The Role Nuclear Medicine in

The Management of Thoracic Disorder

dr.Hanif Afkari, Sp.KN

Sub Division Nuclear Medicine & Molecular Theranostic

Departement Radiology - Dr. Sardjito General Hospital
 Thoracic Disorder

Thoracic disorders are conditions of the heart,

lungs, mediastinum, esophagus, chest wall,
diaphragm, great vessels and lymphnode
Generally divided into :
- Primary Disease
- Extended Disease (Metastases)
 Therapeutic Approach in Nuclear Medicine
• Diagnosis and treatment of disease (cancer) is
still not satisfactory. Must be a multidisciplinary
approach to medical science
• Nuclear Medicine is a promising modality.
• Development of molecular biology and
genetics.
• Requires important involvement in special
imaging
The Evolving Role of Nuclear Medicine in Oncology

SEE and TREAT :

– See: Tag gamma-emitter to molecular agent,
inject in patient, goes to the target molecule,
make images.
– Treat: Add beta-emitter to molecular agent,
inject, goes to the target molecule and delivers
the therapy.
Theranostics and Targeted Therapy
 Thoracic Disorder Diseases
▪ Retrosternal/Sub-sternal
Thyroid Cancer/Mediastinal
Goiter
▪ Lung Neuroendocrine
Tumour / NETs
▪ Thoracic Lymphoma
Retrosternal/Sub-Sternal/Mediastinal Goiter

• A retrosternal or substernal goiter (SSG) is an

enlargement of the thyroid gland that extends
into the mediastinum posterior to the sternum.
• Mediastinal Goiter

• Many are asymptomatic and incidentally

detected on CT as an anterior upper
mediastinal mass. As they enlarge, they may
cause symptoms of dyspnea, stridor, or
dysphagia.
Functional Imaging

Thyroid Functional Imaging :

1. Tc-99m pertechnetate is not ideally
suited for this purpose because of its high
mediastinal blood pool activity, although
the study can sometimes be diagnostic .
2. I-131 has been used because it can be
imaged at 24 to 48 hours and thus will
have high target-to-background ratio.
3. I-123 is usually the first
radiopharmaceutical of choice with images
obtained at 4 hours.
Fig. 1. (A) Contrast-enhanced CT (B) Thyroid scintigraphy Tc-99m pertechnetate. The scanning showed only
marginal activity throughout the mediastinal mass (arrow). (C) Scintigraphy with I-123 2 h post-injection. (D)
Image 24 h later. The late accumulation of I-123 at the right thyroid lobe and the mediastinal mass (E) Image 5
days after I-131 therapy. (F) MRI 1 year after radioiodine therapy
Figure 2. Substernal goiter with I-123 hybrid SPECT/CT. The I-123 thyroid scan is fused with the CT scan in
selected transverse, sagittal, and coronal views. This patient had a multinodular toxic goiter with substernal
extension.
Integrated management
• Surgery :Total thyroidectomy/ Thoracotomy
--> to remove the primary tumor and clinicaly
significant lymph nodes metastases
• Adjuvant therapy :

1. Radioactive Iodine Therapy (RAI) : NaI-131

2. Suppressive Therapy :
Thyroid Hormone --> to decrease TSH level
Neuroendocrine Tumors (NETs)
--> comprise heterogenous goup of malignancies that
arise from neuroendocrine cells throughout the body
and most commonly originate from the lungs, small
instetine and rectum.
--> Lung NETs , can be classified:
1. Well differentiated (low-grade typical carcinoids[TCs]
2. Intermediate-grade atypical carcinoids [ACs])
3. Poorly differentiated (high-grade large cell
neuroendocrine carcinoma or SCLC)
NETs
Diagnostic workup, two critical issues are present:
• Firstly, the need to identify tumor presence
• Secondly, to define the primary location and assess
regional and distant metastases.
Venn diagram of modalities involved in the identification of a NET. 111 InOCT = 111 In-pentetreotide scintigraphy; 68
Ga-PET = PET with 68 Ga-DOTA-peptides; 18 F-DOPA = 18 F-dihydroxyphenylalanine; 11 C-5-HTP = 11 C-5-hydroxy- L -
tryptophan; FNA = fine-needle aspiration; FNB = fine-needle biopsy; CTC = circulating tumor cells.
NETs : Tumour cells with secretory granules
--> storage vesicles of hormones or peptides :
phaeochromocytomas
paragangliomas
carcinoid tumours
medullary carcinoma of thyroid
pancreatic endocrine tumours
somatostatin receptors :
➔ somatostatin analogue :

Diagnostic:
In-111 octreotide (In-111 DTPA-D-Phe1-Octreotide)
Therapy :
Y-90 DOTATOC, I-131 MIBG
I-131 MIBG
Thoracic Lymphoma
• Primary pulmonary lymphoma is a very
rare neoplasm that represents only 3-4%
of extranodal non-Hodgkin lymphoma
(NHL), less than 1% of NHL and only 0.5-
1% of primary pulmonary malignancies.
• Primary pulmonary NHL is most commonly
represented by marginal zone B-cell
lymphoma of mucosa-associated lymphoid
tissue type (MALT lymphoma)
 Diagnostic Modality
18F-FDG PET
--> Targeting glucose metabolism, which is
markedly increased in most malignant tumors
including lymphomas.
--> Assess treatment response during or after
completion of therapy as changes in glucose
metabolism are much earlier than structural
changes.
--> PET has been combined with CT, a well-
established new modality in the evaluation of nodal
and extranodal NHL
Radioimmuno Therapy (RIT)
RIT is a therapeutic technique using antibodies labeled
radionuclides which will be specifically captured by tumor-
specific antigen (TSA) that can be used clinically for the
destruction of malignant / cancerous cells

Advantages :
1. Tumor cells that do not express antigens can still be
killed directly by damaging DNA by the radiation energy
emitted: the cross fire effect

2. Cell near the cells exposed to radiation can still

undergo cell death, mutations, chromosomal damage,
apoptosis, and cell transformation even if the cells are
not exposed to radiation: by stander effect
Radionuclide Therapy

Targeted radiopharmaceuticals in molecular therapy contain a targeting

molecule and a radioactive isotope complexed with a chelating agent.
The targeting molecule binds to the tumor specific receptor according to the lock
and key principle. In most cases the targeting molecule can be used for both
diagnostics and therapy - only the radioisotope has to be changed.
Radionuclide Therapy (RIT) approval FDA

Limphoma non-hodgkin :
- Zevalin® : monoklonal anti-CD20 yang ke
dalamnya telah diikatkan radioisotop pemancar
beta Yttrium-90

- Bexxar® : monoklonal anti-CD20 yang ke

dalamnya telah dimuati dengan radioisotop
Iodium-131
See and Treat
Zevalin® : Non-Hodgkin’s Lymphoma
Monoclonal antibody, very specific to certain NHL

See PET:
- In-111 (gamma) Pre-
Zevalin

Treat PET:
- Y-90 (Beta) 3 mo
Post-
Zevalin
 CONCLUDING REMARKS

The strength of nuclear medicine techniques lies on its ability

to assess metabolic activity of pathologic lesion and to find out
recognition sites as marker of disease.

Nuclear Medicine has significant role in oncology i.e.

in diagnosing, predicting therapeutic response and prognosing
the course of disease; it also plays a certain role in curative
and palliative therapy of certain tumours.
THANK YOU
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