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

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

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

George de Hevesy 1911

Imaging Anatomical vs Molecular

Hybrid imaging

(S) PET / CT (MRI) Υβριδική απεικόνιση

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

Treatment guidelines

March 2015

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.

SSR imaging FDG imaging Clin Cancer Res 2010

Clin Cancer Res 2010

11 C - +

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

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

Fiebrich H et al. Circulation 2008;118:1602-1604

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

Hybrid imaging

«Το τεχνήτιο του PET»

68 Ga-Dotatoc

111 In-Octreoscan 68 Ga-Dotatoc

68 Ga-Dotatoc 111 In-Octreoscan

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

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

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

Πυρηνική Ιατρική & πραγματικότητα στην Ελλάδα

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

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

CT1 7/2012 CT2 10/2012

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.

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

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

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

CT JULY Octreoscan JULY

CT NOVEMBER Octreoscan DECEMBER

JULY DECEMBER CT JULY CT NOVEMBER

7/2012 12/2012

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

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

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

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

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

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

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

liver abdomen ratio, Krenning score 3

2009 2011

3 x 200 mci 177 Lu-DOTATATE 05/2012 07/2012 09/2012

3 x 200 mci 177 Lu-DOTATATE 1 st 177 Lu 05/2012 2 nd 177 Lu 07/2012 3 rd 177 Lu 09/2012

05/2012 01/2013

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

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

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)

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

Onalta 3 x 120 mci 90 Y-DOTATOC 05/2012 07/2012 09/2012

1 st 90 Y 05/2012 2 nd 90 Y 07/2012 3 rd 90 Y 09/2012

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

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

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

Nuklearmedizin Universitätsklinikum des Saarlandes 3 rd Nuclear Medicine dpt Aristotle University 3,3 GBq 90 Y- TheraSphere TheraSphere consists of insoluble 20-30 0m glass spheres with 90Y as an integral constituent of the glass matrix

Right liver lobe SIRT

4 months after 1st SIRT in RL

2nd SIRT LL

SIRT 2nd SIRT LL

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

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

malignant paraganglioma Case 8 SSR SPECT/CT

malignant paraganglioma Case 8

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

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)

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

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

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