Prevention of activated brown adipose tissue on 18F-FDG-PET scans of young lymphoma patients: results of an ancillary study within the EuroNet-PHL-C2 trial

Activated brown fat (aBAT) is known to affect the evaluation of 18F-FDG PET scans, especially in young patients. The aim of this study was to determine factors influencing the occurrence of aBAT, and to investigate the effectiveness of the two preventive measures, warming and beta-blocker (propranolol) administration. Five-hundred-twenty-eight 18F-FDG-PET scans of 241 EuroNet-PHL-C2 trial patients from 41 nuclear medicine departments in Germany and Czech Republic were screened for aBAT. The occurrence of aBAT was analyzed with patient characteristics (age, sex, body mass index, predisposition to aBAT), weather data at the day of 18F-FDG PET scanning as well as the preventive measures taken. Potentially important factors from univariate analyses were included into a logistic regression model. Warming as a preventive measure was used in 243 18F-FDG-PET scans, propranolol was administered in 36, warming and propranolol were combined in 84, and no preventive measures were taken in 165 scans. Whereas age, sex and body mass index had no clear impact, there was an individual predisposition to aBAT. Logistic regression model revealed that the frequency of aBAT mainly depends on the outside temperature (p = 0.005) and can be effectively reduced by warming (p = 0.004), the administration of unselective beta-blocker or the combination of both. Warming is a simple, cheap and non-invasive method to reduce the frequency of aBAT. However, the effect of warming decreases with increasing outside temperatures. Administration of propranolol seems to be equally effective and provides advantages whenever the positive effect of warming is compromised. The combination of both preventive measures could have an additive effect.

Use of PET-CT in diagnostic workup of periprosthetic infection of hip and knee joints: significance in detecting additional infectious focus

Introduction

The diagnosis and management of periprosthetic knee and hip infections as well as the identification and management of possible additional infectious foci is of great importance for successful therapy. This study analyses the importance of ¹⁸F deoxyglucose PET-CT (PET-CT) in the identification of additional infectious focus and subsequent impact on management of periprosthetic infection (PPI).

Material and methods

A retrospective analysis of the clinical data and findings in the period from January 2008 to December 2018 was carried out. One hundred and four patients with in-hospital treatment due to PPI of a hip or knee joint were identified and included in this study. All patients underwent a standardized clinical examination and further surgical and antibiotic therapy. The reevaluation of performed PET-CTs was specifically carried out with regard to the local PPI or detection of secondary foci.

Results

PET-CT successfully verified the PPI in 84.2% of the patients. A total of 78 possible additional foci were detected in PET-CT in 56 (53.8%) of the examined patients. Predilection sites for possible secondary foci were joints (42.3%), pulmonary (15.4%), ear-nose-throat (15.4%), spine (11.5%), and the musculocutaneous tissues (11.5%). Fifty-four positive PET-CT findings were confirmed clinically with need of additional adequate treatment.

Conclusion

PET-CT is a valuable diagnostic tool to confirm periprosthetic joint infection. At the same time, the whole-body PET/CT may detect additional foci of infection with impact on subsequent treatment strategy. PET was of special value in detecting infections at distant locations far from the primary infected joint in significant number. These distant infection locations can be potential cause of a re-infection. This clearly reflects the need of their diagnosis.

Whole-body [18F]-FDG-PET/MRI for staging of pediatric non-Hodgkin lymphoma: first results from a single-center evaluation

Aim

In 2015, the revised International Pediatric Non-Hodgkin Lymphoma Staging System was published. It mentions [¹⁸F]-FDG-PET/MRI as the latest method to perform whole-body imaging. However, supporting data are pending. Our aim was to investigate the performance of whole-body [¹⁸F]-FDG-PET/MRI in pediatric non-Hodgkin lymphoma patients by using a limited number of MRI sequences.

Materials and methods

Ten pediatric patients with histologically proven non-Hodgkin lymphoma underwent whole-body [¹⁸F]-FDG-PET/MRI at staging. The retrospective analysis included three steps: First, [¹⁸F]-FDG-PET and MR scans were evaluated separately by a nuclear medicine physician and a pediatric radiologist. Nineteen nodal and two extranodal regions as well as six organs were checked for involvement. Second, discrepant findings were reviewed together in order to reach consensus. Third, [¹⁸F]-FDG-PET/MRI findings were correlated with the results of other clinical investigations.

Results

Of the 190 lymph node regions evaluated, four were rated controversial. Consensus was reached by considering metabolic, functional and morphologic information combined. Concordantly, [¹⁸F]-FDG-PET and MRI detected Waldeyer’s ring involvement in two patients whose Waldeyer’s ring was negative on clinical assessment. In four patients MRI showed pleural effusion. However, in only two of them an increased glucose metabolism as a reliable sign of pleural involvement was detectable. In six patients [¹⁸F]-FDG-PET and MRI detected skeletal lesions although bone marrow biopsy was positive in only one of them.

Conclusion

Despite the small number of cases evaluated, whole-body [¹⁸F]-FDG-PET turned out to be a valuable tool for staging of pediatric non-Hodgkin lymphoma.

Only strongly enhanced residual FDG uptake in early response PET (Deauville 5 or qPET ≥ 2) is prognostic in pediatric Hodgkin lymphoma: Results of the GPOH-HD2002 trial

PURPOSE

In 2014, we published the qPET method to quantify fluorodeoxyglucose positron emission tomography (FDG-PET) responses. Analysis of the distribution of the quantified signals suggested that a clearly abnormal FDG-PET response corresponds to a visual Deauville score (vDS) of 5 and high qPET values ≥ 2. Evaluation in long-term outcome data is still pending. Therefore, we analyzed progression-free survival (PFS) by early FDG-PET response in a subset of the GPOH-HD2002 trial for pediatric Hodgkin lymphoma (PHL).

PATIENTS/METHODS

Pairwise FDG-PET scans for initial staging and early response assessment after two cycles of chemotherapy were available in 93 PHL patients. vDS and qPET measurement were performed and related to PFS.

RESULTS

Patients with a qPET value ≥ 2.0 or vDS of 5 had 5-year PFS rates of 44%, respectively 50%. Those with qPET values < 2.0 or vDS 1 to 4 had 5-year PFS rates of 90%, respectively 80%. The positive predictive value of FDG-PET response assessment increased from 18% (9%; 33%) using a qPET threshold of 0.95 (vDS ≤ 3) to 30% (13%; 54%) for a qPET threshold of 1.3 (vDS ≤ 4) and to 56% (23%; 85%) when the qPET threshold was ≥ 2.0 (vDS 5). The negative predictive values remained stable at ≥92% (CI: 82%; 98%).

CONCLUSION

Only strongly enhanced residual FDG uptake in early response PET (vDS 5 or qPET ≥ 2, respectively) seems to be markedly prognostic in PHL when treatment according to the GPOH-HD-2002 protocol is given.

Improvement of Brain SPECT by Stabilization of Tc-99m-HMPAO with Methylene Blue or Cobalt Chloride

Aim: This present study was carried out to investigate whether stabilization of Tc-99m-HMPAO with methylene blue (MB) or cobalt chloride (CC) causes a sensible improvement in image quality and how cerebral to noncerebral activity ratios compare with those of Tc-99m-ECD. Methods: 30 minutes after preparation 400-600 MBq unstabilized Tc-99m-HMPAO (N = 35 patients), Tc-99m-HMPAO added with MB (N = 24 patients), added with CC (N = 30 patients) or Tc-99m-ECD (N = 28 patients) were injected. Radiochemical stability was measured in vitro with three chromatographical methods. Image quality was assessed quantitatively using two ratios, one of them determined by count densities of brain/scalp (QS), the other one by count densities of brain/ nose (QN). In addition, image quality (0 = bad, 3 = excellent) and background activity (0 = high, 3 = no) were visually assessed by three independent observers. Results: In contrast to unstabilized Tc-99m-HMPAO the integrity of the complexes of MB-Tc-99m-HMPAO, CC-Tc-99m-HMPAO and Tc-99m-ECD decreased only by a few percent during a period of 2 hours after reconstitution (66.8 ± 9.9 vs. 93.0 ± 2.5, 91.8 ± 1.9 and 96.9 ± 1.4%, p <0.001). Qs and Qn (m.v. ± SD) differed significantly between studies using unstabilized Tc-99m-HMPAO (3.0 ± 0.4 and 2.1 ± 0.3), MB-Tc-99m-HMPAO (3.4 ± 0.4 and 2.3 ± 0.3), CC-Tc-99m-H M PAO (3.6 ± 0.6 and 2.6 ± 0.4) and those using Tc-99m-ECD (4.3 ± 0.7 and 4.8 ± 1.4; p <0.05 and <0.001). Stabilization with CC or MB resulted in significant higher scoring of image quality and lower scoring of background activity in comparison to that of unstabilized Tc-99m-HMPAO, without reaching the scores obtained with Tc-99m-ECD. Conclusions: It is concluded that stabilization of Tc-99m-HMPAO with MB or CC definitely improves image quality in rCBF-SPECT, without reaching that of Tc-99m-ECD. Improvement of image quality results from the reduction of the amount of decomposition products that contribute to considerable extracerebral activity.

Non-Uniform Attenuation Correction for Myocardial SPET Using Two Gd-153 Line Sources

Aim: This study deals with the effect of the non-uniform attenuation correction method on myocardial tomograms of normal subjects. Method: A total of 35 patients (20 female, 15 male) without evidence of cardiac disease underwent SPET with and without attenuation correction using a dual head camera and transmission data obtained by two scanning Gd-153 line sources after administration of 400 MBq Tc-99m-tetrofosmin. Results: In non-corrected (NC) stress studies the lowest count rates were found in the inferior segments with mean differences in count rates between maxima and minima of 35.8 ± 10.8%. In attenuation corrected (AC) images the respective segmental differences averaged only 20.9 ± 3.3% and the images did not show significant count deficiency in the inferior segments. The effects of correction revealed to be sex dependent, but independent of body mass on average. Conclusion: AC using the above technique significantly reduces the variability of count rate distribution in normal subjects and improves the preconditions for accurate diagnostic evaluation of coronary artery disease using SPET.

Position paper nuclear cardiology: Update 2008

Nuclear cardiology is well established in clinical diagnostic algorithms for many years. This is an update 2008 of the first common position paper of the German Association of Nuclear Medicine and the German Association of Cardiology, Heart and Circulation Research published in 2001 aiming at an overview of state-of-the-art scintigraphic methods.

Myocardial perfusion scintigraphy in Germany

The working group Cardiovascular Nuclear Medicine of the German Society of Nuclear Medicine (DGN), in cooperation with the working group Nuclear Cardiology of the German Cardiac Society (DGK), decided to conduct a national survey on myocardial perfusion scintigraphy (MPS). Method: A questionnaire to evaluate MPS for the year 2005 was sent. Results: 346 completed questionnaires had been returned (213 private practices, 99 hospitals and 33 university hospitals). MPS of 112 707 patients were reported with 110 747 stress and 95 878 rest studies. The majority (>75%) was performed with 99mTc-MIBI or tetrofosmin. 201Tl stress-redistribution was used in 22 637 patients (20%). The types of stress were exercise in 78%, vasodilation with adenosine or dipyridamol in 21% and dobutamine in 1%. 99.97% of all MPS were SPECT studies. Gated SPECT was performed in 36% of the stress and in 32% of the rest studies. An attenuation correction was used in 21%. 29 institutions (8%) performed gated SPECT (stress and rest) and attenuation correction. 47% of all MPS were requested by ambulatory care cardiologists, 17% by internists, 12% by primary care physicians, 21% by hospital departments and 2% by others. Conclusion: In Germany, MPS is predominantly performed with 99mTc-perfusion agents. The common type of stress is ergometry. Gated SPECT and attenuation correction do not yet represent standards of MPS practice in Germany, which indicates some potential of optimization.

FDG-PET in Hodgkin lymphoma

The high negative predictive value of FDG-PET in therapy control of Hodgkin lymphoma is proven by the data acquired up to now. Thus, the analysis of the HD15 trial has shown that consolidation radiotherapy might be omitted in PET negative patients after effective chemotherapy. Further response adapted therapy guided by PET seems to be a promising approach in reducing the toxicity for patients undergoing chemotherapy. The criteria used for the PET interpretation have been standardized by the German study groups for Hodgkin lymphoma patients and will be reevaluated in the current studies.

Myocardial perfusion scintigraphy 2006 in Germany

Aim: This second survey was to deliver further information on myocardial perfusion scintigraphy (MPS) in Germany in 2006. Method: 351 questionnaires were evaluated: 207 private practices (PP), 117 hospitals (HO), 27 from university hospitals (UH). Results: MPS of 106 331 patients were reported, 85% were investigated with 99mTc-perfusion tracers. 74% [2005=72%] were performed in PP, 17% [2005=15%] in HO and 9% [2005=13%] in UH. PP, which participated in 2005 and 2006, demonstrated an increase by 3,9% (HO 0%, UH –13,0%). The type of stress was pharmacological in 27% [2005=22%]; 54% adenosine (of these 29% with exercise), 37% dipyridamole (of these 56% with exercise), and 9% dobutamine. Gated SPECT was performed in 42% [2005=36%] of all restand in 39% [2005=32%] of all stress MPS. An attenuation correction was used by 69 [2005=78] institutions. 40% of all MPS were performed in patients suspected to have CAD. 24% of all institutions reported changes in the use of MPS by competing methods. Conclusion: There is a small increase of MPS between 2005 and 2006 despite competing methods. Gated SPECT has experienced more acceptance. Suspicion of CAD is an important indication of MPS. In order to tap the full potential of MPS a gated SPECT should be performed routinely.

[Head and Neck Cancer in Pregnancy - Recommendations for Diagnosis and Therapy With Case Report]

Objective: The diagnosis of cancer in pregnancy is rare, but might become more relevant even for head and neck cancer patients due to a shift of age of primipara towards the last third of reproductive years. Unsureness exists about the risk and benefit of diagnostic and therapeutic cancer modalities for the unborn and established recommendations are still missing. But, according to recent data, even multimodal therapeutic approaches (e. g. surgery, radiation, chemotherapy) seem possible in face of pregnancy and should be traded against the risk of prematurity. Material and Methods: Our findings are discussed on the basis of a case report of a pregnant woman with advanced carcinoma of the outer ear canal and therapy options are formulated. Results: Sufficient performed diagnostic modalities do not reach imperilling uterus dosages. A growing number of case reports und studies did not detect any developmental disadvantage of children of prenatal exposed mothers by radiation or chemotherapy, whereas long-term impairments of premature infants are proven. Conclusion: In cancer in pregnancy, an immediate start of well-established therapy modalities like surgery and/or cisplatin-based chemoradiation seems to be possible without unjustifiable risks for the unborn.

Simultaneous [18F]FDG-PET/MRI: Correlation of Apparent Diffusion Coefficient (ADC) and Standardized Uptake Value (SUV) in Primary and Recurrent Cervical Cancer

Objectives

Previous non–simultaneous PET/MR studies have shown heterogeneous results about the correlation between standardized uptake values (SUVs) and apparent diffusion coefficients (ADCs). The aim of this study was to investigate correlations in patients with primary and recurrent tumors using a simultaneous PET/MRI system which could lead to a better understanding of tumor biology and might play a role in early response assessment.

Methods

We included 31 patients with histologically confirmed primary (n = 14) or recurrent cervical cancer (n = 17) who underwent simultaneous whole-body ¹⁸F-FDG-PET/MRI comprising DWI. Image analysis was performed by a radiologist and a nuclear physician who identified tumor margins and quantified ADC and SUV. Pearson correlations were calculated to investigate the association between ADC and SUV.

Results

92 lesions were detected. We found a significant inverse correlation between SUV_max and ADC_min (r = -0.532, p = 0.05) in primary tumors as well as in primary metastases (r = -0.362, p = 0.05) and between SUV_mean and ADC_min (r = -0.403, p = 0.03). In recurrent local tumors we found correlations for SUV_max and ADC_min (r = -0.747, p = 0.002) and SUV_mean and ADC_min (r = -0.773, p = 0.001). Associations for recurrent metastases were not significant (p>0.05).

Conclusions

Our study demonstrates the feasibility of fast and reliable measurement of SUV and ADC with simultaneous PET/MRI. In patients with cervical cancer we found significant inverse correlations for SUV and ADC which could play a major role for further tumor characterization and therapy decisions.

A fast and reliable detection of indigo in historic and prehistoric textile samples

Across all cultures and over all time periods, as early as the third millennium BC, indigo, a very intense blue vat dye, has been used to dye textiles. Even today, indigo is regarded as one of the most popular blue colorants in items such as blue jeans. While synthetic indigo is used to color textiles today, throughout history, a variety of plants have provided indigo. In this special feature article, René Csuk and co-authors propose to use atmospheric solids analysis probe mass spectrometry (ASAP-MS) to very rapidly and reliably identify indigo colorants tiny amounts in ancient historic fabrics without any sample preparation. The ionization in ASAP experiments is effected by Penning ionization or by the transfer of protons originating from protonated clusters of water. Dr. René Csuk is Professor of organic bioorganic chemistry at the Martin-Luther Universität Halle-Wittenberg (Halle, Germany). His main research interests are in organic and medicinal chemistry, chemical biology and phytochemistry. Graphical Abstract: Historical samples can be investigated conveniently using ASAP®-MS experiments. ASAP®-MS allowed for rapid direct sampling without any preparation of the sample prior to its measurements, and reliable results were generated in less than 1 minute. As demonstrated for indigoid-type dyes, the efficacy of ASAP®-MS analysis is independent of the type of fiber, the age of the sample, the workmanship, and the state of preservation.

The EuroNet paediatric hodgkin network - modern imaging data management for real time central review in multicentre trials

Since 2007, children and adolescents with Hodgkin lymphomas are treated in the Europe-wide EuroNet-PHL trials. A real time central review process for stratification of the patients enhances quality control and efficient therapy management. This process includes reading of all cross-sectional-images. Since reference evaluation is time critical, a fast, easy to handle and safe data transfer is important. In addition, immediate and constant access to all the data has to be guaranteed in case of queries and for regulatory reasons. To meet the mentioned requirements the EuroNet Paediatric Hodgkin Data Network (funded by the European Union - Project Number: 2007108) was established between 2008 and 2011. A respective tailored data protection plan was formulated. The aim of this article is to describe the networks' mode of operation and the advantages for multi-centre trials that include centralized image review.

Estrogen deficiency aggravates insulin resistance and induces β-cell loss and diabetes in female New Zealand obese mice

In several rodent strains such as the New Zealand Obese (NZO) mouse, the incidence of obesity-associated diabetes mellitus is much higher in males than in females. In the present study, we investigated the effects of ovariectomy on glucose homeostasis in female NZO mice in order to elucidate the mechanism of their diabetes resistance. NZO females were ovariectomized at the age of 4 weeks, received a high-fat diet and body weight, body fat, glucose and insulin tolerance were investigated in comparison to sham-operated mice. In a second experiment, operated mice were fed a carbohydrate-free diet up to the age of 19 weeks before they received the high-fat diet. In comparison with a sham-operated control group, ovariectomized female NZO mice exhibited similar body weights, a reduced glucose tolerance, developed significantly higher blood glucose levels, lost insulin producing β-cells, which finally resulted in a diabetes prevalence of 73% at the age of 16 weeks vs. 25% in controls. Similar to male NZO mice, ovariectomized females presented a more severe insulin resistance in the insulin tolerance test than sham-operated controls. Furthermore, the more severe insulin resistance in ovariectomized mice preceded the development of diabetes and pancreatic insulin depletion that was caused by a dietary regimen of carbohydrate restriction and subsequent re-exposure. In summary our data demonstrate that estrogen protects NZO females from β-cell loss and obesity-associated diabetes mellitus. This effect is due to a reduced insulin resistance and possibly also to a reduced sensitivity of β-cells to glucolipotoxic conditions.