The Value of PET/CT in Radiation Therapy

Good afternoon, my name is Amy Carr and on behalf of Siemens Healthineers Petnet solutions, I want to welcome you to today's webcast. So value of pet CT imaging and radiation therapy planning. So today I'd like to welcome our speaker, doctor John Brett Press Kovic, who is the chairman of the Department of Radiation Oncology at the Cleveland Clinic in Florida. So welcome Doctor escovitch. Thank you Amy, and thank you all for attending today. My name is John Draskovich. I'm the chairman of Radiation Oncology at Cleveland Clinic in Weston, FL. And I'm going to be speaking on using PET CT image Ng in the radiation therapy planning process. I thought would be kind of fun to begin to see who our audience is, so I could kind of know what topics are going to be the most important. So if everyone could take the poll. And we'll see if how many aeration technicians from either radiation therapy or diagnostic radiology physicist, dosimetrist physicians an managers. It looks like the polar is also 36%. Our technicians from probably nuclear medicine. There are some radiation therapy technicians, medical dosimetrists that's good to see some managers and. Not many positions, so now I know how to tailor my talk, so thank you. So these are my disclosures. I am a speaker for Siemens invariant. And I want to go through a few of the disclaimer slides. This is sponsored by Petnet, a subsidiary of Siemens. 18 F FDG is indicated for positron emission tomography pet imaging. In the following settings, oncology for assessment of abnormal glucose metabolism to assist in the evaluation of malignancy in patients with known or suspected abnormalities found by other testing modalities or in patients with an existing diagnosis of cancer. Cardiology for the identification of left ventricular my Cardium with residual glucose metabolism and reversible loss of systolic function in patients with coronary artery disease and left ventricular dysfunction when used together with myocardial perfusion imaging. Neurology, for the identification of regions of abnormal glucose metabolism associated with foky of epileptic seizures. Please see accompanying prescribing information of web and R console. Radiation risk radiation emitting products including fludeoxyglucose F18 injection may increase the risk for cancer, especially in pediatric patient use. The smallest dose necessary for imaging and ensure safe handling to protect the patient and health care worker. Blood glucose abnormalities in the oncology and neurology setting. Suboptimal imaging may occur in patients with inadequately regulated blood glucose level in these patients. Considered medical therapy and laboratory testing to assure that at least two days of normal glycemia prior to fludeoxyglucose F18 injection administration. Adverse reaction hypersensitivity reactions with pruritus, edema and rash has been reported. Have emergency resuscitation equipment. And personnel immediately available. Multiple dose 30ML and 50 milliliter glass vial containing 0.74, two 7.40 giga becquerel per milliliter. 20 to 200 military per milliliter are fludeoxyglucose F18 injection, and 4.5 milligrams of sodium chloride with zero point 1 to 0.5%, with or without ethanol as a stabilizer, approximately 15 to 50 milliliter volume for intravenous. Administration. I think after those disclaimers we will move on to the learning objectives. So briefly, I'm going to give introduction on how pet CT became very useful for radiation therapy planning. How I got involved in this back in the early 2000s. I'm going to talk a little bit about how we use PET CT for clinical staging of cancer, specifically non small cell lung cancer and head neck cancers. And also how it's used in radiation therapy planning. I will review some of the advanced radiation therapy techniques that will be very familiar to our radiation therapy technicians, but maybe not so familiar to the others in the audience. I would talk about some practical considerations on how you're going to best get good image quality so that we can use this for coregistration with RC simulation scans and improve the ability of physicist in radiation oncologist a contour off of PET scans. And we'll go Lastly, through some automated ways to contour and delineate targets. So looking back to around the year 2001 was my first experience in using PET scans to image, head, neck and lung cancer patients. An to register those images with RC simulation scans for planning. I was very fortunate to be working in Cleveland, OH, an academic Medical Center and I walked over to my nuclear medicine Department and said is there anyone here that could help me get pet images into our radiation therapy planning software? An within about a minute or two? This great engineer slash physicist watch out and we had about an hour conversation. Within a week he was able to import pet images into racial fairy planning software. An I was probably one of the first, if not the first person in the United States to plan off a pet images. So it was very exciting time to see metabolic or functional images on our treatment planning station, which is obviously very available today, but this is going back 17 years ago. After using the imaging to delineate targets for a shun therapy treatment. I saw all the advantages that were at hand. I presented the findings at a 2002 thoracic tumor board. Are what are the benefits of using FTG pet not only for my use, so my sneaky use was I wanted to do it for each of pre planning, but the true use of pet scanning was just being realized for staging cancer and showing exactly where the tumor was located in the body. So this is my argument at the Thoracic tumor Board, and I say argument because the thoracic surgeons thought the PET scans were not that useful. They thought, you know there's some false positive false negatives and we really shouldn't be using this, but there was. There was a lot of data coming out from the radiology literature, and at RSNA showing the usefulness. And So what I argued was that we can improve our clinical staging. We can therefore appropriately select the treatment. Based off of better staging. The pet imaging can act as a road map for the thoracic surgeon during Media staska B, or for the pulmonary doctor at the time of bronchoscopy or navigational bronchoscopy. To locate the most suspicious lymph nodes for biopsy. And it became very evident that PET scan can image cancer in the bone. It can image cancer in the adrenal glands and we no longer have to order bone scans and Mris as often in these patients and literally this will save money for the healthcare system. And finally, my sneaky reason was I wanted to use these images for planning radiation therapy. So this is a cartoon showing. What radio on college do everyday we draw contours on computers? When I was trained over 20 years ago, we used to draw on plane X Ray films that we took to the X Ray films that we took a patient. Now everything is planned on a nice computer workstation we can bring in. CT scans, MRI scans, SPECT scans, PET scans, any scan that can be put into DICOM format. We can plan off of so. What we typically do is we take the CAT scan which is used for the simulation and we Draw Something called at GTV or gross tumor volume. So anything that looks like tumor from our diagnostic CT MRI I will contour out on a CT simulation scan. Then we expand that volume or target into something called a see TV or clinical target volume that takes new account microscopic spread of cancer from the obvious tumor that we see on our scan. At any sites of. Tumor that might be below the resolution of our scan that we know could hide microscopic cancers such as lymph node stations in the head neck region. Then finally, once we get our see TV and these are our targets, we want to expand it into a P TV or planning target volume that takes no account that daily setup. There were not perfect everyday setting up a patient exactly precisely. We're pretty close, but we add a few more millimeters for that fudge factor where we, if we're not precisely on target, we're going to still encompass the tumor within the high dose volume. But now we introduce something called a metabolic target volume or MTV and that is the actual tumor that we can see on functional imaging test such as FG PET. So. Using metabolic image ingane FTG pad for Deoxyglucose pet is the most common. Obviously, we use that for probably 99% of what we do there. Certainly new tracers that are going to come out and maybe be more specific for certain tumors that will be very useful. But it can or cannot be beneficial for a certain patient. And let me go over some scenarios. If the MTV detected on our PET scan is completely within the GTV that I detected on a CT scan, that may or may not be helpful. If I do not choose to change the shape or size of my GTV, then the pet didn't add much value. You know, I kind of had a second confirmation that that is tumor that I drew from the see T based off of the PET scan showing this metabolic area, but if I don't change what I drew that didn't really change my plan and it might not have changed my stage. But a lot of times the MTV, even if it's within the GTV, it may change. What I drew on the GTV so on this cartoon on the top level, the GTV became smaller and that's because. Sometimes when the tumors close to soft tissue, or if it's in the lung and there's collapsed lung around the tumor, we don't really know what the edge of the tumor is. The pet makes it much more obvious where the edge of the tumor is, and then we can change the shape and size of our GTV and that improves the planning process. It enables us to spare more of the normal healthy tissue. The next scenario would be, how about if the tumor is not imaging imaged? By the PET scan. Some tumors are very slow growing. Some do not have a very high metabolism and do not take up the fluoro deoxyglucose. That's pretty rare today, but there are some slow growing tumors such as prostate, such as some low grade salivary gland tumors. There's a few out there that don't really take up the sugar, so that won't be helpful for us to use the PET scan. The third scenario is when the PET scan detects an MTV that outside our GTV and that is extremely helpful, and that happens quite a few times. So that way we are going to enlarge our GTV encompass all the areas that we can detect the tumor, and make sure we don't have something called a geographic miss. That's probably the worst thing you could do in radiation therapy is not drawing the tumor correctly. Miss it with your beams and the patient has no chance of cure. And then also a very helpful scenario is if the MTV's not only outside of our GTV, but it's found in a distant site. So it's a patient with a primary tumor, but it's metastasized and that may be an incurable situation that's very helpful to us 'cause we don't want to put someone through. Six weeks 8 weeks of chemotherapy rayshon therapy. Very expensive. Very demanding therapy if it's not going to help a patient. Ultimately an if we can detect the distant metastatic metastasis up front, we can more appropriately choose the right treatment for that patient. Let's go into some details about clinical staging. The first thing I looked at was are non small cell lung cancer patients and I got really excited at RSNA meeting in 2001 when Doctor Patz from Duke presented this data and he said that in studies that were done 11 to 29% of the non small cell lung cancer patients were up stage to stage four and that changed the treatment paradigm for. 11 to 29% of patients. He also stated that about 20% of the cases that had an abnormality, denoted on CT imaging where down staged using the PET scan, meaning people maybe 20% of the lung cancer patients thought to be incurable. We're now down stage into a curable stage and that is very important to pick the right treatment. Overall, in his pet CT talk, he said 41% of the time treatment management decisions were changed. So I got excited. I looked at the literature that was coming out in 2001. A very well quoted study from McManus and L from Peter Maccallum Cancer Centre in Australia. Showed the results of staging patients with stage one through three non small cell and cancer with CT scan and then with PET scan afterwards and what they showed. Was that overall 19% of the patients? Were up stage to stage four with the PET scan. And if you look at the pripet stage. Stage one A1B in two A patients. Actually, let me correct myself, says 1B2A and 2B patients. If you look at those three groups, 1718% of them were up stage to stage four. And if you looked at the more advanced stage three patients, 24% of them were upstaged with Stage 4. So it wasn't really helpful for those small stage 18 tumors which 3 centimeter or less primary tumors, but for anything above the three centimeter, there was significant amount of up staging. Another report looking at the mediastinal lymph nodes. And how accurate you could stage if they were positive based off of CT or PET. Show that the pets can improve the sensitivity by 23% and the specificity by about 11% so you're better able to predict which lymph nodes are involved with cancer by adding the PET scan. And this was a publication from France at the Institut Curie in 2001. Let's talk about our initial discoveries. When I started looking at our results in early 2000. I looked at my first 31 non small cell lung patients referred to me for this for radiation therapy 24, then referred for definitive treatment. In other words, they were stage one through three and seven of them were referred for Post Op treatment after surgical resection. When I looked at my pre pet stage in my post pet stage, you can see the yellow rectangles denote a change in the stage from the pripet stage to the post pet stage. So for my 1B patients, one out of four patients were upstaged to a stage 3A. For the stage 2B, one out of two patients were staged as a stage 3A. For my stage 3A patients, four out of seven, the stage changed and were upstaged to a 3D or two a Stage 4. And one of our stage four patients that were sent for palliative treatment were actually down stage three stage 3A and were considered curable. So overall 29% of these patients, the first 31 patient or I'm sorry. The first 24 patients I looked at for definitive treatment had a change in their stage and therefore I changed in the treatment plan. What were the specific changes that I noted where, as I mentioned, 29% had a change in stage. But if you look at the entire Group, 13 out of 2454% of them had a change in the radiation therapy planning target volume. So if I didn't have the PET scan available 50% of the time, I would have missed some of the tumor that I saw in the PET scan. Most of those patients, 38% had lymph nodes that were small and considered quote normal size. An quote on PET CT scan, then FG ability. As you can see in the see T scan on the top, there's a small grey lymph node which on the bottom scan. When you registered with the pets, can you see the bright SVG? Avidity of that lymph node that would have been called positive on the pet but negative on the CT scan. Further, we were better able to delineate tumor. In Atelectatic Lung, which means collapsed lung. So when a tumor. In the lung collapse is part of the lung. It's hard to tell what is tumor and what is collapsed, but with the PET scan you could easily detect that. So let me talk about my first case. The first case is a 50 year old male, has a history of carcinoma of the left upper lung. He underwent surgical therapy in 1999, where he had a left pneumonectomy or removal of the entire left lung, and he had dissection or removal of the mediastinal lymph nodes. The pathology report showed a poorly differentiated adenosquamous carcinoma which was invading into the parietal pleura but not into the chest wall, and the surgical margins were negative. He had a lymph node dissection which showed 16 negative lymph nodes including six negative parabrachial, five negative subcarinal a negative lower paratracheal. Inferior pulmonary ligament node and three negative AP window nodes. So his staging was a pathologic T3 N 0. He did well for about 2 1/2 years and was asymptomatic. At a follow up appointment. His physician. Detected a palpable left super curricular foster lymph node. They did a biopsy and it revealed a recurrent squamous cell carcinoma. He had a CT scan done which showed some suspicious lymph nodes in the left superior mediastinum measuring about 3 to 4 centimeters. A suspicious lymph node at the left hilum measuring 3 centimeters. As well as the left supraclavicular fossa lymph nodes. And on physical exam when he came to see me, I could denote two supercolor lymph nodes, one 2 centimeters in one, 1.5 centimeters on my exam. I presented him at the Thoracic tumor Board and we discussed treatment options and we ordered a pet CT scan. The pet CT scan detected two other areas of disease which were not detected on the see T. First of all. There was detection as you can see in the upper. Image of the pet, CT of a recurrence at the bronchial stump. An interesting Lee on the bottom CT scan image. This soft tissue density had been present there for for a couple years and they just thought that was normal scar tissue after a pneumonectomy. And they were getting a PET scan and follow up if they have done a PET scan they probably would have detected this tumor much earlier, but that was something that was detected only on the PET scan and a PET scan. Definitely confirmed the other areas of tumor. That was found on CT scan. The other area that was not detected on the CT scan that we detected on the PET scan was the small lymph node on the bottom image. You can see the small bright spot in the posterior neck. So when they did the see T you can see on the top image these lymph nodes right next to the trachea. Safaga's on the left. But that tiny little lift doesn't. The posterior neck only showed up as a bright spot on the PET scan. And again, these are the two spots that we may have missed if we planned radiation without having the PET scan available. But that's kind of my initial experience with PET CT for lung cancer that it changed what I did about half the time. So currently it's obviously everyone uses PET scan to stage and information planning, but this was way before people saw the benefits. Let me talk a little bit about what I notice for head neck cancer patients. In late 2001, I took over the head Neck Cancer Service and after seeing the benefit for PET CT imaging for lung cancer patients, I decided to look at the same data for head neck cancer patients. So I looked at my first 18 heads that cancer patients referred for divinus of therapy. All patients had a see T simulation and what I did, which was very important. I. Send the immobilization devices. The mask that we make to immobilize a head neck cancer patient over to our pet scanner. That all my patients were imaged with. Thermoplastic mask immobilization so that the head and neck would be in the same position as we did on the CT simulation. What do we find out? Well, that staging didn't change as much as his lung cancer patients. We kind of know the biology of lung cancer is or does stem the spread to lymph nodes in other parts of the body relatively quickly. Head neck is different. Head neck cancers tend to stay more local and regional. So it only changed the stage in 11% of the patients. But still, that's a very helpful finding. But importantly, it changed my radiation planning target volume 50% of the time, just the same as it did in the lung cancer patients. Because. We can find FTG uptake in small sub centimeter lymph nodes in the neck that would be called normal on a CT scan. By registering the FG pet. And further. Tumors in soft tissues such as tongue tumors. Tumors in the salivary glands. Which are very hard to differentiate sometimes from the surrounding soft tissue on the CT scan can be much more easily differentiated, delineated using a PET scan. So my GTV became either significantly larger or smaller based off of the pet image in about 7 out of 18 patients. So overall 50% of the patients I had a change in my GTV. Let me present some cases to show you how this happens. The first head neck patient is a 50 year old male. He presented with a painless less neck swelling. He noted while shaving one week prior. He did not have any swallowing problems, no hoarseness, no pain in his ear or weight loss. He did have a previous history of smoking tobacco. For 15 years, 1 1/2 packs per day. But he quit 15 years prior and did not have a heavy alcohol history. On examination, when he came to see me, he had two large lymph nodes in his left neck. One measured 4 centimeters and one measure 3 centimeters. The CT scan. As you can see in the image there showed some large lymph nodes in the left neck. But no other sites of suspicious disease. On layering gaska P, when the EMT surgeon put the scope into the patient's larynx and looked around at the tongue and oral cavity oral pharynx. He did not note any primary sites. They did an SNA affine needle aspiration of the lipstone and it came back is suspicious for squamous cell carcinoma. So we ended up getting a PET scan and this showed some very interesting things. Number one. It showed some uptake in the left base of time. And you can see that right here on the PET scan image. It's very bright, easy to see. But if we go back to the seat image, you could see the soft tissue in that area in the city looks very normal. So the see T was negative, but the PET scan shows very brightly where that primary tumor is. And you can see the uptake in the lymph node. Now the whole in snow doesn't have FTG uptake, and that's because this is a very cystic lymph node which is very suspicious for human papilloma virus induced cancers. They all tend to look like this. The surgeon anti surgeon took the patient back to surgery a second time. This time he had the PET scan as a road map to look for the tumor, and he felt the base of tongue with the patient under anesthesia. He still cannot see or feel a definitive tumor, but he said it just felt a little bit more firm there. He did a bunch of biopsies and it came back as a squamous cell carcinoma in the base of tongue human papilloma virus positive for this change completely how we would treat the patient, because now that we know there's a small primary tumor, that's where we're going to focus our radiation beam. If we could not detect that. Primary site his whole oral pharynx would have had to receive radiation for something we call unknown primary radiation therapy treatment. So this was an extremely helpful PET scan. Another case I'm going to present very quickly where the patient. Who had a known left based of tongue cancer and he had a known left level 2A lymph node. So on the see T scan you can see a lymph node in the left side of the neck pretty large and you can see in the left base of tongue. Sorry don't have a pointer here. I should have put an arrow on it but there's a little bit of thicker area. Just look exactly where the last. See T scan or the PET scan showed the base of tongue tumor. Look in that area you can see it's a little thicker in that area. Little Gray or and thicker. So what we did. Once, do a PET scan. The primary tumor shows up very well. The lymph node shows up very well, but look what happened as small right side and lift to now shows up here with FG uptake and if we go back. Again, you can see that small right lymph node. But when you measure it is less than a centimeter. That would be considered normal. And when we do the PET scan now we have three targets, the base it on the left lymph node and the right limb stone. So those are my case presentations to show you how I initially explored using PET scan for each there be planning and we're going to get into now. Why is it so important to have a specific type of technique to do pet CT planning? And it's based off of how radiation therapy has changed over the last two decades. With the ability to now pinpoint the beam of radiation. The narrow the beams down to 2.5 millimeter beams and erected as small areas of the head, neck or long or the body so that we're. Very carefully putting the radiation in specific sites. In avoiding the healthy normal tissues. So duration therapist in. Radiation oncology. You know what I am? Art is but a lot of people do not. So I am RT stands for intensity modulate eration therapy. And the bottom line is I describe it to people who don't know what it is as painting the radiation inside of a patient. So if the tumor looks like an Apple, I'm going to paint the radiation like an Apple just around the tumor in the same shape and size. If you look at this plan, this is an old rayshon plan, probably from 10 years ago that I did the red area, which is colored in is the gross tumor volume and the patient's tongue and tonsil area. All these little colored lives surrounding it that looked like kind of like a Topa graphic map that you see you know when we were in high school. You know the different elevations, but those lines. All. Match up to the different doses you see. The numbers that are on the left side of that picture that go from 15 to 30 all the way up to 100, three, 105. That's called the Isodose Line 100, being the full dose of radiation, and as you get to lower levels. 50 would be half the dose of radiation so you can see the hundred line is painted conformally the same shape as the red tumor right around the tumor. And as you go away from it and you see the yellow line, the light blue, magenta, white line, yellow line again Brown line, those are lower doses of radiation. So it's very important that I drew this red tumor correctly. 'cause if I didn't draw correctly in the tumor, extended into the anterior tongue, I would miss the tumor. The tumor would not get full dose, and therefore the patient would probably have a recurrence. So being able to draw this red tumor volume or gross tumor volume correctly is of utmost importance, and that's why I say here target delineation is of utmost importance to do this advanced type of radiation. If the tumor is not outlined, it probably will not be treated, and that means the patient will fail. If the normal tissue is not outlined correctly, it probably will not be spared, but we spend hours in front of the computer is Rayshon therapist. I always tell. People might buy patient that that's my overtime. I'm in the operating room. I'm a surgeon and I have determine what I'm going to a blade when am I going to remove, and that's what the red. GTV or see TV target is an active determine where all the healthy tissues is. I have to draw in all the healthy structures such as the mandible in the spinal cord and the brain stems. Spying on US celery glands, thyroid gland. Constrictor muscles there's 30 structures that I draw in on a head neck plan now that need to be spared from the high doses of radiation. So I'm going to introduce something called the therapeutic ratio. What is the therapeutic ratio? For every patient that walks in my door, I'm thinking of two curves. I'm thinking of a sigmoid curve called the tumor control curve. If you look at the left diagram. The sigmoid curve as the dose of Asian goes up, the curve starts going up and we're curing more patients, so we're controlling more tumors. The higher dose we give, but the curve to the right is the tissue damage curve, and as the dose goes up, we damage more tissue an we have more. Ill effects for the patient if we take the ratio of the percentage of patients that are cured. Divided by the percent of patients that have normal tissue damage, we get something called the therapeutic ratio and on the left curve, the therapeutic ratio is 1.5. Because we had 90% control rate and 60% tissue damage. This was a situation when I was an early resident and we didn't have amarti. We only could use a few beams and what that meant was the normal tissue that was next to the tumor would receive full dose. And we would have no way to modulate the dose to decrease the risk to the Roma tissues. Well now with what I just showed you the MRT, we could modulate the dose so that on the right diagram. You can see now we have 90% tumor control rate, but we can bring the dose to normal tissues down very low and maybe the tumor control rate is 90% an the normal tissue risk is 10%. So now our therapeutic ratio is gone up to 9.0, so we've really improved the ability to cure patients an to protect the healthy tissues. An improved therapies ratio. There's another technique or technology in the user agent there because I GRT which is image guided radiation therapy and for most radiation college. That means that we take a daily CAT scan before we turn on the rayshon beam to align the patient anatomy to the radiation therapy planning CT scan anatomy. In other words, we have a plan based off of our initial CAT scan and then we have a CT scan that we do every day. We have software that could easily Co register. Those two CT scans very quickly. Our technicians and sometimes the physicians, look at the scans to make sure they're lined up correctly, and then we can move the patient on the treatment table in six degrees of freedom through three translations and three rotations to put the part of the body perfectly matched. Between the crosshairs of the beam so every day is a perfect treatment. So this is a very important technique so that we improve the precision of radiation every day. And it allows us to decrease those P TV margins. If you remember back to that one slide where I showed how we increase our target by. Adding millimeters, the tissue to create a P TV. That's the fudge factor so that if the treatments that after it everyday. Now that we can image everyday, see where the tumor is. See with their own tissues. Are RP TV margins get smaller and smaller? That means less and less normal. Healthy tissue is treated. So look at this cartoon. We have a scenario where we increase our margins from IG TV. the C TV by 5 millimeters and then we increase another 5 millimeters to get to P TV. That is typically done in a lot of centers still today. But we've got to a point where we feel comfortable with our image. Ingane, our pet PET scans to detect a tumor in our daily cone beam CT imaging that we could shrink these margins down to 3 millimeter expansion. And I've even gone down to a 2 millimeter PT expansion over the last year. Why is that important? Because we decrease the normal tissue exposed to high doses of radiation. And this chart will show you how much we decrease. Look at the first row. Take a 1 centimeter radius target. If you expand that into a lyrical target. Is 4 CCS 4.2 CCS? If you then expand it 6 millimeters. Into APTD, this four CC target becomes 17 CCS. If we do the 10 millimeter expansion, we double that target, the 33 CCS and still a lot of places will expand 15 millimeters and that goes up to 65 CC's. So the actual tumor was only four CCS and you could have a target as big as 33 or 65 CCS if you're not sure where the target is or or not accurate with your daily image localization. So that's why this is so important. The PET scans to find the tumor to gain accurate GTV, and then have accurate image in daily so we don't have to expand and damage all the healthy surrounding normal tissue. So ultimately, as this slide shows, the goal is to cure the cancer patient, but to ensure that afterwards that they get back the most highest quality of life possible by sparing the normal tissues. I'm going to move into some practical considerations which are important for our technicians are dosimetrists to consider. And you know, managers to consider if we're going to buy extra equipment for, say, the pet scanner to have available. Using these advanced techniques that I just described, we want to ensure that we do not have a geographic miss where we missed the tumor. So we want to try to get. The regions there be planning CT simulation. And the planning pet CT scan done in the same exact patient position in the same exact immobilization if possible. So I'm going to talk about patient positioning in a mobilization as well as managing patient, an Oregon motion management. But some practical things. Our radiation therapy accelerators have flat table tops. Most pet scanners and CD scanners have curved table tops so. If you just do one thing and get a flat table type insert that is going to improve your. Ability to register your pet CT scans with your see T simulation vastly. That takes care of like 8090% of the problems with registration. So grab one of these flat table tops would be nice if it was indexed like the one I showed here. You have indexing. If you could get one similar to the one in radiation therapy planning, that would be perfect. You can index the immobilization equipment just like you do in relation to every planning and maximize your ability to register your pet CT images with your see T simulation images. Also. Having laser alignment, either external or internal lasers available to line up to the marks that are placed on the patient. As you can see in the middle image, is where the patient would have that patient. Has the lasers lining up to those crosshairs. If you can line that up in the see T simulator an line it up in the pet scanner, that's going to get you even better alignment and make sure the patients nice and straight. If you can get devices such as head holders. You know different we call them. Head neck boards or lung boards that you could attach to your flat table top. That way the patient could be immobilized exactly the same way. Remember that patient comfort is very important because the patient's going to be laying on the pet CT scanner for a little bit of time. Now, back when I made these slides, pet scanner table positions back then were about four minutes. I think a table position, so if you have three or four table positions, the patient could be laying there for 16 twenty 2530 minutes to get all the imaging done. Now I think with some of the time of flight scans image it could be done maybe one minute. The table position I've been told, so it's still important because the patient should hold very still. So we want to make them comfortable. 'cause if they move it degrades the image quality and it degrades your ability to use that pet image to contrast if. So the room is a comfortable temperature. That's a good thing. It's the room has to be a little bit colder. You'll offer them a warm blanket so they don't shiver or feel cold. Try to find out beforehand and this is. Probably the radiation oncology team. They should be responsible for this more than the Diagnostic or Pepsi team. If the patient has anxiety or pain or if they're coughing because they have, you know bad lungs or lung cancer, or if they have nausea from chemo that they be receiving, or if their claustrophobic. We want to give the medication so that they're comfortable at the time of PET CT, the comfortable and they won't move. If they have shortness of breath, you know add supplemental oxygen. If it's a child, or if they have some mental challenge. Anesthesia is sometimes needed for those types of situations. The radiation therapy team. Should communicate well with the PET CT team on how the patients position. They should have the same dress or undress at both locations. If it's decided that we're going to try to do some sort of respiratory gating or use a breath hold technique, or use abdominal compression devices if possible. It's great to duplicate those at the pet CT scanner. I know a lot of pet CT scanners may not be able to do that, but if you have that capability, it's great to duplicate it. If you do not have the ability to use a breath, hold, or gating at the pet CT scanner. It's best not to have the patient do a deep inspiration breath hold like you do for some CT chest imaging. It's best to let the patient have relaxed breathing through the seat during the attenuating CT scan and also doing the PET scan that will best register with our recent very planning CT scan. For head neck patients, we do a lot of different devices. We have patients have head holders. You know if you could bring over the same type of head Holder that will keep the head and neck in the same position. Sometimes we have bite blocks. As can be seen in the top left picture, we have this wax bite block that goes inside the patient's mouth. That does two things. It enables the jaw to be fixed in a certain position and it also sits on top of the tongue to remind the patient not to move the tongue during the see T simulation during the radiation therapy treatment and also during the PET CT procedure. Think about it, if a patient has a tumor in the tongue or the larynx and they're moving their tongue around. The pets that could be useful at all because that image from the tongue is going to be blurred by all the motion. And if the patient swallows. The tongue moves the lyrics, moves babblers those tumors. And we cannot use that data for planning radiation. So we train our radiation therapists. We train our diagnostic therapists and pet CT therapist. Over the months and years, we've done this. We could also send over instructions on a sheet. We did that in the early days to the pet CT scanner so they knew to tell the patient not to swallow during the head neck portion of the PET scan. An that to move the tongue. So that was very important. The grip ring, the blue grip ring on the bottom panel keeps patients more comfortable. And they're not fidgeting as much, and you can see we use the radiation therapy mask to immobilize the head neck. I found out over the years just communicating with the patient beforehand what's going to happen, and then during the procedure what's happening makes them much more at ease and much more to be compliant with. All these instructions that were giving them. So communicate often if there's any you know. Playing music for them that can improve the experience. They can kind of go into his own. Inform them that they're under visual and auditory surveillance from time to time. Let them know that you're you know you're listening to them. You're watching them an how much time is left in the procedure. It makes them feel more secure. And again, you can have are radiation therapists. Go over to the pet CT scanner and work with the nuclear medicine technicians or nuclear medicine technicians could come over the recent therapy and spend a few days in train. I think it's important the beginning if you're going to do this, to send your therapist racing therapists over to the PET CT scanner and we did this Cleveland Clinic for the first six months. Because there's so many different types of patients, so many different types of setups, and it was a good way to educate everyone in both departments on what was important, and then ultimately, nuclear medicine technicians knew what to do and we would just send over instructions on a piece of paper with a Polaroid picture of the patient set up, and so either way works, you know you can send your therapist over, you could communicate well, and training. Quote medicine therapist. And send something over to to let them know how to set the patient up. We should always keep in mind that tumors do grow, so we try to do the PET CT in the see T simulation and the start of treatment vary within a short time period. At the most. One week is nice, but maybe after two weeks is fine. If you wait too long between Pepsi Ctim and treatment start, you know the tumor is going to be different size, so we try to minimize that in children and young adults in the early 20 somethings will see this Brown fat FG uptake. If you know that this person had a lot of Brown fat uptake on a previous PET scan. If you can order another one, you can sometimes give a warming blanket an let them use that and warm up over 30 minutes before the scanner, or give them a beta blocker and that'll decrease the Brown fat uptake and make a better scan. No, the board dimensions of your pet scanner, this top one you know is are. Original PET scanner was archaic. Just dedicated pet scanner without a see T had a very small bore so we had to make very tight immobilization devices for them to fit through there, but most pet CT scanners now are much bigger so kind of know the borders of the two scanners you're going to use and make sure when you make the immobilization devices and rayshon fair, but it's going to fit in your pet scanner. How do we register the different images well? The top row is a planning CT scan. The middle row is taking the PET scan in rigidly registering the pet to the see T. The first thing you can notice is that. In the middle row, if you look at the middle image, that bright spot in the head, neck, region lines up nicely. In the midline. But if you look at the left image, that little dot in the lymph node is miss registered. It's behind the lymph node in the neck by significant distance. That's because the PET scan was not done in the treatment position an it was not done with the mobilization. So you're going to have miss registration. You can use the formal registration software like we did in the bottom row, and now you can see the primary tumor in the middle image is aligned and then on the right side you can see that the lymph nodes align very well. But you know that's. That's probably not as good as if you have the patient immobilized at the time of pets. But registration software can help you, but you always have to, you know, as a position as a physicist, as a dosimetrist, the people were doing the planning. Be careful that the registration is accurate. So how do we draw tumors off of the PET imaging? But there's a lot of different techniques you can threshold based off of the SUV. For instance, you could say everything with the SUV above 2.5 will get contoured and. Software will do that for you, or you could say everything at 42% of the SU VMAX. Or above will be contoured. Or you can use a gradient based technique where you look at the amount of SUV. In each box will and try to come up with a formula which some of the vendors have done to determine where the edge is based off of how the SU values go down in three dimensional space. And then finally physician discretion. You could play with the windows and figure out what window looks right with your experience. The bottom line is, none of these techniques are perfect. You can use one of the automated ones if you want. It will give you an initial contour. But if we look at, for instance, this patient presented to you, it's a 79 year old female. In a CT scan, if you look at the middle row, that's the CT scan showing an endobronchial tumor. And if you look at the middle image in the Middle Rd, that yellow outline is the vendor bronchial tumor that we outlined using one of the automated register automated contouring techniques. That was 42% of them access UV. They biopsied that and was screaming cell carcinoma in the mainstem bronchus. If you notice in the CT scan, there's all this great issue on the top in the medial part of the right upper lobe. Well, is that tumor or not? The only way we know for sure is if we do the PET scan and if you look at the bottom row, the bright spot shows where the tumor is. It's really a truly endobronchial lesion an all that grey stuff up in the upper lobe. If you look at the bottom row, that right most image all the grey stuff in the upper lobe is just collapsed lung called atelectasis. So before we had PET scans we were taught I was taught iteration on college to treat all that 'cause you don't know if that's tumor. So that whole upper lung with been treated for no reason. And you can see the different contours. The yellow is the 42% as UV Max, the light blue, which is the biggest contour, is the SUV of 2.5. So that doesn't work very well at all. 'cause it's going way outside the the tumor. And then the assisted contour where you look at the gradient method is the magenta contour, so the yellow and magenta contours were pretty good, but ultimately again is that Rachel Cologist there's so many factors that determine where, how much SUV, how much FTG gets into each box when you sell that you can't really depend on these techniques very well. So. What I would tell you is automatic conjuring techniques reduced interobserver interobserver variability. In delineating the contours. And you can look at Phantom studies. You could look at multiple studies that have been done an different studies say different things are better. Gradient techniques typically work well even for small tumors, and then they like the 45% or 42% should Max techniques work best if the tumor is a little bit bigger, like 2 centimeters or bigger. But here's all the challenges and actually contouring off of a SVG PET scan. The patient can move, or the organ can move. That's gonna blurry your your target. There's different attenuation correction ways. Ways to correct for attenuation on the CT scan and there could be artifacts in the lung. There's something called partial volume effects. How good is the resolution of your pet scanner so that can create some partial volume problems with contouring. The SU VMAX varies depending on what pet scanner use. Even in the same hospital. There's variability in the SV Max depending on how long you scan the patient. After you inject it with CG. There's different reconstruction algorithms and smoothing techniques. There's differences in your display that you can look at the pet imaging on. There's normal tissues that take up FTG, that your tumor might be right close to so those gradient techniques might not work very well. An there's variable S UV levels based off of the blood glucose level in patients. Here is just one study showing if you image the patient after you inject SDG glucose in a breast cancer patient. Multiple breast cancer patients. But as you the Max varies depending on when you scan the patient. So in the earlier scan. The S UV Max is lower an as you wait twenty 4060 minutes. The STD Max goes up in most of these patients so you have to have a consistency in your Department. You can always scan people whatever. 50 minutes 60 minutes after injection just to kind of have a consistency. If that patient comes back for more PET scans later, it's good to be consistent. And if you have multiple pet scanners, try to use the same scanner every time for the same patient. 'cause again there can be variability on between scanners. The challenge they mentioned about normal background FG, a good example being the head neck. Things such as the basic tongue, the pharynx, the palatina lingual tonsils take up sugar and tumors. Those those areas may be hard to delineate because the normal tissues take up sugar. The larynx will take up sugar, so if you have a patient with the tongue cancer an you do a PET scan of a sudden your PET scan reports. Tumor in the base of tongue, but also a suspicious lesion in the larynx. It may not be in the lyrics at all. It may be that the patient talked after the injection and so the lyrics took up sugar or. If it's only in one side, the lyrics if only the right side. The lyrics takes up FG that could because the left lyrics his vocal cord is paralyzed from the tumor. So there's things you learn as you re PET scans and having a very experienced radiologist and racial cologist who knows these normal variance is very important. If the patient you know is a little nervous and he's moving his tongue or he's moving his neck in his head, those muscles are going to take up the FTG. The brain obviously takes up a lot of sugar. Salivary glands take it up, and then, as I mentioned, the Brown fat and any inflammatory lesion in the body will take SVG. This is that example I showed. You could see the uptake in the muscle in the anterior tongue here on on both sides right next to the mandible. That's normal uptake and a muscle that is not tumor. Don't conclusion. I hope I was able to. Educate some guys and ladies out there about test CT imaging how it improves staging. I specifically use it in mass post alone cancer head neck cancer. In my early years when I was in Cleveland Clinic and now I treat a lot of different tumor types and I use it for the vast majority of our patients with cancer. These days it's going to prove your staging therefore improve your treatment selection and is vitally important for each and every planning to better detect small deposits of tumor that CT scans or MRI scans may not detect. There's many, many practical take home points that could be used to improve the ability of your doctors to register your PET scans with their CT scans and therefore delineate targets for patient. Very planning and events techniques like IMRTI GRT. The automated segmentation techniques, which are basically used for contouring automatically they're good. I mean, I'm not. I'm not bashing them. Go ahead and use your favorite one, but you have to go back and use physician judgment an edit those contours based off of what you see on your. See T MRI scans too, because the pet may not be aligned correctly or it may show some normal tissue uptake. I wanted to finish by wishing everyone a happy spring. I hope those of you from up North that are still getting the 30 degree cold weather and snowy weather or falling out and you're getting some sunshine soon. I'm down in sunny Florida. This is our one year old. Wishing you guys a happy spring and thank you very much for your attention. That was fantastic in would delightful way to end it with such a cute little girl so we have a couple questions that I'd like to just. Just ask you. First of all the great question. In your opinion, what specialist do you feel need additional education on the value of PET CT? That's a great question. I used to do just that. I used to travel when pet CT back in the early 2000s. You know it was coming out a lot of the benefits and RSNA was wonderful. It was just like a hotbed for all these great protocols and studies. And so I took that out to the communities angave Petitti lecture similar to this showing the benefits and I think across the board people who don't have experience. With Pet city planning. The whole radiation oncology team. A lot of teams don't use it at all. Those those folks can certainly. Come the webinars like this. They can you know call people who use PET CT a lot. I'm certainly more than welcome to talk to anyone in the audience who has team members who want more information on this. Get set up a time to talk on the phone. The radiologists are usually the most educated on this. They obviously, unless they're not experienced in PET CT. If they're more, you know, diagnostic radiology. Without nuclear medicine, they may not be, but most radiologists are the most up-to-date, and experts in this. But physicist Dosimetrist Rayshon therapist and technicians in general a lot of times. Would really benefit from this because they might be told to do something like immobilized the patient. Make sure they don't move, but if you don't know why then it's less important to you. Once you see this and how pinpoint radiation can be these days and how your job as a radiation therapist in the PET CT Department. Is as important as my job is racial colleges an are racial therapy technicians sending up the patient today every day because you're helping cure cancer. You're helping makes ensure that the images are the highest quality that I can paint the dose. An once you see that whole presentation in the you know that reason why you're doing it. It makes your job more meaningful. I think it's a great question. The next question is another good question. Where do you see PET CT the most underutilized? In what area? That's another great question. I think I'm blessed to be at institution where we use it a lot. I mean we. We really believe in it. You know, there's some of the new tracers coming out for prostate cancer. We really believe that this is going to explode for all kinds of cancers with. You know, make markers and genomic ways of imaging tumors, so I think outside of. Our main institution when I travel, sometimes I think there's a number of places where it's just not convenient. People will say, well, I know I know PET scans are really, really good for delineate tumors, but we don't have a pet scanner here in our standalone radiation center, and it's either hard for the patient to go from a rural area to get a scan. So I think availability is the main issue. I don't know if it's a specific tumor type. I think that education has been passed on through all the. Continuing medical education courses throughout the country that PET CT is really. Approved for so many types of cancer these days, it's more. I think the convenience for the patient, the availability for different doctors to utilize the technology. Thank you, putting gears a little. The next question is what is your recommended uptake time? For scanning after injection, yes. OK. I am in no way the expert on that. I would probably ask my nuclear medicine positions and radiologist who read the pets. I think from what I've heard throughout most of the meetings I go to is that they use 60 minutes. Now I don't know, 45 minutes is degraded from degrades the quality as far as the SV Max being a little bit lower than 60 minutes. I think most of the places I've been they've used 60 minutes and that's it is going to be 60 minutes against really, really important that those patients are in a quiet room. They know not to move around, not to talk, not to walk around and use any muscles which the sugar is going to those muscles they should be in the choir room and a quiet lazy boy chair. If possible, maybe listening to very relaxing music and then take them in and scan them. We don't want them to be very active 'cause that will degrade the image quality. Thank you, another question, do you think deformable registration is good enough to replace immobilization devices? I think the easy answer is no. I think if they're immobilized. The same way as city simulation. An to be completely honest, a lot of my patients are in to mobilize because the PET scans done outside and they come to see me as a second opinion or their insurance makes them go to another pet scanner because it's cheaper somewhere so I don't have a lot of. I do have a lot of patients that are not immobilized and I use the software and I think it's wonderful. But I think if you put him in the same position, you're going to maximize the chance that it's perfectly lined up, 'cause that's how we duration therapy, right? Every day we put a mask on a patient or we put a body mold around them and we create the exact same position an that's how radiation is defined for stereotactic treatment. If you use the registration software, it's going to improve your ability to take the pet image and market and register with the see T image. But think about that, registration software has to deform things so it's taking boxes and deforming voxels in 3D space into a different shape and size. There has to be some air in there, so I'm a big believer in trying to mobilize people. That's the number one way, but if you can't do that, which there's plenty of people that can't, and I I don't do it and a lot of my patients use the software to help you out. Thank you, we've had a number of people just writing in and thanking you for such a comprehensive presentation. We've had several people ask if the deck will be available afterwards, so I'll go ahead and answer that and let you know that the archived webinar will be available. Will be sending up a follow up email that will have the link to that and it will also be available on pet Nets an my pet source, so I'm going to just end by thanking Doctor Grass. Give it very much and also thanking the audience for participating in today's web and R. And we look forward to future webinars with our audience. Have a nice afternoon. Great, thank you.

FDG PET/CT Fusion IAI IAI Please note that the learning material is for training purposes only! Fludeoxyglucose F 18 injection (18F PET/CT PET MTV 18F FDG* Injection Which best describes you? Sponsored by: PETNET Solutions, Happy Spring! Targeting / Avoiding Radiologic Technologist-radiation therapy 03 *oos Cleveland Clinic PET/CT PETICT Radiation Therapy Targeting / PET/CT PET MTV Practical PET/CT simulation Advanced Radiotherapy For the proper use of the software or hardware, please always use the Operator Manual or Instructions [or Use (herein- FDG) * Injection for Intravenous Use Conclusions Contouriong Radiologic Technologist-radiation therapy RT Planning Planning Wholly owned subsidiary Dosage Forms and Strengths Important Safety Information Radiologic Technologist-diagnostic radiology Introduction Corporate Disclosures Learning Objectives after collectively "Operator Manual") issued by Siemens Healthineers. This material is to be used as training material Clinical Staging RT Planning Planning Planning. Medical Physicist RT Planning Planning Planning. of Siemens Healthineers Considerations Contouring Contouriong Avoiding Techniques Indications and Usage only and shall by no means substitute the Operator Manual. Any material used in this training will not be updated on Radiologic Technologist-diagnostic radiology PET/CT & Radiotherapy Planning a regular basis and does not necessarily reflect the latest version of the software and hardware available at the time of Radiation Risk: Radiation-emitting products, including Medical Dosimetrist 18F FDG is indicated for positron emission tomography (PET) imaging in the training. Medical Physicist Contouring (Segmentation): Fludeoxyglucose F 18 Injection, may increase the risk for cancer, PET/CT imaging improves staging, treatment CTV CIV CT Physician-Radiation Oncology PET/CT for RTP: Contouring (Segmentation) Techniques: CTV 24 pts evaluated the following settings: Case Presentation (H&N #1) Case Presentation (Lung): Post-PET stage Isodoses (% H&N patient positioning, Patient positioning and immobilization Patient positioning, immobilization, instructions 3D 103.7 3D • 103.7 3D Dose M 103.7 578cm 57cm • 103.7 3D M especially in pediatric patients. Use the smallest dose necessary Introduction Commissioned presentation Case Presentation (H&N #1 ) IMRT-IGRT: Case Presentation (H&N #2) IMRT IGRT IGRT: IMRT• IMRT: Argument for upfront FDG PET: CT Metabolic Imaging PET/CT Imaging 4. How does IMRT improve the Therapeutic Ratio? 1050 103.0 for definitive RT PET may improve accuracy PET may improve accuracy of clinical staging. Multiple-dose 30 mL and 50 mL glass vial containing 0.74 to 7.40 selection, and RTP for a variety of tumors. The Operator's Manual shall be used as your main reference, in particular for relevant safety information like warnings Planning Planning CT RT Planning Planning. Medical Dosimetrist IGRT•. 32.31 33.51 Challenge: inconsistent post-injection scan times for imaging and ensure safe handling to protect the patient and Know PET/CT bore diameter to ensure Siemens: speaker immobilization, instructions Challenge is to detect tumor edge on FDG PET images Challenge: Normal background FDG uptake (H&N) SUV threshold methods Auto-contouring techniques reduce inter-observer 803.0% 113.10 11310 103.2% 450.0 103.0% 103.20% 105.20% 31 NSCLC patients referred 18 H&N patients referred to Post-PET stage Iv Post-PET stage IV In 2001 , began co-registering Potential benefits of FDG PET in NSCLC: Benefits of FDG PET in Cancer: Case Presentation (Lung): Case Presentation (H&N #1) Non-small lung cancer: Gradient-based or chemoRT and cautions. Hx: 50 yr male presenting with painless, left neck swelling noted Physician-Radiology Physician-Radiother Patient comfort is of utmost importance! Disclaimer* 111A 111B Total Same dress or undress as in RTP. Flat table insert for PET/CT scanner GBq/mL (20 to 200 mCi/mL) of Fludeoxyglucose F 18 injection Continue to communicate often with patient to decrease Experienced radiation therapists travel to Nuc Med or Advanced, conformal RT delivery techniques Advanced Radiation Treatment Techniques Time from RTP PET/CT to start of radiation therapy should be 5m CT/PET for mediastinal staging: Oncology: For assessment of abnormal glucose metabolism to health care worker. Clinical Staging of clinical staging. Primary left base of tongue Improved precision and conformity from immobilization devices created at CT PET: FDG-avid left Il, Ill, V2 Experience in clinical staging and radiotherapy Physician-Radiation Oncology 1) Improves accuracy of clinical Target delineation is of May or may not be beneficial for Staging or Radiotherapy Planning 98.0 103.0% 980.0 45.0 to me for radiation therapy me for definitive radiation while shaving one week prior. No swallowing problems, voice Decrease variability in delineation of PET MTV. ("fusing") FDG PET images and 4.5 mg of sodium chloride with 0.1 to 0.5% wlw ethanol as Manager/Administrator-Radiation Oncology Confounding factors: Metabolic Target Volume Daily Cone Beam CT (CBCT) to align patient CBCT Many practical techniques can be used to patient's anxiety and ensure compliance assist in the evaluation of malignancy in patients with known or #/total Use standard headrest and Waldeyer's ring: base of tongue, pharyngeal, palatine, (IMRT, SBRT, VMAT) require accurate tumor within 1-2 weeks to minimize chance of tumor growth and training of Nuc Med therapists is required our initial discoveries CTV Cleveland Clinic 103.2% 105.0% 103.0% 119.7% Note: Some [unctions shown in this material are optional and might not be part ot your system. Note: Some functions shown in this material are optional and might not be part ot your system. Patient should be instructed to lie very still. Patient The patient did well, asymptomatic for 2.5 yrs. 50 yr, male with history of carcinoma of the left upper lung. PET detected involvement of Staging changed in 7/24 (29%) of patients with Staging changed in 2/18 (11 of patients with CT-stage If using gating, abdominal compression, or "breath hold" Laser alignment: external or internal PET for RTP confirmed L4 Varian: speaker simulation in Rad Onc will fit PTV margins cancer with large left level lla nodes. Focal FDG at left base Planning. stagning. staging. utmost importance!! IMRT-IGRT leads to better sparing of normal a stabilizer (approximately 15 to 50 mL volume) for intravenous changes, ear pain, weight loss, etc. Mac Manus et al. reported prospectively the therapy. (24 pts referred for definitive suspected abnormalities found by other testing modalities, or in planning using Fludeoxyglucose F 18 injection -7 (MTV) Defined by functional with CT simulation images for anatomy to RTP CT anatomy. 11-29% of NSCLC pts. lingual tonsils 02 5-point thermoplastic mask. uspoing thermoplastic mask. n TR=9.O CT delineation to prevent "geographic miss." need for new mask or new RTP. PET/CT TR=l .5 Differences in reconstruction TR=9.O .5 posterior neck lymph node. Blood Glucose Abnormalities: In the oncology and neurology setting, improve the co-registration (and hence, motion will degrade image quality and limit ability to (paratracheal), LIO (hilum) Phantom studies favor the gradient technique for IA technique for organ motion management in RTP (e.g., lung or lasers. Patient or organ movement Listening to music can relax a patient and improve their 0/21 4/22 CT-stage IA-IllB NSCLC Ill-IVB Cancer 980.0 103.0% administration. Reginistration. Therapy: Left pneumonectomy, mediastinal node dissection, At follow up, a mass was palpated in the left supraclavicular Certain products, product related claims or functionalities (hereinafter collectively "Functionality") may not (yet) be of tongue. patients with an existing diagnosis of cancer. node metastasis. pre- and post-PET staging results in NSCLC Other Nuc Med should do daily QA on laser helpful tissues, decreasing early and late radiation effects. (0.9/0.6) (0.9/0.6) (0.9/0.1) E.S.isa79yr.F RT or chemoRT). imaging such as FDG PET upstaged to Ml (stage IV). 105.0% 7000% 980.0 Tobacco: 22 pk-yr history; quit 15 yrs ago. suboptimal imaging may occur in patients with inadequately Pre-PET PET for NSCL and cancers (OF PET for NSCL and cancers Rigid CT Registration 2) Appropriate treatment selection. Radiation Therapy Planning algorithms / smoothing use PET image for targeting Breast cancer FDG and L supraclavicular LN+. Larynx (if patient talks after FDG injection) commercially available in your country. Due to regulatory requirements, the future availability or said Functionalities upper abdomen SBRT-IMRT) then duplicate technique during experience Excellent communication and collaboration between Use bite block if made for RTP. In children and young adults (early 20's), minimize "brown fat" segmentation) of the PET and CT simulation Physician-Radiology Physician-Radiother fossa. 06/18/99. spheres with diameters <2cm. With scan 32/187 32/167 1B 1B/11 1/46 Attenuation correction artifacts 17 Identical immobilization devices in alignment and isocenter Spensitivity: Range 44-94% 43-75% 237.5% 67-100% Radiation Planning Target Volumes influenced Radiation Planning Target Volumes influenced by PET in Su bmit regulated blood glucose levels. In these patients, consider medical patients with clinical stage I-Ill disease by All patients underwent CT IGRT improves precision of daily IMRT. No alcohol. Stage If tumor is not outlined, it in any specific country is not guaranteed. Please contact your local Siemens Healthineers sales representative for the Right level lla node is < lcm (RTP). E.S. 79 yr. F E.S. is a 79 yr. F uptake versus time Examination under anesthesia Pre-PET —200/0 of cases with "abnormal" —20%/0 of cases with "abnormal" Every life deserves world class care. Identical anatomic conditions during RTP CT Differences in displays PET/CT if possible. FDG uptake by using a warming blanket at least 30 minutes Rad Onc and Nuc Med is paramount for operational Room should have comfortable temperature (use 3) PET acts as a "road map" for Cardiology: For the identification of left ventricular myocardium therapy and laboratory testing to assure at least two days of Neck and tongue muscles in lung Distant Metastasis image data for RTP purposes. most current information. PET/CT as used in Rad Onc. Inform patient that they will be under visual and auditory endobronchial Instruct patient Instruct patient notto_swallow Pathology: poorly differentiated adenosquamous carcinoma Biopsy: revealed recurrent squamous cell carcinoma. 11A 16/62 conventional staging workup. with CT scan With scan Manager/Administrator-Radiation Oncology by PET in 13/24 (54%) of cases. 9/18 (50%) of cases. 24/100 Advanced Radiation Treatment Techniques 1B/11 111A 111BA 111B simulation and FDG PET Radiation therapy Radiation Therapy Our patients benefit from an probably will not be treated!! Evaluate to ensure PET/CT flat table top FDG is Both gradient and 0.45*SUVm threshold had similar 1/2 1/1B Stage after injection 600/0 83% CT scan suspicious for 98.0 105.0% 45.0 805.0 105.0 103.20% Exam: Left level Il, Ill nodes (4.0, 3.0 cm, resp.) (El-JA): no obvious mucosal (short axis) and inconspicuous with residual glucose metabolism and reversible loss of systolic simulation and FDG PET/CT allows for normoglycemia prior to Fludeoxyglucose F 18 Injection PET also detected recurrence mass in R msb showing blanket if cold). before or give a beta-blocker at least 60 minutes before FDG surgeon at mediastinoscopy. efficiency and set up accuracy as well as patient Improved precision affords the radiation Normal background FDG invading the parietal pleural with negative surgical margins. When not using lung motion management device for lung surveillance and inform them how much time is left from time and keep tongue relaxed Brain Partial volume effects does not sag in extended position shows changes in simulation CT images rigidly using thermoplastic mask [18F] fluorodeoxyglucose 0/21 and soft tissue Duplicate devices or bring with patient 111BA 111A 111B 19 17 metastasis are downstaged. endobronchial CT chest: suspicious lymphadenopathy in the left superior Decrease function in patients with coronary artery disease and left The reproduction, transmission or distribution of this training or its contents is not permitted without express written Improved Quality of Life! All 17 19 119 32/167 administration. Reginistration. results in spheres >2cm (Shen, Nelson, Adler) lesion nor ulceration. "Fullness" NSCLC metastasis to normal size lymph nodes Unknown primary detected on PET: 1/18 4/7 on contrast-enhanced CT. accurate tumor delineation using PET. at bronchial stump (thought to CT: Large conglomerate of left level Il, Ill nodes injection. Automated segmentation techniques (contouring) oncologist to decrease PTV margins in RUL satisfaction! uptake in some tissues Early 2002, presented early mass in R msb Medications are necessary if patient has pain, Practical considerations in PET/CT RTP: cancer, instruct patient to have relaxed breathing using quiet Specificity: Spensitivity: to time so they know they are being monitored closely and 44-94% 67-100% 81-100% Range 6mm 1 Omm 15m m authority. Offenders will be liable for damages. without motion. measured SUV. ventricular dysfunction, when used together with myocardial 4) PET can replace bone scan and Deformable CT mediastinum, measuring 3-4 cm, left hilum, measuring 3 cm, Lymph Nodes negative (6 peribronchial, 5 subcarinal, 1 lower co-registered to FDG PET immobilization for RTP. 78 cm Salivary glands by CT criteria: 9/24 (38%) Measured SUVm varies per 24 26 16/62 Standardjze_documentatjon (describe Standardjze_documentation (describe normal tissue Best if PET/CT flat table top is compatible and soft tissue in left BOT corresponding to Radius Vdume expansiM Percent expansim Percent expansim Perce't expansiM Percent expansim Percent expansim Perce"t expansim Percent expansim Percent expansim Percmt expansial Percent expansim Percent expansim Percmt be stable on CT). Management decisions If normal tissue is not outlined (less setup error) which decreases volume Metastasis to normal size lymph nodes by CT criteria: 2/18 0/9 0/1 111B er: Other anxiety, cough, nausea, claustrophobia. perfusion imaging. Patient positioning and immobilization. Patient positioning, immobilization, instructions should be considered assist tools and not a findings to Thoracic Tumor Board Laryngoscopy: No mucosal or ulcerative lesions BX shows SCC respirations not deep inspiration with breath hold. feel secure FDG PET shows FDG-avidity of (cc) Expansial (cc) Expansim MR adrenal (which can saves $). (cc) (cm) (cc) (cm) Variable blood glucose left paratracheal, 1 inferior pulmonary ligament, 3 AP window). and left supraclavicular fossa. Registration in RUL positioning, immobilization, patient instructions Adverse Reactions: Hypersensitivity reactions with pruritus, edema images for R T P. images for RTP. Holding a "grip ring" can type of PET scanner 44-94% 94% Avg All names and data or patients, parameters and configuration dependent designations are fictional and examples with patient positioning and immobilization skin marking, tattoos, patient position) changed 41% of time. FDG avid area on PET. exposed to Brown fat (in children and young adults up to early 20's) R msb NSCLC not appreciated on CT: 3/24 (13%) 11310 26 0/21 4.19 8/46 8/38 17.16 103.10 3096% 309.6% 700.0% 709.0% 7000% 703.0 1370.0% 65.45 195.43 1462.5% 14625% 1462.5". it probably will not be treated!! it probably will not be speared!! it probably will not be spared!! of normal tissue treated to high dose. Larger or smaller GTV (soft tissue or bone involvement not 021 oa ox 0:43 oa ox ies levels in patients 111B 0/1 1131B only. and rash have been reported; have emergency resuscitation on benefits of FDG PET. OOSE 337.51 33.51 173.162 723.62 73.62 735 62 119.7% 309.6% 1197% 113.10 113.10 103.0 13705% 2378% 337.51 237.5% 179.59 179.19 179.16 119.7% 4359% 4359%. 4359%, right level lla node. substitute for physician judgment. Oxygen if short of breath Patient and organ motion management. FNA (left level Il node): suspicous for squamous Bx increase patient comfort. Head First-Supi devices stage: pT3NO Physical exam: 2 supraclavicular nodes (2, 1.5 cm) surrounded Jo n F. Greskovich Jr., M. 5) PET useful for Radiotherapy Variability in post-injection high RT dose 11310 19543 1370% 137 381.70 Neurology: For the identification of regions of abnormal glucose PET: shows Defined tumor in atelectatic lung: 2/24 (8%) appreciated on CT): 7/18 Challenge: FDG uptake in inflammatory lesions equipment and personnel immediately available. *The statements by Siemens' customers described herein are based on results that were achieved in the customer's R msb Rad Onc and Physicist need to ensure registration accuracy for contouring of PET MTV PET and CT sim co-registration / Target delineation v' Z: •12.45 cm v' Z: cm v' Z: •12.45 Cm v' Z: •12.45 Z: •12.45 cm Biopsy left BOT: +SCC (+HPV) carcinoma 268 08 268.08 40772 407 72 52+6 52 "6 52 V' 52+.60 52 $6 723.62 113.10 52380 523 60 103.0 195435 953% 95.3% 69681 160 24 7/24 (29%) /24 (29% by firm induration (5 cm). No palpable neck nodes. By decreasing dose to radiosensitive normal tissues. RUL density is unique setting. Since there is no "Wpical hospital" and many variables exist (e.g., hospital size, case mix, level of IT unique setting. Since there is no "typical hospital" and many variables exist (e.g., hospital size, case mix, level of IT Anesthesia for children or mentally disabled Chairman, Radiation Oncology Chasirman, Radiation Oncology All rights, including rights created by patent grant or registration or a utility model or design, are reserved. IMRT: intensity modulated radiation therapy IGRT: image guided radiation therapy RT Planning Planning. IGRT: image guided radiation therapy IMRT: intensity modulated radiation therapy scan times metabolism associated with foci of epileptic seizures. Injection Use table indexing if available R istration accura o timal if PET done in treatment osition with immobilization! 523 60 523.60 735 62 40 5% 40 904.78 904 78 728% 1150.35 35 1197% 119.7% 4.19 1.19 11B 179.19 111 Beaulieu, S. et al, JNM 44: 1044, 2003 Mac Manus et al., Peter MacCallum Cancer Center (IJROBP 50:287-293, 2001) Ned Patz, Duke, RSNA 2001 Giraud, Institute curie, IJROBP49: 1249-57, 2001 adoption) there can be no guarantee that other customers will achieve the same results. atelectasis PET: shows Cleveland Clinic Florida *Please see accompanying prescribing information on webinar console May or may not be helpful May Or may not be helpful Not helpful Ml-3847 RUL density is ASTRO 2002 Copyright C Siemens Healthcare GmbH 2020 Update on Clinical PET, 2003 Ml-3847 3847 April 18, 2018 atelectasis Ml-3847