Male Cancer NM Flashcards
Prostate cancer N
True pelvis below bifurcation of common iliac arteries
N1 - - stage IV
Prostate cancer M
Bone 90% - - lumbar spine >cervical - - M1b
Lung
Liver
Pleura
ISUP and Gleason
PSA
Nonspecific
Increase with age, size, prostatitis
Elevated - - rectal exam - - US, CT, MRI
TRUS - - >26 mm - - 92% detection rate
Doubling time >6 m– recurrence
Prostate cancer CT, MRI
CT - - staging in high volume disease
Not accurate for intraprostatic, local staging
MRI - - PI-RADS–local staging
Radionuclide therapy Lu177
Beta, 490 keV
Max tissue penetration 2 mm - - better irradiation
Gamma, 208 and 113 keV - - image
T1/2 6.73 days
3-8 GBq up to 6 injections at 6 weeks interval
Slow IV, 5 ml
Hydration before and after 1.5 l
Remain in hospital 2-4 h
Freeze salivary gland for 30 min before
Radionuclide therapy Ra223 dichloride
Xofigo
Alpha, penetration <100 microm - - lethal DNA damage - - lower hematological toxicity
T1/2 11.43 days
Indication: castration - resistant cancer, symptomatic bone MTS, no visceral MTS
Accumulate: bones, areas of high bone turnover
Slow IV, 3.85 MBq (194 microCi) for 70 kg
6 administrations at 4 weeks interval
Xofigo before treatment
Hb>10
Abs neutrophil count >1.5*10^9 l
PLT >100
Subsequent: abs neutrophil count >1, PLT > 50
No fast, well hydration
Stop Calcium, Phosp, Vit D for 4 days before and after
Xofigo objective marker of response
PSA and AlcPhos
Xofigo side effects
Fecal excretion > renal
Combi with chemo - - jaw osteonecrosis
Bone scan indication for prostate cancer
PSA>10 mg/ml
High Gleason
Locally advanced
Elevated AlcPhos
Bone symptoms
Monitor response to treatment
After treatment - - symptomatic patient or after biochemical recurrence
Bone scan sensitivity
More sensitive than CT
Sensitivity 75-95%
PSA >50 ng/mL - - up to 50% likely bone MTS
Bone scan false positive
Osteochondrosis
Inflammation
Trauma
Bone scan interpretation
Flare phenomenon - - between 2w and 3m after chemo - - good response
Continued increase >6 m - - disease progression - - superscan
Androgen deprivation therapy - - gynecomastia
F-fluoride PET/CT
F-NAF
Same mechanism and indication as bone scan
Response to treatment - - better performance than bone scan
Sensitivity 91%
Specificity 83%
40-100 microCi/kg, max 370 MBq for obese
Image 90-120 min after IV
Same interpretation
FDG PET for prostate cancer
Low grade - - low levels of GLUT1 - - low uptake
Aggressive - - high uptake - - poor prognosis
Biochemical recurrence - - high uptake
C11-choline PET
Cyclotron
T1/2 20 min
370-740 MBq
3-5 min after IV
Excretion through liver, little activity in urinary tract
ADT reduce uptake of C-choline in Androgen sensitive cancer
F-choline PET
4.1 MBq/kg
60-90 min
Choline PET
Phosphorylated by choline kinase - - trapped within cancer cells
Fast 4-6h, but not strictly necessary
Hydration
Physiologic uptake - - salivary glands, liver, pancreas, renal parenchyma, urinary bladder
Main limitation - - low specificity
F-choline PET indication
Initial staging of high risk - - Gleason >7, PSA>20, T2c-3a
Restaging - - uptake higher in patients with higher PSA, higher Gleason, shorter PSA doubling time
Localisation if negative biopsy but elevated PSA - - specificity 25%
Treatment monitor - - esp if PSA>4 ng/ml
Radiotherapy planning
Increased PSMA expression correlates with
High tumor grade
Advanced pathological state
Aneuploidy
Biochemical recurrence
Androgen independent tumor
GA68-PSMA indication
Primary staging in high risk before surgery or radio (PSA>20 , Gleason >7, T2c-3a
Staging before and during PSMA directed radiotherapy in metastatic castration resistant cancer - - low uptake - - contra for radiopharm therapy
Targeted biopsy after negative biopsy
Localisation of recurrent cancer with low PSA 0. 2-10
Monitoring of treatment
Not to replace MRI in local delineation
GA68-PSMA
T1/2 67.63 min, generator
1.8-2.2 MBq/kg
No fast, hydration
60 min after IV
Physiologic uptake - - lacrimal, salivary gland, liver, spleen, colon, kidney (proximal renal tubules), epididymis, ovary, small intestine (luminal side of ileum-jejunum), astrocytes in CNS
PSMA other cancer
Colon. Bladder
Pancreas
Esophagus
Thyroid
Lung
RCC
Brain
Benign tissue
PSMA pitfall
Celiac ganglia - - misinterpretation of retriperitoneal LN
Paget disease
Stellate or other ganglia
Ribs
F-PSMA
Better spatial resolution
Shorter positron range
More accurate Quantification
No need for chelator to bind radiometal
F-choline
FDG
Penile cancer
FDG in testicular cancer
Testicular cancer germ cell 95%
Seminoma 50% - - radiosensitive, poor prognosis
Non Seminoma 50% - - early MTS to retriperitoneal
Testicular cancer non germ cell
Sex cord and stromal tumor - - Leydig, Sertoli, Granulosa cell, Fibroma-thecoma
Tumors with both sex cord and stromal cells and germ cells - - gonadoblastoma
Testicular cancer serum
AFP, hCG, LDH
Testicular cancer biopsy
No
Lead to nonperitoneal lymphatic dissemination of tumor cells
Testicular cancer MRI
Complicated cases
Accurate dd Seminoma (multinodular homogenous) vs non Seminoma (heterogenous mass with cystic changes and calcification)
Testicular cancer CT
Insensitive
Only LN, MTS
Residual mass and normal marker
Testicular cancer
FDG
Negative - - surveillance
Positive - - surgery, biopsy
Testicular cancer FDG indication
Not for initial evaluation
SUV >3 - - cutoff for suspicion of malignancy
Equivocal findings on CT
Elevated markers and negative CT
Post chemo residual GCT mass >3 cm - - dd residual vs fibrosis 6 weeks after chemo - - repeat in 6 weeks
Not for post chemo restaging of non GCT
Post chemo residual non GCT mass - - false negative - - necrosis, vital carcinoma, mature teratoma (chemo resistant, FDG avid)
Testicular cancer
FDG diagnosis and staging
Sensitivity 75%
Specificity 80%
Non seminoma - - lower sensitivity
False negative - - partial volume effect on small lesions
Stunned tumor
Mass with residual malignancy remain negative on FDG for 10-14 days after chemo
Penile cancer FDG
No role in primary neoplasm
Staging if palpable LN
Response to chemo
Inguinal LN
Bladder catheter to avoid urine contamination
20 mg IV fusid 20 min after FDG - - accelerate renal clearance
20 mg butylscopolamine - - decrease intestinal activity
F-fluciclovine
F-FACBC PET
Proliferation and angiogenesis
High uptake in liver, red bone marrow, lung, pancreas
Minimal excretion through kidneys
4-5 min after IV
Sensitivity directly correlates with PSA concentration, inversely correlate to PSA doubling time
Similar uptake in benign hyperplasia
