Clinical applications of positron-emission tomography in cancer

Mathematical Simulation of Transport Kinetics of Tumor-Imaging Radiopharmaceutical 99mTc-MIBI

The proposed model describes in a quality way the process of tumor-imaging radiopharmaceutical ^99mTc-MIBI distribution with taking into account radiopharmaceutical accumulation, elimination, and radioactive decay. The dependencies of concentration versus the time are analyzed. The model can be easily tested by the concentration data of the radioactive pharmaceuticals in the blood measured at early time point and late time point of the scanning, and the obtained data can be used for determination of the washout rate coefficient which is one of the existing oncology diagnostics methods.

Is PET useful in detecting occult nonpulmonary metastases in pediatric bone sarcomas?

Orthopaedic oncologists are increasingly utilizing positron emission tomography (PET) technology in the initial workup and staging of sarcomas and for monitoring treatment response. We evaluated the use of PET with fluorine-18-fluoro-2-deoxy D-glucose (FDG) to detect occult nonpulmonary metastases in patients < age 30 newly diagnosed with either Ewing's or osteosarcoma, and the impact of this information upon therapeutic decision making. We retrospectively reviewed prospectively collected data (1994-2004) on 55 patients age < 30 years old over a 10 year span. PET detected metastases in 12/55 (22%) of these patients, eight of whom (67%) harbored disease outside the lung; however, only 4/55 (7%) were upstaged to Stage IV specifically due to findings determined by PET alone. Three of 17 (18%) Ewing's sarcoma patients, but only one of 38 (3%) osteosarcoma patients, were upstaged by PET alone. The most important alteration in treatment decisions was the substitution of irradiation in lieu of surgery for local control in Ewing's sarcoma patients.

LEVEL OF EVIDENCE

Diagnostic study, level II.

Synthesis of syn- and anti-1-amino-3-[18F]fluoromethyl-cyclobutane-1-carboxylic acid (FMACBC), potential PET ligands for tumor detection

syn- and anti-1-amino-3-[18F]fluoromethyl-cyclobutane-1-carboxylic acid (FMACBC, 16 and 17), analogues of anti-1-amino-3-[18F]fluorocyclobutyl-1-carboxylic acid (FACBC), were prepared to evaluate the contributions of C-3 substitution and configuration on the uptake of these radiolabeled amino acids in a rodent model of brain tumors. Radiofluorinated targets [18F]16 and [18F]17 were prepared by no-carrier-added radiofluorination from their corresponding methanesulfonyl esters 12 and 13, respectively, with decay-corrected radiochemical yields of 30% for [18F]16 and 20% for [18F]17. In amino acid transport assays performed in vitro using 9L gliosarcoma cells, both [18F]16 and [18F]17 were substrates for L type amino acid transport, while [18F]17 but not [18F]16 was a substrate for A type transport. Biodistribution studies in normal Fischer rats with [18F]16 and [18F]17 showed high uptake of radioactivity (>2.0% dose/g) in the pancreas while other tissues studied, including liver, heart, lung, kidney, blood, muscle, and testis, showed relatively low uptake of radioactivity (<1.0% dose/g). In rats implanted intracranially with 9L gliosarcoma cells, the retention of radioactivity in tumor tissue was high at 5, 60, and 120 min after intravenous injection of [18F]16 and [18F]17 while the uptake of radioactivity in brain tissue contralateral to the tumor remained low (<0.3% dose/g). Ratios of tumor uptake to normal brain uptake for [18F]16 were 7.5:1, 7:1, and 5:1 at 5, 60, and 120 min, respectively, while for [18F]17 the ratios were 7.5:1, 9:1, and 9:1 at the same time points. This work demonstrates that like anti-[18F]FACBC, [18F]16 and [18F]17 are excellent candidates for imaging brain tumors.

Occult breast cancer: a challenge from a surgical perspective

Patients with occult breast cancer pose a challenging diagnostic and therapeutic problem. High-quality mammography is required to decrease the false-negative rates. A number of other imaging methods have been proposed in the diagnostic evaluation of these women, including breast ultrasonography, color Doppler ultrasonography, breast magnetic resonance imaging (MRI), positron emission tomography (PET), and scintimammography. Among them, MRI may be particularly helpful, since it has a high sensitivity and may enable preoperative localization of the primary, thus allowing the surgeon to perform a breast conserving procedure. Treatment options include surgery, radiotherapy and watchful waiting (followed by mastectomy when a breast tumor is detected). Systemic therapy is usually required in the management of these patients.

FDG SPECT in patients with lung masses

STUDY OBJECTIVES

To determine whether 2-[fluorine-18]fluoro-2-deoxy-D-glucose (FDG) single-photon emission CT (SPECT) is useful in characterizing pulmonary masses.

DESIGN

Scans were prospectively acquired and interpreted. Interpretations were performed with CT or chest radiograph but interpreters were blinded to eventual diagnosis.

SETTING

University hospital practice and affiliated Veterans Administration medical center.

PATIENTS OR PARTICIPANTS

Forty patients participated as part of an institutional review board-approved research protocol, and informed consent was obtained in all. Eight additional patient scans were acquired as part of their clinical evaluation for pulmonary mass.

MEASUREMENTS AND RESULTS

There were 26 malignant lesions (12 were 1 to 2 cm in size, the rest were larger) and 17 benign lesions (3 were < 1 cm in size, 9 were 1 to 2 cm in size, and 5 were larger). Averaged sensitivity, specificity, positive predictive value, and negative predictive value were, respectively, 50% (12 of 24), 94% (17 of 18), 92% (12 of 13), and 59% (17 of 29) for lesions 1 to 2 cm in size, 100% (28 of 28), 90% (9 of 10), 97% (28 of 29), and 100% (9 of 9) for lesions > 2 cm in size. There was good correlation between readers (p < 0.0001).

CONCLUSION

FDG SPECT is useful in characterizing pulmonary masses > 2 cm in size and appears to be equivalent to positron emission tomography for these lesions. Although currently clinically suboptimal for characterizing lesions < or = 2 cm in size, FDG SPECT appears to be better than current anatomic imaging methods. In addition, the positive predictive value of FDG SPECT for small lesions is also high (92%), and this technique appears potentially useful in the subset of patients in whom a positive result would alter clinical diagnostic pathways or care.

Dynamic positron emission tomography with F-18 fluorodeoxyglucose imaging in differentiation of benign from malignant lung/mediastinal lesions

PURPOSE

This study was done to evaluate the diagnostic utility of dynamic positron emission tomography (PET) with F-18 fluorodeoxyglucose (FDG) imaging in patients with suspected malignant pulmonary lesions. We wanted to test the hypothesis that the rate of FDG uptake (FDG influx constant values) would differentiate malignant from benign lung or mediastinal lesions.

MATERIALS AND METHODS

We performed segmental dynamic PET imaging studies following administration of FDG in 19 patients with indeterminate pulmonary lesions based on chest radiograph and/or CT scans. Patlak analysis was done to compute Ki (FDG influx constant) values and compared with FDG standardized uptake values (SUVs) and histology.

RESULTS

FDG Ki values (mean+/-SD) were significantly greater (p < 0.01) in all 12 malignant lesions (0.029+/-0.02) as compared with 7 benign lesions (0.0024+/-0.0011) with good correlation to the SUV values. Distinct time activity curve patterns were identified in malignant and benign lesions with continued uptake in malignant lesions.

CONCLUSION

Dynamic PET-FDG imaging accurately differentiates malignant from benign pulmonary lesions. In certain cases with equivocal findings on visual analysis and SUV values, dynamic imaging may be further helpful in differentiating benign and malignant lesions.

Effectiveness of positron emission tomography for the detection of melanoma metastases

OBJECTIVE

The purpose of this study was to determine the sensitivity, specificity, and clinical utility of 18F 2-fluoro-2-deoxy-D-glucose (FDG) total-body positron emission tomography (PET) scanning for the detection of metastases in patients with malignant melanoma.

SUMMARY BACKGROUND DATA

Recent preliminary reports suggest that PET using FDG may be more sensitive and specific for detection of metastatic melanoma than standard radiologic imaging studies using computed tomography (CT). PET technology is showing utility in the detection of metastatic tumors from multiple primary sites including breast, lung, lymphoma, and melanoma. However, little information is available concerning the general utility, sensitivity, and specificity of PET scanning of patients with metastatic melanoma.

METHODS

One hundred three PET scans done on 76 nonrandomized patients having AJCC stage II to IV melanoma were prospectively evaluated. Patients were derived from two groups. Group 1 (63 patients) had PET, CT (chest and abdomen), and magnetic resonance imaging (MRI; brain) scans as a part of staging requirements for immunotherapy protocols. Group 2 (13 nonprotocol patients) had PET, CT, and MRI scans as in group 1, but for clinical evaluation only. PET scans were done using 12 to 20 mCi of FDG given intravenously. Results of PET scans were compared to CT scans and biopsy or cytology results.

RESULTS

PET scanning for the detection of melanoma metastases had a sensitivity of 94.2% and a specificity of 83.3% compared to 55.3% and 84.4%, respectively, for CT scanning. Factors that produced false-positive PET scans were papillary carcinoma of the thyroid (1), bronchogenic carcinoma (1), inflamed epidermal cyst (1), Warthin's tumor of the parotid gland (1), surgical wound inflammation (2), leiomyoma of the uterus (1), suture granuloma (1), and endometriosis (1). The four false-negative scans were thought to be due to smaller (<0.3 to 0.5 cm) and diffuse areas of melanoma without a mass effect.

CONCLUSIONS

PET scanning is extremely sensitive (94.2%) and very specific (83.3%) for identifying metastatic melanoma, particularly in soft tissues, lymph nodes, and the liver. A number of second primary or metastatic tumors and an inflammatory response can also be localized by PET. This observation mandates a close clinical correlation with positive PET and emphasizes the importance of establishing a tissue diagnosis. False-negative scans in the presence of metastases are rare (4% of scans). Metastases < or =5 mm in diameter may not image well. PET is superior to CT in detecting melanoma metastases and has a role as a primary strategy in the staging of melanoma.

System A amino acid transport in cultured human tumor cells: implications for tumor imaging with PET

The A system of amino acid transport is concentrative and thought to be a regulator of cell growth. The [11C]methyl alpha-aminoisobutyric acid (MeAIB) is prospectively an ideal tracer for transport measurements with PET, as it is not metabolized and concentrates in cells only via System A transport. We examined the factors governing [14C]MeAIB accumulation by cultured human erythroleukemic (K562) cells. Experiments were performed in growth medium and phosphate-buffered saline (PBS) +/- cycloheximide (an inhibitor of protein synthesis) on logarithmically growing cells, as well as cells that had reached a growth plateau. Both inward transport rate and net uptake of MeAIB were positively correlated with cell growth rate and showed a strong inverse relationship to amino acid supply. The observations are consistent with a body of evidence from animal tumor cells, and they suggest that the correlation between System A transport and tumor cell proliferation may be obscured in vivo by variations in amino acid supply. Thus, while [11C]MeAIB might be useful as a PET radiotracer of System A transport per se, this compound may be limited in its ability to provide measurements of tumor growth rate.

Evidence of sodium-dependent glucose transport in human erythroleukemia cells

Sodium-dependent transport of D-glucose has been reported only in epithelial cells of small intestine and kidney, and well-differentiated tumors thereof. We observed a two-fold decrease (p < 0.05) in the intracellular distribution volume (Vic, defined as steady-state intracellular uptake divided by extracellular concentration) of the non-metabolized D-glucose analog 3-O-methylglucose (3-O-MG) when logarithmically growing K562 cells (an anaplastic human erythroleukemia) were incubated 3 h in choline-substituted, phosphate buffered saline (PBS) rather than Na+ PBS, each containing a glucose concentration ([Glu]) of 5.6 mM. Electromechanically measured cellular volume Vc differed < 10% between the different media. In Na+ PBS, Vic (3-O-MG) was approximately twice Vc and declined progressively when [Glu] was reduced to 2.8 and 0.1 mM. We conclude that, in a balanced salt medium containing glucose as the only energy source, K562 cells express a concentrative mechanism having characteristics consistent with Na(+)-dependent transport of glucose.

Preliminary results of a prospective trial using three dimensional radiotherapy for lung cancer

PURPOSE

To evaluate the preliminary results of a prospective trial using three-dimensional (3D) treatment for lung cancer.

METHODS AND MATERIALS

Seventy patients with inoperable Stage I through IIIB lung cancer were treated with three-dimensional thoracic irradiation with or without chemotherapy (35% received chemotherapy). Total prescribed dose to the tumor ranged from 60-74 Gy (uncorrected for lung density). All patients were evaluated for local control, survival, and development of pneumonitis. These parameters were evaluated in respect to and compared with three-dimensional parameters used in their treatment planning.

RESULTS

With a minimum follow-up of 6 to 30 months, the 2-year cause-specific survival rate for Stages I and II was 90% and 53% for Stage III (no difference between Stages IIIA and IIIB). Patients with local tumor control had a better 2-year overall survival rate (47%) than those with local failure (31%). Volumetrically heterogeneously calculated doses were important to the accurate delineation of dose-volume coverage as there was a wide range of discrepancies between a homogeneously prescribed point dose calculation and the heterogeneously calculated volume coverage of that prescription. High-grade pneumonitis was correlated with the location of the tumor with lower lobe tumors having a much higher risk than those with upper lobe tumors. A critical volume effect and threshold dose were apparent in the development of high-grade pneumonitis.

CONCLUSIONS

Three-dimensional therapy for lung cancer has been practically implemented at the Mallinckrodt Institute of Radiology and shows promising results in our preliminary analysis. The incidence of high-grade pneumonitis, however, warrants careful selection of patients for future dose escalation. Future dose escalation trials in lung cancer should be directed to volumes that limit the amount of elective nodal irradiation. However, the volume of necessary elective nodal irradiation remains unknown and should be studied prospectively. Dose escalation trials are indicated and may be facilitated by smaller target volumes.

Contribution of PET in the diagnosis of recurrent colorectal cancer: comparison with conventional imaging

The clinical value of total body PET with FDG was evaluated in 76 patients presenting with or suspected of recurrent local or distant colorectal cancer. PET results were compared to those of routine imaging (CT pelvis, CT/US liver and CXR). The accuracy of PET for local disease was 95% which was superior to CT-pelvis (accuracy 65%). PET accuracy for liver metastases (98%) compared favourably to CT/US-liver accuracy (93%). Unexpected extra-hepatic mestastases were detected by PET in 14 locations in 10 patients. Also, a primary breast cancer was found in one patient. The main value of PET appeared an improved staging of apparently resectable, local or distant recurrent disease. Thereby, a more adequate indication of major secondary surgery could be attained.

Digital clubbing. Demonstration with positron emission tomography

Digital clubbing is a classic cutaneous manifestation of pulmonary disease, but its mechanism is unknown. We describe a patient with lung cancer and clubbing in whom positron emission tomography (PET) demonstrated, for the first time, that increased glucose metabolism occurs at the nailbed. PET may contribute to future investigations of digital clubbing.