核医学教学课件：肿瘤显像

1、Tumor Imaging PET（PET/CT） Imaging OthersPart IPET（PET/CT） Imaging 葡萄糖和18F-FDG的分子结构比较 18F-FDG: Century MoleculeMechanism of 18F-FDG Uptake in tumor cellsF-18-Flurodeoxyglucos 6-P-FDG Glucose CO2 + H2OCell 6-P-glucoseGluthexokinaseGlucose 6 phosphatase1.Increased expression of glucose transporter mole

2、cules at the tumor cell surface;2.Increased amounts/activity of hexokinase;3.Reduced amounts of glucose 6 Phosphatase versus most normal tissues.FDG Uptake Ratios in Tumors荷人肿瘤模型注射18F-FDG 2h后 瘤/血液比值Fused PET/CT scatter correction attenuation correctionSpiral CT: 1-2 min4080 mAs; 140 kVpWB PET: 28 mi

3、n60 min uptakePETCTPET18F-FDG58 mCi I.V.C TFUSIONRESTMethodsImage AnalysisVisual interpretationQuantitative analysis Standardized uptake value (SUV)（标准摄取比值） tissue concentration (MBq/g) injected dose / body weight Metabolic Rate of Glucose (MRGlu)（葡萄糖代谢率） Tumor/nontumor uptake ratios (T/N) SUV =18F-

4、FDG PET : Normal Image(coronal images)假阳性生理性摄取：唾液腺及头颈部淋巴组织、甲状腺、棕色脂肪、胸腺、哺乳乳房、乳晕、骨骼肌和平滑肌、消化道、泌尿系统、女性生殖系统（经期子宫及卵巢黄体囊肿）炎症：术后炎症、感染或出血，活检部位，截肢部位；放疗后；化疗后；局部的炎性病变（结节病、真菌感染、分枝杆菌感染）；造瘘部位（气管、结肠等）；注射部位；甲状腺炎；食管炎、胃炎、炎性肠病；急性或偶发的慢性胰腺炎；急性胆管炎和胆囊炎；骨髓炎、近期的骨折、关节假体；淋巴结炎良性肿瘤：垂体腺瘤、肾上腺腺瘤、甲状腺滤泡状腺瘤、唾液腺肿瘤（Warthins 肿瘤 或 多形性腺瘤）、

5、结肠腺瘤样息肉和绒毛状腺瘤、卵巢的卵泡膜细胞瘤和囊腺瘤、巨细胞瘤、动脉瘤样骨囊肿、平滑肌瘤增生和发育不良：Graves 病，Cushings 病，骨髓增生（贫血或细胞因子治疗），胸腺增生（化疗后），骨纤维异常增生症，Pagets 病缺血：冬眠心肌伪影：PET、CT未配准导致衰减校正伪影，金属和高密度钡剂的伪影棕色脂肪卵巢及乳腺生理性摄取亚甲炎肌肉伪影肠道伪影技术伪影：CT与PET融合误差假阴性病灶小（10 ng/dLnot breast masses or regional nodesCT/MRI neg for extra-pelvic metsnot regional nodesonly

6、non-small cellwhen enrolled in NOPRCED, coverage with evidence development; NC, non-covered;Clinical IndicationDetect occult lesionsDistinguishing between malignant and benign disease (良恶性病变鉴别)Malignant disease staging and grading (临床分期和分级) Treatment planning (制定治疗方案)Radiotherapy planning (辅助制定放疗计划)

7、Differentiating remains/recurrent disease from radiotherapy/ surgery-induced necrosis/ scar(放疗/术后残留/复发与坏死/瘢痕组织鉴别）Monitoring response to therapy and evaluating prognosis（疗效监测评价，预后判断）Searching for primary lesion（寻找原发肿瘤病灶）Lung cancerTNM staging treatment planning prognosis evaluating superior to CT Mon

8、itoring response to therapy and detecting recurrent diseaseFDG PETCTStudies1429Number of patients5142,226Sensitivity79%60%Specificity91%77%SPN (Solitary pulmonary nodule)Meta-analysisSquamous cell carcinoma（鳞状细胞癌）CT: benign lesion in left inferior lobePET/CT: benign lesion Histology: hamartoma（错构瘤）A

9、 51-year-old man, recurrent cough and emptysis for 4 monthsChest CT: benign lesion in right lungOther examinations（bronchoscope and sputum examination）:normalPET/CT: intense uptakemalignant lesion Histology: Squamous cell carcinoma 左侧胸水待查，支纤镜左支气管充血肿胀、左下叶支气管狭窄CT未发现病灶，胸水癌细胞（），CEA（）PET：左叶肺癌穿刺活检：低分化腺癌ad

10、enocarcinoma Tuberculoma(结核球)CT: multi-lesion in right lungPET: intense uptakeHistology： inflammatory granuloma (炎性肉芽肿) Lung cancer with mediastinal lymph nodes metastasisLung cancer with brain metastasisLung cancer with liver，adrenal gland and osseous metastasesLung cancer with mediastinum lymph no

11、des， liver metastases肺癌伴纵膈淋巴结、双肺、肾上腺、脑及广泛骨转移surgeryNo surgerySome surgeryMonitoring Response63 year old man stage 3A lung cancer, has received 4 cycles of chemotherapy 肺癌化疗后Breast cancerSensitivity 82%100%Specificity 68%100%Sensitivity 79%100%Specificity 66%100%。 Distinguishing between malignant and

12、 benign breast tumor Detecting axillary lymph nodes metastasis Detecting recurrent disease or remains post-surgery Monitoring response to therapy and evaluating prognosisBreast cancerBreast cancer with axillary lymph node metastasisBreast cancer with lymph nodes and osseous metastases乳腺癌伴淋巴结、肝、骨转移3

13、years after mammectomy, liver metastasisA 65-year-old female, 5 years after mammectomy of left breast. PET-CT: intense uptake at left supraclavicular and mediastinal lymph node metastasis 监测和评价治疗反应Breast cancer case, chemohormonotherapy Follow-up: 0, 21, 42, 63 days监测和评价治疗反应Breast cancer, after thre

14、e cycles of chemotherapy. A mammectomy required.Tumor of digestive system18F-FDG 评价结直肠癌探测结直肠癌肝转移准确性 PET 92%，常规 CT78%，CT门脉造影80%。肝外转移检出率 PET 92%，CT 71%。对378例患者的研究显示: 27%的患者18F-FDG PET查出原来未发现的转移灶 37%的患者治疗方案因PET结果修订对于血清CEA升高而常规影学检查结果阴性的患者，有必要进行PET检查。A 45-year-old female,3 years post colectomyCEA: increa

15、sedPET-CT: intense uptake at ascending colon and mesenteric lymph nodes recurrent cancer with metastasisRectal carcinoma直肠癌伴多发淋巴结Mpancreatic cancerPancreatic cancer with liver metastasesLiver cancerPET-CT: increased uptake in left liver and portal veinliver cancer with tumor embolus in portal veinA-

16、C：HCC Grade1(Edmondson and Steiner分级). A：CT low density；B：18F-FDG no uptake；C：11C-acetate high uptake (pancreas metastasis).D-F：HCC Grade3 (Edmondson and Steiner分级). D：CT low density；E：18F-FDG high uptake；F：11C-acetate no uptake.Stomach cancerEsophageal cancer with liver metastasis吻合口复发伴纵膈淋巴结转移食管癌术后

17、肝门与胰头间淋巴结MLymphomaDiagnosisClinical StagingMonitoring response to therapy18F-FDG PET/CT已经建议作为恶性淋巴瘤的初始分期、再分期及疗效随访的标准影像技术。弥漫大B淋巴瘤（FUO）Lymphoma（right tonsil） with cervical lymph node metastasis 女，21岁，学生。多浆膜腔积液待查颜面浮肿三月，加重伴呼吸困难半月，发现纵隔淋巴结肿大一周入院。三次心包积液细胞学检查均见可疑瘤细胞。 CT：纵隔内多发淋巴结肿大，心包少量积液。 骨穿：骨髓增生明显活跃。 细胞学：NH

18、L。Non-Hodgkins lymphomaNHL纵隔及腹膜后等广泛淋巴侵犯Hodgkins lymphoma with spinal marrow involvement淋巴瘤浸润淋巴结、肝、脾、骨髓 （NK/T），NH LymphomaDeauville 标准 Pre-TherapyPost-TherapyHead and Neck CancerDiagnosisDetecting the recurrent or remainsMonitoring response to therapyNasopharyngeal carcinomaNasopharyngeal carcinoma w

19、ith cervical lymph nodes metastasis（鼻咽癌伴颈部淋巴结转移）A 32-year-old malePre-radiotherapy: right nasopharyngeal carcinoma with both sides lymph nodes metastasis. Post-radiotherapy: right nasopharyngeal carcinoma and right lymph nodes metastasis disappeared but left lymph nodes metastasis remainedpre-radiot

20、herapypost-radiotherapyA 25-year-old man with Nasopharyngeal carcinoma , 2 years post-radiotherapy.PET-CT: intense uptake recurrent carcinomaLaryngocarcinomaBrain cancerArachnoid cyst (蛛网膜囊肿)Glioma (右额神经胶质瘤)Glioma III-IV 鉴别肿瘤放疗后坏死 /复发 脑肿瘤放射坏死A: MR T1加权图象，病灶边缘呈增强征象。B：PET 图象显示病灶无FDG摄取 A BRecurrent dis

21、ease 1 month post-surgeryA year post-surgeryThyroid Cancerfollicular adenocarcinoma(甲状腺滤泡样腺癌)follicular adenocarcinoma(甲状腺滤泡样腺癌)Melanoma with inguinal lymph node metastasis Searching for Unknown Primary TumorsThe criteria for the diagnosis of UPT Biopsy-proven malignancy (For a cancer that could not

22、 have origin at the biopsy site) No primary tumor found after a thorough medical history or physical examination (including breast and pelvic examination in women and testicle and prostate examination in men) Normal laboratory test results, including the results of a complete blood count, blood chem

23、istry, chest X-ray, computed tomography (CT) scan of the abdomen and pelvis, and mammography or prostate-specific antigen (PSA) test Cancer 2004,100:1776-1785. a 58-year-old male with brain metastasis (be surgically removed). A: The whole body PET image showed increased uptake (red arrow). B: Focus

24、tracer uptake was shown in the right apex (red arrow). Histology confirmed to be large-cell anaplastic carcinoma.OthersHealth examination（？）Sampling directionHealthy Examination A 42-year-old femalePET-CT: intense uptake in right thyroidmalignantHistology: papillary adenocarcinoma体检疑乳腺癌Healthy Exami

25、nationPET-CT: intense uptake at mid-low part of esophagus, SUVave 3.6, SUVmax 7.2; Sampling was taken by gastroscopy according to PET/CTcarcinoma in situ（原位癌）, be confirmed by histology after surgery肿瘤生物调强与适形放疗Multi dimensional conformal radiotherapy, MDCRT （物理适形与生物适形结合） 根据肿瘤不同部位的活性使用不同的放疗剂量PET/CT在放

26、疗全过程中发挥着独特的作用肿瘤定性临床分期靶区勾画剂量指导疗效评价PET与临床决策大约2040的患者因PET检查而改变了治疗方案国内外均在进行相关研究不同国家和不同病种可能有不同结果与医疗保险制度相关至少在肺结节、结（直）肠癌可以大大节省医疗支出。PET的成本效益分析临床分期与治疗抉择Problems and Pitfalls False positive findingsNormal physiologyGranulomas and other infectionsAdenomasTumor histologyLesions smaller than 8 mmDiabetes/Non-fas

27、ting patients False negative findings56 year man with HCV, end stage liver disease, and presumed hepatomaStandard CTPET/CTPhysiologic Uptake: Brown FatInfection68 year old man with solitary lung nodule. Biopsy: aspergillosis (曲霉菌）Tuberculosis of lymph nodesClinical Impact of PET/CT More accurate dia

28、gnosis Avoidance of unnecessary tests, and (potentially) harmful procedures Better treatment or management36.5% change in decision to treat or not treatWhy PET-CT?Part IINon-specific positive imaging67Ga-citrate imaging201Tl/99mTc-MIBI imaging 99mTc-(V)-DMSA imagingApoptosis imaging （ 凋亡显像）Hypoxic i

29、maging （乏氧显像）Gallium-67 tumor imagingMultiple mechanismFirst used clinically in 1969 for tumor detection in patients with Hodgkins diseaseTumor staging and Evaluation response to therapy of patients with HD or non-HL become the most common clinical indication for 67Ga tumor scintigraphyTumor staging

30、 (Hodgkins disease)Stage IStage IIStage IIIResponse to therapy Primary fibrosarcoma of left superior femur左股骨上端原发性纤维肉瘤Lung cancerfollicular adenocarcinoma甲状腺滤泡样腺癌papillary adenocarcinoma甲状腺乳头状腺癌HyperparathyroidismMediastinal adenoma99mTc-MIBIBreast cancermammary x-ray a nodule in left breast99mTc-MI

31、BIintense uptake in left breast and left axilla (腋窝）histological diagnosis infiltrating tubularcarcinoma with metastasis of left axilla lymph node（浸润性导管癌）a palpable mass in right breast99mTc-MIBIslightly increased uptakehistological diagnosis fibroadenoma（纤维腺瘤）鼠肿瘤模型99mTc-Annexin V凋亡显像（A为对照；B为环磷酰胺处理后

32、24h行凋亡显像，箭头处放射性浓聚灶示肿瘤凋亡） Apoptosis imagingHypoxic imaging艾氏腹水癌昆明小鼠模型99mTc-HL91乏氧显像Specific positive imagingTc-99m MDP bone scan I-131: papillary-follicular thyroid cancerTc-99m HIDA: hepatocyte origin tumorsI-131 MIBG: neural crest tumor (adrenal medulla tumor imaging)I-131 NP-59: adrenal cortical t

33、umor imagingRII (radioimummunoimaging): Radiolabeled monoclonal antibodies against tumor surface antigens Receptor Imaging: Radiolabeled peptide against tumor receptors Gene imaging: Antisense imaging/Report gene imagingDiscussed in other chaptersHot spot of studyWhole body bone scan131I whole body

34、scan131I-MIBG imaging: adrenal medulla tumor商品名及上市时间单克隆抗体种类核素适用肿瘤OncoScint1994B72.3抗高分子量肿瘤相关糖蛋白（TAG-72）鼠源性IgG单抗111In结（直）肠癌，卵巢癌CEA-SCAN1996CEA抗体IMMU-4 Fab片段99mTc结（直）肠癌ProstaScint19967E11-C5.3 (CYT356)单抗-GYK-DTA和111In的结合体111In前列腺癌Verluma1996鼠源性抗40kd糖蛋白IgG2b单抗NR-LU-10的Fab片段99mTcSCLC、NSCLC、乳腺癌、卵巢癌、结肠癌和前

35、列腺癌。Radioimummunoimaging (RII)89Zr 标记的抗体热点 111In-OncoScint imagingA 77 year-old male who presented with rectal cancer in 1995. CEA-Scan Positive 5 Months Before CT Receptor Imaging显像剂受体肿瘤用 途123I(131I)-MIBG（间碘苄胍）肾上腺素受体嗜铬细胞瘤、神经母细胞瘤和甲状腺髓样癌等11C-羟基麻黄素肾上腺素受体心脏功能、充血性心力衰竭诊断，心肌存活性，肾上腺素瘤诊断和鉴别诊断111In(99mTc、68Ga)-octreotide(奥曲肽)生长抑素(SMS)受体神经内分泌肿瘤（胃肠、胰、脑神经内分泌肿瘤，小细胞型肺癌、嗜铬细胞瘤和副神经瘤、甲状腺髓样癌、类癌等）18F-FES（16 a-18F-17 b-estradiol）雌激素受体乳腺癌，内分泌治疗和疗效监测18F-FDHT 雄激素受体前列腺癌，内分泌治疗