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PET-CT Fusion Imaging and SUV Assessment Using MIMvista (Resisting RECIST). Pete Anderson MD, PhD Professor, Pediatrics [email protected]. Passive vs Active role. “SCANXIETY” visual images available before report Look at most scans yourself - PowerPoint PPT Presentation
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PET-CT Fusion Imagingand SUV Assessment
Using MIMvista (Resisting RECIST)
PET-CT Fusion Imagingand SUV Assessment
Using MIMvista (Resisting RECIST)Pete Anderson MD, PhDPete Anderson MD, PhD
Professor, PediatricsProfessor, [email protected]@mdanderson.org
Pete Anderson MD, PhDPete Anderson MD, PhDProfessor, PediatricsProfessor, Pediatrics
[email protected]@mdanderson.org
Passive vs Active rolePassive vs Active role
• ““SCANXIETY”SCANXIETY”
• visual images available before reportvisual images available before report
• Look at most scans yourselfLook at most scans yourself
• Information today will empower you to get Information today will empower you to get SUV data from any location in the body SUV data from any location in the body yourself!yourself!
• ““SCANXIETY”SCANXIETY”
• visual images available before reportvisual images available before report
• Look at most scans yourselfLook at most scans yourself
• Information today will empower you to get Information today will empower you to get SUV data from any location in the body SUV data from any location in the body yourself!yourself!
PET-CT ImagingPET-CT Imaging
• Standard Uptake Value (SUV)Standard Uptake Value (SUV)
• FDG is the prototype : “ I Have A DREAM”FDG is the prototype : “ I Have A DREAM”
• Sensitive means to document responsesSensitive means to document responses
• Numeric dataNumeric data from PET-CT using Mimvista from PET-CT using Mimvista
• Downloading of DICOM images from QC Downloading of DICOM images from QC CD for central review (e.g. SARC studies) CD for central review (e.g. SARC studies)
• Standard Uptake Value (SUV)Standard Uptake Value (SUV)
• FDG is the prototype : “ I Have A DREAM”FDG is the prototype : “ I Have A DREAM”
• Sensitive means to document responsesSensitive means to document responses
• Numeric dataNumeric data from PET-CT using Mimvista from PET-CT using Mimvista
• Downloading of DICOM images from QC Downloading of DICOM images from QC CD for central review (e.g. SARC studies) CD for central review (e.g. SARC studies)
Assessing Response of Sarcomas- NOT Always Easy
Assessing Response of Sarcomas- NOT Always Easy
• Clinical: pain improved, alkaline phosphatase Clinical: pain improved, alkaline phosphatase and/or LDH better, exam better functionand/or LDH better, exam better function
• Imaging: shrinkage on CT (Choi) and MRIImaging: shrinkage on CT (Choi) and MRI
• Osteosarcoma: bone scan changes very Osteosarcoma: bone scan changes very slowly and can even increase if some slowly and can even increase if some calcification associated with healing occurscalcification associated with healing occurs
• Sometimes “more” or “worse” lung Sometimes “more” or “worse” lung metastases are just increased calcificationmetastases are just increased calcification
• Clinical: pain improved, alkaline phosphatase Clinical: pain improved, alkaline phosphatase and/or LDH better, exam better functionand/or LDH better, exam better function
• Imaging: shrinkage on CT (Choi) and MRIImaging: shrinkage on CT (Choi) and MRI
• Osteosarcoma: bone scan changes very Osteosarcoma: bone scan changes very slowly and can even increase if some slowly and can even increase if some calcification associated with healing occurscalcification associated with healing occurs
• Sometimes “more” or “worse” lung Sometimes “more” or “worse” lung metastases are just increased calcificationmetastases are just increased calcification
RECIST (Response Evaluation Criteria in Solid
Tumors)
RECIST (Response Evaluation Criteria in Solid
Tumors)• 30% decrease in sum of longest diameter 30% decrease in sum of longest diameter
of target lesion(s): PRof target lesion(s): PR
• PROG >20% PROG >20%
• CR (complete disappearance)- unusualCR (complete disappearance)- unusual
• Most: stable (but patient seems better!) Most: stable (but patient seems better!)
• Ignores stromal or bone componentsIgnores stromal or bone components
• 30% decrease in sum of longest diameter 30% decrease in sum of longest diameter of target lesion(s): PRof target lesion(s): PR
• PROG >20% PROG >20%
• CR (complete disappearance)- unusualCR (complete disappearance)- unusual
• Most: stable (but patient seems better!) Most: stable (but patient seems better!)
• Ignores stromal or bone componentsIgnores stromal or bone components
PET-CT Imaging: A Reality Check for the Both Clinician and PatientPET-CT Imaging: A Reality Check for the Both Clinician and Patient
• Is the ongoing or proposed treatment Is the ongoing or proposed treatment worth the toxicity (chemo) or morbidity worth the toxicity (chemo) or morbidity *Surgery/RT*Surgery/RT
• Any disease elsewhere?Any disease elsewhere?
• 3-D imaging: 3-D imaging: “Seeing is believing”“Seeing is believing”• Helps set priority of intervention(s) such Helps set priority of intervention(s) such
as local control vs chemotherapyas local control vs chemotherapy
• Is the ongoing or proposed treatment Is the ongoing or proposed treatment worth the toxicity (chemo) or morbidity worth the toxicity (chemo) or morbidity *Surgery/RT*Surgery/RT
• Any disease elsewhere?Any disease elsewhere?
• 3-D imaging: 3-D imaging: “Seeing is believing”“Seeing is believing”• Helps set priority of intervention(s) such Helps set priority of intervention(s) such
as local control vs chemotherapyas local control vs chemotherapy
MIMvista PET-CT Fusion ImagesMIMvista PET-CT Fusion Images
• First-hand infoFirst-hand info about tumor location about tumor location• FUSION images allow clinician to determine FUSION images allow clinician to determine
where highest FDG uptake is in-around-where highest FDG uptake is in-around-near a target lesion. near a target lesion. YOU get the SUV!YOU get the SUV!
• VISUAL PICTUREVISUAL PICTURE and numeric data of and numeric data of where there is active tumorwhere there is active tumor
• LOCAL Control strategy (surgery RT, RFA), LOCAL Control strategy (surgery RT, RFA), more chemotherapy , or just follow-up after more chemotherapy , or just follow-up after therapy (esp RT) – “at a glance”therapy (esp RT) – “at a glance”
• First-hand infoFirst-hand info about tumor location about tumor location• FUSION images allow clinician to determine FUSION images allow clinician to determine
where highest FDG uptake is in-around-where highest FDG uptake is in-around-near a target lesion. near a target lesion. YOU get the SUV!YOU get the SUV!
• VISUAL PICTUREVISUAL PICTURE and numeric data of and numeric data of where there is active tumorwhere there is active tumor
• LOCAL Control strategy (surgery RT, RFA), LOCAL Control strategy (surgery RT, RFA), more chemotherapy , or just follow-up after more chemotherapy , or just follow-up after therapy (esp RT) – “at a glance”therapy (esp RT) – “at a glance”
MIMvista Color Fusion ImagesMIMvista Color Fusion Images
• MIMvista for desktop PC (Cleveland OH MIMvista for desktop PC (Cleveland OH ((www.mimvista.com)
• Right click on image (e.g. in MD Anderson Right click on image (e.g. in MD Anderson ClinicStation or other)ClinicStation or other)
• DICOM images are downloaded into the DICOM images are downloaded into the MIMvista program (~1-2 min)MIMvista program (~1-2 min)
• Displays fusion images for Displays fusion images for YOURYOUR analysis analysis
• MIMvista for desktop PC (Cleveland OH MIMvista for desktop PC (Cleveland OH ((www.mimvista.com)
• Right click on image (e.g. in MD Anderson Right click on image (e.g. in MD Anderson ClinicStation or other)ClinicStation or other)
• DICOM images are downloaded into the DICOM images are downloaded into the MIMvista program (~1-2 min)MIMvista program (~1-2 min)
• Displays fusion images for Displays fusion images for YOURYOUR analysis analysis
MIMvista DisplayMIMvista Display
• Top (PET)Top (PET)
• Middle Middle
– (PET-CT (PET-CT FUSION)FUSION)
• Bottom: CTBottom: CT
• Top (PET)Top (PET)
• Middle Middle
– (PET-CT (PET-CT FUSION)FUSION)
• Bottom: CTBottom: CT
• Scroll to adjust PET Scroll to adjust PET vs CT fusionvs CT fusion
• SUV displayed where SUV displayed where click the arrow on click the arrow on coronal, sagittal, or coronal, sagittal, or transverse planestransverse planes
• Can capture file to Can capture file to clipboard for power clipboard for power point and forwardingpoint and forwarding
• Scroll to adjust PET Scroll to adjust PET vs CT fusionvs CT fusion
• SUV displayed where SUV displayed where click the arrow on click the arrow on coronal, sagittal, or coronal, sagittal, or transverse planestransverse planes
• Can capture file to Can capture file to clipboard for power clipboard for power point and forwardingpoint and forwarding
More CT
More PET
Same Lesion
SUV on a Fusion Image - anywhere you point the mouse
SUV on a Fusion Image - anywhere you point the mouse
• All areas of tumor not alike: heterogeneity All areas of tumor not alike: heterogeneity of edges of tumor vs middle of tumorof edges of tumor vs middle of tumor
• Areas near or in vital structures (e.g. Areas near or in vital structures (e.g. spine, mediastinum, liver, chest wall)spine, mediastinum, liver, chest wall)
• Ossified lesions may have small “islands” Ossified lesions may have small “islands” of intense FDG uptake (incomplete of intense FDG uptake (incomplete response to chemotherapy, focal relapse)response to chemotherapy, focal relapse)
• All areas of tumor not alike: heterogeneity All areas of tumor not alike: heterogeneity of edges of tumor vs middle of tumorof edges of tumor vs middle of tumor
• Areas near or in vital structures (e.g. Areas near or in vital structures (e.g. spine, mediastinum, liver, chest wall)spine, mediastinum, liver, chest wall)
• Ossified lesions may have small “islands” Ossified lesions may have small “islands” of intense FDG uptake (incomplete of intense FDG uptake (incomplete response to chemotherapy, focal relapse)response to chemotherapy, focal relapse)
Indicator (Target) LesionIndicator (Target) Lesion
• More PR than RECIST More PR than RECIST (Mahajan SIOP)(Mahajan SIOP)–RT of OS 0/8 by RECISTRT of OS 0/8 by RECIST–6/8 improved SUV on PET-CT 6/8 improved SUV on PET-CT
• PET-CT may allow better F/U PET-CT may allow better F/U after RT + chemoafter RT + chemo
• More PR than RECIST More PR than RECIST (Mahajan SIOP)(Mahajan SIOP)–RT of OS 0/8 by RECISTRT of OS 0/8 by RECIST–6/8 improved SUV on PET-CT 6/8 improved SUV on PET-CT
• PET-CT may allow better F/U PET-CT may allow better F/U after RT + chemoafter RT + chemo
MIMvista PET-CT Fusion Examples
MIMvista PET-CT Fusion Examples
• OsteosarcomaOsteosarcoma
• EwingsEwings
• OsteosarcomaOsteosarcoma
• EwingsEwings
Chest Wall Osteosarcoma: Progression after HD-Ifosfamide
Chest Wall Osteosarcoma: Progression after HD-Ifosfamide
L pleural/chest walldisease unresectable
CT after Doxil +Avastin: Ossification
CT after Doxil +Avastin: Ossification
Was 7Now 4(pleuralEffusionbetter)
PET: Avid
Hmmmm……
PET-CT Fusion: SUV lessPET-CT Fusion: SUV less
SUV was >5
Local Control: Samarium + RTLocal Control: Samarium + RT
Samarium scan and RT plan
After Samarium +RT(SUV less; No new lesions)
After Samarium +RT(SUV less; No new lesions)
No longer next to heart s/p RTNo longer next to heart s/p RT
Continues onL-MTP-PE(Junovan)CIND
“stable” by RECISTBetter on PET-CT
Osteosarcoma of Ilium + Sacrum Osteosarcoma of Ilium + Sacrum
Excellent function, no pain 8 months s/p Proton RTnow NED s/p staged thorocotomies:? “CR” on PET-CT
Osteosarcoma: Pelvic sidewallOsteosarcoma: Pelvic sidewall
RFA- pain gone, no progression at this site; attends High School- Will follow with bone scan and PET-CT
Metastatic Osteosarcoma:Identification of Active Primary
Metastatic Osteosarcoma:Identification of Active Primary
SUV 5.9 Bone scan not avid Where PET was avid
PET- “avid”+bone scan, too
PET-CT showedlocalrecurrence(posterior-lateralSUV 8.1= tumor)
Artifact onMRI and CT s/p limb salvage
Local Recurrence: Fusion Image Local Recurrence: Fusion Image
Right Hilar OsteosarcomaRight Hilar Osteosarcoma
(RT w/o chemo, then chemo-- not enough : now needs surgery)
Osteosarcoma s/p Pneumonectomy
Osteosarcoma s/p Pneumonectomy
Stable – Low SUV in R thorax; continues off all therapy
Response Quality: 1 Year after Samarium- Tumor Islands
Response Quality: 1 Year after Samarium- Tumor Islands
Active “islands” also seen in primary extremity lesions
Osteosarcoma of SacrumOsteosarcoma of Sacrum
Clinical ResponseS/P HD-Ifos and RT(pain gone and NO symptoms x1 yr)
Osteosarcoma Relapse- Sacrum (SUV 5.4 at start of HDIFOS )
Osteosarcoma Relapse- Sacrum (SUV 5.4 at start of HDIFOS )
Sacral Osteosarcoma (SUV 1.9 s/p IFOS)
Sacral Osteosarcoma (SUV 1.9 s/p IFOS)
NO change in size on CT; slightly less avid on bone scanPain gone + clinical response to HD-IFOS
EWS- s/p 3 cycles TMZ + IrinotecanEWS- s/p 3 cycles TMZ + Irinotecan
Began short of breath with massive disease- clinically much better
Stopped TMZ + Irinotecan : Relapse
Stopped TMZ + Irinotecan : Relapse
Given RT, this lesion ok. Stopped Rx again. Increase LUL nodule
EWS: Clinical ResponseEWS: Clinical Response
Now Off TMZ + irinotecanX 5 months
SummarySummary
• MIMvista PET-CT fusion can provide MIMvista PET-CT fusion can provide same-day visual information to clinicianssame-day visual information to clinicians and patients about FDG metabolic activityand patients about FDG metabolic activity
• PET-CT can now be used in the clinic for PET-CT can now be used in the clinic for to capture numeric response data (SUV)to capture numeric response data (SUV)
• SUV obtained-anywhere you clickSUV obtained-anywhere you click• Additional data possible (tumor volumes)Additional data possible (tumor volumes)• Image capture and sharing possibleImage capture and sharing possible
• MIMvista PET-CT fusion can provide MIMvista PET-CT fusion can provide same-day visual information to clinicianssame-day visual information to clinicians and patients about FDG metabolic activityand patients about FDG metabolic activity
• PET-CT can now be used in the clinic for PET-CT can now be used in the clinic for to capture numeric response data (SUV)to capture numeric response data (SUV)
• SUV obtained-anywhere you clickSUV obtained-anywhere you click• Additional data possible (tumor volumes)Additional data possible (tumor volumes)• Image capture and sharing possibleImage capture and sharing possible
ConclusionConclusion
• MIMvista information can MIMvista information can help YOU to help YOU to communicate bettercommunicate better -with patients, -with patients, families, referring physicians, surgeons, families, referring physicians, surgeons, radiotherapistsradiotherapists
• Response data? SARC to determine Response data? SARC to determine • COLORCOLOR fusionfusion images with numeric data images with numeric data
provides best of both worlds in the clinicprovides best of both worlds in the clinic– Response + numbers “at a glance”Response + numbers “at a glance”
• MIMvista information can MIMvista information can help YOU to help YOU to communicate bettercommunicate better -with patients, -with patients, families, referring physicians, surgeons, families, referring physicians, surgeons, radiotherapistsradiotherapists
• Response data? SARC to determine Response data? SARC to determine • COLORCOLOR fusionfusion images with numeric data images with numeric data
provides best of both worlds in the clinicprovides best of both worlds in the clinic– Response + numbers “at a glance”Response + numbers “at a glance”
