Tumori Neuroendocrini - Imaging perioperatorio

Annibale VersariMedicina Nucleare, Az.Osp. S.Maria Nuova-IRCCS - Reggio Emilia

Imaging medico-nucleare=Imaging molecolare

Le immagini sono

espressione delle

caratteristiche

biochimiche e

metaboliche dei tessuti

Peptidi

Ormoni

Neurotrasmettitori

Recettori

Somatostatin

Receptors

Neuroendocrine Tumors (NETs)

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

111In-Octreoscan

Ileum NET

Octreoscan®: SPECT/CT

Ileum NET

Prof. Giuliano Mariani - Pisa

68Ga DOTATOC PET/CT

Generatore 68Ge/68Ga

68Ga PET/CT SSRS SPECT/CT MR CT (4 yrs before)

111In-Octreoscan 68Ga-Dotatoc PET/CT

Metastatic GEP-NET

CONCLUSION

68Ga-DOTATOC and 68Ga-DOTATATE possess a

comparable diagnostic value in the detection of lesions

of NETs

68Ga-DOTANOC PET/CT

Physiological

uptake in the

uncinate process

of pancreatic

head

Pathological

uptake in the

uncinate process

of pancreatic

head

• 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.

Bone

Metastases

from pancreatic

NET

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

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

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

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

Head pancreatic NET (A) with lymph node metastasis (B)

A A

B

B

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

68Ga-DOTATOC PET/CT M.G. m 45 a 18F-FDG PET/CT

Pre-intervento Post-interventoM.G. m 45 a

68Ga-DOTATOC PET/CT : metastasi epatiche da NET ileale

68Ga-DOTATOC FDG-PET/CT

NETsCoesistenza di lesioni con diversa differenziazione

J Nucl Med 2010; 51:353–359

SUV >9

SUV <9

SUV <3

SUV >3

68Ga-DOTATOC PET

Pancreatic Gastrinoma

Multiple

insulinomas

of

pancreatic

body and

tail

(recurrence)

68Ga

DOTATO

C

PET/CT

68Ga-DOTATOC PET

Carcinoma neuroendocrino del pancreas

con metastasi epatiche

Carcinoide dell’ ileo operato Follow up: Metastasi linfonodali

68Ga-DOTATOC PET

Clin Nucl Med 2015

Lococo Clin Nucl Med 2015

68Ga-DOTATATE PET/CT

F

42 aa

18F-FDG

68Ga-DOTA

Carcinoide polmonare tipico

68Ga-DOTATATE PET/CT

F

64aa

18F-FDG 68Ga-DOTA

Carcinoide polmonare atipico

Carcinoma midollare della tiroide

J Nucl Med 2011; 52:1110–1118

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

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

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

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

11 Giugno 2016Un girotondo di cittadini, pazienti, operatori inaugura il nuovo

Centro Oncoematologico di Reggio Emilia

Grazie per l’attenzione