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PET/CT & Nuclear Medicine in Clinical Practice

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PET/CT & Nuclear Medicine in Clinical Practice The 8 th | Snowmass 2017: PET/CT & Nuclear Medicine in Clinical Practice Friday, February 24, 2017 Westin Snowmass Resort • Snowmass Village, Colorado Educational Symposia TABLE OF CONTENTS FRIDAY, FEBRUARY 24, 2017 Fluoride PET/CT Bone Imaging (Kevin L. Berger, M.D.) ................................................................................................. 221 Bone Scintigraphy (Andrew T. Trout, M.D.) .................................................................................................................. 235 Improving Efficiency in PET/CT Practice (Paul Shreve, M.D.) ......................................................................................... 249 Infection and Inflammation Imaging (Don C. Yoo, M.D.) ................................................................................................ 263 Clinical Molecular Imaging: Beyond FDG and PET/CT (Arif Sheikh, M.D.) ..................................................................... 275 SAVE THE DATES - 2018 Winter Symposia 221 222 INTRODUCTION DIAGNOSTIC METHODS Modalities 18F NaF was one of the original • Planar bone scan agents. In fact, FDA • X-Ray • CT approved 18F NaF for clinical use in • MRI 1972. • SPECT/CT • PET • PET/CT Now, there are many choices to Bone Imaging Agents diagnose a bone metastasis. • 99mTc medronate (MDP) • 99mTc oxidronate (HDP) • 18F FDG • 18F NaF INTRODUCTION 18 INTRODUCTION HOW DOES F NaF WORK? ADVANTAGES OF 18F NaF PET/CT BONE SCANS • 18F produced by proton bombardment of 180, represents a precursor in pathway of 18F for FDG production • Combining 18F NaF PET with other imaging, such as CT, can improve the specificity and overall accuracy of skeletal 18F NaF PET • Fluorine is directly incorporated into bone matrix, converting hydroxyapatite to fluoroapatite similar to Tc99m based bone agents which adhere by chemical but at twice the rate of the phosphonate mechanism leads to faster uptake • Although 18F NaF and 99mTc-diphosphonate have a similar patient dosimetry, 18F NaF PET offers shorter study times improved patient convenience, and faster • Approximately 30% of 99mTc-MDP is protein-bound immediately after injection which turnarounds of reports to the referring physicians. increases to approximately 70% by 24 hours after injection. There is no significant protein binding with 18F NaF. Skeletal PET with 18F-fluoride: applying new technology to an old tracer. J Nucl Med. 2008; 49(1):68-78 Skeletal PET with 18F-fluoride: applying new technology to an old tracer. J Nucl Med. 2008; 49(1):68-78 INTRODUCTION TECHNICAL CONSIDERATIONS MORE ADVANTAGES RADIATION EXPOSURE COMPARING 99mTc MDP vs 18F NaF PET • Faster bone uptake Why use PET/CT with • Rapid clearance3 and low protein 18F NaF for 2 bone binding imaging? • Higher bone to background ratios1,3 • Minimal patient prep • Shorter study times2 1Schirrmeister, H et al. Early detection and accurate description of extent of metastatic bone disease in breast cancer with fluoride ion and positron emission tomography. J Clin Oncol. 1999; 17(8): 2381-2389 2Frederick, DG et al. Skeletal PET with 18F-Fluoride: Applying New Technology to an Old Tracer. J Nucl Med 2008; 49:68–78. 3Even-Sapir, E et al. The Detection of Bone Metastases in Patients with High-Risk Prostate Cancer: 99mTc-MDP Planar Bone THE SNM PRACTICE GUIDELINE FOR SODIUM 18F-FLUORIDE PET/CT BONE SCANS 1.1 Scintigraphy, Single- and Multi-Field-of-View SPECT, 18F-Fluoride PET, and 18F-Fluoride PET/CT. J Nucl Med 2006; 47:287–297. 223 TECHNICAL CONSIDERATIONS TECHNICAL CONSIDERATIONS 18F NaF FLOURIDE PET SCAN PET/CT BONE SCAN TECHNIQUE PATIENT PREPARATION 18 • No glucose check • 2.22 MBq/kg or 5 - 10 mCi F NaF i.v. • No dietary restrictions • Allow 60 minutes for distribution • No activity restrictions • Pediatric should be weight based • Patient should be well-hydrated (minimum 0.5 mCi and maximum 5mCi) • Have patient show up TECHNICAL CONSIDERATIONS Will 18F NaF with PET/CT replace PET/CT BONE SCAN TECHNIQUE 99mTc Bone Scintigraphy? • FDA-approved radiotracer Sodium • Helical CT Attenuation scan Fluoride • 3D Whole Body PET emission scan • Automatic Nuclear and CT correlation (90 - 300 seconds/bed) • High resolution scan • Reconstruct CT in bone algorithm • 3-D tomographic reconstructions Is 18F NaF PET/CT effective in Planar 99mTc MDP bone scans identifying metastasis? Patient History • 81 year old male with history of prostate cancer status post irradation presents with elevated PSA and alkaline phosphatase. Outside hospital bone scan reported as normal. 224 Planar 99mTc MDP bone scans 18F NaF 13 18F NaF with PET/CT How does 18F NaF compare to bone scans? PET Whole Body Bone Imaging • ROC Curve was 0.99 for PET and 0.64 for radionuclide bone scintigraphy. In a series of 44 patients, PET identified 96 metastases compared to 46 by bone scan. All lesions found with bone scintigraphy were found by PET Sensitivity in Detecting Osseous Lesions Depends on Anatomic Localization: Planar Bone Scintigraphy Versus 18F PET by Schirrmeister, J Nucl Med 1999; 40:1623-1629. Whole Body PET Whole Body PET Bone Scan Bone Scan Patient History • 74 year-old gentleman with prostate carcinoma and rising PSA Fluoride PET Bone Scan FDG PET Whole Body Scan 225 Whole Body PET Bone Scan Can you use 3 phase bone scans on PET/CT? Patient History • 56 year-old woman who is an avid runner complaining of left foot pain Dynamic PET Bone Scan Dynamic PET Bone Scan Delayed Flow Immediate static Whole Body Bone Scan Whole Body Bone Scan • How specific is 18F NaF PET/CT compared Patient History • 52 year-old woman with known metastatic breast cancer to FDG PET/CT for bone metastasis? status post chemotherapy with PET fluoride bone scan and FDG PET scans performed within the same week. 226 Whole Body Bone Scan Whole Body Bone Scan Fluoride PET Bone Scan FDG PET Whole Body Scan Fluoride PET Bone Scan FDG PET Whole Body Scan Lower Extremity Comparison Fluoride PET Bone Scan FDG PET Whole Body Scan FDG PET 18F NaF PET CASE STUDY 5 Whole Body PET Bone Scan Lower Extremity 18F NaF PET/CT Patient history: • 57 year-old gentleman with lung cancer who complains of back pain. 227 Whole Body PET Bone Scan Whole Body PET Bone Scan Whole Body PET Bone Scan PET Bone Scans in Pediatrics CASE STUDY 7 PET Bone Scans in Pediatrics Patient History: • 11 year-old girl with pain distal left leg 228 PET/CT Bone Scans in Pediatrics Immediate Static PET/CT Bone Scans in Pediatrics PET/CT Bone scan Diagnosis: Osteoid Osteoma • 15 year old complains of persistent low back pain PET/CT Bone Scan Patient History: • 16 year-old cross-country runner with left leg pain 229 PET/CT Bone Scan PET/CT Bone Scan PET/CT Bone Scan PET/CT Bone Scan PET/CT Bone Scan Dual Tracer PET • Improved sensitivity (97% patients showed equal or greater number of lesions) – EJNM. Prospective comparison of combined 18F-FDG and 18F NaF PET/CT vs 18F-FDG PET/CT imaging for detection of malignancy from Lin et al. Freibergs Infraction 230 Dual Tracer PET Case example • Decreased radiation dose (largely secondary • 63 year-old male status post left radical to less CT component) neck dissection for parotid carcinoma. • Patient convenience with more rapid staging turnaround – JNM 2012; 53:586 Evaluation of NaF PET/ CT, FDG PET/CT, combined NaF/FDG PET/ CT and CT alone for detection of bone metastases by Sampath et al. Dual NaF/FDG PET/CT Dual NaF/FDG PET/CT Dual Tracer PET Dual Tracer PET • Improved sensitivity (97% patients showed • Decreased radiation dose (largely secondary equal or greater number of lesions) to less CT component) – EJNM. Prospective comparison of combined • Patient convenience with more rapid 18F-FDG and 18F NaF PET/CT vs 18F-FDG staging turnaround PET/CT imaging for detection of malignancy from Lin et al. – JNM 2012; 53:586 Evaluation of NaF PET/ CT, FDG PET/CT, combined NaF/FDG PET/ CT and CT alone for detection of bone metastases by Sampath et al. 231 Dual NaF/FDG PET/CT 63 year-old male status post left radical neck dissection for parotid carcinoma. Dual NaF/FDG PET/CT Reimbursement & Coding 58 NOPR GUIDELINES NOPR GUIDANCE INITIAL TREATMENT STRATEGY SUBSEQUENT TREATMENT STRATEGY 18F Fluoride PET performed as part of an evaluation for determination of an initial 18F Fluoride PET is also covered by CMS only with participation in this registry when used in treatment strategy is covered by CMS only with participation in this registry. 18F fluoride PET subsequent treatment strategy to identify bone metastases in a patient with a pathologically may be used both for diagnosis of strongly suspected bone metastases in a patient without a proven cancer. pathologically proven diagnosis of cancer and as part of initial staging in a patient with a pathologically proven cancer. 18F Fluoride PET is covered for restaging and detection of suspected recurrences: 1. After completion of treatment for the purpose of detecting residual disease; or Note: 18F Fluoride PET is covered only in clinical situations in which: 2. For detecting suspected recurrence or metastasis; or • The PET results may assist in avoiding an invasive diagnostic procedure 3. To determine the extent of a known recurrence: • The PET results may assist in determining the optimal anatomical location to perform an invasive 4. If it could potentially replace one or more conventional imaging studies when it is expected that diagnostic procedure. In general, for most solid tumors, a tissue diagnosis is made prior to doing conventional study information is insufficient for the clinical management of the patient. a PET bone scan and
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