Nuclear Medicine Nuclear Medicine in in

Oncology Oncology

Dr. Deniz BEDELDr. Deniz BEDEL

WorkflowWorkflow

Radioactivity is given to the patient orally/i.v

These are either the radioactive forms of the elements that are used in the body or organ specific agents

When the agents are accumulated or caught by the target organ, images are obtained by the gamma cameras

The half life of these radiopharmaceuticals are short and eliminated from the body in hours

What is Nuclear Medicine ?What is Nuclear Medicine ?

Images obtained with gamma cameras when radioactivity is given to the patients

Bone scintigraphy: Dark areas are the bone metastases.

Why Do We Use This Method? Why Do We Use This Method?

Non-invazive

Radiology can give information on anatomical details but not function

Functional Evaluation Functional Evaluation

Tumors and Radiopharmaceuticals Tumors and Radiopharmaceuticals

Primary tumor Radiopharmaceutical

Differentiated thyroid carcinoma

123I or 99mTc-pertechnetate

Medullary thyroid carcinoma 99mTc-V-DMSA

Lymphoma 67Ga citrate   

Neuroendocrine tumors 111In-octreotide 

Neural crest tumors 123I-MIBG

Breast carcinoma 99mTc-MIBI

Primary bone tumors 99mTc-MDP 

Differentiated Thyroid CancerDifferentiated Thyroid Cancer

• RadiopharmaceuticalsRadiopharmaceuticals– I-123I-123 – I-131 I-131

• Whole body imaging is used for Whole body imaging is used for detection of residual thyroid tissue and detection of residual thyroid tissue and metastases. metastases.

I-131I-131

Lymphoma imaging using Lymphoma imaging using Gallium-67 Gallium-67

Lymphoma imaging using FDG

Gastroenteropancreatic Gastroenteropancreatic Neuroendocrine Tumors (GEP-NET) Neuroendocrine Tumors (GEP-NET)

• Radioactive somatostatin analogues (Radioactive somatostatin analogues (In-111 In-111 octreotide, Lu-177 DOTA-TATE)) i is used s used because of the presence of somatostatin because of the presence of somatostatin receptors receptors

Primary gastrinomaPrimary gastrinomaIn-111 octreotide In-111 octreotide

Neural Crest TumorsNeural Crest Tumors

• I-131 MIBG resembles noradrenaline I-131 MIBG resembles noradrenaline

• Whole body imaging enables multifocal Whole body imaging enables multifocal or extraadrenal tumor detection or extraadrenal tumor detection

Pheocromacytoma -MIBGPheocromacytoma -MIBG

Neuroblastoma imaging using Neuroblastoma imaging using I-131-MIBG I-131-MIBG

MIBG Bone scan

Bone metastases Detection Bone metastases Detection

• Generally seen as increased radioactivity on bone Generally seen as increased radioactivity on bone scintigraphyscintigraphy

• Rarely (2%) cases may show ‘photopenic’ lesions Rarely (2%) cases may show ‘photopenic’ lesions (renal cell ca, melanoma)(renal cell ca, melanoma)

• Rutine bone scintigraphy Rutine bone scintigraphy – Prostate CaProstate Ca– Breast CaBreast Ca– Lung CaLung Ca

Multiple metastasesMultiple metastases

Sentinel lymph node detection Sentinel lymph node detection

• It is the first lymph node where the It is the first lymph node where the tumor drainstumor drains

• Colloidal particle injectionColloidal particle injection

• Drainage imagesDrainage images

• Intraoperative gamma probe Intraoperative gamma probe

Sentinel nodeSentinel node

Sentinel node intraoperativeSentinel node intraoperative

PETPET

• Positron emission tomographyPositron emission tomography

• Functional and whole body imagingFunctional and whole body imaging

• Evaluation of tumor metabolism via Evaluation of tumor metabolism via radioactive glucose or aminoacids radioactive glucose or aminoacids

PET

Tumor localisation ,

Differentiation between benign / malign

Detection of tumour viability after treatment

18F-florodeoxyglucose (FDG)

FDG Hexokinase

FDG-6-fosfat

Cell

Glucose

Transporter

Hexokinase

Glucose-6-phosphatase

Glycolysis

FDG FDG FDG-6-PO4

FDG PETFDG PET

Glucose-6-isomerase

PET/CT

PETPET

Shorter Shorter Less radiation Less radiation

Better resolution Better resolution Better lesion detection Better lesion detection

RADIONUCLIDE RADIONUCLIDE THERAPY THERAPY

Radionuclide Therapy Radionuclide Therapy TherapyDifferentiated thyroid cancer

Neuroblastoma stage III-VMalign pheochromacytoma

GEP-NET Tumors

Painful bone metastases

Myeloproliferative diseases (polistemia

vera)

Radionuclide Synovectomy

RadiopharmaceuticalI-131

I-131 MIBG

In-111 octreotide,Y-90 DOTATOC,Lu-177 DOTA-TATE

P-32, Sr-89, Sm-153 EDTMP,Re-186 HEDP

P-32

P-32, Re-186, Sm-153, Re-188,Au-198

Radio-iodine ThreapyRadio-iodine Threapy

• Differentiated thyroid cancerDifferentiated thyroid cancer

• Post-op.Post-op.

• Ablation of functional thyroid tissueAblation of functional thyroid tissue

• 100-200 mCi100-200 mCi

• In-patientIn-patient

MIBG therapyMIBG therapy

• Pheocromacytoma and neuroblastoma Pheocromacytoma and neuroblastoma

• Rarely medullary thyroid cancerRarely medullary thyroid cancer

• Pre or post-opPre or post-op

• Pallation or curative Pallation or curative

Lymphoma imaging using Lymphoma imaging using 111111In-In-Anti-CD20 (Anti-CD20 (ZevalinZevalin®®))

Wiseman et al. Cancer 2002;94:1349–1357

4 hours

66 hours

139 hours

Abdominal CT

Abdominal SPECT

Anterior gamma camera scans

Gastroenteropancreatic Gastroenteropancreatic Neuroendocrine Tumours (GEP-NET)Neuroendocrine Tumours (GEP-NET)Lu-177 DOTA-TATE

Treatment of Painful Bone Treatment of Painful Bone Metastases Metastases

• Alternative to analgesics, Alternative to analgesics, non-steroidal anti-non-steroidal anti-inflainflamatuary treatmentmatuary treatment, radiotherapy, , radiotherapy, chemotherapy or hormone therapychemotherapy or hormone therapy

• 3232P and P and 8989Sr Sr (beta)(beta)

• 153153Sm-EDTMPSm-EDTMP (beta and gamma) (beta and gamma)

Radionuclide Synovectomy

Radiolabeled colloidsRadiolabeled colloids

Intra articular injectionIntra articular injection

Combination of glucocorticoidsCombination of glucocorticoids

Hemophilic ArthritisHemophilic Arthritis

Rheumatoid ArthritisRheumatoid Arthritis

Intra articular pigmented villonodular synovitis Intra articular pigmented villonodular synovitis (PVNS)(PVNS)