Renata Milardović, M.D. Nuclear Medicine University-Clinical Center Sarajevo Bosnia and Herzegovina • Research: > 30 years (cardiac, brain, bone) • 1980: First PubMed article published on clinical PET in German journal Herz (Geltman EM, Roberts R, Sobel BE. Cardiac positron tomography: current status and future directions. Herz 1980; 5:107-19) • Clinical breakthrough: last decade • Major propellers: Introduction of F18-fluoro-deoxyglucose Appearance of PET/CT (2001)
• 2008-> all PET became PET/CT • Combines functional + structural information • Higher diagnostic accuracy • CT-based attenuation correction (faster) • Enables creation of an integrated report • Dominates the market today
State-of-the-art
New scintillators (faster) CT-based attenuation More detector rows correction (more axial slices) Smaller crystals (higher Increased x-ray tube spatial resolution) Multidetector arrays (fast, power (stability) high resolution) Increased computer Extended FOV (sensitivity) capacity (fast Time-of-flight (fewer artifacts) processing) Gating (motion correction) Faster rotation times New tracers (fewer motion artifacts)
PET CT
• First PET/CT scanner in BiH • Installed: mid2013 • Operational: 2014
• Discovery 600, General Electric Medical Systems • Dedicated PET scanner using BGO crystals • 16-slice multidetector CT scanner
• 30 mm BGO crystals • Front/rear system panels • Improved patient controls • Increased vertical scan range Tema, Sinergie, OS: Windows Application: automatic. Sporadic Automated dispensing: reduced staff cases manual. One case exposure and accurate dosing automatic+manual. GE Healthcare OS: Linux 1. FDG PET and PET/CT: EANM procedure guidelines for tumour PET imaging: version 1.0 Ronald Boellaard, Mike J. O’Doherty, Wolfgang A. Weber, Felix M. Mottaghy, Markus N. Lonsdale, Sigrid G. Stroobants, Wim J. G. Oyen, Joerg Kotzerke, Otto S. Hoekstra, Jan Pruim, Paul K. Marsden, Klaus Tatsch, Corneline J. Hoekstra, Eric P. Visser, Bertjan Arends, Fred J. Verzijlbergen , Josee M. Zijlstra, Emile F. I. Comans, Adriaan A. Lammertsma, Anne M. Paans, Antoon T. Willemsen, Thomas Beyer, Andreas Bockisch, Cornelia Schaefer-Prokop, Dominique Delbeke, Richard P. Baum, Arturo Chiti, Bernd J. Krause. 2. Evidence-based indications for the use of PET/CT in the UK 2013 Lead Authors: Sally Barrington and Andrew Scarsbrook
3. PET PROS (PET Professional Resources and Outreach Source). SNM. 2009
4. F18-FLUORODEOKSIGLUKOZA (FDG) PET/CT SMJERNICE U ONKOLOGIJI Pripremile: prim. dr. Renata MILARDOVIĆ, doc. dr. Nermina BEŠLIĆ KCUS, 2013 (www.kcus.ba)
1. Low-dose FDG PET/CT • Whole-body PET/CT
2. FDG PET/CT with • Total-body PET/CT diagnostic CT (no contrast) • Head and Neck
• Brain 3. FDG PET/CT with diagnostic CT (with contrast)
Per CT parameters and Per Body Part contrast • Patient preparation: 30 min • Uptake period: 60 min • Scan time: 15 min • Additional pt preparation: Pt should not speak following cannulation. Glucose should not exceed 11 mmol/l.
• Activity: 370 MBq (not weight-adjusted) • Scan duration/bed: 1’45’’ • CT slice: 3,75 mm; 2,5 mm
• Patient preparation: 30 min • Uptake period: 60 min • Scan time: 25 min • Additional pt preparation: Pt should not speak following cannulation. Glucose should not exceed 11 mmol/l.
• Activity: 370 MBq • Scan duration/bed: 1’45’’ • CT slice: 2,5 mm
• Patient preparation: 30 min • Uptake period: 60 min • Scan time: 15+15 min= 30 min • Additional pt preparation: Pt should not speak following cannulation. Glucose should not exceed 11 mmol/l.
• Activity: 370 MBq • Scan duration/bed for WB: 1’45’’ • Scan duration/bed for H&N: 7’ • CT slice for WB: 1,25 mm • CT slice for H&N: 1,25 mm • Patient preparation: 30 min • Uptake period: 30 min • Scan time: 15 min • Additional pt preparation: Pt should not speak following cannulation. Dark room.
• Activity: 250 MBq • Scan duration/bed: 15 min • CT slice: 2,5 mm • Oncologic PET/CT: Most-comprehensive tool in oncologic imaging • PET/CT improves diagnostic accuracy of cancer evaluation in comparison with either scanner used alone
• Tracer: F18-fluodeoxyglucose
• Source: Institute for Public Health FBiH: Overview of Malignant Tumors – Cancer Register of FBiH for 2011 (www.zzjzfbih.ba) • Official data for 2012 remain unpublished • n=5255
Male (all ages) 2729 Female (all ages) 2526
Lung 26,2 26,2 Breast Prostate 12,8 7,1 Lung Rectum 7,0 6,7 Cervix
Bladder 6,5 5,5 Uterus Stomach 6,3 5,2 Ovary Colon 6,0 4,9 Stomach Trachea 3,8 4,9 Colon Liver 3,4 4,7 Rectum Brain, nervous system 3,3 3,5 Liver Pancreas 3,3 3,1 Brain, nervous system Other 21,2 28,2 Other
• Total number of scans: 133 • Total number of patients: 125
• Diagnostic CT: 8 • Contrast (I.V. and oral): 14 • Diazepam: selected cases
• Whole-body protocol: 110 • Total-body protocol: 19 • Head and Neck protocol: 7 • Brain protocol: 4
• Technical problems with scanner: 1 • Technical problems with injector:1 • Discomfort, anxiety: 1 • Problem with needle insertion: 1 • Late deliveries (couple of days): reduced no of patients • Cancelled delivery: 1 (patients referred on the following day)
Application imaging time prolonged Findings: Brown fat Pt subjected to lower temperature Remission of LH • Oncology: 64 • Hematology: 45 • Surgery 6 • Pulmology: 5 • Neurology+Psychiatry: 4 • Nuclear: 2 • Internal: 2 • Other: 5 • Only two specialties (n=133) • Uneven distrubution referrred about 80% of across specialties patients • Lymphoma: 45 • Malignant melanoma: 19 • Lung: 18 • Colorectal: 14 • Breast: 6 • Genitourinary: 5 • Head and neck cancer: 5 • Testicular: 3 • Thyroid: 3 • Lymphoma (all types) • CUP: 2 remain the most • Other: 9 frequent single (n=133) pathology referred to PET/CT
• Staging/restaging: 54 • Response evaluation: 43 • Recurrence: 28 • Primary diagnosis including CUP: 8 • Therapy planning: 0
• Total number n=133 • PET/CT was mainly used for staging and evaluation of treatment response • Most patients were referred by oncologists and hematologists • Most common pathology was lymphoma
• IAEA BOH6014: “Enhancing Nuclear Medicine Capabilities for Patient Management in Oncology, Cardiology and Neurology” • Dr. Sabina Dizdarević, MD, MSc, FRCP, Lead Consultant in Nuclear Medicine, Brighton and Sussex University Hospitals, NHS Trust • Date: 10–14 Feb 2014 • Resulted in: Application of new protocols (H&N) Improvement in reading EANM Guidelines enforcement
• IAEA BOH6014: “Enhancing Nuclear Medicine Capabilities for Patient Management in Oncology, Cardiology and Neurology”, Expert Mission for Acceptance Testing of the New PET/CT at the Nuclear Medicine Center Sarajevo. • Mrs. Elena de Ponti, PhD, Medical Physicist, San Gerardo Hospital, Monza, Italy • Date: 12-16 May 2014 • Resulted in: Additional education of physicists • Completion of commissioning and acceptance testing
PET/CT referred to as “the fastest growing medical technology ever”
Gain clinical acceptance Gain experience in practical use of the existing guidelines High quality interpretation of the findings Expand the field of indications (inflammation, cardiology) Introduction of new tracers Research
Thank you