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Hello and welcome to Noon conferences hosted by MRI online. In response

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to changes happening around the world right now, in the shutting down of

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in person events, we've decided to provide free Noon conferences to all

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radiologists worldwide. Today we're joined by Dr. Arif Sheikh. Dr. Sheikh

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received his undergraduate from the University of Michigan. He attended

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med school at Wayne State University. He was an assistant professor at University

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of North Carolina, associate Professor at Columbia University and Mount

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Sinai Hospital in New York, and was a clinical professor at Temple University.

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He's currently a clinical professor at Wright State University and Medical

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Director and Chief of Nuclear Medicine at Kettering Health. A reminder,

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there'll be a Q and A session at the end of the lecture,

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so please use your Q and A feature to ask your questions,

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and we'll get to as many as we can before time's up.

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That being said, thank you all so much for joining us today,

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Dr. Sheikh, I'll let you take things from here.

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Thank you very much for the invitation. I thank you. Can you hear

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me? Just wanna confirm. Yes. Yes, we can hear you. Wonderful.

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And I appreciate the invitation and being able to join you.

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The initial intent of the lecture had been to

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go over some case studies of some of the newer tracers but

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the past year really has been an explosion

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of developments that we've seen in nuclear medicine and this is despite

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the pandemic taking place. So I was just going to just show you

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a series of quick cases to show you where things are at and

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where things are going. It's a very exciting time to read molecular imaging.

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It's kind of, in some sense, it's almost bewildering to keep up with

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the fast pace as things develop. So I don't have any

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financial disclosures, although I will be talking about some indications

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which are off label at this time. But,

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most of the stuff I'll be discussing about things that have

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been recently approved. So they may be FDA approved, may not be completely

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CMS approved at this time. So we have a bunch of tracers that

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have been approved until about 2020. But, not a whole lot of traction.

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And then suddenly in 2020, we've had 2020 and 2021, we've had a

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series of tracers suddenly come into FDA approval. Some of them are be

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a little bit older like F DOPA but a slew of them have

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come in even as recent as earlier this month, just two weeks ago.

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And that's not it. There's some other tracers that are in development and

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this, that's just a very short list. Some may or may not come

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into clinic, whereas some, a lot of other tracers

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show promise and may actually come into the clinical realm.

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So the area is expanding very rapidly, and it would be important to

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sort of review what all these tracers are and where things are going

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in molecular imaging in general. So we'll discuss the impact of new tracers

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there. The evolution of recently approved tracers, meaning up until 2016

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and 2020, as well as some update in technical developments in nuclear medicine

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as, and look at some future directions of where things are going.

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So there's been a lot of interest in developing nuclear medicine imaging

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or hormonal receptors in particular developing ligands that can

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bind to various receptor areas. So FES, which is fluoroestradiol has been

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been one tracer that's been actually around for a very long time,

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but only in the last year or so has it come into

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clinical development and approval. So why is it important? It is good for

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whereas FDG is very good for aggressive invasive ductal carcinomas. It has

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limited roles in things like lobular carcinomas. And

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the important thing is that in treatment of breast cancer is a big

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emphasis on whether they're hormonal responsive or not. And that's not FDG

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something that FDG can necessarily provide. It does provide very good data

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with regards to chemotherapy, but not necessarily those who are hormonally

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sensitive. And when FES was officially FDA approved in

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May, 2020, there's been a lot of interesting, for example, using it specifically

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for patients recurrent or metastatic breast cancer as an adjunct to biopsy.

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We'll look at a couple of cases there.

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It may actually guide therapy itself without being a diagnostic scan.

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But currently it's only available in limited locations within the country,

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but it does have official FDA approval. Okay. So lobular carcinomas, like

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I mentioned, tend to have lower grade FDG activity.

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They tend to have lower grade markers of prognosis.

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For example, their lesions tend to be more blastic on bone scans and

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therefore less FDG avid and can become more FDG avid if transformed into

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a more aggressive disease. But despite that, it can actually have a worse

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stage mass prognosis. So it can be sometimes difficult to follow with FDG

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for staging response and, and other things. So for example, here is a

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case where a patient gets an FDG PET scan where clearly there's a

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carcinoma. But the issue is that if we look

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at the FDG PET scan there, we see there kind of mass,

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but there really isn't much FDG uptake compared to the contralateral breast,

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which is benign. So you can't really pick that out

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as cancer. Based on the FDG PET scan alone, you might be able

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to figure out an CT or if you knew the patient had

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biopsy proven disease. This is a patient who's had an FDG PET scan, an FES

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scan side by side compared to the bone scan that we see.

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For example, we see a bone lesion, which does not light up on

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the FDG or FES scan. So that may be actually benign,

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but you can see there's a lot more extensive disease on the FES scan

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that was picked up on either of the FDG or bone scans alone.

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So again, changing how this patient is managed and treated is very important.

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In this case, there's a lesion seen on the MRI, which is not

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picked up on the FES scan. So there was concern about whether the

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patient had become hormonally resistant disease. And this shows that this

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indeed is non specific finding and the patient can continue taking hormones

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as needed. This is a patient who actually is ER positive and

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this is before and after treatment PET scan with FES, again,

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showing you that FES can be used in these circumstances too...