overview image guided biopsies current gold standards pet/ct guided biopsy protocol...
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OverviewImage guided biopsies
Current gold standardsPET/CT guided biopsy
ProtocolAdvantages/disadvantagesUtilityFeasibility in Canada
Case Studies
Biopsy SignificanceIndividualized treatment regimen
Accurate tumor stageDistant mets
Patients in palliative situationsLess aggressive treatmentsBurden vs. quality of life
Cell-typing
Gold Standards Ultrasound CT
MRI
http://www.clinicalimagingscience.orghttps://iame.com http://radiology.ucla.edu
Gold Standard Modality Limitation
UltrasoundRetroperitoneal or deep pelvis,
masses surrounded by lung, bone, and/or bowel
CT Contrast is evanescent or valuable only in venous or arterial phase
MRIAbdominal masses require wide or open bore magnet, MR compatible
devices
• Modalities capable of identifying anatomical and structural changes
PET/CT Guided Biopsy
(Klaeser et al., 2009)
Effectiveness of PET/CT Guided BiopsyBegan with retrospective fusion
Previously acquired PET or PET/CT images to intraprocedural CT images
Target alignment not optimalNow moved to real-time imaging in the
PET/CT suite
ProtocolRoutine PET patient prepDiagnostic PET/CT image acquired
Eyes to thighsCan also use 185MBq dose for biopsy
Patient positioning adjusted1 CT bed (15cm) acquired, 1 PET bed (3mins)
acquiredEntry site marked and sterile drapes applied
ProtocolModerate sedationLocal anesthesiaBiopsy needles in place using unenhanced CT
scansFused with previously obtained PET scan
Biopsy needle placed in massRepeat CT and PET scan to confirm
Cytologist present2 hour observation
(Shyn, 2013)
UtilityFrom primary:
Melanoma LungLymphomaBreast
Metastasized to:BoneLiverSoft tissue
Head and NeckEsophagealColonPancreas
AbdomenLymph nodesLung
PET/CT AdvantagesCan indentify tumors without morphological
changesIf metabolic change has occurred“invisible” in U/S, CT and MRI
Identifies lesions with necrosisAble to identify more aggressive lesionsUptake lasts for hoursFDG not affected by procedure-related
complicationsCost-effectiveness
Cases Changed Types of Changes
Intramodality 22%
Chemotherapy with palliative
intent instead of curative intent
Intermodality 50%Systemic therapy chosen instead of
surgery
• If case remained unchanged, confidence in decision made was increased
DisadvantagesOccupancy of PET/CT machine
Room time = 87 mins – 141 minsBiopsy time = 37 mins – 87 mins
Radiation burden to patientRadiation burden to the interventionist Limited resolution
Dose
PET/CT Guided Biopsy 3.5 – 15.2 mSv
CT Component 54% - 81% of total combined dose
Low-Dose CTs in PET/CT
~ 8.2 mSv
CT Guided Biopsy 6.2 mSv – 23 mSv
DisadvantagesOccupancy of PET/CT machineRadiation burden to patientRadiation burden to the interventionist
Originating from the patient 10 uSv – 580 uSv @ 12-24 inches from pt.
Limited resolutionLess than 1.2cm in sizeMinimal amounts of metabolically active cells
Contacted 17 PET sites across Canada• Practicing interventional PET? Known future?• See a need?• Feasible (based on current workload)?
• Blue = Saw need/feasibility• Red = Required more
information
• White = No need/feasibility• Green = Retrospective
method
(Werner et al., 2013)
(Chakraborty et al., 2014)
ConclusionAiming for patient-centered careInterventional PET/CT offers:
EfficiencyBetter patient managementAccurate & timely diagnosisImproved patient outcomes
References Chakraborty, P. S., Dhull, V. S., Karunanithi, S., Verma, S., Kumar, R. (2014).
Malignant melanoma with cavitary pulmonary metastasis: Diagnostic dilemma resolved by FDG PET/CT guided biopsy. Indian Journal of Nuclear Medicine, 29(3), 196-197.
Ferrucci, J. T., Wittenberg, J. (1978) CT biopsy of abdominal tumors: Aids for lesion localization. Radiology, 129, 739-744.
Huang, B., Law, M. W., Khong, P. L. (2009). Whole-body PET/CT scanning: Estimation of radiation dose and cancer risk. Radiology, 251, 166-174.
Klaeser, B., Mueller, M. D., Schmid, R. A., Guevara, C., Krause, T. (2009). PET-CT-guided interventions in the management of FDG-positive lesions in patients suffering from solid malignancies: Initial experiences. European Radiology, 19(7), 1780-1785.
Klaeser, B., Wiskirchen, J., Wartenberg, J., Weitzel, T., Schmid, R. A. (2010). PET/CT-guided biopsies of metabolically active bone lesions: Applications and clinical impact. European Journal of Nuclear Medicine and Molecular Imaging, 37(11), 2027-2036.
Povoski, S. P., Sarolaya, I., & White, W. C. (2009). Comprehensive evaluation of occupational radiation exposure to intraoperative and perioperative personnel from 18F-FDG radioguided surgical procedures. European Journal of Nuclear Medicine and Molecular Imaging, 35, 2026-2034.
Rasmussen, S. N., Holm, H. H., Kristensen, J. K., & Barlebo, H. (1972). Ultrasound-guided liver biopsy. British Medical Journal, 2, 500-502.
Selzner, M., Hany, T. F., Wildbrett, P., McCormack, L., Kadry, Z., & Clavien, P. A. (2004). Does the novel PET/CT imaging modality impact on the treatment of patients with metastatic colorectal cancer of the liver? Annual Surgical, 240, 1027-1034.
Shyn, P. B. (2013). Interventional positron emission tomography/computed tomography: State-of-the-art. Techniques in Vascular and Interventional Radiology, 16(3), 182-190.
Silverman, S. G., Collick, B. D., & Figueira, M. R. (1995). Interactive MR-guided biopsy in an open-configuration MR imaging system. Radiology, 197, 175-181.
Sodickson, A., Baeyens, P. F., Andriole, K. P. (2009). Recurrent CT, cumulative radiation exposure, and associated radiation-induced cancer risks from CT of adults. Radiology, 251, 175-184.
Tatli, S., Gerbaudo, V. H., Feeley, C. M., Shyn, P. B., Tuncali, K., Silverman, S. G. (2011). PET/CT-guided percutaneous biopsy of abdominal masses: Initial experience. Journal of Vascular and Interventional Radiology, 22(4), 507-514.
Tsalafoutas, I. A., Tsapaki, V., Triantopoulou, C., Gorantonaski, A., & Paplliou, J. (2007). CT-guided interventional procedures without CT fluoroscopy assistance: Patient effective dose and absorbed dose considerations. American Journal of Roentgenology, 188, 1479-1484.
Werner, M. K. (2014). FDG-PET/CT-guided biopsy of bone metastases sets a new course in patient management after extensive imaging and multiple futile biopsies. British Journal of Radiology, 84(999), 65-67.
Wiering, B., Ruers, T. J., Krabbe, P. F., Dekker, H. M. & Oyen, W. J. (2007). Comparison of multiphase CT, FDG-PET and intra-operative ultrasound in patients with colorectal liver metastases selected for surgery. Annual Surgical, 14, 818-826.