Transcript No Slide Title

FACET - European Journal of Cancer Care
September 2005
PET in oncology: An oncologist’s view
Mikhaeel, N.G.1
An oncologist’s view
• The cancer journey from diagnosis
to treatment
Slide One
• The role of PET in oncology
• Specific cancers
• The future
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September 2005
PET in oncology: An oncologist’s view
(continued)
Cancer journey
• Diagnosis
Slide Two
• Staging
• Choice of therapy
• Assessment of response
• Follow-up, detection and
treatment of recurrence
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September 2005
PET in oncology: An oncologist’s view
(continued)
Treatment decisions
Cancer treatment depends largely on
its EXTENT (= stage)
Slide Three
• Radical versus palliative
• Operability (and extent of
surgery)
• Radical radiotherapy (and its
extent)
• Need for adjuvant systemic
treatment
• Combination treatment
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September 2005
PET in oncology: An oncologist’s view
(continued)
Late toxicity
In successfully treated cancers,
LATE TOXICITY is important
Slide Four
• example: early Hodgkin’s
Lymphoma (HL)
• A plateau has been reached in
cure rates
• Death from treatment toxicity
exceeds death from HL >10-15
years
• Current research is to improve
the Therapeutic Index
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September 2005
PET in oncology: An oncologist’s view
(continued)
Improving therapeutic
index
Slide Five
(1) Tailoring the treatment to
individual’s prognosis: e.g.
• Prognostic indices
• Radiotherapy planning
(2) Response-adapted therapy –
the oncologist needs:
• accurate staging
• accurate response
assessment
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September 2005
PET in oncology: An oncologist’s view
(continued)
The role of PET (1)
(1) Diagnosis: limited use
Slide Six
• FDG uptake in inflammatory
tissue
• ? SUV
Examples
• Indeterminate solitary pulmonary
nodules
• Cerebral pathology in HIV+
patients
• ? Guiding biopsy in suspected
malignancy
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September 2005
PET in oncology: An oncologist’s view
(continued)
The role of PET (2)
(2) Staging: TNM
Slide Seven
T:
• Primary size (e.g. breast, lung)
• Depth of wall infiltration (e.g.
gastro intestinal (GI), bladder)
• Extent of organ involvement (e.g.
prostate)
• Infiltration of surrounding tissues
(e.g. head & neck, uterine cervix)
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September 2005
PET in oncology: An oncologist’s view
(continued)
The role of PET (3)
N:
Slide Eight
• Size
• normal v abnormal
• size determines N stage (head
& neck)
• Number (colorectal cancer)
• Anatomical extent (lung)
M:
• Liver, lung, bone, brain
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September 2005
PET in oncology: An oncologist’s view
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The role of PET (4)
Where PET may help
T:
Slide Nine
• Difficult areas on cross-sectional
imaging; e.g. lung, head & neck
N:
• Normal size nodes with disease
• Enlarged but reactive nodes
M:
• One whole body staging test
(except brain)
• May be useful in special situations
e.g. liver resection of CRC
metastases
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September 2005
PET in oncology: An oncologist’s view
(continued)
The role of PET (5)
(3) Therapy
Slide Ten
Clinical implication of change in stage:
• Prognosis
• Choice of therapy
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September 2005
PET in oncology: An oncologist’s view
(continued)
The role of PET (6)
(4) Response Assessment
Context
Slide Eleven
• Radical:
– Complete response (CR) is
the aim
– ? salvage treatment
– prognosis
• Palliative:
– quantitative measurement
– continue, stop or change
treatment
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September 2005
PET in oncology: An oncologist’s view
(continued)
The role of PET (7)
• CT: the Gold Standard
(quantitative)
Slide Twelve
Problems with measurements
• inter (15%) and intra (6%) observer variability
• 1D v 2D v 3D measurement
• large mass
nodes
smaller
• Tumours shrink at different rates
(even same disease e.g. HL)
• Residual masses / abnormalities
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PET in oncology: An oncologist’s view
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The role of PET (8)
• Response criteria by CT:
Slide Thirteen
– Objective Response Criteria
– RECIST (Response Evaluation
Criteria In Solid Tumors )
4 categories of response: CR, PR, SD
& PD
• CRu (unconfirmed / uncertain)
• What QUANTITATIVE criteria to
use in PET?
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September 2005
PET in oncology: An oncologist’s view
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The role of PET (9)
Slide Fourteen
• CT has the clear advantage of
size measurement (palliative
treatment, trials)
• PET has the clear advantage of
accurately assessing CR (radical
treatment)
• PET has the clear advantage of
assessing early response in
highly sensitive tumours e.g
lymphomas, ? solid tumours
• ? CT/PET
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FACET - European Journal of Cancer Care
September 2005
PET in oncology: An oncologist’s view
(continued)
The role of PET (10)
Slide Fifteen
(5) Follow-up & detection of
relapse:
PET for routine FU?
Limited by:
•
Possibility of false positive
•
Availability and cost
May be useful:
• selected cases with suspicion of
relapse
• resolve equivocal findings on other
tests
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FACET - European Journal of Cancer Care
September 2005
PET in oncology: An oncologist’s view
(continued)
Slide Sixteen
The role of PET in lung
cancer
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FACET - European Journal of Cancer Care
September 2005
PET in oncology: An oncologist’s view
(continued)
Slide Seventeen
The role of PET in
colorectal cancers
Coronal
Transaxial
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September 2005
PET in oncology: An oncologist’s view
(continued)
Slide Eighteen
The role of PET in
breast, CNS and head
& neck cancers
• Breast cancer – limited role
although it is established in
diagnosing brachial plexopathy and
differentiating between local
recurrence and radiation damage.
• Central nervous system (CNS)
• Head & neck
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FACET - European Journal of Cancer Care
September 2005
PET in oncology: An oncologist’s view
(continued)
Slide Nineteen
The role of PET in other
solid tumours
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September 2005
PET in oncology: An oncologist’s view
(continued)
Role of PET in
lymphomas
• Staging
Slide Twenty
• Early response assessment
• Assessment of remission after
treatment
• Evaluation of residual masses
• Follow-up and early detection of
relapse
Pre-treatment scan demonstrating
FDG uptake by lymphoma is essential
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FACET - European Journal of Cancer Care
September 2005
PET in oncology: An oncologist’s view
(continued)
Slide Twenty One
Studies for staging of
Hodgkin’s Lymphoma
(HL)
N
Stage
Stage
Treatment
change
Bangerter 1998
44
5 (11%)
1 (2%)
6 (14%)
Weidman 1999
20
3 (15%)
0
-
Partridge 2000
44
18 (41%)
3 (7%)
11 (25%)
Hueltenschmidt
2001
25
3 (12%)
7 (28%)
-
Jerusalem 2001
33
4 (12%)
3 (9%)
1 (3%)
Welhrauch 2002
22
4 (18%)
5 (23%)
4 (18%)
Menzel 2002
28
4 (14%)
2 (7%)
-
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FACET - European Journal of Cancer Care
September 2005
PET in oncology: An oncologist’s view
(continued)
Slide Twenty Two
PET in staging early
Follicular Lymphoma
Transaxial
Sagittal
PET showed stage 4 with
L2
lumbar spine & spleen
uptake.
Coronal
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September 2005
Slide Twenty Three
PET in oncology: An oncologist’s view
(continued)
A very novel use of PET in
the management of
lymphomas is the use in
early assessment of
response
• In high-grade NHL a large
proportion of patients is not
cured with primary treatment
• Salvage high dose chemotherapy is
effective but toxic
• Selecting patients unlikely to be
cured by primary chemotherapy is
becoming possible with PET
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September 2005
PET in oncology: An oncologist’s view
(continued)
Slide Twenty Four
High grade NHL:
Progression-free survival
Progression-free survival
Interim PET
positive
Minimal
residual
uptake
Interim PET
negative
2-year
survival
30.3 %
(CI 16.644.1)
59.3 %
(CI
35.582.9)
93.0 %
(CI
85.4100)
5-year
survival
16.2 %
(CI 3.528.8)
59.3 %
(CI
35.582.9)
88.8 %
(CI
77.999.7)
Mikhaeel et al, Ann Oncol 2005
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FACET - European Journal of Cancer Care
September 2005
PET in oncology: An oncologist’s view
(continued)
The future (1)
Technology:
Slide Twenty Five
• CT/PET
• New tracers e.g. 11C, 18F,
peptides, Abs
Studies:
• protocols defining optimal use;
timing, place in management
algorithms etc.
• studies of clinical impact on
patient management
• cost effectiveness
• response criteria
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FACET - European Journal of Cancer Care
September 2005
PET in oncology: An oncologist’s view
(continued)
The future (2)
Research:
Slide Twenty Six
• Drug pharmacokinetics
• Gene expression
• Cell proliferation (e.g. 18F fluorothymidine)
• In vivo imaging of apoptosis,
hypoxia & receptor expression in
the individual patient
Availability
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September 2005
PET in oncology: An oncologist’s view
(continued)
Slide Twenty Seven
References
• Bangerter M., Moog F., Buchmann I., Kotzerke J.,
Griesshammer M., Hafner M., Elsner K., Frickhofen
N., Reske F.N., Bergmann L.. (1998) Whole-body 2[18F]-fluoro-2-deoxy-D-glucose positron emission
tomography (FDG-PET) for accurate staging of
Hodgkin's disease. Annals of Oncology 9(10):1117-22.
• Hueltenschmidt B., Sautter-Bihl M.L., Lang O., Maul
F.D., Fischer J., Mergenthaler H.G. & Bihl H. (2001)
Whole body positron emission tomography in the
treatment of Hodgkin disease. Cancer 91 (2):302-10.
• Jerusalem G., Beguin Y., Fassotte M.F., Najjar F., Paulus
P., Rigo P., Fillet G. (2001) Whole-body positron
emission tomography using 18F-fluorodeoxyglucose
compared to standard procedures for staging
patients with Hodgkin’s disease. Haematologica
86:266–73.
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FACET - European Journal of Cancer Care
September 2005
PET in oncology: An oncologist’s view
(continued)
References (continued)
Slide Twenty Eight
• Menzel C., Dobert N., Mitrou P., Mose S., Diehl M.,
Berner U. & Grunwald F.F. (2002) Positron emission
tomography for the staging of Hodgkin's lymphomaincreasing the body of evidence in favor of the
method. Acta Oncologica 41(5):430-6.
• Mikhaeel N.G., Hutchings M., Fields P.A., O’Doherty
M.J., Timothy A.R. (2005) FDG-PET after two to three
cycles of chemotherapy predicts progression-free and
overall survival in high-grade non-Hodgkin lymphoma
Annals of Oncology Advance Access published online
on June 24, 2005
• Partridge S, Timothy A, O’Doherty MJ, Hain S.F.,
Rankin S., Mickhaeel G. (2000) 2-Fluorine-18-fluoro2-deoxy-d-glucose positron emission tomography in
the pretreatment staging of Hodgkin’s disease:
influence on patient management in a single
institution. Annals of Oncology11:1273–9.
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FACET - European Journal of Cancer Care
September 2005
PET in oncology: An oncologist’s view
(continued)
Slide Twenty Nine
References (continued)
• Weihrauch M.R, Re D, Bischoff S, Dietlein M.,
Scheidhauer K., Krug B., Textoris F., Ansen S., Franklin
J., Bohlen H., Wolf J., Schicha H., Diehl V., Tesch H.
(2002) Whole-body positron emission tomography
using 18F-fluorodeoxyglucose for initial staging of
patients with Hodgkin’s disease. Annals of Hematology
81:20–5.
• Wiedmann E., Baican B., Hertel A., Baum R.P., Chow
K.U. Knupp B. Adams S., Hor G., Hoelzer D. Mitrou
P.S. (1999) Positron emission tomography (PET) for
staging and evaluation of response to treatment in
patients with Hodgkin’s disease. Leukaemia and
Lymphoma 1999;34:545–51.
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