Assessment of renal cell carcinoma by two PET tracer : dual-time … · 2017-09-29 · Page 2 of 15...

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Assessment of renal cell carcinoma by two PETtracer : dual-time-point C-11 methionine and F-18fluorodeoxyglucose

Poster No.: C-0805

Congress: ECR 2015

Type: Scientific Exhibit

Authors: S. Ito1, K. Kato1, T. Okuda2, S. Maeda2, S. Naganawa1; 1Nagoya/

JP, 2Toyota/JP

Keywords: Nuclear medicine, Oncology, Kidney, PET-CT, Diagnosticprocedure, Cancer

DOI: 10.1594/ecr2015/C-0805

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Aims and objectives

Earlier studies demonstrated that F-18 fluoro-deoxyglucose (FDG) PET have lowersensitivity (50 - 60 %) in detecting renal cell carcinoma (RCC) compared with othermalignant tumors. The reasons for low sensitivity are considered to be due to decreasedcontrast between tumor and normal renal tissue caused by renal excretion of FDG and

high activity of glucose-6-phosphatase in RCC1,2).

C-11 methionine has been used for PET imaging to assess the amino acid metabolismin tumors. It is well established that Met-PET is effective in gliomas for detecting tumors,evaluating the response of treatment, and differentiating between tumor recurrence andradiation necrosis. It has been also reported that FDG and Met are equally useful fordetecting residual and recurrent tumors and differentiating benign tumors from head and

neck cancer3), and lung cancer4).

We prospectively assessed usefulness of dual-time-point C-11 methionine PET (Met-PET) and F-18 fluorodeoxyglucose PET (FDG-PET) for renal cell carcinoma (RCC).

Methods and materials

Eleven patients (8 males, 3 femeles; age 44 to 76y, mean ages 59 ± 11y) suspected ofRCC with abdominal ultrasonography and CT were enrolled.

All patients agreed to participate in this study. The Medical Ethics Committee of ToyotaMemorial Hospital approved the study protocol.

FDG-PET and Met-PET scans were performed within the interval of 1 week for all thepatients. All the patients were diagnosed as renal cell carcinoma histopathologically.

Met-PET scan was performed 5 minutes (early-phase) and 30 minutes (delayed-phase) after administration of Met. FDG-PET scan was performed 60 minutes afteradministration of FDG. All patients underwent both Met-PET and FDG-PET within onemonth before the surgical operation.

We measured the maximum standardized uptake value (SUVmax) of RCC lesion withMet-PET (early- and delayed-phase) and FDG-PET. All patients were clinically andradiographically followed up for more than one year after the surgical operation.

Paired t-test was used in comparison between the uptake of MET and FDG for statisticalanalysis.

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Results

The surgical operation (10 total nephrectomy and 1 partial nephrectomy) was performedwithin 1 month after PET scan. Eleven lesions of eleven patients were resected andpathologically diagnosed as RCC. The histopathological subtype and grading wereshown in Table 1. The size of all tumors was over 10mm (range: 17 - 90mm, mean 48mm).Neither metastasis in the regional lymphnodes nor distant metastasis were found in allpatients when nephrectomy was performed.

Both Met and FDG accumulated in all RCC lesions. The SUVmax of RCC lesions in theearly-phase Met-PET, delayed-phase Met-PET, and FDG-PET were 4.6±2.3, 3.1±1.0,and 2.6±1.0, respectively. The SUVmax of the early- phase Met-PET showed significantlyhigher values than that of the delayed- phase Met-PET (p = 0.016) and that of FDG-PET(p = 0.022). On the other hand, there was no significant difference between the SUVmaxof the delayed-phase Met-PET and that of FDG-PET (p = 0.132) [Fig. 1].

During the follow-up period, lung metastases were detected in two patients [Fig.2-6]. Inthese two patients, SUVmax of the early-phase Met-PET of RCC showed over 5.0, andit was higher than SUVmax in patients with no metastases, except for one patient whosevalue was 11.0 [Table 2]. SUVmax of the delayed-phase Met-PET and FDG-PET of twopatients whose metastases were detected also showed higher value than any SUVmaxof patients whose metastases were not detected, whereas all of the values indicatedunder 4.5.

Images for this section:

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Table 1: Histopathologic subtype and grading of patients.

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Fig. 1: The SUVmax of RCC lesions in the early-phase (5 min) Met-PET, delayed phase(30 min) Met-PET, and FDG-PET. The SUVmax of the early- phase Met-PET showedsignificantly higher values than that of the delayed- phase Met-PET and that of FDG-PET.

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Fig. 2: A case of 55-year-old male, clear cell RCC in the left kidney #pT2aN0M0, grade3). Contrast enhanced CT image demonstrated a mass with 9.5cm in size located in theleft kidney.

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Fig. 3: Delayed-phase Met-PET showed high uptake in the tumor. The SUVmax of thetumor indicated 4.5.

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Fig. 4: FDG-PET also showed high uptake in the tumor. The SUVmax of the tumorindicated 3.6.

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Fig. 5: One year later, multiple metastases were found in the bilateral lungs in CT.

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Table 2: The SUVmax of MET and FDG in cases with and without recurrence duringfollow-up period.

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Conclusion

In PET image of RCC, the early-phase Met-PET showed a significantly higher uptakethan FDG-PET [Fig. 6-8]. This suggests that we can detect RCC lesions more distinctlywith Met-PET than with FDG-PET.

In our Met-PET imaging, the image obtained in the early-phase showed a significantlyhigher uptake than that obtained in the delayed-phase. Met uptake in multi-phase ordynamic state for tumors was reported in a few studies. Aki et al. reported three-phase

Met uptake for several kinds of brain tumors5). They showed that dynamic decreasewas seen in meningioma and oligodendrocytic tumors, whereas increase was seenin glioblastoma and malignant lymphoma. Toth et al. reported that short dynamic Met

scanning is a useful method for ensuring the location of prostate cancer6). They showedthat the time-activity curve of prostate cancer demonstrated plateau from 5 minutes to 50minutes, while the curve of normal prostate tissue had a high peak around 5 minutes andthen decreased until 50 minutes. In RCC, both Met and FDG uptakes are often similar tonormal renal tissue. Additionally, in the present study, 10 of 11 lesions histoparhologicallydiagnosed as grade 1 or 2, and only 1 lesion was grade 3. The results of higher uptakein the early phase than in the delayed phase suggest that RCC has similar metabolicactivities to normal renal tissue in amino acid metabolisms.

In conclusion, Met-PET image in the early-phase may provide more useful informationabout the diagnosis of RCC.

Images for this section:

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Fig. 6: A case of 47-year-old male, chromophobe RCC in the right kidney #pT2bN0M0,grade 2). Contrast enhanced CT image demonstrated a mass with 12.5cm in size locatedin the right kidney.

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Fig. 7: Early-phase Met-PET showed high uptake in the tumor. The SUVmax of the tumorindicated 4.6.

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Fig. 8: FDG-PET showed low uptake in the tumor. The SUVmax of the tumor indicated1.6.

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Personal information

References

1. Kang DE, White RL Jr., Zuger JH, Sasser HC, Teigland CM. Clinical useof fluorodeoxyglucose F-18 positron emission tomography for detection ofrenal cell carcinoma. J Urol. 2004; 171: 1806-1809

2. Nicolas Aide, Olivier Cappele, et al. Efficacy of F-18 FDG PET incharactering renal cell cancer and distant metastases. Eur J Nucl MolImaging 2003; 30: 1236-1245

3. Lindholm P, et al. Comparison of F-18 FDG and C-11 methionine in headand neck cancer. J Nucl Med. 1993; 34: 1711-1716

4. Sasaki M, Kuwabara Y, et al. Comparison of MET-PET and FDG-PET fordifferentiation between benign lesions and malignant tumors of the lung. AnnNucl Med 2001; 15: 425-431

5. Aki T, Nakayama N, et al. Evaluation of brain tumors using dynamic C-11methionine PET. J Neurooncol. 2012; 109: 115-122

6. Toth G, Lengyel Z, et al. Detection of prostate cancer with C-11 methioninepositron emission tomography. J Urol. 2005; 173: 66-69

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