Fast track — ArticlesStaging of carcinoid tumours with 18F-DOPA PET: a prospective, diagnostic accuracy study
Introduction
Neuroendocrine tumours are a heterogeneous group of slow-growing lesions arising from neuroendocrine cells, of which carcinoid tumours are the most common. These tumours are often located in the abdomen and can produce and secrete a large variety of products because of their intrinsic ability to take up, accumulate, and decarboxylate amine precursors.1 In metastatic disease, these products, such as serotonin and catecholamines, can bypass the first-pass metabolisation and inactivation by the liver and can cause symptoms. Treatment options for carcinoid tumours include curative or debulking surgery, medical treatment with somatostatin analogues, and interferon.2
To assess individual treatment options, accurate knowledge of tumour localisation, biochemical activity, and progression is essential. The initial work-up for patients with carcinoid tumours consists of morphological imaging methods such as CT, combined with functional whole-body imaging with somatostatin-receptor scintigraphy (SRS).3, 4, 5 However, CT and MRI of the abdomen have difficulties in correctly separating tumours and mesenterial metastases from intestinal structures.6, 7, 8 Furthermore, SRS can produce false-negative findings, because of the variable affinity and expression of somatostatin receptors and the restricted resolution of gamma cameras and single-photon-emission tomography (SPECT) methods.9, 10
PET using the catecholamine precursor 6-[fluoride-18]fluoro-levodopa (18F-DOPA) has emerged as a new imaging method for neuroendocrine tumours.6 By contrast with other methods, this procedure is based on the intrinsic property of neuroendocrine tumours to take up amine precursors, such as 18F-DOPA.11, 12, 13, 14, 15 The combination of this specific tracer with the high resolution provided by PET could lead to a clinically relevant improvement in the detection and staging of neuroendocrine tumours. A few small studies6, 16, 17 have shown some potential of 18F-DOPA PET in small and heterogeneous groups of patients with neuroendocrine tumours.
Therefore, the aim of this study was to compare the diagnostic sensitivity of 18F-DOPA PET with that of conventional imaging methods such as SRS and CT, in a large and homogeneous population of patients with carcinoid tumours.
Section snippets
Patients
Eligible patients for this prospective single-centre diagnostic accuracy study included: those who were newly referred to our centre (which serves the northern region of the Netherlands) with a carcinoid tumour, based on clinical or biochemical findings, and at least one abnormal lesion detected on CT, MRI, sonography, or SRS; and those known to have a histopathologically proven carcinoid tumour, who had a clinical indication for restaging, and who had at least one abnormal lesion on
Results
Between October, 2003, and February, 2006, we asked 68 consecutive patients to participate in the study (figure 1); however, three declined PET scanning, and we could not obtain all required information for 12, because of various logistical reasons (eg, no biochemistry or pathology findings, no SRS). Sensitivity was calculated in the remaining 53 patients assessed, of whom 25 were newly diagnosed with carcinoid disease (table 1). The median time between PET and CT was 59 days (range 1–191) and
Discussion
We showed improved diagnostic sensitivity of 18F-DOPA PET in staging and identification of carcinoid tumours, compared with currently applied, standard whole-body imaging with SRS. Compared with the combination of SRS with CT, 18F-DOPA PET detected substantially more individual tumour lesions, more affected body regions, and more lesions per region. The improved lesion detection of carcinoid tumours with 18F-DOPA PET provides a better understanding of the true extent of tumour spread in
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