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Puranik AD, Rangarajan V, Dev ID, Jain Y, Purandare NC, Sahu A, Choudhary A, Gupta T, Chatterjee A, Moiyadi A, Shetty P, Sridhar E, Sahay A, Patil VM, Shah S, Agrawal A. Brain FET PET tumor-to-white mater ratio to differentiate recurrence from post-treatment changes in high-grade gliomas. J Neuroimaging 2021; 31:1211-1218. [PMID: 34388273 DOI: 10.1111/jon.12914] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Revised: 07/17/2021] [Accepted: 07/17/2021] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND AND PURPOSE Highergrade glial neoplasms undergo standard treatment with surgery, radiotherapy, and alkylating agents. There is often a clinical/neuroimaging dilemma in the post-treatment setting to differentiate disease recurrence from treatment-related changes. FET (fluoro-ethyl-tyrosine) PET has emerged as a molecular imaging modality for cases where MR imaging is inconclusive. This study aims to develop a cutoff on FET PET for differentiating true recurrence from post-treatment changes. METHODS We retrospectively analyzed72 patientswith post-treatment grade 3 or 4 brain gliomas. Five to six mCi of 18 F-FET was injected and static imaging of the brain was performed at 20 min. A tumor-to-white matter (T/Wm) ratio was used as semiquantitative parameter. A T/Wm cutoff of 2.5 was used for image interpretation. Imaging findings were confirmed by either histopathologic diagnosis in a multidisciplinary joint clinic or based on follow-up of clinical and neuroimaging findings. RESULTS Forty-one of 72 patients (57%) showed recurrent disease on FET PET. Thirty-five of them were confirmed to have tumor recurrence; six patients showed post-treatment changes. Thirty-one of 72 patients (43%) showed post-treatment changes on FET PET; 27 were confirmed as post-treatment change and four patients had tumor recurrence on subsequent MR imaging. An optimum T/Wm cutoff of 2.65 was derived based on receiver operating characteristic analysis with a sensitivity of 80% and specificity of 87.5%. CONCLUSION Static FET PET can be used as problem-solving imaging modality with a T/Wm cutoff of 2.65 to differentiate late recurrence from post-treatment changes in grade 3 or 4 brain gliomas with equivocal MR features.
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Agrawal A, Kazi M, Gori J, Dev I, Rangarajan V, Veer A, Patil P, Engineer R, Desouza A, Saklani A. Prospective study to assess the role of FDG PET/CT in detecting systemic metastatic spread in rectal cancers with lateral pelvic lymph nodes. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2022; 48:1093-1099. [PMID: 34986999 DOI: 10.1016/j.ejso.2021.12.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Revised: 12/03/2021] [Accepted: 12/17/2021] [Indexed: 02/07/2023]
Abstract
INTRODUCTION The utility of positron emission tomography (PET) in detecting additional M1 patients over conventional staging modalities is not known in rectal cancer patients with enlarged lateral pelvic nodes. METHODS Prospective, single center, single-arm interventional study of consecutive rectal cancer patients that had baseline lateral pelvic nodes on MRI (>10 mm) between February 2017 to December 2018. Such patients underwent PET after confirming non-metastatic status on CT of thorax and abdomen. Primary outcome measure was additional M1 sites detected on PET. A 10% distant metastasis rate was expected with 80% confidence interval (CI) set at 5% as the lower limit. RESULTS 44 patients were included and the concordance between MRI and PET in detection of lateral nodes was 97.7% (43 patients). Additional sites of metastasis were detected in 5 patients (11.36%; 80% CI - 5.63%-20.6%), and there was a change in treatment plan in 7 (15.9%). The number needed to treat (NNT) for PET scans to detect additional metastatic sites and change treatment were 9 and 6 respectively. There was a change in treatment intent (curative to palliative) in 2 patients (4.5%, NNT - 22). CONCLUSION In rectal cancer patients with LPLN, the use of FDG-PET-CT over conventional staging studies led to the detection of additional extra-pelvic metastasis in 11.4% and changed the treatment plan in 15.9%. This met the pre-defined threshold to endorse the use of PET-CT in patients that match the study characteristics.
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Dev ID, Rangarajan V, Puranik AD, Agrawal A, Shah S, Sahay A, Purandare NC. Sporadic Cerebellar Hemangioblastoma With Strong SSTR Expression on 68 Ga-DOTANOC PET/CT. Clin Nucl Med 2023; 48:e28-e30. [PMID: 36240749 DOI: 10.1097/rlu.0000000000004456] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
ABSTRACT Sporadic cerebellar hemangioblastomas are rare with majority of these tumors presenting as a part of von Hippel-Lindau syndrome. We demonstrate an unusual case of a symptomatic sporadic cerebellar hemangioblastoma mimicking a meningioma on MRI and 68 Ga-DOTANOC PET imaging.
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Case Reports |
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Puranik AD, Boon M, Purandare N, Rangarajan V, Gupta T, Moiyadi A, Shetty P, Sridhar E, Agrawal A, Dev I, Shah S. Utility of FET-PET in detecting high-grade gliomas presenting with equivocal MR imaging features. World J Nucl Med 2019; 18:266-272. [PMID: 31516370 PMCID: PMC6714153 DOI: 10.4103/wjnm.wjnm_89_18] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
High-grade gliomas, metastases, and primary central nervous system lymphoma (PCNSL) are common high-grade brain lesions, which may have overlapping features on magnetic resonance (MR) imaging. Our objective was to assess the utility of 18-fluoride-fluoro-ethyl-tyrosine positron emission tomography (FET-PET) in reliably differentiating between these lesions, by studying their metabolic characteristics. Patients with high-grade brain lesions suspicious for glioma, with overlapping features for metastases and PCNSL were referred for FET-PET by Neuroradiologists from Multidisciplinary Neuro-Oncology Joint Clinic. Tumor-to-contralateral white mater ratio (T/Wm) at 5 and 20 min was derived and compared to histopathology. Receiver operating characteristic curve analysis was used to find the optimal T/Wm cutoff to differentiate between the tumor types. T/Wm was higher for glial tumors compared to nonglial tumors (metastases, PCNSL, tuberculoma, and anaplastic meningioma). A cutoff of 1.9 was derived to reliably diagnose a tumor of glial origin with a sensitivity and specificity of 93.8% and 91%, respectively. FET-PET can be used to diagnose glial tumors presenting as high-grade brain lesions when MR findings show overlapping features for other common high-grade lesions.
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Dev ID, Puranik AD, Rangarajan V, Purandare NC, Agrawal A, Shah S, Sahay A. Unusual Variant of Breast Cancer Presenting With Pituitary Symptoms Detected on 68Ga-DOTATATE PET/CT. Clin Nucl Med 2021; 46:e556-e558. [PMID: 34172604 DOI: 10.1097/rlu.0000000000003768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
ABSTRACT Carcinoma of breast with neuroendocrine differentiation is an extremely rare entity, especially in male population. Although the "garden variety" of male breast cancers is often metastatic at presentation, with an aggressive course, there is hardly any literature about neuroendocrine variants. We report a case of a 57-year-old man who had pituitary symptoms, which on 68Ga-DOTANOC PET/CT imaging turned out to be a metastatic lesion, with somatostatin expressing primary in breast and other sites, with histopathological confirmation of neuroendocrine differentiation in breast cancer.
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Case Reports |
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Dev ID, Puranik AD, Singh B, Prasad V. Current and Future Perspectives of PDL1 PET and SPECT Imaging. Semin Nucl Med 2024; 54:966-975. [PMID: 39510854 DOI: 10.1053/j.semnuclmed.2024.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2024] [Accepted: 09/20/2024] [Indexed: 11/15/2024]
Abstract
Programmed Death 1 (PD1) and Programmed Death Ligand (PDL1) play a crucial role in tumor microenvironment by helping cancer cells evade innate immunity. Numerous inhibitor anticancer drugs targeting this interplay have been used in clinical practice and many more are in preclinical stage. These drugs have shown promising results in achieving good response and long-term clinical benefit, is routinely performed to identify patients who may benefit. However, there are major challenges associated with these immunohistochemistry tests which have opened the space for noninvasive imaging modalities using PD1 and PDL1 inhibitors labeled with either PET or SPECT radionuclides. These radiopharmaceuticals, although primarily developed for the field of immunotherapy, have great potential in expanding and optimizing the combination of radiopharmaceutical therapies with PD1-PDL1 targeting anticancer drugs. This review elaborates currently available PET and SPECT radiopharmaceuticals targeting PD1-PDL1 axis. It also explores the potential future role of newer targets which are being developed and tested in various preclinical studies.
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Review |
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Puranik AD, Dev ID. Ga-68 Prostate-Specific Membrane Antigen PET/CT: Imaging and Clinical Perspective in Prostate Cancer. PET Clin 2022; 17:595-606. [DOI: 10.1016/j.cpet.2022.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Kievit E, Bershad E, Ng E, Sethna P, Dev I, Lawrence TS, Rehemtulla A. Superiority of yeast over bacterial cytosine deaminase for enzyme/prodrug gene therapy in colon cancer xenografts. Cancer Res 1999; 59:1417-21. [PMID: 10197605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
The enzyme/prodrug strategy using bacterial cytosine deaminase (bCD) and 5-fluorocytosine (5-FC) is currently under investigation for cancer gene therapy. A major limitation for the use of bCD is that it is inefficient in the conversion of 5-FC into 5-fluorouracil. In the present study, we show that the K(m) of yeast cytosine deaminase (yCD) for 5-FC was 22-fold lower when compared with that of bCD. HT29 human colon cancer cells transduced with yCD (HT29/yCD) were significantly more sensitive to 5-FC in vitro than HT29 cells transduced with bCD (HT29/bCD). In tumor-bearing nude mice, complete tumor regression was observed in 6 of 13 HT29/yCD tumors in response to 5-FC treatment (500 mg/kg i.p. daily, 5 days a week for 2 weeks), whereas 0 of 10 HT29/bCD tumors were cured. Our study demonstrates an improved efficacy of the CD/5-FC treatment strategy when yCD was used. This enzyme has, therefore, a high potential to increase the therapeutic outcome of the enzyme/prodrug strategy in cancer patients.
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Sahu A, Mathew R, Ashtekar R, Dasgupta A, Puranik A, Mahajan A, Janu A, Choudhari A, Desai S, Patnam NG, Chatterjee A, Patil V, Menon N, Jain Y, Rangarajan V, Dev I, Epari S, Sahay A, Shetty P, Goda J, Moiyadi A, Gupta T. The complementary role of MRI and FET PET in high-grade gliomas to differentiate recurrence from radionecrosis. FRONTIERS IN NUCLEAR MEDICINE (LAUSANNE, SWITZERLAND) 2023; 3:1040998. [PMID: 39355021 PMCID: PMC11440952 DOI: 10.3389/fnume.2023.1040998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 04/11/2023] [Indexed: 10/03/2024]
Abstract
Introduction Conventional magnetic resonance imaging (MRI) has limitations in differentiating tumor recurrence (TR) from radionecrosis (RN) in high-grade gliomas (HGG), which can present with morphologically similar appearances. Multiparametric advanced MR sequences and Positron Emission Tomography (PET) with amino acid tracers can aid in diagnosing tumor metabolism. The role of both modalities on an individual basis and combined performances were investigated in the current study. Materials and Methods Patients with HGG with MRI and PET within three weeks were included in the retrospective analysis. The multiparametric MRI included T1-contrast, T2-weighted sequences, perfusion, diffusion, and spectroscopy. MRI was interpreted by a neuroradiologist without using information from PET imaging. 18F-Fluoroethyl-Tyrosine (FET) uptake was calculated from the areas of maximum enhancement/suspicion, which was assessed by a nuclear medicine physician (having access to MRI to determine tumor-to-white matter ratio over a specific region). A definitive diagnosis of TR or RN was made based on the combination of multidisciplinary joint clinic decisions, histopathological examination, and clinic-radiological follow-up as applicable. Results 62 patients were included in the study between July 2018 and August 2021. The histology during initial diagnosis was glioblastoma, oligodendroglioma, and astrocytoma in 43, 7, and 6 patients, respectively, while in 6, no definitive histological characterization was available. The median time from radiation (RT) was 23 months. 46 and 16 patients had TR and RN recurrence, respectively. Sensitivity, specificity, and accuracy using MRI were 98, 77, and 94%, respectively. Using PET imaging with T/W cut-off of 2.65, sensitivity, specificity, and accuracy were 79, 84, and 80%, respectively. The best results were obtained using both imaging combined with sensitivity, specificity, and accuracy of 98, 100, and 98%, respectively. Conclusion Combined imaging with MRI and FET-PET offers multiparametric assessment of glioma recurrence that is correlative and complimentary, with higher accuracy and clinical value.
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Mohite A, Agrawal A, Purandare N, Shah S, Puranik A, Choudhury S, Dev I, Ghosh S, Rangarajan V. Congenital Melanocytic Nevi Syndrome With Leptomeningeal Melanoma. Clin Nucl Med 2022; 47:e765-e766. [PMID: 35867990 DOI: 10.1097/rlu.0000000000004354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
ABSTRACT The incidence of congenital melanocytic nevi (CMNs) is 1% to 6% for small- to intermediate-size nevi to 1 in 500,000 for giant size nevi. Large and satellite CMNs are known to be associated with neurocutaneous melanosis and central nervous system malformations such as Dandy-Walker malformation, defects of the vertebra-skull, and intraspinal lipomas. We hereby present a case of CMN syndrome in an 18-year-old girl with leptomeningeal melanoma, evaluated with MRI, adequately staged, and screened with FDG PET.
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Case Reports |
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Puranik AD, Dev ID, Rangarajan V, Kulkarni S, Shetty N, Gala K, Sahu A, Bhattacharya K, Dasgupta A, Chatterjee A, Gupta T, Sridhar E, Sahay A, Shetty P, Singh V, Moiyadi A, Menon N, Purandare NC, Agrawal A, Shah S, Choudhury S, Ghosh S, Jha AK. PRRT with Lu-177 DOTATATE in Treatment-Refractory Progressive Meningioma: Initial Experience from a Tertiary-Care Neuro-Oncology Center. Neurol India 2024; 72:278-284. [PMID: 38691470 DOI: 10.4103/ni.neurol-india-d-23-00252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 11/15/2023] [Indexed: 05/03/2024]
Abstract
PURPOSE Refractory and/or recurrent meningiomas have poor outcomes, and the treatment options are limited. Peptide receptor radionuclide therapy (PRRT) has been used in this setting with promising results. We have documented our experience of using intravenous (IV) and intra-arterial (IA) approaches of Lu-177 DOTATATE PRRT. METHODS Eight patients with relapsed/refractory high-grade meningioma received PRRT with Lu-177 DOTATATE by IV and an IA route. At least 2 cycles were administered. Time to progression was calculated from the first PRRT session to progression. The response was assessed on MRI using RANO criteria, and visual analysis of uptake was done on Ga-68 DOTANOC PET/CT. Post-therapy dosimetry calculations for estimating the absorbed dose were performed. RESULTS Median time to progression was 8.9 months. One patient showed disease progression, whereas seven patients showed stable disease at 4 weeks following 2 cycles of PRRT. Dosimetric analysis showed higher dose and retention time by IA approach. No significant peri-procedural or PRRT associated toxicity was seen. CONCLUSION PRRT is a safe and effective therapeutic option for relapsed/refractory meningioma. The IA approach yields better dose delivery and should be routinely practised.
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Dasgupta A, Mani S, Chatterjee A, Kannan S, Moiyadi A, Shetty P, Singh V, Menon N, Sahu A, Choudhary A, Bhattacharya K, Puranik A, Dev I, Epari S, Sahay A, Shah A, Bano N, Shaikh F, Gupta T. Study protocol of short versus long-term levetiracetam in brain tumors (LIBRA): a phase 3 randomized controlled trial. BMC Cancer 2025; 25:911. [PMID: 40399827 PMCID: PMC12096528 DOI: 10.1186/s12885-025-14305-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2024] [Accepted: 05/09/2025] [Indexed: 05/23/2025] Open
Abstract
BACKGROUND Seizures are common in patients with brain tumors, impacting daily life and healthcare burden. In contemporary neuro-oncology practice, levetiracetam is the most commonly prescribed anti-seizure medication (ASM). Although the practice is widely variable, levetiracetam is usually used for 2-3 years following surgery to prevent further seizures. However, the incidence of seizures post antitumoral treatment is relatively low, and the duration of use is not well defined. To address this knowledge gap, the current randomized controlled non-inferiority trial will be conducted comparing a shorter regimen of levetiracetam with the standard long-term schedule. METHODS AND ANALYSIS Patients with newly diagnosed primary brain tumors (brain metastasis excluded) in the supratentorial compartment with a prior history of seizure will be eligible for the study. Adults (> 18 years), within 1 year from surgery, and controlled on levetiracetam monotherapy for 6 months will be randomized in a 1:1 ratio to either standard arm (long course: additional 2 years levetiracetam) or experimental arm (short course: tapered of levetiracetam and stopped). Stratification factors include tumor location, seizure type, histology, grade, and adjuvant therapy. The primary endpoint is 2-year seizure-free survival (SFS); secondary endpoints include seizure impact, quality of life, progression-free survival (PFS), and overall survival (OS). Assuming a 2-year SFS rate of 80%, a total of 431 patients (167 events) will be needed to prove the non-inferiority of the experimental arm (non-inferiority margin of 8%, α = 0.05, power = 80%). Considering an attrition rate of 40% (25% accounting for death and 15% lost to follow-up), the final sample size is 604. DISCUSSION The trial will provide level 1 evidence on the optimal duration of ASM use in primary brain tumors with a history of seizures. If short-term ASM use is non-inferior, it will reduce drug utilization, lower neurotoxicity, improve quality of life, and optimize resource usage. ETHICS AND DISSEMINATION The trial has been approved by the Institutional Ethics Committee of Tata Memorial Centre, Mumbai. REGISTRATION Registered with CTRI/2024/06/069498, Clinicaltrials.gov: NCT06442748.
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Clinical Trial Protocol |
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Dev ID, Puranik AD, Rangarajan V, Patra S, Purandare N, Sahu A, Choudhary A, Bhattacharya K, Gupta T, Chatterjee A, Dasgupta A, Moiyadi A, Shetty P, Singh V, Sridhar E, Sahay A, Shah A, Ghosh S, Choudhury S, Shah S, Agrawal A. Preliminary evaluation of FAPI-04-PET/CT for differentiating recurrence and post-treatment changes in high-grade gliomas. EXPLORATION OF TARGETED ANTI-TUMOR THERAPY 2024; 5:1289-1296. [PMID: 39759219 PMCID: PMC11700622 DOI: 10.37349/etat.2024.00276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2024] [Accepted: 09/30/2024] [Indexed: 01/07/2025] Open
Abstract
Fibroblast-activated protein (FAP) expression in glial cells is attributed to FAP-positive foci on tumor vessels and neoplastic cells. Preclinical and pilot studies have shown FAP expression in high-grade gliomas. We aimed at comparing PET imaging with FAP-inhibitor (FAPI-PET) with current standard, i.e., fluoro-ethyl tyrosine (FET) PET in post-treatment setting to differentiate recurrence and post-treatment changes. 6 patients with WHO Grade III and IV glioma who received standard treatment underwent Ga-68-FAPI-04 PET/CT (FAPI-PET/CT). Tracer uptake greater than background was considered positive. FET PET was performed and interpreted as per institutional standards, which formed the basis of treatment decision. There was concordance between FAPI expression and FET uptake in 5 patients suggestive of disease recurrence. There was no FAPI expression seen in 1 patient, in whom FET PET was suggestive of post-treatment changes. FAPI PET uptake correlated with amino acid expression to differentiate post treatment changes from recurrence in high-grade glial tumors; further validation with prospective study and histopathological confirmation is needed.
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Puranik AD, Dev ID, Rangarajan V, Jain Y, Patra S, Purandare NC, Sahu A, Choudhary A, Bhattacharya K, Gupta T, Chatterjee A, Dasgupta A, Moiyadi A, Shetty P, Singh V, Sridhar E, Sahay A, Shah A, Menon N, Ghosh S, Choudhury S, Shah S, Agrawal A, Lakshminarayanan N, Kumar A, Gopalakrishna A. FET PET to differentiate between post-treatment changes and recurrence in high-grade gliomas: a single center multidisciplinary clinic controlled study. Neuroradiology 2025; 67:363-369. [PMID: 39527264 PMCID: PMC11893651 DOI: 10.1007/s00234-024-03495-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2024] [Accepted: 10/30/2024] [Indexed: 11/16/2024]
Abstract
PURPOSE The clinico-radiological dilemma in post-treatment high-grade gliomas, between disease recurrence (TR) and treatment-related changes (TRC), still persists. FET (Fluoro-ethyl-tyrosine) PET has been extensively used as problem-solving modality for cases where MR imaging is inconclusive. We incorporated a systematic imaging and clinical follow-up algorithm in a multi-disciplinary clinic (MDC) setting to analyse our cohort of FET PET in post-treatment gliomas. METHODS We retrospectively analyzed 171 patients of post-treatment grade III and IV glioma with equivocal findings on MRI. 185-222 MBq of 18 F-FET was injected and dedicated static imaging of brain was performed at 20 min. TBR (Tumor to background ratio) was used as semi-quantitative parameter. Cutoff of 2.5 was used for image interpretation. Imaging findings were confirmed with histopathological diagnosis, wherever available or in a multidisciplinary joint clinic based on serial imaging. RESULTS 121 of 171 patients showed recurrent disease on FET PET, on follow up, 109 were confirmed with recurrence; 7 patients showed TRC, whereas 5 were treated with bevacizumab, with no further clinico-radiological deterioration, thus confirming TRC. 50 patients showed TRC on FET PET, on follow up on follow up, 40 were confirmed as true-negative. 10 patients who showed TBR less than 2.5 had confirmed TR on subsequent MR imaging. The overall sensitivity and specificity was 91.6 and 76.9% respectively, with a diagnostic accuracy of 87.13%. CONCLUSION There is potential for FET PET to be used along with MRI in the post treatment algorithm of high-grade glial tumors.
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Dev ID, Rangarajan V, Purandare NC, Agrawal A, Shah S, Puranik AD. All that Glitters on PSMA is Not a Lesion: An Unusual Artifact on PSMA PET/CT. Indian J Nucl Med 2021; 36:310-311. [PMID: 34658558 PMCID: PMC8481840 DOI: 10.4103/ijnm.ijnm_3_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Accepted: 05/29/2021] [Indexed: 12/04/2022] Open
Abstract
Nonspecific uptake of prostate-specific membrane antigen (PSMA) on PSMA positron-emission tomography/computed tomography (CT) is normally encountered in benign conditions, which is detected on morphological changes on CT component. However, having a site of uptake without any CT finding is a rare occurrence. We herewith report one such rare case of a 66-year-old male with metastatic prostatic adenocarcinoma, who demonstrated an incidental finding of intense focal PSMA uptake in the lung parenchyma.
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Case Reports |
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Puranik AD, Choudhury S, Ghosh S, Dev ID, Ramchandani V, Uppal A, Bhosale V, Palsapure A, Rungta R, Pandey R, Khatri S, George G, Satamwar Y, Maske R, Agrawal A, Shah S, Purandare NC, Rangarajan V. Tata Memorial Centre Evidence Based Use of Nuclear medicine diagnostic and treatment modalities in cancer. Indian J Cancer 2024; 61:S1-S28. [PMID: 38424680 DOI: 10.4103/ijc.ijc_52_24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Accepted: 01/31/2024] [Indexed: 03/02/2024]
Abstract
ABSTRACT PET/CT and radioisotope therapy are diagnostic and therapeutic arms of Nuclear Medicine, respectively. With the emergence of better technology, PET/CT has become an accessible modality. Diagnostic tracers exploring disease-specific targets has led the clinicians to look beyond FDG PET. Moreover, with the emergence of theranostic pairs of radiopharmaceuticals, radioisotope therapy is gradually making it's way into treatment algorithm of common cancers in India. We therefore would like to discuss in detail the updates in PET/CT imaging and radionuclide therapy and generate a consensus-driven evidence based document which would guide the practitioners of Oncology.
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Dev ID, Puranik AD, Sahay A, Purandare NC, Agrawal A, Shah S, Rangarajan V. Primary Neuroendocrine Tumor of Prostate in a Case of Metastatic Adenocarcinoma of Lung: Rare Entity with Histopathological and Gallium 68 DOTANOC Positron Emission Tomography Correlation. Indian J Nucl Med 2023; 38:154-156. [PMID: 37456183 PMCID: PMC10348502 DOI: 10.4103/ijnm.ijnm_193_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 12/07/2022] [Accepted: 12/24/2022] [Indexed: 07/18/2023] Open
Abstract
Neuroendocrine tumor (NET) of the prostate is an extremely rare entity which represents <1% of the prostatic cancers, but with increasing incidence. Its spectrum encompasses several histological variants ranging from well-differentiated tumor which are often indolent in nature; to aggressive neuroendocrine carcinoma which portends aggressive management. Hence, such rare entities are to be characterized and treated accordingly. We report an unusual case of well-differentiated NET of prostate which was flagged on fluorodeoxyglucose positron emission tomography computed tomography (PET/CT) performed for other indication and confirmed on Gallium-68 DOTANOC PET/CT. Histopathology and immunohistochemistry confirmed the findings subsequently.
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Datta D, Dasgupta A, Chatterjee A, Sahu A, Bhattacharya K, Meena L, Joshi K, Puranik A, Dev I, Moiyadi A, Shetty P, Singh V, Patil V, Menon N, Epari S, Sahay A, Gupta T. Imaging-Based Patterns of Failure following Re-Irradiation for Recurrent/Progressive High-Grade Glioma. J Pers Med 2023; 13:685. [PMID: 37109071 PMCID: PMC10144403 DOI: 10.3390/jpm13040685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Revised: 03/17/2023] [Accepted: 04/17/2023] [Indexed: 04/29/2023] Open
Abstract
BACKGROUND Re-irradiation (ReRT) is an effective treatment modality in appropriately selected patients with recurrent/progressive high-grade glioma (HGG). The literature is limited regarding recurrence patterns following ReRT, which was investigated in the current study. METHODS Patients with available radiation (RT) contours, dosimetry, and imaging-based evidence of recurrence were included in the retrospective study. All patients were treated with fractionated focal conformal RT. Recurrence was detected on imaging with magnetic resonance imaging (MRI) and/ or amino-acid positron emission tomography (PET), which was co-registered with the RT planning dataset. Failure patterns were classified as central, marginal, and distant if >80%, 20-80%, or <20% of the recurrence volumes were within 95% isodose lines, respectively. RESULTS Thirty-seven patients were included in the current analysis. A total of 92% of patients had undergone surgery before ReRT, and 84% received chemotherapy. The median time to recurrence was 9 months. Central, marginal, and distant failures were seen in 27 (73%), 4 (11%), and 6 (16%) patients, respectively. None of the patient-, disease-, or treatment-related factors were significantly different across different recurrence patterns. CONCLUSION Failures are seen predominantly within the high-dose region following ReRT in recurrent/ progressive HGG.
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Puranik AD, Rangarajan V, Shetty NS, Gala K, Kulkarni S, Mohite A, Marotkar M, Gawale Y, Dev ID, Shrikhande SV, Chaudhari V, Bhandare M, Agrawal A, Shah S, Purandare NC, Ghosh S, Choudhury S. Intra-arterial PRRT with Lu-177 DOTATATE in Liver-dominant Metastatic Neuroendocrine Tumors: Early Assessment of Efficacy and Toxicity. Indian J Nucl Med 2024; 39:71-76. [PMID: 38989301 PMCID: PMC11232720 DOI: 10.4103/ijnm.ijnm_7_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 03/31/2023] [Accepted: 04/11/2023] [Indexed: 07/12/2024] Open
Abstract
Purpose We proposed to administer Lu-177-DOTATATE in intra-arterial (IA) mode for higher first-pass localization to somatostatin receptors, higher residence time in liver metastases, and more radiation to tumor. This study aimed at assessing early hematological, renal and hepatotoxicity; and objective response to IA peptide receptor radionuclide therapy (PRRT). Materials and Methods Fourteen patients (4 females and 10 males) were prospectively assessed. 5/14 patients underwent 2 cycles, whereas 3/14 underwent 3 cycles, and 6/14 received 1 cycle of IA PRRT. 200 mCi of Lu-177-DOTATATE was administered in 15-20 min by IA route under angiographic guidance. Patients were asked to follow-up at 4 and 8 weeks with hematological, liver, and renal functional parameters, and Ga-68 DOTATATE positron emission tomography/computed tomography (PET/CT) after 8 weeks. Response was assessed using RECIST 1.1 and EORTC PET criteria. Results Safety: 2/14 patients had high total and direct bilirubin, which reverted to normal after IA PRRT. Three patients had low albumin, which improved after 1 cycle. Nine patients showed no worsening of liver function. Two patients showed Grade 1 hematotoxicity which reverted to normal. Five patients showed high creatinine, but preserved glomerular filtration rate and EC clearance. On follow-up at 8 weeks, serum creatinine reverted to normal. Efficacy: In five patients who underwent 2 cycles of IA PRRT, 3 showed partial response (PR) on RECIST 1.1 and partial metabolic response (PMR) on EORTC criteria, whereas 2 showed stable disease (SD). In patients who underwent 3 cycles, 1 showed SD, whereas other patient showed PMR on DOTANOC PET/CT, with PR in size. Among the remaining seven patients, 5 showed PMR, whereas the other 2 showed SD. Thus 9/14 patients showed PR, whereas 5 showed SD on metabolic and size criteria. Conclusions IA PRRT is a safe and efficacious approach for the treatment of liver dominant metastatic neuroendocrine tumors.
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Jain Y, Agrawal A, Joshi A, Menon S, Prakash G, Murthy V, Purandare N, Shah S, Puranik A, Choudhury S, Shukla V, Dev I, Prabhash K, Noronha V, Rangarajan V. Can 18 F FDG PET/CT metabolic parameters be used to noninvasively differentiate between different histopathological subtypes and Fuhrman grades of renal cell cancer? Nucl Med Commun 2024; 45:601-611. [PMID: 38686492 DOI: 10.1097/mnm.0000000000001844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2024]
Abstract
AIM To evaluate relationship between metabolic PET metabolic parameters and size of the primary tumor, various histopathological subtypes of renal cell carcinoma (RCC) and Fuhrman grade of the tumors. MATERIAL AND METHODS Retrospective analysis of 93 biopsy-proven RCC patients who underwent pretreatment flourine 18 flourodeoxyglucose PET/computed tomography ( 18 F FDG PET/CT) was performed. Quantitative PET parameters, size of the primary tumor, histopathological subtypes and Fuhrman grades of the tumor were extracted. We tried to assess if there was any significant difference in the metabolic patterns of various histopathological subtypes of RCCs, Fuhrman grade of the tumors and size of the primary tumor. RESULTS A significant correlation was noted between the size of primary tumor and maximum standardized uptake value (SUV max ), metabolic tumor volume (MTV) and total lesion glycolysis (TLG) ( P < 0.01, P < 0.001 and P < 0.001, respectively). SUV max values correlated significantly with the histopathological subtype ( P < 0.001). Further sub-analyses was also done by segregating the patients into Low grade (Fuhrman grade 1 and 2) vs. High grade (Fuhrman grade 3 and 4). SUV max , MTV and TLG were significantly different between high grade vs. low grade tumors. ROC analysis yielded cut off values for SUV max , MTV and TLG to differentiate between high grade from low grade tumors. CONCLUSION FDG PET/CT with the use of metabolic PET parameters can differentiate between different histopathological subtypes of RCC. Incorporation of metabolic parameters into clinical practice can potentially noninvasively identify patients with low-grade vs. high-grade RCC.
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Dasgupta A, Sawant S, Chatterjee A, Gota V, Sahu A, Choudhari A, Bhattacharya K, Puranik A, Dev I, Moiyadi A, Shetty P, Singh V, Menon N, Epari S, Sahay A, Shah A, Bano N, Shaikh F, Jirage A, Gupta T. Study Protocol of a Prospective Phase 2 Study of Chlorophyllin for the Management of Brain Radionecrosis in Patients With Diffuse Glioma (CHROME). Cancer Med 2025; 14:e70657. [PMID: 40025673 PMCID: PMC11872794 DOI: 10.1002/cam4.70657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2024] [Revised: 01/12/2025] [Accepted: 01/27/2025] [Indexed: 03/04/2025] Open
Abstract
INTRODUCTION Chlorophyllin (CHL) effectively decreases the side effects of radiotherapy (RT) by scavenging radiation-induced free radicals and reactive oxygen species in preclinical trials. This study aims to assess the efficacy of oral CHL for the treatment of brain radionecrosis in patients with diffuse glioma. METHODS This is a phase 2 trial prospective, interventional study. Adults (> 18 years) with a histological diagnosis of diffuse glioma developing radionecrosis will be eligible for the study. Radionecrosis will be identified using standard imaging protocols with magnetic resonance imaging (MRI) with or without positron emission tomography (PET). Patients will be accrued in two strata: symptomatic (stratum A) and asymptomatic (stratum B). Chlorophyllin will be prescribed to all patients using a morning oral dose of 750 mg before breakfast for 3 months. In addition, participants in stratum A will be given a tapering dose of dexamethasone for 1 month, while stratum B will not be receiving any steroids. Imaging with an MRI brain protocol and PET scan will be planned at 1 month and MRI at 3 months after starting CHL. The primary endpoint is the clinical-radiological response at 1 month. Secondary endpoints include response at 3 months, biological responses, survival analysis, and quality-of-life scores. The total sample size is 118 (60 and 58 in stratum A and B, respectively), with one interim analysis planned. DISCUSSION Radionecrosis leads to significant morbidity and is usually treated with corticosteroids, which can lead to several side effects from both acute and long-term use. Refractory radionecrosis requires treatment with bevacizumab or surgical resection. Chlorophyllin is a cheap, safe, and readily available phytopharmaceutical drug, which is being investigated in the phase 2 study and, if proven effective, can be considered an alternative for treating radionecrosis. TRIAL REGISTRATION Clinical Trial Registry India (CTRI): CTRI/2023/08/056166; ClinicalTrials.gov: NCT06016452.
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Dev ID, Puranik AD, Trikalinos NA, Girod BJ, Kim H, Prasad V. Theranostics in Lung Neuroendocrine Tumors. Semin Nucl Med 2025; 55:221-233. [PMID: 40055049 DOI: 10.1053/j.semnuclmed.2025.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2025] [Accepted: 02/18/2025] [Indexed: 03/17/2025]
Abstract
In the last 2 decades, there has been a noticeable increase in the incidence of neuroendocrine tumors, in part due to improved understanding of pathology and/or availability of more sensitive and accurate diagnostic tests. While gastrointestinal tract and pancreas are the most common sites of origin, lung neuroendocrine tumors (LNETs) are also frequently reported and need special considerations from diagnostic as well as therapeutic aspects. Radiopharmaceutical therapy (Theranostics) is a novel approach which utilizes a pair of diagnostic and therapeutic agents that share a common target on tumor sites. Precise treatment of the disease with minimum side effects is the principal aim of Theranostics. It's a known fact that somatostatin receptors (SSTR) are abundantly expressed in neuroendocrine tumors. With the advent of highly specific radiopharmaceuticals targeting SSTR receptors for both diagnosis as well as treatment and other targeted therapies, management of LNETs has become less challenging. Still, there exists significant ambiguity in relation to management of LNETs with a scope of novel diagnostic and therapeutic strategies to pitch in. This review focuses on the role of established evidence for Theranostics strategies in the management of LNETs and highlights the potential future role of newer targets which would be of promising value in addressing such rare and complex tumor biology.
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Dev ID, Puranik AD, Rangarajan V, Gupta T, Purandare NC, Agrawal A, Shah S. Radiation-Induced Meningioma in a Case of Medulloblastoma Treated 11 Years Ago-Detected on 68Ga-DOTANOC PET/CT. Clin Nucl Med 2022; 47:e108-e110. [PMID: 34183498 DOI: 10.1097/rlu.0000000000003788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT Medulloblastomas, especially the sonic hedgehog subgroup, are treated aggressively with surgery and chemoradiotherapy, as they are associated with high local site recurrence rate and poor overall survival. Radiation-induced meningioma is the most common delayed complication of craniospinal irradiation. This needs to be differentiated from meningeal or ependymal metastases as the later need aggressive management. We report one such rare case, in a patient who completed treatment for medulloblastoma 11 years ago, was in remission, and now presented with dural-based lesions.
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