False positive PET in lymphoma

Transcription

1 False positive PET in lymphoma Thomas Krause

2 Introduction and conclusion 2

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4 Introduction 4

5 FDG-PET in staging of lymphoma 34 studies with 2227 Patients CT FDG-PET Sensitivity 63 % 89 % (58%-100%) (63%-100%) Specificity 93 % 97 % (17%-97%) (69%-100%) Gambhir et al.; J Nucl Med. 2001: 42: 18S 5

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7 Causes of false-positive interpretation Technical artifacts Physiological uptake patterns Non-malignant pathological conditions Post therapy 7

8 18F-FDG - embolism Chondrosarcoma post therapy 8

9 18F-FDG - contamination B.M. m; 65y; Colon Ca., hemicolectomy 11/2010 9

10 18F-FDG para vascular injection G.R. m; 72y; squamous cell cancer 10

11 Causes of false-positive interpretation Technical artifacts Physiological uptake patterns Non-malignant pathological conditions Post therapy 11

12 Metabolism (Glucose) Plasma Glucose Cell Hexokinase GLUT Glucose Glucose-6-Phosphate Phosphatase CO2 H2 O Hexokinase 18 FDG GLUT 18FDG Phosphatase 18FDG-6-Phosphate 12

13 18F-FDG normal distribution I A.L. m; 46y; papillary thyroid cancer 13

14 18F-FDG normal distribution II A.L. m; 46y; papillary thyroid cancer 14

15 18F-FDG normal distribution III A.L. m; 46y; papillary thyroid cancer 15

16 18F-FDG normal distribution IV A.L. m; 46y; papillary thyroid cancer 16

17 18F-FDG normal distribution V C.G. m; 53 y; supraglottic squamous cell cancer 17

18 Negative influence on FDG uptake ingestion glucose injection diabetes mellitus increased chance of a false positive physical stress interpretation activation of brown fat chemotherapy 18

19 Diabetes mellitus M.J. 40J, m, Diabetes mellitus Sarkoidose 19

20 Metastasis in Seminoma? 18F-FDG Projektion - PET Coronal 3879/03: M.S., m, cryptorchidism; hemi-orchiectomy 20

21 Hodgkin Lymphom 4759/05, B.D. m, 10y, HD ED 05/03, LN resection, chemotherapy (2 cycles) 21

22 Hodgkin Lymphom 5829/05,, B.D. m, 10y, HD ED 05/03, LN resection, after chemotherapy 22

23 Hodgkin Lymphoma /11G.V. f, 61y, HD IIA ED 02/11; activated bone marrow after chemotherapy / G-CSF 23

24 Causes of false-positive interpretation Technical artifacts Physiological uptake patterns Non-malignant pathological conditions Post therapy 24

25 Non-malignant diseases Sarcoidosis Infection Warthin s tumour Langerhans cell histiocytosis Fracture Osteoarthitis Vasculitis 25

26 Benign diseases with high FDG uptake Sarcoidosis Hodgkin s disease 26

27 NSCLC 2624/06, K.D. f, 50y, NSCLC IIIB restaging after chemotherapy; Paget disease of the sacrum 27

28 CUP Ascariasis 317/09, K.E., f, 69y, CUP, metastases of the liver? 28

29 Recent rip fracture m, 11y, HD IV 29

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31 Maligne transformation Hexokinase Hexokinase 31

32 SUV Nodular lymphocytic predominace Clasical Hodgkin lymohoma Nodular sclerosis Mixed cellularity Not specified 32

33 SUV

34 FDG uptake and histology T-cell lymphoma Mantle cell lymphoma 34

35 Development of PET and PET/CT mm mm mm Transaxial resolution 35

36 Development of PET respectively PET/CT mm mm A.S. f; 25y, Ovarian cancer 36

37 What is a positive finding? Any distinquishable uptake?* Focal or diffuse uptake above background?** Uptake greater than blood pool? Liver?*** Hepatic or splenic lesions 1.5 cm or larger, if uptake is more than uptake in liver or spleen; or diffusely increased splenic uptake?** Any increased uptake in a mass smaller than 2 cm?** Clearly increased focal or multifocal bone involvement?** * Young H. et al: Measurement of clinical and subclinical tumour response using [18F]-fluorodeoxyglucose and positron emission tomography: review and 1999 EORTC recommendations. European Organization for Research and Treatment of Cancer (EORTC) PET Study Group. Eur J Cancer. 1999;35:1773 **Juweid ME et al.: Use of positron emission tomography for response assessment of lymphoma: consensus of the Imaging Subcommittee of International Harmonization Project in Lymphoma. J Clin Oncol. 2007;25:571 *** Wahl RL et al.: From RECIST to PERCIST: Evolving Considerations for PET Response Criteria in Solid Tumors. JNM 2009; 50: 122S 37

38 Causes of false-positive interpretation Technical artifacts Physiological uptake patterns Non-malignant pathological conditions Post therapy 38

39 FDG uptake after therapy What is the time course of uptake after therapy? How much uptake is normal? Are there typical differences depending on Histology? Therapy regimen? Tumor stage? 39

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41 M. Hodgkin 641/06, Z.P., m, 11y, HD IV before therapy and after 3 cycles COPDIC

42 Mantle cell lymphoma 1167/06, K.A., m 61J, Mantle cell lymphoma before therapy and after 4 cycles' R-CHOP 42

43 Hodgkin disease , C.R., m, 42y, Hodgkin disease St. IIIA before, after 2 cycles and after completion of chemotherapy 43

44 Hodgkin disease , W.F., m, 32y, Hodgkin disease St. III before, after 2 cycles and after completion of chemotherapy 44

45 4 Endoxan 3.5 Tumour mouse model SUV 2 Viable Tumor Cells % 1.5 Mononuclear Infiltration % Day 0 Day 1 Day 3 Day 8 Day 10 Day 15 45

46 Timing of Restaging 2-3 weeks after chemotherapy or chemoimmunotherapy 8-12 weeks after radiation or chemoradiotherapy 4-8 weeks after surgery 46

47 What is a positive finding after therapy? Any distinquishable uptake?* Focal or diffuse uptake above background?** SUV > 1.5 x mean liver SUV + 2 SDs of mean SUV SUV > XY SUV Decrease < 25% (after 2 cycles)* * Young H. et al: Measurement of clinical and subclinical tumour response using [18F]-fluorodeoxyglucose and positron emission tomography: review and 1999 EORTC recommendations. European Organization for Research and Treatment of Cancer (EORTC) PET Study Group. Eur J Cancer. 1999;35:1773 **Juweid ME et al.: Use of positron emission tomography for response assessment of lymphoma: consensus of the Imaging Subcommittee of International Harmonization Project in Lymphoma. J Clin Oncol. 2007;25:571 47

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49 Background Initial staging of a patient (74) with cervical cancer: PET-positive distant metastases 49

50 but considered negative in CT and MRI FDG PET-CT T1 fat sat with iv contrast CT 2mm slice thickness 50

51 Patient treated as planned: Follow-up PET-CT after chemotherapy and radiotherapy 51

52 PET guided Biopsy ARTORG CENTER BIOMEDICAL ENGINEERING RESEARCH 52

53 45-year-old woman with breast cancer > Suspicion of local recurrence CT: no morphological changes PET: Increased FDG uptake PET-guided biopsy of the hypermetabolic region Histology: Bone metastasis 53

54 Take home message Artifact must be detected by your nuclear medicine specialist. The physiological pattern of metabolism must be known. Correct patient preparation is mandatory. There is no false positive PET but wrong interpretation. Most inflammatory deceases show increased metabolism. Positive or negative interpretation depends on histology, therapy and anatomy. Patient s history is helpful to prevent misinterpretation. Histology? Inflammation? Therapy? Holistic image reading is essential. In a therapeutic setting a basic scan for comparison may be helpful. PET guided biopsy can help to avoid wrong interpretation. 54

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