Fluorine-18 Deoxyglucose Positron Emission Tomography Research Articles

Validation of the 8th edition UICC/AJCC TNM staging system for HPV associated oropharyngeal cancer patients managed with contemporary chemo-radiotherapy

BackgroundTo compare outcomes of high-risk human papilloma virus-related oropharyngeal squamous cell carcinoma (HPV OPSCC) treated with modern radiation treatment (RT) and daily image-guidance, staged with the 7th versus the 8th Edition (Ed) Union for International Cancer Control (UICC)/American Joint Committee on Cancer (AJCC) TNM staging systems.MethodsAll eligible patients with HPV OPSCC treated definitively over a 10-year period (2007–2016) at a single institution were included. Protocols consisting of either RT or chemo-radiation (CRT) (weekly cisplatin or cetuximab) +/− neoadjuvant chemotherapy for those with bulky disease were used. All patients were Fluorine-18-deoxyglucose positron emission tomography (FDG-PET) staged at baseline and at intervals for up to 2 years post-treatment. Patients received parotid-sparing intensity modulated or volumetric modulated arc therapy with simultaneous integrated boost to either 70Gy in 35 fractions or 66Gy in 30 fractions. The overall survival (OS) was determined for each stage using the 7th Ed and subsequently with the updated 8th Ed staging system.ResultsOne hundred fifty-three patients were analysed. Patient stage groupings varied between the 7th and 8th Eds respectively; Stage I (0.7% vs 64.7%), Stage II (8.5% vs 22.2%), stage III (21.6% vs 12.4%) and stage IV (69.3% vs 0.7%). In the 7th Ed, the 5 year probability of OS for stages I to III was 90%, versus stage IV 85.5%. There was no statistically significant difference between the staging groups (p = 0.85). In the 8th Ed there was a statistically significant difference in 5 year OS for stage I and stage II disease (96.9% vs 77.1% respectively; p < 0.0001), but not between stage II and III disease (p = 0.98).ConclusionsThe new 8th Ed UICC/AJCC TNM staging system better discriminates between stage I and Stage II HPV OPSCC with respect to OS compared with the 7th Ed staging system. Further investigation is required for stage III or IV patients.

The value of fluorine-18 deoxyglucose positron emission tomography scans in patients with ventricular assist device specific infections†.

Infections are major complications in patients with ventricular assist devices (VAD). Positron emission tomography with deoxyglucose marked by fluorine-18 ( 18 F-FDG PET/CT) is a diagnostic tool to scan for tissue with high metabolism as present in infections. The specificity of 18 F-FDG PET/CT to discriminate between infection and an aseptic reaction of the implanted device is not defined and its evaluation is the aim of this retrospective analysis. Until September 2015 a total of 100 patients underwent VAD implantations in our institution. Twenty-one patients (mean age 53.7 ± 14.3 years) had 29 PET-CT examinations for a suspected infection. All radiology reports were compared to clinical and intraoperative parameters. Infections were reported according to the guidelines of the International Society of Heart and Lung Transplantation. Follow-up was 222 days (range 107-484 days) after PET-CT scans and was complete in all patients. In 7 patients PET-CT scan ruled out any VAD associated infection. Sixteen patients had a VAD specific infection. Two patients had false negative PET-CT scan results. The sensitivity of VAD-specific infections was 87.5%, the specificity 100%, the positive predictive value was 100% and the negative predictive value 86.7%. Seven patients had more than one PET-CT scans at different time points. PET-CT scan findings showed a high specificity and positive predictive value for VAD-specific infections. Therefore, it may have the potential to guide the clinician in handling patients with infectious complications after VAD implantation.

Combining Multimodal Neuroimaging Biomarkers in the Diagnosis of Alzheimer’s Disease and Mild Cognitive Impairment

Effective diagnosis of Alzheimer’s disease (AD) and Mild Cognitive Impairment (MCI), a transitional state between normal and AD, is of great importance in dementia research. Different neuroimaging biomarkers for AD may be potentially different and complementary in the diagnosis of AD. It is necessary to combine multimodal neuroimaging biomarkers simultaneously for the higher classification accuracy and more effective diagnosis. In this study, Magnetic Resonance Imaging (MRI) and Fluorine-18 deoxyglucose (FDG) positron emission tomography (PET) were firstly analysed separately, then biomarkers from both MRI and FDG-PET were combined using logistic regression and fisher linear discrimination, widely used approaches to combine multiple variables for the simultaneous analysis. The results showed that MRI and FDG-PET biomarkers were all sensitive to the AD diagnosis, although some differences existed. Combining information from multiple brain regions or from multimodal neuroimaging data sets could increase the accuracy of distinguishing AD or MCI patients from NC group, instead of causing information redundancy. Keywords: Alzheimer’s disease (AD), mild cognitive impairment (MCI), neuroimaging biomarker, MRI, FDG-PET.

The use of PET-MRI in the follow-up after radiofrequency- and microwave ablation of colorectal liver metastases

BackgroundThermal ablation of colorectal liver metastases (CRLM) may result in local progression, which generally appear within a year of treatment. As the timely diagnosis of this progression allows potentially curative local treatment, an optimal follow-up imaging strategy is essential. PET-MRI is a one potential imaging modality, combining the advantages of PET and MRI. The aim of this study is evaluate fluorine-18 deoxyglucose positron emission tomography (FDG) PET-MRI as a modality for detection of local tumor progression during the first year following thermal ablation, as compared to the current standard, FDG PET-CT. The ability of FDG PET-MRI to detect new intrahepatic lesions, and the extent to which FDG PET-MRI alters clinical management, inter-observer variability and patient preference will also be included as secondary outcomes.Methods/DesignTwenty patients undergoing treatment with radiofrequency or microwave ablation for (recurrent) CRLM will be included in this prospective trial. During the first year of follow-up, patients will be scanned at the VU University Medical Center at 3-monthly intervals using a 4-phase liver CT, FDG PET-CT and FDG PET-MRI. Patients treated with chemotherapy <6 weeks prior to scanning or with a contra-indication for MRI will be excluded. MRI will be performed using both whole body imaging (mDixon) and dedicated liver sequences, including diffusion-weighted imaging, T1 in-phase and opposed-phase, T2 and dynamic contrast-enhanced imaging. The results of all modalities will be scored by 4 individual reviewers and inter-observer agreement will be determined. The reference standard will be histology or clinical follow-up. A questionnaire regarding patients’ experience with both modalities will also be completed at the end of the follow-up year.DiscussionImproved treatment options for local site recurrences following CRLM ablation mean that accurate post-ablation staging is becoming increasingly important. The combination of the sensitivity of MRI as a detection method for small intrahepatic lesions with the ability of FDG PET to visualize enhanced metabolism at the ablation site suggests that FDG PET-MRI could potentially improve the accuracy of (early) detection of progressive disease, and thus allow swifter and more effective decision-making regarding appropriate treatment.Trial registrationTrial registration number: NCT01895673

Preoperative FDG-PET-Scan in Patients with Resectable Colorectal Liver Metastases Does Not Improve Overall Survival: A Retrospective Analyses Stratified by Clinical Risk Score

Background: The aim of this study was to determine whether selection with fluorine-18-deoxyglucose positron emission tomography (FDG-PET) imaging would result in an improved outcome in surgically treated patients with curative resection of colorectal liver metastases (CRLM), stratified by the clinical risk score (CRS) of Fong et al. [Ann Surg 1999;230:309-318]. Patients and Methods: Between January 2000 and December 2009, all patients who underwent resection for CRLM from two different university teaching hospitals in the Netherlands were analysed. Patients were stratified by the CRS. Results: In total 613 patients were eligible for analysis. There was no statistical difference in median disease-free survival (DFS) between patients with and without an FDG-PET scan in both low CRS [17 months (95% CI 12-22) vs. 14 months (95% CI 11-17), p = 0.332] and high CRS [14 months (95% CI 7-21) vs. 9 months (95% CI 8-10), p = 0.073]. There was no statistical difference in median overall survival (OS) between patients with and without an FDG-PET scan in both low CRS [64 months (95% CI 54-74) vs. 54 months (95% CI 42-66), p = 0.663] and high CRS [39 months (95% CI 23-55) vs. 41 months (95% CI 34-48), p = 0.903]. Conclusion: The present study could not demonstrate that patients selected by an FDG-PET scan before liver resection, and stratified by CRS, have an improvement in DFS or OS.

Is there any significance of lung cancer histology to compare the diagnostic accuracies of (18)F-FDG-PET/CT and (99m)Tc-MDP BS for the detection of bone metastases in advanced NSCLC?

Aim of the studyBone scintigraphy (BS) and fluorine-18 deoxyglucose positron emission tomography computed tomography (18F-FDG-PET/CT) are widely used for the detection of bone involvement. The optimal imaging modality for the detection of bone metastases in histological subgroups of non-small cell lung cancer (NSCLC) remains ambiguous. The aim of this study was to compare the efficacy of 18F-FDG-PET/C and 99mTc-methylene diphosphonate (99mTc-MDP) BS in the detection of bone metastases of patients in NSCLC. Specifically, we compared the diagnostic accuracies of these imaging techniques evaluating bone metastasis in histological subgroups of NSCLC.Material and methodsFifty-three patients with advanced NSCLC, who had undergone both 18F-FDG-PET/CT and BS and were eventually diagnosed as having bone metastasis, were enrolled in this retrospective study.ResultsThe sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of 18F-FDG-PET/CT and BS were 90.4%, 99.4%, 98.1%, 96.6%, 97.0% and 84.6%, 93.1%, 82.5%, 93.2, 90.8%, respectively. The κ statistics were calculated for 18F-FDG-PET/CT and BS. The κ-value was 0.67 between 18F-FDG-PET/CT and BS in all patients. On the other hand, the κ-value was 0.65 in adenocarcinoma, and 0.61 in squamous cell carcinoma between 18F-FDG-PET/CT and BS. The κ-values suggested excellent agreement between all patients and histological subgroups of NSCLC.Conclusions 18F-FDG-PET/CT was more favorable than BS in the screening of metastatic bone lesions, but the trend did not reach statistical significance in all patients and histological subgroups of NSCLC. Our results need to be validated in prospective and larger study clinical trials to further clarify this topic.

Is 18F-FDG-PET/CT prognostic factor for survival in patients with small cell lung cancer? Single center experience

BackgroundAlthough a number of studies in patients with a variety of malignant tumors have shown that metabolic activity on fluorine-18 deoxyglucose positron emission tomography computed tomography (18F-FDG-PET/CT) is correlated with survival, there are few studies about the impact of 18F-FDG-PET/CT for survival in small cell lung cancer (SCLC) patients. There is still some ambiguity as to whether FDG PET in patients with SCLC will ensure prognostic knowledge for survival. We performed a retrospective analysis of prognostic implication of 18F-FDG-PET/CT in patients with SCLC. MethodsWe retrospectively reviewed 54 patients with histologically or cytologically proven SCLC who had undergone pre-treatment 18F-FDG-PET/CT scanning between September 2007 and November 2011 in the Dicle University, School of Medicine, Department of Medical Oncology. SUVmax and other potential prognostic variables were chosen for analysis in this study. Univariate and multivariate analyses were conducted to identify prognostic factors associated with survival. ResultAmong the eleven variables of univariate analysis, three variables were identified as having prognostic significance: Performance status (p<0.001), stage (p=0.02) and diabetes mellitus (p=0.05).Multivariate analysis showed that performance status and stage were considered independent prognostic factors for survival (p<0.001 and p=0.002 respectively). ConclusionIn conclusion, performance status and stage were identified as important prognostic factors, while 18F-FDG-PET/CT uptake of the primary lesions was not associated with prognostic importance for survival in patients with SCLC.

Is 18F-FDG-PET/CT prognostic factor for survival in patients with small cell lung cancer? Single center experience

BackgroundAlthough a number of studies in patients with a variety of malignant tumors have shown that metabolic activity on fluorine-18 deoxyglucose positron emission tomography computed tomography (18F-FDG-PET/CT) is correlated with survival, there are few studies about the impact of 18F-FDG-PET/CT for survival in small cell lung cancer (SCLC) patients. There is still some ambiguity as to whether FDG PET in patients with SCLC will ensure prognostic knowledge for survival. We performed a retrospective analysis of prognostic implication of 18F-FDG-PET/CT in patients with SCLC. MethodsWe retrospectively reviewed 54 patients with histologically or cytologically proven SCLC who had undergone pre-treatment 18F-FDG-PET/CT scanning between September 2007 and November 2011 in the Dicle University, School of Medicine, Department of Medical Oncology. SUVmax and other potential prognostic variables were chosen for analysis in this study. Univariate and multivariate analyses were conducted to identify prognostic factors associated with survival. ResultAmong the eleven variables of univariate analysis, three variables were identified as having prognostic significance: Performance status (p<0.001), stage (p=0.02) and diabetes mellitus (p=0.05).Multivariate analysis showed that performance status and stage were considered independent prognostic factors for survival (p<0.001 and p=0.002 respectively). ConclusionIn conclusion, performance status and stage were identified as important prognostic factors, while 18F-FDG-PET/CT uptake of the primary lesions was not associated with prognostic importance for survival in patients with SCLC.

Pre-Transplant FDG-PET Scan Lacks Prognostic Value in Chemosensitive B-Cell Non-Hodgkin Lymphoma Patients Undergoing Non-Myeloablative Allogeneic Stem Cell Transplantation.

AbstractAbstract 3130▪▪This icon denotes a clinically relevant abstract Background:Allogeneic stem cell transplantation (alloSCT) remains the only curative therapy for patients with indolent B cell non-Hodgkin’s Lymphoma (B-NHL) as well as patients with aggressive B-NHL that have failed prior autologous stem cell transplants (ASCT). Non-myeloablative (NMA) alloSCT has been universally implemented for B-NHL given the extensive prior therapy and advanced age of the typical patient undergoing alloSCT for these diseases and resultant 40–50% incidence of transplant-related mortality (TRM) with myeloablative conditioning per registry series’. NMA alloSCT relies on graft-versus-lymphoma (GVL) effect for disease control. While the literature has suggested improved event-free survival (EFS) for B-NHL patients with a negative fluorine-18-deoxyglucose positron emission tomography (FDG-PET) scan prior to ASCT in chemosensitive patients, this has not been elucidated in a conventional NMA alloSCT treatment platform. Our hypothesis is that FDG avidity pre-NMA alloSCT is not prognostic to progression-free survival (PFS) in chemosensitive patients with B-NHL. Methods:This is a retrospective study of adult B-NHL patients with disease assessed by CT and FDG-PET prior to undergoing a T-cell replete NMA alloSCT from a 9/10 or 10/10 HLA matched related or unrelated donor conditioned with cyclophosphamide 50 mg/kg x1, fludarabine 25 mg/m2 daily over 5 days and 2 Gy total body irradiation, with or without peri-allo-SCT rituximab 375 mg/m2 administered approximately day (d) -8, d+21, d+28, d+25, d+42 as per an internal protocol. Patients receiving an unrelated donor graft received equine anti-thymocyte globulin 30 mg/kg administered daily d-3 and d-2. Graft-versus-host disease (GVHD) prophylaxis consisted of tacrolimus, sirolimus and methotrexate (n=51) or cyclosporin-A and mycophenolate mofetil (n=15). Event-free survival (EFS) was calculated using Kaplan-Meier method. An event is defined as progression of disease (PD) or death from any cause. Results:This analysis includes 66 patients with a median age of 54 (range 33–69) years at the time of allo-SCT. Diagnoses included: 16 CLL/SLL, 30 FL, 11 DLBCL/transformed B-NHL, 6 MCL and 3 other. Patients were previously treated with a median of 3 prior chemotherapy regimens (range 1–6) and 12 patients had undergone a previous ASCT. Fifty-one patients (77%) were chemosensitive at the time of alloSCT by CT criteria, as defined by either a complete or partial remission (Cheson et al, JCO 1999; Hallek et al, Blood 2005 for CLL/SLL). Of these 51 patients, 18 had FDG-avidity on FDG-PET at time of allo-SCT above liver background per Deauville criteria (Meignan et al, Leukemia and Lymphoma 2009). The median hematopoietic comorbidity index (HCT-CI) was 1 (range 0–8). Twenty-six patients received a graft from a 10/10 HLA matched related donor, 34 from a 10/10 HLA matched unrelated donor and 6 from a 9/10 HLA mismatched unrelated donor. Eighty-six percent of the patients received peri-alloSCT rituximab. The median follow-up for survivors is 29 (range 3–67) months. Of the 15 events, 10 were TRM (7 GVHD-related deaths) and 5 PD (3 chemosensitive patients and 2 chemorefractory patients pre-alloSCT). Only 1 event has occurred beyond 13 months. The estimated 2 year EFS is 77%. There was no difference in EFS according to: CR vs PR, graft source, number of previous lines of therapy, GVHD prophylaxis, peri-alloSCT rituximab, previous ASCT, or HCT-CI. The estimated EFS at 2 years for chemosensitive patients per CT criteria is 86% compared to 50% for patients without chemosensitivity pre-allo-HCT (figure 1, p<0.01). FDG-PET (+) was not prognostic in the chemosensitive patients prior to alloSCT (figure 2, p=ns). Only 2 of the 15 non-chemosensitive patients were FDG-PET (−) at time of alloSCT. Both of these patients had CLL/SLL and are event-free at 20 and 35 months post-alloSCT. Conclusions:Chemosensitivity prior to T-cell replete NMA alloSCT for B-NHL predicts outcome post-transplant. FDG-PET scan did not add prognostic value to patients deemed chemosensitive by traditional CT criteria in our dataset. The majority of the events were TRM, which needs to be taken into consideration when interpreting these results. Transplant related mortality, especially GVHD related, continues to greatly impact survival of B-NHL patients undergoing NMA alloSCT. [Display omitted] [Display omitted] Disclosures:No relevant conflicts of interest to declare.

Determinants for malignancy in surgically treated adrenal lesions

It is difficult to definitively rule out or establish malignancy pre-operatively in patients with adrenal lesions referred for adrenal surgery. The aim of this study was to identify risk factors for a malignant diagnosis in patients treated with adrenalectomy. Consecutive adrenalectomies at the Department of Surgery, Lund University Hospital between 2000 and 2009 were identified. Pre-operative clinical, radiological and biochemical data, as well as details on the operation and histology, were retrieved from patients' medical records. There were 175 adrenal operations in 172 patients (98 female and 77 male). There were 28 malignancies. Malignant tumours were larger than in benign cases (p = 0.003), had radiological signs of malignancy more often (p = 0.001) and the patients were more likely to have a history of malignancy (p = 0.001). There were no differences regarding age, gender, body mass index or mode of detection (incidental vs. clinical) between patients with benign and malignant diagnoses. A unilateral uptake on fluorine-18 deoxyglucose positron emission tomography was more frequent in malignant cases than in benign; however, this association did not reach statistical significance. Size of adrenal lesion, suspicious radiological findings and history of malignancy were factors associated with malignancy.

Fluorine-18 deoxyglucose Positron Emission Tomography, Magnetic Resonance Imaging and Bone Scintigraphy for the Diagnosis of Bone Metastases in Patients with Lung Cancer: Which One is the Best? – a Meta-analysis

Aims To carry out a meta-analysis to compare fluorine-18 deoxyglucose ( 18FDG) positron emission tomography (PET), magnetic resonance imaging (MRI) and bone scintigraphy imaging for the diagnosis of bone metastases in patients with lung cancer. Materials and methods MEDLINE, EMBASE, Scopus and other databases were searched for relevant original articles published between January 1995 and January 2010. Inclusion criteria were as follows: 18FDG PET, MRI or 99mTc-MDP bone scintigraphy was carried out to detect bone metastases in patients with lung cancer; sufficient data were presented to construct a 2 × 2 contingency table; histopathological analysis and/or close clinical and imaging follow-up and/or radiographic confirmation by multiple imaging modalities were used as the reference standard. Two reviewers independently extracted data. META-DiSc was used to obtain pooled estimates of sensitivity, specificity, diagnostic odds ratio (DOR), summary receiver operating characteristic (SROC) curves and the *Q index. Results In total, 14 articles that consisted of 34 studies fulfilled all inclusion criteria. On a per-patient basis, the pooled sensitivity estimates for PET, MRI and bone scintigraphy were 91.9, 80.0 and 91.8%, respectively. The sensitivity for PET and bone scintigraphy were significantly higher than for MRI ( P < 0.05). There was no significant difference between PET and bone scintigraphy ( P > 0.05). The pooled specificity estimates for PET, MRI and bone scintigraphy were 96.8, 90.6 and 68.8%, respectively. The specificity for PET was significantly higher than for MRI and bone scintigraphy ( P < 0.05), and the specificity for MRI was significantly higher than for bone scintigraphy ( P < 0.05). The pooled DOR estimates for PET, MRI and bone scintigraphy were 365.5, 53.8 and 34.4, respectively. The DOR for PET was significantly higher than for MRI and bone scintigraphy ( P < 0.05). There was no significant difference between MRI and bone scintigraphy ( P > 0.05). The SROC curve for PET showed better diagnostic accuracy than for MRI and bone scintigraphy. The SROC curve for MRI was better than for bone scintigraphy. The *Q index estimates for PET, MRI and bone scintigraphy were 0.933, 0.903 and 0.857, respectively. The *Q index for PET and MRI were significantly higher than for bone scintigraphy ( P < 0.05). There was no significant difference between PET and MRI ( P > 0.05). On a per-lesion basis, the pooled sensitivity estimates for PET, MRI and bone scintigraphy were 95.0, 83.8 and 71.5%, respectively. The sensitivity for PET was significantly higher than for MRI and bone scintigraphy ( P < 0.05), and the sensitivity for MRI was significantly higher than for bone scintigraphy ( P < 0.05). The pooled specificity estimates for PET, MRI and bone scintigraphy were 94.6, 96.3 and 91.0%, respectively. The specificity for MRI was significantly higher than for PET and bone scintigraphy ( P < 0.05), and the specificity for PET was significantly higher than for bone scintigraphy ( P < 0.05). The pooled DOR estimates for PET, MRI and bone scintigraphy were 431.9, 158.1 and 9.0, respectively. The DOR for PET was significantly higher than for MRI and bone scintigraphy ( P < 0.05) and the DOR for MRI was significantly higher than for bone scintigraphy ( P < 0.05). The SROC curve for PET and MRI showed better diagnostic accuracy than for bone scintigraphy. There was no significant difference between PET and MRI. The *Q index estimates for PET, MRI and bone scintigraphy were 0.953, 0.962 and 0.778, respectively. The *Q index for PET and MRI were significantly higher than for bone scintigraphy ( P < 0.05). There was no significant difference between PET and MRI ( P > 0.05). Conclusion 18FDG PET was found to be the best modality to detect bone metastasis in patients with lung cancer, both on a per-patient basis and a per-lesion basis; MRI had the highest specificity on a per-lesion basis. For the subgroup analysis of 18FDG PET, PET/computed tomography was shown to be better than PET and there were no significant differences between using 68Ge and computed tomography for attenuation correction on a per-patient basis.

ACR Appropriateness Criteria® on Metastatic Bone Disease

Appropriate imaging modalities for screening, staging, and surveillance of patients with suspected and documented metastatic disease to bone include (99m)Tc bone scanning, MRI, CT, radiography, and 2-[(18)F]fluoro-2-deoxyglucose-PET. Clinical scenarios reviewed include asymptomatic stage 1 breast carcinoma, symptomatic stage 2 breast carcinoma, abnormal bone scan results with breast carcinoma, pathologic fracture with known metastatic breast carcinoma, asymptomatic well-differentiated and poorly differentiated prostate carcinoma, vertebral fracture with history of malignancy, non-small-cell lung carcinoma staging, symptomatic multiple myeloma, osteosarcoma staging and surveillance, and suspected bone metastasis in a pregnant patient. No single imaging modality is consistently best for the assessment of metastatic bone disease across all tumor types and clinical situations. In some cases, no imaging is indicated. The recommendations contained herein are the result of evidence-based consensus by the ACR Appropriateness Criteria((R)) Expert Panel on Musculoskeletal Radiology.

The Prognostic Value of Residual FDG-Avidity Prior to Allogeneic Stem Cell Transplantation for Lymphoma.

Abstract 1200Poster Board I-222 Background:Chemosensitive disease, as determined by computed tomography (CT) or fluorine-18-deoxyglucose positron emission tomography (FDG-PET), is required for successful autologous hematopoietic stem cell transplant (autoHSCT) in patients with aggressive non-Hodgkin's lymphoma (NHL) and Hodgkin lymphoma (HL). However, whether chemosensitivity, as determined by FDG-PET, is a requirement for successful allogeneic hematopoietic stem cell transplantation (alloHSCT) has yet to be established. Therefore, we analyzed the survival of alloHSCT recipients transplanted at MSKCC between 2001-2007 for the treatment of relapsed or refractory NHL and HL who had both FDG-PET and CT imaging to assess response prior to alloHSCT. Our hypothesis is that FDG-PET prior to alloHSCT will add prognostic information compared to CT scan alone prior to alloHSCT. Methods:Thirty-seven lymphoma patients had combined pre-alloHSCT imaging (10 aggressive NHL, 12 indolent NHL, and 15 HL by WHO classification). Patients were scored as either complete remission (CR), partial remission (PR) or stable disease (SD) by CT according to previously published criteria (Cheson et al. JCO 1999). For the purposes of analysis, patients with PR or SD were classified together as non-CR. FDG-PET was scored as either positive, if FDG-avid disease was measurable on corresponding imaging (CT or magnetic resonance imaging), or FDG-negative prior to alloHSCT. Patients with progression of disease prior to alloHSCT by either FDG-PET and/or CT were excluded in view of their historically poor survival following alloHSCT. Results:The median age was 42 years (range 18-66) with 5 patients receiving myeloablative (MA) conditioning while the remainder received non-myeloablative (NMA) conditioning. Seventeen (46%) had received prior autologous transplants. Thirteen patients were transplanted with HLA-identical related donors (1 mismatched related donor) and the remaining 23 patients from unrelated donors (12 fully HLA-matched and 11 mismatched). Twenty-four (65%) of the patients were FDG-negative and 16 (43%) were in CR by CT prior to alloHSCT. Disparity between CT and FDG-PET response was observed in 8 FDG-PET negative patients (5 SD and 3 PR by CT). With a median follow-up for survivors of 38 months (range 9-92), the Kaplan-Meier estimates of overall (OS) and progression free survival (PFS) at 3 years post-alloHSCT were 64% and 56%, respectively. There was no significant difference in survival according to age < or ≥ 40 years, prior autoHSCT, conditioning intensity (MA or NMA) or WHO classification. FDG-negative patients had significant OS (Figure) and PFS improvement compared to FDG-positive patients (p=0.006 and p=0.02, respectively). Patients in CR had improved OS compared to those in PR/SD by CT imaging (p=0.02), however improvement in PFS was not significant (p=0.13). Patients that were FDG-PET negative and CT CR (n=16) had 88% OS at 3 years compared to 63% in the 8 patients that were FDG-PET negative and CT non-CR, although this difference was not significant (p=0.22). Conclusion:Response to therapy prior to alloHSCT as determined by FDG-PET offers critical prognostic information beyond traditional cross-sectional CT imaging considering the significant improvement in both OS and PFS. These data suggests that the goal of therapy prior to alloHSCT should be to normalize FDG-PET independent of tumor bulk. Prospective investigation is warranted to validate this conclusion. [Display omitted] Disclosures:No relevant conflicts of interest to declare.

The Role of FDG-PET in the Selection of Patients with Colorectal Liver Metastases

Selection of patients for hepatic resection of colorectal liver metastases is still limited. After conventional work up by computed tomography (CT) scan, 60% of patients will develop recurrent disease in the early years after resection. The aim of the present study was to evaluate whether an additional fluorine-18-deoxyglucose positron emission tomography (FDG-PET) improves patient selection and therefore adds value to select patients for curative liver resection. Data from 203 patients selected for surgical treatment of colorectal liver metastases between 1995 and 2003 were collected in a prospective database. Group A consisted of 100 consecutive patients selected for hepatic surgery by conventional diagnostic imaging (CT chest and abdomen) only. Group B consisted of 103 consecutive patients selected for hepatic surgery by conventional diagnostic methods plus an additional FDG-PET. The number of patients with futile surgery, in which further treatment was considered inappropriate at laparotomy, was 28.0% in group A and 19.4% in group B. The reason for unresectable disease differed between groups. In group A, 10/100 (10.0%) patients showed extrahepatic abdominal disease versus 2/103 patients (1.9%) in group B (P = .017). In all other cases, resection was not performed because liver disease proved too extensive at laparotomy. For patients ultimately undergoing surgical treatment of the metastases, survival was comparable between groups. Overall survival at 3 years was 57.1% in group A versus 60.1% in group B. Disease-free survival at 3 years was 23.0% in group A and 31.4% in group B. In patients with colorectal liver metastases, FDG-PET may reduce the number of negative laparotomies. However, the effect size on the selection of these patients seems not sufficient enough to affect the overall and disease-free survival after treatment.

Pneumoconiosis Associated with an Esophageal Ulcer and Uptake Revealed in FDGPET

A 76-year-old man with a past history of pneumoconiosis visited the Department of Gastroenterology in our hospital suffering from dysphagia. Gastroscopy revealed an esophageal ulcer on the top of a torus lesion. Chest computed tomography (CT) revealed it was caused by a swollen lymph node in the mediastinum. Squamous cell carcinoma related antigen (SCC) was elevated to 1.8 ng/ml. To rule out malignancy, we performed fluorine-18 deoxyglucose positron emission tomography (FDGPET) which revealed a significantly increased uptake in a nodular lesion in the right upper lobe and mediastinal lymph nodes. Biopsy and cytology of the nodular lesion revealed only pneumoconiosis. We must be careful when we interpret the findings of FDGPET in pneumoconiosis patients.

Relation of End-Diastolic Wall Thickness and the Residual Rim of Viable Myocardium by Magnetic Resonance Imaging to Myocardial Viability Assessed by Fluorine-18 Deoxyglucose Positron Emission Tomography

End-diastolic wall thickness (EDWT) and thickness of the residual non-contrast-enhanced myocardial rim have been suggested as markers for the assessment of myocardial viability by cardiovascular magnetic resonance (CMR) imaging. This study compared these parameters as derived from contrast-enhanced CMR images for the prediction of myocardial viability as determined by fluorine-18 deoxyglucose positron emission tomography (FDG-PET). Twenty-two patients with ischemic cardiomyopathy (ejection fraction 31 +/- 11%) were investigated. For contrast-enhanced CMR imaging, a standard inversion-recovery sequence was used. FDG-PET was performed using a hyperinsulinemic-euglycemic clamp. Data were analyzed with a 17-segment model. Of 146 severely dysfunctional segments, 112 were assessed as viable and 34 as nonviable by nuclear imaging. Using receiver-operator characteristic analysis, areas under the curve were 0.95 for unenhanced myocardial rim (95% confidence interval 0.92 to 0.98) and 0.86 for EDWT (95% confidence interval 0.80 to 0.93, p <0.001 vs unenhanced myocardial rim) for the prediction of viability as assessed by FDG-PET. Cutoffs of 5.4 mm for EDWT and 3.0 mm for unenhanced myocardial rim were found to optimally differentiate viability by FDG-PET. In 25 segments with divergent results, 94% of segments with an EDWT < or =5.4 mm and an unenhanced myocardial rim >3.0 mm were scored as viable by FDG-PET, whereas 57% of segments with an EDWT >5.4 mm and an unenhanced myocardial rim < or =3.0 mm were scored nonviable with the reference technique. In conclusion, unenhanced myocardial rim is superior to EDWT for the prediction of myocardial viability as determined by FDG-PET and may be clinically useful for assessment of myocardial viability in patients with ischemic cardiomyopathy and regional wall thinning.

Intense PET Signal in the Degenerative Necrosis Superimposed on Chronic Pancreatitis

Although fluorine-18 deoxyglucose-positron emission tomography (FDG-PET) is a sensitive diagnostic modality in detecting malignant tumors, differential diagnosis of malignant tumors from inflammatory lesion is challenging. We experienced a case of acute degenerative necrosis superimposed on chronic pancreatitis, which was difficult to distinguish from pancreatic cancer. The patient was a 66-year-old man with a complaint of upper abdominal pain. Abdominal computed tomography revealed low-density masses in the head and body of the pancreas. FDG-PET revealed intense accumulations at the head and body of the pancreas (mean standard uptake value for the head and body pancreatic tumors was 4.1 and 6.7, respectively) corresponding to the 2 tumors detected by computed tomography. Because of a possible malignant pancreatic tumor, the patient underwent pylorus-preserving pancreatoduodenectomy. Histologic examination of the resected specimen revealed a characteristic of chronic pancreatitis in a nontumorous area. Two tumors detected by FDG-PET consisted of degenerative necrosis surrounded by granulation tissue. The amount of granulation tissue was correlated to the levels of standard uptake value. No malignant tumors were observed. This case suggests a limitation of FDG-PET in distinguishing malignant neoplastic lesions in the pancreas, especially from acute degenerative changes in chronic pancreatitis. Repetitive PET examination is recommended for the accurate diagnosis.

Bupropion and venlafaxine responders differ in pretreatment regional cerebral metabolism in unipolar depression

Pretreatment functional brain imaging was examined for never-hospitalized outpatients with unipolar depression compared with control subjects in a crossover treatment trial involving bupropion or venlafaxine monotherapy. Patients (n = 20) with unipolar depression received baseline (medication-free) fluorine-18 deoxyglucose (FDG) positron emission tomography (PET) scan and then at least 6 weeks of bupropion or venlafaxine monotherapy in a single-blind crossover trial. Age-matched healthy control subjects (n = 20) also received baseline FDG PET scans. For each medication PET data from patients compared with control subjects was analyzed as a function of treatment response (defined as moderate to marked improvement on the Clinical Global Impression Scale). Treatment response rates were similar for buproprion (32%) and venlafaxine (33%). Compared with control subjects, responders but not nonresponders, to both drugs demonstrated frontal and left temporal hypometabolism. Selectively, compared with control subjects bupropion responders (n = 6) also had cerebellar hypermetabolism, whereas venlafaxine responders (n = 7) showed bilateral temporal and basal ganglia hypometabolism. These data suggest that pretreatment frontal and left temporal hypometabolism in never-hospitalized depressed outpatients compared with control subjects is linked to positive antidepressant response and that additional alterations in regional metabolism may be linked to differential responsivity to bupropion and venlafaxine monotherapy.

Assessment of myocardial viability in dysfunctional myocardium by resting myocardial blood flow determined with oxygen 15 water PET

Background. There is controversy about the role of decreased resting blood flow as the pathophysiologic correlate of hibernating myocardium. The aim of this study was an absolute quantification of volumetric myocardial blood flow (MBFvol) in dysfunctional myocardium with different viability conditions as defined by fluorine 18 deoxyglucose (FDG) positron emission tomography (PET) while taking into consideration the functional recovery after revascularization. The impact of MBFvol in the diagnosis of functional recovery was also investigated. Methods and Results. Forty-two patients with severe coronary artery disease and dysfunctional myocardium underwent resting oxygen 15 water PET, as well as FDG PET and technetium 99m tetrofosmin single photon emission computed tomography, all attenuation-corrected. Relative FDG and Tc-99m tetrofosmin uptake (normalized to the segment with 100% Tc-99m tetrofosmin uptake), as well as MBFvol (myocardial blood flow multiplied by the water-perfusable tissue fraction to account for the flow to the entire segment volume), were determined in 18 myocardial segments per patient. Viability in dysfunctional segments (estimated by ventriculography) with reduced Tc-99m tetrofosmin uptake of 70% or lower was classified as viable (FDG >70%, mismatch) or nonviable (FDG ≤70%, match). Fifteen patients underwent revascularization and were followed up. Mismatch segments with improved function were classified as hibernating myocardium. Mean MBFvol in viable myocardium was slightly reduced (0.60 ± 0.02 mL · min–1 · mL–1) compared with that in normokinetic myocardium (0.64 ± 0.01 mL · min–1 · mL–1) (P = .036) and was significantly higher than in nonviable myocardium (0.36 ± 0.01 mL · min–1 · mL–1) (P < .001). Receiver operating characteristic analysis confirmed an FDG uptake greater than 70% as the optimal threshold to predict functional recovery (diagnostic accuracy [ACC], 76%). MBFvol in hibernating myocardium (0.62 ± 0.04 mL · min–1 · mL–1) was not significantly reduced compared with that in normokinetic myocardium (0.66 ± 0.02 mL · min–1 · mL–1) and was significantly higher than in persistently dysfunctional myocardium (0.51 ± 0.04 mL · min–1 · mL–1) (P < .05). The ACC of MBFvol greater than 0.40 mL · min–1 · mL–1 as the threshold to predict functional recovery was 61% but did not improve the accuracy of FDG PET by itself. Conclusions. In patients with severe coronary artery disease and dysfunctional myocardium, MBFvol as determined with O-15 water differs significantly between viable and nonviable myocardium as determined by FDG PET and is not significantly reduced in hibernating compared with normokinetic myocardium. Therefore chronically reduced resting blood flow appears unlikely to be the pathophysiologic correlate of the functional state of hibernation. However, MBFvol does not improve the ACC of FDG PET by itself. (J Nucl Cardiol 2003;10:34-45)

Regional cerebral glucose utilization in patients with a range of severities of unipolar depression

Background: Patients with unipolar depression are most often reported to have decreased regional cerebral glucose metabolism (rCMRglu) in dorsal prefrontal and anterior cingulate cortices compared with healthy control subjects, often correlating inversely with severity of depression. Methods: We measured rCMRglu with fluorine-18 deoxyglucose positron emission tomography (PET) in 38 medication-free patients with unipolar depression and 37 healthy control subjects performing an auditory continuous performance task to further investigate potential prefrontal and anterior paralimbic rCMRglu abnormalities in patients attending to this task. Results: Compared with control subjects, the subgroup of patients with Hamilton depression scores of 22 or greater demonstrated decreased absolute rCMRglu in right prefrontal cortex and paralimbic/amygdala regions as well as bilaterally in the insula and temporoparietal cortex (right > left); they also exhibited increased normalized metabolic activity bilaterally in the cerebellum, lingula/cuneus, and brain stem. Severity of depression negatively correlated with absolute rCMRglu in almost the entire extent of the right cingulate cortex as well as bilaterally in prefrontal cortex, insula, basal ganglia, and temporoparietal cortex (right > left). Conclusions: Areas of frontal, cingulate, insula, and temporal cortex appear hypometabolic in association with different components of the severity and course of illness in treatment-resistant unipolar depression.