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