Table Of ContentJ. Ruhlmann . P.Oehr . H.-J. Biersack (Eds.)
PET in Oncology
Springer
Berlin
Heidelberg
New York
Barcelona
Hong Kong
London
Milan
Paris
Singapore
Tokyo
J. Ruhlmann . P. Oehr . H.-J. Biersack
Editors
PET in Oncology
Basics and Clinical Application
With 95 Figures, some in Color
and 58 Tables
Springer
Dr. Dr. Jiirgen Ruhlmann
PD Dr. Peter Oehr
PET-Center
Miinsterstra6e 20
53111 Bonn, Germany
Prof. Dr. H.-J. Biersack
University Clinic Bonn
Clinic and Policlinic for Nuclear Medicine
Rheinisch-Westfalische University Bonn
Sigmund-Freud-Stra6e 25
53127 Bonn, Germany
Translated from German by:
Judith F. Lee, Ph.D. and Mary W. Tannert, Ph.D.
ISBN -13: 978-3-642-64220-3 e-ISBN-13: 978-3-642-60010-4
DOl: 10.1007/978-3-642-60010-4
Library of Congress Cataloging-in-Publication Data
PET in der Onkologie. English. PET in oncology: basics and clinical application 1 [edited by] J. Ruhl
mann, P. Oehr, and H.-J. Biersack. p. cm.
Includes bibliographical references and index. ISBN 3-540-65077-6 (hardcover: alk. paper)
1. Cancer-Tomography. 2. Tomography, Emission. I. Ruhlmann, J. (Jiirgen), 1955 - . II. Oehr, P. (Peter),
1942- . III. Biersack, H. J. IV. Title. [DNLM: 1. Neoplasms-radionuclide imaging. 2. Tomography,
Emission-Computed-methods. QZ 241 P477P 1999a]
RC270·3· T65P 4613 1999 616.99' 407575-dc21
DNLM/DLC for Library of Congress 99-26968
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Preface
Development of Positron -Emissiontomography respect to reimbursement, as well as the European
(PET) dates back to the Mid-70ieS. However, this PET consensus conferences. Nowadays, PET is a
imaging procedure gained clinical importance not well established routine procedure in lung and co
before 1990. First clinical papers were published lorectal cancer as well as malignant melanoma,
by US researchers. The patient populations were head and neck cancer and breast cancer. Other
relatively small by that time, and European as indications are lymphoma and pancreatic cancer.
well as German authors contributed results in larger Within the next years, the diagnostic spectrum of
patient populations. These clinical papers led to a PET will be widened, especially in the field of therapy
widespread application of PET in clinical routine. follow-up and proof of vitality after chemotherapy.
The clinical relevance was documented by several The increased use of PET in oncology makes evi
PET consensus conferences. However, the National dent, that it is necessary to train referring physians
Health Service System is very reluctant to pay for in PET. The aim of this book is to summarize the
PET studies. Even in Germany, PET is not yet a reg basics and the clinical results of PET and to bring
ular part of the reimbursement system. On the other them of the attention of general medicine.
hand, in solitary pulmonary nodules and brain tu
mors third party payers in United States have accep Bonn, Spring 1999 J. Ruhlmann
ted these indications. The high popularity of PET in P.Oehr
US will certainly lead to an improved situation with H.-J. Biersack
Contents
Part I Principles l.3.3 NaI Detector Technology
for Dedicated Pet-Systems ........ . 18
l.3.4 Post Injection CS-137 Singles Trans
1 Physical Principles ............. . 3
mission Improves Clinical Image
H. Newiger, Y. Harnisch, P. Oehr,
Quality, Quantitative Accuracy and
J. Ruhlmann, B. Vollet, and S. Ziegler
Enables Flexible Clinical Operation 19
1.1 PET Technology ............... . 3 1.4 Quality Control ............... . 26
H. Newiger
B. Vollet
l.1.1 The Physics of Positrons ......... . 3 l.4.1 Integrity Testing for PET Scanners
l.1.2 Measurement of Positron or Gamma Cameras with Integrated
Radiation .................... . 4 Coincidence Acquisition ......... . 28
l.1.3 Advantages of PET ............. . 4 l.4.2 Quality Assurance for
l.l.4 Production of Positron Emitters ... . 5 Transmission Measurement ....... . 32
1.1.5 Detectors for PET .............. . 6 l.4.3 Integrity Testing for In Vitro
l.l.6 Quantitative Imaging with PET 7 Analyzers and Activity Meters ..... . 32
l.l.7 Further Development l.4.4 Quality Assurance for Documentation
of PET Technology
of Findings ................... . 33
and Reconstruction Methods ...... . 9
2 Radiopharmaceutical Technology,
1.2 Dual Head Coincidence Camera 10 Toxicity and Radiation Dosages 35
S. Ziegler J. Ruhlmann and P. Oehr
1.2.1 Comparison of the
2.1 Introduction .................. . 35
Dual Head Coincidence Camera
with Other Techniques .......... . 10
2.2 The Synthesis of 2-[18F1FDG ...... . 36
l.2.2 Measurement Problems .......... . 11
2.3 Purity of the 2-[18F1FDG Solution .. . 36
1.3 Design Considerations of NaI(Tl)
Based PET Imaging Systems
2.4 2-[18F1FDG Activity Dosages ...... . 37
Adressing the Clinical and Technical
Requirements of Wholebody PET ... 15
2.5 Radiation Exposure ............ . 38
Y. Harnisch
1.3.1 Introduction .................. . 15 2.6 Biochemical Toxicity ............ . 40
1.3.2 Digital Detectors Improve Countrate
Capability .................... . 15 2.7 Conclusions .................. . 40
VIII Contents
3 Metabolism and Transport of Glucose 5.1.1 Epidemiology ................. . 67
and FDG .................... . 43 5.1.2 Histology and Staging ........... . 67
P.Oehr 5.1.3 Prognosis .................... . 67
5.1.4 Malignant Melanoma Therapy ..... . 68
3.1 Biological Functions 5.1.5 Staging and Follow-Up .......... . 68
of Carbohydrate Metabolism ...... . 43 5.1.6 Indications ................... . 69
5.1.7 Summary .................... . 69
3.1.1 Carbohydrate Requirements
& Supply .................... . 43
5.2 Head and Neck Tumors ......... . 76
3.1.2 Regulation Mechanisms ......... . 43
C. Laubenbacher, R.J. Kau, e. Alexiou,
3.1.3 Factors in Glucose Homeostasis ... . 44
W. Arnold, and M. Schwaiger
3.2 Metabolism of Glucose, 2-DG, 2-FDG 5.2.1 Introduction .................. . 76
and 3-FDG ................... . 45 5.2.2 Significance of PET ............. . 78
5.2.3 Study Protocol and Interpretation
3.2.1 Glucose ..................... . 45
of PET ...................... . 85
3.2.2 Metabolism of 2-DG, 2-FDG
5.2.4 Summary .................... . 87
and 3-FDG ................... . 46
3.3 FDG Uptake .................. . 46 5.3 Thyroid Carcinomas ............ . 89
F. Grunwald
3.3.1 Glucose Transport Systems ....... . 46
3.3.2 Glucose Transporters 5.3.1 Clinical Background ............. 89
in Cancer Diseases ............. . 50 5.3.2 Therapy. . . . . . . . . . . . . . . . . . . . .. 91
3.3.3 Kinetics of Glucose Transport ..... . 51 5.3.3 Use of FDG PET. . . . . . . . . . . . . . .. 92
3.3.4 Quantification of PET 5.3.4 Indications . . . . . . . . . . . . . . . . . . .. 98
Measurements ................ . 52 5.3.5 Results and Interpretation . . . . . . . .. 99
5.3.6 Limits of Interpretation .......... 100
5.4 Pulmonary Nodules and Non-Small-
Part II Clinical Applications
Cell Bronchial Carcinoma . . . . . . . .. 102
R.P. Baum, N. Presselt, and R. Bonnet
4 Patient Preparation ............. . 61 5.4.1 Epidemiology and Etiology
B. Kozak of Lung Cancer. . . . . . . . . . . . . . . .. 102
5.4.2 Prognosis, Histology and Staging . . .. 103
4.1 PET Scanning Technique 61
5.4.3 Diagnosis of Lung Cancer. . . . . . . .. 103
5.4.4 Therapy for Non-Small-Cell Bronchial
5 Clinical Indications ............. . 67
Carcinoma ...... . . . . . . . . . . . . .. 104
e. Alexiou, R. An, W. Arnold,
5.4.5 Positron Emission Tomography. . . .. 106
M. Bangard, R.P. Baum, H.-J. Biersack,
5.4.6 Clinical Indications for Positron
R. Bonnet, U. Bull, U. Cremerius,
Emission Tomography ........... 108
e.G. Diederichs, F. Grunwald, R.J. Kau,
5.4.7 Positron Emission Tomography:
R. Kaufmann, C. Laubenbacher,
Limitations and Pitfalls . . . . . . . . . .. 115
C. Menzel, P. Oehr, H. Palmedo,
N. Presselt, J. Reul, D. Rinne,
5.5 Breast Cancer . . . . . . . . . . . . . . . . .. 119
J. Ruhlmann, M. Schwaiger,
P. Willkomm, H. Palmedo,
P. Willkomm, and M. Zimny
M. Bangard, P. Oehr, and H.-J. Biersack
5.1 Malignant Melanoma ........... . 67 5.5.1 Introduction, Clinical Background,
D. Rinne, R. Kaufmann, Prognosis . . . . . . . . . . . . . . . . . . . .. 119
and R.P. Baum 5.5.2 Technical Aspects. . . . . . . . . . . . . .. 120
Contents IX
5.5.3 Indications . . . . . . . . . . . . . . . . . . .. 121 5.11 PET and Neuro-Imaging:
5.5.4 Summary . . . . . . . . . . . . . . . . . . . .. 126 Diagnostic and Therapeutic
Value, Current Applications
5.6 Pancreatic Cancer . . . . . . . . . . . . . .. 128 and Future Perspective ........... 165
C.G. Diederichs J. Reul
5.6.1 Clinical Principles . . . . . . . . . . . . . .. 128 5.11.1 Introduction................... 165
5.6.2 Current Therapy . . . . . . . . . . . . . . .. 129 5.11.2 Diagnostic N euroimaging
5.6.3 PET ......................... 129 and Tumour Classification ........ 166
5.6.4 Other Diagnostic Methods . . . . . . . .. 133 5.11.3 Diagnostic Imaging with PET ...... 169
5.6.5 Indications . . . . . . . . . . . . . . . . . . .. 134 5.11.4 Conclusion .................... 170
5.7 Colorectal Cancer . . . . . . . . . . . . . .. 135 5.12 Miscellaneous Tumors ........... 171
J. Ruhlmann and P. Oehr H.-J. Biersack, P. Willkomm, R. An,
and J. Ruhlmann
5.7.1 Incidence, Etiology
and Risk Factors . . . . . . . . . . . . . . .. 135 5.12.1 Brain Tumors .................. 171
5.7.2 Diagnostics . . . . . . . . . . . . . . . . . . .. 137 5.12.2 Musculoskeletal Tumors .......... 171
5.7.3 Prognosis, Staging 5.12.3 Prostate Cancer ................ 172
and Tumor Spread .............. 138 5.12.4 Bladder Cancer. . . . . . . . . . . . . . . .. 173
5.7.4 Therapy ...................... 138 5.12.5 Kidney Tumors ................ 173
5.7.5 Positron Emission Tomography. . . .. 139 5.12.6 Esophageal Cancer .............. 174
5.12.7 Gastric Cancer ................. 175
5.8 Ovarian Cancer ................ 144
5.12.8 Liver Cancer ................. " 175
M. Zimny, U. Cremerius, and U. Biill
5.8.1 Epidemiology .................. 144 6 Cancer Screening with Whole-Body
5.8.2 Pathophysiology FDG PET ..................... 179
and Tumor Spread .. . . . . . . . . . . .. 145 S. Yasuda, M. Ide, and A. Shohtsu
5.8.3 Histology .................... , 145
5.8.4 Tumor Staging ................. 145 6.1 Background ................... 179
5.8.5 Therapy ... . . . . . . . . . . . . . . . . . .. 146
5.8.6 Diagnosis ..................... 146 6.2 Cancer Screening with Whole-Body
5.8.7 Positron Emission Tomography. . . .. 146 FDG PET ..................... 179
5.8.8 Results . . . . . . . . . . . . . . . . . . . . . .. 148
6.2.1 Subjects and Methods . . . . . . . . . . .. 179
6.2.2 Results . . . . . . . . . . . . . . . . . . . . . .. 181
5.9 Testicular Tumors .............. 151
6.2.3 Cancer Screening ............... 183
U. Cremerius, M. Zimny, and U. Bull
5.9.1 Clinical Principles 6.3 Conclusions ................... 187
and Current Therapy ............ 151
5.9.2 Performing PET Scans ........... 153
7 PET and Radiotherapy 189
5.9.3 Results of PET Scans ............ 153
Val J. Lowe
5.9.4 Indications . . . . . . . . . . . . . . . . . . .. 156
7.1 Introduction . . . . . . . . . . . . . . . . . .. 189
5.10 Hodgkin's Disease
and Non-Hodgkin's Lymphomas 158
7.2 PET Before Radiation Therapy 189
C. Menzel
5.10.1 Hodgkin's Disease .............. 158 7.3 PET During Radiation Therapy 190
5.10.2 Malignant Lymphomas -
Non-Hodgkin's Lymphomas ....... 159 7.4 Reoxygenation and PET .......... 190
X Contents
7.5 PET Imaging After Completion 8 Cost Effectiveness of PET
of Radiation Therapy ............ 191 in Oncology 195
P.E. Valk
7.6 Diagnosing Recurrent Disease
with PET ..................... 191 8.1 Diagnosis and Staging of Non-Small
Cell Lung Cancer ............... 195
7.7 Timing of PET After Radiation
Therapy . . . . . . . . . . . . . . . . . . . . .. 192 8.2 Staging of Recurrent Colorectal
Cancer ...................... , 196
7.8 Summary. . . . . . . . . . . . . . . . . . . .. 193
8.3 Staging of Metastatic Melanoma .... 197
Subject Index ....................... 199
List of Contributors
Alexiou, e. Cremerius, U.
Department of Otorhinolaryngology Clinic for Nuclear Medicine
Head and Neck Surgery RWTH Aachen
Isar Right Bank Clinic, Technical University Munich PauwelsstraBe 30, 52074 Aachen, Germany
Ismaninger StraBe 22, 81675 Munchen, Germany
Diederichs, e.G.
An, R. Department of Nuclear Medicine
Clinic and Policlinic for Nuclear Medicine Ulm University Clinic
University of Bonn Robert-Koch-StraBe 8, 89070 Ulm, Germany
Sigmund-Freud-StraBe 25, 53127 Bonn
Grunwald, F.
Germany
Clinic and Policlinic for Nuclear Medicine
Arnold, W. University of Bonn
Department of Otorhinolaryngology Sigmund-Freud-StraBe 25, 53127 Bonn, Germany
Head and Neck Surgery
Harnisch, Y.
Isar Right Bank Clinic, Technical University Munich
ADAC, Europe
Ismaninger StraBe 22, 81675 Munchen, Germany
GroBenbaumer Weg 6, 40472 Dusseldorf, Germany
Bangard, M.
Ide, M.
Clinic and Policlinic for Nuclear Medicine
HIMEDIC Imaging Center at Lake Yamanaka
University of Bonn
Yanagihara 562-12
Sigmund-Freud-StraBe 25, 53127 Bonn
Hirano, Yamanashi, 401-0502, Japan
Germany
Kau, R.J.
Baum, R. P. Department of Otorhinolaryngology
PET Center, Central Clinic Bad Berka GmbH Head and Neck Surgery
99437 Bad Berka, Germany Isar Right Bank Clinic, Technical University Munich
Ismaninger StraBe 22, 81675 Munchen, Germany
Biersack, H.-J.
Clinic and Policlinic for Nuclear Medicine Kaufmann, R.
University of Bonn Department of Dermatology, Medical Center
Sigmund-Freud-StraBe 25, 53127 Bonn University of Frankfurt
Germany Theodor-Stern-Kai 7, 60590 Frankfurt, Germany
Bonnet, R. Kozak, B.
PET Center, Central Clinic Bad Berka GmbH Nuclear Medicine and Radiology Practice
99437 Bad Berka, Germany MunsterstraBe 20, 53111 Bonn, Germany
Bull, U. Laubenbacher, C.
Clinic for Nuclear Medicine Clinic and Policlinic for Nuclear Medicine
RWTH Aachen Isar Right Bank Clinic, Technical University Munich
PauwelsstraBe 30, 52074 Aachen, Germany Ismaninger StraBe 22, 81675 Munchen, Germany
