"We literally 'illuminate' the tumor"

Expert Profile

Maxim Yaroslavovich Smolyarchuk – radiologist, leading expert in PET/CT diagnostics of oncological diseases, Deputy Director of the Institute of Nuclear Medicine for Scientific and Organizational Work at A.F. Tsyb Medical Radiological Research Center (branch of the National Medical Research Radiological Center of the Ministry of Health of the Russian Federation). Advocate for radiation diagnostic methods, hosts Telegram channel for patients "Gamma of Dr. Smolyarchuk".  

Education:

2005 – Medical Faculty of Ulyanovsk State University

2007-2011 – Residency and graduate school at A.F. Tsyb Medical Radiological Research Center of the Ministry of Health of the Russian Federation in "radiology," "radiation diagnostics," and "radiation therapy"

International training and internships:

EANM and ESR training course in multimodal imaging (Spain)

Internship at Assaf Harofeh Medical Center (Israel)

Internship at University Hospital Zurich (Switzerland)

Work experience:

Over 15 years in radiology and nuclear medicine.

2014-2016 – organized and headed the radionuclide diagnostics department at European Medical Center in Moscow.

2016-2022 – Deputy Chief Freelance Specialist in Radiation Diagnostics for Moscow in radionuclide diagnostics.

2020-2023 – President of the International Organization "Society of Nuclear Medicine."

2022-2024 – Deputy Chief Medical Officer for Clinical and Expert Work at "Medicine and Nuclear Technologies."

Since 2024 – Deputy Director of the Institute of Nuclear Medicine for Scientific and Organizational Work at A.F. Tsyb Medical Radiological Research Center (branch of the National Medical Research Radiological Center of the Ministry of Health of the Russian Federation). 

Author of over 45 scientific works and publications. Research interests include developing novel radionuclide examination methods, including hybrid imaging modalities.

How PET Differs from Other Radiation Diagnostic Modalities

CT and MRI devices demonstrate only anatomy, organ morphology, size, and location. To characterize tissue on CT, we administer contrast. MRI demonstrates water concentration in tissues and also allows detecting changes in them. PET demonstrates functional cellular activity. We visualize how cells "live", capturing and processing substances, how receptors on cell surfaces behave, what antigens they produce and with what expression.

Such "receptor imaging" provides enormous oncology opportunities, for understanding the current clinical picture, prescribing and adjusting therapy. Malignant cells differ from healthy ones: they divide more rapidly, consume glucose more actively, and produce specific antigens. Using radiopharmaceuticals (RPs) that bind to specific molecules on cell surfaces, we literally "illuminate" tumors.

Over 90% of all PET/CT examinations are performed with fluorodeoxyglucose (FDG). Most malignant tumors express increased numbers of glucose receptors. Tumor cells cannot fully metabolize it, so they capture more and more; thus, radioactively labeled glucose accumulates within them.

Second among diagnostic RPs is prostate-specific membrane antigen (PSMA) labeled with gallium-68 or fluorine-18. This RP is indicated for prostate cancer diagnostics. PSMA is a molecule expressed in increased quantities by prostate cancer cells. Incidentally, indications for this RP are currently expanding. For example, PSMA can be utilized for clear cell renal carcinoma.

Third in frequency of use are amino acids methionine and fluoroethyltyrosine. Their target is brain tumors. Normally, the brain very actively consumes glucose. Attempting to visualize tumors there using FDG is like looking at a lighter flame against a bonfire background. Nothing can be seen. However, amino acids are practically unnecessary for healthy brain tissue, neurons don't synthesize new proteins. Therefore, if on PET/CT we visualize a region actively capturing amino acids, it's highly likely a malignant neoplasm. This method is particularly important following surgical treatment of glioblastomas: MRI cannot distinguish tumor recurrence from scar tissue and post-radiation necrosis. PET with amino acids can.

Somatostatin analogues are utilized for PET/CT diagnostics of neuroendocrine tumors. Well-differentiated tumors (resembling healthy cells) aren't visible on FDG PET: they proliferate slowly and don't consume glucose as actively. However, they express somatostatin receptors and become visible with another agent. Incidentally, this same agent, labeled with lutetium-177 instead of gallium-68, is utilized for radionuclide therapy. This is called theranostics, when diagnostics and treatment are performed with one molecule.

When PET/CT Is Utilized

There's a common misconception that PET/CT is an early diagnostic modality. Actually, it's the final component in the patient's diagnostic pathway. Except in extremely rare cases.

PET/CT's main "strength" in oncology is detecting metastases. And here timely examinations are important. In practice, diagnostics are sometimes limited to CT, surgery is performed, then metastases are discovered. Retrospectively we understand they existed initially and are difficult to identify on CT. Thanks to PET/CT, we can clearly stratify patients. PET allows us to visualize what we can cure. And we can visualize in advance where the agent will "distribute."

WHEN PET/CT IS DEFINITELY NOT REQUIRED

There's also a downside to PET/CT diagnostics accessibility. This is an excessive prescription. Consider breast cancer (BC). Hormone-sensitive and HER2-positive, approximately 85% of all BC in women. They don't require PET diagnostics at all. And it can even be detrimental, as it may lead to premature therapy change when hormonal therapy (first-second line therapy) can still inhibit tumor cell proliferation. Next in the oncologist's armamentarium is only chemotherapy, which is both more difficult to tolerate and less effective.

For treatment effectiveness assessment, PET/CT is also often unnecessary; everything is visible on CT. However, when deciding about resecting or irradiating a specific metastasis, PET/CT is absolutely necessary.

PREPARATION FOR PET/CT: WHAT TO CONSIDER

I developed specialized guidelines for patients. Very briefly, the specifics of preparing for FDG PET/CT involve strict fasting and carbohydrate restriction to lower blood glucose. For PSMA PET/CT this isn't required.

Common PET/CT Preparation Errors

Error #1.

Refusing water. Many believe: if eating is prohibited, drinking is too. This isn't correct. When the stomach is empty, it contracts, walls approximate. On images such a stomach appears as a tissue mass, and the physician cannot properly assess its condition.

Error #2.

Canceling medication. Another misconception relates to medication therapy. Many believe if fasting before PET is necessary, tablets can't be taken either. They arrive with severely elevated blood pressure, pain episodes. Take analgesics, normalize blood pressure. Even glucose-lowering agents used to be canceled, but it's been proven this doesn't affect PET at all. Why do we need unnecessary comorbidity exacerbations?

Error #3.

Concealing comorbidities from radiologists. Usually pneumonia, infections, HIV aren't mentioned. However, this is critically important for correct result interpretation.

PET/CT in Russia

Today few countries can boast such PET/CT diagnostics coverage in terms of equipment availability (0.68 per 1 million population, Marus Media), insurance medicine capabilities, and examination costs. With appropriate quality levels at leading centers with strong reputations, both in federal state medical organizations and some private clinics.

Federal centers are now acquiring the latest PET/CT scanners with expanded fields of view through the "Long and Active Life" national project. They scan three times faster, and examination costs are lower. Image quality is significantly superior. Additionally, centers of excellence and physician teams achieving the highest levels in their field have formed. 

For international patients, there's an opportunity to receive comprehensive care in Russia: quality examination, primary treatment, radiation therapy, surgical treatment, receive systemic therapy prescriptions. And then maintain remote contact with their Russian oncologist. As well as undergo nuclear medicine treatment, including theranostic modalities.