Download Radionuclide methods in oncology

Radionuclide methods
in oncology
Materials for medical students
Otto Lang, MD, PhD
Otakar Bělohlávek, MD, CSc
Dept Nucl Med
Charles Univ, 3rd Med Fac
Role for Nuclear Medicine
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Diagnosis
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Staging
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Important for proper therapy
Follow-up
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Specific or non-specific
Early detection of recurrens
Treatment
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Specific or non-specific
Tumors
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Metabolically active tissues – many similar
properties as inflammation
Increased vascularization
 Increased capillary permeability
 Newly proliferated capillaries
 Increased blood flow
 Metabolically active cells
 Increased energy demand
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Tumor cells
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High density of some common receptors
Expression of several specific receptors
Expression of some specific tumor antigenes
All these properties could be used for imaging
and therapy
Diagnostic radiopharmaceuticals
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Non-specific - demonstrate tumor sites but are not
specific for malignancy
PET or PET-CT
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F-18 FDG – anaerobic metabolism
Planar, SPECT or SPECT-CT
Diphosphonates – bone scan
 Ga-67 citrate – similar to FDG – localising agent
 Colloids – liver-spleen scan
 Leukocytes – bone marrow scan
 MIBI – several tumors
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Diagnostic radiopharmaceuticals
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Specific – binds directly to special tumor antigens
or receptors or are accumulated by special
metabolic pathway
PET or PET/CT - no commercially available
Planar, SPECT or SPECT/CT
I-123/131 MIBG for neuroendocrine tumours
 I-131 for differentiated thyroid carcinomas
 In-111 octreotide for tumours expressing somatostatin
receptors.
 monoclonal antibodies labelled with In-111, I-123/131
or Tc-99m
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Therapeutic radiopharmaceuticals
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Non-specific
Sr-89, Sm-153, Re-189
 Bone pain palliation
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Specific
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I-131
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Thyroid cancer, as specific diagnostic if tumor significantly
accumulates
Y-90
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Zevalin – monoclonal antibody for B-cell lymphomas
Ga-67 scan
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Introduced in seventies of 20th century for
lymphomas (prof. Dienstbier)
Mechanisms of accumulation
tumour viability
 blood flow
 capillary permeability
 lymphatic drainage
 transferrin receptors on the tumour cells
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Ga-67 scan
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Procedure
Patient preparation
Laxatives for bowel preparation post injection,
nothing else
Several weeks post tumor therapy (FN)
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radiation therapy and chemotherapy can alter the
normal pattern of gallium distribution
180 MBq is usually administered
imaging follows after 48 – 72 hours
 WB + SPECT, middle-energy collimator
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Ga-67 scan
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Normal scan
Accumulates in bone marrow and liver.
 Splenic uptake is variable.
 The kidneys are usually visualized and also lacrimal,
salivary, nasopharyngeal and genital activity is often
present.
 Female breasts can be visualized, but accumulation is
physiologically symmetrical.
 Radioactivity is commonly seen in the colon
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Ga-67 scan
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Clinical indications
lymphoma
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staging and monitoring effect of therapy
melanoma
lung cancer
hepatoma
Combination with other imaging modalities is
necessary (SPECT/CT)
Bone scan
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Radiopharmaceuticals
Tc-99m MDP, HDP
Tissue accumulation depends on
blood flow
 capillary permeability
 metabolic activity of osteoblasts and osteoclasts
 mineral turnover
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500 to 800 MBq, imaging 2 to 3 hours later – WB
+ SPECT
Bone scan
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Clinical indications:
Diagnosis of metastases of different tumors
– staging and follow-up
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Positivity many months before an abnormality can
be detected on X ray - method of choice to seek for
bone metastases
Mainly
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Bronchogenous carcinoma, prostate, breast, thyroid,
and renal tumours
Bone scan
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Scan pattern
increased accumulation in the surrounding bone - hot
lesion
 defect - cold lesion (some metastases –breast) - rare
(very fast grow – no bone reaction)
 flare phenomenon – increased number of lesions in the
case of effective therapy
 super-scan (spread malignancies) - diffusely increased
uptake
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Liver/spleen scan
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Metastases of GI tumors
Replaced by sono and CT
Scan pattern – cold nodules, different number
and size
Mainly
Colorectal, ovarian, breast, lung, lymphoma
 Always poor prognosis
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Thyroid scan
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Non-specific test with pertechnetate
Mainly cold nodules – especially in children –
must be biopsied!!!
Bone marrow scan
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Colloids or leukocytes
Similar as bone scan
Better sensitivity
FDG PET
http://www.homolka.cz/nm/
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For several tumors – staging and follow-up
Mainly lymphomas, lung cancers, melanoma,
colorectal cancers and others
Not suitable for prostate cancer
Patient preparation
At least 1 w post chemo, 3 m radiotherapy
 One hour before injection physical rest
 Fasting, no milk, no sugar
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Specific methods
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Binding to receptors or antigens
I-123 MIBG – pheochromocytoma,
neuroblastoma in children
In-111 Octreoscan – neuroendocrine tumors
(insulinoma, vipoma, carcinoid), SCLC
I-131 – thyroid cancer – follow-up and
treatment
Specific methods
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Monoclonal antibodies
Anti-CEA – rather in detection of relaps
In the pelvis better than CT
 In the liver CT better
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In-111 Oncoscint – colorectal, ovarian
Melanoma – antibody against melanin
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Ga scan is better
Bone scan –
multiple
metastases
Bone scan – multiple metastases
Lung cancer – cold lesion
Breast cancer
normal X ray with hot spot on scintigraphy
Superscan
– prostate
cancer
Bone scan - prostate cancer
progression
Breast cancer – FU – progr.
Thyroid – folicular ca
on sonography solid nodule
Thyroid cancer - anaplastic
Thyroid cancer
Tc-99m
Tc-99m post surgery
I-131
Thyroid cancer –I-131 - meta
Tc-99m sestamibi
parathyroid adenoma
early
late
Neuroblastoma
liver and bone involvment
Bone
scan
I-131
MIBG
scan
Carcinoid – liver meta
Ga scan – lung cancer
Ga scan - lymphomas
Palpable mass on the neck
lymphoma
Tc-99m pertechnetate
Ga-67 citrate
SPECT/CT carcinoid
SPECT/CT breast cancer
SPECT/CT lung cancer
SPECT/CT lung cancer
FDG PET - normal
FDG PET melanoma
FDG PET
Tumor of unknown origin
Metastatic involvment of neck lymph nodes
FDG PET
Tumor of unknown origin
Pharyngeal cancer
FDG PET – brain tumor post th
two foci on CT, only one viable tumor
Staging
colorectal CA
Effect of therapy
Lung cancer
Stomach cancer
PET:100 %
CT:
0 %
Stomach cancer
PET: 80 %
CT: 20 %
Stomach cancer
PET: 60 %
CT: 40 %
Stomach cancer
PET: 40 %
CT: 60 %
Stomach cancer
PET: 20 %
CT: 80 %
Stomach cancer
PET: 0 %
CT: 100 %
Stomach cancer
NSCLC
CT:
T2 N0 Mx ~ stg. IB ?
NSCLC
CT:
T2 N0 Mx ~ stg. IB ?
PET:
T2 N2 M0 ~ stg. II
NSCLC
CT:
T2 N0 Mx ~ stg. IB ?
PET:
T2 N2 M0 ~ stg. II
PET/CT: T2 N2 M1 ~ stg. IV
PET/CT is more than
PET and CT