the role of pet in the management of thyroid cancer
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PET in Endocrine Response Neoplasms: Thyroid, Prostate
and Breast Cancer Steven M. Larson, M.D.
Memorial Sloan Kettering Cancer Center
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Molecular Imaging and Targeted Radiotherapy: Key Collaborators
@MSKCC Akhurst T; Blasberg R; Ballangrud A; Cheung
NKV; Divgi C; Erdi A; Erdi Y; Finn R, Fong Y, Guillem J; Hamacher K; Heelan R; Humm J.; Hricak H; Jurcic J; Kalaigian J; Kelly WK; Koehne G; Koutcher J; Ling C; Liebel S; Ma D; Macapinlac H; Mehta B; McDevitt M; Nunez R; O’Donoghue J; O’Reilly R; Old L; Pentlow K; Robbins R, Scheinberg D., Scher H; Sgouros G; Sheh H; Slovin S; Tjuvavev Y; Turlakow, A; Welt S; Yeung H; Zanzonico P
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Detecting Tumor: Strategy
• We detect the living chemistry of the tumor with biomedical tracers (e.g.FDG, a form of glucose)
• PET imaging is a sensitive diagnostic test that can read these chemical signals that come from a living tumor.
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Diagnostic Testing in Thyroid Ca• Blood tests: TSH, T4, TG• Diagnostic Imaging Tests
– Ultrasound– Thyroid Scintigraphy (99mTc, 123I)– MRI– Spiral CT– Whole Body 131I/123I Testing (+/- Thyrogen)– PET* (FDG, Iodine-124 )
*An important complement to other tests
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ClinicallyLocalized
Disease
Rising TGno known site
Clinical Metastases:Progressive
ClinicalMetastases:
stable
Nodule Evaluation: No
Cancer Diagnosis
Natural History of Thyroid Ca
CURE
15%
85%
* * *
*PET Improves Care
5%
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What Does PET Tell Us about Thyroid Cancer
• Rising Tg
• Known metastases •Stable ?•Progressive/RX•I-131 Rx
Clinical Setting PET Question
• Where is tumor?•Should it be Rx’ed
• How Extensive•Aggressive/Prognosis?•Response to Rx•Will Rx help (124I)
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Elevated TG/Negative Dosimetry
• GS, 29 yo female undergoing rTSH dosimetry testing.
• Negative Iodine-131 Whole Body Scans
• TG levels =6 ng/ml @ 72 hr.s after Thyrogen
• PET-FDG scan shows R. Cervical lymph node
• US guided biopsy reveals papillary Ca
• Rx with 200 mCi of I-131
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Thyroid Ca
3 March 2000
I-131 Post-RxPET FDG
9 February 2000: Neg. I-131 Dosimetry, post rTSH TG=6 : Where is the tumor?
17 February 2000
360317
Transaxial Coronal Sagittal
Anterior
21 February 2000 US guided FNA R. neck “Positive..Papillary Ca..Thyroid Primary
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MB763123
Post RxI-131
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FDG-PET Coronal-1 FDG-PET Coronal-2Post Therapy Scan (anterior)
A2 A3
B1 B2 B3
A1
Figure 2
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Prognostic Value of FDG-PET Conclusions
• FDG PET scanning can identify a subset of thyroid cancer patients who have more aggressive tumors
• Patients with FDG-avid tumor volumes greater than 125 ml have markedly reduced survival times.
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““ // Pairs” Important to Pairs” Important to Targeted Therapies @ Targeted Therapies @
MSKCCMSKCC
TracerTracer • 124I-Iodide • 124I-IUDR• 124I-FAIU• 124I-A33, huM195• 86Y-MX35,huM195
,EC,ECTherapeuticTherapeutic • 131I-Iodide • 125,131I-IUDR• 131,125,123I-FAIU• 125,131I-A33, huM195• 90Y-MX35,huM195
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124I-Dosimetry in Metastases
• PK, 53 yo white male with numerous pulmonary nodules discovered on routine CXR, while being W/U for prostate Ca
• 4/28/00 Papillary thyroid Ca, moderately differentiated, locally invasive, 2.0 cm in diameter, with 13/23 lymph nodes
• Refered for Dosimetry 7/2000
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THYROID CA 277269
4/25/2000
CXR PA . LT.
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THYROID CA 277269
6/20/2000PET-124I7/5/2000
PET-FDG
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124I-Iodine in Thyroid Cancer
277269
229 cGy/mCi203 cGy/mCi
125 cGy/mCi
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PET in Thyroid Cancer: Reading the Biochemical Signals
• Staging. Extent of Aggressive Ca for optimal treatment planning
• Prognosis: high-risk (FDG positive) and low-risk (FDG negative)
• Dosimetry. Individual lesions with 124I
• Response. Predict susceptibility to treatment and monitor treatment effect
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Thyroid Dosimetry
• 124I and 131I give identical results in whole body and blood clearance
• 124I can be used to measure tumor specific dosimetry
• Tumor dose may vary by a factor of 4 or more in the tumor