covered
Esophagus
Covered
Covered
Head Neck
Covered
Covered
Lymphoma
Covered
Covered
Melanoma
Covered 3
Covered
Myeloma
Covered
Covered
NSCLC
Covered
Covered
Ovary
Covered
Covered
Prostate
NC
CED
Thyroid
Covered
Covered 4/CED
All other solid tumors
Covered
CED
63‐year
63‐
year‐‐old male with newly
with newly diagnosed lung ca
From Delbeke
From Delbeke D. Diagnostic Imaging 2003
Lung Cancer (NSCLC): Initial Staging
The
PLUS Multicenter Randomized Trial
The PLUS Multicenter Randomized Trial
• 188 patients from 9 hospitals were randomized to – Conventional work‐up (CWU)
– CWU + PET
• End point: futile (unnecessary) thoracotomy
• Results
– CWU: 41% futile thoracotomy
– CWU + PET: 21% futile thoracotomy
Decrease in unnecessary surgery by 50%
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Van Tinteren
Van Tinteren H et al. Lancet 2002;359 (9315):1388‐
H et al. Lancet 2002;359 (9315):1388‐1393.
Lung Cancer
PET/CT
f R di ti T t
t Pl
i
PET/CT for Radiation Treatment Planning
• Change TNM stage: 25‐30%
• Change treatment from curative to palliative: 10‐25%
• Increase GTV: LN not meeting size criteria
g
• Decrease GTV: atelectasis, post‐obstructive pneumonia
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Delbeke D et al. Semin Nucl Med 2009;39(3): 308308-40.
92 year‐old woman with NSCLC underwent PET/CT 92 year‐
old woman with NSCLC underwent PET/CT for radiation for radiation therapy planning
From Spratt DE et al. Clin
From Spratt DE et al. Clin Nucl Med 2010;35:237‐
Med 2010;35:237‐243.
NOPR: Change
During
g in Intended Management
g
g
Treatment
• 8,240 patients who had 10,497 treatment 8 240 ti t h h d 10 497 t t
t
monitoring PET scans at 946 centers
– Chemotherapy alone 82%
– Radiation therapy alone 6% – Combination 12%
• Metastatic disease in 54% of scans • Type of cancer: 37% of patients had ovarian, pancreatic or lung cancers p
g
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Hillner B et al. Cancer B et al. Cancer 2009
2009;;115 115 ((2):410
):410‐‐18
18,,
NOPR: Change
During
g in Intended Management
g
g
Treatment
• 8,240 patients who had 10,497 treatment monitoring PET scans at 946 centers
t 946
t
• If PET was not available, intended management :
– Other imaging 53%
– Ongoing treatment 41%
– Biopsy or watching 6%
• Post‐ PET intended management:
– Switching to another therapy: 26‐28% of scans
– Adjusting of dose or duration of therapy: 16‐19% of scans
Adjusting of dose or duration of therapy 16 19% of scans
– Switch to palliative care: 6%
• PET
enabled 91% of patients to avoid future tests
PET enabled 91% of patients to avoid future tests
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Hillner B et al. Cancer 2009;115 (2):410
B et al. Cancer 2009;115 (2):410‐‐18.
FDG PET/CT for Breast Cancer
• A 40 Year
old female with stage IV breast A 40 Year‐old
female with stage IV breast
cancer
– Pulmonary
Pulmonary and Skeletal Metastases
and Skeletal Metastases
– Systemic therapy
– Progression of skeletal metastases noted on Progression of skeletal metastases noted on
PET/CT
– Therapy changed to include capecitabine
Therapy changed to include capecitabine
– Repeat PET/CT following two cycles of chemotherapy
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Prior to Change in Therapy:
Following Change in Therapy:
1/46
CT
FDG PET/CT for Breast Cancer
• A 40 Year
old female with stage IV breast A 40 Year‐old
female with stage IV breast
cancer
PET/CT
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FDG PET/CT for Breast Cancer
• Initial staging
– Early breast cancer: Sentinel node biopsy is standard of care
– Locally advanced breast: • Increased risk for distant metastases
• Inner quadrant lesions (internal mammary LN ~ 25%*)
– Technically difficult or Positive SLNB (?)
– Equivocal lesions by other modalities
• Restaging – To replace multiple modalities
• Monitoring chemotherapy of locally advanced disease
– Identify non‐responders early.
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Eubank BE et al. Semin Nucl Med 2005;35:84‐
Eubank BE et al. Semin
Med 2005;35:84‐99.
*Bellon JR et al. Am J JR et al. Am J Clin
Clin Oncol 2004;27 (4):407‐
2004;27 (4):407‐410.
PET/CT Imaging: Impact on Management
B
C
Breast Cancer
Disease Process
Author Year
# patients
Modality
Comparison
Change of management
Breast cancer
Breast cancer
Radan 75
2006
Suspected Suspected
Recurrence
FDG PET/CT
FDG PET/CT
Contrasted Contrasted
CT
51%
Breast cancer
Breast cancer
Heron 80
Heron
2006
simulation
FDG PET/CT
FDG PET/CT
Radiation Radiation
therapy planning
(simulation)
50%
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Delbeke D et al. Semin
Delbeke D et al. Semin Nucl Med 2009;39(3): 308‐
Med 2009;39(3): 308‐40.
PET/CT
for Brain Imaging
PET/CT for Brain Imaging
old male
• 41 year
41 year‐old
male
–
–
–
–
HIV positive
Presented to emergency department
New onset neurological symptoms
Fever
• MRI of Brain
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Axial FLAIR
Axial T1‐wt p Gd
PET/CT
for Brain Imaging
PET/CT for Brain Imaging
•
18F‐FDG PET/CT
– Relative decreased metabolism in left basal ganlgia
– Corresponds to ring‐enhancing lesion on MRI
Toxoplasmosis
abscess of the brain
Toxoplasmosis abscess of the brain
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PET/CT
for Brain Imaging
PET/CT for Brain Imaging
• Toxoplasmosis
–
–
–
–
Intracellular protozoan parasite Toxoplasma gondii
Seroprevalence = 15% US, 50% Europe
Usually asymptomatic in immunocompetent hosts
Toxoplasmic encephalitis: 2.2 per 1000 person years
(HIV patients)
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PET/CT
for Brain Imaging
PET/CT for Brain Imaging
• Toxoplasmosis of the Brain
Toxoplasmosis of the Brain
– HIV patients at higher risk for opportunistic infections and lymphoma
– Toxoplasmosis and lymphoma may appear similar on MRI
– Accurate diagnosis required promptly
–
18F‐FDG PET/CT
• Lymphoma: HOT
Lymphoma: HOT
• Toxoplasmosis: NOT
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CNS Lymphoma
CNS Lymphoma
T1‐wt p Gd
18F‐FDG PET/CT
Toxoplasma gondii
PET/CT
for Brain Imaging
PET/CT for Brain Imaging
– Clinical Course
• Prompt initiation of anti‐ toxoplasmosis therapy
• Rapid clinical improvement
8
week follow‐up
MRI
8 week follow
up MRI
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Hybrid SPECT/CT Imaging System Integrated system provides:
O ti l attenuation
Optimal
tt
ti correction
ti
Fusion images for anatomical mapping
Clinical Applications for Hybrid SPECT/CT
– Clinical Indications: • Cardiac attenuation correction
• Neoplasms
– Thyroid carcinoma (131I‐iodide) – Parathyroid adenoma (
y
(99mTc‐MIBI) )
– Somatostatin receptor‐positive tumors (111In‐Octreotide)
– Pheochromocytoma/Neuroblastoma (I‐MIBG)
– Hemangioma (99mTc‐RBC) – Focal nodular hyperplasia (
Focal nodular hyperplasia (99mTc
Tc‐sulfur
sulfur colloid)
colloid)
– Splenosis
– Sentinel node localization – Lymphoma (67Ga)
– Prostate carcinoma (
Prostate carcinoma (111In‐Prostascint) In Prostascint)
– Skeletal (99mTc‐MDP)
• Infection (111In‐ and 99mTc‐WBC and 67Ga)
• Bone trauma (99mTc‐MDP)
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Keidar Z et al. Semin
Z et al. Semin Nucl Med 2003;XXXIII (3):205‐
Med 2003;XXXIII (3):205‐218
Buch AK et al. J Nucl
AK et al. J Nucl Med 2008;49 (9): 1407.
Thyroid Carcinoma with 131I‐SPECT/CT
• Review of 71 patients
– Vanderbilt: n = 39, Rambam
Vanderbilt: n = 39 Rambam Medical Center: n =32
Medical Center: n =32
– Post‐therapy: n = 54, Diagnostic scintigraphy: n = 17 • Incremental Diagnostic Value of 131I‐SPECT‐CT over planar imaging i 57% f ti t
in 57% of patients:
• Precise localization – In the neck: 21% of patients
– To the skeleton: 17% of patients p
• Characterization as physiologic or benign: 13%
• Incremental clinical value:
Impact on therapy:
– Impact on therapy: • Surgery versus 131I‐therapy
• Dose for 131I‐therapy
– Impact on prognosis
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Tharp K et al. Tharp K et al. Europ
Europ J J Nucl
Nucl Med 2004;31 (10):1435‐
Med 2004;31 (10):1435‐1442.
A 60‐ year
A 60‐
year‐‐old female s/p total thyroidectomy for papillary thyroid carcinoma was evaluated for metastases ..
metastases Diagnosis: Probable metastases in the neck and left femur
Diagnosis: Probable metastases in the neck and left femur.
A bone radiograph of the left femur was normal
A 60‐ year
A 60‐
year‐‐old female s/p total thyroidectomy for papillary thyroid carcinoma was evaluated for i
l
df
metastases ..
metastases Diagnosis: Metastases in the neck and precisely localized in the left femur on the SPECT/CT images.
Integrated CT
131I SPECT
Fusion integrated SPECT/CT
• A 53 year‐old male with papillary thyroid carcinoma
ill th id
i
– Stage II, T2 Nx Mx
•
123I scintigraphy
I scintigraphy
prior to prior
to
radioactive iodine therapy therapy
1/24
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• A 53 year‐old male with papillary thyroid ill th id
carcinoma
• Unsuspected
Unsuspected pulmonary pulmonary
metastasis on 123I SPECT/CT
• Changed management by altering planned therapeutic dose of 131I
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• Post
therapy Post‐therapy
131I scintigraphy
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99mTc
Parathyroid Adenoma with Tc‐‐MIBI
MIBI‐‐SPECT/CT
y
/
g
pp
• Modification of Surgical Approach
– 36 patients with primary hyperparathyroidism
– Impact on management of 39% patients
Impact on management of 39% patients
• Retrotracheal parathyroid glands
p p
y
• Ectopic parathyroid adenoma
• Distorded neck anatomy
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Krausz Y et al. World J Surg
Y et al. World J Surg 2006;30:76
2006;30:76‐‐80
99mTc
Parathyroid Adenoma with Tc‐‐MIBI
MIBI‐‐SPECT/CT
y
/
y
• A 75 year‐old male with primary hyperparathyroidism
– Serum Calcium: 10.4 mg/dL
Serum Calcium: 10.4 mg/dL
– PTH: 142 pg/mL
Early
Delayed
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Krausz Y et al. World J Surg
Y et al. World J Surg 2006;30:76
2006;30:76‐‐80
A 53‐year
A 53‐
year‐‐old male with old male with hyperparathyroidism: hyperparathyroidism: the fusion SPECT/CT image allowed precise the fusion SPECT/CT image allowed precise localization of the focus of uptake in the left localization of the focus of uptake in the left mediastinum
mediastinum. Brown . Brown tumors tumors are also seen in are also seen in the ribs.
Integrated CT
99mTc
Tc‐‐MIBI SPECT
Fusion integrated SPECT/CT
Neuroendocrine Tumors
with SPECT/CT
Tumors with SPECT/CT
• 54 patients with known or suspected neuroendocrine
tumors
– 111In‐octreoscan: n = 43
– 123I‐MIBG: n=11
– High‐end spiral CT with contrast: n=54
• Comparison SPECT and high‐end CT for 120 lesions
Comparison SPECT and high end CT for 120 lesions
– Histopathology or follow‐up for 114 lesions
– Concordance: 49% of lesions
– Discordance: 51% of lesions
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Pfannenberg AC et al. Europ
AC et al. Europ J J Nucl
Nucl Med 2003;30:835‐
Med 2003;30:835‐843.
Neuroendocrine Tumors
with SPECT/CT
Tumors with SPECT/CT
• Value of fusion images for discordant lesions:
– 31 equivocal or benign ‐> malignant
– 27 equivocal or malignant ‐>benign
– Highest accuracy (99%) by combined analysis SPECT and high
Highest accuracy (99%) by combined analysis SPECT and high‐
end CT.
• Impact on therapy of image fusion: 28% (14/50) patients
Impact on therapy of image fusion: 28% (14/50) patients
– Sparing of unnecessary surgery (n =8)
• Benign (n = 5), metastases (n = 3)
– Surgical approach changed (n = 4)
– Medical treatment changed (n = 2)
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Pfannenberg AC et al. Europ
AC et al. Europ J J Nucl
Nucl Med 2003;30:835‐
Med 2003;30:835‐843.
A 39 year
A 39 year‐‐old male with suspected pancreatic old male with suspected pancreatic neuroendocrine
neuroendocrine tumor.
111In‐Octreotide
4 hours
24 hours
A 39 year
A 39 year‐‐old male with suspected pancreatic old male with suspected pancreatic neuroendocrine
neuroendocrine tumor.
111In‐Octreotide
24 hour SPECT
1/30
A 39 year
A 39 year‐‐old male with suspected pancreatic old male with suspected pancreatic neuroendocrine
neuroendocrine tumor.
111In‐Octrotide SPECT/CT
CT with contrast
Pathology: Well‐differentiated/intermediate grade pancreatic Pathology: Well‐
endocrine neoplasm measuring 2.4 X 2.4 X 2.0 cm.
A 71‐year
A 71‐
year‐‐old female who had recent resection of a rectal polyp with carcinoid
old female who had recent resection of a rectal polyp with carcinoid
presented with a 1 cm LN in the mesorectum
presented with a 1 cm LN in the mesorectum
Transrectal exploration: negative
Surgical exploration: metastatic lymph node
Sentinel
Node Localization with SPECT/CT
Sentinel Node Localization with SPECT/CT
p
(
• 34 patients with sentinel LN localization (28 melanoma and 6 SCC of head and neck)
/
g g
• SPECT/CT imaging identified:
– Multiple draining basins in:
• 50% (6/12) of patients with trunk melanoma • 33% (3/9) of patients with head and neck SCC
– Sentinel LN missed on planar images in 43% (9/21) of patients, two of which were involved by tumors:
• Three located close to injection site
Three located close to injection site
• Two in‐transit LN
• Fourth in an additional basin
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Even‐‐Sapir E et al. J Even
Sapir E et al. J Nucl
Nucl Med 2003;44:1413‐
Med 2003;44:1413‐1420.
A 42 year‐‐old male with a right parietal scalp melanoma referred A 42 year
old male with a right parietal scalp melanoma referred for sentinel node localization
g
g
Planar images show migration inferior to the right ear.
SPECT/CT localize the sentinel node
node in the posterior triangle in node in the posterior in the posterior triangle in triangle in
the right occipital chain
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From Delbeke D & Israel O (eds
From Delbeke
D & Israel O (eds): Hybrid PET/CT and ): Hybrid PET/CT and SPECT/CT Imaging –– A Teaching File. Springer SPECT/CT Imaging A Teaching File. Springer 2009
2009..
A 52 year
A 52 year‐‐old male with Clark level IV invasive melanoma of the mid‐‐upper back
mid
pp
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A 52 year
A 52 year‐‐old male with Clark level IV invasive melanoma of the mid‐‐upper back
mid
pp
• Pathology:
– 1 left posterior cervical node: metastatic melanoma
– 5 left axillary nodes (3/5 hot): negative
– 2
right axillary nodes
(1/2 hot): negative
2 right axillary
nodes (1/2 hot): negative
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A 73 year
A A 73 year‐‐old male with prostate cancer ‐
old male with prostate cancer ‐ elevated PSA following prostatectomy
p
y
ACOI
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A 73 year
A A 73 year‐‐old male with prostate cancer ‐
old male with prostate cancer ‐ elevated PSA following prostatectomy
p
y
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L5 metastasis
In
Summary
In Summary
• Hybrid PET/CT and SPECT/CT
Hybrid PET/CT and SPECT/CT
– Incremental diagnostic value over:
• PET or SPECT alone
PET or SPECT alone
• PET or SPECT correlated with separate CT
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In
Summary
In Summary
• Hybrid PET/CT and SPECT/CT
Hybrid PET/CT and SPECT/CT
– Improved lesion detection
– Precise lesion localization
Precise lesion localization
– Differentiation of physiologic from pathologic uptake
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In
Summary
In Summary
• Hybrid PET/CT and SPECT/CT
Hybrid PET/CT and SPECT/CT
– Affect clinical management by:
• Guiding further procedures
Guiding further procedures
• Excluding the need for further procedures
• Changing inter‐
g g
and intramodalityy therapy
py
• Providing prognostic information
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