Sinonasal NUT-Midline Carcinoma - A Multimodality Approach to Diagnosis, Staging and Post-Surgical Restaging

Nuclear protein testis (NUT) midline carcinoma is a rare malignancy involving predominantly the midline structures of the body. It is characterized by its genotypic feature of BRD4-NUT translocation, which is in contrast with other malignant processes that are usually categorized based on their histologic/phenotypic features. As these tumors may vary in their histologic presentation, they can be misdiagnosed as poorly differentiated carcinomas. Moreover, they are often very aggressive and associated with high mortality. Therefore, it is extremely important to diagnose them early using computed tomography (CT) and magnetic resonance imaging (MRI) and perform staging and restaging using 18-fluorodeoxyglucose positron emission tomography/computed tomography (18-FDG PET/CT), in addition to accurately identifying them at a microscopic and molecular level. We report a unique case of a sinonasal NUT midline carcinoma that was diagnosed with CT, staged with PET/CT, and restaged using PET/CT and MRI.

Rationale and design of the RAPID-WATER-FLOW trial: Radiolabeled perfusion to identify coronary artery disease using water to evaluate responses of myocardial FLOW

OBJECTIVES

The objective of this study was to determine the diagnostic performance of 15O-water positron emission tomography (PET) myocardial perfusion imaging to detect coronary artery disease (CAD) using the truth-standard of invasive coronary angiography (ICA) with fractional flow reserve (FFR) or instantaneous wave-Free Ratio (iFR) or coronary computed tomography angiogram (CCTA).

BACKGROUND

15O-water has a very high first-pass extraction that allows accurate quantification of myocardial blood flow and detection of flow-limiting CAD. However, the need for an on-site cyclotron and lack of automated production at the point of care and relatively complex image analysis protocol has limited its clinical use to date.

METHODS

The RAPID WATER FLOW study is an open-label, multicenter, prospective investigation of the accuracy of 15O-water PET to detect obstructive angiographic and physiologically significant stenosis in patients with suspected CAD. The study will include the use of an automated system for producing, dosing, and injecting 15O-water and enrolling approximately 215 individuals with suspected CAD at approximately 10 study sites in North America and Europe. The primary endpoint of the study is the diagnostic sensitivity and specificity of the 15O-water PET study using the truth-standard of ICA with FFR or iFR to determine flow-limiting stenosis, or CCTA to rule out CAD and incorporating a quantitative analytic platform developed for the 15O-water PET acquisitions. Sensitivity and specificity are to be considered positive if the lower bound of the 95% confidence interval is superior to the threshold of 60% for both, consistent with prior registration studies. Subgroup analyses include assessments of diagnostic sensitivity, specificity, and accuracy in female, obese, and diabetic individuals, as well as in those with multivessel disease. All enrolled individuals will be followed for adverse and serious adverse events for up to 32 hours after the index PET scan. The study will have >90% power (one-sided test, α = 0.025) to test the hypothesis that sensitivity and specificity of 15O-water PET are both >60%.

CONCLUSIONS

The RAPID WATER FLOW study is a prospective, multicenter study to determine the diagnostic sensitivity and specificity of 15O-water PET as compared to ICA with FFR/iFR or CCTA. This study will introduce several novel aspects to imaging registration studies, including a more relevant truth standard incorporating invasive physiologic indexes, coronary CTA to qualify normal individuals for eligibility, and a more quantitative approach to image analysis than has been done in prior pivotal studies.

CLINICAL TRIAL REGISTRATION INFORMATION

Clinical-Trials.gov (#NCT05134012).

Long pulse large area beam extraction with a rf driven H(-)/D(-) source

IPP Garching is heavily involved in the development of the rf driven H(-)/D(-) ion source for the ITER NBI. After the successful demonstration of the required physical parameters, the experimental conditions have been extended to long pulses and large area beam extraction. This paper contains descriptions of the source and power supply modifications necessitated for long pulses as well as the latest results including the first 1 h pulse. Suppression of the coextracted electron current is a key issue. Experiments with potential control, different magnetic filter fields, and cesium handling to suppress the electrons and stabilize the currents are also reported.

Nuclear Imaging of Neuroendocrine Tumors

Consensus guidelines acknowledge the role of gallium Ga-68 (⁶⁸Ga) 1,4,7,10-tetraazacyclododecane-N,N',N'',N'''-tetraacetic (DOTA) somatostatin receptor (SSTR) positron emission tomography/computed tomography (PET/CT) in management of neuroendocrine tumor (NET) patients. ⁶⁸Ga-DOTA-SSTR PET/CT demonstrates superior performance to conventional imaging in initial detection, staging, detection of recurrent tumor, and detection of unknown primary in known metastatic disease. ⁶⁸Ga-DOTA-SSTR PET/CT is low yield for NET detection in the setting of symptoms or elevated biomarkers when conventional imaging is negative, but may still guide management. The role of ⁶⁸Ga-DOTA-SSTR PET/CT is not established in monitoring response to systemic therapy but may identify progression through detection of new metastases.

Charge exchange recombination spectroscopy at Wendelstein 7-X

The Charge Exchange Recombination Spectroscopy (CXRS) diagnostic has become a routine diagnostic on almost all major high temperature fusion experimental devices. For the optimized stellarator Wendelstein 7-X (W7-X), a highly flexible and extensive CXRS diagnostic has been built to provide high-resolution local measurements of several important plasma parameters using the recently commissioned neutral beam heating. This paper outlines the design specifics of the W7-X CXRS system and gives examples of the initial results obtained, including typical ion temperature profiles for several common heating scenarios, toroidal flow and radial electric field derived from velocity measurements, beam attenuation via beam emission spectra, and normalized impurity density profiles under some typical plasma conditions.

Low pressure and high power rf sources for negative hydrogen ions for fusion applications (ITER neutral beam injection)

The international fusion experiment ITER requires for the plasma heating and current drive a neutral beam injection system based on negative hydrogen ion sources at 0.3 Pa. The ion source must deliver a current of 40 A D(-) for up to 1 h with an accelerated current density of 200 Am/(2) and a ratio of coextracted electrons to ions below 1. The extraction area is 0.2 m(2) from an aperture array with an envelope of 1.5 x 0.6 m(2). A high power rf-driven negative ion source has been successfully developed at the Max-Planck Institute for Plasma Physics (IPP) at three test facilities in parallel. Current densities of 330 and 230 Am/(2) have been achieved for hydrogen and deuterium, respectively, at a pressure of 0.3 Pa and an electron/ion ratio below 1 for a small extraction area (0.007 m(2)) and short pulses (<4 s). In the long pulse experiment, equipped with an extraction area of 0.02 m(2), the pulse length has been extended to 3600 s. A large rf source, with the width and half the height of the ITER source but without extraction system, is intended to demonstrate the size scaling and plasma homogeneity of rf ion sources. The source operates routinely now. First results on plasma homogeneity obtained from optical emission spectroscopy and Langmuir probes are very promising. Based on the success of the IPP development program, the high power rf-driven negative ion source has been chosen recently for the ITER beam systems in the ITER design review process.

Investigation of fringe plasma parameters on a high power rf driven ion source

It has been observed that there are differences between the uncompensated Langmuir probes installed in the upper and lower areas of the rf driven H(-) sources at IPP Garching. The two probes often had substantially different floating potentials or ion saturation currents. In an effort to understand the reasons for these differences a Langmuir probe analysis system was used on the probes to collect the full current voltage characteristic. The results show what is likely the formation of an ion-ion plasma. The paper shows the effect of beam extraction and the presence of caesium on the probe characteristics.

Chronic venous insufficiency causing a diagnostic conundrum on Tc-99m bone scan done for osteosarcoma surveillance: Awareness is the key!

Bone scans are the most commonly used imaging technique to rule out local recurrence or metastasis during surveillance of malignant bone tumors after treatment. Although bone scans are very sensitive in detecting recurrence or metastasis, they are less specific. There are many nonmalignant conditions which can mimic either recurrence or metastasis on a Tc-99m bone scan. Therefore, physicians must be aware of such conditions to avoid unnecessary workup and invasive procedures. We present such an interesting case where chronic venous insufficiency mimicked either osteomyelitis or regional metastasis on a Tc-99m bone scan done for osteosarcoma surveillance.

Safety and accuracy of 68Ga-DOTATOC PET/CT in children and young adults with solid tumors

⁶⁸Ga-DOTA-tyr3-Octreotide (⁶⁸Ga-DOTATOC) PET/CT has been shown to have high accuracy in adults with neuroendocrine tumors, however has not been studied in pediatric patients. This study evaluated the safety and accuracy of ⁶⁸Ga-DOTATOC PET/CT in children and young adults with solid tumors that express somatostatin receptor type 2. A series of three prospective, IRB approved, clinical trials evaluating safety and efficacy of ⁶⁸Ga-DOTATOC PET/CT were conducted for subjects aged 6 months to 90 years. This study reports the results for the 26 children and young adults, aged 16 months to 29 years who participated in these trials. The administered activity of ⁶⁸Ga-DOTATOC was 1.59 MBq/kg with an upper limit of 111 MBq for subjects < 18 years and 148 MBq for young adults. Safety was assessed with laboratory studies and patient/parent report of symptoms before and after the scan. Scans were interpreted in consensus by two board-certified nuclear medicine physicians. Each scan was categorized on a patient basis as true positive, true negative, false negative or false positive against a reference standard that included a combination of histopathology, other imaging modalities and clinical follow-up. Nine Grade I adverse events (AEs) occurred among 26 subjects, none of which were attributable to ⁶⁸Ga-DOTATOC. Sensitivity of ⁶⁸Ga-DOTATOC PET/CT was 88% (14 true positive, 2 false negative) and specificity was 100% (10 true negative, 0 false positive). ⁶⁸Ga-DOTATOC PET/CT is safe and accurate in children and young adults with solid tumors expressing somatostatin receptor type 2.