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F18 NaF PET Imaging: Bone Scintigraphy for Metastatic Bone Disease

Bone imaging has been around for quite some time, but it still comes with some challenges. In this video presentation, the speaker will discuss F18 NaF PET Bone imaging and how it can be incorporated in your daily clinical practice. The topics of this session include F18 NaF bone imaging in the initial assessment of potential disease and in long term care following therapy, the strengths and weaknesses of NaF bone scintigraphy in comparison to F18 FDG imaging, maximizing the utilization of PET/CT imaging to help characterize and differentiate benign from malignant disease, and how to facilitate integration of F18 NaF scintigraphy into your daily clinical environment

"Super Scan" Follow-up 18F NaF scans will encounter "flare" particularly from healing lytic bone lesions Interpreted example: Multiple metastatic lesions with arthritic chan es for knee Interpreted example: Multiple metastatic lesions with arthritic chan es for Sl joint Interpreted example: "Opportunistic Fusion" : The CT portion of the PET/CT may not fully characterize a Non-lytic/ Non-sclerotic Bone Metastases Only Seen with NaF-18 Breast — Interpreted example: Multiple lesions Prostate — Prostate — Met or Bone Island? Tracer Distribution Fludeoxyglucose F 18 Injection* Fludexoxyglucose F 18 Injection* "Decoder Ring" Indications for bone imaging — Oncology - CMS Fludexoyglucose F18 Injection for Intravenous Use* Renal Cell Cancer- Lytic Bone metastases NaF PET Bone Imaging in Oncology Ongoing Research Based on Response to Therapy using 18F NaF Sodium Fluoride F 18 Injection* Extent of activity On F 18 NaF Problem solving: Back pain in patient with surgery lower lumbar spine Non-lytic/ Non-sclerotic Bone Metastases Location of abnormal uptake on PET/CT Technica/ Considerations Improving Throughput The Challenge Going Forward "Cold" areas of markedly diminished or absent osteoblastic activity Transformational Imaging— "Decoding" 18F NaF with correlative imaging NSCLC Physics and Pharmacokinetics Fludexoyglucose F18 Injection* 18F PET Bone Compared to Conventional Imaging Problem solving: Performance Comparison Conventional vs 18F NaF Bone Scans Soft tissue uptake with 18F NaF Beyond CT — "Decoding" with MRI - Uptake in benign lesion Bone scans in Prostate Cancer — Present Indications* Lytic to Sclerotic Spectrum lesion. Having access to recent correlative imaging or using selective sequences from other 186 Major Shortcoming of Planar Imaging Combined Approach to Interpretation Radiopharmaceutical Therapy In Prostate Cancer Bones saturated with sclerotic predominate metastases Classic "hot" lesion only on 18F NaF bone imaging Performance of 18F NaF compared to metabolic glucose - Multi SPECT/CT and PET/CT Tc-99m and 18F NaF Imaging Techniques Same patient Solitary nonlytic/non-sclerotic lesion - vertebral body metastasis oo Flare Phenomena Data Supporting 18F NaF PET Bone Imaging History of 18F NaF Imaging Performance of 18F NaF compared to metabolic glucose imaging Radiation Exposure 18F NaF manifestation of abnormal uptake Problem Solving — Sorting out Complicated Studies Case example: Prostate Cancer — Negative Planar CMS Coverage through National Oncology PET Registry 02/05 (F18 FDG and NaF PET/CTs) 02/05 FDG and NaF PET/CTs) Poorly differentiated adeno- 06/05 Sponsored by : Siemens' PETNET Solutions modalities fused to the PET may better evaluate the significance of abnormal uptake, as Abdominal Aortic Aneurysm Non-Small Cell Lung Cancer 40 Multiple compression fractures( recent and old) and successful kyphoplasties Prostate Cancer Sclerotic predominate lesions 18F NaF Fluoride in Response to Therapy Disclaimer* * "Cliffnotes" on Interpretation 3 years earlier Current study Tubular Epiaphsysis PET/CT > SPECT and SPECT/CT NOPR COVERAGE Hot lesion in Ll body, Indications and usage Case In Point Important Safety Information Conclusion "Super Scan": No Longer the Classic Presentation BREAST Deposition favors axial Present indications are predicated on the clinical experience with conventional bone scans Why Bone Scanning? imaging and conventional BS for sclerotic predominant lesions seen with this skull lesion. MRI is a "natural" for fusion as acquisition of both PET and MRI carcinoma of the lung with What the "secret decoder ring" did for Captain Midnight in the 1940's, for sclerotic predominant lesions (preceding case example) Attenuation Correction Two classes of calcium analog isotopes : Alpha emitter— Rd-223 (Xofigo) Synergy —Anatomic and Functional Imaging Making "heads and tails" out of difficult scans with PET/CT Twice as many benign and twice as many malignant lesions will be Prostate Ca coarsened trabecular 18F skeleton over appendicular Dosage forms and strengths Trans-axial images from the previous case showing lytic predominant loss of bone Correlative imaging, whether dedicated Abbreviating scanning to the knees has been suggested to increase throughput are obtained with normal respiratory motion. lesions will have primarily significant destructive loss of trabecular The Challenge of Diagnostic Imaging NOPR Results Webinar Goals Skull Presentation Layout Caveats on NOPR Prostate Cancer NOPR Post Ant Tubular and flat Scanner Sensitivity (%) PET Specificity (%) In this case, the lesion is 18F FDG negative as noted on the right for the superior right widely metastatic disease to the CT portion of the today's hybrid scanners does for 18F NaF . visualized on 18F NaF PET bone imaging versus conventional Conventional bone scan vs 18F NaF PET in 44 patients with Beta emitters - Strontium 89 18F FDG and 18F NaF (emission) scans of a pattern. Intensity of presentation: skeleton and/or cortical bone on CT imaging. Depending on the aggressiveness of for the left pedicle and lamina including loss of cortex. Following therapy, sclerotic hybrid scanner or from standalone fusion, since majority of metastatic disease rarely extends into lower legs. bone Baseline As with the TC-99m phosphonate portion of the body of L2 as pointed out by the red arrow. The lesion has displaced the technetium 99m based imaging. (Schirrmeister) the soft tissues, lymph nodes, Exposure levels for 18F NaF are similar to Personal Declarations: 18F NaF was one of the first series of agents used for bone Allergic Reactions Ribs the lesion, there may be little to no uptake of 18F NaF and conspicuous on CMS coverage for 18F NaF Bone PET in the evaluation of suspected or known 49 Patients with newly diagnosed prostate cancer and patient with multiple myeloma obtained within Tc-99m Bone Scan PET PET/CT FDG PET/CT. Samarium 153 With adequate treatment, either from radiation therapy and/or chemotherapy the NOPR (NaF-PET) Workflow Large ulcerating breast cancer new bone healing is evident with visualization of bony margins. By report, the flare is a blend of the two disciplines of nuclear Fludeoxyglucose F 18 injection (18F FDG) is indicated for positron emission a mixture of primary cancers (lung, prostate, thyroid) PSA 316 Progression on viewing: MIP (big picture) — Number and pattern Glucose metabolism PET/CT imaging is a major integral part in the Radiation Risk Radiation Exposure compounds, 18F NaF can accumulate in •Subset of prostate cancer which is aggressive with U.S. guidelines for patients with life expectancy of 5 years or more: reported, and Sodium Fluoride F 18 Injection for Intravenous Use* marrow, probably having a low metabolic rate, but evoking a strong osteoblastic. and the osseous structures. Planar bone scan Hot (greater than background bone activity) : osteoblastic activity predominates. Can be seen with trauma, FDG PET/CT. PET PET/CT 54 70 79 those of standard bone scans in both 88 57 70 98 three weeks of each other. Any previous imaging? Gleason score of at least 8 January 21 , 2009 Deposition favors joints over Lytic phenomena is greater for 18F NaF than MDP. In one case, 18F NaF uptake was seen medicine and diagnostic radiology. retaining good diagnostic quality. on 18F FDG (left image)with left body's response is one of reparative restoration of bone matrix destroyed by the imaging, relying on rectilinear scanners and, in limited metastasis (only oncology applications) if patient is enrolled in CED trial. The Multiple-dose vial containing 370—7,400 Present clinical considerations, 18F FDG PET/CT imaging is most helpful where •18F NaF Fluoride bone scans are a valuable tool in assessing the presence and As with any injectable drug, allergic reactions and anaphylaxis may occur. Upper L2 The increased sensitivity and specificity of 18F NaF 18F NaF PET results changed clinical management in —18% of The most prevalent cancers in the US are Scapula areas of necrosis and tumor calcifications. detection, staging and assessment of treatment (PERCIST) of lung PET and Fused PET/CT — Categorize and Characterize tomography (PET) imaging in the following settings: PET Bone imaging infection, and neoplastic disease where the body can mount an osteoblastic response. Radiation-emitting products, including 18F FDG, may increase the risk for cancer, Solitary (NaF-18) Positron Emission Tomography to Identify Bone Metastasis of interpreted, Structure: Compared management plans before and after NaF-18 scans in shafts of long bones • Rapid equilibration into the extracellular space progression requiring therapeutic intervention Third commissioned presentation for Siemens/PETNET Solutions adults and children. Dose - 20 mCi (7.4 MBq/kg Dose- IOmCi (2.11MBq/kg before treatment when no MDP uptake was present. hip met and a questionable Presently guidelines for therapy include Rd-223 with palliative radiotherapy malignancy. In lytic-predominate and non-lytic/non-sclerotic disease the response PET Bone imaging: patients (previous data). (NOPR = 40%) Planar + SPECT extent of metastatic bone disease standard staging studies are equivocal or suspicious in the setting of locally clinical studies for which Medicare will provide coverage must answer one or availability, early positron cameras. Emergency resuscitation equipment and personnel should be immediately The stand alone bone scan can reveal the extent Increased spensitivity over conventional bone scans (97% versus 80%) lesions may have increased uptake of 18F without •While not a head to head competition with conventional bone scans, cancer. Metastatic presentation of lung cancer to bone is 85% lytic and CT alone — Soft tissue and Lytic predomiate lesions that olume bone scanning and the lack of significant residual Indications and usage Cancer especially in pediatric patients. Use the smallest dose necessary for imaging and • identification of 100% of known metastases CT commonly associated with a Ongoing Tl and PSA 20 The 18F FDG scan on the far left has several Pelvis physician Note the strikingly positive 18F patients receiving therapy for metastatic cancer. MBq/mL (10—200 mCi/mL) at EOS reference (First two available at Ml PET Source) increase in activity for ribs, Interpretation of combined imaging •Improved Sensitivity : 2-3 orders of magnitude Multiple-dose 30 mL and 50 mL glass vial containing ** The statements by Siemens' customers described reserved for Strontium 89 and Samarium 153. will be increased bony metabolism which will present as increased uptake Frame A with 18F FDG and Frame B with •About 4% of patients have metastatic disease at first Cold any alteration of bone architecture on CT, nor conspicuity on glucose advanced or metastatic disease. If the glucose metabolic PET scan is positive for max) ( Less than background bone activity) : Highly aggressive lytic lesions out-stripping reparative Cold ( Less than background bone activity) : Highly aggressive lytic lesions out-stripping reparative of disease. The entire data set of information is max) •Second most common cancer in men world-wide Multiple - More sensitive than diffusion weighted magnetic more of the following questions: 15% mixed. can be missed on PET. Aggressive lesions Presentation the proven increase in sensitivity and specificity of 18F NaF over the • Rapid clearance to bone and through kidneys available. Understand the role of 18F NaF bone imaging in the initial PFS 5.5 Brief history, imaging techniques In initial staging, provide the most complete assessment of totality of the Multi FOV SPECT 92 83 92 well identified lesions, particularly the large Referring MD ensure safe handling to protect the patient and health care worker. patient Twice the incorporation of 18F T2 and PSA over 10 Tl and PSA over 20 With sensitivity and specificity approaching 100%, bone Increased spensitivity over conventional bone scans (97% versus 80%) activity within the kidneys alters the evaluation of requires characterization of areas of sternum and vertebral. Similar to FDG NOPR structure. • detected all osteoblastic metastases in prostate assessment NaF uptake in bone lesions As with the Calcium isotopes and analogs (Strontium), Hot The principle and largest dose for the osteoblastic activity. This presentation can include virilulant bacterial infections. Conversely, can also present metabolism PET/CT imaging. 18F NaF show respective uptake in colon herein are based on results that were achieved in — Oncology: For assessment of abnormal glucose metabolism to assist in Ssymmetric available, but may not be readily grasped due to in the areas of previous metastasis followed by waning uptake. For sclerotic- •18F NaF Fluoride scans are complimentary to glucose metabolism PET/CT and bone metastases than additional bone scans, either conventional or 18F NaF may high incidence of metastatic bone resonance imaging (DW-MRI) months moinths Joinths Ask patient 000 This national coverage (NCO) issued February 26, 2010. It establishes This national coverage (NCO) was issued February 26, 2010. It establishes Specific may no show up with 18F NaF. Also, as with Endplates Case examples of critical value of 18F NaF in early determination of 0.74 to 7.40 GBq/mL (20 to 200 mCi/mL) of disease process. Inventory of disease to define future recurrence versus osteoscintigraphy has reached a more sophisticated level of CT NaF versus phosphonate lesion in the anterior left chest which has presentation •Most frequent cancer in United States (233,000 new Sons per conventional bone scan, both planar and SPECT, can be expected to assessment of potential metastatic bone disease and in the long- requests PET done bone done. altered uptake by the combined criteria type management Prospectively, in Medicare beneficiaries whose treating physician determines time of no-carrier-added sodium fluoride F18 Gleason Score at least 8 or higher as a conspicuous indolent soft tissue lesion displacing physiologic bone with isointense interface with normal submitted per 18F PET NaF PET 18F FDG Blood Poo/ — 5 minutes Included prostate, breast, lung, "other" and "combined" cancers Blood Poo/ — Blood Poo/ — Immediate/y !!! (especially the right sphenoid Early adopter of 18F NaF when pioneering PET imaging in Alaska 000 100 PET/CT comes from the CT scanner and cancer for consent metastases. widely metastatic involvement of the osseous the numerous areas of abnormality and ill-defined Increased spatial and contrast resolution (6-8 mm v. 10-15 mm) energies and half-life were not suitable for widespread use. Rd-223 (Xofigo): Extends survival to 14 months from 11.3 months for placebo Bi-exponential, first phase 0.4 hr half-life and then 2.6 30 mCi 99m Tc Bone Scan predominate malignant disease, response to therapy will be waning uptake. •Improved image quality the customer's unique setting. Since there is no indicaions under which CMS cover NaF-18 Positron Emission Tomography (NaF-18 PET). The NCO concluded not be necessary. the evaluation of malignancy in patients with known or suspected practicality. PET/MRI scans particularly when dealing with potential non-lytic/non-sclerotic and compounds in normal bone • Sodium fluoride F 18 injection is a radioactive encompassed and destroyed several ribs. The potential benefit of 18F NaF PET imaging, with its increased FDG PET, about 3% of patients have other 'tar spread. metastatic disease. lesions will have abnormal uptake of 18F accompanied by bone. Lytic? from both disciplines. NaF PET bone scan (right disease: breast cancer, prostate TNM: T3 and T4 improve detectability of all metastatic lesions. that the 18F NaF PET study results are needed to inform the initial antitumor term care following therapy wing) not seen in the 18F FDG Body •Up to 75% of patients with aggressive disease will in 2003. Followed lead of Seattle Nuclear. can be two to three times the exposure anatomy. cases in 2014 in USA) 18Fludexoyglucose injection and 4.5 mg of sodium Blood Glucose Abnormalities Conventional BS SPECT/CT that NaF-18 PET scans are reasonable and necessary under Section of the Social Security Act in the An alpha emitter with T 1/2 of 11.4 days causing dual strand DNA Cancer Risk NaF PET/CT skeleton. The lack of significant residual activity in 100 100 97 18F FDG sclerotic predominate metastatic bone disease Decay products for some were carcinogenic. CT F18 FDG 18F Post Chemo CT primarily increased bone density, whether cortical, trabecular bone or "typical" hospital and many variables exist (e.g., F-18 NaF abnormalities found by other testing modalities, or in patient with an Faster completion of whole body scanning sensitivity and specificity over conventional bone scintigraphy in the hour half-life significant non-oncological findings (AAA,etc.) Delays — 3 hours General discussion of expected presentation of 18F NaF imaging. image) clarifies the rib, sternal Quantify disease for decision of curable intent versus management of in aqueous 0.9% sodium chloride solution. Mosavi al. AJR, 2012; 199:1114-20 Symptomatic or suggestive of bone metastases Comparing the CT image of the tumor in Ssymmetric Appreciate the strengths and weaknesses of 18F NaF bone •Limitations : Non-comparative — Not head to head competition with MDP. The old dogma of "nonspecific" uptake is no longer adequate. The scan on the left of the screen. thyroid cancer Other cancers from the tracer. context of Coverage with Evidence Development (CED). treatment strategy or to guide subsequent antitumor treatment strategy after diagnostic agent for positron emission Vertebral Distribution of presentation: both. breaks. Up to eight times more 18F NaF deposition can be significantly more positive than with conventional bone The 18F NaF, on close examination of this eventually have metastases. cancer patients, lung cancer, renal cell Pedicles However, while 75% of bone metastases are lytic in initial presentation, 25% are •Most common cancer in European men (416,732 with In the oncology and neurology setting, suboptimal imaging may occur in patients 10 mCi FDG PET and vertebral activity as The sensitivity of 18F NaF , including its Conventional SPECT/CT •Shorter scan times : example — Full PET/CT bone in same time as planar diagnosis of Stage 4/M1 disease is uncertain. Again, the apparent the kidneys is a key finding for the "super scan" for hospital size, case mix, level of IT adoption) there (CPT 78306) existing diagnosis of cancer Each Lesion (CPT 2. 1. Case examples demonstrating how the CT portion of the PET/CT can Sodium fluoride F 18 injection may increase the risk of cancer. Use the chronic disease process through episodes of regression and progression chloride with 0.1 to 0.5% w/w ethanol as a stabilizer Post-dasatinib enhanced specificity of PET/CT combined with the markedly improved frame C with the FDG PET/CT image in Non-Lytic/Non- The mid-sagittal slice from an 18F NaF PET bone • Introduced in the 1960's, 18F NaF was quickly eclipsed by the Combined anatomically with correlative information- CT/MRI F-18 Scan Little information on specific impact of 18F NaF on clinical Experience with 18F NaF for both oncology and standard osteo- Pedicles bonies •The demonstrated detection of lesions by 18F NaF imaging not seen scintigraphy in a relationship complementary to 18F FDG imaging incorporation of 18F NaF versus the completion of initial treatment, does the addition of 18F NaF PET imaging Adheres by chemabsorption, conversion of • detected twice as many benign & malignant skeletal 2 phase (blood poo/ and 3 phase early emission only acquisition, has prominent Alpha particle — short range of 2-10 cells in 2008 in in in scanning agent yielding the classic "flare" phenomena. From clinical reports, flare mixed. In a predominately sclerotic presentation of metastatic bone disease, 18F with inadequately regulated blood glucose levels. In these patients, consider pattern of distribution and rudimentary metastatic. The PET bone scan •The contribution from the hybrid scanner's CT improves localization and Sodium Fluoride F 18 Injection is a clear, sensitivity of 18F NaF bone scanning requires a new level of Prospectively under CED, NaF-18 PET irnaging must lead to: PSA 712 complimentary contribution of 18F NaF PET in imaging of non-lytic/non- sclerotic ? improve sensitivity of 18F NaF PET bone imaging. requiring stage appropriate therapy frame D shows the characteristic uptake at •50% of patients 10 years out from radical prostatectomy carcinoma, follicular thyroid can be no guarantee that other customers will Schirrmeister, J Med 2001; 1800-04 Even-Sapir. J Med 92,237 deaths in 2014) FDG scan obtained for the diagnosis of compression smallest dose necessary for imaging and ensure safe handling to protect Lamina technetium 99m phosphate scans. for Tc99m phosphonates in European guidelines: Solitary lesion: Can run the gamut, including benign disease such as trauma and infection, to benign — Cardiology: For the identification of left ventricular myocardium with decision making. Classic presentation of bone Medicare tomography (PET) indicated for imaging bone scintigraphy utilizing standalone PET, software fusion of SNMMI and ACR strongly recommend photopenic defects corresponding to many of lesions as conventional bone scans introduction of the Mo-99/Tc-99m generator by Brookhaven Increased utilization of scanner with MDP could also change the earliest staging of patients for Maximize the utilization of hybrid PET/CT imaging to help 8 fold target to background ratio further identifies additional has been seen on 18F NaF scans while conventional bone scans remained interpretive skills and commitment. localization of uptake, is interpreted lead to: (approximately 15 to 50 mL volume) for intravenous NaF findings may be more conspicuous than either glucose metabolism PET or medical therapy and laboratory testing to assure at least two days of characterization of bony involvement in metastatic disease. Ill-defined and hydroxyapatite to fluoroapatite delay) the periphery of the tumor, with either core 521.5871' Solitary sclerotic and sclerotic predominate bone lesions may be beneficial for fracture of L-1 also has additional information that pathologic bone lesions. 1. 52 patients with lung cancer Accurately access the extent of response to therapy (PERCIST vs RECIST) Discussion of NOPR (National Oncologic PET Registry) 44 patients with high risk prostate cancer trnefictanes neoplastic and malignant disease. Time - and SPECT Non-lytic/nonsclerotic •Improved temporal resolution achieve the same results. loot. the patient and healthcare worker. • A change in patient managernent to more appropriate palEative care; or the lytic lesions. Only a few limited areas of metastasis of the lesser will have detectable rise in prostate-specific antigen (PSA) Posterior 46 hormone naive Patients with biopsy proven prostate cancer and residual glucose metabolism and reversible loss of systolic function in PET with CT and MRI, and with hybrid PET/CT scanners that one "image lightly" , tailoring the •In 2014, the leading cause of cancer deaths in men in through the filter of anatomic presentation metastatic foci not detected on colorless, sterile, pyrogen-free and >900/0 Convenient to dispense from Actinium 227 generator Other cancers • superior spatial resolution enabled 97% of lesions to negative. Labs, the Tc99m labeled phosphate agents by Subramanian metastatic disease and possible alter the present algorithms for patient characterize and differentiate benign from malignant disease conventional bone scan imaging. normoglycemia prior to 18F FDG. All so complex presentation of multiple areas of abnormal uptake can be more readily hypoxia and/or necrosis. is difficult to identify without anatomic reference. 13 (523%) had bone mets Increased revenue for low volume centers early detection of metastatic bone disease. Positive 18F NaF PET 1. Detect at the earliest point the recurrence or progression of disease should A change in the likelihood of appropriate referrals for palliative care; Lower L2 to define areas of altered osteogenic activity. spines Joints •Findings: 40% change in overall management associated with 18F NaF . There is an inverse relationship of uptake of FDG and 18F NaF in bone lesions. FDG increased activity on 18F NaF are seen, Gleason 4+3 Faced with a potentially bewildering number and assortment of administration. trochanter of the right femur. Gleason score of 7.7 amount of total exposure to the diagnostic of the bony structures on CT or MRI. the FDG PET scan. 18F FDG Unlike the phosphonate compounds, 18F NaF is minimally Time — Same of FDG per patients with coronary artery disease and left ventricular dysfunction, June 5, 2009 Symmetric lesions: Usually seen with degenerative joint disease , arthritides. The 18F NaF bone scan will demonstrate a be correctly classified as benign or malignant versus 6 — 50kBq/kg (1.3 uCi/kg) doses IV at 4 week intervals •10-20% of patients will develop castration-resistant Planar — with/without USA (29,480) categorized care. One could expect more than 4% of prostate patients to initially Provide better understanding of NOPR and reimbursement Little residual retention in soft Cold PET/CT bone scan with "normal" appearing bone on CT was found to and McAfee, and the Anger Camera. additional or altered therapeutic regimen be needed. potentially benign and malignant lesions, utilization of the CT findings Lesion Lesions. including the lower margin of the left chest 79% continued same management when no change from previous 18F NaF uptake favors soft tissue lesions which can often be seen as lytic or expansile lesions PSA over 10 3-axis and whole body viewing characteristic of PET/CT Prostate preservative-free solution for intravenous • Improved or •Multiple field of view scanning Improved quality of life; or • Improved quality of life; or Publication (on topic): An Introduction to Na18F Bone Scintigraphy: PET Bone imaging: requirements of the study. Yen et al. Med Commun pre_pET 80.5% for conventional bone scans Post-PET Post-PET Form Frame E shows the NaF PET/CT image when used together with myocardial perfusion imaging Emission Only The patient has had kyphoplasties. tissues and the renal Attenuation Correction Attenuation Corrected The CT portion of the sodium 18F NaF PET/CT scan will demonstrate increased As such 18F NaF may be a complimentary modality to Fludeoxygluose F 18 As such 18F NaF may be a complimentary modality to Fludeoxygluose F18 can significantly simplify the determination of benign versus malignant 1261' 261' protein bound. Better target to background ratio. bed 'granular" appearance. This granularity may be Blastic Adverse Reactions pathways for 18F NaF after treatment 135.613 present with metastatic disease when solely based on conventional identify bone metastases in 94% such case presentationsl. 1. Acquire the best information to provide the patient, through the treating lesion, other ribs and the left hemi-pelvis. prostate cancer (CRCP) •Higher incidence in American men of African descent or Asymmetric, multiple lesions: May reflect a combination of arthritic changes, metabolic disease, trauma, January 21 , 2009 Previously, areas of complex uptake of 18F 18F NaF PET complimentary to June 5, 2009 of the skeleton with little or no 18F NaF uptake. Decreased neoplastic cellular density 76% switch in management with progression of disease by 18F NaF F_18 CT + 18F FDG FOG CT + Prospective study comparing 18F NaF PET/CT vs conventional planar bone scan Improved survival "High sensitivity of 18F NaF PET/CT in revealing bone metastases • However, the FDA approved 18F NaF for bone scintigraphy in Basic Principles, Advanced Imaging Concepts, and Case parenchyma of the same area with partial fill in of the 18F is readily available for use as 18F NaF since it is the precursor in Form disease and provide a more thorough and complete evaluation of the Form sent, Surface completed. Xofigo indication: CRPC with symptomatic bone mets, but no visceral metastases. sclerosis and some degree of restoration of anatomic appearance due to new bone Breast Improved survival? • as sensitive as MRI in detecting both osteoblastic and metabolic imaging to categorize the full spectrum of the presentation of metastatic •There are successful pathways for reimbursement allowing integration of infection, and neoplastic disease. *Narrative synonyms: "F-18" for 18F NaF Facilitate integration of 18F NaF scintigraphy into the daily clinical — Neurology: For the identification of regions of abnormal glucose A) Advanced hypertrophic degenerative disease of lower cervical spine Lytic met to left pedicle and left transverse process Non-lytic/non-sclerotic right L3 pedicle metastatasis physicians, the truest measure for understanding diagnosis and prognosis. bone scans. 1. 4. subtle presenting only as a "smudgy" or "granular" glucose metabolic imaging of Multiple - tracer created an often ill-defined administration. within the bone will present as decreased 18F FDG PET activity with potentially No adverse reactions have been reported based on a review of the 34 patients with HCC Unlike 18F FDG PET, the 18F NaF PET bone scan has the skeleton as a general Conventional bone scans will under-represent disease in the spine, pelvis and Evan Y. Yu J Nucl Med 2015;56: 354-360 Evan Y. Yu J Nucl Med 354-360 Evan Y. Yu al J Nucl Med 354-360 osseous skeleton. core of the tumor with 18F NaF. 62 12 •33% of patients without metastatic disease at diagnosis Hypersensitivity reactions with pruritus, edema and rash have been reported; Cam-er About 30-50% transiently in red blood cells — "blood Examples J. Nucl. Med. Techno]. June 2007 35:64-76 State of the art hybrid scanners with "fast" With correlative imaging from the onboard CT in those history of prostate cancer The patient was anemic, with the diffuse uptake in the Subtle soft tissue activity may only be seen after attenuation correction. including Claim submitted Sagittal Slice MDP SPECT/CT •Dynamic PET far easier than with SPECT 1972 and re-approved it for PET use in the modernization of Concomitant use of denosumab or zoledronic acid is approved. osteolytic metastases matrix formation. The CT component provides the increased specificity to identify Standard Gamma the modern production of Fludeoxyglucose F 18 18F NaF into your clinical practice bone disease. research study also must adhere to certain standards Of integrity and relevance to the Medicare research study also must adhere to certain standards Of scientifÉc integrity and relevance to the Medicare research study also must adhere to certain standards Of scientific integrity and relevance to Medicare Metastatic poorly differentiated adenocarcinoma. 18F FDG faintly detected o on Ssymmetric Peri-articular montage of findings. With CT, and in the bone versus conventional bone B) Sclerotic met to right lesser trochanter and left ischial tuberosity Non-lytic/non-sclerotic met to right anterior superior illiac crest DJD of anterior Sl joint and sclerotic met to right posterior superior ilium "FDG" for Fludeoxyglucose F18 PET and PETCT CPT descriptor changes effective January 2008 (removed metabolism associated with foci of epileptic seizures 18F FDG PET All ottrr Caveat: It may take upwards of 5 years for micro-metastatic bone disease to progress NaF PET environment vertebral bodies showing increase in hemopoietic metabolism increased 18F NaF uptake . This may be accompanied by no appreciable alteration of reference platform for determination of location and extent of osseous disease. sacrum due to superimposition particularly with DJD. With greater spatial and appearance of the bones. published literature, publicly available reference sources and adverse drug the PET/CT scanner, all of these abnormal areas have emergency resuscitation equipment and personnel immediately available. 1. Even-Sapir, E et al, "Assessment of Malignant Skeletal Disease: Initial Experience with 18F-Fluoride OMS Emission only images for blood pool phase may be spuriously negative. (10.2967/jnmt.106.032870) crystals , TOF and adaptable CT protocols 50% of solitary foci of increased uptake are metastatic on bone scintigraphy requiring correlation 1 for which question for population. No extension of survival with visceral or bulky nodal disease Away from joint, not an enthesis, sclerotic focus by CT in response to therapy with this repair of bone. The CT scanner in the PET/CT Decreasing bone uptake (except L5) in image companion trial of a multi-center metastatic will develop metastases within two year pool" Conversion from lytic destructive lesions (18F FDG) to sclerotic healing bone (18F NaF ) Schirrmeister, al. JNM, 1999; Schirrmeister, al. JNM, 1999; 40:1623-1629 1. 62 90 62 one lesion in the vertebrae while 18F NaF PET detected two lesions, including the FDA regulations in 2000 along with N-13 and 18F FDG rather than solely neoplastic extension. MRI, these multiple areas can be scans for sclerotic predominant Unlike glucose metabolism PET which has a relative threshold for Chang CY al. Acta Radiol. 2014 Dec 22. •Solitary bone metastasis changes both prognosis and therapeutic regimen Bursal area uptake, CT normal in cancer patient = bursitis C) Sclerotic metastases to both scapular glenoids CT A) Lytic met to skull Expansile rib metastasis PET/CT and Comparison Between 18F-Fluorine and 18F-Fluoride PET/CT", J Nucl Med 2004; 45: 272- to detection. Higher sensitivity and specificity of 18F NaF may result in earlier PET/MR/ 009 000 "tumor") facilitates negotiations with private payers •Use of 18F NaF imaging may provide a more accurate assessment of of increased and decreased activity become much bony architecture on CT (non-lytic/non-sclerotic ). Sclerotic lesions on CT will have an the CT portion of the PET/CT can improve specificity. However, accompanying soft tissue involvement can only be inferred at times from the SPECT/CT contrast resolution 18F NaF better characterizes lesions as seen even on this MIP Cortex FOG Behesti al. Semin Med, wikipedia can lessen the radiation exposure while reaction reporting systems. The completeness of the sources is not patient with prostate cancer = metastasis April 2007 FDG PET/CT Breast cancer patient scanned the same week with both planar BS (frames A and B) Feb 2008 NaF PET/CT CRPC tissue biomarker-guided therapeutic trial. Ability to delineate response linked to cancer at an SUVmax=2.5, benign and malignant 18F NaF bone (Presently being evaluated for treatment for other cancers) scanner acts as the "decoder ring" for the anatomic changes in the healing bone. 278. lesions. Benign Synovial Pit on 18F NaF software fused with MRI individually "decoded" and their 18F-Fluoride PET Used for Treatment Monitoring of Systemic Cancer therapy; the superior body-pedicle non-lytic/non-sclerotic lesion. (Lower lesion shown in 202 adult cancer patients underwent both conventional diagnosis. •Note improved spatial and contrast resolution of PET/CT versus SPECT/CT D) Exuberant benign spur formation lower lumbar spine Lytic met to lesser trochanter. Classic site for metastatis Sclerotic sternal metastasis is strongly positive on 18F NaF PET while only faintly seen on 18F FDG NaF PET/CT PET PET/CT easier to localize and categorize. elevated 18F NaF uptake and little or no uptake of 18F FDG . In this case, the blood pool activity at the interface of native tibia with the tibia PET bone images. In combination with CT, and also MRI, there is improved • Target is bone and critical organ is urinary bladder Both thin and heavy patients benefit from attenutation In this example, both sclerotic (femur) and non-lytic/non-sclerotic (pelvic) lesions Planar prognosis to better inform the patient on potential treatment plans. Presentations: Multiple including SNMMI, PET NET, Stanford retaining good diagnostic quality. uptake can be similar, and difficult to differentiate without added CT or and 18F NaF PET (frames C and D). 18F NaF clearly identifies numerous lesions with Alk Phos but not PSA. Revisiting previous clinical trials with 18F NaF may be beneficial. Metastatic Colon Cancer— comparison off8F FDG and f8F NaF uptake in tumor (geographic loss of bone) (sclerotic new bone) r 30 730 ( flare phenomena) known. These Non-lytic/Non-sclerotic lesions on CT better visualized with 18F NaF. 94% of Results from the National Oncologic PET Registry. Hillner et al. J Nucl Med consent January 21 , 2009: miliary lung mets and liver mets IIS June 5, 2009 : all mets gone 115% Sub-cortical Rahhmin et al Nucl Med Commun 2008, 29: 193-207 significance readily ascertained. bone scan and 18F NaF PET/CT within 31 days for staging "Opportunistic Fusion" — correlative imaging - + PET scan with + MRI for better Accentuated "flare" with bony healing adds complexity "decoded" readily with CT cross-section.) 18F NaF may be superior to metabolic glucose and is superior to 1 Rosenthal, DA "Radiologic Diagnosis of Bone Metastases" ,Cancer, AURA with SPECT/CT Widely disseminated metastatic breast cancer presenting with sclerotic metastases metabolic glucose imaging. NaF PET/CT NaF PET •Functional PET/CT resolution at 5-7 mm while SPECT/CT at 10-15 mm A) DJD lateral patellar-femoral joint arthroplasty is obscured without attenuation correction . Predilection for metastases to remain in "fertile ground" as demonstrated in this case of 18F NaF avid / Away from joint / Indistinct margins / Prostate Ca = metastasis Conventional Planar Bone Scan NaF 3-D MIP MRI. discrimination of the origin of the altered uptake in both benign and malignant disease *Please see accompanying full prescribing information 2015: 222-228 Symposium Marrow Serial scans in breast cancer.... How much better or worse? No Change ? correction. Target to background ratios improve 50%. Sclerotic greater confidence due to increased sensitivity and spatial resolution. vol. 80, no. 8, pp 1595-1607, 1997 CT negative/F-18 NaF positive lesions were malignant. (Even-Sapir) Strontium 89 and Samarium 153 with or without external beam radiation Image courtesy Of California Diagnostic Irnaging Image courtesy Of California Diagnostic Irmaging 18F 18F NaF MIP 18F FDG FDG MIP PET/CT CT assessment of abnormal uptake. MRI superior to CT for soft tissue characterization conventional bone scan for all such lesions. Slide courtesy Of Seattle Nuclear Cancer Survival Center widely disseminated metastatic breast cancer. Bone Island Image by permission from Dr. Evan Yu *Please see accompanying full prescribing information Images of Seattk Nuc*eM Images Seattk Images cnurtesy Seattk Image courtesy Of Sodety of Nuclear Mediine Image courtesy Of Sodety Of Nuclear MedZine Image courtesy Of Sodety of Nuclear Medhine Image courtesy Of Sodety Of Nuclear Medtine Image courtesy Of Sodety Of Nuclear Med6ine 18F Images courtesy Dr. George Segall 'Palo Alto VAMC Images of Seattk Images cnurteSy of Seattk Image courtesy Of Sodety of Nuclear Med6ine Image courtesy Of Sodew Of Nuclear Mediine Image courtesy Of Sodew Of Nuclear Med6ine Image courtesy Of of Nuclear Mediine Images cnurteSy Seattk Images courtesy of Dr. Joanna Fair/ UNM (c) copyright 2014 SNMMI; all rights reserved Image courtesy Of Of Nuclear MedZine Image courtesy Of Sodet Of Nuclear MedZine Image courtesy Or. George Sega" 'Palo Alto VANC Image courtesy Or. George Segall 'Palo Alto VANC