Exon Publications

Front Matter

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Foreword

Scott B. Perlman, MD, MS — Wed, 08 Nov 2023 00:00:00 +1000

Molecular imaging and therapy have made important contributions to the diagnosis and treatment of many medical disease processes, especially in the area of oncology. The advancements in planar imaging, SPECT/CT, and positron emission tomography (PET) (PET/CT and PET/MRI) and targeted molecular radiotherapy will continue to play an increasing role in patient care as newer molecular agents are introduced into clinical medicine. Molecular Imaging and Therapy provides a robust introduction into selected clinical topics that utilize molecular imaging and targeted radiotherapy and provides sufficient evidence-based details to allow clinicians of various specialties and backgrounds to gain a thorough understanding of the appropriate clinical uses and benefits of these molecular imaging and therapy techniques. The information in this book will greatly benefit Nuclear Medicine Physicians and Radiologists currently in practice and in training but will also be very useful to healthcare providers of all specialties wishing to stay current in their understanding of these molecular techniques as they apply to a wide spectrum of oncological and non-oncological diseases. CONTINUE READING…..

Preface

Lance T. Hall, MD — Wed, 08 Nov 2023 00:00:00 +1000

The book Molecular Imaging and Therapy focuses on selected topics of the clinical uses of molecular imaging and targeted molecular radiotherapy techniques with an emphasis on oncological disease processes. This book is primarily designed for clinicians and students/trainees in fields that interpret or utilize molecular imaging techniques to diagnose and/or treat their patients, though scientists and clinicians in other fields will hopefully find use as well. Chapter 1 reviews molecular imaging of Parkinson’s disease. Diagnosis of Parkinson’s disease by clinical examination alone is limited because there are other disease conditions such as essential tremors, multiple systemic atrophy, and progressive supranuclear palsy that may present with similar symptoms. Imaging has played an important role in early diagnosis and management of the disease. Molecular imaging is essential for early detection and enabling clear distinction between other similar disease entities that may mimic Parkinson’s disease. Chapter 2 reviews molecular imaging of head and neck cancers. FDG PET/CT and PET/MRI are essential tools in the evaluation of head and neck cancers (HNC) and can detect the primary site of malignancy in patients with cervical lymph node metastases from an unknown origin and guide treatment. CONTINUE READING.....

Contributors

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AMOL M. TAKALKAR, MD
Department of Radiology and Imaging Sciences, Emory University, Atlanta, GA, USA

BHAGWANT RAI MITTAL, MD
Department of Nuclear Medicine, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India

BRUCE BARRON, MD, MHA, FACNM
Department of Radiology and Imaging Sciences, Emory University, Atlanta, GA, USA

DOMNIQUE NEWALLO, MD
Department of Radiology and Imaging Sciences, Nuclear Medicine and Molecular Imaging Emory University Hospital, 1364 Clifton Rd NE, Atlanta, GA, USA

ERIN E. GRADY, MD
Stanford University School of Medicine, Department of Radiology, Division of Nuclear Medicine and Molecular Imaging, Stanford, CA, USA

GBENGA SHOGBESAN, MD
Department of Radiology and Imaging Sciences, Nuclear Medicine and Molecular Imaging Emory University Hospital, 1364 Clifton Rd NE, Atlanta, GA, USA

HARDIK VEERWAL, MD
Department of Nuclear Medicine, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India

HARMANDEEP SINGH, MD
Department of Nuclear Medicine, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India

HARRY W. SCHROEDER III, MD, PHD
Department of Radiology and Imaging Sciences, Emory University, Atlanta, GA, USA

JAYKANTH AMALACHANDRAN, MD
Department of Nuclear Medicine and Molecular Imaging, Apollo Proton Cancer Centre, Chennai, India

KARTHIKEYAN SUBRAMANIAN, MD
Department of Nuclear Medicine, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India

KRITIN SHANKAR, MD
Department of Nuclear Medicine, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India

LANCE T. HALL, MD
Department of Radiology and Imaging Sciences, Emory University, Atlanta, GA, USA

PIYUSH AGGARWAL, MD
Department of Nuclear Medicine, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India

RAJENDER KUMAR, MD
Department of Nuclear Medicine, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India

SAIMA MUZAHIR, MD
Emory University School of Medicine, Department of Radiology and Imaging Sciences, Atlanta, Georgia, USA

SANCHAY JAIN, MD
Department of Nuclear Medicine, All India Institute of Medical Sciences, Bhopal, MP, India

SCOTT J. LEE, MD
Emory University School of Medicine, Department of Radiology and Imaging Sciences, Division of Nuclear Medicine and Molecular Imaging, Atlanta, GA, USA

SURAJ KUMAR, MD
Department of Nuclear Medicine, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India

THANGALAKSHMI SIVATHAPANDI, MD
Department of Radiology and Imaging Sciences, Emory University, Atlanta, GA, USA

VENKATA SUBRAMANIAN KRISHNARAJU, MD
Department of Nuclear Medicine, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India

YAMINI MATHUR, MD
Department of Nuclear Medicine, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India

Molecular Imaging of Parkinson’s Disease

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ABSTRACT

Parkinson’s disease is a chronic debilitating disease of the central nervous system. Diagnosis by clinical examination alone is limited because there are other disease conditions such as essential tremors, multiple systemic atrophy, and progressive supranuclear palsy that may present with similar symptoms. The signs and symptoms in these patients are called parkinsonian syndrome, usually before a definitive diagnosis is made. Imaging has played an important role in early diagnosis and management of the disease. Molecular imaging, as discussed in this chapter, is essential for early detection and enabling clear distinction between other similar disease entities that may mimic Parkinson’s disease. Furthermore, systemic manifestations of Parkinson’s disease can also be detected in some cases, as discussed in this chapter.

Molecular Imaging of Head and Neck Cancers

Sanchay Jain, MD, Amol M. Takalkar, MD, Lance T. Hall, MD — Wed, 08 Nov 2023 00:00:00 +1000

ABSTRACT

Fluorine-18 (18F)-fluorodeoxyglucose (FDG) positron emission tomography - computed tomography (PET/CT) is an essential tool in the evaluation of head and neck cancers (HNC). 18F-FDG PET/CT can detect the primary site of malignancy in patients with cervical lymph node metastases from an unknown origin and guide treatment. Compared to traditional imaging, 18F-FDG PET/CT has higher sensitivity in detecting distant metastases and potential second primary malignancy, which significantly impacts management. 18F-FDG PET/CT also helps in evaluating recurrent or persistent disease that can be treated with salvage surgery and enables safe avoidance of planned post-radiation neck dissection with a high negative predictive value. For response evaluation, the Hopkins criteria and Neck Imaging Reporting and Data System (NI-RADS) are helpful for a standardized evaluation and recommendation. 18F-FDG PET/CT is also integrated in radiotherapy planning for accurate target delineation. PET/magnetic resonance (PET/MR) is advantageous in HNC because of high soft-tissue resolution of MR imaging and molecular information provided by the PET component. Hypoxia imaging in head and neck cancers has also been evaluated with novel molecular imaging agents. Sentinel lymph node biopsy with SPECT/CT and gamma probe guides early-stage HNC surgeries. This chapter highlights the role of molecular imaging in the management of HNC.

Nuclear Imaging and Therapy of Thyroid Disorders

Saima Muzahir, MD, Erin E. Grady, MD — Wed, 08 Nov 2023 00:00:00 +1000

ABSTRACT

This chapter reviews the basics of molecular imaging in thyroid disease and special considerations in radioiodine therapy of benign diseases such as Graves’ disease, autonomously functioning nodules, and toxic multinodular goiter. It also discusses the use of radioiodine therapy in the setting of differentiated thyroid carcinomas. A brief discussion of peptide receptor radionuclide therapy in medullary thyroid cancer is also included.

Molecular Imaging of Lung and Pleural Tumors

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ABSTRACT

The thorax has many important structures within, therefore a deep knowledge of its anatomy and developing a search pattern in thoracic imaging are critical in disease identification and characterization of disease. With the increase in clinical utilization of molecular imaging techniques, along with the continuous development of new radiopharmaceuticals, the role of molecular imaging and targeted radiotherapy of thoracic tumors is expanding. PET/CT and PET / MRI imaging play an imminent role in thoracic oncology such as pulmonary nodule evaluation, initial disease staging, therapy planning, response evaluation, and post treatment monitoring for disease recurrence. The purpose of this chapter is to give an overview of the various clinical uses, advantages, pitfalls, and advancements in molecular imaging and therapy of lung and pleural tumors.

Molecular Imaging of Mediastinal Tumors

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ABSTRACT

Imaging plays a crucial role in the diagnosis, characterization, and management of mediastinal tumors. The mediastinal tumors discussed are categorized into anterior mediastinal tumors, including thymic tumors, teratoma/Germ cell tumors, lymphomas, and neurogenic tumors in the posterior mediastinum. Cross sectional imaging with computed tomography (CT) and magnetic resonance imaging (MRI) generates highly detailed images showing the precise location, size, extent of the tumor involvement, as well as its relationship with adjacent critical structures, especially vascular involvement and spinal canal extension, and differentiating solid and cystic masses. Molecular imaging with whole-body positron emission tomography (PET) when combined with CT or MRI can provide valuable information on tumor metabolism, staging, therapy planning, response assessment, and post-treatment monitoring for disease recurrence. With the advent of new non-FDG PET radiopharmaceuticals, the utility of molecular imaging in mediastinal tumors has further broadened. The purpose of this chapter is to provide a clear review of the role, advantages, pitfalls, and advancements of molecular imaging in each mediastinal tumor.

Molecular Imaging of Breast Cancer

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ABSTRACT

Breast cancer is one of the most common types of malignancy, with an increasing incidence worldwide. Breast cancers are subtyped based on their histopathological features and hormonal receptor expression status. Conventional radiological modalities such as mammography, ultrasonography, computed tomography, and magnetic resonance imaging play a major role in the diagnosis and initial staging of breast cancer. Positron emission tomography with F-18-fluorodeoxyglucose (FDG) has an established role in the staging of locally advanced breast cancers, along with its use in response assessment after systemic therapy. Non-FDG radiopharmaceuticals also have a potential role in breast cancer imaging. These include agents that target hormonal and tyrosine kinase receptors, tumor microenvironment, and fibroblast activation protein inhibitors. Gamma camera-based modalities such as breast-specific gamma imaging, sentinel lymph node imaging, and skeletal scintigraphy also play a significant role in the management of subsets of patients with breast malignancy.

Molecular Imaging of Hepatobiliary Cancers

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ABSTRACT

Currently, molecular imaging modalities are not recommended in the initial workup of hepatobiliary malignancies except in equivocal cases on conventional imaging. But the role of molecular imaging in hepatobiliary tumors is evolving and the development of new technology and molecular imaging agents has renewed the interest in molecular imaging applications in hepatobiliary malignancies. In addition to providing information for tumor staging, treatment planning, response assessment, and detection of disease recurrence, molecular imaging provides additional information on the biological and molecular behavior of the tumor to assess disease prognosis and outcome. Recent meta-analysis shows promising results favoring molecular imaging over structural imaging in hepatobiliary malignancies. Molecular imaging agents targeting different metabolic pathways (glucose and lipid metabolism) and receptors (somatostatin and fibroblast activation protein inhibitors) have been tried in hepatocellular carcinoma, cholangiocarcinoma, liver metastasis and neuroendocrine tumors. We explore and summarize the current role of molecular imaging in hepatobiliary tumors and its advantages and disadvantages over conventional imaging modalities, along with a brief overview of newer PET molecular imaging agents.

Molecular Imaging and Therapy of Neuroendocrine Tumors

Saima Muzahir, MD, Erin E. Grady, MD — Wed, 08 Nov 2023 00:00:00 +1000

ABSTRACT

Neuroendocrine tumors are a diverse group of neoplastic entities with variable degrees of neuroendocrine differentiation that are imaged and, in some cases, treated with nuclear medicine techniques. They are generally uncommon, with an incidence of 50 per million people, and are often considered ‘zebra’ diagnoses. This chapter provides an overview of molecular imaging and therapy of neuroendocrine tumors with radiopharmaceuticals including ¹¹¹In-octreotide, ¹²³I-mIBG, ¹³¹I-mIBG, ⁶⁸Ga- or ⁶⁴Cu-DOTATATE, ¹⁷⁷Lu DOTATATE, and ¹⁸F-FDG. The biodistribution of these radiopharmaceuticals is reviewed along with dosing and, for therapies, the inclusion and exclusion criteria.

Utility of FDG PET/CT in Non-Prostate Male Genitourinary Pathology

Harry W. Schroeder III, MD, PhD, Bruce Barron, MD, MHA, FACNM — Wed, 08 Nov 2023 00:00:00 +1000

ABSTRACT

Much has been written about the utility of FDG PET/CT (fluorodeoxyglucose positron emission tomography/computed tomography) in frequently encountered malignancies such as lung cancer, breast cancer, and gastrointestinal cancers. Although less common, FDG PET/CT can be a useful modality in the evaluation and staging of cancers of the male GU (genitourinary) tract. Similar to its application with the more common malignancies, FDG PET/CT can provide helpful information when evaluating for sites of disease such as recurrent, nodal, and/or metastatic disease in the setting of these GU cancers. This chapter reviews the utility of PET/CT in the evaluation of non-prostate male GU pathologies such as the penis and testicles. Some very rare tumors as well as infectious and/or inflammatory conditions that can affect the GU system are also described.

Molecular Targeted Radionuclide Therapy for Prostate Cancer

Saima Muzahir, MD, Erin E. Grady, MD, Scott J. Lee, MD — Wed, 08 Nov 2023 00:00:00 +1000

ABSTRACT

According to the American Cancer Society, prostate cancer affects 1 in 8 men. This chapter reviews the molecular targeted radionuclide therapy for prostate cancer, including pretherapy imaging and evaluation, considerations during the course of therapy, and follow-up. Dosimetry and alpha-particle therapies are also discussed.

Molecular Imaging of Pediatric Lymphoma, Sarcomas, and Other Solid Tumors

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ABSTRACT

Pediatric tumors are rare, but often rapidly progressive malignancies which require early diagnosis, accurate staging, and appropriate treatment. Complications due to over treatment or under treatment of pediatric malignancies are a major concern and thus, prompt but pertinent workup along with early treatment response evaluation of tumors is vital. Molecular imaging techniques with positron emission tomography (PET) with computed tomography (PET/CT) and single photon emission computed tomography (SPECT) with CT (SPECT/CT) can often localize and accurately stage pediatric malignancies before morphological changes are evident with anatomical imaging techniques. These findings can help determine the clinical prognosis and treatment plan. In post-therapy patients, PET/CT and SPECT/CT may more accurately identify or exclude residual/recurrent malignancy. Since pediatric tumors often have overexpression of various molecular pathways, a variety of molecular imaging agents for PET/CT and SPECT/CT can be used (FDG). PET/CT with 18F-FDG usually shows increased tumor uptake in pediatric lymphoma and many other extra-cranial solid tumors. Amino acid based molecular imaging agents can be used in brain tumors and somatostatin receptor (SSTR) peptide molecular imaging agents can be used for tumors of neuroendocrine origin. Ongoing research has developed many novel molecular imaging agents which are in clinical trials.

Molecular Imaging of Infection

Erin E. Grady, MD — Wed, 08 Nov 2023 00:00:00 +1000

ABSTRACT

Molecular imaging of infection has been part of diagnostic imaging since the early days of radiopharmaceuticals. This chapter discusses the properties of diagnostic radiopharmaceuticals ⁶⁷Ga-citrate, ¹¹¹In- and ^99mTc-labeled leukocytes and ¹⁸F-FDG, along with when they are best deployed. Imaging of infection is best performed with ¹⁸F FDG for the majority of indications. This chapter explores the currently available means of diagnosis and best practices.

Index

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About the Editor

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Lance T. Hall, MD is an associate professor of Nuclear Medicine and Molecular Imaging in the Department of Radiology and Imaging Sciences at Emory University, Atlanta, Georgia, USA. Dr. Hall received post-graduate training in both Nuclear Medicine and Neurosurgery. He has extensive research experience as a principal investigator and co-investigator in clinical trials exploring novel molecular imaging and targeted molecular radiotherapy agents, including several first-in-human and first-in-child trials. His research interests include oncological disease processes with an emphasis on central nervous system malignancies as well as non oncological central nervous system disorders. His research has been supported by numerous grants and results of his research have been presented as numerous scientific presentations and peer-reviewed publications. In addition to research, Dr. Hall has a very active role in teaching students, residents/fellows, and faculty. He has served as a Nuclear Medicine Residency Program Director at the University of Wisconsin in Madison, Wisconsin, USA and is currently the Chair of the Nuclear Medicine Review Committee for the Accreditation Council for Graduate Medical Education (ACGME) and serves on several committees and working groups related to residency training and education for the Society of Nuclear Medicine and Molecular Imaging (SNMMI).