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1 PET/CT applications in head and neck cancer 黃淑華高雄長庚醫院核子醫學科

2 高雄長庚紀念醫院正子斷層造影中心

4 Positron Emitters (Cyclotron) F-18 (108 min) - FDG (glycolysis( glycolysis/cardiac viability/cerebral metabolism) C-11 (20 min) - Methionine (amino acid metabolism) N-13 (10 min) - Ammonia (myocardial perfusion) O-15 (2 min) - water (cerebral perfusion)

6 Oncologic application Neurologic application Psychologic disorders Cardiac application

7 Applications of PET/CT Lung cancer Head and neck tumor Colorectal Lymphoma Melanoma Thyroid cancer Breast cancer Esophagus Seizure disorder

8 Patient preparation No vigorous exercise for one day Fasting> 4 hours except water Early morning appointment for DM patient No pregnancy for female patient Check Blood sugar < 150 mg

9 FDG PET in head and neck cancer Staging of head and neck cancer Primary tumor evaluation by PET Regional nodal staging by PET Distant staging by PET Diagnosis of unknown primary tumor Treatment planning Therapeutic monitoring Assessment of recurrent head and neck cancer

10 Normal FDG uptake, variants, and pitfalls

11 PET/CT in T staging Sensitive and specific: more than 90% to 95% Limited in primary tumor extension delineation. Dental artifacts on CT or MR images. The radiotherpy planning especially by delineating the gross tumor volume in intensity- modulated raidation therapy (IMRT)

13 Bone Invasion in Patients with Oral Cavity Cancer: Comparison of Conventional CT with PET/CT and SPECT/CT Radiology 2005

a In the non-attenuation-corrected PET image (filtered back-projection), white spots at the site of non-removable metallicdental artwork are visible.

14 a In the non-attenuation-corrected PET image (filtered back-projection), white spots at the site of non-removable metallicdental artwork are visible. b An artefact mimicking FDG uptake adjacent to the metallic foreign body is present on the identical slice when using attenuation correction (iterative reconstruction). c In the co-registered PET/CT image, interpretation of this region is impossible.

15 a Dental fillings in a non-attenuation-corrected PET image in another patient. b, c After applying attenuation correction, pseudo-uptake is present adjacent to the metallic dental bridgework. There is a difference between the PETGe68 image (b) and the PETCT scan (c)

16 54-y-old male patient with squamous cell carcinomas of right retromolar area

17 Standardized uptake value SUV = = Tissue activity (uci/cc) Administered activity (uci/g) Mean ROI activity (mci/ml) Injected dose (mci)/body wt(g)

18 Factor affecting SUV Body composition and habitus Length of uptake period Glucose & insulin level,renal function Partial volume effect Recent physical activity Inflammation can have elevated SUV

19 PET/CT in N staging PET has a high positive predictive value, greater than 90% to 95%, and is superior to CT and MRI with respect to sensitivity and specificity in the detection of nodal disease.

23 Distant Metastases Staging (M0) and Detection of Synchronous Primary Tumors PET is useful in identifying distant metastases and synchronous second malignancies that may not have been detected on routine conventional imaging. Some series have reported a detection rate of previously unrecognized distant metastases of 27%.

24 Limitations Low grade malignancies Small lesion - Size detectable is a function of reconstructed resolution and contrast - Partial volume effect or respiratory motion - <1mm Limited ability to distinguish between residual or recurrent tumor from scar Inability to biologically characterize disease Inflammatory diseases

25 Diagnosis of unknown primary tumor There have been conflicting reports with respect to the usefulness of PET in this setting. In a review of the published series by Rusthoven and colleagues17 the overall ability of PET to detect the occult primary was 25-49%, with a sensitivity, specificity, and accuracy of 88%, 75%, and 79%, respectively.

28 INITIAL MANAGEMENT The ability of PET to alter the TNM staging following conventional imaging, mainly N and M staging Connell and colleagues found PET/CT altered the TNM staging in 34% of patients, with 10/35 patients up-staged and 2/35 down-staged. In most cases the alteration was attributable to a change in N staging.

29 Clinically Node-Negative Neck (N0) clinical/radiologic N0 is based on perceived risk for less than 15% to 20% occult neck disease PET: Positive predictive value : 90% ~ 95%; Negative predictive value : 50% ~ 85%. Ng and colleagues assessed the usefulness of PET, CT, and MRI in patients who had oral cavity SCC and a palpably N0 neck 134 patients, 26% were found to have neck metastases The sensitivity of PET was 51% and this increased after visual correlation with CT/MRI to 57%.

30 Radiotherapy Planning PET fusion with RT planning CT scans to assist with definition of tongue base tumor

32 Post-Radiotherapy Restaging Assessment of the neck following chemotherapy and RT can be difficult because of residual clinical or radiologic abnormalities. Following RT, PET/CT has the ability to distinguish whether there is ongoing metabolic activity within residual structural abnormalities and has a high negative predictive value, in excess of 95%. Yao and colleagues assessed the role of PET at a median of 15 weeks following definitive RT and found the negative predictive value was 100%. The optimal time for a restaging PET seems to be 12 to 15 weeks following treatment.

33 THERAPEUTIC MONITORING AND PROGNOSTICATION PET response following RT seems to have some role in predicting long-term outcome. Brun and colleagues evaluated the metabolic response (MR) and standardized uptake value (SUV) in 47 patients who had HNSCC Patients underwent a preatment PET followed by another PET after 1 to 3 weeks of radical RT Low and high MR FDG PET, with median value as cutoff, was associated with complete response in 96% and 62% (P =0.007) 5-year survival, 72% versus 35% (P )

34 RESTAGING AT RELAPSE AND SURVEILLANCE In patients treated with HNSCC the 5-year rate of locoregional recurrence, second malignancy, and development of distant metastases are 40% to 50%, 10% to 30%, and 15% to 20%, respectively.

35 NOVELTRACERS AND CLINICAL Hypoxia imaging IMPLICATIONS Hypoxia has long been recognized as an adverse determinant of RT treatment outcome in head and neck cancer 18F-labelled FMISO PET fluorine-18 fluoroazomycin arabinoside (FAZA) PET

36 FDG PET demonstrating uptake at the tongue base and level II node with the FAZA PET demonstrating hypoxia in the node only.

37 Proliferation Imaging Increased proliferation is one of the hallmarks of cancer cells. fluorine-18 fluoro-deoxy-l-thymidine (FLT)

38 Novel tracers, such as fluorine-18 fluoromisonidazole (FMISO) and fluorine-18 fluoro-deoxy-l-thymidine (FLT), are being evaluated in their ability to biologically characterize disease and provide prognostic information

聖馬爾定醫院正子中心健保開單診療指引（guideline）

聖馬爾定醫院正子中心健保開單診療指引（guideline）聖馬爾定醫院正子中心健保開單診療指引 (guideline) 2011.10.27 全身癌症掃描檢查 (2010 年 6 月 1 日起健保開始對下列正子掃描之適應症給付 ): 1. 乳癌淋巴癌之分期治療及懷疑復發或再分期 2. 大腸癌直腸癌食道癌頭頸部癌 (