Role of 18F-FCH PET/CT in Detecting Recurrences of Prostate Cancer After Curative Treatments

Objectives

To evaluate the role of 18F-fluorocholine (18F-FCH) positron emission tomography/computed tomography (PET/CT) in prostate cancer (PC) patients with biochemical recurrence who were submitted to different curative treatments.

Methods

Seventy-five patients with PC who underwent 18F-FCH PET/CT for biochemical recurrence were retrospectively analyzed to distinguish patients who were submitted only to prostatectomy (PR group), only to radiotherapy (RT) on prostate with curative intent (RT group), and to both (PR + RT group). Correlations between 18F-FCH PET/CT and outcome and between prostate-specific antigen (PSA) values and sites and the number of metastases were analyzed. The performance of 18F-FCH PET/CT in relation to the PSA value and of maximum standardized uptake value (SUVmax) value in relation to patient outcome were assessed by receiver operating characteristic (ROC) curves.

Results

18F-FCH PET/CT relapses mostly involved lymph nodes, bones, and prostate bed. K-cohen test showed moderate agreement with the outcome in the whole population and in the PR group, whereas in the RT group it was perfect and in PR + RT fair. A statistically significant difference in PSA values was observed in the presence of lymph node metastases and with multiple metastases. ROC curves showed PSA cut-off values of 1.96 ng/dL, 1.95, 1.81, and 2.96, respectively, in the whole population, PR, RT and PR + RT group. SUVmax cut-off values of 3.75, 3.45, and 4.7 were described in the whole population, PR group, and PR + RT group.

Conclusion

The study confirms that 18F-FCH PET/CT is still valid in PC patients with suspected biochemical recurrence. Therefore, we can affirm that it still makes sense to perform it both with high PSA values and with lower values when prostate-specific membrane antigen tracers are not available.

[The role of oropharyngoesophageal scintigraphy in the assessment of dysphagia in neurological patients.]

PURPOSE

The aim of this study was to assess the role of oropharingoesophageal scintigraphy (OPES) in the management of neurological patients, investigating the clinical value of semiquantitative analysis.

MATERIALS AND METHODS

We enrolled 39 neurological patients clinically evaluated and scored according to the Dysphagia Outcome Severity Scale (DOSS) scale who underwent fibrolaryngoscopic swallowing examination (FEES) and OPES using a 99mTc-nanocolloid-radioblabelled semiliquid bolus. We calculated the following semiquantitative parameters: Oral Transit Time (OTT), Pharyngeal Transit Time (PTT), Esophageal Transit Time (ETT), Retention Index (RI), and Esophageal Emptying Rate (EER10s). Differences in OPES semiquantitative parameters between patients classified according to the DOSS scale were performed using the nonparametric Mann-Whitney U test. Optimal semiquantitative parameters cut-off values that correlated with DOSS classification were investigated with ROC curves. The agreement between OPES, FEES and DOSS results was measured using Cohen's Kappa test (K).

RESULTS

A significantly higher OTT (p=0.028), PTT (p=0.011) and ETT (p=0.030) and lower EER10s (p=0.016) values were identified. Moderate agreement resulted between OPES and DOSS results (k=0.429, 95%CI: 0.143-0.715, p=0.002).

CONCLUSIONS

Our study revealed a significant correlation between clinical dysphagia graded using DOSS scale and semiquantitative parameters obtained by OPES evaluation. Despite reliable and reproducible OPES results, allowing an adequate study also of the esophageal phase, nowadays scintigraphic study remains an underestimated method to be considered in the diagnosis of dysphagia and related complications.

Safety culture to improve accidental event reporting in radiotherapy

BACKGROUND AND PURPOSE

The potential for unintended and adverse radiation exposure in radiotherapy (RT) is real and should be studied because RT is a highly complex, multistep process, which requires input from numerous individuals from different areas and steps of the RT workflow. The 'Incident' (I) is an event the consequence of which is not negligible from the point of view of protection or safety. A 'near miss' (NM) is defined as an event that is highly likely to happen but did not occur. The purpose of this work is to show that through systematic reporting and analysis of these adverse events, their occurrence can be reduced.

MATERIALS AND METHODS

Staff were trained to report every type of unintended and adverse radiation exposure and to provide a full description of it.

RESULTS

By 2018, 110 worksheets had been collected, with an average of 6.1 adverse events per year (with 780 patients treated per year, meaning an average incident rate of 0.78%). In 2001-2009, 37 events were registered (13 I and 24 NM), the majority of them were in the decision phase (12/37), while in 2010-2013, there were 42 (1 I and 41 NM) in both the dose-calculation and transfer phase (19/42). In 2014-2018, 31 events (1 I and 30 NM) were equally distributed across the phases of the RT process. In 9/15 cases of I, some checkpoint was introduced.

CONCLUSION

The complexity of the RT workflow is prone to errors, and this must be taken into account by encouraging a safety culture. The aim of this paper is to present the collected incidents and near misses and to show how organization and practice were modified by the acquired knowledge.

Early Evaluation of Immunotherapy Response in Lymphoma Patients by 18F-FDG PET/CT: A Literature Overview

Immunotherapy is a promising therapeutic strategy both for solid and hematologic tumors, such as in Hodgkin (HL) and non-Hodgkin lymphoma (NHL). In particular, immune-checkpoint inhibitors, such as nivolumab and pembrolizumab, are increasingly used for the treatment of refractory/relapsed HL. At the same time, evidence of chimeric antigen receptor (CAR)-T-cell immunotherapy efficacy mostly in NHL is growing. In this setting, the challenge is to identify an appropriate imaging method to evaluate immunotherapy response. The role of 18F-Fluorodeoxyglucose (18F-FDG) positron-emission tomography/computed tomography (PET/CT), especially in early evaluation, is under investigation in order to guide therapeutic strategies, taking into account the possible atypical responses (hyperprogression and pseudoprogression) and immune-related adverse events that could appear on PET images. Herein, we aimed to present a critical overview about the role of 18F-FDG PET/CT in evaluating treatment response to immunotherapy in lymphoma patients.

Heterogeneous Response to Immunotherapy in a Patient with Tonsillar Squamous Cell Carcinoma Assessed by 18F-FDG PET/CT

Tonsillar carcinoma is the second most common malignancy of the head and neck region, with Squamous Cell Carcinoma (TSCC) as the most common histological type (>90%). For the advanced stage of TSCC, radiotherapy with or without platinum-based chemotherapy is the only therapeutic option. Immuno-checkpoint inhibitors (ICIs), in particular Nivolumab, considerably improves clinical management of these patients, but the response can be unpredictable. Difficulties can be encountered in evaluating response to immunotherapy, especially with morphological imaging, which can show an atypical response, such as pseudo-progression, leading to a premature discontinuation. Conversely, metabolic imaging can guide a more properly therapeutic decision. We present a case of a 71-year-old man affected by TSCC, treated with chemotherapy, radiotherapy, and Nivolumab as the last line of treatment. Pre- and post-immunotherapy ¹⁸F-FDG PET/CT showed an impressive response, avoiding early drug discontinuation and ensuring better management of this patient.

Dyspnea in Patients Receiving Radical Radiotherapy for Non-Small Cell Lung Cancer: A Prospective Study

Background and Purpose

Dyspnea is an important symptomatic endpoint for assessment of radiation-induced lung injury (RILI) following radical radiotherapy in locally advanced disease, which remains the mainstay of treatment at the time of significant advances in therapy including combination treatments with immunotherapy and chemotherapy and the use of local ablative radiotherapy techniques. We investigated the relationship between dose-volume parameters and subjective changes in dyspnea as a measure of RILI and the relationship to spirometry.

Material and Methods

Eighty patients receiving radical radiotherapy for non-small cell lung cancer were prospectively assessed for dyspnea using two patient-completed tools: EORTC QLQ-LC13 dyspnea quality of life assessment and dyspnea visual analogue scale (VAS). Global quality of life, spirometry and radiation pneumonitis grade were also assessed. Comparisons were made with lung dose-volume parameters.

Results

The median survival of the cohort was 26 months. In the evaluable group of 59 patients there were positive correlations between lung dose-volume parameters and a change in dyspnea quality of life scale at 3 months (V₃₀ p=0.017; V₄₀ p=0.026; V₅₀ p=0.049; mean lung dose p=0.05), and a change in dyspnea VAS at 6 months (V₃₀ p=0.05; V₄₀ p=0.026; V₅₀ p=0.028) after radiotherapy. Lung dose-volume parameters predicted a 10% increase in dyspnea quality of life score at 3 months (V₄₀; p=0.041, V₅₀; p=0.037) and dyspnea VAS score at 6 months (V₄₀; p=0.027) post-treatment.

Conclusions

Worsening of dyspnea is an important symptom of RILI. We demonstrate a relationship between lung dose-volume parameters and a 10% worsening of subjective dyspnea scores. Our findings support the use of subjective dyspnea tools in future studies on radiation-induced lung toxicity, particularly at doses below conventional lung radiation tolerance limits.

Somatostatin Receptors in Merkel-Cell Carcinoma: A Therapeutic Opportunity Using Somatostatin Analog Alone or in Association With Checkpoint Inhibitors Immunotherapy. A Case Report

Background: Merkel-cell carcinoma (MCC) is a rare, highly aggressive skin cancer typically involving elderly people. Surgery is usually the first treatment for primary tumor. In adjuvant setting, radiotherapy is effective in reducing local recurrence and in improving overall survival. Regarding advanced disease, systemic chemotherapy ended up disappointing results whereas antiPD1/antiPD-L1 immunotherapy recently gave relevant clinical benefits. Interestingly, about the half of MCC patients expresses high somatostatin receptors (SRs) to possibly represent a target for the therapeutic use of somatostatin analogs (SSAs). Nevertheless, SSAs have been little studied in MCC and cases treated with SSAs in association with checkpoint inhibitor immunotherapy have not been published yet.

Case Report: We report the case of a 73-year-old man affected by metastatic MCC of right arm previously treated with surgery and adjuvant radio and chemotherapy. Three years later the patient presented loco-regional relapse involving lateral-cervical, mediastinal, and submandibular lymph nodes with high value of chromogranin A and neuron specific enolase. Due to the high expression of SRs at octreoscan and immunoistochemistry, patient started octreotide 30 mg i.m. every 28 days with a good control of disease for about 2 years. A widespread progression of disease was reported afterwards. The patient started the antiPD-L1 avelumab immunotherapy, only recently available in Italy, while still taking SSA. The patient showed an impressive regression of the disease after only four cycles of avelumab until complete remission.

Conclusions: SSA could be a valid therapeutic option in patients with MCC with high SR expression. When combined with PD-1/PD-L1 immune-checkpoint inhibition, SSA is likely to enhance antiproliferative activity. Our case report provides the rationale to conduct a prospective trial and translational research to verify the efficacy and safety of combined SSA and checkpoint inhibitors for advanced MCC.

Heterogeneous response to target therapy in metastatic papillary renal cell carcinoma evaluated by morphologic and metabolic multimodality imaging: A case report

RATIONALE

Papillary renal cell carcinoma (PRCC) accounts for about 15% to 20% of renal cell carcinoma and is histologically distinguished in type I and type II. The last one is associated with poorer prognosis.Treatment options for PRCC patients are surgery, immunotherapy, revolutionized by Nivolumab, and other target-therapy with an improvement in overall survival. Heterogenous response and a pseudo-progression may be observed in the initial phase of biological treatment that could induce premature discontinuation.

PATIENT CONCERNS

We present the case of a 44-year-old woman with left cervical palpable mass increased in size and without concomitant disease or previous surgery.

DIAGNOSIS

Neck ultrasonography, contrast-enhanced Computed Tomography, and 18F-FDG PET/CT were performed with the detection of lymph nodes involvement and a left renal lesion.

INTERVENTIONS

The patients underwent left radical nephrectomy and homolateral cervical and para-aortic lymphadenectomy, with histological diagnosis of PRCC, type II. After disease relapse, the inter-aortocaval lymph node was laparoscopically removed. Following the detection of further disease relapse in several lymph nodes and the lung, several lines of target-therapy were started; then disease progression and worsening of clinical and hematological status led us to start Nivolumab as last-line therapy.

OUTCOMES

A heterogeneous response to therapies was documented with morphological and nuclear medicine imaging, however the concomitant deterioration of performance status and liver function led to discontinuation of Nivolumab; then the patient died, 30 months after diagnosis.

LESSONS

Here we describe the clinical case and radiological and nuclear medicine imaging investigations performed by our patient, highlighting that 18F-FDG PET/CT shows greater adequacy in assessing the response to therapy, avoiding premature drug discontinuation, and ensuring better management of a patient with advanced PRCC.

How often suspected pulmonary embolism is diagnosed and its main diagnostic characteristics, in an emergency nuclear medicine service? Four years experience

OBJECTIVE

Acute pulmonary embolism (APE) is an emergency condition and its treatment must be immediate. Nevertheless, the diagnosis of APE is diffcult because its symptoms and risk factors are not specific. We present our 4 years experience on this subject.

SUBJECTS AND METHODS

We retrospectively studied 2178 lung perfusion scintigraphies (LPS). Of them 1846 were performed to patients suspected for APE admitted to the emergency departments of the University Polyclinic of Bari and examined immediately by our Nuclear Medicine Department. Contingency tables and odds ratio (OR) were used to estimate the relation between symptoms, risk factors, D-dimers dosage, other imaging diagnostic tools and LPS results.

RESULTS

Lung perfusion scintigraphy was positive for APE in 309/1846 (16.7%) patients which then were treated successfully. In 89.5% of these, 309 patients D-dimer dosage was previously examined and was increased in 97.7% of them, but was not predictive of APE (OR=1.04, P=1). Among all symptoms, a low diagnostic capacity was found for cough (OR=1.25, P=0.066) and for chest pain (OR=0.95, P=649). On the contrary, dyspnea was a significant symptom correlated with positive LPS (OR=1.78, P<0.001). The presence of risk factors was predictive of positive LPS and positively correlated with the number of positive 2 oglin lesions in LPS. x²l^oglin=6.472, P=0.011). Lung perfusion scintigraphy positive for APE were significantly associated with computed tomography pulmonary angiography and/or chest X-ray results (x =9.618, P=0.022).

CONCLUSION

Lung perfusion scintigraphy could early diagnose APE in 16.7% of the cases (referred to our Nuclear Medicine Emergency Service) and exclude APE in 83.3% of these cases. Immediate treatment or release of these patients from the emergency department was thus possible. LPS has a key role in the early diagnosis but even more in exclusion of APE, optimizing the management of patients who do not require admission to intensive care. Our four-year and large-scale experience, based on clinical and resource optimization, support the need of Nuclear Medicine Units to perform LPS as emergency in on-call 24 hrs service.

Impact of pre-treatment variables on the completion of 223radium-dichloride therapy in mCRPC patients with bone metastases

INTRODUCTION

Radium-223 dichloride (²²³Ra) is an alpha-particle-emitter radiopharmaceutical, approved for metastatic castration-resistant prostate cancer (mCRPC) patients with symptomatic bone metastases and no visceral involvement. Its administration is based on a schedule of intravenous injection (55kBq/kg) every four weeks for up to six cycles. Because the biological effectiveness of ²²³Ra-therapy is dose-dependent, the main goal is to complete the entire treatment to achieve a better patient outcome. This study aims to identify potential pre-treatment variables that could impact on ²²³Ra-treatment completion and then be used to improve the clinical and supportive management of mCRPC patients.

MATERIALS AND METHODS

30 consecutive mCRPC patients (mean age 77 years old), who were admitted for Ra223-therapy at our Department from February 2016 to October 2018, were enrolled for the analysis. The population was grouped as patients who completed ²²³Ra-therapy (group Ra223-C) and patients who do not (group ²²³Ra-U). For each group, we analyzed the effects of potential pre-treatment variables (age, Gleason Score, tumor burden, "Time From Diagnosis To ²²³Ra therapy", type and number of previous treatments, hemoglobin level, Alkaline Phosphatase, Prostate Specific Antigen and pain) on the Ra223-therapy completion. Statistical analysis was performed to evaluate the association between the completion of ²²³Ra therapy and the variables examined.

RESULTS

16/30 (53%) patients were ²²³Ra-C, conversely 14/30 (47%) patients were ²²³Ra-U because of an early interrupted treatment. A statistically significant association was found only with tumor burden: 68.7% of patients who completed ²²³-therapy had less than 20 bone metastases (χ²=4.821, p=0.028).

CONCLUSION

Our preliminary analysis demonstrates that the high tumor burden represents the most important pre-treatment factor that could affect treatment completion and that needs to be considered before starting ²²³Ra-therapy to achieve a better outcome in mCRPC patients.

[Role of 18F-FDG PET/CT in comparison with CECT for whole-body assessment of patients with esophageal cancer.]

AIM

We aimed to evaluate the role of 18F-FDG PET/CT in the TNM staging of esophageal cancer in comparison with contrast-enhancement computed-tomography (CECT). Futhermore we set out to determine the role of semiquantitative PET parameters.

METHODS

55 patients performed 18F-FDG PET/CT and CECT. Values of Sensitivity (Se), specificity (Sp), accuracy and predictability (PPV and NPV) were evaluated. McNemar test was applied for comparison. Cohen's K was calculated to measure the agreement. 18F-FDG PET/CT semiquantitative parameters (SUVmax, SUVmean, MTV and TLG) in relation to site and histotype, were assessed by ANOVA test and post-hoc test.

RESULTS

About T parameter, Se, Sp, accuracy, PPV and NPV of CECT and 18F-FDG PET/CT were respectively 82.35%, 94.48%, 85.00%, 93.33% and 76% for both the tecniques; the agreement resulted substantial. There were no statistically significant relationships between 18F-FDG PET/CT parameters and sites; MTV value differs in histotypes. About N parameter, Se, Sp, accuracy, PPV and NPV of CECT were respectively 82.35%, 57.89%, 65.00%, 46.67%, 88%; for 18F-FDG PET/CT were 88.23%, 60.53%, 61%, 50% and 92%; the agreement resulted fair. About M parameter, Se, Sp, accuracy, PPV and NPV PET/CT were equal for both techniques: 76.92%, 52.38%, 58.33%, 33%, 88%; the agreement resulted moderate. No statistical difference was observed in any comparison.

CONCLUSION

18F-FDG PET/CT is a useful tool for whole-body evaluation of patients with esophageal cancer, allowing an effective clinical TNM staging. In particular 18F-FDG PET/CT's ability in detecting distant metastases suggest its routinary performance as a second level of investigation.

Sickle cell diseases: What can nuclear medicine offer?

Sickle cell disease (SCD) is the best known haemoglobinopathy, caused by a mutation substituting valina for glutamic acid at position 6 of the beta-globin chain of adult hemoglobin A, resulting in hemoglobin S (HbS). The homozygous HbS disease (HbSS), an autosomal recessive disorder, is the most common form and the Mediterranean area, along with sub-Saharian African and India, have the highest prevalence (1%-15%). In particular, Sicily with a prevalence of 2%-5%, is among the most interested regions. However, migratory flows have led to a wider diffusion of the disease no longer confined to endemic areas. In Europe, the yearly estimate of affected births are 1,300 but more than 90% of children with SCD survive into adulthood thanks to screening programs and early available care; however, their lifespan remains shortened by two or three decades compared to general population. In Greece, the number of affected births surpassing 100,000 yearly and the total number of newborns carrying two deleterious genes, if no prevention measures are taken, is estimated to be about 120-130/year. Diagnosis of SCD is based on analysis of haemoglobin through protein electrophoresis or chromatography, that are cheap and widely available techniques, even if haemoglobin mass spectrometry and DNA analysis are techniques with high-throughput testing. Prenatal diagnosis is used in many European countries, so the number of affected newborns has significantly decreased during the last 3 years. Over the course of SCD, sickling process may cause acute and chronic abdominal pain due to vaso-occlusive crisis, bone pain often in long bones due to bone marrow infarction, chronic hemolytic anemia, splenic sequestration with rapid enlargement of the spleen, delayed sexual maturation and cholelithiasis, with important inter-indivuidual variability. Sickle hepatopathy reflects liver sickling process within hepatic sinusoids and includes gallstone disease, hepatic sequestration, hepatic sideroris, acute sickle cell hepatic crises (ASHC) and sickle cell intrahepatic cholestasis (SCIC). Clinically, it appears with fever, right upper quadrant pain, jaundice and increased serum liver function tests. These patients are repeatedly esposed to trasfused red cells that contributes to iron overload and may contribute to hepatic haemosiderosis. Increased bone turnover and resorption by osteoclasts and by marrow expansion due to activation of hematopoiesis. The hematopoietic system may expand physiologically. Computed tomography (CT) is an easily reproducible imaging method that allows the morphologic whole-body evaluation although with a high dose of radiation exposure and possible side effects from intravenous contrast media. Magnetic resonance cholangiopancreatography (MRCP) is a noninvasive technique without radiation chosen to image cholangiopathy and may be followed by the execution of endoscopic retrograde cholangiopancreatography (ERCP) in case of gallstone disease. Otherwise it can be helpful in identifying extramedullary hematopoiesis sites. Dual-energy X-rays absorptiometry (DEXA) is performed to evaluate deficit of bone mineral density (BMD), in which reduction of osteoblastic activity, high risk for necrosis may induce to fragility fractures. We recently had the experience of a typical case of a 56 years old Albanian woman with SCD, with jaundice after a long history of recurrent vaso-occlusive crisis. She was submitted to splenectomy and cholecystectomy 5 years before and since then she was treated with hydroxyurea. Hemocromatosis was excluded by genetic analysis. Hepatic biopsy (Pearl's stain) showed sinusoidal dilatation and diffuse iron accumulation in hepatocytes and Kupffer cells. Endo-hepatic jaundice was observed in MRCP images. It was interesting that DEXA examination was within normal range in both right proximal femur. This may probably be due to the presence of sclerotic lesions in the vertebrae, as was seen in the CT images. Technetium-99m-methylen bisphosphonate (^99mTc-MDP) skeletal scintigraphy is a higly sensitive whole-body diagnostic nuclear medicine technique able to evaluate early bone metabolic changes. Multimodality SPET/CT allows to correlate scintigraphic findings with anatomical images with higher sensitivity and specificity. The higher uptake of ^99mTc-MDP in SCD patients is due to the activation of hematopoetic system and relies on the osteoblastic response to bone resorption as in our patient. The ^99mTc-MDP scan may be better than fluorine-18-fluorodeoxyglucose positron emission tomography/computed tomography (¹⁸F-FDG PET/CT) to show sclerotic lesions. Technetium-99m nanocolloids bone marrow scintigraphy (BMS) provides information about the assessment of the reticulum-endothelial system (RES), the whole-body distribution of functional red bone marrow and the presence and the extent of extramedullary hematopoiesis, especially in liver, spleen and bone marrow. Fluorine-18-FDG PET/CT completes the whole-body assessment with an integrated multimodal approach with high spatial resolution that evaluates the metabolic activity and the standardized uptake value (SUV) in SCD patients. Modern genetic diagnosis and gene treatment give promise for having fewer cases of SCD in the future.

Diagnostic Performance of 18F-FDG PET/CT Semiquantitative Analysis in the Management of Sarcoidosis

Background:

Sarcoidosis is a multisystem granulomatous disorder of unknown origin characterized by nonspecific clinical symptomatology. 18F-FDG PET/CT can visualize activated inflammatory cells of sarcoidosis and simultaneously provide whole-body images. </P><P> Objective: To evaluate the clinical usefulness of 18F-FDG PET/CT and its semiquantitative parameters for the assessment of treatment efficacy in patients with sarcoidosis.

Methods:

Thirty-one consecutive patients who performed 18F-FDG PET/CT for sarcoidosis assessment were selected. All subjects performed 18F-FDG PET/CT before any treatment (PET1) and after 6-12 months (PET2). SUVmax and SUVmean on PET1 and PET2 were collected. SUVs values were employed to evaluate the ratios with the liver (R-LIVERmax, R-LIVERmean) and the blood (R-BLOODmax, R-BLOODmean). The difference between the PET1 and PET2 values was evaluated (&#916;SUVmax, &#916;SUVmean, &#916;R-LIVERmax, &#916;R-LIVERmean, &#916;R-BLOODmax, &#916;R-BLOODmean). Patients were classified as Responders (R), Partial-Responders (PR) and Non- Responders (NR).

Results:

Seventeen patients (54.8%) had a complete metabolic response (R), 4 (12.9%) were PR while 10 (32.3%) had no Metabolic Response (NR). The chi-square test showed that response groups were related neither to the stage of disease (p=0.59) nor to therapy performed (p<0.079). The comparison between each &#916; semiquantitative parameter showed a statistically significant decrease from PET1 to PET2 (0.0001 < p < 0.002). The comparison between &#916; mean values in relation to response groups showed to be statistically significant (0.001 < p < 0.005). Conversely, they did not show statistical significance in relation to the clinical stage groups and to the kind of therapy performed (p>0.05). Pearson’s coefficient demonstrated a reverse correlation between a number of sites still involved in disease after therapy and each &#916; semiquantitative parameters (p&#8804;0.0001).

Conclusion:

18F-FDG PET/CT should be considered a useful technique for the evaluation of sarcoidosis and semiquantitative parameters. Further studies are needed to determine the long-term impact of 18F-FDG PET/CT on clinical outcomes.

18F-FDG PET/CT in therapy response and in predicting responders or non-responders in malignant pleural mesothelioma patients, by using semi-quantitative mRECIST and EORTC criteria

OBJECTIVE

To evaluate the role of fluorine-18-fluorodeoxyglucose positron emission tomography/computed tomography (¹⁸F-FDG PET/CT) in therapy response assessment according modified response evaluating criteria of solid tumors (mRECIST) and the predictive role of volume-based semi-quantitative parameters in patients with malignant pleural mesothelioma (MPM). Furthermore modified RECIST criteria for MPM mRECIST and the European Organization for Research and Treatment of Cancer (EORTC) criteria were compared and the predictive role of ¹⁸F-FDG PET/CT in the post-therapy outcome.

SUBJECTS AND METHODS

Thirty five selected patients with MPM underwent ¹⁸F-FDG PET/CT scan at baseline (1) and after therapy (2). Semi-quantitative ¹⁸F-FDG PET/CT parameters were collected for each scan and also differences (Δ) ΔSUVmax, ΔSUVav, ΔMTV, ΔTLG, response index (RI)max% and RIav% were evaluated. Radiologic response to therapy was assessed by using the mRECIST and EORTC.

RESULTS

The correlation between response to therapy assessed by EORTC and mRECIST criteria was moderate (K=0.418; 95%CI:0099-0736). According to mRECIST, statistical differences between responders and non-responders were significant in the analysis of semi-quantitative parameters. According mRECIST criteria, all parameters defined a good area under the curve (AUC) but the better AUC resulted for ΔMTV (cut-off≤11.3, sensitivity=91.3%, specificity=91.7%) and ΔTLG (cut-off≤59.1, sensitivity=82.6%, specificity=100%). Kaplan-Meier curves between responders and non-responders did not show statistically significant differences.

CONCLUSION

The semi-quantitative analysis of ¹⁸F-FDG PET/CT has an important role in MPM therapy response assessment and has a predictive role in distinguishing responders and non-responders.

Bone Involvement in Hodgkin's Lymphoma: Clinical Features and Outcome

Hodgkin's lymphoma (HL) is now a highly curable disease, with an improving 5-year survival rate that has now reached 86%. At the time of presentation, HL is usually almost entirely confined to the lymph nodes. We performed a retrospective single-institution study of 384 cases with a median follow-up of 44 months, with the aim of identifying clinical and radiological characteristics and outcomes of patients with bone HL; 32 patients (8%) had primary bone involvement, always with concurrent nodal disease. These included 22 men (69%) and 10 women (31%) with the median age as 41 years. Advanced stages and nodular sclerosis histology prevailed among the subgroup. Radiographic features of bone HL are not specific but indicate a destructive malignant process with osteosclerosis and/or osteolysis. With current chemotherapeutic regimens, the long-term prognosis of patients with osseous HL appears good. The presence of bone lesions in HL should not be interpreted as implying a worse prognosis than without bone involvement.

Lung Perfusion Imaging in Tetralogy of Fallot: A Case Report

Congenital heart diseases, such as tetralogy of fallot (TOF), are the most common human birth defects that may cause pulmonary diseases. Lung perfusion scintigraphy (LPS) has an important role in evaluating pulmonary involvement in patients with these defects, both as part of the diagnostic work-up and for follow-up to guide best therapeutic strategy. Herein, we report a 10-year-old female patient with TOF who underwent LPS two years after cardiac surgery. The scan showed hypo-perfusion of the left respect to the right lung and abnormal uptake of Tc-99m-macroaggregated albumin in the kidneys and spleen, revealing the presence of a right-to-left shunt, and the necessity for further cardiac surgery. This case is a demonstrative example of the usefulness of LPS in patients with TOF, allowing an accurate evaluation of the best therapeutic strategy with the benefits of low radiation exposure, lack of side effects, reproducibility, management ease and good patient compliance.

Chronic coffee consumption and striatal DAT-SPECT findings in Parkinson's disease

Coffee may interfere with the dopaminergic transmission, and this action would possibly enhance motor activity and exert an antidyskinetic effect in Parkinson's disease (PD). This study aimed to see whether coffee habit could be associated with change in striatal dopamine active transporter (DAT)-single photon emission computed tomography (SPECT) imaging in PD. A total of 83 PD patients (71 current coffee drinkers and 12 never drinkers) underwent a DAT-SPECT study, using [123I]FP-CIT as radionuclide. Socio-demographic and clinical information as well as smoking habit was collected at the time of imaging acquisition. The Unified Parkinson's Disease Rating Scale part III was used to evaluate disease severity. On multivariable analysis, chronic coffee consumption was not associated with any significant change in striatal uptake of the radionuclide. However, the number of years patients drunk coffee was correlated with a significant increase in age at PD onset (p < 0.001). Confirming a previous report, current cigarette smoking was associated with a reduction of radionuclide uptake in putamen and caudate (p < 0.001).

Tyrosine-Kinase Inhibitors Therapies with Mainly Anti-Angiogenic Activity in Advanced Renal Cell Carcinoma: Value of PET/CT in Response Evaluation

Renal cell carcinoma (RCC) is the most frequent renal tumor and the majority of patients are diagnosed with advanced disease. Tumor angiogenesis plays a crucial role in the development and progression of RCC together with hypoxia and glucose metabolism. These three pathways are strictly connected to the cell growth and proliferation, like a loop that is self-feeding. Over the last few years, the ever-deeper knowledge of its contribution in metastatic RCC led to the discovery of numerous tyrosine kinase inhibitors (TKIs) targeting pro-angiogenic receptors at different levels such as sunitinib, sorafenib, pazopanib, axitinib, tivozanib, and dovitinib. As anti-angiogenic agents, TKIs interfere the loop, being able to inhibit tumor proliferation. TKIs are now available treatments for advanced RCC, which demonstrated to improve overall survival and/or progression free survival. Their effects can be detectable early on Positron Emission Tomography/Computed Tomography (PET/CT) by change in ¹⁸F-fluoro-2-deoxy-2-d-glucose (¹⁸F-FDG) uptake, the main radiotracer used to date, as a strong indicator of biological response. ¹⁸F-FDG PET/CT demonstrated an ability to predict and monitor disease progression, allowing an early and reliable identification of responders, and could be used for image-guided optimization and "personalization" of anti-angiogenic regimens. New radiotracers for biometabolic imaging are currently under investigation, which exploit the other pathways involved in the cancer process, including cellular proliferation, aerobic metabolism, cell membrane synthesis, hypoxia and amino acid transport, as well as the angiogenic process, but they require further studies.

Comparison between CT Net enhancement and PET/CT SUV for N staging of gastric cancer: A case series

BACKGROUND

The therapeutic approach of gastric cancer strictly depends on TNM staging mainly provided by CT and PET/CT. However, the lymph node size criterion as detected by MDCT causes a poor differential diagnosis between reactive and metastatic enlarged lymph nodes with low specificity values. Our study aims to compare 320-row CT Net enhancement and fluorine-18 fluoro-2-deoxy-d-glucose positron emission tomography/computed tomography (F-FDG PET/CT) SUV for N staging of gastric cancer.

MATERIALS AND METHODS

45 patients with histologically proven gastric cancer underwent CT and F-FDG PET/CT. Two radiologists in consensus evaluated all images and calculated the CT Net enhancement and F-FDG PET/CT SUV for N staging, having the histological findings as the reference standard. CT and F-FDG PET/CT sensitivity, specificity, diagnostic accuracy, positive and negative predictive values (PPV and NPV) were evaluated and compared by using the Mc Nemar test.

RESULTS

The histological examination revealed nodal metastases in 29/45 cases (64%). CT Net enhancement obtained sensitivity, specificity, accuracy, PPV and NPV of 90%, 81%, 87%, 90% and 81%, respectively. F-FDG PET/CT SUV obtained sensitivity, specificity, accuracy, PPV and NPV of 66%, 88%, 73%, 90% and 58%, respectively. No statistically significant difference between the two imaging modalities was found (p = 0.1).

CONCLUSION

CT Net enhancement represents an accurate tool for N staging of gastric cancer and could be considered as the CT corresponding quantitative parameter of F-FDG PET/CT SUV. It could be applied in the clinical practice for differentiating reactive lymph nodes from metastatic ones improving accuracy and specificity of CT.

Multimodality Imaging in Tumor Angiogenesis: Present Status and Perspectives

Angiogenesis is a complex biological process that plays a central role in progression of tumor growth and metastasis. It led to a search for antiangiogenic molecules, and to design antiangiogenic strategies for cancer treatment. Noninvasive molecular imaging, such as positron emission tomography (PET) and single photon emission computed tomography (SPECT), could be useful for lesion detection, to select patients likely to respond to antiangiogenic therapies, to confirm successful targeting, and dose optimization. Additionally, nuclear imaging techniques could also aid in the development of new angiogenesis-targeted drugs and their validation. Angiogenesis imaging can be categorized as targeted at three major cell types: (I) non-endothelial cell targets, (II) endothelial cell targets, and (III) extracellular matrix proteins and matrix proteases. Even if radiopharmaceuticals studying the metabolism and hypoxia can be also used for the study of angiogenesis, many of the agents used in nuclear imaging for this purpose are yet to be investigated. The purpose of this review is to describe the role of molecular imaging in tumor angiogenesis, highlighting the advances in this field.

Increased and normalized uptake of 18F-FDG in a case of bone periprosthetic infection treated by antibiotics

We report the case of a 69 years old man with left hip prosthesis, who presented clinical, biochemical and imaging signs of periprosthetic infection treated with linezolid, an antibacterial agent of the oxazolidinone class. Two weeks after this treatment, a fluorine-18-fluoro-2-deoxy-d-glucose positron emission tomography/computed tomography (¹⁸F-FDG PET/CT) scan showed increased uptake in the skeleton and also increased uptake in several focal areas in the spine and near the prosthesis and the surgical wound on the left gluteus medius. Bone marrow biopsy was negative; meanwhile the antibiotic therapy, after four weeks of treatment was stopped due to red blood cells and platelets toxicity. Six weeks later, the patient developed high fever again and in order to revaluate the periprosthetic inflammation, he was resubmitted to ¹⁸F-FDG PET/CT which showed normal ¹⁸F-FDG uptake in the whole skeleton, including the prosthesis and the subcutaneous wound. Some focal areas of increased uptake in the lumbar spine were still detected. In the next 4 weeks the patient was under a "watch and wait" follow-up in a steady state.

IN CONCLUSION

In the case we report, since we found no otnt focal areas in the lumbar spine where due to age-related bone deformities including some Schmorl's nodes. The inflammation in the bone prosthesis and the subcutaneous wound responded almost totally to the antibiotic treatment we applied.

Pediatric Hodgkin Lymphoma: Predictive value of interim 18F-FDG PET/CT in therapy response assessment

We investigated the prognostic value of interim F-FDG PET/CT (PET-2) in pediatric Hodgkin lymphoma (pHL), evaluating both visual and semiquantitative analysis.Thirty pHL patients (age ≤16) underwent serial F-FDG PET/CT: at baseline (PET-0), after 2 cycles of chemotherapy (PET-2) and at the end of first-line chemotherapy (PET-T). PET response assessment was carried out visually according to the Deauville Score (DS), as well as semiquantitatively by using the semiquantitative parameters reduction from PET-0 to PET-2 (ΔΣSUVmax0-2, ΔΣSUVmean0-2). Final clinical response assessment (outcome) at the end of first-line chemotherapy was the criterion standard, considering patients as responders (R) or nonresponders (NR). Disease status was followed identifying patients with absence or relapsed/progression disease (mean follow-up: 24 months, range 3-78).Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of visual and semiquantitative assessment were calculated; furthermore, Fisher exact test was performed to evaluate the association between both visual and semiquantitative assessment and outcome at the end of the first-line chemotherapy. The prognostic capability of PET-2 semiquantitative parameters was calculated by ROC analysis and expressed as area under curve (AUC). Finally, progression-free survival (PFS) was analyzed according to PET-2 results based on the 5-point scale and semiquantitative criteria, using the Kaplan-Meier method.Based on the outcome at the end of first-line chemotherapy, 5 of 30 patients were NR, the remnant 25 of 30 were R. Sensitivity, specificity, PPV, NPV, and accuracy of visual analysis were 60%,72%,30%,90%,70%; conversely, sensitivity, specificity, PPV, NPV, and accuracy of semiquantitative assessment were 80%, 92%, 66.7%, 95.8%, 90%. The highest AUC resulted for ΔΣSUVmax0-2 (0.836; cut-off <12.5; sensitivity 80%; specificity 91%). The association between ΔΣSUVmax0-2 and outcome at the end of first-line chemotherapy resulted to have a strong statistical significance (P = 0.0026). Both methods demonstrated to influence PFS, even if the semiquantitative assessment allowed a more accurate identification of patients with a high risk of treatment failure (P = 0.005).Our preliminary results showed that PET-2 visual assessment, by using Deauville criteria, can be improved by using the semiquantitative analysis. The SUV max reduction (ΔΣSUVmax0-2) evaluation might provide a support for the interpretation of intermediate scores, predicting with good confidence those patients who will have a poor outcome and require alternative therapies.

A pilot study employing hepatic intra-arterial irinotecan injection of drug-eluting beads as salvage therapy in liver metastatic colorectal cancer patients without extrahepatic involvement: the first southern Italy experience

BACKGROUND

The main aim of this prospective study was to evaluate the efficacy of drug-eluting beads with irinotecan (DEBIRI) for liver metastases from colorectal cancer. Secondary aims were to evaluate survival and toxicity.

METHODS

Twenty-five patients with metastases in <50% of the liver and without extrahepatic involvement were enrolled. Treatment response assessment was performed by multidetector contrast enhancement computed tomography (MDCT) with evaluation of the enhancement pattern of the target lesion and tumor response rates according to modified Response Evaluation Criteria in Solid Tumors (mRECIST, Version 1.1). All adverse events were recorded by the Cancer Therapy Evaluation Program Common Terminology Criteria for Adverse Events, Version 3.0. Associations of tumor response and variables were calculated using the chi-squared test. Overall survival (OS) was calculated using the Kaplan-Meier method. Comparisons were made using the log-rank test.

RESULTS

According to mRECIST, complete response (CR) was observed in 21.8% of patients, partial response (PR) in 13%, stable disease (SD) in 52.2% and progressive disease (PD) in 13% of patients. Response rate (RR = CR + PR) was 34.8%. No associations between treatment response and variables such as Dukes' classification, grading and Kras status were found (P>0.05). The median OS was 37 months (95% CI: 13.881 to 60.119). Cox regression model showed that neither site, Dukes' classification, grading, Kras status nor number of chemotherapy treatments pre-DEBIRI influenced the OS. The log-rank test showed no statistically significant difference in OS among patients who underwent 1, 2 or 3 DEBIRI treatments (χ²=2.831, P=0.09). In our study, the main toxicities included postembolization syndrome (PES), hypertransaminasemia and fever.

CONCLUSION

The favorable tumor response and the favorable toxicity profile make DEBIRI treatment a potential third-line therapy. Although further larger studies are needed to confirm these data, we can state that DEBIRI is an attractive emerging treatment in these patients.

[Added value of SPECT/CT over planar imaging in improving sentinel node detection in breast cancer patients]

The aim of the study was to assess the diagnostic contribution of hybrid SPECT/CT lymphoscintigraphy compared to planar imaging for the correct identification of sentinel lymph nodes (SLN) in breast cancer (BC) patients.

MATERIALS AND METHODS

73 planar and SPECT/CT lymphoscintigraphies were performed in 70 consecutive patients with BC (70 women, mean age 55.7±12.0 years, range 26-84) for pre-surgical SLNs research. Cohen'K was performed to evaluate the agreement between both techniques; their diagnostic capability was evaluated by the Student's t-test for paired data.

RESULTS

In 54/73 (73.9%) lymphoscintigraphies, SLNs were detected both on planar and SPECT/CT images. In 19/73 (26.1%) discordant cases, planar technique showed a higher number of SLNs in 4/19 lymphoscintigraphies, while SPECT/CT in 15/19. Radio-guided surgery confirmed SPECT/CT findings. Concordance between the two techniques was poor (K=-0.095). Overall, SPECT/CT detected 13 SLNs more than planar imaging (p=0.07). Furthermore, in 17/73 (23.2%) lymphoscintigraphies, SPECT/CT defined the exact SLNs anatomical localization, equivocal on planar images.

CONCLUSIONS

SPECT/CT demonstrated added value over planar imaging, providing more information for the best surgical approach. It is useful especially in patients with negative or doubt planar imaging.

Role of WB-MR/DWIBS compared to (18)F-FDG PET/CT in the therapy response assessment of lymphoma

INTRODUCTION

This study prospectively evaluated whole-body magnetic resonance/diffusion-weighted imaging with body signal suppression (WB-MR/DWIBS) reliability compared to (18)F-FDG PET/CT in the treatment response assessment of classic Hodgkin lymphomas (HL) and aggressive non-Hodgkin lymphomas (aNHL).

MATERIALS AND METHODS

Twenty-seven consecutive patients were prospectively enrolled at the time of diagnosis. Eighteen (11 HL and seven aNHL) were considered for the analysis. They received chemo/radiotherapy as induction and completed post-treatment evaluation performing both (18)F-FDG PET/CT and WB-MR/DWIBS. The revised response criteria for malignant lymphomas were used to assess the response to treatment. We evaluated the agreement between the two methods by Cohen's K test. Post-therapy WB-MR/DWIBS sensitivity, specificity, PPV, NPV and accuracy were then calculated, considering the 12 months of follow-up period as the gold standard.

RESULTS

By using an evaluation on a lesion-by-lesion basis, WB-MR/DWIBS and (18)F-FDG PET/CT showed an overall good agreement (K = 0.796, 95% IC = 0.651-0.941), especially in the evaluation of the nodal basins in aNHL (K = 0.937, 95% IC = 0.814-1). In reference to the revised response criteria for malignant lymphomas, the two methods showed a good agreement (K = 0.824, 95% IC = 0.493-1). Post-therapy sensitivity, specificity, PPV, NPV and accuracy of WB-MR/DWIBS were 43, 91, 75, 71 and 72%, respectively.

CONCLUSION

WB-MR/DWIBS seems to be an appropriate method for the post-treatment assessment of patients affected by HL and aNHL. The small discrepancies between the two methods found within HL could be due to the biological and metabolic behavior of this group of diseases. Larger prospective studies are necessary to better define the role of WB-MR/DWIBS in this setting of patients.

Role of dopaminergic neurotransmission in pathophysiology of action tremor in Parkinson's disease

BACKGROUND

Rest tremor (RT), a tremor that occurs in a body part that is completely supported against gravity, is together with rigidity and bradykinesia among the core features of Parkinson's disease (PD). In addition to classical RT, many PD patients also have action tremor (AT) occurring during sustained postures or voluntary movement. Earlier studies showed a good correlation between striatal dopamine transporter (DAT) binding, measured with [(123)I] FP-CIT SPET and bradykinesia. By contrast, neither rigidity nor rest tremor seems to be closely related to the degree of dopaminergic denervation as measured by DAT imaging. Little is known about the relationship, if any, between the severity of action tremor and striatal DAT binding.

SUBJECTS AND METHODS

A cross-sectional study was conducted in 94 patients (57 men and 37 women) with Parkinson's disease staging 1-2 on the Hoehn-Yahr scale. Data on the severity of action tremor and other motor signs were collected using the Unified Parkinson's Disease Rating Scale part III. DAT imaging was performed after injection of 111-185MBq of (123)I-FP-CIT. Images were visualized on Workstation Xeleris 3.0 (GE Healthcare) and reconstructed with dedicated software by a nuclear physician blinded about the clinical information of patients. Spearman correlation coefficient was performed to evaluate the relationship between putamen DAT binding and severity of bradykinesia, severity of rigidity, RT and AT respectively. Multivariable logistic regression analysis was used to assess the association between age, sex, disease duration, and levodopa equivalent daily dose and investigated variables after adjusting for possible confounders.

RESULTS

In this group of patients with early PD, DAT binding in the putamen significantly correlated with the severity of bradykinesia (Spearman r=-0.35, P<0.001) but not with the severity of rigidity (Spearman r=0.02, P=0.8), RT (Spearman r=0.05, P=0.6), or AT (Spearman r=-0.03, P=0.7). The findings were confirmed by multivariable regression analysis adjusted by age, sex, disease duration, and levodopa equivalent daily dose.

CONCLUSION

Our study confirms the good correlation between putamen DAT binding and bradykinesia and the lack of correlation between putamen DAT binding and rigidity/RT. In addition, we failed to found any significant correlation between putamen DAT binding and severity of action tremor, which suggests a contribution of non-dopaminergic mechanisms to its pathophysiology.

Role of (18)F-FDG PET/CT in the evaluation of response to antibiotic therapy in patients affected by infectious spondylodiscitis

OBJECTIVE

Spondylodiscitis is characterized by infection involving the intervertebral disc and adjacent vertebrae. It can occur anywhere in the vertebral column but more commonly involves lumbar spine. Our aim was to evaluate the usefulness of (18)F-FDG PET/CT to detect the early response to antibiotic therapy in patients affected by infectious spondylodiscitis and to compare the role of (18)F-FDG PET/CT and MRI in post-treatment evaluation.

MATERIALS AND METHODS

15 patients (12M, 3F), with mean age 65±13 years old, with typical clinical symptoms of Infectious Spondylodiscitis (pain, fever and increase of inflammatory indexes) and confirmed by blood culture or vertebral biopsy underwent within three day-interval a (18)F-FDG PET/CT and Magnetic Resonance (MR) at "baseline" and after antibiotic therapy. Semiquantitative parameters at (18)F-FDG PET/CT "baseline" SUVmax1, MTV1 and TLG1 and after therapy SUVmax2, MTV2 and TLG2 of involved vertebrae were calculated. Follow-up period of at least three months was available for all patients. T-student test for paired groups was performed to compare baseline and after therapy (18)F-FDG PET/CT semiquantitative parameters.

RESULTS

According to (18)F-FDG PET/CT parameters all patients showed a response to antibiotic therapy. All patients were positive at "baseline" MRI of the spine, while at follow-up, 7/15 patients showed MR signs of infection and were considered "positive" and 8/15 showed resolution of infectious condition and, therefore they were considered "negative". A statistical significant difference between (18)F-FDG PET/CT "baseline" and after antibiotic therapy was found for all semiquantitative parameters: SUVmax (t=5.8, P=0.01); MTV (t=5.17, P=0.001); TLG (t=5,26, P=0,001). The comparison between the "baseline" and "after treatment" (18)F-FDG semiquantitative parameters showed a significant reduction of all parameters. This reduction was relevant also in patients with positive post-treatment MRI. This can be probably related to the tissue remodeling in the very immediate phase post-treatment, resulted positive at MRI and negative at (18)F-FDG PET/CT. Clinical follow-up of at least three months confirmed these results.

CONCLUSIONS

(18)F-FDG PET/CT is useful to detect the early response to antibiotic therapy in patients affected by infectious spondylodiscitis. (18)F-FDG PET/CT semiquantitative parameters provide critical diagnostic information of the infectious process. (18)F-FDG PET/CT should be considered as first-line exam in the early post-treatment evaluation of spondylodiscitis while MR should be preferred for delayed assessment.

[18F-FDG PET/CT in ocular and orbital abnormalities not only neopastic: comparison with traditional imaging]

Orbital and ocular neoplasms are rare tumors that could be benign or malign, primary or metastatic. Abnormalities within the orbit present a challenge in evaluation for imaging, both for morphologic examinations (ME) as weel as computed tomography (CT) and magnetic resonance (MR) and [18F]-2-deoxy-D-glucose Positron emission tomography/computed tomography (18F-FDG PET/CT). The aim of our study was evaluate 18F-FDG PET/CT role in orbital abnormalities, comparing it with CT and MR.

MATERIALS AND METHODS

A retrospective analysis of 67 patients (pts) (34 males and 33 females; mean age 59.91 years old) who performed 18F-FDG PET/CT for orbital and ocular abnormalities was performed. Comparison between 18F-FDG PET/CT and ME was performed by Cohen's K also within the most representative hystologic subtypes.

RESULTS

18F-FDG PET/CT resulted positive in 19/67 pts. 47/67 pts performed ME (27/47 performed CT and 20/27 MR) within 20 days before 18F-FDG PET/CT and concordance was very poor (K=0.154). Considering 27/47 pts who performed CT, concordance was very poor (K=0.100). Considering the 20/47 pts who performed MR concordance was poor (K=0.266). Considering 19/47 pts with primary ocular NHL concordance resulted poor (K=0.269). Considering 6/47 pts with primary ocular melanoma concordance resulted very poor (K=0.182). In 9/47 pts with metastases diagnosis, concordance was absent (K=-0.189).

CONCLUSIONS

CT and MR are ME that permit the evaluation of the orbital region even with limits related to the difficulties of the region. 18F-FDG PET/CT is a sensitive tecnique for several malignancies. The low concordance among 18F-FDG PET/CT and ME suggests their complementary role, then to associate 18F-FDG PET/CT even for the whole-body evaluation.

Comparison of (18)F-FDG PET/CT methods of analysis for predicting response to neoadjuvant chemoradiation therapy in patients with locally advanced low rectal cancer

PURPOSE

The aim of this study was to prospectively investigate the predictive value of (18)F-FDG PET/CT semiquantitative parameters for locally advanced low rectal cancer (LARC) treated by neoadjuvant chemoradiation therapy (nCRT).

METHODS

68 patients with LARC had (18)F-FDG PET/CT scans twice (baseline and 5-6 weeks post-nCRT). All patients underwent surgery with preservation of the sphincter 8 weeks later. (18)F-FDG PET/CT analysis was performed by visual response assessment (VRA) and semiquantitative parameters: SUVmax(baseline), SUVmean(baseline), MTV(baseline), TLG(baseline), SUVmax(post-nCRT), SUVmean(post-nCRT), MTV(post-nCRT), TLG(post-nCRT); ΔSUVmax and mean and Response indexes (RImax% and RImean%). Assessment of nCRT tumor response was performed according to the Mandard's Tumor Regression Grade (TRG) and (y)pTNM staging on the surgical specimens. Concordances of VRA with TRG, and with (y)pTNM criteria were evaluated by Cohen's K. Results were compared by t student test for unpaired groups. ROC curve analysis was performed.

RESULTS

VRA analysis of post-nCRT (18)F-FDG PET/CT scan for the (y)pTNM outcome showed sensitivity, specificity, accuracy, PPV, and NPV of 87.5%, 66.7%, 83.8%, 92.5%, and 53.3%, respectively. Concordances of VRA with TRG and with (y)pTNM were moderate. For the outcome variable TRG, the statistical difference between responders and non-responders was significant for SUVmax(post-nCRT) and RImean%; for the outcome variable (y)pTNM, there was a significant difference for MTV(baseline), SUVmax(post-nCRT), SUVmean(post-nCRT), MTV(post-nCRT), RImax%, and RImean%. ROC analysis showed better AUCs: for the outcome variable TRG for SUVmax(post-nCRT), SUVmean(post-nCRT), and RImean%; for the outcome variable (y)pTNM for MTVbaseline, SUVmax(post-nCRT), SUVmean(post-nCRT), MTV(post-nCRT), RImax%, and RImean%. No significant differences among parameters were found.

CONCLUSIONS

Qualitative and semiquantitative evaluations for (18)F-FDG PET/CT are the optimal approach; a valid parameter for response prediction has still to be established.

18F-FDG PET/CT role in staging of gastric carcinomas: comparison with conventional contrast enhancement computed tomography

The purpose of the report was to evaluate the role of fluorine-18 fluoro-2-deoxy-D-glucose positron emission tomography/computed tomography (F-FDG PET/CT) in staging gastric cancer comparing it with contrast enhancement computed tomography (CECT).This retrospective study included 45 patients who underwent performed whole body CECT and F-FDG PET/CT before any treatment. We calculated CECT and F-FDG PET/CT sensitivity, specificity, accuracy, positive and negative predictive values (PPV and NPV) for gastric, lymphnode, and distant localizations; furthermore, we compared the 2 techniques by McNemar test. The role of F-FDG PET/CT semiquantitative parameters in relation to histotype, grading, and site of gastric lesions were evaluated by ANOVA test.Sensitivity, specificity, accuracy, PPV and NPV of CECT, and F-FDG PET/CT for gastric lesion were, respectively, 92.11%, 57.14%, 86.66%, 92.11%, 57.14% and 81.58%, 85.71%, 82.22%, 96.88%, 46.15%. No differences were identified between the 2 techniques about sensitivity and specificity. No statistical differences were observed between PET parameters and histotype, grading, and site of gastric lesion. The results of CECT and F-FDG PET/CT about lymphnode involvement were 70.83%, 61.90%, 66.66%, 68%, 65% and 58.33%, 95.24%, 75.55%, 93.33%, 66.67%. The results of CECT and F-FDG PET/CT about distant metastases were 80%, 62.86%, 66.66%, 38.10%, 91.67% and 60%, 88.57%, 82.22%, 60%, 88.57%. FDG PET/CT specificity was significantly higher both for lymphnode and distant metastases.The F-FDG PET/CT is a useful tool for the evaluation of gastric carcinoma to detect primary lesion, lymphnode, and distant metastases using 1 single image whole-body technique. Integration of CECT with F-FDG PET/CT permits a more valid staging in these patients.

Diagnostic and prognostic value of 18F-FDG PET/CT in comparison with morphological imaging in primary adrenal gland malignancies - a multicenter experience

OBJECTIVE

To evaluate the diagnostic and prognostic role of fluorine-18 fluoro-2-deoxy-D-glucose positron emission tomography/computed tomography ((18)F-FDG PET/CT) in comparison to morphological imaging such as computed tomography in primary adrenal malignancies.

MATERIALS AND METHODS

In this multicenter retrospective study, 68 patients with adrenal malignancy were included. All patients had histologically proven diagnosis of primary adrenal malignancy (adrenocortical carcinoma, malignant pheochromocytoma, neuroblastoma and lymphoma), one whole body (18)F-FDG PET/CT scan and one whole-body contrast enhancement computed tomography (CECT) scan acquired within one month and were followed clinically and by performing morphological tests for at least 12 months.

RESULTS

Overall sensitivity, specificity, accuracy, positive and negative predictive values for CECT and (18)F-FDG PET/CT were respectively, 59%, 100%, 65%, 100%, 27% and 75%, 100%, 82%, 100% and 63%. For adrenocortical carcinomas, (18)F-FDG PET/CT showed a better accuracy (93.4%) than CECT (75%). For neuroblastomas (18)F-FDG PET/CT also showed better accuracy (70.4%) than CECT (66.7%). For malignant pheochromocytomas (18)F-FDG PET/CT and CECT showed the same accuracy (90%). For primary adrenal lymphomas, (18)F-FDG PET/CT showed better accuracy (100%) than CECT (74.41%). Kaplan-Mayer curves showed that "histotypes" and "metastases at the last follow-up" were similarly detected for both disease free survival (DFS) and overall survival (OS), while "global 18F-FDG PET/CT" and "presence of metastases at diagnosis" were significant for DFS. Stratifying the sample by the presence or absence of metastases at diagnosis, standardized uptake value (SUVmax) was a significant prognostic factor for DFS when metastases were absent (Wald test=7.035, P=0.008).

CONCLUSION

Our multicenter study demonstrated that (18)F-FDG PET/CT better than CECT diagnosed adrenal malignancies achieving also a good prognostic performance. Therefore management algorithms should include (18)F-FDG PET/CT.

(18)F-FDG PET/CT contribution to diagnosis and treatment response of rhino-orbital-cerebral mucormycosis

OBJECTIVE

Mucormycosis is an infection caused by mycetes mucorales, emerged as a life-threatening infection associated with severe morbidity and high mortality. Conventional imaging such as computed tomography (CT) and magnetic resonance imaging (MRI) are usually performed to assess mucormycosis extension, but they may present insufficiencies in their performance.

CASE PRESENTATION

We present the case of a 13 years old patient with diagnosis of rhino-orbital-cerebral mucormycosis (RCM) who performed head MRI and [(18)F]2-fluoro-2-deoxy-D-glucose positron emission tomography/computed tomography ((18)F-FDG PET/CT) both for the infection spread assessment and for the early evaluation of response to systemic amphotericin-B treatment.

CONCLUSION

This case suggests that (18)F-FDG PET/CT could be considered as a valuable tool for the initial staging of RCM when compared with MRI and should be performed as soon as possible after the first clinical suspicion of this disease. In addition (18)F-FDG PET/CT may also be useful for the assessment of response to treatment.

Useful diagnostic biometabolic data obtained by PET/CT and MR fusion imaging using open source software

In the last decade numerous attempts were considered to co-register and integrate different imaging data. Like PET/CT the integration of PET to MR showed great interest. PET/MR scanners are recently tested on different distrectual or systemic pathologies. Unfortunately PET/MR scanners are expensive and diagnostic protocols are still under studies and investigations. Nuclear Medicine imaging highlights functional and biometabolic information but has poor anatomic details. The aim of this study is to integrate MR and PET data to produce distrectual or whole body fused images acquired from different scanners even in different days. We propose an offline method to fuse PET with MR data using an open-source software that has to be inexpensive, reproducible and capable to exchange data over the network. We also evaluate global quality, alignment quality, and diagnostic confidence of fused PET-MR images. We selected PET/CT studies performed in our Nuclear Medicine unit, MR studies provided by patients on DICOM CD media or network received. We used Osirix 5.7 open source version. We aligned CT slices with the first MR slice, pointed and marked for co-registration using MR-T1 sequence and CT as reference and fused with PET to produce a PET-MR image. A total of 100 PET/CT studies were fused with the following MR studies: 20 head, 15 thorax, 24 abdomen, 31 pelvis, 10 whole body. An interval of no more than 15 days between PET and MR was the inclusion criteria. PET/CT, MR and fused studies were evaluated by two experienced radiologist and two experienced nuclear medicine physicians. Each one filled a five point based evaluation scoring scheme based on image quality, image artifacts, segmentation errors, fusion misalignment and diagnostic confidence. Our fusion method showed best results for head, thorax and pelvic districts in terms of global quality, alignment quality and diagnostic confidence,while for the abdomen and pelvis alignement quality and global quality resulted poor due to internal organs filling variation and time shifting beetwen examinations. PET/CT images with time of flight reconstruction and real attenuation correction were combined with anatomical detailed MRI images. We used Osirix, an image processing Open Source Software dedicated to DICOM images. No additional costs, to buy and upgrade proprietary software are required for combining data. No high technology or very expensive PET/MR scanner, that requires dedicated shielded room spaces and personnel to be employed or to be trained, are needed. Our method allows to share patient PET/MR fused data with different medical staff using dedicated networks. The proposed method may be applied to every MR sequence (MR-DWI and MR-STIR, magnet enhanced sequences) to characterize soft tissue alterations and improve discrimination diseases. It can be applied not only to PET with MR but virtually to every DICOM study.

Whole body magnetic resonance with diffusion weighted sequence with body signal suppression compared to (18)F-FDG PET/CT in newly diagnosed lymphoma

Lymphomas are a heterogeneous group of lymphoid malignancies, which can be broadly divided into non-Hodgkin Lymphomas (NHL) and Hodgkin lymphoma (HL) that display different patterns of biological behavior and response to treatment. Their incidence is still increasing and for this reason they require a lot of effort in scientific research. The management of both NHL and HL follows well-established guidelines based on the initial staging assessment. Therefore an accurate staging is the basis for the selection of an appropriate therapeutic approach in order to prevent over or under treatment as well as to minimize morbidity related to the radio-chemotherapy regimens given. (18)F-FDG-PET is currently regarded as the reference standard imaging modality in the staging of the majority of lymphoma type, for evaluation of distribution of the disease by providing both functional and anatomic information in a single whole body examination. In particular its role is established in HL and high-grade NHL, confirmed also in Follicular Lymphoma, but its impact on the other histotypes remains to be demonstrated. Among the diagnostic tools currently available for a bio-molecular imaging assessment, of great interest is the Whole Body-Magnetic Resonance with DWIBS sequence (WB-MR/DWIBS), an emerging and promising functional whole body imaging modality to evaluate oncologic and non-oncologic lesions, resulting in images that remarkably resemble (18)F-FDG PET/CT studies. In our research study we evaluated the role of WB-MR/DWIBS, compared with (18)F-FDG-PET/CT in the initial staging of lymphomas, considering its impact on the management of these patients and how it could influence the therapeutic choice. We prospectively enrolled 27 consecutive patients with newly diagnosed lymphoma (13 HL, 14 NHL) histologically proven, who underwent (18)F-FDG-PET/CT and WB-MR/DWIBS (coronal T1-weighted, coronal STIR, axial sequences DWIBS) within 10 days from the diagnosis and before start the treatment. We evaluated the overall agreement between the two methods, the general agreement in evaluating both nodal and extra-nodal involvement and a specific site agreement according to lymph nodal basins or extra-nodal sites involvement. The agreement between the two diagnostic tools in relation to histological types (HL/NHL) and in relation to indolent and aggressive forms, within NHL histotypes, as well as in relation to the Ann Arbor stage was also evaluated. We also analyzed the role of WB-MRI/DWIBS and (18)F-FDG-PET/CT in bone marrow involvement detection by calculating their sensitivity and specificity, with bone marrow biopsy as the reference standard, and comparing them with McNemar test. A total of 85 lesions, nodal (74) and extra-nodal (11), were detected by (18)F-FDG-PET/CT. WB-MRI/DWIBS showed a total of 91 sites involved, (81) nodal and (13) extra-nodal lesions. The overall agreement between the two imaging modalities was very good (k=0.815; IC:0.739-0.890); however considering histotypes, the agreement comes down to good in evaluating NHL for both nodal and extra-nodal involvement (k=0.763, IC: 0.627-0.898; k=0.629, IC:-0.021-1.278). Considering indolent or aggressive forms the agreement between WB-MR/DWIBS and (18)F-FDG PET/CT findings was very good in aggressive forms while it appeared to be lower in indolent forms. Sensitivity and specificity of WB-MRI/DWIBS and (18)F-FDG PET/CT in bone marrow involvement detection were respectively: 100%and 100% vs. 50% and 96%. The switch from (18)F-FDG PET/CT to WB-MR/DWIBS in the AA Staging System resulted in an over-staging in 1/27 patient. The two methods were concordant in the staging in 26/27 patients (96%). In conclusion, our initial results show a good overall agreement between the two diagnostic tools. (18)F-FDG-PET/CT remains the gold standard for lymphoma staging, however WB-MRI/DWIBS can be useful in histotypes not (18)F-FDG-avid or in the evaluation of "critical" organs for (18)F-FDG PET/CT. The integrated information provided by metabolic and tissutal functional imaging can be complementary to assist hematologic decision of tailored patient's treatment.

[18F-FDG PET/CT in staging and restaging cholangiocarcinoma]

The prognosis for hepatobiliary malignancies is dismal. Surgery remains the primary curative option. The positron emission tomography/computed tomography (PET/CT) provides simultaneous metabolic and anatomic information on tumors in the same imaging session. The role of PET/CT in detecting hepatobiliary malignancies has not yet been established. The purpose of this review was to examine the literature on the use of PET/CT in cholangiocarcinomas, also in order to improve the preoperative staging and the restaging, for a proper oncology management of patients.

[Correlation between cognitive impairment and plasma levels of clusterin/ApoJ in Parkinson disease patients not affected by dementia]

Cognitive impairment is frequent in patients with Parkinson's disease (PD), and can range from mild deterioration to dementia. Recently a contribution of Alzheimer's disease for the cognitive dysfunction in PD has been proposed, whereas the presence of tau protein and amyloid was recognized. Clusterin/ApoJ is a protein involved in the deposition of beta-amyloid and in its neurotoxicity. In this study we aimed to investigate the clusterin/ApoJ's plasma levels in patients with PD to assess its potential role in fisiopathogenetic cognitive impairment.

[Pulmonary arteriovenous fistulas in patients with hereditary hemorrhagic telangiectasia: role of MR angiography]

The aim of this work is to establish the accuracy of pulmonary magnetic resonance angiography (MRA) compared to multidetector computed tomography (MDCT) and pulmonary angiography in the diagnostic evaluation of pulmonary arteriovenous malformations (PAVMs) in patients with hereditary hemorrhagic telangiectasia. Eight consecutive patients underwent MRA, MDCT and pulmonary angiography. All patients were carriers of PAVMs amenable to endovascular treatment. The parameters we have evaluated were the presence, the number of fistulas and the diameter of the feeding artery of the malformation. In all cases, the findings of the three tests were comparable. In only one case, MR images were considered qualitatively poorer than MDCT, although sufficient for the recognition of the lesion located in the hilum. The diameters of the arteries showed no statistically differences between MRA and CT. In conclusion, the MRA technique was found to be valid and reliable in the diagnosis of PAVMs in patients with HHT.

Current clinical use of 18FDG-PET/CT in patients with thoracic and systemic sarcoidosis

PURPOSE

This study assessed the role of whole-body (18)fluorodeoxyglucose positron-emission tomography/computed tomography ((18)FDG PET/CT) in the restaging and follow-up of patients with sarcoidosis previously studied by multidetector computed tomography (MDCT).

MATERIALS AND METHODS

This retrospective study enrolled 21 patients to evaluate the sensitivity, specificity and accuracy of (18)FDG-PET/CT and MDCT. The results of the two techniques were compared with the Mc Nemar test. Cohen's K was used to compare concordance at the different lesion sites.

RESULTS

The sensitivity, specificity and accuracy of (18)FDG-PET/CT were 80, 66.67, and 76.19 %, respectively. The sensitivity, specificity and accuracy of MDCT were 93.33, 33.33, and 76.19 %, respectively. In 16 patients who underwent whole-body MDCT, the sensitivity, specificity and accuracy values were 91.67, 81.25, and 50 % (MDCT) and 100, 50, and 87.5 % ((18)FDG-PET/CT).

CONCLUSIONS

(18)FDG-PET/CT is useful in evaluating the extent of sarcoidosis and recognising lesions at different sites, including lymph nodes, lungs, liver, spleen and bone. It also improves the interpretation of the morphological lesions seen on MDCT and depicts a larger number of lesions. Therefore, (18)FDG-PET/CT could be used to complement other more traditional techniques for the restaging and follow-up in patients with sarcoidosis.

[Lung perfusion scintigraphy in pediatric patients with congenital malformations]

Congenital malformations are an heterogeneous group of disorders that can lead changes in pulmonary perfusion and then can be evaluated with lung perfusion scintigraphy. We selected five patients in which the role of lung perfusion scintigraphy emerges as a reliable and non-invasive imaging technique. Lung perfusion scintigraphy is a useful tool in pediatric patients with congenital malformations allowing an accurate evaluation of the best therapeutic strategy and its results.

[Unusual sentinel lymph nodes detected by lymphoscintigraphy in cutaneous melanoma patients]

Lymphoscintigraphy and radio-guided research of the sentinel lymph node is the most important investigation in the staging of patients with cutaneous melanoma, because it allows the identification of the lymphatic drainage pathways, not always predictable, and locate the sentinel node in classic basins and in "unexpected" regions. The aim of this study was to evaluate the incidence of cases of unusual sentinel nodes detected by lymphoscintigraphy and their prognostic significance in patients with cutaneous melanoma.

[18F-FDG PET/CT in a patient with clinical suspicion of giant cell arteritis]

We report the case of a 72 year old man with clinical suspicion of giant cell arteritis (GCA); in this case 18F-FDG PET/CT has been useful from the diagnosis to the control of the response to therapy. He performed the first 18F-FDG PET/CT that showed increased uptake of 18F-FDG in the aortic arch, brachial artery, common iliac and femoral arteries and in the temporal cerebral sites bilaterally. The patient then began a cortisonic therapy that led straight to the improvement of clinical symptoms, and repeated 18F-FDG PET/CT 3 months later the beginning of therapy that showed reduced uptake in the same sites of the first 18F-FDG PET/CT. This patient continued the cortisonic therapy, progressively reducing it until the definitive ending.

18F-FDG Positron Emission Tomography/Computed Tomography in the Diagnosis and Post-Therapeutic Treatment in a Patient with an Early Stage of Retroperitoneal Fibrosis

Here, we report an experience about 18F-FDG-PET/CT in a patient with an early stage of Idiopathic Retroperitoneal Fibrosis (IRF). At the diagnosis Contrast Enhanced Computed Tomography (CE-CT) revealed periaortic solid tissue in the infrarenal section and locoregional lymph nodes; findings were interpreted as lymphomatous tissue. 18F-FDG-PET/CT showed elevated 18F-FDG uptake in the periaortic tissue but no uptake was detected in lymph nodes. The histologic examination showed recent-onset IRF. The patient began corticosteroid therapy. Nearly at the end of the therapy, CE-CT showed the enlargement of the fibrous tissue and 18F-FDG-PET/CT showed an increased 18F-FDG uptake in the aforesaid lesion and another area of uptake in the aortic wall. 18F-FDG-PET/CT can play an important role in the diagnosis of patients with an initial clinical suspicion of retroperitoneal fibrosis and in their management. Then the patient began a therapy with methotrexate and after six months we performed an 18F-FDG-PET/CT which didn’t show 18F-FDG uptake.

Conflict of interest:None declared.

[Adult transient intestinal intussusception: can abdominal CT guide resolution?]

The purpose of this study was to evaluate the adult transient intestinal intussusceptions on CT before and after the administration of gastrointestinal contrast material. We evaluated two different gastrointestinal contrast materials: hyperdense and hypodense. In all cases the gastrointestinal contrast agent solved the invaginations. In the group of patients treated with hypodense contrast medium relapses occurred in the short and long term; no recurrence was observed in the other group. CT is useful in the recognition of intestinal intussusception. The gastrointestinal contrast agent could define the real transience of intussusceptions and hyperdense contrast agent could be more effective in short and long term resolution.

[Peritoneal carcinomatosis from ovarian cancer: role of 18F-FDG-PET/CT and CA125]

The purpose of this study was to evaluate the contribution of 18F-FDG-PET/CT in highlighting the peritoneal involvement in patients with ovarian cancer, also in relation to the biomarker CA125. We retrospectively analyzed 64 female patients with histological diagnosis of ovarian cancer who underwent 18F-FDG-PET/CT and CA125 measurement. Sensitivity and specificity of 18F-FDG-PET/CT were both 90.63% (95% CI: 80-100%). Sensitivity and specificity of CA125 were 93.33% (95% CI: 80-100%) and 33.33% (95% CI: 25-64%), respectively. In patients with peritoneal carcinomatosis from ovarian cancer, it is recommended to perform 18F-FDG-PET/CT, in particular when elevated CA125 levels are detected.

[Role of imaging techniques in the evaluation of chyluria]

Lymphoscintigraphy is a first-line imaging technique for the assessment of abnormal lymphatic drainage in chyluria. It can provide information about the site of origin of chyluria, and may be helpful in selecting patients for surgery and assessing treatment efficacy. We report the case of a 59-year-old male with chyluria correctly diagnosed with lymphoscintigraphy.

[Relapse of primary testicular non-Hodgkin's lymphoma detected by 18F-FDG-PET/CT]

We report the case of a 62-year-old male with a history of primary testicular non-Hodgkin's lymphoma, treated with orchidectomy. After 14 months, the patient developed left leg swelling and pain, and was diagnosed and treated as having leg vein thrombosis. 18F-FDG-PET/CT showed a relapse of testicular lymphoma in the cutaneous muscle tissue of the left leg.

[Multidetector CT for the assessment of the groin region]

Assessment of the complex anatomy of the groin region using different imaging modalities is important to identify those pathological conditions that may present with atypical symptoms. In obese patients or in the presence of complications, physical examination may be unremarkable and instrumental studies based on non-invasive techniques (e.g., ultrasounds) do not allow accurate assessment of this region. Multidetector CT scanning and reconstruction can provide useful information on inguinal canal anatomy and its related diseases, contributing to timely therapeutic interventions.

[Atypical appearance of pneumatosis intestinalis at multidetector CT]

Pneumatosis intestinalis may be caused by bowel ischemia and may display different patterns of appearance. We report a case of pneumatosis intestinalis with an atypical target pattern, detected by multidetector computed tomography (CT) in a 66-year-old male presenting with acute abdominal syndrome. Abdominal CT scan showed a double gas collection within the wall of a jejunal segment, with a characteristic target air distribution. The patient was surgically treated and successfully discharged from our hospital with the diagnosis of acute bowel ischemia. The target air sign can be an initial CT finding of the typical pneumatosis intestinalis and it can be useful in the early diagnosis of bowel ischemia.