Docstoc

Slide 1 - Emory University Schoo

Document Sample
Slide 1 - Emory University Schoo Powered By Docstoc
					SPECT-CT and Other New Molecular
     Imaging Developments
               David M Schuster, MD
    Division of Nuclear Medicine and Molecular Imaging
      Department of Radiology and Imaging Sciences
Talk can be found at
radiology.emory.edu
       What is PET/SPECT/CT?

• Hybrid Imaging
• Combines functional imaging with anatomical
  imaging
• We are familiar with the power of PET-CT
• This talk will concentrate on the clinical aspects
  of SPECT-CT
      Why Hybrid Imaging?

• Advantages
 -   Attenuation correction
 -   Increased sensitivity and specificity
 -   Anatomic localization
 -   Improved confidence in interpretation
 -   Shortened acquisition time
 Prostate Cancer With Rising PSA
Cystoprostatectomy:
urinary drainage bag


But also foci of abnormal
uptake near right SI joint,
lower LS spine, and
elsewhere

Degenerative or
Metastatic?

Can SPECT-CT help?
L-Spine – Degenerative
   with Confidence
    Right SI Region –
Metastasis with Confidence
Added Confidence
  from CT Alone
                 SPECT/CT
• Heyler V et al. Eur J Nucl Med Mol Imaging
  2010;37:706
   - 40 patient retrospective; 50 lesions
   - Planar and SPECT: 61% lesions equivocal
   - SPECT/CT: 8% equivocal
   - Kappa: Planar .43; SPECT .56; SPECT-CT .87
   - SPECT/CT resulted in significant reduction in
     equivocal reports
      SPECT/CT Protocol
• SPECT and CT not at same time
• Free breathing
   - CT images acquired much more quickly
     than SPECT images.
      • Respiratory Gating
• Potential to use oral contrast
• Potential to use IV Contrast
• Radiation exposure from CT
   - But generally lower dose CT
   - ½ dose or less
• Price same as SPECT for now
SPECT/CT Scanning
                                         Detector 1
1)    Position patient
     a)   Scintillation Camera
          p-scope or
     b)   X-ray survey scan
2)    CT Scan
                                                      or
3)    SPECT Scan
4)    Reconstruct SPECT                  Detector 2
      W & WO AC
5)    Fusion Display                     Detector 1


Note: 2 and 3 can be
    reversed.
      At Emory we usually do CT first
      because the fast moving
      Hawkeye detector can startle a
      patient who has been lying still   Detector 2
      for a long time.
SPECT/CT Scanning
                                 Detector 1
1)    Position patient
     a)   X-ray survey scan
          or
     b)   Scintillation Camera
          p-scope
2)    CT Scan
3)    SPECT Scan                 Detector 2
4)    Reconstruct SPECT
      W & WO AC
                                 Detector 1
5)    Fusion Display

Note: 2 and 3 can be
    reversed.

                                 Detector 2
SPECT/CT Scanning
                                 AC
1)    Position patient
     a)   X-ray survey scan
          or
     b)   Scintillation Camera   NAC
          p-scope
2)    CT Scan
3)    SPECT Scan
4)    Reconstruct SPECT
      W & WO AC
5)    Fusion Display

Note: 2 and 3 can be
    reversed.
GE Discovery 670
at Emory University Hospital Midtown
X-ray
Detector




           X-ray tube




                          Installation Pictures – March 2011
    Siemens Symbia T6
at Emory University Hospital




                 123I   MIBG SPECT/CT
GE Hawkeye at EUH
             Utility of SPECT/CT
•   Bone                             • Coronary artery
•   Endocrine                          disease
•   Neuroendocrine                   • Pulmonary embolism
•   Prostate                         • Splenosis
•   Parathyroid imaging              • Radionuclide therapy
•   Infection                        • Many others waiting
•   Neurology                          to be described….


      Good review:
      Mariani et al. Eur J Nucl Med Mol Imaging 2010;37:1959
                  Bones
• SPECT/CT
   - More accurate localization of radiotracer
     activity and evaluation of morphological
     changes on the CT
   - Localizing bone infection or joint
     inflammation
   - Correlation scintigraphic findings with
     anatomical images for better clarification
     of indeterminate bone lesions
   - Provides higher diagnostic confidence
                    Bones
• Gnanasegaran et al. 2009 Semin Nucl Med
  39:431
  - Good review

• Even-Sapir et al. J Nucl Med. 2007 Feb;48:319
  - 76 patients nonspecific findings
  - Added clinical value in 89%
     • 59% SPECT-CT definitive
     • 30% optimization next definitive step
                 Back Pain
• 18 year old with back pain
• Plain films equivocal
• Bone scan ordered
Abnormal uptake
lower lumbar
spine
Confident
diagnosis
of pars
defects
Not seen on
original
outside MRI
but seen upon
focused repeat
          Man vs Fake 911 Call


Planar only
can be
confusing
  SPECT-CT Differentiates Trauma
    from Degenerative/Post-op

With confidence we can say:
Degenerative at L2-3.

Fusion cage uptake at L4-5.

Endplate fractures L5
inferiorly and S1 superiorly
with hematoma.
      Fracture Therapy Planning
      What is Causing the Pain?


Difficult
with CT
(or MR)
alone
          Fracture Therapy Planning
          What is Causing the Pain?

SPECT-CT shows
intense uptake at
minimal compression
at L1

and only mild uptake
at superior endplate
of moderate-severe
L2 compression
And Also That Posterior
Elements Not Involved
  Known Ovarian Cancer
• Question bony metastases




 Bone scan
 ordered
Hawkeye SPECT/CT to localize
extraosseous uptake…
                          Endocrine

Tharp et. al. Eur J Nucl Med Mol Imaging
2004;31:1435
71 thyroid patients
• SPECT/CT additional value over planar in 57%
    - Lymph node metastases versus remnant thyroid tissue
    - Lung versus mediastinal metastases
    - Skeleton
•     Impact on patient management
    - Influencing referral for I-131 treatment
    - Tailoring of the administered radioiodine dose
    - Addition of surgery or external radiation therapy when indicated
            Thyroid Cancer


• Patient treated for thyroid cancer post
  surgery with 100 mCi
• Lymph nodes negative
• No pre-treatment scan
• 7-10 day post therapy scan
Expected
uptake in
thyroid bed
but is that a
metastasis
next to
stomach
activity?

Did not
disappear with
water.
               SPECT-CT Performed




  Uptake in left parapelvic renal cyst.


Uptake has been described in renal and hepatic cysts and many other locations

        Shapiro et al. Seminars Nuc Med 2000;30(2):115
            Question Lingual Thyroid
4 hours lateral
                                                                24 hours




                  Note no thyroid bed uptake and low 24 hour uptake
SPECT-CT Confirms
            Parathyroid Imaging
• SPECT/CT based scans identify more tumors than
  planar or SPECT alone.
• Higher diagnostic performance and/or confidence
  in general
   - Enable minimally invasive resection
• Demonstrated in a number of papers
  - Wimmer et al. Langenbecks Arch Surg 2008;393:687
        • Sensitivity 87%, specificity 97% fusion with CT
        • Sensitivity 50%, specificity 92% SPECT alone
  - Serra et. al. Radiol Med 2006;111:999–1008
        • SPECT/CT localized 100% positive lesions vs 61% for
          SPECT only
               Fusion Imaging
• Lavely et al. J Nucl Med 2007;48:1084
   - 110 patients with primary hyperparathyroidism
   - Different combination of planar, SPECT,
     SPECT-CT
      • Early SPECT-CT with any delayed imaging
        best combination
         - 72-73% sensitivity; >99% specificity; 86.3-
           90.7% PPV
Hyperparathyroidism
Hyperparathyroidism

          Right inferior within
          thyroid. Proven to be
          thyroid adenoma.
Hyperparathyroidism
         Subtle uptake left inferior
         tracheoesophageal groove
         is the real parathyroid
         adenoma. Corresponds to
         soft tissue on CT.
Goiter and Parathyroid Adenoma?
Nicely Defined with SPECT-CT
Hyperparathyroidism


  SPECT-CT really
  shines with ectopic
  adenomas…
Hyperparathyroidism
            Hyperparathyroidism


Pinpoints
ectopic
      Neuroendocrine
•   Carcinoid
•   Pheochromocytoma
•   Paraganglioma
•   MIBG imaging

• SPECT/CT
   - Increases accuracy for detection of
     disease
   - Degree and distribution of tracer
     uptake allows for assessment of
     potential therapies
                Neuroendocrine
• Krausz et. al. Clin Endocrinol 2003;59:565
   - 72 patients
      • In-111-DTPA-pentetreotid (Octreotide)
   - SPECT/CT improved localization of SPECT
     detected tumors in 23/44 positive cases
   - Affected clinical management in 10 patients
• Perri et al. Q J Nucl Med Mol Imaging 2008;52:323
   - 81 patients
      • In-111-DTPA-pentetreotid (Octreotide)
   - ROC analysis SPECT/CT better than SPECT
   - SPECT/CT correctly localized 94.7% vs SPECT
     45.6%
             Carcinoid


• 53 year old female
• History carcinoid
• Recent abdominal CT demonstrates hepatic
  lesion consistent with metastases but
  otherwise negative
Liver metastasis
confirmed with
OctreoScan
Lymph node met
confirmed on
OctreoScan but
overlooked on CT
     Elevated Serum Gastrin



Detected on
planar
Pretty good
localization
with SPECT
CT and SPECT side by side.
Where is it exactly on the CT?
Fusion Nails It
Fusion Nails It
We Can Do Software Fusion of
       Select Cases

   • More labor intensive
   • Software fusion does a good job
   • Especially if the hardware has not
     been invented yet
Fused OctreoScan SPECT-MR
       of Insulinoma
I-123 MIBG for Suspected
   Pheochromocytoma
                Pheochromocytoma


Right adrenal
mass seen
well.

But also
other lesion
detected with
SPECT.
              Pheochromocytoma

Localizes
precisely as
small node
behind right
renal vein
unsuspected on
prior CT scan.

And
differentiated
from nearby
renal activity.
                 NeuroImaging
• In the brain it is thought that it is easier to compare
  a prior obtained CT or MR to SPECT
   - Structures are relatively fixed
   - SPECT-CT or software fusion has added value
      • Structures are also very close to each other
      • There may be changes even over a short time

• Sulkin et al. Clin Radiol 2008;63:289
  - SPECT/CT cerebral perfusion
  - 25% low dose CT had abnormalities
  - 15% discordance with previous imaging
                  Dementia

• 32-year-old married white male
   - 8-month history of progressive cognitive loss
     forgetfulness, misplacing things, good mood,
     word finding difficulty

• MRI “negative”; PET/CT ordered
Diagnosis of
FTD can be
made with PET
alone, but having
CT showing
subtle frontal
atrophy in a 35
year old adds to
confidence.

Similar principles
for SPECT/CT
such as DATscan
and other
radiotracers
           Arachnoid cyst?
• 32 year old female with headaches
• Communicating or noncommunicating arachnoid
  cyst?
In-111 DTPA Study
SPECT/CT has
added value
over planar to
confirm
communication
                    Cardiac
• Nuclear Cardiology
  - SPECT
  - Evaluate myocardial ischemia and functional
    significance of coronary artery disease
  - Can be combined with calcium score and/or
    CTCA
  - SPECT/CT high resolution, high count rate,
    low noise AC maps

• Nakaura et al AJR Am J Roentgenol 2005;185:1554
• Utsunomiya et al. Ann Nucl Med 2005;19:485
Cardiac
Cardiac
                      Cardiac
Presence or absence of calcium can influence
reading confidence depending on clinical scenario
Cardiac

          More advanced
          possibilities
         Radionuclide Therapy
• SPECT/CT with Y-90 Microspheres
     - 3D quantification for therapy dose with more
       accuracy than planar imaging
     - More accurate dosimetry planning
     - Useful in pre and post therapy imaging
     - May aid in the future for more precise
       dosimetry
     - Other therapies in the future such as Y-90
       labelled substance P for glioma
             Radionuclide Therapy
• Hamami ME et. al.
  J Nucl Med
  2009;50:688
   - SPECT/CT
     increases
     sensitivity and
     specificity of
     Tc99m MAA
     SPECT for
     detecting
     extraheptic
     arterial shunting
Radionuclide Therapy
            Radionuclide Therapy

SPECT-
CT
shows
uptake in
stomach
on MAA
Radionuclide Therapy
               More precisely map
               Y-90 deposition on
               Bremsstrahlung
               SPECT/CT
               compared with
               planar images
     Radionuclide Therapy




CT         FDG PET-CT    Brem SPECT-CT



     Fused FDG and
     Bremsstrahlung
     confirms 90Y
     coverage of tumor
                     Infection
• WBC, Gallium, new infection tracers
• Ingui et al. J Comput Assist Tomogr 2007;31:375
   - 17 studies in 16 patients
   - Compared with "side-by-side" SPECT-CT
      • Fused SPECT/CT images yielded "added
        value" for anatomical localization in 65%,
        diagnostic confidence in 71%, altered
        interpretations in 47% of cases

• Filippi et al. J Nucl Med 2009;50:1042
   - SPECT/CT changed interpretation in 10/19 suspected
      sites in diabetic foot
Sofat Tissue vs Osteomyelitis
                    Splenosis
• Positive papers on advantages

• Horger et al. Eur J Nucl Med Mol Imaging 2003;30:316
   - All 20 equivocal lesions correctly classified.
   - 3 additional lesions overlooked by CT or MRI detected

• Alvarez et al. Eur J Nucl Med Mol Imaging 2007;34:96
   - Localization of splenosis using 99mTc-damaged red
     blood cell SPECT/CT and intraoperative gamma probe
     measurements
                 ProstaScint
• Fusion with CT or MR has been reported to
  improve accuracy
   - Anatomic localization improves specificity
   - Makes RBC imaging “superfluous”
   - Synergistic value
   - Improved AC and resolution recovery

• Schettino CJ et al. AJR Am J Roentgenol. 2004;183:519

• Sodee DB et al. Semin Nucl Med 2007;37:17
                 ProstaScint

Addition of CT helps
differentiate blood pool from
nodal involvement
      Sentinel Lymph Node
      Lymphoscintigraphy
• SPECT/CT
   - Improves accuracy of sentinel lymph node
     localization at various sites
       • Breast, neck, chest, pelvis
   - Allows detection of nodal disease not seen on
     planar imaging especially in obese
• van der Ploeg et al. Ann Surg Oncol. 2009;16:1537
   - Melanoma: clear advantage in 35% patients
• Gallowitsch et al. Nuklearmedizin. 2007;46:252
   - SPECT/CT more accurate characterization size,
     depth and anatomical location
        Pulmonary Embolism
• VQ and the addition of SPECT has been
  demonstrated to have added value even in the
  era of MDCT
• How about VQ SPECT-CT?
   - May help clarify cause of perfusion defects
   - Novel advanced techniques to improve
     accuracy
• Early work show promise:
  - Suga et al. AJR Am J Roentgenol 2007;189:455
  - Zaki et al. Nucl Med Commun 2005;26:465
      Many Other Possibilities
• GI bleeding studies for
  better localization
  - Schillaci et al. Q J Nucl
    Med Mol Imaging
    2009;53:281


• Meckel’s Scan
  - Papathanassiou et al. Clin
    Nucl Med 2007;32:218
End of Part One
  Move on…
Part 2: Other New Developments
    DaTSCANTM (loflupane I-123 Injection)

    Peripheral and Central Nervous System
    Drugs Advisory Committee Meeting




              Normal    Abnormal
        Differential Diagnosis
• Limited diagnostic methods are available for
  Parkinsonian syndromes
   – Currently rely on clinical criteria – these may include
     slowness or difficulty of movement, rigidity, tremor
   – Formal confirmation only possible at postmortem
   – Response to drug therapy has been used as an aid to
     diagnosis
       • cannot reliably confirm or exclude diagnosis and
         may in fact cause further problems
• Structural imaging techniques have limited usefulness,
  particularly in the early stages
 The Importance of Early and
     Accurate Diagnosis




“…accurate diagnosis is the key to the effective long-term treatment
and management of Parkinsonism…”
Ioflupane Binds to Dat on
  Nigrostriatal Neurons
  Uptake Correlates with Markers
        of DaT Reduction
   Murine 1-methyl-4-phenyl-1,2,3,6-tetrahydrophridine (MPTP) Model1




1. Andringa G et al. Neuroimage 2005.                           C-8
Uptake Correlates with Markers
      of DaT Reduction
Murine 1-methyl-4-phenyl-1,2,3,6-tetrahydrophridine (MPTP) Model1




1. Andringa G et al. Neuroimage 2005.                    C-9
DaTSCAN Visualizes Striatal DaT
Visual Detection of DaT
  Distribution in vivo




                          C-14
 Patient
 48 years old Female            20110719 PT3
 Indication

 Abnormal Involuntary Tremors

    Normal tracer distribution. These findings were not consistent with
    Parkinson's syndrome, but rather essential tremor.
 Patient
 74 years old Male
                          20110711 PT2
 Indication

 Abnormal Involuntary Movements and Tremors

Abnormal tracer distribution consistent with Parkinson's syndrome
Diagnostic Possibilities in
  Parkinsonism/Tremor
Diagnostic Possibilities in
  Parkinsonism/Tremor
            DaTscan is Not…
• As a stand-alone diagnostic tool for neurological
  disorders
• Confirmation of clinically definite PD
   - Good L-dopa response, dyskinesia
• To differentiate PD from MSA, PSP, or other
  disorders with striatal dopaminergic
  degeneration
• To grade disease severity or monitor disease
  progression
               Preparation


• Report meds
• Preferable to take off meds. But unknown effect.
  Discrepant studies.
• Inject to image 4 hours
• Takes about one hour
• We give Lugol's to block thyroid uptake
                Conclusion
• Fusion imaging with SPECT/CT
   - Increases accuracy, localization, confidence
• Can help take the “unclear” out of “nuclear”
• DaTscan is a new radiotracer available at EUH
  and EUHM
   - Differentiate Parkinsonian Syndrome from
     Essential Tremor
• Utility of new technologies limited only by our
  imaginations (and third party payers)
The End

				
DOCUMENT INFO
Shared By:
Categories:
Tags:
Stats:
views:41
posted:3/11/2012
language:English
pages:109