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NM By Myself > NET NM > Flashcards

NET NM Flashcards

1
Q

NET of Pancreas inoperable

A

Celiac trunk
SMA

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2
Q

NET of Pancreas M

A

Liver
Bone
Abdomen
Lung

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3
Q

NET of Pancreas G

A

G1 Ki67 <3%
G2 Ki67 3-20%
G3 Ki67 >20%

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4
Q

NET of Pancreas Syndromic

A

20%
Early detection
Small size
Insulinoma
Gastrinoma
Glucagonoma
VIPoma
Somatostatinoma
Carcinoid

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5
Q

Insulinoma

A

Most common
6-10% malignancy
Solitary
25% MEN1
10% Islet cell hyperplasia
90% < 2 cm

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6
Q

Whipple triad

A

Insulinoma
Fasting glucose <50 mg/dL
Hypoglycemia
Relief of symptoms after glucose administration

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7
Q

Gastrinoma triangle

A

Cystic duct confluence
Junction of pancreatic head and body
Junction of second and third parts of duodenum

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8
Q

Gastrinoma

A

60-90% malignant
30% with liver MTS
Multiple
75% MEN1
Zollinger-Ellinson sy - - excess of gastrin - - ulcer–PPI
Epigastric pain
Diarrhoea

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9
Q

Glucagonoma

A

60% malignant
Usually large 6 cm
Necrolytic migratory erythema (usually genitals)
4D: dermatosis, diarrhea, depression, DVT
Stomatitis, anemia, weight loss

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10
Q

VIPoma

A

10-20% extrapancreatic
80% malignant
VIP - vasoactive intestinal peptide
WDHA sy: watery diarrhea, Hypokalemia, achlorhydria

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11
Q

MEN1

A

Pituitary adenoma
Parathyroid hyperplasia
Pancreatic tumor - 40-70% NET

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12
Q

NET of Pancreas genetic

A

MEN1 - 40-70%
Von Hippel Landau - 10-17%
Neurofibromatosis type 1
Tuberous Sclerosis

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13
Q

NET of Pancreas Octreoscan

A

Negative doesn’t exclude gastrinoma or insulinoma
Glucagonoma 100%
VIPoma 88%
Carcinoid 87%
Gastrinoma 73%
Insulinoma <25%

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14
Q

NET of Pancreas Ga-DOTA-TATE

A

Gold Standard
Localisation of unknown primary
More accurate than octreoscan

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15
Q

ASVS = arterial stimulation with venous sampling

A

Intraarterial calcium stimulate insulin production
Localised insulin-secreting NET

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16
Q

NET from neuroendocrine organ

A

Medullary thyroid cancer
Pancreatic
Pheo
Paraganglioma

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17
Q

NET from dispersed neuroendocrine cells

A

Pulmonary
Gastro-entero-pancreatic

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18
Q

NET from non endocrine organ

A

Thymus
Cutaneous NET

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19
Q

Pheo and paraganglioma M

A

Bone
Liver
Lung

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20
Q

Pheo genetic

A

MEN2A, MEN2B
VHL
Neurofibromatosis type 1

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21
Q

Pheo 10%

A

Bilateral
Extra adrenal
Children
Malignant (>5 cm, SDHB mutation)

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22
Q

Pheo image

A

DOTA - most sensitive, highest detection rate of MTS, SDHB mutation
MRI - 100%
Octreotide <30%

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23
Q

MIBG Pheo and paraganglioma %

A

Specificity 100%
Sensitivity 80% 50%
MTS avid 60%

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24
Q

Preoperative biopsy not recommended
Pheo

A

Catecholamine crisis
Tumor rupture
Seeding
Complications: severe hypertension, hematoma, inadequate biopsy, delay in surgery

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25
Q

Low suspicion Pheo

A

24h urine test
Normetanephrine >900 mcg/24h
Metanephrine >400 mcg/24h
Norepinephrine >170 mcg/24h
Dopamine >700 mcg/24h

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26
Q

High suspicion Pheo

A

Plasma test
Metanephrine <0.5 nmol/L
Normetanephrine <0.9 nmol/L

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27
Q

Type I gastric Carcinoid

A

80-90%
Ass with chronic autoimmune gastritis and pernicious anemia
Fundus and body
<2 cm, multiple, localized in gastric wall

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28
Q

Type II gastric Carcinoid

A

5-7%
Hypergastrinemia from Zollinger-Ellinson sy or small intestine
Recurrent peptic ulcers
<2 cm, multiple, localized in gastric wall

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29
Q

Type III gastric Carcinoid

A

10-15%
>2 cm, single, infiltrate Perigastric tissue
Well diff - - MTS 50-70%

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30
Q

Duodenal NET

A

Gastrin producing G-cells 62% - - proximal duodenum - - MEN1
Somatostatin producing D-cells - periampullary - - somatostatinoma - - Neurofibromatosis type 1
<1 cm duodenal gastrinoma - - bulky adenopathy

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31
Q

Best prognosis among gastrointestinal NET

A

Rectum

32
Q

Worst prognosis among gastrointestinal NET

A

Colon

33
Q

Octreoscan in jejunum and ileum

A

Distinguish sclerosing mesenteritis from metastatic carcinoid

34
Q

DOTA in colon and rectum NET

A

Localization if unknown primary

35
Q

Octreotide highest affinity

A

SSTR2a/b

36
Q

SSTR density in malignant tissue

A

80-2000 fmol/mg protein

37
Q

Octreoscan protocol and preparation

A

IN111-DTPA octreotide
4h and 24h
No consensus - Stop cold octreotide: 1 day for short lived molecule, 3-4 weeks for long-acting
Mild oral laxative 1 day before and continue
120-200 MBq, SPECT
Medium energy collimator
Dual peak energy 172 and 245 keV

38
Q

Octreoscan indication

A

GEP-NET, pulmonary NET
Less - skin, paraganglioma, genital tract
Liver MTS isointense, hard to detect
Intense uptake - - higher response to PRRNT

39
Q

Small insulinoma

A

No SSTR expression

40
Q

Tc99-EDDA/HYNIC-TOC octreotide dose

A

370-740 MBq
VS Octreoscan:
Better distribution pattern
Higher tumor-non-tumor ratio
Lower radiation dose
Better spatial resolution

41
Q

Ga68-DOTA PET protocol

A

T1/2 68 min
100-200 MBq
TOC - - SSTR2
TATE - - 10*SSTR2
NOC–SSTR2, 3, 5

42
Q

Ga - DOTA uptake

A

Pituitary
Thyroid
Liver
Adrenal
Kidney
Spleen
Excrete - - bladder, intestine

43
Q

Ga-DOTA indication

A

GEP-NET and pulmonary NET
Congenital hyperinsulinism,
breast ca,
medulloblastoma,
supratentorial primitive neuroectodermal tumor,
Meningioma
Neuroblastoma
Pheo
Paraganglioma

44
Q

Catecholamine analog

A

C11-epinephrine
C11-hydroxyephedrine
F18-dopamine
F18-DOPA
I123-MIBG

45
Q

NET synthesize catecholamine

A

Transported by VMAT 1 and 2
VMAT2 in head and neck

46
Q

I123-MIBG protocol

A

At least 24h
Option 4-6h
VMAT 1
200-400 MBq
Slow IV to avoid tachycardia, pallor, vomit, abd pain
WBS speed 5-7 cm/min
Spot images 10 min per view
Medium energy high resolution collimator, 159 keV, 20% window

47
Q

I123-MIBG vs I131-MIBG

A

Imaging quality better than I131
Better spatial resolution
Higher count rate

48
Q

Stop drugs 1-3 days before MIBG
Sympathomimetics and cardiovascular

A

Antiarrhythmics
Alpha and beta blockers
Adrenergic neuron blockers
Ca-channel blockers
Vasoconstricters
Nasal decongestant
Glaucoma Sympathomimetics

49
Q

Stop neurological drugs 1-3 days before MIBG

A

Antipsychotics
Sedating antihistamine
Opioids
Tricyclic antidepressants
CNS stimulants

50
Q

Before MIBG thyroid block

A

Lugol solution 1 day before, 2 days after
K-perchlorate 4h before, 2 days after 400-600 mg/day

51
Q

MIBG uptake

A

Salivary glands
Lung
Heart
Liver
Spleen
Normal adrenal (late image)
Excrete - - kidneys, fecal

52
Q

MIBG image indication

A

Paraganglioma – uptake in heart can be very low (down regulation in response to elevated catecholamine)
High uptake in enlarged adrenal - - adrenal paraganglioma
Reduced sensitivity in extra adrenal lesions due to close to physiological uptake
Low sensitivity in paraganglioma of head and neck

53
Q

F18-DOPA preparation

A

Fast 4h
200 mg carbidopa 1h before - - increase uptake

54
Q

F18-DOPA vs MIBG

A

Higher spatial resolution
Low background activity - - detect smaller lesions
30-60 min vs 24h
No need for thyroid block and stop medication
Both VMAT1 and 2 vs VMAT1
Esp VMAT2 in head and neck paraganglioma

55
Q

F18-DOPA uptake

A

Striatum
Kidneys
Pancreas
Liver
Gallbladder
Biliary tract
Duodenum
Adrenal (high uptake in enlarged - - paraganglioma

56
Q

F18-DOPA indication

A

Highly sensitive for extra adrenal paraganglioma, esp head and neck
Residual MTC, rising markers
Pancreatic NET in patients with VHL sy
Insulinoma - preop Localisation if congenital hyperinsulinism
Children - - affected Pancreas takes up DOPA and convert to dopamine
Adults - - no dd affected vs normal pancreas due to high physiologic uptake

57
Q

F18-FDG GLUT

A

GLUT
Well-diff NET overexpress SSTR and not GLUT
poorly - diff NET - - decline tin SSTR, increase in GLUT expression

58
Q

F18-FDG indication

A

Not to localize paraganglioma
Preferred for staging and treatment monitor of metastatic adrenal paraganglioma with SDHB mutation
GEP-NET with positive FDG - - more aggressive
Pulmonary PET - - uptake depends on mitotic index and tumor proliferation rate

59
Q

Typical Carcinoid
Low proliferative index

A

Overexpress SSTR
High DOTA
low FDG

60
Q

Well-diff

A

Slow grow
Chemo ineffective
Biotherapy with somatostatin analog
Tachypylaxis early after initiation of therapy
<10% partial response

61
Q

Radionuclide therapy indication

A

All patients affected by metastatic/unresectable SSTR2-expressing NET
GEP - - frequent liver MTS
Pulmonary
Pheo
Paraganglioma
Neuroblastoma
MTC

62
Q

Y90-DOTA-TOC and Lu177-DOTA-TATE contra

A

Abs:
Pregnancy
Severe acute illness
Unmanageable psychiatric disorder
Relative:
Breastfeeding
Creatinine >1.7 (esp Y)
RBC <3, WBC <3, PLT <90 (TOC), <75 (TATE)

63
Q

Y90-DOTA-TOC and Lu111-DOTA-TATE pretreatment

A

Renal protection - L-lysine / L-arginine
Inhibit tubular reabsorption
Reduce renal absorbed dose
Hydration - over 4h,starting 30-60 min before PRRNT
25g lysine or arginine in 2L Saline
Amino acids + Gelofusine infusion (plasma expander)

64
Q

Y90-DOTA-TOC administration

A

Beta emitters
100 mCi per m^2 of body surface
Second cycle in 6-12 weeks
Or 75-120 mCi in 2-4 cycles at 6-12 weeks interval

65
Q

LU177-DOTA-TATE administration

A

150-200 mCi 3-5 cycles at 6-12 weeks interval

66
Q

Y90-DOTA-TOC vs Lu177-DOTA-TATE

A

Y90 - - higher energy beta - - more penetrating
Y90 shorter T1/2 - - higher dose rate to tumor
Lu177 - - lower energy and penetration, gamma camera suitable, shorter beta range (higher dose rate to small tumor), lower nephrotoxicity

67
Q

Y90-DOTA-TOC indication

A

Bulky and lesions with inhomogenous SSTR

68
Q

Lu177-DOTA-TATE therapy indication

A

Smaller tumors

69
Q

I131-MIBG Contra

A

Abs
Pregnancy
Life expectancy <3 months (unless palliative)
Severe renal failure + planned dialysis
Relative
Unacceptable medical risk for isolation, urinary incontinence
GFR <30 mL/min
Severe toxycities from prior treatment
WBC <3, PLT <100

70
Q

I131-MIBG treatment preparation

A

stop medication
Thyroid block 1-2 days before, over 14 days after

71
Q

I131-MIBG administration

A

No consensus - 268 or 149 mCi
Higher activity deliver dose faster with modest increase in toxicity but similar response
Slow IV 45 min-4h to avoid nausea, vomit, hypertension
Monitor vital signs over next 2-3 days
Specific activity for therapy should be higher than for diagnostic purpose

72
Q

I131-MIBG therapy indication

A

Inoperable pheo, paraganglioma, carcinoid
Stage III or IV neuroblastoma
Metastatic or recurrent MTC
GEP-NET - - palliative in SSTR-negative, borderline renal function, resistant to somatostatin therapy

73
Q

Assess SSTR overexpression and select patients for PRRNT

A

Ga68-DOTA-TATE or Ga68-DOTA-TOC

74
Q

MEN 2a

A

Parathyroid hyperplasia
Medullary thyroid carcinoma
Pheo

75
Q

MEN2b

A

Mucosal neuroma
Marfanoid body habitus
Medullary thyroid carcinoma
Pheo

76
Q

Familial Pheo

A

Hippel-Landau gene - - VHL
RET gene - - MEN2
Neurofibromatosis type 1 gene - - Von Recklinghausen disease
SDHB and SDHD genes - - familial Pheo and paraganglioma

NM By Myself (25 decks)

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