Minimal Extrathyroid Extension (mETE) as the Only Risk Factor in Patients with Papillary Thyroid Carcinoma (PC): Its Clinical Impact on Recurrence and Outcome during Long-Term Follow-Up

Minimal extrathyroid extension (mETE) effect on papillary thyroid carcinoma (PC) prognosis is still debated even more so now that this factor has been removed in the 8th AJCC Edition, supporting the hypothesis that mETE is not associated with aggressive tumors. We retrospectively enrolled 91 PC patients (Group 1) submitted to total thyroidectomy and radioiodine ablation. At the time of the primary tumor surgery, mETE was ascertained in all patients with no other risk factors, such as multifocality, vascular invasion, neck and distant metastases, and aggressive histological variants. As controls, 205 consecutive matched PC patients (Group 2) without mETE and the aforementioned risk factors were enrolled. During the follow-up (average 8 years), 16/91 (17.58%) Group 1 patients and 15/205 (7.32%) Group 2 patients developed metastases (p = 0.0078). Cox regression analysis showed an increased risk of metastases in patients with mETE (HR: 2.58 (95% CI 1.28-5.22) p = 0.008). Disease-free survival (DFS) was significantly lower in patients with mETE than in controls (p = 0.0059). The present study seems to demonstrate that mETE can be associated with an aggressive PC and can be considered, even alone without other risk factors, an independent factor of unfavorable DFS. Thus, by excluding mETE in the 8th AJCC Edition, patient care and management could be compromised.

Hashimoto's Thyroiditis and Papillary Thyroid Carcinoma: A Follow-Up Study in Patients with Absence of Aggressive Risk Factors at the Surgery of the Primary Tumor

Hashimoto's thyroiditis (HT) is often associated with papillary thyroid carcinoma (PC); it is still a matter of controversy whether the behavior of carcinoma is more aggressive or not. During the follow-up, we retrospectively enrolled 97 patients with PC/HT after thyroidectomy without risk factors at the surgery of the primary tumor, such as multifocality/multicentricity, extrathyroid tumor extension, vascular invasion, neck and distant metastases, and aggressive histological variants. HT diagnosis was confirmed by histology and serum thyroid antibodies. Tumor size was ≤10 mm in 64 cases (microcarcinomas); 206 matched PC patients after thyroidectomy without HT and risk factors were enrolled as controls, totaling 122 microcarcinomas. During follow-up, metastases occurred in 15/97 (15.5%) PC/HT cases, eight microcarcinomas, and in 16/206 (7.8%) without HT, eight microcarcinomas (p = 0.04). Considering both PC/HT and PC patients without HT who developed metastases, univariate analysis showed an increased risk of metastases in patients with HT coexistence, OR: 2.17 (95% CI 1.03-4.60) p = 0.043. Disease-free survival (DFS) was significantly (p = 0.0253) shorter in PC/HT than in the controls. The present study seems to demonstrate that HT is not a cancer protective factor in PC patients given the less favorable outcomes and significantly shorter DFS. HT may also represent an independent recurrence predictor without other risk factors.

Performance Analysis of Six Semi-Automated Tumour Delineation Methods on [18F] Fluorodeoxyglucose Positron Emission Tomography/Computed Tomography (FDG PET/CT) in Patients with Head and Neck Cancer

Background. Head and neck cancer (HNC) is the seventh most common neoplastic disorder at the global level. Contouring HNC lesions on [18F] Fluorodeoxyglucose positron emission tomography/computed tomography (FDG PET/CT) scans plays a fundamental role for diagnosis, risk assessment, radiotherapy planning and post-treatment evaluation. However, manual contouring is a lengthy and tedious procedure which requires significant effort from the clinician. Methods. We evaluated the performance of six hand-crafted, training-free methods (four threshold-based, two algorithm-based) for the semi-automated delineation of HNC lesions on FDG PET/CT. This study was carried out on a single-centre population of n=103 subjects, and the standard of reference was manual segmentation generated by nuclear medicine specialists. Figures of merit were the Sørensen-Dice coefficient (DSC) and relative volume difference (RVD). Results. Median DSC ranged between 0.595 and 0.792, median RVD between -22.0% and 87.4%. Click and draw and Nestle's methods achieved the best segmentation accuracy (median DSC, respectively, 0.792 ± 0.178 and 0.762 ± 0.107; median RVD, respectively, -21.6% ± 1270.8% and -32.7% ± 40.0%) and outperformed the other methods by a significant margin. Nestle's method also resulted in a lower dispersion of the data, hence showing stronger inter-patient stability. The accuracy of the two best methods was in agreement with the most recent state-of-the art results. Conclusions. Semi-automated PET delineation methods show potential to assist clinicians in the segmentation of HNC lesions on FDG PET/CT images, although manual refinement may sometimes be needed to obtain clinically acceptable ROIs.

Role of Functional Neuroimaging with 123I-MIBG and 123I-FP-CIT in De Novo Parkinson's Disease: A Multicenter Study

BACKGROUND

Parkinson's disease is a progressive neurodegenerative disorder, with incidence and prevalence rates of 8-18 per 100,000 people per year and 0.3-1%, respectively. As parkinsonian symptoms do not appear until approximately 50-60% of the nigral DA-releasing neurons have been lost, the impact of routine structural imaging findings is minimal at early stages, making Parkinson's disease an ideal condition for the application of functional imaging techniques. The aim of this multicenter study is to assess whether 123I-FP-CIT (DAT-SPECT), 123I-MIBG (mIBG-scintigraphy) or an association of both exams presents the highest diagnostic accuracy in de novo PD patients.

METHODS

288 consecutive patients with suspected diagnoses of Parkinson's disease or non- Parkinson's disease syndromes were analyzed in the present Italian multicenter retrospective study. All subjects were de novo, drug-naive patients and met the inclusion criteria of having undergone both DAT-SPECT and mIBG-scintigraphy within one month of each other.

RESULTS

The univariate analysis including age and both mIBG-SPECT and DAT-SPECT parameters showed that the only significant values for predicting Parkinson's disease in our population were eH/M, lH/M, ESS and LSS obtained from mIBG-scintigraphy (p < 0.001).

CONCLUSIONS

mIBG-scintigraphy shows higher diagnostic accuracy in de novo Parkinson's disease patients than DAT-SPECT, so given the superiority of the MIBG study, the combined use of both exams does not appear to be mandatory in the early phase of Parkinson's disease.

The DASciS Software for BSI Calculation as a Valuable Prognostic Tool in mCRPC Treated with 223RaCl2: A Multicenter Italian Study

BACKGROUND/AIM

Radium-223 dichloride (²²³RaCl₂) represents a therapeutic option for metastatic castration-resistant prostate cancer (mCRPC) patients dealing with symptomatic bone metastases. The identification of baseline variables potentially affecting the life-prolonging role of ²²³RaCl₂ is still ongoing. Bone scan index (BSI) defines the total load of bone metastatic disease detected on a bone scan (BS) and is expressed as a percentage value of the whole bone mass. The aim of this multicenter study was to assess the impact of baseline BSI on overall survival (OS) in mCRPC patients treated with ²²³RaCl₂. For this purpose, the DASciS software developed by the Sapienza University of Rome for BSI calculation was shared between six Italian Nuclear Medicine Units.

METHODS

370 pre-treatment BS were analyzed through the DASciS software. Other clinical variables relevant to OS analysis were taken into account for the statistical analysis.

RESULTS

Of a total of 370 patients, 326 subjects had died at the time of our retrospective analysis. The median OS time from the first cycle of ²²³RaCl₂ to the date of death from any cause or last contact was 13 months (95%CI 12-14 months). The mean BSI value resulted in 2.98% ± 2.42. The center-adjusted univariate analysis showed that baseline BSI was significantly associated with OS as an independent risk factor (HR 1.137, 95%CI: 1.052-1.230, p = 0.001), meaning that patients with higher BSI values had worse OS. When adjusting for other measures on multivariate analysis, in addition to Gleason score and baseline values of Hb, tALP, and PSA, baseline BSI was confirmed to be a statistically significant parameter (HR 1.054, 95%CI: 1.040-1.068, p < 0.001).

CONCLUSIONS

Baseline BSI significantly predicts OS in mCRPC treated with ²²³RaCl₂. The DASciS software was revealed to be a valuable tool for BSI calculation, showing rapid processing time and requiring no more than a single demonstrative training for each participating center.

First-, Second-, and Third-Generation Radiolabeled Epidermal Growth Factor Receptor Tyrosine Kinase Inhibitors in Positron Emission Tomography: State of the Art, a Systematic Review

Introduction: Lung cancer (LC) is a leading cause of death among men and women, with non-small cell LC (NSCLC) accounting for a substantial portion of the histopathological spectrum and epidermal growth factor receptor (EGFR) mutations being correlated with its manifestation and evolution. Positron emission tomography (PET)/computed tomography has been the most widely used instrument to assess and monitor LC in a noninvasive way, including EGFR-mutated NSCLC, and its course during therapy, indicating to the referring physician the response to ongoing treatment or the lack of it. This systematic review aims to evaluate the feasibility and safety of radiolabeled EGFR tyrosine kinase inhibitors (TKis) in PET in clinical practice. Materials and Methods: From 1999 to April 2022 a Medline search was conducted on four different databases such as PubMed, Cochrane Library, Scopus, and Web of Sciences. Clinical studies were assessed by Quality Assessment of Diagnostic accuracy Studies-2 (QUADAS-2) and preclinical studies were also reported in this review. Results: Nine clinical studies were QUADAS-2 assessed and risk-of-bias assessment, and it turned out acceptable as two out of eight studies had low risk of bias in all four domains for risk-of-bias assessment, and the other four studies had three low-risk domains. The overall assessment for applicability risks was low. Conclusions: Radiolabeled EGFR-TKis in PET are a valid tool in identifying patients who may benefit from TKi therapy and who may not as a means to start an effective treatment. Although the number of clinical studies conducted so far is meager, these new PET tracers are already proving to be very useful in clinical settings as patient prognosis can be better assessed.

Evaluation of Bone Scan Index as a Prognostic Tool in Breast Cancer Patients with Bone Metastasis

BACKGROUND

Bone metastatic involvement represents a leading cause of death in patients with advanced breast cancer (BC). At present, it is not clear whether the bone metastatic load might impact Overall Survival (OS) in patients with bone metastatic BC at diagnosis. For this purpose, we used the Bone Scan Index (BSI), which is a reproducible and quantitative expression of tumor load observed at bone scintigraphy.

OBJECTIVE

The aim of this study was to associate BSI with OS in bone metastatic BC patients.

METHODS

In this retrospective study, we enrolled BC patients with bone metastases at the scintigraphic bone scan performed for staging purposes. The BSI was calculated through the DASciS software, and statistical analysis was carried out. Other clinical variables relevant to OS analysis were taken into account.

RESULTS

Of a total of 94 patients, 32% died. In most cases, the histotype was ductal infiltrating carcinoma. The median OS from diagnosis was 72 months (CI 95%: 62-NA). The univariate analysis with COX regression showed that only hormone therapy significantly correlates with OS (HR 0.417, CI 95%: 0.174-0.997, p < 0.049). As concerning BSI, the statistical analysis showed that it does not predict OS in BC patients (HR 0.960, 95% CI: 0.416-2.216, p < 0.924).

CONCLUSION

Although the BSI significantly predicts OS in prostate cancer and in other tumors, we observed that the metastatic load of bone disease has not a key role in prognostic stratification in our population.

A Comparative Follow-Up Study of Patients with Papillary Thyroid Carcinoma Associated or Not with Graves' Disease

Whether papillary carcinoma (PC) behavior is more aggressive in Graves’ disease (GD) patients than PC cases without GD is controversial. We retrospectively enrolled 33 thyroidectomized PC/GD patients during long-term follow-up, 23/33 without risk factors at surgery, and 18/33 microcarcinomas; 312 PC euthyroid-matched patients without risk factors served as controls. A total of 14/33 (42.4%) PC/GD patients, 4 with and 10 without risk factors at diagnosis, 6 with microcarcinoma, underwent metastases during follow-up. In controls, metastases in 21/312 (6.7%) were ascertained. Considering 10/23 PC/GD patients and 21/312 controls without risk factors who developed metastases, univariate analysis showed that there was an increased risk of metastasis appearance for PC/GD cases (p < 0.001). Disease-free survival (DFS) was significantly (p < 0.0001, log-rank test) shorter in PC/GD patients than in controls. Significantly more elevated aggressiveness in 6/18 PC/GD patients with microcarcinoma than in controls was also ascertained with shorter DFS. Thus, in the present study, PC/GD had aggressive behavior during follow-up also when carcinoma characteristics were favorable and some cases were microcarcinomas. GD and non-GD patient comparison in the cases without risk factors at diagnosis showed an increased risk to develop metastases in GD during follow-up, suggesting that GD alone might be a tumor aggressiveness predictive factor in these cases.

Prostate-specific membrane antigen-directed imaging and radioguided surgery with single-photon emission computed tomography: state of the art and future outlook

INTRODUCTION

Prostate-specific membrane antigen (PSMA) has emerged as a highly relevant target for prostate cancer (PC) diagnosis and therapy. PSMA inhibitors targeting PSMA-enzymatic domain have been successfully labeled with radionuclides emitting positrons or gamma-photons, thus obtaining tracers suitable for imaging with positron emission computed tomography (PET/CT) or single-photon emission tomography (SPECT).

AREAS COVERED

The different approaches for obtaining PSMA-ligands labeled with gamma-emitting nuclides (^99mTc or¹¹¹In) are reviewed. Furthermore, the applications of ^99mTc/¹¹¹In-PSMA SPECT for the imaging of PC patients in different clinical settings (staging or biochemical recurrence) are covered. Lastly, the employment of PSMA-targeted SPECT tracers for radioguided surgery (RGS) during primary or salvage lymphadenectomy is discussed.

EXPERT OPINION

RGS provided satisfying preliminary results in both primary and salvage lymphadenectomy, allowing to discriminate between pathological and non-pathological nodes with high accuracy, although prospective studies with larger cohorts are needed to further validate this surgical approach. The potential of PSMA-targeted SPECT/CT has not been fully explored yet, but it might represent a relatively cost-effective alternative to PSMA PET/CT in limited resource environments. In this perspective, the implementation of novel SPECT technologies or algorithms, such as semiconductor-ionization detectors or resolution recovery reconstruction, will be topic of future investigation.

Imaging Findings of 18F-Choline and 18F-DOPA PET/MRI in a Case of Glioblastoma Multiforme Pseudoprogression: Correlation with Clinical Outcome

We describe the case of 74-year-old-male, previously treated with fronto-parietal craniotomy due to primary glioblastoma multiforme (GBM), followed by concurrent radiation therapy (RT) and temozolomide (TMZ) chemotherapy. Magnetic resonance imaging (MRI) of the brain, at 1 month after completing RT + TMZ, depicted partial response. Three months later, the patient was submitted to a further brain MRI, that resulted doubtful for therapy induced changes (i.e., pseudoprogression). The patient, who had been previously treated with prostatectomy for prostate cancer (PC), underwent a positron emission tomography/computed tomography (PET/CT) scan with 18F-choline for PC biochemical recurrence. 18F-choline whole body PET/CT resulted negative for PC relapse, while segmental brain PET, co-registered with MRI, demonstrated increased tracer uptake corresponding to tumor boundaries. In order to solve differential diagnosis between pseudoprogression and GBM recurrence, brain PET/CT with 18F-L-dihydroxy-phenil-alanine (18F-DOPA) was subsequently performed: fused axial PET/MRI images showed increased 18F-DOPA incorporation in the peri-tumoral edema, but not in tumor boundaries, consistent with the suspicion of GBM pseudoprogression, as then confirmed by clinical and radiological follow-up.

Form Factors as Potential Imaging Biomarkers to Differentiate Benign vs. Malignant Lung Lesions on CT Scans

Indeterminate lung nodules detected on CT scans are common findings in clinical practice. Their correct assessment is critical, as early diagnosis of malignancy is crucial to maximise the treatment outcome. In this work, we evaluated the role of form factors as imaging biomarkers to differentiate benign vs. malignant lung lesions on CT scans. We tested a total of three conventional imaging features, six form factors, and two shape features for significant differences between benign and malignant lung lesions on CT scans. The study population consisted of 192 lung nodules from two independent datasets, containing 109 (38 benign, 71 malignant) and 83 (42 benign, 41 malignant) lung lesions, respectively. The standard of reference was either histological evaluation or stability on radiological followup. The statistical significance was determined via the Mann-Whitney U nonparametric test, and the ability of the form factors to discriminate a benign vs. a malignant lesion was assessed through multivariate prediction models based on Support Vector Machines. The univariate analysis returned four form factors (Angelidakis compactness and flatness, Kong flatness, and maximum projection sphericity) that were significantly different between the benign and malignant group in both datasets. In particular, we found that the benign lesions were on average flatter than the malignant ones; conversely, the malignant ones were on average more compact (isotropic) than the benign ones. The multivariate prediction models showed that adding form factors to conventional imaging features improved the prediction accuracy by up to 14.5 pp. We conclude that form factors evaluated on lung nodules on CT scans can improve the differential diagnosis between benign and malignant lesions.

The Role and Potential of 18F-FDG PET/CT in Malignant Melanoma: Prognostication, Monitoring Response to Targeted and Immunotherapy, and Radiomics

Novel therapeutic approaches, consisting of immune check-point inhibitors (ICIs) and molecularly targeted therapy, have thoroughly changed the clinical management of malignant melanoma (MM), the most frequent and deadly skin cancer. Since only 30–40% of MM patients respond to ICIs, imaging biomarkers suitable for the pre-therapeutic stratification and response assessment are warmly welcome. In this scenario, positron emission computed tomography (PET/CT) with 18F-fluorodeoxyglucose (18F-FDG) has been successfully utilized for advanced MM staging and therapy response evaluation. Furthermore, several PET-derived parameters (SUVmax, MTV, TLG) were particularly impactful for the prognostic evaluation of patients submitted to targeted and immunotherapy. In this review, we performed a web-based and desktop research on the clinical applications of 18F-FDG PET/CT in MM, with a particular emphasis on the various metabolic criteria developed for interpreting PET/CT scan in patients undergoing immunotherapy or targeted therapy or a combination of both. Furthermore, the emerging role of radiomics, a quantitative approach to medical imaging applying analysis methodology derived by the field of artificial intelligence, was examined in the peculiar context, putting a particular emphasis on the potential of this discipline to support clinicians in the delicate process of building patient-tailored pathways of care.

The prognostic power of inflammatory indices and clinical factors in metastatic castration-resistant prostate cancer patients treated with radium-223 (BIO-Ra study)

Purpose

To combine peripheral blood indices and clinical factors in a prognostic score for metastatic castration-resistant prostate cancer (mCRPC) patients treated with radium-223 dichloride ([²²³Ra]RaCl₂).

Patients and methods

Baseline neutrophil-to-lymphocyte ratio (NLR), derived NLR (donor), lymphocyte-to-monocyte ratio (LMR), platelet-to-lymphocyte ratio (PLR), systemic inflammation index (SII), Eastern Cooperative Oncology Group performance status (ECOG PS), Gleason score (GS) group, number of bone metastases, prostate-specific antigen (PSA), alkaline phosphatase (ALP), line of therapy, previous chemotherapy, and the presence of lymphadenopathies were collected from seven Italian centers between 2013 and 2020. Lab and clinical data were assessed in correlation with the overall survival (OS). Inflammatory indices were then included separately in the multivariable analyses with the prognostic clinical factors. The model with the highest discriminative ability (c-index) was chosen to develop the BIO-Ra score.

Results

Five hundred and nineteen mCRPC patients (median OS: 19.9 months) were enrolled. Higher NLR, dNLR, PLR, and SII and lower LMR predicted worse OS (all with a p < 0.001). The multivariable model including NLR, ECOG PS, number of bone metastases, ALP, and PSA (c-index: 0.724) was chosen to develop the BIO-Ra score. Using the Schneeweiss scoring system, the BIO-Ra score identified three prognostic groups (36%, 27.3%, and 36.6% patients, respectively) with distinct median OS (31, 26.6, and 9.6 months, respectively; hazard ratio: 1.62, p = 0.008 for group 2 vs. 1 and 5.77, p < 0.001 for group 3 vs. 1).

Conclusions

The BIO-Ra score represents an easy and widely applicable tool for the prognostic stratification of mCRPC patients treated with [²²³Ra]RaCl₂ with no additional costs.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00259-021-05550-6.

123I-Ioflupane SPECT and 18F-FDG PET Combined Use in the Characterization of Movement and Cognitive Associated Disorders in Neurodegenerative Diseases

BACKGROUND

Both movement (MD) and cognitive (CD) disorders can occur associated in some neurodegenerative diseases, such as Parkinson's disease (PD) and Alzheimer's disease (AD).

OBJECTIVE

We further investigated the usefulness of 123I-Ioflupane SPECT and 18F-FDG PET combined use in patients with these disorders in the early stage.

METHODS

We retrospectively enrolled twenty-five consecutive patients with MD and CD clinical symptoms of recent appearance. All patients had undergone neurologic examination, neuropsychological tests, and magnetic resonance imaging. 123I-Ioflupane SPECT was performed in all cases, followed by 18F-FDG PET two weeks later. In the two procedures, both qualitative (QL) and quantitative (QN) image analyses were determined.

RESULTS

In patients with both 123I-Ioflupane SPECT and 18F-FDG PET pathologic data, associated dopaminergic and cognitive impairments were confirmed in 56% of cases. Pathologic SPECT with normal PET in 16% of cases could diagnose MD and exclude an associated CD, despite clinical symptoms. On the contrary, normal SPECT with pathologic PET in 28% of cases could exclude basal ganglia damage while confirming CD. QN 123I-Ioflupane SPECT analysis showed better performance than QL since QN correctly characterized two cases of MD with normal QL. Moreover, correct classification of normal metabolism was made only by QN analysis of 18F-FDG PET in four cases, despite suspect areas of hypometabolism at QL.

CONCLUSION

The combined use of these imaging procedures proved a reliable diagnostic tool to accurately identify and characterize MD and CD in early stage. QN analysis was effective in supporting QL evaluation, and its routine use is suggested, especially with inconclusive QL.

Prevalence of interstitial pneumonia suggestive of COVID-19 at 18F-FDG PET/CT in oncological asymptomatic patients in a high prevalence country during pandemic period: a national multi-centric retrospective study

PURPOSE

To assess the presence and pattern of incidental interstitial lung alterations suspicious of COVID-19 on fluorine-18-fluorodeoxyglucose positron emission tomography (PET)/computed tomography (CT) ([18F]FDG PET/CT) in asymptomatic oncological patients during the period of active COVID-19 in a country with high prevalence of the virus.

METHODS

This is a multi-center retrospective observational study involving 59 Italian centers. We retrospectively reviewed the prevalence of interstitial pneumonia detected during the COVID period (between March 16 and 27, 2020) and compared to a pre-COVID period (January-February 2020) and a control time (in 2019). The diagnosis of interstitial pneumonia was done considering lung alterations of CT of PET.

RESULTS

Overall, [18F]FDG PET/CT was performed on 4008 patients in the COVID period, 19,267 in the pre-COVID period, and 5513 in the control period. The rate of interstitial pneumonia suspicious for COVID-19 was significantly higher during the COVID period (7.1%) compared with that found in the pre-COVID (5.35%) and control periods (5.15%) (p < 0.001). Instead, no significant difference among pre-COVID and control periods was present. The prevalence of interstitial pneumonia detected at PET/CT was directly associated with geographic virus diffusion, with the higher rate in Northern Italy. Among 284 interstitial pneumonia detected during COVID period, 169 (59%) were FDG-avid (average SUVmax of 4.1).

CONCLUSIONS

A significant increase of interstitial pneumonia incidentally detected with [18F]FDG PET/CT has been demonstrated during the COVID-19 pandemic. A majority of interstitial pneumonia were FDG-avid. Our results underlined the importance of paying attention to incidental CT findings of pneumonia detected at PET/CT, and these reports might help to recognize early COVID-19 cases guiding the subsequent management.

Comparative evaluation of conventional and deep learning methods for semi-automated segmentation of pulmonary nodules on CT

Background

Accurate segmentation of pulmonary nodules on computed tomography (CT) scans plays a crucial role in the evaluation and management of patients with suspicion of lung cancer (LC). When performed manually, not only the process requires highly skilled operators, but is also tiresome and time-consuming. To assist the physician in this task several automated and semi-automated methods have been proposed in the literature. In recent years, in particular, the appearance of deep learning has brought about major advances in the field.

Methods

Twenty-four (12 conventional and 12 based on deep learning) semi-automated-'one-click'-methods for segmenting pulmonary nodules on CT were evaluated in this study. The experiments were carried out on two datasets: a proprietary one (383 images from a cohort of 111 patients) and a public one (259 images from a cohort of 100). All the patients had a positive transcript for suspect pulmonary nodules.

Results

The methods based on deep learning clearly outperformed the conventional ones. The best performance [Sørensen-Dice coefficient (DSC)] in the two datasets was, respectively, 0.853 and 0.763 for the deep learning methods, and 0.761 and 0.704 for the traditional ones.

Conclusions

Deep learning is a viable approach for semi-automated segmentation of pulmonary nodules on CT scans.

[123I]Metaiodobenzylguanidine (MIBG) Cardiac Scintigraphy and Automated Classification Techniques in Parkinsonian Disorders

PURPOSE

To provide reliable and reproducible heart/mediastinum (H/M) ratio cut-off values for parkinsonian disorders using two machine learning techniques, Support Vector Machines (SVM) and Random Forest (RF) classifier, applied to [¹²³I]MIBG cardiac scintigraphy.

PROCEDURES

We studied 85 subjects, 50 with idiopathic Parkinson's disease, 26 with atypical Parkinsonian syndromes (P), and 9 with essential tremor (ET). All patients underwent planar early and delayed cardiac scintigraphy after [¹²³I]MIBG (111 MBq) intravenous injection. Images were evaluated both qualitatively and quantitatively; the latter by the early and delayed H/M ratio obtained from regions of interest (ROIt₁ and ROIt₂) drawn on planar images. SVM and RF classifiers were finally used to obtain the correct cut-off value.

RESULTS

SVM and RF produced excellent classification performances: SVM classifier achieved perfect classification and RF also attained very good accuracy. The better cut-off for H/M value was 1.55 since it remains the same for both ROIt₁ and ROIt_2. This value allowed to correctly classify PD from P and ET: patients with H/M ratio less than 1.55 were classified as PD while those with values higher than 1.55 were considered as affected by parkinsonism and/or ET. No difference was found when early or late H/M ratio were considered separately thus suggesting that a single early evaluation could be sufficient to obtain the final diagnosis.

CONCLUSIONS

Our results evidenced that the use of SVM and CT permitted to define the better cut-off value for H/M ratios both in early and in delayed phase thus underlining the role of [¹²³I]MIBG cardiac scintigraphy and the effectiveness of H/M ratio in differentiating PD from other parkinsonism or ET. Moreover, early scans alone could be used for a reliable diagnosis since no difference was found between early and late. Definitely, a larger series of cases is needed to confirm this data.

Prognostic role of inflammatory biomarkers from peripheral blood and clinical factors in metastatic castration-resistant prostate cancer (mCRPC) patients (pts) treated with radium-223 (Ra-223) (BIO-Ra-223 study)

e17026

Background: Ra-223 is a treatment option for mCRPC pts with bone metastases according to the survival benefit observed compared to placebo in the ALSYMPCA trial. In the last years, many studies showed this benefit in the real-life pts is lower than that reported in the trial, probably due to a suboptimal selection of pts with poor prognostic characteristics. Therefore, the identification of prognostic factors to select mCRPC pts most likely to benefit from Ra-223 is needed. The multicentre retrospective BIO-Ra-223 study has investigated the prognostic role of peripheral blood immune cells and clinical factors to develop a novel prognostic score for mCRPC pts treated with Ra-223. Methods: Complete blood count was assessed before Ra-223 treatment calculating neutrophil-to-lymphocyte ratio (NLR), derived NLR (dNLR), lymphocyte-to-monocyte ratio (LMR), platelet-to-lymphocyte ratio (PLR), systemic inflammation index (SII). Clinical factors included pre-treatment Eastern Cooperative Oncology Group performance status (ECOG PS), Gleason Score (GS) group, number of bone metastases, alkaline phosphatase (ALP), line of therapy, previous chemotherapy and the presence of lymphadenopathies. Statistical analyses included survival ROC curves for biomarkers’ cutoffs, univariable and multivariable Cox analyses, internal validation, c-index calculation and Schneeweiss scoring system. Results: From September 2013 to July 2020, 519 mCRPC pts received Ra-223 as 1st-2nd, 3rd-4th and further-line in 48%, 38% and 14% of pts. The median overall survival (mOS) of the entire cohort was 19.9 months. All biomarkers and clinical factors (except for GS group) significantly predicted OS at the univariable analyses. In the multivariable ones, all biomarkers, ECOG PS, number of bone metastases and ALP significantly correlated with OS. The multivariable model with NLR (< 3.1 vs ≥3.1), ECOG PS (0-1 vs 2-3), number of bone metastases (< 6, 6-20, > 20) and ALP (< 220 vs ≥220) showed the highest c-index (0.711), which was maintained after internal validation (bootstrap re-sampling) (c-index: 0.707). Using the Schneeweiss scoring system, ten categories were identified in 494 pts with complete data and merged in two prognostic groups with distinctive OSs: group 1 (score 0-4, 337 pts) with a mOS of 27.8 months and group 2 (score 5-10, 157 pts) with a mOS of 9.7 months (HR 4.03, p < 0.001). Conclusions: The obtained score, composed of NLR, ECOG PS, number of bone metastases, and ALP identifies two distinctive prognostic groups of mCRPC pts. Moreover, this score is easily and widely applicable for clinical practice and trials at no additional costs. Although external validation is needed, these preliminary results showed that this novel prognostic score is promising and could help the patients’ selection for Ra-223 treatment.

SPECT imaging of cerebral blood flow changes induced by acute trigeminal nerve stimulation in drug-resistant epilepsy. A pilot study

OBJECTIVE

To explore the cortical areas targeted by acute transcutaneous trigeminal nerve stimulation (TNS) in patients with drug-resistant epilepsy (DRE) using single photon emission computed tomography (SPECT).

METHODS

Ten patients with DRE underwent brain SPECT at baseline and immediately after a 20-minute TNS (0.25 ms; 120 Hz; 30 s ON and 30 s OFF) applied bilaterally to the infraorbital nerve. The French Color Standard International Scale was used for qualitative analyses and z-scores were used to calculate the Odds Ratio (OR).

RESULTS

At baseline global hypoperfusion (mainly in temporo-mesial, temporo-parietal and fronto-temporal and temporo-occipital areas) was detected in all patients. Following TNS, a global increase in cortical tracer uptake and a significant decrease in median hypoperfusion score were observed. A significant effect favoring a general TNS-induced increase in cortical perfusion (OR = 4.96; p = 0.0005) was detected in 70% of cases, with significant effects in the limbic (p = 0.003) and temporal (p = 0.003) lobes. Quantitative analyses of z-scores confirmed significant TNS-induced increases in perfusion in the temporal (+0.59 SDs; p = 0.001), and limbic (+0.43 SDs; p = 0.03) lobes.

CONCLUSION

Short-term TNS is followed a global increase in cortical perfusion, namely in the temporal and limbic lobes.

SIGNIFICANCE

The TNS-induced perfusion increase may reflect neurons' activity changes in cortical areas implicated in the epilepsy network.

A National Multicenter Study on overall survival in elderly metastatic castrate-resistant prostate cancer patients treated with Radium-223

BACKGROUND

Radium-223 prolongs overall survival (OS) and delays time to the first symptomatic skeletal events in patients with symptomatic metastatic castration-resistant prostate cancer (mCRPC). There is a lack of evidence on the safety and efficacy of Radium-223 treatment in the very elderly population.

AIMS

Aim of this multicentre study is to analyze mCRPC patients treated with Radium-223 in terms of OS and to assess whether there are differences between young and elderly, as well as to verify efficacy and safety in patients ≥ 75 years of age.

METHODS

430 mCRPC patients of six Italian Centres were analyzed in this multicenter retrospective study. At baseline and after each cycle were collected clinical and diagnostic patients' parameters. The whole cohort was divided into two groups based on the age of the patients (< 75 years old and ≥ 75 years old).

RESULTS

47% of the patients were < 75 years old and 53% were ≥ 75 years old. The primary outcome, OS, does not show significant differences between the two subgroups if other basal parameters are considered. Considering clinical covariates in univariate models (p < 0.05) several clinical aspects have an impact on OS, except for age (p = 0.072). Age continues to have no significant impact on the OS (p = 0.274) even in multivariate models in the two groups. The toxic effects are similar in the two groups.

CONCLUSIONS

Radium-223 prolongs survival in both younger and older patients at the same baseline condition and is a good option in the symptomatic mCRPC setting compared to other agents.

Artificial intelligence techniques support nuclear medicine modalities to improve the diagnosis of Parkinson’s disease and Parkinsonian syndromes

Purpose

The aim of this review is to discuss the most significant contributions about the role of Artificial Intelligence (AI) techniques to support the diagnosis of movement disorders through nuclear medicine modalities.

Methods

The work is based on a selection of papers available on PubMed, Scopus and Web of Sciences. Articles not written in English were not considered in this study.

Results

Many papers are available concerning the increasing contribution of machine learning techniques to classify Parkinson’s disease (PD), Parkinsonian syndromes and Essential Tremor (ET) using data derived from brain SPECT with dopamine transporter radiopharmaceuticals. Other papers investigate by AI techniques data obtained by 123I-MIBG myocardial scintigraphy to differentially diagnose PD and other Parkinsonian syndromes.

Conclusion

The recent literature provides strong evidence that AI techniques can play a fundamental role in the diagnosis of movement disorders by means of nuclear medicine modalities, therefore paving the way towards personalized medicine.

Overall survival in mCPRC patients treated with Radium-223 in association with bone health agents: a national multicenter study

PURPOSE

Radium-223 has demonstrated efficacy in improving overall survival (OS) and in delaying symptomatic skeletal-related events (SREs). Bone Health Agents (BHA), i.e. RANK ligand inhibitor (Denosumab) and bisphosphonate such as zoledronic acid, are indicated to prevent SREs without a clear survival benefit. SREs on patient health have a high impact and it is, therefore, important to consider the role of new therapies with BHA to better understand the involvement of combination therapy. The primary aim of this multicentric study is to assess OS in mCRPC patients treated with Radium-223 in combination with BHA.

MATERIALS AND METHODS

430 consecutive patients treated with Radium-223 alone or in combination with BHA, affected by mCRPC, from January 2015 to July 2019 in six Italian Nuclear Medicine Units, were included. Furthermore, data were collected at baseline, after every Radium-223 administration, and during follow-up, at 3 and 6 months and 1 year after the 6th cycle. Clinical data have been evaluated before starting treatment with Radium-223 and at the end of treatment and/or at progression. Patients who received target bone therapy with BHA before Radium-223 treatment together with patients who did not receive this therapy at all (NO BHA GROUP), were compared to patients treated with concomitant Radium-223 and BHA (BHA GROUP).

RESULTS

In univariate models (p < .05) several clinical aspects have an impact on OS: concomitant BHA (p = .018), BMI (p .001), ECOG PS (p = .000), Baseline Hb (p = .000), Baseline PSA (p = .000), Baseline tALP (p = .000), Baseline LDH (p = .000), and Baseline neutrophils (p = .009). Baseline Hb, Baseline tALP, and Baseline LDH have been confirmed as statistically significant parameters in multivariate models. Indeed, concomitant BHA has not a significant impact on OS (p = .244) in multivariate models.

CONCLUSIONS

At univariate analysis, our data showed that NO BHA GROUP and BHA GROUP differ in OS by 7 months (95%CI: (1-16.4), p = .02). This is not confirmed at multivariate analysis where after adjusting for other baseline factors, BHA is not significant anymore. This is clearly explained as bias by indication: patients with the same levels of tALP, Hb, and LDH receiving or not receiving BHA are expected to have a similar survival. Our results support and confirm the role of Radium-223 therapy on OS and, furthermore, appear to confirm that BHA treatment has not a survival benefit.

Stretchable screen-printed PEDOT:PSS electrodes for upper-arm surface electromyography

In the past ten years, wearable electronics underwent tremendous growth. Undoubtedly, one of the fields that led this trend is represented by biomedical applications. In this field, wearable technologies can provide unique features such as the unobtrusive monitoring of biopotentials. Polymerbased electrodes developed for this purpose can take advantage of their seamless integration in the garments. However, the available solutions exhibit fragility in relation with the stretchability of the fabric, causing significant performance degradation.In this work, this problem is tackled by a novel deposition approach based on screen-printing technology. The electrodes are deposited onto the pre-stretched fabric to ensure the full functionality during common operating conditions. To this aim, a novel PEDOT:PSS conductive ink formulation and printing procedure were conceived. In order to prove the electrode performance for surface electromyography, we printed the electrodes directly onto a commercial stretchable polyester sleeve for sport applications. The electrodes allowed to reliably record the muscular activity of the forearm with performance comparable to that of commercial gelled Ag/AgCl electrodes. The obtained results suggest that the proposed approach can be valuably used in health and fitness applications.

Value of Shape and Texture Features from 18F-FDG PET/CT to Discriminate between Benign and Malignant Solitary Pulmonary Nodules: An Experimental Evaluation

In this paper, we investigate the role of shape and texture features from 18F-FDG PET/CT to discriminate between benign and malignant solitary pulmonary nodules. To this end, we retrospectively evaluated cross-sectional data from 111 patients (64 males, 47 females, age = 67.5 ± 11.0) all with histologically confirmed benign (n=39) or malignant (n=72) solitary pulmonary nodules. Eighteen three-dimensional imaging features, including conventional, texture, and shape features from PET and CT were tested for significant differences (Wilcoxon-Mann-Withney) between the benign and malignant groups. Prediction models based on different feature sets and three classification strategies (Classification Tree, k-Nearest Neighbours, and Naïve Bayes) were also evaluated to assess the potential benefit of shape and texture features compared with conventional imaging features alone. Eight features from CT and 15 from PET were significantly different between the benign and malignant groups. Adding shape and texture features increased the performance of both the CT-based and PET-based prediction models with overall accuracy gain being 3.4-11.2 pp and 2.2-10.2 pp, respectively. In conclusion, we found that shape and texture features from 18F-FDG PET/CT can lead to a better discrimination between benign and malignant lung nodules by increasing the accuracy of the prediction models by an appreciable margin.

Radium-223 in mCPRC patients: a large real-life Italian multicenter study

BACKGROUND

Radium-223 is a targeted alpha-particles therapy approved for the treatment of mCRPC patients with symptomatic bone metastases. To our knowledge we account for the largest cohort of mCRPC patients subjected to Radium-223 treatment in our country. We aim to describe in a real-life setting the largest cohort of mCRPC patients treated with Radium-223 ever taken into consideration.

METHODS

Four hundred and thirty consecutive mCRPC patients were enrolled. Clinical data have been collected at baseline and at the end of the Radium-223 treatment. Furthermore, the overall survival(OS) of our population has been provided.

RESULTS

One hundred fifty-seven patients (36.5%) were still alive at the time of data analysis. A mean number of 4.95±1.6 cycles of Radium-223 was reached by our cohort. 265 patients (61.6%) completed the whole six cycles regimen. The mean follow-up period from the first cycle of Radium-223 to the date of the analysis was 12.7 months. The analysis of patients Annual Incidence Rate (AIR) in relation to the number of Radium-223 cycles received depicting a clear advantage for those patients who completed the whole six administrations planned, with an AIR (AIR=0.32) of much lesser value compared to those that have performed five cycles (AIR =0.98). 165 patients (38.4%) dropped out of treatment for death or disease progression.

CONCLUSIONS

This study offers a cross-section of the clinical performance of Radium-223 treatment in a real-world context, confirming on a large scale the effectiveness of Radium-223 in improving the OS and quality of life, along with the preservation of an excellent safety profile.

Radium-223 in mCPRC patients: a large real-life Italian multicenter study

BACKGROUND

Radium-223 is a targeted alpha-particles therapy approved for the treatment of mCRPC patients with symptomatic bone metastases. To our knowledge we account for the largest cohort of mCRPC patients subjected to Radium-223 treatment in our country. We aim to describe in a real-life setting the largest cohort of mCRPC patients treated with Radium-223 ever taken into consideration.

METHODS

430 consecutive mCRPC patients were enrolled. Clinical data have been collected at baseline and at the end of the Radium-223 treatment. Furthermore, the overall survival(OS) of our population has been provided.

RESULTS

157 patients (36.5%) were still alive at the time of data analysis. A mean number of 4.95±1.6 cycles of Radium-223 was reached by our cohort. 265 patients (61.6%) completed the whole six cycles regimen. The mean follow-up period from the first cycle of Radium-223 to the date of the analysis was 12.7 months. The analysis of patients Annual Incidence Rate (AIR) in relation to the number of Radium-223 cycles received depicting a clear advantage for those patients who completed the whole six administrations planned, with an AIR (AIR=0.32) of much lesser value compared to those that have performed five cycles (AIR =0.98). 165 patients (38.4%) dropped out of treatment for death or disease progression.

CONCLUSIONS

This study offers a cross-section of the clinical performance of Radium-223 treatment in a real-world context, confirming on a large scale the effectiveness of Radium-223 in improving the OS and quality of life, along with the preservation of an excellent safety profile.

Qualitative and Quantitative Analyses of Brain 18Fluoro-Deoxy-Glucose Positron Emission Tomography in Primary Progressive Aphasia

BACKGROUND

A primary progressive aphasia (PPA) diagnosis is generally based on clinical criteria, but often symptoms and signs may overlap in the different forms. Recent data have evidenced that brain 18fluoro-deoxy-glucose positron emission tomography (18F-FDG PET) could support the clinical diagnosis, since specific metabolic patterns are described for the different variants.

AIMS

We further evaluated the usefulness of 18F-FDG PET, by both visual qualitative (QL) and quantitative (QN) methods in the initial diagnosis of PPA, focusing on the classification of different variants. Moreover, we also analyzed the role of 18F-FDG PET in clarifying the association of PPA with the early phase of Alzheimer's disease (AD) or frontotemporal (FTD) dementias.

METHODS

We consecutively enrolled 35 patients with clinical symptoms of aphasia, suspect of or attributable to PPA. Patients were classified into two groups: 18 cases with clinical symptoms of aphasia but normal neuropsychological tests and an unclear classification of a specific PPA variant (group A) and 17 cases with clinical and neuropsychological signs attributable to PPA with an uncertain differential diagnosis between AD and FTD (group B). All patients underwent brain 18F-FDG PET/CT, and images were evaluated both by QL and QN, the latter applying an automated analysis program that produced brain regional metabolicmaps and normal age-matched control group comparative analysis (zscore).

RESULTS

18F-FDG PET showed different patterns of bilateral cortical hypometabolism in the two groups. The combined use of QL and QN permitted to achieved a correct PPA variant diagnosis in 8 of 18 (44.4%) cases of group A and in 14 of 17 (82.3%) of group B, while only QN could support the correct classification of PPA variants in 10 of 18 (55.6%) cases of group A and in 3 of 17 (17.7%) cases of group B in whom the procedure better localized the hypometabolic areas.

CONCLUSIONS

Brain 18F-FDG PET had an elevated performance in the early diagnosis of PPA variants and in the advanced PPA AD/FTD classification. QL clarified the development of AD or FTD in advanced PPA cases and supported the differential diagnosis of a PPA variant in a few early cases. QN 18F-FDG PET evaluation better contributed to the early diagnosis of an unclear metabolic pattern. To correctly identify all cases, patients with diffuse cortical hypometabolism were also included. Larger series are necessary to confirm these data.

Validation of the 3-variable prognostic score (3-PS) in mCRPC patients treated with 223Radium-dichloride: a national multicenter study

Objective

Radium-223 (²²³Ra) has been approved for treatment in patients with metastatic castration-resistant prostatic cancer (mCRPC) and bone metastasis. This α-emitting radionuclide has a beneficial effect on pain and is also capable to increase overall survival (OS). Several studies evaluated the prognostic value of different biomarkers at baseline, such as serum values, imaging parameters or pain. To date, however, clinicians lack a validated and simple system to assess which patients will most likely benefit from ²²³Ra treatment. The 3-variable prognostic score (3-PS), proposed in a single-center study in 2017 classifies patients in five prognostic groups with a specific OS. This study aims to validate the 3-PS in a larger multicenter population.

Methods

Four hundred and thirty mCRPC patients treated with ²²³Ra from six different centers were analyzed. The 3-PS score consists of the collection of baseline hemoglobin, prostatic specific antigen and Eastern cooperative oncology group performance status and was initially applied to the whole population (total group). The score was then validated on the 338 patient’s subgroup (clean group) obtained by subtracting the 92 patients enrolled for the original study of the 3-PS score. This purified group served as further validation evidence.

Results

Statistical analysis showed that the 3-PS score was valid on the total group as well as in the clean group as the AUC estimated (0.74) falls within the CI of the AUC calculated on the validation sample (95% CI 0.66–0.82).

Conclusion

This study confirms the validity of the 3-PS score for mCRPC patients. This score is simple, noninvasive and affordable and can be easily used to select patients that will most probably complete ²²³Ra treatment. In addition, this tool provides an exact estimate of life expectancy in terms of OS.

Targeted Alpha Therapy with Thorium-227

Targeted alpha therapy (TAT) can deliver high localized burden of radiation selectively to cancer cells as well as the tumor microenvironment, while minimizing toxicity to normal surrounding cell. Radium-223 (²²³Ra), the first-in-class α-emitter approved for bone metastatic castration-resistant prostate cancer has shown the ability to prolong patient survival. Targeted Thorium-227 (²²⁷Th) conjugates represent a new class of therapeutic radiopharmaceuticals for TAT. They are comprised of the α-emitter ²²⁷Th complexed to a chelator conjugated to a tumor-targeting monoclonal antibody. In this review, the authors will focus out interest on this therapeutic agent. In recent studies ²²⁷Th-labeled radioimmunoconjugates showed a relevant stability both in serum and vivo conditions with a significant antigen-dependent inhibition of cell growth. Unlike ²²³Ra, the parent radionuclide ²²⁷Th can form highly stable chelator complexes and is therefore amenable to targeted radioimmunotherapy. The authors discuss the future potential role of ²²⁷Th TAT in the treatment of several solid as well as hematologic malignancies.

P976 Can calcium score predict the appropriate treatment for high risk patients? (a 5 years follow up study)

Coronary artery calcium score (CAC) measures the calcium contained in the artery wall and it is evaluated using multi-slice cardiac CT and CAC represents a useful tool for appreciating the burden of coronary atherosclerosis and for determining the risk for cardiovascular events.

The purpose of this study is that CAC can be use for guiding treatment strategy in patients classified as high risk based on Framingham score .

We prospectively enrolled 64 pts (79% male), 62,7+/-5 year, between 2002-2017. All included patients were considered high risk based on EuroSCORE model.

A multislice heart CT scan was performed for every patient with CAC score determination quantified with the Agatston score and expressed as Agatston Units (AU). The patients were divided in 3 groups according to the treatment that they received during the 5 years follow up: optimal medical treatment for coronary artery disease (OMT) – 35.9% (23), percutaneous coronary angioplasty (PCA) – 29.7% (19) and coronary artery bypass graft (CABG) – 34.4%.

The CAC score for pts treated by OMT vs CABG +/_ PCA were compared using the ROC curves. CAC score was statistically significantly superior in CABG+ PCA patients versus OMT (AUC: 0.96, p &lt; 0.001 vs AUC 0.42, p = 0.212). Also, a comparison of CAC score score for CABG vs OMT revealed the same results (AUC: 0.96, p&lt; 0.001 vs AUC: 0.42, p = 0.264). OMT vs CABG + PCA presented a cut-off value of 382 AU with a specificity of 90% and a sensitivity of 95%. OMT vs CABG presented a cut-off value of 530 AU with a specificity of 89% and a sensitivity of 95%.

In conclusion, CAC score has a good predictability and sensitivity in determining the outcome and can be a promising tool to guide therapy in high risk patients, mainly regarding medical vs surgical treatment for coronary artery disease.

The additional role of 18F-FDG PET/CT in prosthetic valve endocarditis

OBJECTIVE

The purpose of the present review is an update on the diagnosis of prosthetic valve endocarditis (PVE), evaluating the additional value of 18F-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT) to the standard modified DUKE criteria on which for a long time is based the diagnostic strategy of the disease.

MATERIALS AND METHODS

We did a comprehensive research on the studies reported in the literature and regarding the employment of 18F-FDG PET/CT in the early diagnosis of PVE in patients with suspected disease. Scientific databases have been examined such as Medline and PubMed, followed by a review of citations and reference lists. The research included the following terms: infective endocarditis, prosthetic heart valve and cardiac valve replacement infections, 18F-FDG PET/CT and endocarditis.

RESULTS

The recent studies reported in the literature on the PVE diagnostic approaches showed elevated sensitivity and specificity values of 18F-FDG PET/CT ranging from 73 to 96.6% and from 80 to 94%, respectively, reducing the number of misdiagnosed patients. The usefulness of the radioisotopic procedure is even more important when the other diagnostic conventional diagnostic tools, such as echocardiography, are inconclusive or negative in patients in whom the diagnosis of PVE is definitively ascertained. However, false negative and positive results of 18F-FDG PET/CT were also ascertained in some studies interfering with image interpretation even if such limitation can be reduced with an adequate patient preparation, with a better knowledge of clinical course of the disease, of the treatment in progress and of the different technical aspects of the method.

CONCLUSIONS

In different studies reported in the literature, 18F-FDG PET/CT proved to improve the diagnostic accuracy of the conventional modified DUKE criteria in patients with suspected IE, and in particular with PVE, giving the highest diagnostic performance and providing additional diagnostic benefits. Thus, the radioisotopic hybrid procedure should be included in the diagnostic protocol of PVE as complementary tool to modified DUKE criteria. Finally, the usefulness of 18F-FDG PET/CT in monitoring the response to antibiotic therapy, although the few data reported in the literature are encouraging, needs more numerous studies and with a major number of cases.

Body fat changes in HIV patients on highly active antiretroviral therapy (HAART): a longitudinal DEXA study

OBJECTIVE

We aimed to quantitatively evaluate body fat composition in a group of HIV patients treated with Highly Active Anti-retroviral Therapy (HAART) to ascertain both fat loss and fat distribution changes and to identify possible therapeutic and host related associated risk factors.

PATIENTS AND METHODS

A total of 180 patients with available total body DEXA scan were assigned to a) Group 1, with clinically evident body fat changes, (BFC) and b) Group 2, without BFC. Clinical and immunovirologic data were collected. We used Student t-test and x2 or Fisher exact test to compare the characteristics of the two groups. Paired t-test was used to compare basal and follow-up data. The relationships between variables were evaluated by calculating Pearson's correlation coefficient and its significance.

RESULTS

HAART duration was significantly (p<0.0001) higher for patients in Group 1 than in Group 2, as well as PI (p<0.02) and NRTI (p<0.002) therapy duration. Current CD4 count and CD4 rise from nadir resulted significantly higher in Group 1 than in Group 2 (p<0.02 and 0.006, respectively). Whole Body Fat (WBF), Peripheral Fat (PF) and Leg (L) fat negatively correlated with PI and NRTI therapy duration, while Trunk Fat (TF)/PF positively correlated with PI and NNRTI duration. No significant correlation was found, instead, with NNRTI therapy duration. At 5-year follow-up, we registered a further increase in TF, Arms (A) and L fat, especially in PI-treated patients.

CONCLUSIONS

Body fat changes should always be considered when dealing with HIV-affected patients on HAART. The fat loss seemed to involve mainly peripheral regions, while fat accumulation tendency occurred in the trunk.

Benefits of Organized Mammographic Screening Programs in Women Aged 50 to 69 years: A Surgical Perspective

BACKGROUND

The benefits of organized mammographic screening programs (OMSPs) in reducing breast cancer mortality have been addressed by several studies. This study was designed to specifically evaluate the advantages of OMPSs in terms of surgical management of patients with breast cancer.

MATERIALS AND METHODS

Surgical treatment of 201 patients with breast cancer aged 50 to 69 years coming from OMSPs was compared with that of 532 non-OMSP patients in same age group. The likelihood of receiving BCS was analyzed through a multivariable regression model.

RESULTS

The mean tumor size was smaller in the OMSP patients (14 mm vs. 18 mm; P < .01). The proportion of patients having metastatic lymph nodes was higher in the non-OMSP group (33.3% vs. 17.9%; P < .01). Rates of breast-conserving surgery (BCS) were significantly higher in the OMSP group (89.1% vs. 59.1%; P < .01). Sentinel node biopsy was carried out in 84.1% and 62.5% of patients in the OMSP and non-OMSP groups, respectively (P < .01). Rates of axillary lymph node dissection were significantly different (24.9% in the OMSP group and 35.8% in the non-OMSP group; P = .02). Re-excisions for infiltrated margins after BCS were lower in the OMSP group (4.8% vs. 12.7%; P < .01). Hospital stay was shorter in the OMSP group (2.13 vs. 3.02 days; P < .01). OMPS women had a 3-fold higher probability of receiving BCS.

CONCLUSIONS

Patients with breast cancer belonging to OMSPs had a higher probability to receive less invasive surgery and to have shorter hospital stay. Our results support the use of campaigns aimed at increasing adhesion to mammography screening.

Targeted Therapies in Cholangiocarcinoma: Emerging Evidence from Clinical Trials

Cholangiocarcinoma (CCA) is a highly-aggressive malignancy arising from the biliary tree, characterized by a steady increase in incidence globally and a high mortality rate. Most CCAs are diagnosed in the advanced and metastatic phases of the disease, due to the paucity of signs and symptoms in the early stages. This fact, along with the poor results of the local and systemic therapies currently employed, is responsible for the poor outcome of CCA patients and strongly supports the need for novel therapeutic agents and strategies. In recent years, the introduction of next-generation sequencing technologies has opened new horizons for a better understanding of the genetic pathophysiology of CCA and, consequently, for the identification and evaluation of new treatments tailored to the molecular features or alterations progressively elucidated. In this review article, we describe the potential targets under investigation and the current molecular therapies employed in biliary tract cancers. In addition, we summarize the main drugs against CCA under evaluation in ongoing trials and describe the preliminary data coming from these pioneering studies.

An organic neurophysiological tool for neuronal metabolic activity monitoring

Monitoring cell metabolism in vitro is considered a relevant methodology in several scientific fields ranging from fundamental biology research to neuro-toxicology. In the last 20 years, several in vitro neuro-pharmacological and neuro-toxicological approaches have been developed, with the intent of addressing the increasing demand for real-time, non-invasive in vitro systems capable of continuously and reliably monitoring cellular activity. In this paper, an Organic Charge Modulated Field Effect Transistor-based device is proposed as a promising tool for neuro-pharmacological applications, thanks to its ultra-high pH sensitivity and a simple fabrication technology. The preliminary characterization of this versatile organic device with primary neuronal cultures shows how these remarkable properties can be exploited for the realization of ultra-sensitive metabolic probes, which are both reference-less and low cost. These features, together with the already assessed capability of this sensor to also monitor the electrical activity of electrogenic cells, could provide important advances in the fabrication of multi-sensing lab-on-chip devices, thus opening up interesting perspectives in the neuro-pharmacological field.

Sentinel Node Detection with Imaging Probe

A one-square-inch-field-of-view mini gamma camera, whose first prototype was built by us in 1998 and given the name imaging probe (IP), was initially employed in sentinel lymph node (SLN) detection. This is probably the best way of learning how to use it. In the present work IP was used for SLN localization by a medical team that, after having been trained by the group of nuclear physicians of “La Sapienza” University who designed and first used the detector, used IP at their own hospital to 1) acquire experience for future use during surgery (a cooperative project on IP-radioguided orthopedic surgery is ongoing) and 2) start multicenter trials with IP. The SLN was identified and localized with IP and a non-imaging probe, Neoprobe 2000, in six patients with breast cancer who underwent lymphoscintigraphy for SLN biopsy. The operators who used Neoprobe and IP were blinded to each other's findings and to the results obtained with the large-field-of-view Anger camera that was used for lymphoscintigraphy. The Anger camera, IP and Neoprobe detected seven SLNs in six patients. The mean detection time was 2 mins 6 s (standard deviation (SD) 26 s) with IP, and 2 mins 18 s (SD 47 s) with Neoprobe 2000. The SLN that was most difficult to find was detected in 2 mins 56 s with IP and 3 mins 45 s with Neoprobe. The operators' subjective impression of having detected the SLN was “absolutely sure” for 7/7 nodes with IP and “absolutely sure” for 5/7 nodes with Neoprobe.

123I-ioflupane SPET and 123I-MIBG in the diagnosis of Parkinson's disease and parkinsonian disorders and in the differential diagnosis between Alzheimer's and Lewy's bodies dementias

Nuclear medicine procedures are widely used as "in vivo" biomarkers in a large number of brain diseases, especially in the diagnosis of Parkinson's disease (PD) and of parkinsonian disorders (pD). Furthermore, nuclear medicine is used in the differential diagnosis of dementias especially Alzheimer's disease (AD) and dementia with Lewy's bodies (LBD) which share many clinical symptoms and often LBD is misdiagnosed as AD. The differential diagnosis between these clinical entities is crucial for treatment since LBD also shares some clinical symptoms with parkinsonian disorders. We reviewed the most relevant papers that study the usefulness of both iodine-123-ioflupane studied by single photon emission tomography (¹²³I-ioflupane SPET) and of ¹²³I-metaiodobenzylguanidine (¹²³I-MIBG) cardiac scintigraphy in the diagnosis of PD and pD and in the differential diagnosis between AD and LBD in order to contribute to the clinical practice of the diseases.

Mastectomy patterns, but not rates, are changing in the treatment of early breast cancer. Experience of a single European institution on 2315 consecutive patients

BACKGROUND

Recent literature reports that rates of mastectomy are increasing in early breast cancer. However, data from European institutions are limited and revealed conflicting results. We report on 15-year trends of mastectomy, mastectomy plus immediate reconstruction and contralateral prophylactic mastectomy (CPM) at an academic institution.

METHODS

We identified women diagnosed with unilateral early breast cancer at stage 0-IIa, with tumour size ≤ 4 cm, between 2002 and 2016. Trends were assessed using the Cochrane-Armitage test. Multivariable logistic regression was used to identify factors associated with receipt of mastectomy plus immediate reconstruction.

RESULTS

A total of 2315 patients were identified. Of them, 65.7% underwent breast conserving surgery (BCS), while 34.3% underwent mastectomy as upfront surgery. Two point four per cent also received CPM. Immediate reconstruction was performed in 36.0% of patients receiving mastectomy. There was no change in trends of mastectomy over the 15 years studied (p = 0.69), as well as in trends of patients undergoing CPM (p = 0.44). In contrast, rates of immediate reconstruction rose significantly over the study period (from 12.2% in 2002 to 62.7% in 2016, p < 0.0001). Women were more likely to receive mastectomy plus immediate reconstruction if they were aged 50 years or younger, or had tumours larger than 2 cm, or had non-invasive carcinoma.

CONCLUSIONS

Our study suggests that rates of both mastectomy and CPM in early breast cancer are not increasing, while use of immediate reconstruction is on the rise.

The role of molecular breast imaging in predicting complete tumor response to treatment and residual tumor extent following neoadjuvant therapy

The aim of the present study was to investigate the usefulness of molecular breast imaging (MBI) in predicting complete tumor response to treatment and residual tumor extent following neoadjuvant therapy. A consecutive series of 43 female patients with large or locally advanced primary breast cancer, scheduled for surgery following neoadjuvant therapy, was retrospectively reviewed. Prior to surgery, all patients underwent MBI using a high-resolution semiconductor-based device for image acquisition. MBI data were correlated with surgical histopathological findings. Spearman's correlation coefficient was calculated to assess differences in residual tumor size with MBI and histopathological examination. From the images obtained using MBI, 7 patients were negative for residual tumors with pathological complete response (specificity, 100%) and positive in 34/36 patients with residual disease (sensitivity, 94.4%), including 26/27 patients with unifocal and 8/9 patients with multicentric/multifocal tumors, 5 of which exhibited multiple microscopic foci scattered in a fibrotic area. Overall accuracy was 95.3% and the positive predictive value (PPV) and negative predictive value (NPV) were 100 and 77.8%, respectively. MBI was false-negative in one patient with a 2.5-cm invasive ductal carcinoma located close to the chest wall and in one patient with microscopic foci of epithelial carcinoma. In the patients with unifocal residual tumors, correlation of tumor size between MBI and histopathology was r=0.981 (P<0.0001); however, MBI overestimated the number of lesions in one of these cases. In the patients with multifocal/multicentric tumors, MBI adequately assessed residual tumor extent in 5/8 positive cases, overestimating the number of lesions in one case and underestimating tumor extent in 2 further cases with microscopic foci scattered in a fibrotic area. MBI proved to be a highly accurate diagnostic tool in predicting complete tumor response to neoadjuvant therapy and residual tumor extent, correlating with surgical histopathological findings in 86% of overall cases. A positive result was always associated with the presence of residual disease and MBI tumor size was strongly correlated with histopathological analysis mainly in unifocal residual tumors.

Intracranial Leptomeningeal Carcinomatosis: A Diagnostic Study with 18F-Fluorodeoxyglucose Positron Emission Tomography/Computed Tomography

Leptomeningeal carcinomatosis (LC) diagnosis is based on cerebrospinal fluid (CSF) cytological analysis and contrast-enhanced magnetic resonance imaging (MRI); however, low sensitivity was evidenced in some cases delaying prompt and adequate treatments. Brain ¹⁸F-fluorodeoxyglucose positron emission tomography (¹⁸F-FDG PET) was also employed in doubtful cases. We retrospectively described 4 suspected LC cases with uncertain or undetectable MRI and initially negative CSF cytology. Whole-body (WB) and brain ¹⁸F-FDG PET/computed tomography (CT) were used, the latter showing intracranial tracer uptakes suspected for LC in 3/4 cases. In 2 of these 3 cases, WB scan also evidenced spinal cord lesion and pulmonary tumor, respectively, while both procedures were true negative in the fourth case. CSF cytology became positive after repeated exams in the 3 PET/CT-positive cases. In 1 of these 3 patients, it was also confirmed at MRI, while it stayed negative in the remaining PET/CT-negative case with uncertain MRI. ¹⁸F-FDG PET/CT could be a useful supportive diagnostic tool in doubtful intracranial and spinal LC.

Sentinel Node Biopsy in Early Breast Cancer: Lessons Learned from More than 1000 Cases at a Single Institution

Aims

The aims of this paper are to report the development of sentinel node biopsy (SNB) in breast cancer at a single institution and to discuss the relevant issues on SNB still to be elucidated.

Patients and methods

From 1998 to 2010, 1021 SNBs with frozen section examination were carried out in patients with breast cancer. In the early period (1998–2002) SNB was always combined with axillary lymph node dissection (ALND). From 2002 onwards, only patients with a positive SNB result underwent ALND (late period). The characteristics of patients with infiltrating carcinoma (IC) and ductal carcinoma in situ (DCIS) and the histological status of the sentinel nodes were examined. The survival outcomes of node-negative patients were compared between patients submitted to SNB and ALND (ALND group) during the early period and patients who underwent only SNB during the late period (SNB group).

Results

The sentinel node was identified intraoperatively in 98.3% of cases. During the early period the overall accuracy of SNB was 97.0%. During the late period, 700 patients with IC and 140 with DCIS underwent SNB. In the IC group, 149 patients (21.3%) had sentinel node macrometastases and 36 (5.1%) micrometastases; of that subgroup, 21 underwent ALND and no other metastatic lymph nodes were found, and 15 underwent SNB only. Axillary recurrences were observed in 4 patients (0.77%) with negative SNB; none of these were among the patients with micrometastatic SNB. Two patients (1.4%) with DCIS had a positive SNB. In node-negative patients the 5-year overall survival was 96.7% in the ALND group and 96.5% in the SNB group (P = 0.63). The 5-year disease-free survival was 93.8% and 93.2% in the ALND and SNB groups, respectively (P = 0.77).

Conclusions

Overall and disease-free survival in patients with a negative SNB result and no further axillary surgery were equal to those in patients with negative ALND. Intraoperative assessment of the sentinel node in expert hands has a low false-negative rate and allows immediate ALND in patients with sentinel node metastases, avoiding the need for a second operation. ALND for sentinel node micrometastases may be safely omitted in most patients with early stage breast cancer.

Brain SPECT with Perfusion Radiopharmaceuticals and Dopaminergic System Radiocompounds in Dementia Disorders

As well known, the increase in life expectancy and the better physical condition of people in western countries will lead in the next 20 years to a dramatic development of neurodegenerative diseases, especially of dementia that could be considered one of the most important problems in clinical, social and economic fields for the future. Therefore, the differential diagnosis of the various types of dementia is a critical step for patients, clinicians and researchers since an accurate "in vivo" diagnosis can lead to a better patients management. Neuroimaging techniques and in particular the most diffuse and affordable single photon emission computed tomography (SPECT) have provided useful information about dementia disorders and these methods, on the basis of the recent advances, will have an increasingly important role in research and clinical practice. The purpose of this article is to analyze the different SPECT techniques now available which proved clinically useful in correctly formulating the differential diagnosis of dementia.

Underserved populations and bacterial and protozoal sexually transmitted infections: a lost health-care opportunity

OBJECTIVE

The purpose of our review is an update about the burden of sexually transmitted infections (STIs) among various types of underserved populations, such as migrants, substance abusers, homeless and incarcerated inmates. First-line test and treatment based on the latest available evidence according to the revised guidelines of Centers for Disease Control and Prevention have also been considered.

MATERIALS AND METHODS

We performed a comprehensive research using scientific databases such as Medline and Pubmed, followed by a review of citations and reference list. A consultation with other experts in the management of the various subpopulations was also conducted.

RESULTS

Health-care is often influenced by social determinants, which play a vital role in the diffusion of STIs. The consequence is a socio-economical and ethnic disparity in the rate of STIs. Early screening and treatment of STIs should be implemented in clinical practice, starting from marginalized social groups, which are the most affected by this health problem.

CONCLUSIONS

In the literature, there are very few papers containing information on STIs prevalence in various types of underserved populations, such as migrants, substance abusers, homeless and incarcerated inmates. The availability of more accurate epidemiological data is needed. In these groups, the most relevant barrier is the lower perception of health-care need, with an underestimation of risk and symptoms of STIs, causing a retard of diagnosis and health-care provision and use. For these populations, targeted interventions are needed, particularly on unaware people, responsible for most STIs transmissions.

Non-functioning gastroenteropancreatic (GEP) tumors: a 111In-Pentetreotide SPECT/CT diagnostic study

In a retrospective study performed in non-functioning GEP tumor patients we further investigated ¹¹¹In-Pentetreotide SPECT/CT usefulness in diagnosis, staging and follow-up also evaluating whether the procedure may give more information than conventional imaging procedures (CIP), such as CT, MRI, US. We enrolled 104 consecutive patients with non-functioning GEP tumors, 30 in initial diagnosis and staging phases (IDS) and 74 in follow-up (FU). All patients underwent somatostatin receptor scintigraphy (SRS) whole body scan at 4, 24 and, if necessary, 48 hours followed by abdominal and chest SPECT/CT after ¹¹¹In-Pentetreotide 148-222 MBq i.v. injection. The patients previously underwent 2 to 3 CIP. At both CIP and SPECT/CT, 34/104 patients were classified as no evidence of disease (NED); in 70/104 patients, neoplastic lesions were ascertained and 12 IDS and 17 FU were classified as not operable and treated with octeotride or chemotherapy. SPECT/CT and CIP were concordantly positive in 44 patients, while only CIP was positive in 6 cases and only SPECT/CT in 20. Both per-patient sensitivity and accuracy of SPECT/CT (91.4 and 94.2%, respectively) were higher than CIP (71.4 and 80.8%, respectively), but not significantly. Globally, 292 lesions were ascertained: 141 hepatic, 78 abdominal extra-hepatic and 73 extra-abdominal. CIP detected 191/292 (65.4%) lesions in 50 patients, while SPECT/CT 244/292 (83.6%) in 64, the difference being significant (p<0.0001). No false positive results were found at both SPECT/CT and CIP. Both SPECT/CT sensitivity and accuracy were higher than CIP in G1, G2, neuroendocrine carcinoma (NEC) and mixed adeno-neuroendocrine carcinoma (MANEC) patients, but significantly only for G1. Globally, SPECT/CT incremental value than CIP was 35.6%. SPECT/CT correctly modified CIP classification and patient management in 27.9% of cases, while it down-staged the disease than CIP in 9.6% of cases. However, the two procedures combined use could achieve the highest accuracy value. ¹¹¹In-Pentetreotide SRS, acquired as SPECT/CT, showing high sensitivity and accuracy values, more elevated than CIP in the present study, can still have a wide employment in the routine diagnostic protocol of non-functioning GEP tumors with significant impact on patient management and therapy planning. The procedure is simple to perform, has limited cost and wide availability in all Nuclear Medicine Centers.

123I-ioflupane brain SPECT and 123I-MIBG cardiac planar scintigraphy combined use in uncertain parkinsonian disorders

We evaluated the clinical usefulness of the combined use of I-ioflupane brain single photon emission computed tomography (SPECT) and I-metaiodobenzylguanidine (MIBG) cardiac scintigraphy in discriminating uncertain parkinsonism with vascular lesions in striatal nuclei at magnetic resonance imaging (MRI). Forty-three consecutive patients with uncertain parkinsonism and vascular lesions at MRI in striatal nuclei were retrospectively evaluated; the uncertain differential diagnosis was between Parkinson's disease and vascular parkinsonism (PD/VP) in 22 patients, between PD and other neurodegenerative parkinsonism (PD/PS) in 11 patients and between Lewy body dementia and Alzheimer disease (LBD/AD) in the remaining 10 cases. All patients underwent I-ioflupane SPECT with striatal dopaminergic activity determination as binding potentials (BP; cut-off: 3.3). I-MIBG cardiac planar scintigraphy was performed 2 weeks later, in early (15 minutes) and delayed (240 minutes) phases also calculating heart to mediastinum (H/M) ratio (cut-off: 1.56). I-Ioflupane uptake was normal in 9 patients with BP values >3.3, while it was reduced in 34/43 cases with BP values <3.3 at least in one of the striatal nuclei. I-MIBG uptake was normal in 21/43 patients (5 of whom with normal and 16 with I-ioflupane striatal defects) showing the H/M ratio >1.56 in all cases; the uptake was reduced in 22/43 cases, (4 of whom were normal and 18 were with I-ioflupane striatal defects) with the H/M ratio <1.56 in all cases. No statistical differences were found when early and delayed H/M ratios were mutually compared. Combining the 2 radioisotopic procedures, a more reliable diagnosis was achieved in 39/43 cases properly classifying 13 PD, 10 VP, 7 PS, 5 LBD, and 4 AD. However, the diagnosis remained uncertain in four patients with normal I-ioflupane and reduced I-MIBG uptake. The results of the present study confirmed that in uncertain parkinsonian syndromes associated with vascular lesions in striatal nuclei, brain I-ioflupane SPECT alone did not prove able to discriminate between the different forms of disease. Only the association with I-MIBG cardiac scintigraphy, also with the early acquisition alone, allowed the most appropriate diagnosis in 90.7% of our cases. However, patients with normal I-ioflupane and reduced I-I-MIBG uptakes need a close clinical and instrumental follow-up as sympathetic damage could precede striatal disorders in the early stage of PD and LBD.

The burden of HIV-associated neurocognitive disorder (HAND) in post-HAART era: a multidisciplinary review of the literature

OBJECTIVE

The purpose of the present multidisciplinary review is to give an updated insight into the most recent findings regarding the pathophysiology, diagnosis and therapeutics of HIV-associated neurocognitive disorder (HAND).

MATERIALS AND METHODS

We performed a comprehensive search, through electronic databases (Pubmed - MEDLINE) and search engines (Google Scholar), of peer-reviewed publications (articles and reviews) and conferences proceedings on HAND pathophysiology, diagnosis, and therapy, from 1999 to 2016.

RESULTS

It seems to be increasingly clear that neurodegeneration in HIV-1 affected patients is a multi-faceted disease involving numerous factors, from chronic inflammation to central nervous system (CNS) compartmentalization of HIV. Diagnosis of HAND may benefit from both laboratory analysis and advanced specific neuroimaging techniques. As regards HAND therapy, modified HAART combinations and simplification strategies have been tested, while novel exciting frontiers seem to involve the use of nanoparticles with the ability to cross the Blood-Brain Barrier (BBB).

CONCLUSIONS

Albeit highly active antiretroviral therapy (HAART) allowed a major decrease in morbidity and mortality for AIDS patients, CNS involvement still represents a challenge in HIV patients even today, affecting up to 50% of patients with access to combination antiretroviral therapy (cART). Future studies will have to focus on CNS compartmentalization, drugs' ability to penetrate and suppress viral replication in this compartment, and on new approaches to reduce HIV-associated neuroinflammation.