IGF-2 INDUCED HYPOGLYCEMIA ASSOCIATED WITH LUNG SARCOMA

Hypoglycemia from a non-insulin-secreting extrapancreatic tumor is a paraneoplastic syndrome characterized by the tumor production of a substance with an insulin-like effect (insulin-like growth factor 1 or 2 - IGF 1 or 2). Diagnosis is confirmed by the determination of IGF-1 and IGF-2 and finding an elevated IGF - 2/IGF-1 ratio. The availability of these tests is limited in many laboratories, so prompt recognition and therapies are late. We present the case of a 70-year-old patient diagnosed with right lower lobe bronchopulmonary neoplasm who presented to the emergency department with an altered general condition and hypoglycemic coma. The evaluation revealed low levels of insulin and C-peptide along with an elevated IGF-2/IGF-1 ratio of more than 10, suggesting a diagnosis of lung sarcoma with production of IGF-2. Because the tumor could not be resected in this case, chemotherapy and radiotherapy were performed, along with glucocorticoid therapy to prevent recurrent hypoglycemia. In the case of a patient with lung sarcoma and recurrent hypoglycemia (especially severe hypoglycemia or coma), extrapancreatic non-hyperinsulinemic hypoglycemia should be determinate tumor IGF-2 secretion.

Molecular Imaging for Thyrotoxicosis and Thyroid Nodules

After exclusion of exogenous iodine overload, radioiodine uptake (RAIU) testing with ¹²³I or ¹³¹I enables the accurate evaluation and quantification of iodine uptake and kinetics within thyroid cells. In addition, scintigraphic evaluation with ¹²³I or ^99mTc-pertechnetate (^99mTc04-) provides the topographic distribution of thyroid cell activity and allows the detection and localization of ectopic thyroid tissue. Destructive thyrotoxicosis is characterized by abolished or reduced uptake whereas productive thyrotoxicosis (i.e., hyperthyroidism "sensu strictu") is characterized by high RAIU with scintigraphically diffuse (i.e., Graves disease and diffuse thyroid autonomy) or focal (i.e., autonomously functioning thyroid nodules [AFTN]) overactivity. Accordingly, RAIU or thyroid scintigraphy are widely used to differentiate different causes of thyrotoxicosis. In addition, several radiopharmaceuticals are also available to help in differentiating benign from malignant thyroid nodules and inform clinical decision making. In fact, AFTNs can be safely excluded from fine-needle aspiration biopsy while either ^99mTc-methoxyisobutylisonitrile (MIBI) and ¹⁸F-FDG may complement the work-up of cytologically indeterminate cold nodules and contribute to reducing the need for diagnostic lobectomies/thyroidectomies. Finally, RAIU studies are also useful for calculating the administered therapeutic activity of ¹³¹I to treat hyperthyroidism and euthyroid multinodular goiter. All considered, thyroid molecular imaging allows us to characterize molecular/functional aspects of different thyroid diseases, even before clinical symptoms become manifest and remains integral to properly managing such conditions. Our present paper summarizes basic concepts, clinical applications, and potential developments of thyroid molecular imaging in patients affected by thyrotoxicosis and thyroid nodules.

Abstract CT254: COMPETE Phase III Trial - Peptide Receptor Radionuclide Therapy (PRRT) with 177Lu-Edotreotide vs. Everolimus in Progressive GEP-NET

Background Gastroenteropancreatic neuroendocrine tumors (GEP-NETs) make up 75% of all NETs and are often diagnosed at an advanced state with only limited treatment options. Current standard therapies include somatostatin (SST) analogues and targeted drugs such as mTOR inhibitor Everolimus. While these treatments may achieve disease stabilization for a limited time, they rarely induce objective tumor remission. PRRT has recently emerged as a promising option providing more durable responses and potentially higher objective response rates. It uses radiolabeled SST analogues which specifically target and destroy tumor cells, this way significantly sparing benign tissues. PRRT with radiolabeled SST receptor (SSTR)-ligands, such as 177Lu-DOTATATE in NETTER-1, has shown promising results in the subgroup of progressive midgut NET, with significantly improved median progression-free survival (mPFS). 177Lu-Edotreotide is an innovative radiolabeled SST analogue, with a favourable safety profile and promising efficacy. Retrospective data in metastasized GEP-NET demonstrated a mPFS of 34.5 months. A prospective study of PRRT with an approved comparator has not yet been performed. Here we report the trial design and study objectives comparing the efficacy and safety of 177Lu-Edotreotide with Everolimus.

Methods Trial design COMPETE (NCT03049189) is a prospective, randomized, controlled, open-label, multi-center Phase III study to evaluate the efficacy and safety of 177Lu-Edotreotide PRRT compared to Everolimus in patients with inoperable, progressive, SSTR+ GEP-NET. 300 patients with progressive Grade 1 and 2 GEP-NET will be randomized: 200 will receive a maximum of 4 cycles of 177Lu-Edotreotide (7.5 GBq/cycle) every 3 months or until diagnosis of progression; 100 will receive 10 mg Everolimus daily for 24 months, or until diagnosis of progression. Study treatment duration/patient is 24 months.

Study Objectives Primary objective is to demonstrate prolonged mPFS in patients in the 177Lu-Edotreotide arm, vs. Everolimus.

Secondary objectives include safety, objective response rates and overall survival after treatment with 177Lu-Edotreotide, vs. Everolimus.

Conclusion COMPETE is the first pivotal study to compare PRRT in patients with Grade 1 and 2 GEP-NET using a comparator with an approved therapeutic. It is expected that COMPETE will increase their treatment options, including 1st-line therapy. Further studies with 177Lu-Edotreotide in NET patients with high unmet medical need are under review.

Citation Format: Mona M. Wahba, Jonathan Strosberg, Anca Avram, Carina Mari Aparici. COMPETE Phase III Trial - Peptide Receptor Radionuclide Therapy (PRRT) with 177Lu-Edotreotide vs. Everolimus in Progressive GEP-NET [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2021; 2021 Apr 10-15 and May 17-21. Philadelphia (PA): AACR; Cancer Res 2021;81(13_Suppl):Abstract nr CT254.

Testing polymineral post-IR IRSL and quartz SAR-OSL protocols on Middle to Late Pleistocene loess at Batajnica, Serbia

The loess-palaeosol sequence of Batajnica (Vojvodina region, Serbia) is considered as one of the most complete and thickest terrestrial palaeoclimate archives for the Middle and Late Pleistocene. In order to achieve a numerical chronology for this profile, four sets of ages were obtained on 18 individual samples. Equivalent doses were determined using the SAR protocol on fine (4-11 μm) and coarse (63-90 μm) quartz fractions, as well as on polymineral fine grains by using two elevated temperature infrared stimulation methods, pIRIR 290 and pIRIR 225. We show that the upper age limit of coarse quartz OSL and polymineral pIRIR 290 and pIRIR 225 techniques is restricted to the Last Glacial/Interglacial cycle due to the field saturation of the natural signals. Luminescence ages on coarse quartz, pIRIR 225 and pIRIR 290 polymineral fine grains are in general agreement. Fine quartz ages are systematically lower than the coarse quartz and pIRIR ages, the degree of underestimation increasing with age. Comparison between natural and laboratory dose response curves indicate the age range over which each protocol provides reliable ages. For fine and coarse quartz, the natural and laboratory dose response curves overlap up to ~150 and ~250 Gy, respectively, suggesting that the SAR protocol provides reliable ages up to c. 50 ka on fine quartz and c. 100 ka on coarse quartz. Using the pIRIR 225 and pIRIR 290 protocols, equivalent doses up to ~400 Gy can be determined, beyond which in the case of the former the natural dose response curve slightly overestimates the laboratory dose response curve. Our results suggest that the choice of the mineral and luminescence technique to be used for dating loess sediments should take into consideration the reported limited reliability.

European Association of Nuclear Medicine Practice Guideline/Society of Nuclear Medicine and Molecular Imaging Procedure Standard 2019 for radionuclide imaging of phaeochromocytoma and paraganglioma

PURPOSE

Diverse radionuclide imaging techniques are available for the diagnosis, staging, and follow-up of phaeochromocytoma and paraganglioma (PPGL). Beyond their ability to detect and localise the disease, these imaging approaches variably characterise these tumours at the cellular and molecular levels and can guide therapy. Here we present updated guidelines jointly approved by the EANM and SNMMI for assisting nuclear medicine practitioners in not only the selection and performance of currently available single-photon emission computed tomography and positron emission tomography procedures, but also the interpretation and reporting of the results.

METHODS

Guidelines from related fields and relevant literature have been considered in consultation with leading experts involved in the management of PPGL. The provided information should be applied according to local laws and regulations as well as the availability of various radiopharmaceuticals.

CONCLUSION

Since the European Association of Nuclear Medicine 2012 guidelines, the excellent results obtained with gallium-68 (⁶⁸Ga)-labelled somatostatin analogues (SSAs) in recent years have simplified the imaging approach for PPGL patients that can also be used for selecting patients for peptide receptor radionuclide therapy as a potential alternative or complement to the traditional theranostic approach with iodine-123 (¹²³I)/iodine-131 (¹³¹I)-labelled meta-iodobenzylguanidine. Genomic characterisation of subgroups with differing risk of lesion development and subsequent metastatic spread is refining the use of molecular imaging in the personalised approach to hereditary PPGL patients for detection, staging, and follow-up surveillance.

Laparoscopic Repair of a Left Retrocaval Ureter in a 16-Year-Old Girl

Left retrocaval ureter is an extremely rare congenital malformation which is associated with situs inversus, duplicated or translated inferior vena cava (IVC). We report a female adolescent who presented with a history of intermittent, colicky lumbar pain. Diagnostic workup revealed left retrocaval ureter and left ureterohydronephrosis. The girl underwent laparoscopy. The renal pelvis and ureter posterior to the vena cava were dissected, transected at the caudal point of the dilated ureteral segment, and uncrossed and repositioned lateral to the vena cava. Ureteroureterostomy was performed over a double-J ureteral stent after spatulation of the distal ureter. The postoperative course was uneventful and the ureteral stent removed after 5 weeks. During follow-up, the patient is symptom-free. Our case demonstrates that our laparoscopic approach is feasible in this rare anatomic anomaly.

Adrenal Imaging

Cross-sectional imaging can make a specific diagnosis in lesions, such as myelolipomas, cysts, and hemorrhage, and is often sufficient to distinguish benign from malignant adrenal processes. CT and MRI are useful studies to identify pheochromocytomas and cortisol-secreting or androgen-secreting tumors. In patients with primary aldosteronism, adrenal venous sampling remains the most accurate localizing study and should be performed in all patients older than 35. Radiolabeled isotope studies serve as second-line diagnostic tests for malignant adrenal tumors, primary or metastatic, as well as for pheochromocytoma. Nuclear imaging studies should follow a robust hormonal diagnosis and be correlated with findings on cross-sectional imaging.

Phase 1 study of radiosensitization using bortezomib in patients with relapsed non-Hodgkin lymphoma receiving radioimmunotherapy with 131I-tositumomab

Radioimmunotherapy (RIT) is effective treatment for indolent non-Hodgkin lymphomas (NHLs), but response durations are usually limited, especially in aggressive NHL. We hypothesized that administration of bortezomib as a radiosensitizer with RIT would be tolerable and improve efficacy in NHL. This phase 1 dose-escalation study evaluated escalating doses of bortezomib combined with 131I-tositumomab in patients with relapsed/refractory NHL. Twenty-five patients were treated. Treatment was well tolerated, with primarily hematologic toxicity. The maximum tolerated dose (MTD) was determined to be 0.9 mg/m2 bortezomib, in combination with a standard dose of 75 cGy 131I-tositumomab. Sixteen patients responded (64%), including 44% complete responses (CRs), with 82% CR in patients with follicular lymphoma (FL). At a median follow-up of 7 months, median progression-free survival was 7 months, and seven of 11 patients with FL remained in remission at a median of 22 months. In conclusion, bortezomib can be safely administered in combination with 131I-tositumomab with promising response rates.

Renal metastasis from Hurthle cell thyroid carcinoma and its evaluation with hybrid imaging

BACKGROUND

In general, thyroid carcinomas, when they behave aggressively, metastasize to lungs and occasionally to bone and brain. Metastases to other organs are distinctly unusual. Renal metastases have been reported in only 10 patients. Here we report, to the best of our knowledge, the first patient with Hurthle cell thyroid cancer and renal metastasis. The evaluation of this patient was enhanced by utilizing a variety of imaging techniques.

SUMMARY

The patient was a 75-year-old man who had a history of a total thyroidectomy 9 years previously for a right thyroid lobe Hurthle cell carcinoma. He postoperatively received 150 mCi (5550 MBq) of 131-I therapy and was maintained on thyrotropin suppressive therapy with levothyroxine. He presented to us with a recent history of a progressively enlarging left neck mass. The serum thyroglobulin was elevated to 1183 ng/mL. Multimodality imaging with fluorodeoxyglucose positron emission tomography-computed tomography, magnetic resonance imaging, and Somatostatin receptor scintigraphy with single photon emission computed tomography (SPECT)-computed tomography revealed numerous foci in the skeleton and right kidney. Anatomic imaging characteristics favored a primary renal cell cancer with the additional evidence of renal vein invasion and thrombosis. Histology later revealed a metastatic renal Hurthle cell cancer with positive thyroglobulin stains. Several of the skeletal foci responded partially to cryoablative therapy. The patient refused noncurative Somatostatin analog therapy. He is alive and doing well clinically.

CONCLUSION

The management of thyroid cancers in high-risk groups, such as our patient, frequently requires expert management by the use of novel multimodality imaging and therapeutic techniques.

PET in the diagnostic evaluation of adrenal tumors

Early experience with positron emission tomography (PET) has provided exciting results in the evaluation of a broad spectrum of neoplasms, to include primary adrenal tumors, their metastases and metastatic disease to the adrenal glands. By virtue of the well-recognized propensity of malignancies to preferentially use glycolysis as an important energy source and the stimulation of mechanisms designed to absorb substrate glucose, the glucose analog, [18F]fluorodeoxyglucose, has become a successful radiopharmaceutical in the scintigraphic evaluation of adrenal tumors. Building upon prior experience gained with imaging the adrenal gland, other positron-labeled radiopharmaceuticals are finding their way into clinical use. The 11b-hydroxylase inhibitor, metomidate labeled with 11C has been used to scintigraphically identify tissues of adrenocortical origin, to accurately identify recurrent and metastatic adrenocortical carcinoma and may be useful in assessing the malignant potential of these tumors and predicting survival in afflicted patients. Adrenomedulla imaging with 11C- and 18F-labeled catecholamines and catecholamine analogs draws heavily from the experience gained from predecessor compounds, labeled with single photon emitting isotopes and, in some instances, single photon emission tomography, and has been shown to depict with high efficacy pheochromocytomas, neuroblastomas and other neoplasms of neural crest origin. Additional structural and functional information provided by computed tomography (CT), performed as part of hybrid PET/CT imaging directly complements PET and adds measurable diagnostic value in the evaluation of adrenal tumors.

Contemporary adrenal scintigraphy

INTRODUCTION

High-resolution computed tomography (CT) and magnetic resonance (MR) imaging have replaced scintigraphy as primary imaging modalities for the evaluation of adrenal diseases.

DISCUSSION

Thin-slice CT, CT contrast washout studies and MR pulse sequences specifically designed to identify adrenal lipid content have radically changed the approach to anatomic imaging and provide unique insight into the physical characteristics of the adrenals. With a confirmed biochemical diagnosis, further evaluation is often unnecessary, especially in diagnostic localization of diseases of the adrenal cortex. However, despite the exquisite detail afforded by anatomy-based imaging, there are not infrequently clinical situations in which the functional insight provided by scintigraphy is crucial to identify adrenal dysfunction and to assist in localization of adrenocortical and adrenomedullary disease. The introduction of hybrid PET/CT and SPECT/CT, modalities that directly integrate anatomic and functional information, redefine the radiotracer principle in the larger context of high-resolution anatomic imaging. Instead of becoming obsolete, scintigraphy is an element of a device that combines it with CT or MR to allow a direct correlation between function and anatomy, whereby the combination creates a more powerful diagnostic tool than the separate component modalities.

[The incidence of anti-HIV antibodies in hospitalized patients in a tuberculosis clinic]

HIV antibody prevalence was studied in 1274 patients, including 150 children, hospitalized in phthisiology services. The sixteen EIA positive samples were confirmed by the Western blot test (1.25%). The other seventeen EIA positive samples gave undetermined results in W.B. In children, antibody incidence was 7.33% versus 0.45% only in adults: this ratio seems to be characteristic for AIDS endemia in Romania, where parenteral transmission is the quasi unique way of HIV infection dissemination in children. The presence of nonspecific multiple bands in the gp 41 region was noted on seven of the seventeen undetermined samples, which is to confirm the reports about the presence of W.B. detectable anti-HIV antibodies cross-reacting with anti-mycobacterial antibodies.

Rapid percutaneous tracheostomy

We describe a new method of performing percutaneous tracheostomy rapidly and safely using a specialized instrument kit. The technique permits the safe insertion of a full-sized 7.0 (ID) or 7.5 mm (ID) cuffed cannula into the trachea within 1-2 min, through the membranous second intercartilagenous space. Animal studies have demonstrated a superior healing process compared to that seen after conventional tracheostomy techniques.

Human infection by a bovine strain of parainfluenza virus type 3

Etiological relationship between a bovine strain of parainfluenza virus type 3 and pneumonia in a child is suggested. Haemagglutination inhibition tests have clearly demonstrated that specific antibodies against the bovine virus were present in the patient's serum. The significance of this finding in relation to human infection is discussed.