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NET NM Flashcards

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1
Q

NET of Pancreas inoperable

A

Celiac trunk
SMA

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2
Q

NET of Pancreas M

A

Liver
Bone
Abdomen
Lung

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3
Q

NET of Pancreas G

A

G1 Ki67 <3%
G2 Ki67 3-20%
G3 Ki67 >20%

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4
Q

NET of Pancreas Syndromic

A

20%
Early detection
Small size
Insulinoma
Gastrinoma
Glucagonoma
VIPoma
Somatostatinoma
Carcinoid

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5
Q

Insulinoma

A

Most common
6-10% malignancy
Solitary
25% MEN1
10% Islet cell hyperplasia
90% < 2 cm

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6
Q

Whipple triad

A

Insulinoma
Fasting glucose <50 mg/dL
Hypoglycemia
Relief of symptoms after glucose administration

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7
Q

Gastrinoma triangle

A

Cystic duct confluence
Junction of pancreatic head and body
Junction of second and third parts of duodenum

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8
Q

Gastrinoma

A

60-90% malignant
30% with liver MTS
Multiple
75% MEN1
Zollinger-Ellinson sy - - excess of gastrin - - ulcer–PPI
Epigastric pain
Diarrhoea

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9
Q

Glucagonoma

A

60% malignant
Usually large 6 cm
Necrolytic migratory erythema (usually genitals)
4D: dermatosis, diarrhea, depression, DVT
Stomatitis, anemia, weight loss

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10
Q

VIPoma

A

10-20% extrapancreatic
80% malignant
VIP - vasoactive intestinal peptide
WDHA sy: watery diarrhea, Hypokalemia, achlorhydria

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11
Q

MEN1

A

Pituitary adenoma
Parathyroid hyperplasia
Pancreatic tumor - 40-70% NET

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12
Q

NET of Pancreas genetic

A

MEN1 - 40-70%
Von Hippel Landau - 10-17%
Neurofibromatosis type 1
Tuberous Sclerosis

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13
Q

NET of Pancreas Octreoscan

A

Negative doesn’t exclude gastrinoma or insulinoma
Glucagonoma 100%
VIPoma 88%
Carcinoid 87%
Gastrinoma 73%
Insulinoma <25%

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14
Q

NET of Pancreas Ga-DOTA-TATE

A

Gold Standard
Localisation of unknown primary
More accurate than octreoscan

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15
Q

ASVS = arterial stimulation with venous sampling

A

Intraarterial calcium stimulate insulin production
Localised insulin-secreting NET

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16
Q

NET from neuroendocrine organ

A

Medullary thyroid cancer
Pancreatic
Pheo
Paraganglioma

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17
Q

NET from dispersed neuroendocrine cells

A

Pulmonary
Gastro-entero-pancreatic

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18
Q

NET from non endocrine organ

A

Thymus
Cutaneous NET

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19
Q

Pheo and paraganglioma M

A

Bone
Liver
Lung

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20
Q

Pheo genetic

A

MEN2A, MEN2B
VHL
Neurofibromatosis type 1

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21
Q

Pheo 10%

A

Bilateral
Extra adrenal
Children
Malignant (>5 cm, SDHB mutation)

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22
Q

Pheo image

A

DOTA - most sensitive, highest detection rate of MTS, SDHB mutation
MRI - 100%
Octreotide <30%

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23
Q

MIBG Pheo and paraganglioma %

A

Specificity 100%
Sensitivity 80% 50%
MTS avid 60%

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24
Q

Preoperative biopsy not recommended
Pheo

A

Catecholamine crisis
Tumor rupture
Seeding
Complications: severe hypertension, hematoma, inadequate biopsy, delay in surgery

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25
Low suspicion Pheo
24h urine test Normetanephrine >900 mcg/24h Metanephrine >400 mcg/24h Norepinephrine >170 mcg/24h Dopamine >700 mcg/24h
26
High suspicion Pheo
Plasma test Metanephrine <0.5 nmol/L Normetanephrine <0.9 nmol/L
27
Type I gastric Carcinoid
80-90% Ass with chronic autoimmune gastritis and pernicious anemia Fundus and body <2 cm, multiple, localized in gastric wall
28
Type II gastric Carcinoid
5-7% Hypergastrinemia from Zollinger-Ellinson sy or small intestine Recurrent peptic ulcers <2 cm, multiple, localized in gastric wall
29
Type III gastric Carcinoid
10-15% >2 cm, single, infiltrate Perigastric tissue Well diff - - MTS 50-70%
30
Duodenal NET
Gastrin producing G-cells 62% - - proximal duodenum - - MEN1 Somatostatin producing D-cells - periampullary - - somatostatinoma - - Neurofibromatosis type 1 <1 cm duodenal gastrinoma - - bulky adenopathy
31
Best prognosis among gastrointestinal NET
Rectum
32
Worst prognosis among gastrointestinal NET
Colon
33
Octreoscan in jejunum and ileum
Distinguish sclerosing mesenteritis from metastatic carcinoid
34
DOTA in colon and rectum NET
Localization if unknown primary
35
Octreotide highest affinity
SSTR2a/b
36
SSTR density in malignant tissue
80-2000 fmol/mg protein
37
Octreoscan protocol and preparation
IN111-DTPA octreotide 4h and 24h No consensus - Stop cold octreotide: 1 day for short lived molecule, 3-4 weeks for long-acting Mild oral laxative 1 day before and continue 120-200 MBq, SPECT Medium energy collimator Dual peak energy 172 and 245 keV
38
Octreoscan indication
GEP-NET, pulmonary NET Less - skin, paraganglioma, genital tract Liver MTS isointense, hard to detect Intense uptake - - higher response to PRRNT
39
Small insulinoma
No SSTR expression
40
Tc99-EDDA/HYNIC-TOC octreotide dose
370-740 MBq VS Octreoscan: Better distribution pattern Higher tumor-non-tumor ratio Lower radiation dose Better spatial resolution
41
Ga68-DOTA PET protocol
T1/2 68 min 100-200 MBq TOC - - SSTR2 TATE - - 10*SSTR2 NOC--SSTR2, 3, 5
42
Ga - DOTA uptake
Pituitary Thyroid Liver Adrenal Kidney Spleen Excrete - - bladder, intestine
43
Ga-DOTA indication
GEP-NET and pulmonary NET Congenital hyperinsulinism, breast ca, medulloblastoma, supratentorial primitive neuroectodermal tumor, Meningioma Neuroblastoma Pheo Paraganglioma
44
Catecholamine analog
C11-epinephrine C11-hydroxyephedrine F18-dopamine F18-DOPA I123-MIBG
45
NET synthesize catecholamine
Transported by VMAT 1 and 2 VMAT2 in head and neck
46
I123-MIBG protocol
At least 24h Option 4-6h VMAT 1 200-400 MBq Slow IV to avoid tachycardia, pallor, vomit, abd pain WBS speed 5-7 cm/min Spot images 10 min per view Medium energy high resolution collimator, 159 keV, 20% window
47
I123-MIBG vs I131-MIBG
Imaging quality better than I131 Better spatial resolution Higher count rate
48
Stop drugs 1-3 days before MIBG Sympathomimetics and cardiovascular
Antiarrhythmics Alpha and beta blockers Adrenergic neuron blockers Ca-channel blockers Vasoconstricters Nasal decongestant Glaucoma Sympathomimetics
49
Stop neurological drugs 1-3 days before MIBG
Antipsychotics Sedating antihistamine Opioids Tricyclic antidepressants CNS stimulants
50
Before MIBG thyroid block
Lugol solution 1 day before, 2 days after K-perchlorate 4h before, 2 days after 400-600 mg/day
51
MIBG uptake
Salivary glands Lung Heart Liver Spleen Normal adrenal (late image) Excrete - - kidneys, fecal
52
MIBG image indication
Paraganglioma -- uptake in heart can be very low (down regulation in response to elevated catecholamine) High uptake in enlarged adrenal - - adrenal paraganglioma Reduced sensitivity in extra adrenal lesions due to close to physiological uptake Low sensitivity in paraganglioma of head and neck
53
F18-DOPA preparation
Fast 4h 200 mg carbidopa 1h before - - increase uptake
54
F18-DOPA vs MIBG
Higher spatial resolution Low background activity - - detect smaller lesions 30-60 min vs 24h No need for thyroid block and stop medication Both VMAT1 and 2 vs VMAT1 Esp VMAT2 in head and neck paraganglioma
55
F18-DOPA uptake
Striatum Kidneys Pancreas Liver Gallbladder Biliary tract Duodenum Adrenal (high uptake in enlarged - - paraganglioma
56
F18-DOPA indication
Highly sensitive for extra adrenal paraganglioma, esp head and neck Residual MTC, rising markers Pancreatic NET in patients with VHL sy Insulinoma - preop Localisation if congenital hyperinsulinism Children - - affected Pancreas takes up DOPA and convert to dopamine Adults - - no dd affected vs normal pancreas due to high physiologic uptake
57
F18-FDG GLUT
GLUT Well-diff NET overexpress SSTR and not GLUT poorly - diff NET - - decline tin SSTR, increase in GLUT expression
58
F18-FDG indication
Not to localize paraganglioma Preferred for staging and treatment monitor of metastatic adrenal paraganglioma with SDHB mutation GEP-NET with positive FDG - - more aggressive Pulmonary PET - - uptake depends on mitotic index and tumor proliferation rate
59
Typical Carcinoid Low proliferative index
Overexpress SSTR High DOTA low FDG
60
Well-diff
Slow grow Chemo ineffective Biotherapy with somatostatin analog Tachypylaxis early after initiation of therapy <10% partial response
61
Radionuclide therapy indication
All patients affected by metastatic/unresectable SSTR2-expressing NET GEP - - frequent liver MTS Pulmonary Pheo Paraganglioma Neuroblastoma MTC
62
Y90-DOTA-TOC and Lu177-DOTA-TATE contra
Abs: Pregnancy Severe acute illness Unmanageable psychiatric disorder Relative: Breastfeeding Creatinine >1.7 (esp Y) RBC <3, WBC <3, PLT <90 (TOC), <75 (TATE)
63
Y90-DOTA-TOC and Lu111-DOTA-TATE pretreatment
Renal protection - L-lysine / L-arginine Inhibit tubular reabsorption Reduce renal absorbed dose Hydration - over 4h,starting 30-60 min before PRRNT 25g lysine or arginine in 2L Saline Amino acids + Gelofusine infusion (plasma expander)
64
Y90-DOTA-TOC administration
Beta emitters 100 mCi per m^2 of body surface Second cycle in 6-12 weeks Or 75-120 mCi in 2-4 cycles at 6-12 weeks interval
65
LU177-DOTA-TATE administration
150-200 mCi 3-5 cycles at 6-12 weeks interval
66
Y90-DOTA-TOC vs Lu177-DOTA-TATE
Y90 - - higher energy beta - - more penetrating Y90 shorter T1/2 - - higher dose rate to tumor Lu177 - - lower energy and penetration, gamma camera suitable, shorter beta range (higher dose rate to small tumor), lower nephrotoxicity
67
Y90-DOTA-TOC indication
Bulky and lesions with inhomogenous SSTR
68
Lu177-DOTA-TATE therapy indication
Smaller tumors
69
I131-MIBG Contra
Abs Pregnancy Life expectancy <3 months (unless palliative) Severe renal failure + planned dialysis Relative Unacceptable medical risk for isolation, urinary incontinence GFR <30 mL/min Severe toxycities from prior treatment WBC <3, PLT <100
70
I131-MIBG treatment preparation
stop medication Thyroid block 1-2 days before, over 14 days after
71
I131-MIBG administration
No consensus - 268 or 149 mCi Higher activity deliver dose faster with modest increase in toxicity but similar response Slow IV 45 min-4h to avoid nausea, vomit, hypertension Monitor vital signs over next 2-3 days Specific activity for therapy should be higher than for diagnostic purpose
72
I131-MIBG therapy indication
Inoperable pheo, paraganglioma, carcinoid Stage III or IV neuroblastoma Metastatic or recurrent MTC GEP-NET - - palliative in SSTR-negative, borderline renal function, resistant to somatostatin therapy
73
Assess SSTR overexpression and select patients for PRRNT
Ga68-DOTA-TATE or Ga68-DOTA-TOC
74
MEN 2a
Parathyroid hyperplasia Medullary thyroid carcinoma Pheo
75
MEN2b
Mucosal neuroma Marfanoid body habitus Medullary thyroid carcinoma Pheo
76
Familial Pheo
Hippel-Landau gene - - VHL RET gene - - MEN2 Neurofibromatosis type 1 gene - - Von Recklinghausen disease SDHB and SDHD genes - - familial Pheo and paraganglioma

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