© 2007 Cardinal Health. All rights reserved. Marketing PET in Radiation Treatment Planning PET Marketing Forum – Accelerating Practice Growth May 23, 2007

© 2007 Cardinal Health. All rights reserved.

Marketing PET in Radiation Marketing PET in Radiation Treatment Planning Treatment Planning

PET Marketing Forum – Accelerating Practice Growth

May 23, 2007Dr. Homer Macapinlac

Welcome!


Brought To You By Brought To You By Cardinal HealthCardinal Health

• Part of PET FoundationsSM > comprehensive marketing and education program

• Continuation of 2006 series > advanced topics

• Recorded presentation and PowerPoint available on www.PETFoundations.com > News > Marketing Forum

• Exclusive benefit to Cardinal Health PET customers

• Continuing this Fall

http://www.petfoundations.com/


Dr. Homer MacapinlacDr. Homer Macapinlac

• Over 15 years of PET experience

• Read over 15,000 clinical PET scans

• MD Anderson Cancer Center

• MDA Volume > X PET/CTs per month


Promises, PromisesPromises, Promises

• Know your target

• NSCLC

• Head and Neck Ca

• FDG PET is approved for staging

• No CPT code for FDG PET in RT planning


Copyright ©2006 American Cancer SocietyFrom Jemal, A. et al. CA Cancer J Clin 2006;56:106-130.


Lung Cancer StagingLung Cancer Staging

• Treatment based on stage

• Survival correlates with stage

Stage 5-Year Survival

I 60-80%

II 5-50%

IIIa 10-40%

IIIb, IV <5%


FDG PET Improves StagingFDG PET Improves Staging

• PET potentially avoided unnecessary thoracotomy in 1 out of 5 patients

• Reed J et.al. Thorac Cardiovasc Surg. 2003;126(6):1943-51

• Van Tinteren et.al. Lancet 2002; 359: 1388–92

• Nodal Stage:Sensitivity/Specificity 85/91%

• High NPV

• M1 detection – mean 13%• Stage I -7.5%, Stage II - 18%, Stage III – 24%

• McManus, et.al. I J R O B P 2001;50:287293



PET/CT Better Than PETPET/CT Better Than PETProspective, Blinded, 120 ptsProspective, Blinded, 120 pts

• PET-CT was more accurate for N2 nodes (96% VS 93%) and N1 nodes (90% VS 80%, p=0.001)

• PET-CT more sensitive, specific, and >PPV for both N2 and N1 nodes (p < 0.05 for all).

• PET-CT is significantly more sensitive at the 4R, 5, 7, 10 L and 11 stations and more accurate at the 7 and 11 stations than dedicated PET.

Cerfolio et.al. Ann Thorac Surg. 2004 Sep;78(3):1017-23;


RT PlanRT Plan

• Planned target volume

• Gross tumor volume

• Clinical target volume

CTVGTV

CTV

PTV


Right Lung

Left Lung

Heart

Esophagus

Spinal Cord

Target Volume(TV)

Delineation of GTV & Normal Organs in the Thorax

How to reduce NTCP?How to reduce NTCP?3DCRT/IMRT/Proton3DCRT/IMRT/Proton


Effect of FDG-PET on Radiation Treatment Volumes in NSCLC

Study Year Patients w/ change in RTP

Hiffer (1998) 7/15 (46%)

Nestle (1999) 12/34 (35%)

Munley (1999) 12/35 (34%)

Vanuystel (2000) 45/73 (62%)

Giraud (2001) 5/12 (42%)

McManus (2001) 38/102 (37%)

Erdi (2002) 7/11 (64%)

Ciernik (2003) 18/39 (56%)*

Brianzoni (2005) 11/25 (44%)*PET/CT






Differences Between PET and CTDifferences Between PET and CT

• Scan of 90 cm < 30 sec

• Spatial resolution < 0.5 mm

• Temporal resolution < 1 sec

CT – 0.5 sec rotationCT – 0.5 sec rotationPETPET

• Scan of 15 cm for 3 to 6 mins,

• Spatial resolution ~ 6 mm

• Temporal resolution ~ breathing cycle

Potential Misalignment Between PET and CT Images


Scout Helical CT

End-inspiration (FB)

End-expiration (FB)

Mid-expiration(BH)

X-ray on

Misalignment In Breathing StatesMisalignment In Breathing States

0 20 40 60 80 100 120 (sec)


4D-CT: Pan et.al. Med Phys. 2004 Feb;31(2):333-40. 4D-CT: Pan et.al. Med Phys. 2004 Feb;31(2):333-40.

Respiratory Motion Tracking With Retrospective Gating

Signal from RPM system

X-ray on First couch position

• Respiratory tracking with Varian RPM optical monitor

• CT images acquired over complete respiratory cycles

Second couch position Third couch

Impact of Respiratory Motion on IMRTImpact of Respiratory Motion on IMRT

10 Gy 20 Gy 35 Gy 50 Gy 70 Gy

Composite

Components

Dong, Zhang, et al MDACC


Determining optimal clinical target volume margins on the basis of microscopic extracapsular extension of metastatic nodes in patients with non-small-cell lung cancer.

Int J Radiat Oncol Biol Phys. 2007 Mar 1;67(3):727-34.

3-mm CTV margins for pathologic lymph nodes <20 mm and more generous margins for lymph nodes >or=20 mm


Head and Neck CAHead and Neck CA

• Sixth Most Common Cancer Worldwide

• USA: 2% of all cancers, 2% of all deaths

• Imaging vital for detection, staging and treatment.

• Early stage curable (T1/2 N0M0)

• Most w/ nodal mets 45%, M1-10%

• Second primary – 5% annual rate



• May improve tumor localization

• Enlarge/reduce/confirm primary tumor target

• Enlarge/reduce/confirm neck coverage

How Could PET/CT Help How Could PET/CT Help XRT?XRT?

• May improve treatment selection

• Whole body staging

• Biological characterization, heterogeneity

• May improve response assessment

• Need for neck dissection

• Dose/treatment selection

Frank SJ et al. (2005) Technology Insight: PET and PET/CT in head and neck tumor staging and radiation therapy planning Nat Clin Pract Oncol 2: 526–533 10.1038/ncponc0322

Figure 1 PET/CT images of a 58-year-old male with squamous cell carcinoma of the right tonsil


Figure 2 Radiation treatment planning prior to definitive chemoradiation therapy


Figure 3 Response to definitive chemoradiation therapy after 3 months


PET/CT Challenges—PET/CT Challenges—GTV RegistrationGTV Registration

Nature Clin Oncol :2:10:526-534;2005


PET/CT Challenges—GTV PET/CT Challenges—GTV ThresholdingThresholding

Nature Clin Oncol :2:10:526-534;2005


Nodal CTV Nodal CTV DelineationDelineation

0.5 – 1 cm CTVmargins

Apisarnthanarax et al. Int J Radiat Oncol Biol Phys. 64:678, 2006




Synchronous Primary CancersSynchronous Primary CancersReferencesReferences

• Head Neck and Esophageal – 12%

Radiother Oncol. 2005 Dec;77(3):267-70.

• Screening for Distant mets or secondary primaries with FDG PET – 6%

Oral Oncol. 2006 Mar;42(3):275-80.


New PET Foundations New PET Foundations Marketing Tools Marketing Tools

www.PETFoundations.com

Under Construction• RTP Module

PowerPoints Case Studies Referring Physician Letter New Service Announcement


Marketing PET in Radiation Marketing PET in Radiation Treatment Planning Treatment Planning

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Thank You!Thank You!

Continuing This Fall!

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© 2007 Cardinal Health. All rights reserved. Marketing PET in Radiation Treatment Planning PET Marketing Forum – Accelerating Practice Growth May 23, 2007