PET/CT in the Management of Colorectal Cancer
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1 PET/CT in the Management of Colorectal Cancer R. Petter Tonseth BSc., MD, FRCPC Radiologist / Nuclear Medicine Physician BCCA Centre of Excellence for Functional Cancer Imaging 2012 Fall Update in Surgical Oncology: Malignancies of the Lower GI Tract October 20, 2012 pete.tonseth@bccancer.bc.ca S
2 Disclosures S None
3 Objectives S Briefly review the fundamentals of Positron Emission Tomography S Review the indications for PET/CT in colorectal carcinoma S Review the sensitivity/specificity of PET/CT in CRC S Review the current availability and usage of PET/CT in BC S Questions
4 Objectives S Briefly review the fundamentals of Positron Emission Tomography S Review the indications for PET/CT in colorectal carcinoma S Review the sensitivity/specificity of PET/CT in CRC S Review the current availability and usage of PET/CT in BC S Questions
5 Fundamentals of PET imaging S H2 (O-18) + H-1 + energy è H2 (F-18) S H2 (F-18) + glucose è FDG
6 Fundamentals of PET imaging S FDG dispensed S Injected into patient S 1 hour uptake S βdecay with positron emission S Annihilation with an electron S Release of 511keV photons at 180
7 Fundamentals of PET imaging S Patient positioned S Coincidence detection S Image reconstruction S Patients are in the department for 2h Phelps M E PNAS 2000;97:
8 Objectives S Briefly review the fundamentals of Positron Emission Tomography S Review the indications for PET/CT in colorectal carcinoma S Review the sensitivity/specificity/accuracy of PET/CT in CRC S Review the current availability and usage of PET/CT in BC S Questions
9 PET/CT Worldwide
10 Funded indications for PET/CT in Colorectal Carcinoma: BCCA Colorectal Carcinoma S Determination of stage in patients with potentially resectable recurrence (including rising CEA)
11 Current BCCA Indications for PET/CT S Other cancers given specific clinical indications, as approved by the BC Cancer Agency, on an individual basis. S It is recognized in clinical practice that there may be clinical scenarios that do not meet specific guidelines but where expert medical opinion indicates the procedure could have a major impact on patient management. PET scan referrals in these cases will be reviewed on an individual basis and if approved by consensus, the patient will be offered participation in the study.
12 Funded indications for PET/CT in Colorectal Carcinoma: Ontario Colorectal Carcinoma S determining management and prognosis if conventional imaging is equivocal for the presence of metastatic disease S to determine the site of recurrence in the setting of rising CEA when a conventional workup fails to unequivocally identify metastatic disease S in the preoperative management assessment of colorectal cancer liver metastases prior to surgical resection
13 Funded indications for PET/CT in Colorectal Carcinoma: USA S Colorectal carcinoma Preoperative evaluation of patients with potentially resectable metastatic disease Determining location of tumours when rising CEA level suggests recurrence
14 Funded indications for PET/CT in Colorectal Carcinoma: Australia S Colorectal carcinoma Prior to resection of primary or limited metastatic disease Suspected recurrence or residual on structural imaging after definitive therapy
15 Current UK Indications for PET/ CT in Colorectal Carcinoma The Royal College of Physicians and The Royal College of Radiologists. Evidence-based indications for the use of PET-CT in the United Kingdom London: The Royal College of Physicians and The Royal College of Radiologists, 2012.
16 Colorectal Carcinoma S 57 yo female, colon CA with potentially resectable hepatic mets on CT
17 Colorectal Carcinoma S 57 yo female, colon CA with potentially resectable hepatic mets on CT
18 Colorectal Carcinoma S 57 yo female, colon CA with potentially resectable hepatic mets on CT
19 Colorectal Carcinoma S Rectal CA, staging Abd/Pel CT July 4, diversion ileostomy July 20, Chest CT Aug. 24 to complete staging, PET/CT Sept. 6 July 4 Aug 24
20 Colorectal Carcinoma S Rectal CA, staging Abd/Pel CT July 4, diversion ileostomy July 20, Chest CT Aug. 24 to complete staging PET/CT Sept. 6
21 Colorectal Carcinoma S 81 yo female, limited colon CA resected in 2011 with 0/31 nodes positive,? isolated hepatic metastasis
22 Colorectal Carcinoma S 81 yo female, limited colon CA resected in 2011 with 0/31 nodes positive,? isolated hepatic metastasis
23 Colorectal Carcinoma S 55 yo male, T3 N0 rectal carcinoma with pulmonary nodules on CT Aug 2011 August 2012
24 Colorectal Carcinoma S 55 yo male, T3 N0 rectal carcinoma with pulmonary nodules on CT, PET/CT shows no apparent activity
25 Colorectal Carcinoma S 55 yo male, T3 N0 rectal carcinoma with pulmonary nodules on CT, PET/CT shows no apparent activity respiratory motion artifact
26 PET/CT not recommended in : S Diagnosis or staging of clinical stage I-III colorectal cancers S The routine surveillance in patients with colorectal cancer treated with curative surgery at high risk for recurrence
27 PET/CT not recommended in : S The measurement of treatment response in locally advanced rectal cancer before and after preoperative chemotherapy
28 Treatment response Monitoring and Predicting Response to Therapy with 18F-FDG PET in Colorectal Cancer: A Systematic Review Lioe-Fee de Geus-Oei1, Dennis Vriens1, Hanneke W.M. van Laarhoven2, Winette T.A. van der Graaf2, and Wim J.G. Oyen1 - therapy response assessment with 18 F-FDG PET remains a very worthwhile research topic. J Nucl Med 2009; 50:43S 54S
29 Treatment response Prognostic Ability of 18F-FDG PET/CT in the Assessment of Colorectal Liver Metastases Vijayaragavan Muralidharan1, Marco Kwok1, Sze Ting Lee2,3, Lawrence Lau1, Andrew M. Scott*2,3, and Christopher Christophi - Maximum and mean standardized uptake value did not show any significant predictive ability. - volumetric 18F-FDG PET parameters. may enable better risk stratification of patients. J Nucl Med 2012; 53:1 7
30 Objectives S Briefly review the fundamentals of Positron Emission Tomography S Review the indications for PET/CT in colorectal carcinoma S Review the sensitivity/specificity of PET/CT in CRC S Review the current availability and usage of PET/CT in BC S Questions
31 Colorectal Carcinoma Detection of Recurrence in Patients With Rectal Cancer: PET/CT After Abdominoperineal or Anterior Resection Even-Sapir, E., Parag, Y., Lerman, H. PET/CT was used to distinguish benign and malignant presacral abnormalities with a sensitivity, specificity, positive predictive value, and negative predictive value of 100%, 96%, 88%, and 100%, respectively. Radiology vol. 232, , 2004
32 Colorectal Carcinoma PET changes management and improves prognostic stratification in patients with recurrent colorectal cancer: results of a multicenter prospective study. Scott AM, Gunawardana DH, Kelley B, Stuckey JG, Byrne AJ, Ramshaw JE, Fulham MJ. J Nucl Med Sep;49(9): Epub 2008 Aug 14.
33 Colorectal Carcinoma Group A structural lesion suggestive of recurrence - Additional disease in 48.4%; change in management in 65.6% Group B resectable pulmonary or hepatic metastases - Additional disease in 43.9%; change in management in 49% J Nucl Med Sep;49(9): Epub 2008 Aug 14.
34 Colorectal Carcinoma The Value of FDG Positron Emission Tomography/ Computerised Tomography (PET/CT) in Pre-Operative Staging of Colorectal Cancer: A Systematic Review and Economic Evaluation Health Technology Assessment, No , September 2011 J Brush, K Boyd, F Chappell, F Crawford, M Dozier, E McIntosh, A Renehan, D Weller, and M Dunlop. Fenwick, J Glanville, H
35 Colorectal Carcinoma UK based, systematic review of published and unpublished articles colorectal, neoplasm, FDG/PET 3933 titles/abstracts identified by search words; 3431 excluded Of the remaining 502, only 30 met the inclusion criteria Brush J, Boyd K, Chappell F, Crawford F, Dozier M, Fenwick E, et al. The value of FDG positron emission tomography/computerised tomography (PET/CT) in pre-operative staging of colorectal cancer: a systematic review and economic evaluation. Health Technol Assess 2011;15(35).
36 Colorectal Carcinoma - 2 studies looked at primary CRC insufficient data to support - 5 studies looked at detection of recurrent disease Sensitivity 91% Specificity 91% - 23 studies looked at detection of metastatic disease Sensitivity 91% Specificity 76% Brush J, Boyd K, Chappell F, Crawford F, Dozier M, Fenwick E, et al. The value of FDG positron emission tomography/computerised tomography (PET/CT) in pre-operative staging of colorectal cancer: a systematic review and economic evaluation. Health Technol Assess 2011;15(35).
37 Objectives S Briefly review the fundamentals of Positron Emission Tomography S Review the indications for PET/CT in colorectal carcinoma S Review the sensitivity/specificity/accuracy of PET/CT in CRC S Review the current availability and usage of PET/CT in BC S Questions
38 PET/CT in BC S Two scanners located at BCCA S 6000 scans per year S 4100 Jan-Sept 2012 S 500 related to colorectal carcinoma S Urgent scans can currently be completed within 2 weeks
39 PET/CT in BC 12% Colorectal Cancer PET/CT Scans 10% 8% 6% 4% 2% 0% COLORECTAL - other COLORECTAL - staging
40 PET/CT in BC Colorectal Cancer PET/CT Scans by Health Authority 4.5% 4.0% 3.5% 3.0% 2.5% 2.0% COLORECTAL - other COLORECTAL - staging 1.5% 1.0% 0.5% 0.0% Interior Fraser Vancouver Coastal Vancouver Island Northern
41 Current Indications for PET/CT in Colorectal Carcinoma Colorectal Carcinoma S Determination of stage in patients with potentially resectable recurrence (including rising CEA)
42 Objectives S Briefly review the fundamentals of Positron Emission Tomography S Review the indications for PET/CT in colorectal carcinoma S Review the sensitivity/specificity of PET/CT in CRC S Review the current availability and usage of PET/CT in BC S Questions
43 Thank you R. Petter Tonseth BSc., MD, FRCPC Radiologist / Nuclear Medicine Physician BCCA Centre of Excellence for Functional Cancer Imaging 2012 Fall Update in Surgical Oncology: Malignancies of the Lower GI Tract October 20, 2012 pete.tonseth@bccancer.bc.ca S
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