the clinical role of pet scanning in a consecutive series of gist patients
DESCRIPTION
The clinical role of PET scanning in a consecutive series of GIST patients. Frits van Coevorden & Lester van Ravenswade. Department of Surgery Netherlands Cancer Institute - Antoni van Leeuwenhoek ziekenhuis Amsterdam The Netherlands. - PowerPoint PPT PresentationTRANSCRIPT
The clinical role of PET scanning in GISTThe clinical role of PET scanning in GIST
Seattle Seattle 20072007
The clinical role of PET scanning in a consecutive series of GIST patients
Department of SurgeryDepartment of Surgery
Netherlands Cancer InstituteNetherlands Cancer Institute - - Antoni van Leeuwenhoek ziekenhuisAntoni van Leeuwenhoek ziekenhuis Amsterdam The NetherlandsAmsterdam The Netherlands
Frits van CoevordenFrits van Coevorden & &
Lester van RavenswadeLester van Ravenswade
The clinical role of PET scanning in GISTThe clinical role of PET scanning in GIST
Seattle Seattle 20072007
• The metabolic activity in GastroIntestinal Stromal Tumors The metabolic activity in GastroIntestinal Stromal Tumors has become of interest in this era of targeted therapyhas become of interest in this era of targeted therapy
• Positron Emission Tomography is Positron Emission Tomography is thethe imaging modality to imaging modality to assess metabolic activity in tumorsassess metabolic activity in tumors
The clinical role of PET scanning in GISTThe clinical role of PET scanning in GIST
Seattle Seattle 20072007
• The metabolic activity in GastroIntestinal Stromal Tumors has The metabolic activity in GastroIntestinal Stromal Tumors has become of interest in this new Imatinib erabecome of interest in this new Imatinib era
• Positron Emission Tomography is Positron Emission Tomography is thethe imaging modality to imaging modality to assess metabolic activity in tumorsassess metabolic activity in tumors
• PET imaging may reveal the metastatic character of tumorsPET imaging may reveal the metastatic character of tumors
• Comparing PET activity before and after the start of TKI’s Comparing PET activity before and after the start of TKI’s may provide useful information in assessing the response to may provide useful information in assessing the response to drug treatmentdrug treatment
The clinical role of PET scanning in GISTThe clinical role of PET scanning in GIST
Seattle Seattle 20072007
• In a consecutive series of 98 evaluable patients seen in the In a consecutive series of 98 evaluable patients seen in the Netherlands Cancer Institute between 2000 – 2007 our GIST Netherlands Cancer Institute between 2000 – 2007 our GIST database was reviewed with focus on the use of PET scanningdatabase was reviewed with focus on the use of PET scanning
• The indication for PET imaging was classified as:The indication for PET imaging was classified as:
• Diagnostic to evaluate the primary tumorDiagnostic to evaluate the primary tumor
• Diagnostic to evaluate metastatic diseaseDiagnostic to evaluate metastatic disease
The clinical role of PET scanning in GISTThe clinical role of PET scanning in GIST
Seattle Seattle 20072007
• In a consecutive series of 98 evaluable patients seen in the In a consecutive series of 98 evaluable patients seen in the Netherlands Cancer Institute between 2000 – 2007 our GIST Netherlands Cancer Institute between 2000 – 2007 our GIST database was reviewed with focus on the use of PET scanningdatabase was reviewed with focus on the use of PET scanning
• The indication for PET imaging was classified as:The indication for PET imaging was classified as:
• Diagnostic to evaluate a primary tumorDiagnostic to evaluate a primary tumor
• Diagnostic to evaluate metastatic diseaseDiagnostic to evaluate metastatic disease
• Diagnostic tool to prove or exclude recurrent or Diagnostic tool to prove or exclude recurrent or residual disease after previous surgeryresidual disease after previous surgery
• Response assessment of drug treatmentResponse assessment of drug treatment
The clinical role of PET scanning in GISTThe clinical role of PET scanning in GIST
Seattle Seattle 20072007
MethodsMethods
• We reviewed all files and PET -CT studiesWe reviewed all files and PET -CT studies
• Classified PET imaging as: Classified PET imaging as:
• diagnostic onlydiagnostic only
• diagnostic and used for response evaluationdiagnostic and used for response evaluation
The clinical role of PET scanning in GISTThe clinical role of PET scanning in GIST
Seattle Seattle 20072007
MethodsMethods
• We reviewed all files and PET -CT studiesWe reviewed all files and PET -CT studies
• Classified PET imaging as: Classified PET imaging as:
• diagnostic onlydiagnostic only
• diagnostic and used for response evaluationdiagnostic and used for response evaluation
• Correlated the outcome to the associated CT scanCorrelated the outcome to the associated CT scan
• Classified the comparison results as:Classified the comparison results as:
• Conformal or DiscrepantConformal or Discrepant
The clinical role of PET scanning in GISTThe clinical role of PET scanning in GIST
Seattle Seattle 20072007
MethodsMethods
• We reviewed all files and PET -CT studiesWe reviewed all files and PET -CT studies
• Classified PET imaging as: Classified PET imaging as:
• diagnostic onlydiagnostic only
• diagnostic and used for response evaluationdiagnostic and used for response evaluation
• Correlated the outcome to the associated CT scanCorrelated the outcome to the associated CT scan
• Classified the comparison results as:Classified the comparison results as:
• Conformal or DiscrepantConformal or Discrepant
• Correlated the results to the clinical course of the patient Correlated the results to the clinical course of the patient with follow upwith follow up
The clinical role of PET scanning in GISTThe clinical role of PET scanning in GIST
Seattle Seattle 20072007
Results (1)Results (1)
• the data here presented are an update of those in abstract 934the data here presented are an update of those in abstract 934
• 98 evaluable patients98 evaluable patients
• 45 patients had one or more PET scans45 patients had one or more PET scans
• 4 scans as tool to search for residual or possible 4 scans as tool to search for residual or possible recurrent disease after surgery: recurrent disease after surgery:
All were negative, as was the clinical and CT correlateAll were negative, as was the clinical and CT correlate
• In 41 patients PET was supposed to show activityIn 41 patients PET was supposed to show activity
The clinical role of PET scanning in GISTThe clinical role of PET scanning in GIST
Seattle Seattle 20072007
Results (2)Results (2)
• PET was false negative in PET was false negative in 9 9 //4545 patients (20 %) patients (20 %)
• 33 in active primary or local recurrent disease in active primary or local recurrent disease
• 66 in metastatic hepatic or peritoneal disease in metastatic hepatic or peritoneal disease
The clinical role of PET scanning in GISTThe clinical role of PET scanning in GIST
Seattle Seattle 20072007
Results (2)Results (2)
• PET was false negative in PET was false negative in 9 9 //4545 patients (20 %) patients (20 %)
• 3 in active primary or local recurrent disease3 in active primary or local recurrent disease
45 yr female45 yr female 6 cm bilobar endogastric Gist 6 cm bilobar endogastric Gist
The clinical role of PET scanning in GISTThe clinical role of PET scanning in GIST
Seattle Seattle 20072007
Results (2)Results (2)
• PET was false negative in PET was false negative in 9 9 //4545 patients (20%) patients (20%)
• 3 in active primary or local recurrent disease3 in active primary or local recurrent disease
51 yr male51 yr male 10 cm small curvature gastric Gist 10 cm small curvature gastric Gist
50% vital after 1 yr Imatinib50% vital after 1 yr Imatinib
The clinical role of PET scanning in GISTThe clinical role of PET scanning in GIST
Seattle Seattle 20072007
Results (3)Results (3)
• PET was false negative in PET was false negative in 9 9 //4545 patients (20 %) patients (20 %)
• PET was true negative in 4 patients (post surgery controls)PET was true negative in 4 patients (post surgery controls)
• PET was true positive in 32 patientsPET was true positive in 32 patients
… …. so 80 % correlation to CT scan and Clinic !!. so 80 % correlation to CT scan and Clinic !!
The clinical role of PET scanning in GISTThe clinical role of PET scanning in GIST
Seattle Seattle 20072007
Results (3)Results (3)
• PET was false negative in PET was false negative in 9 9 //4545 patients (20 %) patients (20 %)
• PET was true negative in 4 patients (post surgery controls)PET was true negative in 4 patients (post surgery controls)
• PET was true positive in 32 patientsPET was true positive in 32 patients
• Repeat PET used for response assessment in 23 patientsRepeat PET used for response assessment in 23 patients
The clinical role of PET scanning in GISTThe clinical role of PET scanning in GIST
Seattle Seattle 20072007
Results (4)Results (4)
• Repeat PET for Repeat PET for response assessment in 23 patientsresponse assessment in 23 patients
• 19 19 patients PET confirmed good response patients PET confirmed good response
• 3 3 unchanged PET activity confirmed active SD on CT unchanged PET activity confirmed active SD on CT
……. . so if 1so if 1stst PET shows disease activity PET shows disease activity
95 %95 % correlation to CT scan and Clinic !! correlation to CT scan and Clinic !!
The clinical role of PET scanning in GISTThe clinical role of PET scanning in GIST
Seattle Seattle 20072007
Results (4)Results (4)
• Repeat PET for Repeat PET for response assessment in 23 patientsresponse assessment in 23 patients
• 19 19 patients confirmed good response patients confirmed good response
• 3 3 unchanged PET activity confirmed active SD on CTunchanged PET activity confirmed active SD on CT
• 1 1 discrepancydiscrepancy
The clinical role of PET scanning in GISTThe clinical role of PET scanning in GIST
Seattle Seattle 20072007
Case presented at CTOS 2006 in VeniceCase presented at CTOS 2006 in Venice
• 33 yr male33 yr male
• dec 2005 resection of high grade small bowel GISTdec 2005 resection of high grade small bowel GIST
• randomized in 62024 to control grouprandomized in 62024 to control group
The clinical role of PET scanning in GISTThe clinical role of PET scanning in GIST
Seattle Seattle 20072007
Case presented at CTOS 2006 in VeniceCase presented at CTOS 2006 in Venice
• 33 yr male33 yr male
• dec 2005 resection of high grade small bowel GISTdec 2005 resection of high grade small bowel GIST
• randomized in 62024 to control grouprandomized in 62024 to control group
• aug 2006: peritoneal recurrenceaug 2006: peritoneal recurrence
• Start Imatinib 400 mgStart Imatinib 400 mg
The clinical role of PET scanning in GISTThe clinical role of PET scanning in GIST
Seattle Seattle 20072007
Case presented at CTOS 2006 in VeniceCase presented at CTOS 2006 in Venice
The clinical role of PET scanning in GISTThe clinical role of PET scanning in GIST
Seattle Seattle 20072007
August 2006: Start (neoadjuvant)Imatinib 400 mgAugust 2006: Start (neoadjuvant)Imatinib 400 mg
October 2006: effect ???October 2006: effect ???After GlivecAfter Glivec
Before Glivec Before Glivec After GlivecAfter Glivec
Progression ?Progression ?
So he went for surgerySo he went for surgery
Or response ?Or response ?
The clinical role of PET scanning in GISTThe clinical role of PET scanning in GIST
Seattle Seattle 20072007
Before Glivec Before Glivec After GlivecAfter Glivec
After GlivecAfter Glivec
Bad message: Bad message:
At pathology the At pathology the PET negative tumor PET negative tumor more than 90% vital GISTmore than 90% vital GIST
The clinical role of PET scanning in GISTThe clinical role of PET scanning in GIST
Seattle Seattle 20072007
Bad message: Bad message:
At pathology the PET negative tumor more than 90% vital GISTAt pathology the PET negative tumor more than 90% vital GIST
Good message: Good message:
Exon 9 mutationExon 9 mutation
Now 1 year later on 800 mg Imatinib: NO ACTIVE DISEASENow 1 year later on 800 mg Imatinib: NO ACTIVE DISEASE
So maybe PET did predict a favourable outcome very So maybe PET did predict a favourable outcome very early ??early ??
The clinical role of PET scanning in GISTThe clinical role of PET scanning in GIST
Seattle Seattle 20072007
PET PET positive positive initial initial scanscan
False False PET PET
negative negative scanscan
True PET True PET negative negative
scanscanALLALL
45 pat45 pat
NEDNED 1212 55 44 2121
Alive withAlive with
inactive diseaseinactive disease99 22 1111
Alive with Alive with active diseaseactive disease
33 11 44
Dead of diseaseDead of disease 88 11 99
Survival related to PET scanningSurvival related to PET scanning
The clinical role of PET scanning in GISTThe clinical role of PET scanning in GIST
Seattle Seattle 20072007
BeneficialBeneficial
PET responsePET response
No change or No change or progressive disease at progressive disease at
PET PET ALLALL
NED or NED or inactive diseaseinactive disease
1313 1313
Alive with Alive with active diseaseactive disease
55 55
Dead of diseaseDead of disease 33 22 55
PET response correlated to outcome at FUPET response correlated to outcome at FU
The clinical role of PET scanning in GISTThe clinical role of PET scanning in GIST
Seattle Seattle 20072007
ConclusionsConclusions
PET had a 80 % correlation to active GIST PET had a 80 % correlation to active GIST
but PET was false negative in 20 %but PET was false negative in 20 %
• If PET is positive: 95% correct response correlationIf PET is positive: 95% correct response correlation
• No change or PD at response assessment No change or PD at response assessment predicts a poor predicts a poor
outcome outcome
The clinical role of PET scanning in GISTThe clinical role of PET scanning in GIST
Seattle Seattle 20072007
Thank youThank you