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Tumori Neuroendocrini - Imaging perioperatorio
Annibale VersariMedicina Nucleare, Az.Osp. S.Maria Nuova-IRCCS - Reggio Emilia
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Imaging medico-nucleare=Imaging molecolare
Le immagini sono
espressione delle
caratteristiche
biochimiche e
metaboliche dei tessuti
Peptidi
Ormoni
Neurotrasmettitori
Recettori
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Somatostatin
Receptors
Neuroendocrine Tumors (NETs)
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NETsNuclear Medicine Imaging
(molecular imaging)
SomatostatinAnalogs
Target
Neuroendocrine Tumors expressing somatostatin
receptors
MainlySSTR2
Scintigraphy, SPECT, SPECT/CT with
• 111In-Octreoscan
PET/CT con
•68Ga-DOTATOC
•68Ga-DOTANOC
•68Ga-DOTATATE
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111In-Octreoscan
Ileum NET
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Octreoscan®: SPECT/CT
Ileum NET
Prof. Giuliano Mariani - Pisa
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68Ga DOTATOC PET/CT
Generatore 68Ge/68Ga
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68Ga PET/CT SSRS SPECT/CT MR CT (4 yrs before)
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111In-Octreoscan 68Ga-Dotatoc PET/CT
Metastatic GEP-NET
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CONCLUSION
68Ga-DOTATOC and 68Ga-DOTATATE possess a
comparable diagnostic value in the detection of lesions
of NETs
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68Ga-DOTANOC PET/CT
Physiological
uptake in the
uncinate process
of pancreatic
head
Pathological
uptake in the
uncinate process
of pancreatic
head
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• Any visible focal tracer uptake in the pancreas must be
considered as suspicious for malignancy irrespective of
quantitative parameters.
• Therefore, follow-up with 68Gasstr-PET/CT is mandatory in
the clinical setting if uptake in the head/uncinate process is
observed.
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Bone
Metastases
from pancreatic
NET
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Grimaldi F et al. Italian Association of Clinical Endocrinologists (AME) position statement: a stepwise clinical approach to the diagnosis of gastroenteropancreatic neuroendocrine neoplasms.J Endocrinol Invest (2014) 37:875-909
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Grimaldi F et al. Italian Association of Clinical Endocrinologists (AME) position statement: a stepwise clinical approach to the diagnosis of gastroenteropancreatic neuroendocrine neoplasms.J Endocrinol Invest (2014) 37:875-909
Diagnostic flow-chart for GEP-NENsuspected at endoscopy
Endoscopy ± biopsy
Small bowel NENGastric or duodenal or rectal
NEN
CT, MRI ± biopsy EUS ± FNA
68Ga-PET-CT or SRS (G1-G2)18F-FDG-PET-CT if G3 or high G2
Dia
gno
sis
Stag
ing
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Grimaldi F et al. Italian Association of Clinical Endocrinologists (AME) position statement: a stepwise clinical approach to the diagnosis of gastroenteropancreatic neuroendocrine neoplasms.J Endocrinol Invest (2014) 37:875-909
Diagnostic flow-chart for GEP-NENsuspected at morphological imaging
Abdominal secondary lesion (e.g. liver metastasis)
Dia
gno
sis
Stag
ing
Pancreatic lesion
CT/MRI CT/MRI
US-guided biopsy EUS-FNA/FNB
68Ga-PET-CT or SRS (G1-G2)18F-FDG-PET-CT if G3 or high G2
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Grimaldi F et al. Italian Association of Clinical Endocrinologists (AME) position statement: a stepwise clinical approach to the diagnosis of gastroenteropancreatic neuroendocrine neoplasms.J Endocrinol Invest (2014) 37:875-909
Diagnostic flow-chart in the patient with metastatic disease and unknown primary tumor
Liver NEN metastases
Dia
gno
sis
Low grade High grade
Unknown primary atconventional imaging
18F-FDG-PET
IHC for site oforigin + lab tests
MRI, EUS, enteroCT/MRI, 68Ga-DOTA-PET, VCE, DBE
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Head pancreatic NET (A) with lymph node metastasis (B)
A A
B
B
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M.G. m 45 a Reperto ecografico di lesioni epatiche multiple. Biopsia: NET G1
TC: sospetta primitività intestinale68Ga-DOTATOC PET/CT : conferma di primitività ileale
68Ga-DOTATOC PET/CT
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68Ga-DOTATOC PET/CT M.G. m 45 a 18F-FDG PET/CT
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Pre-intervento Post-interventoM.G. m 45 a
68Ga-DOTATOC PET/CT : metastasi epatiche da NET ileale
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68Ga-DOTATOC FDG-PET/CT
NETsCoesistenza di lesioni con diversa differenziazione
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J Nucl Med 2010; 51:353–359
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SUV >9
SUV <9
SUV <3
SUV >3
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68Ga-DOTATOC PET
Pancreatic Gastrinoma
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Multiple
insulinomas
of
pancreatic
body and
tail
(recurrence)
68Ga
DOTATO
C
PET/CT
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68Ga-DOTATOC PET
Carcinoma neuroendocrino del pancreas
con metastasi epatiche
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Carcinoide dell’ ileo operato Follow up: Metastasi linfonodali
68Ga-DOTATOC PET
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Clin Nucl Med 2015
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Lococo Clin Nucl Med 2015
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68Ga-DOTATATE PET/CT
F
42 aa
18F-FDG
68Ga-DOTA
Carcinoide polmonare tipico
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68Ga-DOTATATE PET/CT
F
64aa
18F-FDG 68Ga-DOTA
Carcinoide polmonare atipico
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Carcinoma midollare della tiroide
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J Nucl Med 2011; 52:1110–1118
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Gastroenteropancreatic Neuroendocrine Tumor Patients Imaged Favorably
with Somatostatin Receptor Antagonist: Results of a Phase I/II Study
Comparing 68Ga-OPS202 with 68Ga-DOTATOC PET/CT
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Availability Clinical
use
Cost Duration Accuracy NPV PPV
111In-
pentetreotide
(Octreoscan®)
widespread yes high 2 days ++ ++ +++
68Ga-DOTA-
coniugate
peptides
low
but increasing
yes high 2 hours +++ +++ +++
NETs
Octreoscan versus 68Ga-DOTA PET/CT
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269
470487 476
536510
418
0
100
200
300
400
500
600
2008 2010 2011 2012 2013 2014 2015
68Ga DOTATOC/TATE PET/CTReggio Emilia
Ga68PET/CT Colonna1
February 2007- June 2016
68Ga DOTATOC/TATE PET/CT: 3892
68Ga PET/CT
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Nuclear medicine procedures
• We recommend the use of SSTR functional imaging for localization and staging of G1-G2 GEP-NENs
• We recommend PET/CT with 68Ga-labeled SA as the procedure of choice. When not available,111In-pentetreotide (Octreoscan®) scintigraphy may be used
• We recommend against the routine use of 18F-FDG PET/CT
• We suggest 18F-FDG PET/CT for staging high grade (G3) and selected G2 GEP-NENs
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11 Giugno 2016Un girotondo di cittadini, pazienti, operatori inaugura il nuovo
Centro Oncoematologico di Reggio Emilia
Grazie per l’attenzione