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Pet And Radiotherapy For Head And Neck
1. PET and Radiotherapy for Head and
Neck Cancer: today and tomorrow…
Vincent GREGOIRE, M.D., Ph.D.
Head and Neck Oncology Program, Radiation
Oncology Dept., & Center for Molecular Imaging
and Experimental Radiotherapy, Université
Catholique de Louvain, St-Luc University
Hospital, Brussels, Belgium
MAESTRO
Jan. 2007
2. Potential added-value of PET in oncology
S / RxTh / CH
Work-up-staging
prognostic evaluation
GTV/CTV
Selection/delineation
Functional Image-guided
IMRT
Early response
FDG evaluation
C-methionine
EF3 - F-miso - CuATSM Final response
BFU - FLT evaluation
… Early detection
of recurrence
MAESTRO
Jan. 2007
3. Imaging in radiotherapy:
… today and tomorrow …
• Selection of Target Volumes with FDG-PET
• Delineation of GTV with FDG-PET
• Selection / delineation of CTV
MAESTRO
Jan. 2007
4. The use of FDG-PET for the selection of
Target Volume: setting the scene
Laryngeal SCC: T2-N1-M0
Q: unilateral vs bilateral
neck irradiation?
A: highly sensitive
examination
MAESTRO
Jan. 2007
5. Detection of metastatic disease in the neck
• N=106 patients
• oral cavity tumors
• Neck dissection for all patients (2196 lymph nodes)
Sensitivity Specificity Accuracy NPV PPV
PET 70% 82% 75% 71% 81%
CT 66% 69% 70% 66% 74%
MRI 64% 69% 66% 62% 71%
US 84% 68% 76% 79% 75%
MAESTRO
Jan. 2007 Stuckensen et al., 2000
6. Potential added-value of PET in oncology
Comparison between CT and FDG-PET for nodal staging.
Site Sensitivity Specificity
CT FDG-PET CT FDG-PET
Head and neck cancer 36-86% 50-96% 56-100% 88-100%
NSC lung cancer 45% 80-90% 85% 85-100%
Cervix carcinoma 57-73%1 75-91% 83-100%1 92-100%
Esophageal cancer 11-87% 30-78% 28-99% 86-98%
1
CT or MRI
MAESTRO
Jan. 2007 Grégoire, 2004
7. Potential added-value of PET in oncology
Comparison between PET and PET/CT for N staging (n=260)
Sensitivity (%) Specificity (%) PPV NPV
PET/CT 92 93 88 94
PET+CT 88 89 83 92
PET 85 88 82 90
CT 64 83 70 79
MAESTRO
Jan. 2007 Antoch et al., 2004
12. Functional imaging and automatic
segmentation
Volume delineation based on automatic thresholding with 18F-FDG
MAESTRO Daisne et al, 2003
Jan. 2007 Geets et al, 2004
14. Image-Guided Radiation Therapy in HNSCC
Impact of imaging modality on CTV/PTV delineation
Larynx/hypopharynx (n=9) Oropharynx (n=10)
200
Average (± sem) volume (cc)
CT-scan 250 CT-scan
Average (± sem) volume (cc)
FDG-PET FDG-PET
150 200
ANOVA: p<0.05 ANOVA: p<0.01
150
100
100
50
50
0 0
GTV CTV PTV GTV CTV PTV
MAESTRO
Jan. 2007 Geets et al, 2003
15. Image-Guided Radiation Therapy in HNSCC
Impact of imaging modality on dose distribution
MAESTRO
Jan. 2007 Geets et al, 2006
16. Conformal radiotherapy and IMRT
in Head and Neck Tumors
DAHANCA: http://www.dshho.suite.dk/dahanca/guidelines.html
EORTC: http://www.eortc.be/home/ Radio/EDUCATION.htm
MAESTRO RTOG: http://www.rtog.org/hnatlas/main.htm
Jan. 2007
17. CT-based delineation of lymph node levels in
the neck: Brussels- Rotterdam consensus guidelines
Level II
Ant. submandibular gland
post. belly of digastric m.
Post. sternocleidomastoid m.
LII Lat. sternocleidomastoid m.
Med. paraspinal m.
int. carotid artery
LV
Cra. lateral process of C1
Cau. hyoid bone
MAESTRO
Jan. 2007
18. Imaging in radiotherapy:
… today and tomorrow …
• Atlases
• Adaptive Target Volume delineation
• Non-rigid registration
• Adaptive dose distribution
• Other PET tracers
MAESTRO
Jan. 2007
19. H&N IMRT practice heterogeneity
Atlases?
MAESTRO
Jan. 2007 Harari et al., 2005
31. Dose registration…
Time 1 (t1)
Deformed checkerboard
showing the non- rigid Deformed dose at t1
transformation from t1 to t2 Deformed contour on CT at t2
Time 2 (t2)
MAESTRO
Jan. 2007 Lee, 2006
32. Other PET tracers…
Hypoxia: 18F-EF3
Metabolism: 18F-FDG
11C-Met
Proliferation: 76Br-BFU
MAESTRO
Jan. 2007
33. From microscopy to PET images…
CT-scan MRI
µPET-scan Autoradiography
MAESTRO
Jan. 2007 N. Christian, 2006
35. Acknowledgements
• Communication and Remote Sensing Lab. Alois du BOIS d’AISCHE, Eng.
Pierre-François d’HAESE, Eng.
Benoit MACQ,Eng., Ph.D.
• ENT and Head & Neck surgery Marc HAMOIR, M.D.
Philippe ROMBAUX, M.D.
• Imaging Emmanuel COCHE, M.D.
Thierry DUPREZ, M.D.
Max LONNEUX, M.D.
• Oral & Maxillo-Facial surgery Pierre MAHY, M.D.
Hervé REYCHLER, M.D., D.M.D.
• Pathology Birgit WEYNAND, M.D.
• PET laboratory Anne BOL, Ph.D.
Daniel LABARE, Ph.D.
• Radiation Oncology Nicholas CHRISTIAN, M.D.
Jean-François DAISNE, M.D., Ph.D.
Xavier GEETS, M.D.
John LEE, eng., Ph.D.
Pierre SCALLIET, M.D., Ph.D.
MAESTRO
Jan. 2007 Milan TOMSEJ, M. Sc.
44. From microscopy to PET images…
Mean minimal distance Mean angle (°)
between two skew lines
MR-CT: 0.21 0.06 mm 2.23 0.31
PET-CT: 0.23 0.11 mm 2.52 0.74
PET-MR: 0.28 0.07 mm 2.47 0.46
PET-AR: 0.18 0.04 mm 3.53 0.39
MAESTRO
Jan. 2007 N. Christian, 2006
45. Work in progress: other tracers…
PET-FLT
FLT ?
FDG
0 Gy 20 Gy Before surgery
MAESTRO
Jan. 2007 Lee & et al,
HaustermansGeets 2006
46. Gradient Intensity Image
Image saturation (window level)
Raw image
Grad. Int. image
MAESTRO Boundaries do not move! Lee & Geets 2006
Jan. 2007