Μοριακή απεικόνιση και θεραπεία. 3 rd Nuclear Medicine dpt of AUTh I. Iakovou Assist. Professor

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1 Μοριακή απεικόνιση και θεραπεία 3 rd Nuclear Medicine dpt of AUTh I. Iakovou Assist. Professor

2 3 rd Nuclear Medicine dpt of AUTh I. Iakovou Assist. Professor I have no conflict of interest

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4 George de Hevesy 1911

5 Imaging Anatomical vs Molecular

6 Imaging Anatomical vs Molecular

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8 Hybrid imaging

9 (S) PET / CT (MRI) Υβριδική απεικόνιση

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17 The European Neuroendocrine Society (ENETS) grading system WHO classification of neuroendocrine tumours

18 Treatment guidelines

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21 March 2015

22 March 2015

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25 March 2015

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29 March 2015

30 Non specific tumor imaging 18 F-FDG Substrate based imaging 18 F-FDOPA, 11 C-5HTP Receptor-based imaging 68Ga-DOTA- TOC - NOC - TATE However, 18F-FDG-PET is currently not used for the study of neuroendocrine tumors (NETs) in a routine basis because these tumors are generally slow-growing and, accordingly, have low glycolytic activity compared to other malignancies, which may lead to a low sensitivity for 18F-FDG-PET.

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32 SSR imaging FDG imaging Clin Cancer Res 2010

33 Clin Cancer Res 2010

34 Clin Cancer Res 2010

35 11 C

36 11 C - +

37 Cured carcinoid of the small intestine? Oberg K - Theranostics (2012)

38 Mid gut carcinoid tumor with negative CI Oberg K - Theranostics (2012)

39 Fiebrich H et al. Circulation 2008;118:

40 Metastatic glucagonoma of pancreas 18 F-FDOPA 111 In-Octreoscan Multislice CT

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43 Hybrid imaging

44 «Το τεχνήτιο του PET»

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46 68 Ga-Dotatoc

47 111 In-Octreoscan 68 Ga-Dotatoc

48 68 Ga-Dotatoc 111 In-Octreoscan

49 Non functional NET with multiple liver metastases (CUP). The primary tumor was detected by PET/CT in the tail of pancread and later confirmed by EUS and biopsy

50 Non functional NET with multiple liver metastases (CUP). The primary tumor was detected by PET/CT in the tail of pancread and later confirmed by EUS and biopsy

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68 Normal 111 In-pentetreotide scan, planar + SPECT Liver meastasis

69 Binds to: SSTR 2 with high affinity, SSTR 3 and SSTR 5 with low affinity

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76 Πυρηνική Ιατρική & πραγματικότητα στην Ελλάδα

77 Πυρηνική Ιατρική & πραγματικότητα στην Ελλάδα 18 FDG, 11 CHTP, 18 FDOPA 68 Ga DOTATOC

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79 Case 1 T.S. 69 yrs Unknown primary Liver meta B SST (++), Ki67<5 Transcatheter Arterial ChemoEmbolization Ask NMdpt for PRRT

80 CT1 7/2012 CT2 10/2012

81 ΣΥΜΠΕΡΑΣΜΑ: Σε σύγκριση με το σπινθηρογράφημα ήπατος-σπληνός και την CT απεικόνιση του ήπατος (οι οποίες και αναδεικνύουν πληθώρα δευτερογενών βλαβών) δυο μόνο από αυτές (στο ΔΕ ηπατικό λοβό) εκφράζουν παθολογικά υποδοχείς σωματοστατίνης (κατά κύριο λόγο τύπου ΙΙ). Η πολύ χαμηλή πρόσληψη του ραδιοφαρμάκου δεν καθιστά την ασθενή υποψήφια για θεραπεία με επισημασμένα ανάλογα σωματοστατίνης.

82 ΣΥΜΠΕΡΑΣΜΑ: Σε σύγκριση με το σπινθηρογράφημα ήπατος-σπληνός και την CT απεικόνιση του ήπατος (οι οποίες και αναδεικνύουν πληθώρα δευτερογενών βλαβών) δυο μόνο από αυτές (στο ΔΕ ηπατικό λοβό) εκφράζουν παθολογικά υποδοχείς σωματοστατίνης (κατά κύριο λόγο τύπου ΙΙ). Η πολύ χαμηλή πρόσληψη του ραδιοφαρμάκου δεν καθιστά την ασθενή υποψήφια για θεραπεία με επισημασμένα ανάλογα σωματοστατίνης.

83 Case 2 R.A. 49 yrs Small Cell Lung Cancer B TTF1 (-), CD56 (+), Ki67 2 Chemo ttt Ask NMdpt for PRRT

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86 Left lung Posterior & middle mediastenum & Right anteroposterior mediastenum ratio, Krenning score 3

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90 Case 3 X.T. 59 yrs Carcinoid of small intestine (ressetced) Liver meta B grade G2 (ENETS), Ki67 4% Ask NMdpt for PRRT

91 CT JULY Octreoscan JULY

92 CT NOVEMBER Octreoscan DECEMBER

93 JULY DECEMBER CT JULY CT NOVEMBER

94 7/ /2012

95 Hofman MS. Australian Doctor, Mar. 16, 2011.

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97 Case 4 M.A. 58 yrs 2003 carcinoid in small intestine ressected, no mitotic activity 2007: mdtc ressetced, RAI, WB(-) Tg(-) AbTg(-) 2008: liver meta + symptomatology, CT (-) 2009: octreoscan (+) liver, abdomen 2011: progression (liver CT + symptoms) Ask NMdpt for PRRT

98 Case 4 M.A. 58 yrs 2003 carcinoid in small intestine ressected, no mitotic activity 2007: mdtc ressected, RAI, WB(-) ablation

99 Case 4 M.A. 58 yrs 2003 carcinoid in small intestine ressected, no mitotic activity 2007: mdtc ressected, RAI, WB(-) 2008: liver meta + symptomatology, CT brain (-) 2009: octreoscan (+) liver, abdomen Ask NMdpt for PRRT

100 Case 4 M.A. 58 yrs 2003 carcinoid in small intestine ressected, no mitotic activity 2007: mdtc resetced, RAI, WB(-) 2008: liver meta + symptomatology, CT (-) 2009: octreoscan (SST+) liver, abdomen Myoset + SSA_LAR OK

101 Case 4 M.A. 58 yrs 2003 carcinoid in small intestine ressected, no mitotic activity 2007: mdtc resetced, RAI, WB(-) 2008: liver meta + symptomatology, CT (-) 2009: octreoscan (+) liver, abdomen 2011: progression (liver CT + symptoms) carvoplatine CT stable disease, chromogranine (665), diarrhea

102 Case 4 M.A. 58 yrs 2003 carcinoid in small intestine ressected, no mitotic activity 2007: mdtc ressected, RAI, WB(-) 2008: liver meta + symptomatology, CT (-) 2009: octreoscan i (+) liver, abdomen 2011: progression (liver CT + symptoms) 11/2011: octreoscan ii Ask NMdpt for PRRT

103 liver abdomen ratio, Krenning score 3

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105 3 x 200 mci 177 Lu-DOTATATE 05/ / /2012

106 3 x 200 mci 177 Lu-DOTATATE 1 st 177 Lu 05/ nd 177 Lu 07/ rd 177 Lu 09/2012

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108 Case 4 M.A. 58 yrs 2003 carcinoid in small intestine resetced, no mitotic avtivity 2007: mdtc resetced, RAI, WB(-) 2008: liver meta + symptomatology, CT (-) 2009: ocreoscan i (+) liver, abdomen 2011: progression (liver CT + symptoms) 11/2011: octreoscan ii Ask NMdpt for PRRT

109 Tu Relaps 200 mci 177Lu-DOTATATE relaps 200 mci 177 Lu-DOTATATE 4th cycle 5th cycle

110 Case 5 S. G. 64 yrs History of interstitial lung disease Unknown primary (small intestine?) Liver, abdominal, bone meta + symptomatology 2011: progression (liver CT + symptoms)

111 Case 5 S. G. 64 yrs History of interstitial lung disease Unknown primary (small intestine?) Liver, abdominal, bone meta + symptomatology 2011: progression (liver CT + symptoms)

112 Case 5 S. G. 64 yrs History of interstitial lung disease Unknown primary (small intestine?) Liver, abdominal, bone meta + symptomatology 2011: progression (liver CT + symptoms) Ask NMdpt for PRRT

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115 Onalta 3 x 120 mci 90 Y-DOTATOC 05/ / /2012

116 1 st 90 Y 05/ nd 90 Y 07/ rd 90 Y 09/2012

117 Case 5 S. G. 64 yrs History of interstitial lung disease Unknown primary (small intestine?) Liver, abdomianl, bone meta + symptomatology 2011: progression (liver CT + symptoms) Symptoms remission, Cga Died 01/2013 pulmonary infection Ask NMdpt for PRRT

118 Case 5 S. G. 64 yrs History of interstitial lung disease Unknown primary (small intestine?) Liver, abdomianl, bone meta + symptomatology 2011: progression (liver CT + symptoms) Symptoms remission, Cga Died 01/2013 pulmonary infection Ask NMdpt for PRRT

119 Case 5 S. G. 64 yrs History of interstitial lung disease Unknown primary (small intestine?) Liver, abdomianl, bone meta + symptomatology 2011: progression (liver CT + symptoms) Symptoms remission, Cga 90 Y DOTATOC Died 01/2013 pulmonary infection Ask NMdpt for PRRT

120 Case 6 Α. G. 64 yrs Unknown primary Symptomatology ± controlled with SSA_LAR Liver meta B grade G3 (ENETS), Ki67 23% Ask NMdpt for SIRT Selective Internal RadioTherapy

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122 Nuklearmedizin Universitätsklinikum des Saarlandes 3 rd Nuclear Medicine dpt Aristotle University 3,3 GBq 90 Y- TheraSphere TheraSphere consists of insoluble m glass spheres with 90Y as an integral constituent of the glass matrix

123 Right liver lobe SIRT

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125 4 months after 1st SIRT in RL

126 2nd SIRT LL

127 2nd SIRT LL

128 SIRT 2nd SIRT LL

129 Case 7 G. G. 64 yrs bronchopulmonary neuroendocrine tumor Liver, abdomianl, bone meta + symptomatology 2014: progression (liver CT + symptoms) Ask NMdpt for PRRT

130 Case 7 G. G. 64 yrs bronchopulmonary neuroendocrine tumor Liver, abdomianl, bone meta + symptomatology 2014: progression (liver CT + symptoms) Ask NMdpt for PRRT

131 Case 7 G.G 64 yrs bronchopulmonary neuroendocrine tumor Liver, abdomianl, bone meta + symptomatology 2014: progression (liver CT + symptoms) DO NOT Ask

132 malignant paraganglioma Case 8 SSR SPECT/CT

133 malignant paraganglioma Case 8

134 Case 8 G.G 64 yrs bronchopulmonary neuroendocrine tumor Liver, abdomianl, bone meta + symptomatology 2014: progression (liver CT + symptoms) DO NOT Ask

135 C o n c l u s i o n s - No OCTREOSCAN TEKTROTYD - No PET/CT 68 Ga DOTATOC, 18 FDG, 11 CHTP, 18 FDOPA -15,000 Euro for one (1) therapy session!!! - γραφειοκρατεία (± 2 months, indication)

136 C o n c l u s i o n s Success condition? Cooperation and specialization

137 Romanticism vs. Realism vs. Hyperrealism Jeune orpheline au cimetière (Eugène Delacroix) Woman Eating (Duane Hanson) Young Women from the Village (Gustave Courbet)

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140 111 In DOTA gastrin Χαμηλή νεφρική πρόσληψη Ελκυστική (-) τάχιστη ενζυματική αποδόμιση συγχoρήγηση με αναστολέα ενδοπεπτιδάσης (phosphoramidon) Tumor uptake μεχρι και 72 p.i. με χαμηλή νεφρική πρόσληψη

141 111 In DOTA gastrin Χαμηλή νεφρική πρόσληψη Ελκυστική (-) τάχιστη ενζυματική αποδόμιση συγχoρήγηση με αναστολέα ενδοπεπτιδάσης (phosphoramidon) Tumor uptake μεχρι και 72 p.i. με χαμηλή νεφρική πρόσληψη

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