Nuclear imaging of neuroendocrine tumours

The diagnosis of neuroendocrine tumours (NETs) and monitoring of therapy in many patients relies mainly on morphological imaging techniques such as computed tomography (CT), ultrasound (US) and magnetic resonance imaging (MRI). However, functional imaging modalities – such as somatostatin receptor scintigraphy (SRS) – have great impact on patient management by providing tools for better staging of the disease, visualization of occult tumour, and evaluation of eligibility for somatostatin analogue treatment. Positron emission tomography (PET) using 18F-fluoro-deoxy-glucose (FDG) is a powerful functional modality for oncological imaging. Unfortunately, FDG is not accumulated in NETs except in the case of dedifferentiated tumours and tumours with high proliferative activity. Based on the concept of amine precursor uptake and decarboxylation (APUD), the 18F- and 11C-labelled amine precursors L-dihydroxyphenylalanine and 5-hydroxy-L-tryptophan (5-HTP) have been utilized for PET imaging of NETs. In comparative studies of patients with a variety of NETs, 11C5-HTP-PET proved better than CT and SRS by visualizing additional small lesions. With carbidopa premedication orally before 11C5-HTP-PET examination the tumour uptake could be increased and the urinary radioactivity concentration considerably reduced. This concept may also be applied to 18F-L-DOPA-PET, a method which in a limited number of studies has gained additional diagnostic information in NET patients compared to SRS and morphological imaging. 68Ga is available from an in-house generator and has been utilized for labelling of somatostatin analogues for PET imaging of NETs with promising results in a small number of patients. However, SRS is an established functional imaging method for patients with NETs, whereas the role for PET in the clinical routine needs further evaluation in comparative studies in larger groups of patients.