Oncology – Nuclear Medicine

PET / BT

PET / CT Whole Body Cancer Imaging

Cancer Scanning with PET/CT

It is an imaging system consisted com- bination of PET / CT (Positron Emis- sion Tomography) and CT (Computed Tomography). This imaging method, which was selected as “ the invention of the year” and published on the cov- er page by “ TIME Magazine” in the 1990s, is an effective imaging method in cancer types and it is a nuclear med- icine method that gives a 3-dimensional view of physiological processes in the body. By combining the PET device with CT, it provides anatomical and physiological information in a single session and helps to increase the accu- racy of the examination.

How to examine with PET/CT?

PET / CT is an intravenous injection of FDG (fluorodeoxyglucose) 2-fluo- ro-2-deoxy D-glucose (radiolabeled sugar molecule). Like FDG accumu- lates in cells that multiply rapidly, i.e. high metabolic activity, like tumor cells.

In order to perform the examination, the patient must stay hungry 6 hours before the examination. Patients to be imag- ined can use other drugs except insulin or oral antidiabetic drugs. In diabetic patients, image quality may be subopti- mal due to endogenous glucose enters into competition with FDG. Therefore, blood glucose level is determined be- fore FDG injection and patients over 180 mg / dL are not examined.

Which Diseases are suitable for PET/CT examination?

PET / CT may be used in staging of many cancer types; lung cancer, lym- phoma, malignant melanoma, head and neck tumors, breast cancer, colorectal cancers, esophageal and gastric tu- mors, gynecologic cancers, mesotheli- oma, primary bone tumors and diagno- sis, staging, re-staging of primary un- known and evaluation of the treatment that is used

Why is PET/CT Requested?

It is an imaging method that in use to evaluate the status of cancer patients and cancer staging. In addition, diag- nosis of “undiagnosed diseases” such as fever of unknown cause, exploration of foci of infections, detection of living tissue in heart patients, it is also in use for the separation of Alzheimer’s and dementia. PET / CT with FDG (radiola- beled sugar molecule) injected intrave- nously to the patients by the physician request due to obtain physiological information in a single session and to increase the diagnostic accuracy.

What are the advantages of PET/CT?

PET / CT, which is a medical imaging system and is combined with “Positron Emission Tomography” (PET) and“Computed Tomography” (CT) which is evaluated as “Invention of the Year” by TIME Magazine, is a method of ex- amination that we obtain high level of physiological information in many types of cancer with high accuracy in a single session. PET / CT cancer screening provides clear information in the diag- nosis and staging of cancer patients with significant advantages such as unnecessary reduction of biopsies, reduction of potential operations and shortening of the examination period

GALLIUM DOTA-TATE PET / BT

NET is clearer with Gallium DOTATE PET!

Gallium-68 Dota-Tate PET in Neuroendocrine Tumors

Although neuroendocrine tumors (NET) are rarely seen diseases, they are the ones that need to be emphasized in terms of “mortality”. In the modern med- ical world, it is possible to diagnose the disease and find the appropriate treat- ment methods by carrying out a serious study about neuroendocrine tumors.

GA-68 Dote-Tate PET presents higher sensitivity than other scintigraphic tests used to detect tumor sites and to identi- fy NETs. There is no definite conclusion about the factors that cause neuroen- docrine tumor.

Symptoms of gastroenterology and endocrinology outpatient clinics include face flushing and sweating attacks, hypoglycemia or secreted ectopic hor- mone-related findings. In addition, neu- roendocrine tumors detected incidentally from gastroenterology / general surgery outpatient clinics may present with dia- betes, pancreatic mass or diarrhea.

Why is Gallium- 68 Dotetate Requested?

Neuroendocrine tumors occur inciden- tally in certain examinations or surgical operations because they do not show any specific symptoms. Gallium-68 DOTA PET is requested in case of signs of flushing, sweating attacks, hypoglycemia or secreted ectopic hormone findings in examinations in Gastroenterology and Endocrinology policlinics. Gallium-68 DOTA PET im- aging is required because it provides useful results in the detection of neuro- endocrine tumors (NET) in symptom- atic patients with negative anatomical imaging. It is also requested to detect neuroendocrine tumors in cases where physical examination is not possible.

How to image Dotetate?

Neuroendocrine tumors, one of the non-functional cancers, are suspected from applying pressure to surrounding structures after growing. In order to identify the neuroendocrine tumors that causes different conditions according to the organ and secreted hormone and to determine the appropriate treat- ment, the doctor asks the patient to image Galyum-68 DOTATE PET. This procedure is performed after the phy- sician and specialist technicians guide the patients and inform them about the issues that need attention before imag- ing. The processing time may be pro- longed or shortened depending on the area where the neuroendocrine tumor is suspected.

What are the Advantages of Gallium Dotetate?

With the help of studies on cancer dis- eases, it is possible to detect and treat most diseases in advance. Gallium-68 DOTA PET is in use for the detection of neuroendocrine tumors which are among the “latent growing cancers” and seriously reduces the quality of life of the person. In addition, the results of Galium-68 DOTA PET will help to plan treatment to determine the appropriate treatment method.

Attention to Neuroendocrine Cancers

According to the information given by the International Association of Neuro- endocrine Cancers (INCA);

• Every year, between 5 and 7 people are diagnosed neuroendocrine tumor (NET) among 100 thousand people in the
• During the time of diagnosis, more than half of the patients develop a second tumor due to
• 60-80 percent of neuroendocrine cancer patients are diagnosed only at advanced
• NET, is seen more in; stomach, intes- tines, lungs and
• The patient visits at least 5-6 different specialists until the diagnosis is made because of NET is a secretly growing cancer that causes different condi- tions.
• Because NET symptoms are often confused with irritable bowel syn- drome, asthma and diabetes, treat- ment can often be

GALLIUM PSMA PET CT

The Golden Standard in Prostate Cancer Imaging!

Prostate Cancer Shouldn’t Intimidate You

Prostate cancer is a type of cancer that occurs in one in every six men in the world. It is a type of cancer that can be treatable in the early stage but can se- riously reduce the quality of life in case of postponed treatment and can cause death in advanced stages. The prostate cancer, that can be predetermined with modern medical devices and it’s fear are going to become history.

The Most Effective Result Due to Gallium PSMA Through PET Imaging

Gallium PSMA PET CT, which is de- veloped against prostate cancer which is the most common cancer type after lung cancer in men, is a type of imag- ing that gives clear results in cancer screening. With “Prostate Specific Membrane Antigen” (PSMA) screening, it is much easier to determine the stage of prostate cancer and if it has spread to surrounding organs or tissues

Why is Gallium PSMA PET Requested?

After the inurement of developed mod- ern medical devices, certain results can be obtained in prostate cancer as well as in many types of cancer. Gallium PSMA PET, which one of the imaging methods with smart molecules, is an ideal target as a smart molecule for the diagnosis and treatment of prostate cancer.

It is very beneficial in the diagnosis stage of prostate cancer in patients with risk of spread in pathological ex- amination. Gallium PSMA PET is used for staging the disease, determining whether there are recurrences after

treatment and for detecting metastases. PSA values, which are cancer mark- ers, are more successful than imaging methods such as ultrasound, tomogra- phy and MRI.

How to image Gallium PSMA PET?

The biggest difference between cancer cells and normal cells is that cancer cells grow rapidly and spread to other parts of the body. Gallium PSMA PET is performed to learn these spread values and determine the appropriate treat- ment method according to these val- ues. The patient does not need to make any special preparations before the examination. After waiting for the radio- active material to spread to the body (this takes approximately 1 hour), the patient is passed to the Gallium PSMA PET CT imaging procedure by taken to PET CT device

What are the Advantages of Gallium PSMA?

Gallium PSMA PET was found to be more accurate than any other device in any stage of prostate cancer.

Before deciding on the treatment of cancer diseases, it is necessary to determine the stage of cancer. Again, it is known that the results of PSMA imaging are more effective than other imaging methods because the results can be obtained more clearly.

In many European studies, Gallium PSMA PET / CT has been reported to be the best imaging method for detect- ing prostate cancer recurrence even in cases where the PSA level is 0.2 ng / ml. In other words, it gives effective results even when the cancer size is very small.Gallium PSMA PET, which has a very high degree of sensitivity, gives an ef- fective result in detection of very small metastases in bones.

LUTESYUM-177 DOTA TATE TREATMENT

Neuroendocrine Tumor Treatment          

What is Lutetium-Octreotide treatment?

Lutetium-Octreotide, [Lutetium-DO- TATATE (177Lu-DOTATATE)] is an increasingly common treatment for patients with advanced neuroendocrine cancer. Peptide receptor radionuclide thera- py (PRRT) is another name of Lute- tium-Octreotide treatment. The aim of this treatment is to reduce tumor size and to stop the proliferation of tumor cells.In this context, the progress of the disease can be controlled and it is possible to alleviate the symptoms of advanced disease such as diffuse bone pain and fatigue.This treatment is generally used when the disease progresses, spreads, or when the side effects of other treat- ments cannot be tolerated by the pa- tient.

How does Lutetium-Octreotide work?

Somatostatin receptors are a receptor on the surface of cells in many tissues in the body. However, these receptors are denser in neuroendocrine cancer cells.If the cancer has spread to other parts of the body, somatostatin receptors are also found in high density in metastatic cells in organs such as lymph nodes, bones and lungs.Lutetium-Octreotide treatment uses a special molecule (smart molecule) that binds itself to somatostatin receptors in cancer cells.Before being injected to the patient, the smart molecule (DOTATATE) is bound to each other with Lutetium (177Lu) in the laboratory. In this way, the radioac- tive Lutetium atom is transported to the cancer cell with a smart molecule.Cancer cells disintegrate over time with destructive beta radiation emitted by lutetium. The smart molecule acts as a carrier and transports radiation to the cancer cell, whereby not the entire body but the targeted areas, are ex- posed to radiation

Why should I choose this treatment?

This treatment can be used primarily in cases where neuroendocrine cancers spread, the disease progresses, can not be controlled or does not respond to other treatments. Neuroendocrine tumors usually have a somatostatin receptor on cell surfaces, but Octreotide PET / CT imaging should be performed on candidate patients to ensure that radiation will target the cor- rect areas before treatment. It is not necessary to interrupt the hormone therapy (Sandostatin®) in patients who will be treated with lute- tium-octreotide. However, if the patient is receiving chemotherapy and it is decided to give Lutetium-Octreotide treatment to the patient, chemotherapy should be discontinued

What other cancers does this treatment administrate to?

This treatment can also be used to treat other cancers with somatostatin recep- tors, if the disease has a resistant to other treatments such as chemothera- py, radiotherapy, and so on, if treatment is unresponsive or if the disease has progressed under treatment. Medullary thyroid cancer, iodine-re- sistant papillary type thyroid cancers, paraganglioma and neuroblastoma can be considered as these kinds of can- cers. The suitability of the patients to the treatment is should be decided by a multidisciplinary approach.

Is Lutetium-Octreotide treat- ment safe?

Radiation used in the treatment of lute- tium-octreotide is designed to destroy cancer cells. Smart molecules that targets somatostatin receptors injected into the body, target cancerous cells during their journey towards the tumor. Apart from cancer cells, somatostatin receptors are found in many different organs. Therefore, these tissues may also be exposed to radiation. However, this effect is low and does not show any of the devastating side effects of che- motherapy, as smart molecules adhere directly to cancer cells.

Side effects in the form of temporary decrease in blood values may occur in some patients. In the post-treatment period, these effects can be controlled by regular blood tests. In addition, pa- tients who are likely to be exposed to side effects can be identified by testing before the treatment decision is made. Side effects are kept to the lowest possible level due to patient-specific personalized treatment strategies sup- ported by test results and dosimeter studies.

LUTESYUM – 177 PSMA

Smart Molecular Treatment Option in Prostate Cancer

Prostate Cancer Treatment with LUTETIUM-177 PSMA

Prostate cancer, which is the most common cancer among men in the world after lung cancer, is no longer a nightmare all thanks to the developed modern medical technology. Lute- tium-177 PSMA treatment; is method increasingly used method for patients with metastatic prostate cancer. The treatment method has been found to be highly effective on prostate cancer, which allows to reduce the size of the tumor, stop growth and spread, and re- duce complaints such as common bone pain in prostate cancer patients. Lute- tium-177 PSMA, which is used in ad- vanced stages of prostate cancer and in cases that do not respond to other treatment methods, helps to keep the disease under control in some patients for a longer period without progression.

What is LUTETIUM-177 PSMA?

Lutetium-177 PSMA has become one of the most commonly used treatment modalities in the treatment of metastatic and castration resistant prostate cancer (mKDPK). PSMA also known as glu- tamatecarboxypeptidase II, which was found approximately 30 years ago, is a transmembrane glycoprotein which has enzyme functions in the cell. In addition to having an active role in the uptake of folate into the cell, it is also involved in cell migration, cell survival and pro- liferation. PSMA molecule developed through the studies and researches has become the target for the diagnosis and treatment of the prostate cancer.

Why is LUTETIUM-177 PSMA

Desirable?

Thanks to the studies carried out in today’s modern medical technology, smart molecules that are targeting various cancers have been developed. Through these smart molecules, we can target cancerous tissue without damaging healthy tissue. Treatment with Lu-177 PSMA smart molecule is a successful alternative when there is no response to standard therapies in prostate cancer or if side effects of standard therapies are avoided. One of the smarts molecules, PSMA and Lu- 177 (Lutetium-177), are combined and given to the patient intravenously and irradiates only prostate cancer cells and their metastases.

Which Patients Does LUTETIUM-177 PSMA Provide Solutions for?

Despite many studies on the diagno- sis and treatment of prostate cancer, prostate cancer is still among the most causes of death in men. Although the effectiveness of hormonal therapies with medical or surgical castration has been established in prostate cancer treatment, prostate cancer patients are progressing to the metastatic stage and are showing resistant to hormonal treat- ments. The group of patients, defined as “metastatic prostate cancer” (CM- MPC), plays an important role in the treatment of patients with CMMPC due to the inurement of radionuclide com- pounds that targets “prostate specific membrane antigen ”(PSMA) for the purpose of diagnosis and treatment.

LUTESYUM – 177 EDTMP TREATMENT

In Common Bone Metastases Pain Relief

What is the purpose of using the radioactive drug called EDTMP labeled Lu-177?

Lu-177 labeled EDTMP radioactive drug is used in order to reduce pain in bone metastases. This radioactive drug can be applied in all cancer pa-tients with painful bone metastasis, if a positive image is obtained after bone scintigraphy performed in the nuclear medicine department. This radioactive drug, which can be used for the treat- ment of pain in patients with cancer-re- lated bone metastases determined by scintigraphy, is prepared and applied in the hospital. In this process, when the kidney functions and blood parameters of the patient are evaluated by nuclear medical doctors, when the parameters are favorable, they can be applied easily without hospitalization, and the patient can then be sent home.

In which tumors Lu-177 EDT- MP treatment is recommend- ed?

This treatment is recommended for all types of cancers if bone involvement is positive, in other words increased os- teoblastic activity, in scintigraphy.

How and in which patients bone pain treatment can be done with Lu 177 EDTMP in cancer?

–           Bone scintigraphy should be per- formed before treatment.

–           Positive bone scintigraphy should be consistent with the painful area.

–           This treatment offers an effective solution and is given to patients with resistant bone pain despite the use of painkillers.

Lu-177 EDTMP for pain relief in bone metastasis:

–           It increases the success rate in combi- nation with other treatments.

–           It can be applied in combination with radiotherapy. It has a kinetic effect.

–           Lu-177 EDTMP may be repeated at regular intervals depending on the pa- tient’s clinical condition.

–           Today, it is also recommended to be used in the early stages of the disease because of the delay in recurrence of pain.

AC-225 Treatment

Alpha Treatment in Prostate Cancer

Actinium-225-PSMA is the name of the radioactive substance given to the patient in targeted alpha treatment in prostate cancer. It can be used in metastatic advanced prostate cancer patients. The aim of this treatment is to reduce tumor size, stop the proliferation of tumor cells and destroy tumor cells. Radionuclide therapies are preferred in the treatment of prostate cancer when the disease progresses, spreads, or when other treatments, such as che- motherapy and etc. are ineffective or the side effects are not tolerated by the patient. As a general approach, lutetium PSMA treatment is the first choice in patients with radionuclide therapy. Lutetium-PS- MA, is a treatment method has been applied to thousands of patients in Tur- key and in the world. The main goals in the treatment of lutetium-PSMA are to reduce symptoms, prolong life and im- prove quality of life. However, some patients may not re- spond to treatment despite lutetium-PS- MA treatment or the response of the disease to treatment may be insuffi- cient. Even with treatment, the disease may continue to progress. Day by day, it is shown in the medical literature that targeted alpha therapies with Actinium-225-PSMA are much bet- ter in this group of patients.

How does actinium-PSMA treatment work?

PSMA is a naturally occurring protein on prostate gland cells. However, pros- tate cancer cells have much more of them. If prostate cancer has spread to other parts of the body, metastatic cells in organs such as lymph nodes, bones, lungs also have a high concentration of PSMA. Actinium-225-PSMA treatment uses a smart molecule that binds itself to PSMA receptors in cancer cells. Be-fore being injected into the patient, the PSMA molecule is linked together with Actinium-225 in the laboratory. In this way, the radioactive Actinium atom is transported to the cancer cell with a smart molecule. With destructive alpha radiation emitted by actinium, cancer cells fractionate over time. The PSMA molecule as a smart mol- ecule, acts as a carrier and transports radiation to the cancer cell, whereby, not the entire body but the targeted areas are exposed to radiation.

What other cancers does this treatment administrate to?

This method of treatment is specific to cancers originating from prostate can- cer only. It is used in cases where prostate cancer does not respond to other treat- ments, especially hormone therapy. Almost all types of prostate cancer con- tain PSMA on cell surfaces, but before treatment is given, PSMA PET imaging should be performed to ensure that the radiation will target the correct areas. Alpha therapy is generally preferred in patients who do not get the desired re- sponse after lutetium PSMA, but it can be used as the first radionuclide treat- ment option if your physician deems it necessary. However, in this case, it is appropriate to evaluate the alpha treatment option with a multidisciplinary approach includ- ing nuclear medicine physicians and oncology, urology and radiation oncolo- gy specialists.It is not necessary to interrupt hormone therapy in patients who will be treated with actinium 225-PSMA. However, it should not be given with chemotherapy. If the patient is receiving chemotherapy and it is decided to give Actinium 225- PSMA treatment, chemotherapy should be discontinued.

Is actinium-PSMA treatment safe?

The radiation used in this treatment is designed to destroy cancer cells. The PSMA injected into the body targets cancer cells during its journey towards the tumor. Apart from prostate cancer cells, PSMA is also found in tissues such as salivary glands, tear glands, kidneys. Therefore, these tissues may also be exposed to radiation. However, this effect is very low and does not show any devastating side effects of chemotherapy as PSMA adheres directly to cancerous cells. Side effects, such as dry mouth, tem- porary fatigue, or temporary decrease in blood values, may occur in some patients. In the post-treatment period, these effects can be controlled by regu- lar blood tests and examination.

Is it easy to administer?

Actinium-PSMA treatment is consisted of several steps such as preliminary tests, dosimeter studies, supply of nec- essary radioisotopes and smart mole- cules and their synthesis in the labora- tory, quality control; Following the treat- ment decision with a multidisciplinary approach, it is a process that requires the work of Nuclear Medicine physician, radiopharmacy specialists and health physicists at various stages.However, patients are not affected by this sensitive process. Actinium-PSMA synthesized on the day of treatment is administered intravenously to the pa- tient after the necessary quality control tests have been completed.Patients may return home on the same day after treatment is completed. The patients who is working can work the next day. Treatment can be tolerated quite easily. There are no expected side effects during treatment.In the long run, the most significant side effect was reported as dry mouth. How- ever, this side effect is not observed in all patients. No side effects, including dry mouth, were observed in patients treated with Actinium-PSMA in the De- partment of Nuclear Medicine, Istanbul Medical School.

The alpha particle breaks the DNA chain in the cancer cell and causes the cancer cell to die.

HO – 166  MICROSPHERE TREATMENT

New Hope in Liver Cancer Treatment

Ho-166 Microsphere Treatment

Liver cancer is a type of cancer that starts with the replacement of normal cells in the liver by abnormal cells and, when it’s not treated in the early period, causes the person to die by leaping into the surrounding organs and tissues.Although there are many drugs and treatment methods produced against cancer in the medical world, it may not be enough to prevent cancer growth in some patients. “Microsphere” treatment was more accurate for users who did not respond to the drug treatment who had no change of chemotherapy or surgical operation.The “microsphere” treatment meth- od, which is applied only by injecting a radioactive isotope into the vessels feeding the tumor, helps the patients to regain their health.

What is the Ho-166 Microsphere Treatment?

Microsphere treatment, or “radioembo- lization”, is a method of treatment for other organ tumors with a primary focus on the liver or metastasis to the liver. In other words; microsphere treatment is  a treatment method which is developed against tumors that have metastasized to liver or firstly formed in liver and applied by using radioactive material (Ho-166).

How is the Procedure of Ho-166 Microsphere Treatment?

Microsphere treatment, which is de- fined as “effective treatment method” for the liver cancers, is a treatment method used in patients who cannot be intervened by surgical operation.It is based on the reduction or complete destruction of the tumor by giving high radiation dose to the tumor and the liver tumor site. Radioactive drug is injected by the interventional radiologist to the hepatic artery which feeds the tumor in the liver.

Are There any Side effects of Ho- 166 Microsphere Treat- ment?

In cases of liver cancer, microsphere treatment is a treatment proceed by injecting radioactive material (Ho-166 microsphere) directly into the vessel that feeds the tumor in the liver for the patients determined by the con- sensus of a council that includes anuclear medicine specialist. During the treatment dull stomach pain and the dull pain in the liver may be experi- enced. These are short-term conditions that can be treated with medication. The main advantage of microsphere treatment is that there are no serious complications after the treatment. This treatment method is developing day by day and new radioactive prod- ucts are offered as treatment options. Since 2008, radioembolization treat- ment has been performed in our coun- try. The radioembolization product with the Holmium-166 radioisotope, a new generation microsphere agent, was released. The radioisotope difference of the product brings along patients comfort and treatment procedure ad- vantages

These advantages can be listed as fol- lows;

• Ho-166 radioisotope is used instead of Y-90 radioisotope.
• With the help of the Q-Suite software, the shots required in the treatment procedure can be evaluated in more detail in 3D. This software can be used for dosimetry verification of tumor-dose and tissue-dose after practice.
• Ho-166 isotope produces gamma oscillation alongside beta oscillation. Gamma oscillation allows immediate follow-up of the treatment and imaging at any time with MRI and SPECT-CT.
• In the Y-90 based radioembolization products, the materials that retain the radioisotope are glass and resin, mean- while the product with the Ho- 166 ra- dioisotope is PLLA (Poly L-lactic Acid). This material is completely organic and does not cause any harm to the patient and it is biodegradable.

In Which Situations Can Ho-166 Microsphere Treatment Be Used?

Ho-166 Microsphere is in use for ad- vanced liver tumors that are not suit- able for surgical operation.

When shouldn’t Ho-166 Micro- sphere Treatment Be Used?

For the patients who have previously received external radiation therapy to the liver,

For the individuals with hepatic and renal failure,

For the individuals with full portal vein thrombosis,

For the patients with vascular abnor- malities in hepatic artery which feeds the tumor in the liver that may cause significant reflux of blood to the stom- ach, intestine or pancreas, the treat- ment shouldn’t be used