Non FDG PET
Introduction
Since its introduction into clinical practice, positron-emission tomography (PET) has been associated with the use of 2- [18F]-fluoro-2-deoxy-d-glucose (FDG). FDG, a glucose analogue, has a very high sensitivity for the detection of malignant involvement by more than 90% of tumours, and has proved to be useful in staging,1 re-staging,2 assessing therapy response 3, 4 and during follow-up.5, 6 Furthermore, FDG can be employed for the identification of several types of dementia,7, 8 where imaging abnormalities can significantly precede the onset of clinical signs, and in the evaluation of cardiac viability.9
Despite the large field of application for FDG, some malignant tumours (for example, prostate cancer,10 neuroendocrine tumours,11 hepatic tumours 12 and others) frequently do not show a significantly increased FDG uptake and, therefore, may be undetectable by FDG PET. Furthermore, FDG presents two major drawbacks in oncology: it is not useful for evaluating malignant masses that are located in tissues with physiologically high glycolytic metabolism (for example, central nervous system tumours) 13 and cannot distinguish between inflammation and cancer,14, 15, 16 as both processes are characterized by increased glucose metabolism.
Similarly, FDG is not suitable for diagnosing patients with movement disorders, while in cardiology it cannot be used to evaluate coronary blood flow 17 due to its low first-pass extraction. For these reasons, expansion of the pool of PET tracers available for use in oncology, neurology, and cardiology was considered of primary importance and several other compounds have been tested.
Of these new tracers, the most important in current clinical practice are: choline (11C- and 18F-labelled); 11C-methionine; 18F-DOPA; 68Ga-DOTANOC and other somatostatin analogues; 11C-acetate and 18F-FLT (3ٰ-deoxy-3ٰ-fluorothymidine).
The aim of this paper is to provide a concise overview of the most commonly used non-FDG tracers in clinical use and reviews the most promising developments in the field.
Section snippets
11C-Choline
As stated above, well-differentiated prostate cancer is one the most clinically important low glucose-utilizing tumours. Furthermore, the frequent co-existence of inflammatory processes in the prostate and the gland’s close proximity to the bladder with its contained urinary activity, result in difficulties when using FDG to diagnose primary prostate cancer or, more importantly, to assess prostate cancer local relapse with FDG.18, 19
11C-choline is a small molecule that, once injected
18F-DOPA
18F-deoxiphenilalanine is a radiolabelled amino acid precursor of dopamine. It was synthesized for the in vivo evaluation of striatal activity in patients with suspected Parkinson’s disease (PD), but recently it has also been employed in oncology for the detection of malignant tumours derived from neural crest tissue.52 Such tumours (carcinoid, pheocromocytoma, neuroblastoma, medullary thyroid cancer, microcytoma, carotid glomus tumours, and melanoma) are usually very well-differentiated and 18
Conclusion
Approximately 90% of PET examinations in oncology, cardiology, and neurology currently employ FDG. However, there are several indications where FDG is not useful; in particular, prostate cancer, liver cancer, CNS tumours, and NETs. Other tracers, labelled either with 11C or 18F, have been synthesized and tested for the types of malignant tumours that where FDG is unhelpful. These radiotracers are specific for tumours with a relatively low incidence and for which there is no established
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