Tumor/ Infection and Inflammation imaging

What is another word for tumors?

neoplasms

What is a tumor

abnormal tissue growth caused by uncontrolled cell division, can be benign or malignant

Benign tumors

Non-cancerous growths that do not spread.

Malignant tumors

cancerous, invade surrounding tissues and can metastasize

how do malignant tumors spread

invasion and metastasis through blood or lymphatics, may need treatment

Oncology

the study and treatment of tumors, prevention of cancer

What do tumors require to grow?

oxygen and nutrients supplied by blood vessels

Tumor growth

Increase in size and number of cancer cells.

Hyperplasia

increase in number of cells, not cancer, controlled process

Dysplasia

abnormal development or growth of cells, tissues, or organs

Neoplasia

uncontrolled new growth

Metastasis

The spread of cancer cells to locations distant from their original site.

What are the common routes for METS?

lymphatic system, blood stream, body cavities

causes of cancer

smoking, radiation exposure, viral infections

carcinogen

A cancer-causing substance

genetic factors of cancer

faulty genes, mutations in BRCA genes

prevention of cancer

-Primary: avoid chemicals, don't smoke, don't burn in the sun, reduce weight, eat balanced meals

-Secondary: Screenings; colonoscopy, mamograms

Warning signs of cancer

-Tertiary: [after already had cancer] hormone therapy, eat well balanced meals

Surgery for cancer treatment

removal of cells

Chemotherapy for cancer treatment

drugs to destroy cells

Radiation therapy for cancer treatment

radiation to destroy cells

Immunotherapy for cancer treatment

increase bodies defense

hormone therapy for cancer treatment

blocks the effects of hormones that stimulate cancer growth

Stem cell transplantation for cancer treatment

replace damaged or destroyed blood forming cells

Target therapy for cancer treatment

targets molecules or genetic changes, attaching cells while causing less damage to normal cells

Theranostics

Combining diagnostics and therapy into a single personalized treatment approach (precision medicine)

Advantages of Theranostics

•Personalized cancer treatment

•Targets cancer cells with high specificity

•Reduces radiation exposure to health tissues

•Improves treatment planning

•Monitors treatment response

•Often few systemic side effects than conventional chemotherapy

•Provides therapy for cancers not typically managed well

Image Guided Therapy

broad principle in which imaging is adopted to then plan and perform therapeutic intervention

Development of Hybrid Technology

provides accurate localization and quantitation of imaging thus improves the outcome of therapy

Common Types of cancer in males

prostate, lung, colorectal

Common Types of cancer in females

breast, lung, colorectal

blood cancer

When cancer begins in abnormal blood cells, it is known as blood cancer

How many types of blood cancer is there

3

what are the 3 types of blood cancer

Lymphoma, Leukemia, Myeloma

Lymphoma

cancer of the lymphatic system

two types- Hodgkins and Non Hodgkins

Hodgkins Lymphoma

•Common in teens/young adults (13-39 yrs) adults over 60 yrs

•More common in males

•Contain an abnormal white blood cell, Reed-Sternberg cell

•Predictable spread from one lymph node to the next

Non-Hodgkins Lymphoma

•More common in males

•Most cases occur in people over 60 yrs old

•Unpredictable spread to various organs throughout the body

Leukemia

white blood cells

Myeloma

blood plasma

What is inflammation

Body's response to abnormal stress placed on cells

What is infection

Invasion of the body by pathogenic microorganisms

Common Pathogens

Bacteria, Viruses, Fungi, Parasites

Immune response for inflammation and infection

•White blood cells migrate to infection

•Phagocytes destroy microorganisms

•Abscess

What is an Abscess

collection of pus containing dead WBCs, bacteria and cellular debris

Signs & Symptoms of infection

•Fever, pain, redness, warmth, swelling, tenderness, loss of function

•All classic signs of inflammation, with fever commonly indicating a systemic infection

Sources of Inflammation and Infection

external pathogens, normal flora becoming opportunistic

high risk patients for inflammation and infection

•Cancer patients

•Organ transplant recipients

•HIV/AIDS

•Diabetes

•Chemotherapy patients

•Elderly

•Immunocompromised patients

what is health care associated infections?

Nosocomial

what causes nosocomial and treatment?

•Infection acquired during hospitalization

•Often associated with invasive devices or procedures

treatment- Depends on the organism, antibiotics are effective only against bacterial infections

Adrenal Medulla Imaging indications:

•Identify normal, ectopic or hyperfunctioning adrenal medullary tissue

•Identify the location of neuroendocrine tumors and their metastases

•Neuroblastoma

•Pheochromocytoma

•Paraganglioma

Adrenal Medulla Imaging RP/Localization:

Metaiodobenzylguanidine (MIBG)

Labeled to 123I (imaging) or 131I (therapy

Adrenal Medulla Imaging patient prep:

•Lugol solution or 400mg of potassium perchlorate to block free iodine from localizing within the thyroid, continues through delayed images

•Discontinue medication that affect the adrenergic system (sympathetic nervous system responsible for the fight or flight response)

•Alpha & beta blockers

•Decongestants

•Calcium channel blockers

Tricyclic antidepressants

what are somatostatin receptor imaging?

are proteins located on the surface of certain normal and tumor cells that bind the hormone somatostatin, it is a naturally occurring hormone that inhibits the release of many other hormones and slows cellular activity

SSTR 5 subtypes

•SSTR1-SSTR5

•SSTR2 (somatostatin Receptor Type 2) is the receptor subtype most highly express on the surface of well-differentiated neuroendocrine tumor (NETs) cells.

•Neuroendocrine tumors are found in the pituitary, thyroid, and Pancreatic Islet Cells

somatostatin receptor imaging indications:

•Evaluation of the following:

•Pituitary adenomas

•Pancreatic islet cell neoplasms

•Neuroblastomas

•Pheochromocytomas

•Paraganglioma

•Gastrinomas

•Small cell lung cancer

•Identification, staging, therapy, and recurrence of METS from neuroendocrine tumors

somatostatin receptor pt prep:

•Patient should be well hydrated 1-day prior and after injection

•Instruct patients to void frequently post injection

somatostatin receptor imaging:

•Anterior & posterior whole-body images at 4 and 24 hours

•Static head/neck, right/left laterals

•SPECT imaging performed at 24-hours

•Can carry out delays to 48 hours if needed

what is monoclonal antibody imaging?

technique that uses radiolabeled monoclonal antibodies to target specific antigens expressed on tumor cells

HER2 (tumor antigen)

breast cancer

CD20 (tumor antigen)

lymphoma

PSMA (tumor antigen)

prostate cancer

CEA (tumor antigen)

colorectal, gastric, pancreatic, medullary thyroid and some lung cancers

EGFR (tumor antigen)

colorectal, non-small cell lung, glioblastoma, and head/neck squamous cell carcinomas

Monoclonal Antibody Radiopharmaceuticals Rituximab

•89Zr (Zirconium) ibritumomab

•Commonly used for lymphoma

Monoclonal Antibody Radiopharmaceuticals Carcinoembryonic Antigen

•111In or 99mTc can be labeled to arcitumomab

•Commonly used for colorectal cancer

Monoclonal Antibody Radiopharmaceuticals ProstaScint

•111In capromab pendetide

•Commonly used for prostate cancer

Monoclonal Antibody Radiopharmaceuticals OncoScint

•111In satumomab pendetide

•Commonly used for ovarian and colon cancer

Monoclonal Antibody Radiopharmaceuticals Doses

•111In- 5 mCi

•99mTc- 20 mCi

•89Zr- 1-2 mCi

Monoclonal Antibody Imaging pt prep:

•No specific prep

•Human anti-mouse antibody testing may be required for patient with previous scans

•Increased risk of an allergic reaction if human anti-mouse antibodies are already present with the patient

Monoclonal Antibody Imaging

•Whole-body imaging beginning at 4 & 24-hours

•Delays out to 48 if needed

•SPECT increases sensitivity at 24-hours

What is gallium-67 citrate tumor imaging?

67Ga binds to proteins within the WBC and is attracted by inflammatory leukocytes and low molecular-weight molecules of bacteria (primarily transferrin proteins)

gallium-67 citrate indications:

•Evaluation of inflammation and abscesses

•Myocardial infections

•Detection and localization of lymphomas, tumors, Hodgkin's disease and osteomyelitis

•Fever of unknown origin

gallium-67 citrate RP and dose

•8-10 mCi is preferred for tumor imaging

•Higher doses are needed if SPECT is used

•67Ga has an affinity for tumors

gallium-67 citrate pt prep:

none

gallium-67 citrate imaging

•Inject 67Ga-Citrate IV

•Imaging for tumors starting at 48-hours post injection

•Whole-body images are obtained ANT and POST

•SPECT is optional & will improve sensitivity

•Additional images are acquired at 72 and 96-hours

•Target to background ratio increase after time

gallium-67 citrate normal distributions:

•Bone marrow-especially spine & sternum

•Nasopharynx

•Liver

•Bowel-should move over time/physiologic bowel activity

gallium-67 citrate abnormal distributions:

•Areas outside the normal regions

•Lymphoma- sensitivity is related to size & location

•Tumors need to be >1cm in size

•Sensitivity is 85% for Hodgkins's disease less for Non-Hodgkin's

201 Tl- Chloride Tumor Imaging biologic principles:

•Normally localizes in muscle, myocardium, liver, spleen, stomach and colon

•Concentrated by some tumors

•Tumors need to possess a working Na/K pump

201 Tl- Chloride Tumor Imaging clinical principles:

•Lung carcinoma

•Brain carcinoma

•Certain AIDS related tumors

•Some lymphoma's- Not as good as 67Ga

201 Tl- Chloride Tumor Imaging RP and dose:

2-5 mCi IV (higher for SPECT)

201 Tl- Chloride Tumor Imaging pt prep:

none

201 Tl- Chloride Tumor Imaging

•Inject Thallium IV

•ANT & POST images are acquired 2-4 hours post injection

•SPECT may be performed to improve sensitivity

201 Tl- Chloride Tumor Imaging results:

•Normal Thallium results at 2-hours are:

•Muscle, myocardium, liver, spleen, stomach & colon

•Any activity outside the normal regions should be considered as a neoplasm

Tumor Imaging Lymphoma indications:

•Treatment of patients with relapsed or refractory low grade, follicular/transformed B-Cell non-Hodgkin's Lymphoma

•Patients including Rituxan refractory follicular non-Hodgkin's Lymphoma

What is 90Y ibritumomab Tiuxetan (Zevalin)?

radioimmunotherapy used to treat positive B-cell Non-Hodgkin lymphoma

What is ibritumomab

a monoclonal antibody that targets the CD20 antigen receptor on the B-cell

What is Tiuxetan?

a chelating agent that securely attaches the radionuclide to the antibody

What is Yttrium-90?

•therapeutic beta emitting radionuclide

Tumor Imaging Lymphoma contraindications:

•Patients receiving bone marrow transplants or radioimmunotherapy

•Patients with known type 1 hypersensitivity or anaphylactic reactions to murine proteins (MoAbs) including yttrium chloride and indium chloride

•Patients with leukemia, HIV or AIDS

•Platelet counts < 100,000 mm3

•Neutrophil counts < 1500cells/ml

•Patients with > 25% lymphoma bone marrow or impaired bone marrow reserve

•Biodistrubutions is seen on In-111 Zevalin images

Tumor Imaging Lymphoma diagnostic dose and route:

•In-111 Zevalin 5mCi injected IV

•No longer required prior to therapeutic dosing in the United States

Tumor Imaging Lymphoma therapeutic dose and route:

•Y-90 Zevalin 0.3mCi/kg with platelet count 100,000 to 149,000/mm3 Injected IV

•0.4mCi/kg with platelet count >150,000/mm3 injected IV

Tumor Imaging Lymphoma pt prep:

•Patient is to receive the Rituxan (cold ibritumomab) 4hrs before receiving the In-111 dosage and before Y-90 therapy

•Verify minimum platelet count of 100,000/mm3

•Patients with previous MoAbs test should have a HAMA titer prior to another injection

•Patient should be well hydrated

Tumor Imaging Lymphoma camera and matrix:

Medium Energy collimator

Static images- 128 x 128 matrix or 256 x 156, 600 secs or 800 kcts per view

Whole body- Matric 256 x 1024 (5-10 cm/min)

Tumor Imaging Lymphoma procedure:

•Within 4 hours of completing the Rituximab infusion

•Administer 5 mCi In-111 Zevalin IV over 10 minutes

•Use 0.22-micron low protein-binding in-line filter between the syringe and infusion port

•Make sure you have flushed the filter with saline before injection to dampen

•Flush IV line with minimum of 10ml of saline post injection

Tumor Imaging Lymphoma imaging:

•Whole-body images at 48 to 72 hours post injection of In-111 Zevalin to assess Biodistribution's

•7-10 days following In-111 Zevalin infusion

•Within 4 hours of the rituximab infusion

•The therapeutic dose of Y-90 Zevalin can be administered

•Based on the patient's platelet count and body weight

•10 minute IV injection with filter (using previous method)

•Injection preformed by Radiologist or Nuclear Medicine Technologist

Nurse to monitor patient vitals every 15 minutes for 1 hour

Tumor Imaging Lymphoma Expected Biodistributions:

•Increased activity seen in the blood pool at 24 hours decreasing on delayed images

•High uptake in normal liver and spleen

•Low uptake in kidneys, urinary bladder and bowel

•Tumor uptake visualized as areas of increased intensity

Tumor Imaging Lymphoma altered Biodistributions:

•Blood pool not visualized on 24-hour images

•Lung uptake more intense than liver on 48-hour images

•Kidney uptake greater than liver on 48-hour images

•Diffuse intense uptake in bowel comparable to liver on 48-hour images

What is lymphoscintigraphy?

Elective lymph node dissection (ELND) or axillary lymph node dissection (ALND)

What is sentinel node?

first lymph node that receives lymphatic drainage from the tumor site represent the primary site for metastasis

lymphoscintigraphy rp and dose

•A radiocolloid in a small volume (0.1-0.5 ml) is used

•The colloid must be a small particle (0.1 um)

•A modified preparation of 99mTc-SC is usually used

•The small colloid is removed from the area it's injected into by the lymphatic system

•The colloid gets taken up by metastatic lymph nodes

lymphoscintigraphy procedure:

•Inject RP at/near the tumor/biopsy site

•Take immediate dynamic images of the tumor site

•Take 30-60-minute delays for mapping

•Imaging uses a "transmission image" technique