1 PET/CT in Lung Cancer Rodolfo Núñez Miller, M.D. Nuclear Medicine and Diagnostic Imaging Section Division of Human Health International Atomic Energy Agency Vienna, Austria
2 GLOBOCAN 2012 #1 #3
3 FDG-PET/CT in Lung Cancer OUTLINE: Staging of NSCLC. Detection of tumor recurrence. Assessment of response to therapy. To determine prognosis. For RT planning. Small cell lung cancer. Mesothelioma
4 74 year old man that after undergoing a routine medical check up, he is found to have a mass in the left lung. The CT scan done one month before the surgical consultation was reported as.a mass in the lingula of 3.8 cm. x 3.1 cm is noted by no evidence of mediastinal adenopathy.. Bronchoscopy was positive, having an initial clinical staging of T2, N0. Which means he was potentially a surgical candidate. The surgeon requested an MR of the brain and a PET/CT scan to confirm the staging.
5 FDG PET/CT
6 10 x 7 mm
7 Why did the PET/CT help?
8 Why did the PET/CT help? It demonstrated that the disease was far more advance from what it was initially suspected. The staging increased to stage 4, and therefore, surgery was no longer indicated for this patient. In one study * with 102 lung cancer patients, considered to be resectable based on conventional imaging techniques, FDG PET increased the stage in 42 of them and decreased it in other 20. * N Engl J Med 2000; 343:254-61
9 PET/CT in mediastinal staging. Although the CT scan is better for T staging, PET-CT can be helpful in the characterization of other nodules, or in cases where the primary tumor may be infiltrating adjacent structures. FDG PET-CT is the best imaging technique for the accurate staging of disease in the mediastinum. The sensitivity is 88% and specificities of 91%. In addition, it allows detection of disease in difficult to reach (by mediastinoscopy) mediastinal regions. FDG PET-CT has a very high negative predictive value (NPV) in the staging of the mediastinum (92%).
10 PET/CT in mediastinal staging. Meta-analysis for FDG PET and CT: Includes 14 studies (514 patients) for FDG PET and 29 studies (2,226 patients) for CT: Sensitivity of FDG PET = 79%, CT = 60% Specificity of FDG PET = 91%, CT = 77% Prospective study of 102 patients: Sensitivity of FDG PET = 91%, CT = 75% Specificity of FDG PET = 86%, CT = 77% FDG PET detected distant metastases in 10% patients FDG PET changed the stage in 60% patients Cost effectiveness of FDG PET has been demonstrated Dwamena BA et al.radiology 1999;213: Peterman RM et al.n Engl J Med 2000,343: Gambhir SS, et al.j Nucl Med 1996;37:
11 ACCP Evidenced-Based Clinical Practice Guidelines FDG PET compared to CT for mediastinal staging PET CT Silvestri GA et al. Chest 2007;132:178S-201S
12 ACCP Evidenced-Based Clinical Practice Guidelines: Recommendations for FDG PET Stage IA being treated with curative intend Stage IB-IIIB treated with curative intend If PET is abnormal, biopsy is recommended Silvestri GA et al. Chest 2007;132:178S-201S
13 ESTS guideline for preoperative node staging for non-small cell lung cancer Due to the high NPV of FDG PET, invasive staging procedures can generally be omitted in patients with clinical stage I NSCLC with negative mediastinal PET scan. However. Central tumors Central hilar N1 disease on CT scan Broncho-alveolar cell carcinoma Tumors with low FDG uptake Mediastinal PET negative LNs 16 mm on CT scan In case of positive mediastinal PET, histologic confirmation is still needed to confirm metastasis. European Journal of Cardio-thoracic Surgery 2007
14 Since the last iteration of the staging guidelines, PET scanning has assumed a more prominent role both in its use prior to surgery and when evaluating for metastatic disease. Minimally invasive needle techniques (EBUS-needle aspiration) to stage the mediastinum have become increasingly accepted, and are the tests of first choice to confirm mediastinal disease in accessible lymph node stations. If negative, these needle techniques should be followed by surgical biopsy. All abnormal scans should be confirmed by tissue biopsy (by whatever method is available) to ensure accurate staging. Evidence suggests that more complete staging improves patient outcomes.
15 PET/CT in the assessment for distant metastases In one study comparing FDG PET with conventional imaging (CT of the head and thorax, or MRI of the brain + bone scan), FDG PET detected metastatic disease in 9% more patients, than the combination of all the conventional imaging modalities*. Other study demonstrated that FDG PET was capable of correctly detecting metastatic lesions, not depicted by conventional imaging techniques (CT of the thorax, and abdomen + bone scintigraphy) in 6.4% of patients. At the same time, in 7% of patients correctly excluded disease in equivocal lesions thought to be metastatic by conventional imaging**. * Marom E, et al. Radiology 212, ** Bury T, et al. Eur Respir J 10, 1997.
16 PET/CT in the assessment for distant metastases Common metastases to adrenals, skeleton, liver, brain. FDG PET is superior to conventional imaging: Detect unsuspected distant metastases: ~13% of patients Stage I: 7.5% Stage II: 18% Stage III: 24% Change management: 18% of these. In a meta-analysis from the National Institute for Clinical Excellence (NICE), the average sensitivity and specificity were 93% and 96% for detection of distant metastases. In addition, 15% of these were unsuspected. The use of PET-CT increased even more the specificity over stand alone PET. In the skeleton, FDG PET is superior to bone scans (BS= 82%, 62% vs. PET>90%) MacManus MP et al.int J radat Oncol Biol Phys 2001;50: Mayor S. Br Med J 2005; 330:439 Silvestri GA et al. Chest 2007; 132(3 Suppl):178S-146S
17 Indeterminate Adrenal Masses Patients with malignancy: ~ 30% are malignant. Patients without known malignancy: rarely malignant. Contrast-CT with delayed washout images and MRI with T2-weighted images: accurate but requires additional imaging FDG PET: high accuracy Study of 27 patients with NSCLC: Sensitivity = 100%, specificity = 80% Boland GW et al. Radiology 1995;194: Erasmus JJ et al. AJR 1997;168:
18 FDG PET/CT for Detection of Skeletal metastases 110 patients comparing bone scintigraphy and FDG PET 43 patients with metastases, 21 of which with bone metastases proven with other imaging studies or biopsy Modality PPV NPV Acc BS 90% 61% 66% FDG PET 90% 98% 96% Specificity PET (95%) > BS (61%) FDG PET better for lytic metastases Bone scintigraphy better for blastic metastases Bury T et al. Eur J Nucl Med 1998;25:
19 In several studies * it is shown that by using PET-CT, there can be a reduction of futile thoracotomies in up to 51% of patients. *Van Tinteren H, et al. Lancet 359, April 2002.
20 Fischer B, et al. N Engl J Med 2009;361:32-9
21 61 year old woman with NSCLC (squamous cell) in the RLL. PET/CT did not revealed any metastases. Thoracotomy was done in another hospital on September 2005, with a RLL and RML resection. Since there was evidence at the time of surgery of right hilar involvement (T1,N2), she was referred for adjuvant chemotherapy. An FDG PET/CT scan was requested to re-stage. Pre-operative CT scan from September 2005
22 PET/CT October 2005
23 PET/CT February 2006
24 CT February 2006 Biopsy March 2006 Why did the PET help?
25 Why did the PET/CT help? The PET-CT scan allowed to confirm the presence of tumor recurrence. It provided valuable information as to the site to perform the biopsy. It ruled out the presence (at the time of the scan) of distant metastases.
26 PET/CT for detection of tumor recurrence PET and PET/CT have proven to be superior to conventional imaging techniques, for detecting tumor recurrence, changing therapeutic management in up to 63% of patients. Several studies demonstrate sensitivities of 98% to 100%, and specificities of 62% to 92%, for detection of tumor recurrence, after treatments with curative intention. PET/CT provides valuable information over stand alone CT and PET scanners, specially avoiding false positive interpretations with the use of the fused image.
27 Hellwig D. et al. Eur J Nucl Med Mol Imaging (2006)33:13-21
28 PET/CT for detection of tumor recurrence. Prospective study* evaluating the diagnostic value and management impact of PET/CT in 42 nsclc patients suspected of having tumor recurrence. Twenty-four of 27 positive PET/CT studies (89%) were proven to have recurrent disease. Fourteen of 15 negative PET/CT studies (93%) had no evidence of disease. The sensitivity, specificity, and positive and negative predictive values of PET/CT for diagnosis of recurrence were 96%, 82%, 89%, and 93% compared with 96%, 53%, 75%, and 90%, respectively, for PET. PET/CT changed the PET lesion classification in 22 patients (52%), by determining the precise localization of sites of increased 18F-FDG uptake. PET/CT changed the management of 12 patients (29%). *Keidar Z, et al. J Nuc Med, 45; 2004
29 PET/CT June 2006
30 CT images of the PET/CT from June 2006 CT images of the PET/CT from September 2006
31 September 2006 PET/CT scan
32 Why did the PET/CT help? It determined that there was a partial response to proton bean therapy. Unfortunately, it showed that there were distant metastases in both kidneys. Surgical management is excluded, since the patient already has stage 4 disease.
33 58 year old man with nsclc (adenocarcinoma) of the right lung. Treated with initial induction chemotherapy follow by surgery in February After surgery had adjuvant RT. PET/CT November 2004
34 Post-therapy scan: Surgery and RT. RT finished on April January 2006 PET/CT
35 May 2006 PET/CT
36 October 2006 CT scan
37 Why did the PET/CT help? It accurately evaluated tumor response to therapy, excluding the presence of tumor recurrence. Rules out distant metastases. A clean PET/CT scan is obtained, which can serve if needed- as the new reference for future comparison studies. January May
38 PET and PET/CT are considerably more precise than CT for assessment of tumor response to therapy, and determining the presence of tumor recurrence in lung cancer. However: There are false positive cases from post-rt pneumonitis. After RT is recommended to wait at least 3 to 6 months before repeating and FDG PET/CT scan.
39 FDG PET for prognostication in nsclc Survival plot of 125 patients with nsclc according to the SUV of the primary tumor.
41 EJNMMI 2012
42 Eur J Nucl Med Mol Imaging May;41(5): Impact of initial PET/CT staging in terms of clinical stage, management plan, and prognosis in 592 patients with non-small-cell lung cancer. Takeuchi S 1, Khiewvan B, Fox PS, Swisher SG, Rohren EM, Bassett RL Jr, Macapinlac HA. 1 Department of Nuclear Medicine, Unit 1483, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Houston, TX, 77030, USA, Abstract PURPOSE: Our objective was to determine the impact of initial (18)F-FDG PET/CT (PET/CT) staging on clinical stage and the management plan and the prognostic value of PET/CT in patients with non-small-cell lung cancer (NSCLC). METHODS: We retrospectively reviewed the records of 592 patients with NSCLC who were referred to The University of Texas MD Anderson Cancer Center during 2002/2011 and had both PET/CT and conventional CT for initial staging. Clinical stages and management plans were compared between PET/CT and CT. The impact of PET/CT on management plans was considered medium/high when PET/CT changed the planned treatment modality or treatment intent. PET/CT and CT stages were compared with all-cause mortality and survival rates. We also assessed potential prognostic factors for progression-free survival (PFS) and overall survival (OS). RESULTS: PET/CT changed the stage in 170 patients (28.7 %; 16.4 % upstaged, 12.3 % downstaged). PET/CT had a medium/high impact on the management plan in 220 patients (37.2 %). PFS and OS were significantly worse in patients with upstaged disease than in patients with no change in stage (median PFS 29.0 vs months, P < 0.001; median OS:64.7 vs months, P = 0.006). PFS and OS were significantly worse in patients with medium/high impact of PET/CT than in patients with no/low impact of PET/CT (median PFS 24.7 vs months, P < 0.001; median OS 64.7 vs months, P < 0.001). In multivariate analysis, a medium/high impact of PET/CT was an independent predictor of worse PFS (hazard ratio, HR, 1.73; 95 % CI ; P = ) and OS (HR 1.84; 95 % CI ; P = 0.002). CONCLUSION: Initial PET/CT staging not only impacts stage and management plan but also has prognostic value
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