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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. Diagnosis Specific or non-specific Staging Important for proper therapy Follow-up

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Radionuclide methods in oncology

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  1. Radionuclide methods in oncology Materials for medical students Otto Lang, MD, PhD Otakar Bělohlávek, MD, CSc Dept Nucl Med Charles Univ, 3rd Med Fac

  2. Role for Nuclear Medicine • Diagnosis • Specific or non-specific • Staging • Important for proper therapy • Follow-up • Early detection of recurrens • Treatment • Specific or non-specific

  3. Tumors • 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

  4. Tumor cells • 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

  5. Diagnostic radiopharmaceuticals • Non-specific - demonstrate tumor sites but are not specific for malignancy • PET or PET-CT • 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

  6. Diagnostic radiopharmaceuticals • 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

  7. Therapeutic radiopharmaceuticals • Non-specific • Sr-89, Sm-153, Re-189 • Bone pain palliation • Specific • I-131 • Thyroid cancer, as specific diagnostic if tumor significantly accumulates • Y-90 • Zevalin – monoclonal antibody for B-cell lymphomas

  8. Ga-67 scan • 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

  9. Ga-67 scan • Procedure • Patient preparation • Laxatives for bowel preparation post injection, nothing else • Several weeks post tumor therapy (FN) • 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

  10. Ga-67 scan • 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

  11. Ga-67 scan • Clinical indications • lymphoma • staging and monitoring effect of therapy • melanoma • lung cancer • hepatoma • Combination with other imaging modalities is necessary (SPECT/CT)

  12. Bone scan • Radiopharmaceuticals • Tc-99m MDP, HDP • Tissue accumulation depends on • blood flow • capillary permeability • metabolic activity of osteoblasts and osteoclasts • mineral turnover • 500 to 800 MBq, imaging 2 to 3 hours later – WB + SPECT

  13. Bone scan • Clinical indications: • Diagnosis of metastases of different tumors – staging and follow-up • Positivity many months before an abnormality can be detected on X ray - method of choice to seek for bone metastases • Mainly • Bronchogenous carcinoma, prostate, breast, thyroid, and renal tumours

  14. Bone scan • 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

  15. Liver/spleen scan • 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

  16. Thyroid scan • Non-specific test with pertechnetate • Mainly cold nodules – especially in children – must be biopsied!!!

  17. Bone marrow scan • Colloids or leukocytes • Similar as bone scan • Better sensitivity

  18. FDG PEThttp://www.homolka.cz/nm/ • 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

  19. Specific methods • 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

  20. Specific methods • Monoclonal antibodies • Anti-CEA – rather in detection of relaps • In the pelvis better than CT • In the liver CT better • In-111 Oncoscint – colorectal, ovarian • Melanoma – antibody against melanin • Ga scan is better

  21. Bone scan – multiple metastases

  22. Bone scan – multiple metastases

  23. Lung cancer – cold lesion

  24. Breast cancernormal X ray with hot spot on scintigraphy

  25. Superscan – prostate cancer

  26. Bone scan - prostate cancerprogression

  27. Breast cancer – FU – progr.

  28. Thyroid – folicular caon sonography solid nodule

  29. Thyroid cancer - anaplastic

  30. Thyroid cancer I-131 Tc-99m Tc-99m post surgery

  31. Thyroid cancer –I-131 - meta

  32. Tc-99m sestamibiparathyroid adenoma early late

  33. Neuroblastoma liver and bone involvment I-131 MIBG scan Bone scan

  34. Carcinoid – liver meta

  35. Ga scan – lung cancer

  36. Ga scan - lymphomas

  37. Palpable mass on the necklymphoma Tc-99m pertechnetate Ga-67 citrate

  38. SPECT/CT carcinoid

  39. SPECT/CT breast cancer

  40. SPECT/CT lung cancer

  41. SPECT/CT lung cancer

  42. FDG PET - normal

  43. FDG PET melanoma

  44. FDG PET Tumor of unknown origin Metastatic involvment of neck lymph nodes

  45. FDG PET Tumor of unknown origin Pharyngeal cancer

  46. FDG PET – brain tumor post thtwo foci on CT, only one viable tumor

  47. Staging colorectal CA

  48. Lung cancer Effect of therapy

  49. Stomach cancer

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