PET Presentation
18F- Sodium Fluoride PET/[CT]:
Role in Skeletal Imaging
Akinwale Ayeni
CMJAH
11th August 2016
Outline
• Background
• 18F-NaF :
– Production
– Pharmacokinetics/ Biologic properties
– Comparison with 99mTc-MDP
• 18F-NaF PET/CT:
– Imaging Protocol
– Image interpretation
– Clinical indications
– Comparisons : Planar WB, SPECT &18F- FDG PET/CT
– Radiation dosimetry
– Limitations
• Conclusion
Background
• Blau M, Nagler W, Bender M. Fluorine-18:
a new isotope for bone scanning.
J Nucl Med. ;3:332–334.
• Subramanian G, McAfee J. A new complex of
99mTc for skeletal imaging.
Radiology. ;99:192–196.
Re-emergence of 18F-NaF bone imaging
Ignited by :
1. Introduction of PET and PET/CT
2. The widespread use of 18F-fluoride
3. Shortage /limited availability of 99mTc.
Semin Nucl Med 41:246-264, 2011
Why 18F-Fluoride?
• Faster
• Higher Resolution
• Anatomic Correlation
Preparation
18O + p → 18F + n
• Passed through ion-exchange column
• No further processing is required
J Nucl Med 2010; 51:1826–1829
Chemisorption
Pharmacokinetics
(1) Plasma,
(2) Extracellular fluid space,
(3) Shell of bound water (surrounding each crystal),
(4) Crystal surface,
(5) Interior of the crystal.
Seminars in Nuclear Medicine, Vol. 2, No. 1 {January}, 1972
18F-NaF Kinetics
• The “first-pass ” extraction almost 100%
• The rate-limiting step of bone uptake = blood flow
• Very high regional clearance
• Bone marrow uptake is negligible
• Excreted via the kidneys (10% in plasma @ 1hr)
J Nucl Med 2010; 51:1826–1829
Tc-99m MDP vs 18F Fluoride
Tc- 99m MDP 18F NaF
RBC uptake Negligible 30 – 40%
Protein binding 25% @ admin – 70% @ 24hr Minimal
First pass extraction 40 – 60% Nearly 100%
Clearance from Blood Slower Fast
Half-life 6 hrs 110 mins
Time from injection to 3 -4 hrs 0.5 – 1.5 hrs
imaging
Spatial resolution Lower resolution of gamma Higher resolution of PET
cameras systems
Capability for dynamic Three-phase bone Limited
imaging scintigraphy
THE SNM PRACTICE GUIDELINE FOR
Sodium 18F-Fluoride PET/CT Bone Scans
Version 1.1 June, 2010
• Hydration
• Dose
– Adult: 5 - 10 mCi
– Paed: 1 - 5 mCi
(0.07 mCi/kg)
• Start imaging
Trunk: 30 - 45 min
Extrem: 90 - 120 min
• Arm position
Trunk: raised
W Body: sides
• Emission acquisition time
2 - 5 min / stop
Semin Nucl Med 36:73-92 , 2006
• CT protocol
No CT vs
AC and registration vs
Optimized for diagnosis
ALARA
Image Interpretation
“ A potential problem with 18F is that it is almost
too sensitive and one has to learn again how to
read a ‘bone scan’…….. “
Semin Nucl Med 35:135-142 ,2005
RadioGraphics 2014; 34:1295–1316
Indications
• All other ‘standard’ indications ?
Clinical indications
• The main clinical indications are:
– Identification of bone metastases,
– correct determination of the extent of disease,
– localization of the malignant bony lesions
• Other indications may be appropriate in
certain individuals
18F-NaF PET/CT: EANM procedure guidelines for bone imaging. 2015
SNM Practice Guideline for Sodium 18F-Fluoride PET/CT Bone Scans 1.1, 2010
Semin Nucl Med 35:135-142, 2005
77 year old man with newly dx prostate ca.
(PSA 168 )
************Tc-99m MDP************** ************F-18 FLUORIDE**********
Metastatic disease – Lung Ca.
Schirrmeister. J Nucl Med 2001;42:1800-04
• 52 patients
• 13 (23%) had bone mets
Sensitivity (%) Specificity (%)
Planar BS 54 88
Planar + SPECT 92 100
18F Fluoride PET 100 100
Metastatic disease – Prostate Ca.
Even-Sapir. J Nucl Med 2006;47:287-97
• 44 patients with high-risk prostate
• 23 (52%) had bone mets
Sensitivity (%) Specificity (%)
Planar BS 70 57
Multi FOV SPECT 92 82
18F Fluoride PET/CT 100 100
Metastatic disease – HCC.
Yen et al. Nucl Med Commun 2010;31:637-645
Prospective study : 34 pts with HCC
Lesion Patient
Sensitivity Specificity Sensitivity Specificity
(n=90) (n=48) (n=24) (n=10)
Planar BS 73% 79% 79% 70%
18F-Fluoride 93% 100% 100% 100%
PET/CT
Bone metastases: FDG vs NaF
F-18FDG
Blastic
Lytic
F-18 NaF
Bone metastases: FDG vs NaF
Langsteger. Semin Nucl Med 2006;36:73-89
20 patients with different cancers
150 Metastatic Lesions
• 72 FDG and F18 +
• 44 FDG + but F18 –
• 34 FDG - but F18 +
Semin Nucl Med 36:73-92, 2006
NaF
FDG
BS
J Nucl Med 2008; 49:68–78
18F Fluoride + FDG
FDG NaF FDG+NaF
Iagaru. J Nucl Med 2009;50:501-505
Benign diseases
• Potential limitation :
– inability to yield an equivalent of a 3-phase scan
• “It is possible that 99mTc diphosphonates will
continue to have a role in clinical situations
requiring a 3-phase bone scan”
J Nucl Med 2008; 49:68–78
J Nucl Med 2008; 49:68–78
J Nucl Med 2008; 49:68–78
Quantitative Measurement
• Can be derived from dynamic PET
bone blood flow & metabolism
• Useful as a research tool
• Not yet in routine clinical practice
Dosimetry
Bone Bladder Breast Ovary Effective
dose
rads rem
Tc-99m MDP 3.2 3.0 0.09 0.30 0.55
(25 mCi)
F-18 NaF 2.2 9.1 0.10 0.39 1.0
(10mCi)
CT Trunk 1.9 1.7 1.6 1.5 1.5
(100mAs,
Pitch 1.2)
Dosimetry
ADULT CHILD (5 YEARS OLD)
rem/mCi
Tc-99m MDP 0.02 0.09
F-18 Fluoride 0.09 0.32
Paediatric radiation dose is 3.5 - 4.5 x adult dose
Problems and Limitations
• Availability/Accessibility
• Radiation Exposure
• Cost and reimbursement
Conclusion
• 18F- NaF PET/CT bone scans:
– Important in known or suspected skeletal mets.
– Other indications in selected patients
• 18F-NaF PET/CT provides higher diagnostic
performance:
– higher quality images
– within a shorter period
– ‘relatively comparable’ radiation dosimetry
– albeit at currently higher scan cost
Where do we stand?
“…..we expect that in the coming years
conventional bone imaging with 99mTc-labeled
diphosphonates—performed with non-tomographic
scanning techniques—will be replaced completely
with 18F-fluoride PET.”
Langester, Heinisch, Fogelman. Semin Nucl Med 2006;73-92
