High Standardized Uptake Value Research Articles

18F]fluorodeoxyglucose uptake as a predictor of large joint destruction in patients with rheumatoid arthritis.

The present retrospective study investigated the relationship between [(18)F]fluorodeoxyglucose-positron emission tomography (FDG-PET) findings and subsequent progression of joint destruction on plain X-ray. Nineteen rheumatoid arthritis (RA) patients (59 joints) who underwent FDG-PET and whose joints could be evaluated on plain X-ray 5 years later were included in this retrospective investigation. The relationship between the standardized uptake value (SUV) on FDG-PET and Larsen grade progression on plain X-ray was investigated for each joint. Factors related to progression of joint destruction were also investigated. Joints with advanced joint destruction (Larsen grades IV and V) on X-ray imaging at the time of FDG-PET were excluded. On initial plain X-ray images taken at the time of FDG-PET, a significant correlation was observed between the initial SUV of each joint and the progression of joint destruction 5 years later (R = 0.47, P < 0.01). Significant correlations between the SUV and progression of joint destruction were observed in both load-bearing (R = 0.52, P < 0.01) and non-load-bearing joints (R = 0.52, P < 0.01). On logistic regression analysis, higher SUV and lower prednisolone dose were associated with greater risk of progressive joint destruction (P < 0.05). On receiver operating characteristics curve analysis, the optimum threshold for identifying preceding joint destruction was an SUVmean of 1.33. In RA joints, FDG uptake was seen mostly by inflammatory cells; therefore, FDG uptake reflected joint inflammation. Additionally, the activity seen on FDG-PET might be associated with future radiographic changes in RA patients.

Abstract 1486: Fatty acid and phospholipid profiling of liver tumor tissue: correlation with in vivo molecular PET imaging of phosphocholine synthesis

Abstract Alterations in phospholipid and fatty acid metabolism may play key roles in hepatocarcinogenesis. Phosphocholine synthesis can be imaged and quantified in-vivo by positron emission tomography (PET) using radiopharmaceuticals bearing the choline moiety. Results from this PET assessment of tissue phospholipid metabolism were compared to phospholipid and fatty acid profiles of both tumor and liver parenchymal tissues in patients with liver cancer undergoing hepatectomy. Fluorine-18 fluorocholine PET/CT of the liver was completed &amp;lt;2 weeks prior to surgery as part of a clinicaltrials.gov-registered (NCT01395030) IRB-approved clinical study with written informed consent. Paired tumor and parenchymal tissue samples were collected in liquid nitrogen (20 hepatocellular carcinoma, 3 with intrahepatic cholangiocarcinoma), freeze-dried, homogenized and extracted with methanol/CHCl3/water containing BHT as preservative. The organic phase was analyzed by orbitrap LCMS after electrospray ionization in positive mode to quantify fatty acids (after derivatization) and phospholipid metabolites. Tumor and liver standardized uptake value (SUV) measurements were obtained from static PET images. Tumors exhibited significantly lower levels of docosahexaenoic acid, docasopentanoic acid, alpha-linolenic acid and significantly higher levels of palmitoleic acid, eicosadienoic acid, arachadonic acid, and linoleic acid than peritumoral liver tissue. Tumors also exhibited significantly higher SUVs than surrounding liver. Highest tumor SUV correlated significantly with tumor levels of palmitoleic acid, gamma linolenic acid, CDP choline, phosphatidylcholine, phosphatidylethanolamine and phosphatidylinsolitol. In contrast, no significant correlations were noted between tumor SUV and peri-tumoral levels of these compounds. Peritumoral liver SUV was significantly correlated with levels of myristic acid, eicosaptaenoic acid, gamma-linolenic acid, palmitoleic acid, docosapentaenoic acid, linoleic acid, oleic acid, and palmitic acid in peritumoral liver tissue. Furthermore, parenchymal liver SUV was inversely correlated with the Knodell histologic activity index (HAI), as well as histologic features of portal inflammation, piecemeal necrosis, and fibrosis. These histology features were also inversely correlated with liver tissue concentrations of docosahexaenoic acid, CDP-choline, total phosphaticylcholine, and total phosphatidylinositol. No significant correlations were found between tumor fatty acid/phospholipid levels and Edmonson-Steiner tumor grade. These preliminary results may indicate multiple inter-related metabolic alterations involving phospholipid and fatty acid metabolism in primary liver cancer. Chronic liver disease appears to be associated with diminishing hepatic phospholipid reserve. Note: This abstract was not presented at the meeting. Citation Format: Sandi Alexander Kwee, Adrian A. Franke, Laurie J. Custer, Xingnan Li, Linda L. Wong. Fatty acid and phospholipid profiling of liver tumor tissue: correlation with in vivo molecular PET imaging of phosphocholine synthesis. [abstract]. In: Proceedings of the 106th Annual Meeting of the American Association for Cancer Research; 2015 Apr 18-22; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Res 2015;75(15 Suppl):Abstract nr 1486. doi:10.1158/1538-7445.AM2015-1486

XV. Clinical aspects of transformed lymphoma.

XV. Clinical aspects of transformed lymphoma.

Positron Emission Tomography/Computed Tomography for the Pleural Staging of Malignant Pleural Mesothelioma: How Accurate Is It?

Background: Careful clinical staging in patients with malignant pleural mesothelioma (MPM) is fundamental in management planning. Positron emission tomography/computed tomography (PET/CT) is increasingly recognized as an important staging modality. Objectives: The purpose of this study was to assess whether the metabolic activity of the pleural tumor detected with PET/CT correlates with specific endoscopic features and pleural distribution of the lesions as assessed by medical thoracoscopy. Methods: Consecutive patients with MPM and available PET/CT performed before thoracoscopy were separated into 2 groups, according to their standardized uptake value (SUV). Kaplan-Meier-analysis for survival was performed on groups with low and high SUV. Agreement between PET/CT and thoracoscopy evaluation was analyzed using Cohen's kappa coefficient. The Wilcoxon test was used to compare the median SUV, and the χ² test was used to evaluate differences in endoscopic findings. Results: A total of 32 patients were included. The median maximum SUV (SUV max) was 6.1 and patients were separated into 2 groups based on this cutoff. Patients with SUV max <6.1 had a better survival than those with SUV max ≥6.1 (p = 0.005). The comparison between PET/CT and thoracoscopy showed a fair agreement for visceral and diaphragmatic pleural involvement and moderate agreement for the presence of nodular lesions. There was a statistically significant association between median SUV max and visceral pleural involvement; nodular lesions and visceral pleural involvement were more common in the high-SUV group than in the low-SUV group (p = 0.0012 and p = 0.03, respectively). Conclusions: PET/CT data may be predictive of thoracoscopic features of MPM associated with prognosis and staging, but the correlation is moderate at best. A degree of disagreement exists between these two modalities, which supports thoracoscopy as the gold standard for assessment of local invasion in MPM.

CORRELATION BETWEEN STANDARDIZED UPTAKE VALUE AND HISTOPATHOLOGY OF OESOPHAGEAL CARCINOMA: A SINGLE CENTER ANALYSIS

Aim: This study aims to evaluate the correlation between oesophageal cancer histopathology and the standardised uptake value (SUV) of the primary lesion on positron emission tomography/computed tomography (PET/CT) scan.Methods: We reviewed clinical data of consecutive newly diagnosed oesophageal cancer patients who underwent positron emission tomography with 2-deoxy-2-[ uorine-18] uoro-D glucose integrated with CT (18F-FDG PET/CT) between September 2009 and July 2014. Results: A total of 289 baseline scans were performed in this 55-month period. Of these, 171 (59%) were male. The mean age was 52.6 years (standard deviation ± 12.4 years). On histological review, 214 were squamous cell carcinomas (SCCa) and 75 were adenocarcinomas. Of the SCCa, 15.9% were poorly differentiated, 70.6% were moderately differentiated and 13.5% were well differentiated. Of the adenocarcinomas, 20% were poorly differentiated, 45% were moderately differentiated, 28% were well differentiated and signet ring cell was 7%. Mean maximum SUV (SUVmax) for SCCa was 12.6 ± 5.14 and 10.5 ± 6.2 for adenocarcinomas. In bivariate analysis, being a female was associated with a higher SUV in the primary lesion by 1.66 units (P = 0.011) compared to males. Adenocarcinomas were associated with a lower SUV by 2.14 units (P = 0.004) compared to SCCa. In bivariate analysis, no signi cant correlation was found between the T-stage of the tumour and the SUVmax of the primary tumour (P = 0.339). Multivariate analyses showed no association of the SUV of the primary oesophageal tumour with the degree of differentiation of either SCCa or adenocarcinoma. There was no correlation between the SUVmax of the primary lesion and the presence or activity level of a metastatic focus, whether visceral or nodal. Conclusion: At our centre, three-fourths of patients with oesophageal carcinoma had squamous cell carcinoma on histology. Adenocarcinoma is associated with a lower SUV compared to SCCa. There is no association between the SUVmax and degree of differentiation of the primary oesophageal cancer. Key words: Fluorodeoxyglucose, oesophageal adenocarcinoma, oesophageal squamous cell carcinoma, positron emission tomography/computed tomography, standardised uptake value

Results of 68Gallium-DOTATATE PET/CT Scanning in Patients with Multiple Endocrine Neoplasia Type 1

Screening for neuroendocrine tumors (NETs) in patients with multiple endocrine neoplasia type 1 (MEN1) is recommended to detect primary and metastatic tumors, which can result in significant morbidity and mortality. The utility of somatostatin receptor imaging (68)Gallium-DOTATATE PET/CT in patients with MEN1 is not known. The aim of this study was to prospectively determine the accuracy of (68)Gallium-DOTATATE PET/CT vs (111)In- pentetreotide single-photon emission CT (SPECT)/CT and anatomic imaging in patients with MEN1. We performed a prospective study comparing (68)Gallium-DOTATATE PET/CT, (111)In-pentetreotide SPECT/CT, and triphasic CT scan to clinical, biochemical, and pathologic data in 26 patients with MEN1. (68)Gallium-DOTATATE PET/CT detected 107 lesions; (111)In-pentetreotide SPECT/CT detected 33 lesions; and CT scan detected 48 lesions. Lesions detected on (68)Gallium-DOTATATE PET/CT had high standard uptake value (SUV)(max) (median SUV(max) = 72.8 [range 19 to 191]). In 7 of the 26 patients (27%), (68)Gallium-DOTATATE PET/CT was positive, with a negative (111)In-pentetreotide SPECT/CT, and in 10 patients (38.5%), additional metastases were detected (range 0.3 cm to 1.5 cm). In 8 of the 26 patients (31%), there was a change in management recommendations as a result of the findings on (68)Gallium-DOTATATE PET/CT that were not seen on (111)In-pentetreotide SPECT/CT and CT scan. (68)Gallium-DOTATATE PET/CT is more sensitive for detecting NETs than (111)In-pentetreotide SPECT/CT and CT scan in patients with MEN1. This imaging technique should be integrated into radiologic screening and surveillance of patients with MEN1 because it can significantly alter management recommendations.

18F-FDG-PET/CT parameters as imaging biomarkers in oral cavity squamous cell carcinoma, is visual analysis of PET and contrast enhanced CT better than the numbers?

PurposeThis study was designed to seek associations between positron emission tomography/computed tomography (PET/CT) parameters, contrast enhanced neck computed tomography (CECT) and pathological findings, and to determine the potential prognostic value of PET/CT and CECT parameters in oral cavity squamous cell carcinoma (OCSCC). Materials and method36 OCSCC patients underwent staging PET/CT and 30/36 of patients had CECT. PET/CT parameters were measured for the primary tumor and the hottest involved node, including maximum, mean, and peak standardized uptake values (SUV max, SUV mean, and SUV peak), metabolic tumor volume (MTV), total lesion glycolysis (TLG), standardized added metabolic activity (SAM), and normalized standardized added metabolic activity (N SAM). Qualitative assessment of PET/CT and CECT were also performed. Pathological outcomes included: perineural invasion, lymphovascular invasion, nodal extracapsular spread, grade, pathologic T and N stages. Multivariable logistic regression models were fit for each parameter and outcome adjusting for potentially confounding variables. Multivariable Cox proportional hazards models were used for progression free survival (PFS), locoregional recurrence free survival (LRFS), overall survival (OS) and distant metastasis free survival (DMFS). ResultsIn multivariable analysis, patients with high (≥ median) tumor SUV max (OR 6.3), SUV mean (OR 6.3), MTV (OR 19.0), TLG (OR 19.0), SAM (OR 11.7) and N SAM (OR 19.0) had high pathological T-stage (T3/T4) (p<0.05). Ring/heterogeneous pattern on CECT qualitative assessment was associated with worse DMFS and OS. ConclusionHigh PET/CT parameters were associated with pathologically advanced T stage (T3/T4). Qualitative assessment of CECT has prognostic value. PET/CT parameters did not predict clinical outcome.

Molecular Imaging Biomarkers of Resistance to Radiation Therapy for Spontaneous Nasal Tumors in Canines

Imaging biomarkers of resistance to radiation therapy can inform and guide treatment management. Most studies have so far focused on assessing a single imaging biomarker. The goal of this study was to explore a number of different molecular imaging biomarkers as surrogates of resistance to radiation therapy. Twenty-two canine patients with spontaneous sinonasal tumors were treated with accelerated hypofractionated radiation therapy, receiving either 10 fractions of 4.2 Gy each or 10 fractions of 5.0 Gy each to the gross tumor volume. Patients underwent fluorodeoxyglucose (FDG)-, fluorothymidine (FLT)-, and Cu(II)-diacetyl-bis(N4-methylthiosemicarbazone) (Cu-ATSM)-labeled positron emission tomography/computed tomography (PET/CT) imaging before therapy and FLT and Cu-ATSM PET/CT imaging during therapy. In addition to conventional maximum and mean standardized uptake values (SUV(max); SUV(mean)) measurements, imaging metrics providing response and spatiotemporal information were extracted for each patient. Progression-free survival was assessed according to response evaluation criteria in solid tumor. The prognostic value of each imaging biomarker was evaluated using univariable Cox proportional hazards regression. Multivariable analysis was also performed but was restricted to 2 predictor variables due to the limited number of patients. The best bivariable model was selected according to pseudo-R(2). The following variables were significantly associated with poor clinical outcome following radiation therapy according to univariable analysis: tumor volume (P=.011), midtreatment FLT SUV(mean) (P=.018), and midtreatment FLT SUV(max) (P=.006). Large decreases in FLT SUV(mean) from pretreatment to midtreatment were associated with worse clinical outcome (P=.013). In the bivariable model, the best 2-variable combination for predicting poor outcome was high midtreatment FLT SUV(max) (P=.022) in combination with large FLT response from pretreatment to midtreatment (P=.041). In addition to tumor volume, pronounced tumor proliferative response quantified using FLT PET, especially when associated with high residual FLT PET at midtreatment, is a negative prognostic biomarker of outcome in canine tumors following radiation therapy. Neither FDG PET nor Cu-ATSM PET were predictive of outcome.

Metabolic PET/CT-guided lung lesion biopsies: impact on diagnostic accuracy and rate of sampling error.

CT-guided fine-needle aspiration (FNA) of lung lesions is subject to sampling errors. The current study assessed whether information provided by (18)F-FDG PET/CT will decrease the false-negative (FN) rate and thus improve the accuracy of CT-guided FNA. Data from 311 consecutive patients with lung nodules who underwent (18)F-FDG PET/CT and CT-guided FNA within an interval of less than 30 d were retrospectively assessed. In-house-developed software was used to register CT images performed for the FNA procedure (CT FNA) with corresponding slices of the PET/CT study. The quality of registration was rated on a scale of 1 (excellent) to 5 (misregistration). Only cases scored 1 or 2 were further evaluated. The software provided the highest standardized uptake value (SUV) within the lesion and at the location of the tip of the aspirating needle. The distance between the tip and the area with the highest SUV within the lesion was measured. The mean distance from the tip of the needle to the focus with the highest SUV, as well as the mean difference between the maximum SUV in the whole lesion and at the needle tip, was calculated and compared for cases with true-positive (TP) and FN FNA results. Anatomic and metabolic parameters of lesions included in these 2 groups were also compared. There were 267 patients (86%) with score 1 or 2 registration quality for CT FNA and PET/CT/CT images, including 179 TP (67%), 5 false-positive (FP, 2%), 49 true-negative (TN, 18%), and 34 FN (13%) FNA results. The distance between the location of the needle tip and the focus with the highest SUV in the lesion was significantly greater in the FN group (15.4 ± 14 mm) than in the TP group (5.9 ± 13.4 mm, P < 0.001). The maximum SUV at the location of the aspirating needle tip was significantly higher in the TP group, at 6.4 ± 6.4, than in the FN group, at 4 ± 4.7 (P < 0.05). The present results demonstrate a relationship between the degree of metabolism at the site of tissue-sampling aspiration in lung lesions and the accuracy of FNA results. Anatomy- and metabolism-based FNA guidance using information provided by both (18)F-FDG PET and CT may improve the accuracy of histologic examinations, decrease the rate of FN results, and thus increase the probability of achieving a definitive diagnosis.

Multiparametric analysis of bone marrow in cancer patients using simultaneous PET/MR imaging: Correlation of fat fraction, diffusivity, metabolic activity, and anthropometric data.

To analyze the regional composition of bone marrow (BM) in correlation with metabolic activity and diffusivity using simultaneous positron emission tomography (PET)/MRI. Retrospective analysis of 18F-FDG-PET/MR scans of 110 patients was performed. A three-dimensional gradient-echo sequence with Dixon-based fat-water separation was used for fat quantification. Dixon images, diffusion-weighted images (DWI) and 18F-FDG-PET were co-registered. Mean values of fat fraction (FF), standardized uptake value (SUV), and apparent diffusion coefficient (ADC) of BM were measured in different anatomical regions. Correlation of FF, SUV, and ADC and association of BM fat content and metabolic activity with anthropometric data was analyzed (Pearson). BM fat content and metabolic activity was compared in patients with and without chemotherapy (t-test). Regional differences in BM were found with highest fat content (93 ± 8%) and lowest ADC (0.22 ± 0.18 × 10(-3) mm(2) /s) in the peripheral skeleton and highest SUV in the spine (1.77 ± 0.6). There was a significant inverse correlation between FF and SUV (r = -0.73; P < 0.0001) and a significant inverse correlation between FF and ADC (r = -0.62; P < 0.0001). In patients with chemotherapy, a tendency to higher fat content and lower metabolic activity was observed in the proximal skeleton, although no statistical significance was reached. BM shows distinct regional variations in FF, SUV, and ADC. The inverse correlation of FF and SUV in BM suggests that BM adipose tissue does not have a comparable high metabolic activity as brown adipose tissue.

The predictive value of metabolic tumor volume on FDG PET/CT for transarterial chemoembolization and transarterial chemotherapy infusion in hepatocellular carcinoma patients without extrahepatic metastasis.

The aim of this study was to evaluate the prognostic value of metabolic tumor volume (MTV) on pre-treatment F-18 fluorodeoxyglucose (FDG) PET/CT in patients with hepatocellular carcinoma (HCC). A total of 59 HCC patients who underwent FDG PET/CT before transarterial chemoembolization (TACE) or transarterial chemotherapy infusion (TACI) were retrospectively enrolled. The region of interest was drawn in the HCC and normal liver tissue. MTV2SD, defined as the sum of the voxels with higher standardized uptake values (SUV) than the SUV of the 97.5th percentile of voxels of the normal liver for each patient, was calculated using an intensity-volume histogram (IVH). The ratio of the maximum SUV of the tumor to the mean SUV of normal liver (T max/L mean) was also calculated. The prognostic significance of MTV2SD and Tmax/Lmean for progression-free survival (PFS) and overall survival (OS) was evaluated along with other clinical factors. The tumor number, Tmax/Lmean, and MTV2SD were significant prognostic factors affecting PFS (p<0.05), whereas tumor number, serum alpha-fetoprotein level, tumor stage, portal vein thrombosis, Tmax/Lmean, and MTV2SD were significant prognostic factors for OS (p<0.05). In multivariate analysis, the tumor number and MTV2SD were independent prognostic factors for PFS (p<0.05), whereas the independent prognostic factors for OS were tumor number, tumor stage, and MTV2SD (p<0.05). The mean PFS and OS in patients with low MTV2SD (15.4 and 63.1months, respectively) were significantly longer than those in patients with high MTV2SD (6.0 and 15.2months, respectively; p=0.005 and p<0.0001, respectively). Metabolic tumor volume was an independent prognostic factor for PFS and OS in patients with HCC. Therefore, FDG PET/CT can provide valuable prognostic information for HCC patients who undergo TACE or TACI.

Primary Tumor Standardized Uptake Value Predicts Survival in Head and Neck Squamous Cell Carcinoma

Background: The purpose of this study was to determine whether the pretreatment primary tumor standardized uptake value (SUV), as measured by positron emission tomography (PET), can add prognostic information for predicting survival in patients with head and neck squamous cell carcinoma (HNSCC). Materials and Methods: 7 articles were identified by searching electronic databases. Statistical analysis was performed with RevMan 4.2.2. SUV measurement and SUV threshold for defining high SUV were studied dependently. For each publication, we first obtained an estimate of the relative risk (RR) for comparing patients with a low or a high SUV. Subsequently, we aggregated the individual RRs into a combined RR, using a fixed-effect model. Publication bias was assessed using a funnel plot. Results: The study included 7 clinical trials dedicated to HNSCC, involving 674 patients who underwent fluoro-2-deoxy-<smlcap>D</smlcap>-glucose-PET scanning before treatment. The combined RR from the 7 reports for the survival was 0.53 (95% confidence interval: 0.46-0.62). The funnel plot showed symmetrical distribution, indicating no evidence of any substantial publication bias. Conclusion: Our meta-analysis indicates that patients with HNSCC who have a primary tumor with a high SUV have poor survival; this should be further confirmed in a meta-analysis based on individual patient data.

Diagnostic yield of non‐guided flexible bronchoscopy for peripheral pulmonary neoplasia

BackgroundThe role of conventional bronchoscopy for peripheral pulmonary neoplasia remains controversial. We aimed to assess the diagnostic yield and the added value of non-guided bronchial aspiration, bronchoalveolar lavage (BAL), and brushing for the diagnosis of pulmonary neoplasia not visible endoscopically.MethodsWe retrospectively assessed 207 consecutive patients with a final diagnosis of peripheral lung malignancy who underwent bronchoscopy with non-guided aspiration, brushing, and BAL as their initial evaluation. The influence of clinical and radiological factors on diagnostic yield was assessed using univariate logistic regression analyses.ResultsThe overall sensitivity of non-guided bronchoscopy was 25.6%, whereas sensitivities for bronchial aspiration, BAL, and brushing were 14.2%, 11.6%, and 16.5%, respectively. Younger age, larger lesion, central/intermediate distance from the hilum, presence of a bronchus sign, and higher standardized uptake value (SUV) on positron emission tomography scan were predictors of a higher diagnostic yield. Conversely, forced expiratory volume in one second, fellow implication in the procedure, and tumor histology did not influence sensitivity. The overall sensitivity of bronshoscopy was >40% for tumors >4 cm, located in the central/intermediate thirds of the lung, showing a bronchus sign, with an SUV >12 or occurring in patients <50 years of age. Conversely, the sensitivity was <10% for tumors <2 cm, located peripherally or with an SUV <4.ConclusionNeoplasia characteristics may help targeting situations in which conventional bronchoscopy could be used as the initial diagnostic procedure when advanced techniques are unavailable. However, advanced diagnostic tools should probably be proposed as the initial modality for the diagnosis of peripheral malignant lesions when available.

Primary Retroperitoneal Inflammatory Myofibroblastic Tumour.

Inflammatory myofibroblastic tumours are uncommon neoplasms of unknown aetiology. They commonly involve the lung and their occurrence in the retroperitoneum can be considered anecdotal. A 30-year-old female presented with dull aching, intermittent pain in the right flank for six months. There was a history of weight loss of 4kg over six months. There was no history of any medical co-morbidity or past surgical intervention. The clinical examination was normal. Haemogram revealed increased erythrocyte sedimentation rate but the serum biochemistry was within normal limits. Ultrasound examination of the abdomen was suggestive of a heterogeneous mass in close relation to the lower pole of the right kidney. Contrast enhanced CT scan revealed a 5 cm x 6 cm mass in the retroperitoneum, anterior to the right psoas muscle and in close relation to the lower pole of the right kidney. The mass showed contrast enhancement in the arterial phase and the enhancement persisted even in the delayed scan. There was evidence of fat stranding around the mass [Table/Fig-1a&b]. The possibility of a retroperitoneal sarcoma, Castleman’s disease and an inflammatory mass were considered. As the diagnosis was not certain, a CT guided tru-cut biopsy from the mass was performed which suggestive of an inflammatory myofibroblastic tumour. The metastatic work-up was negative. The patient was taken up for open surgical excision of the mass via right flank approach. At surgery, the mass was well circumscribed and could be separated from the kidney and the inferior venacava by blunt and sharp dissection [Table/Fig-2a-d]. The histopathological examination shows polymorphic cells composed of lymphocytes and plasma cells along with plump spindle cells arranged in fasicular pattern which is consistent with the diagnosis of inflammatory myofibroblastic tumour [Table/Fig-3]. The patient made an uneventful recovery and is well at a follow up of six months. [Table/Fig-1]: (a) Contrast enhanced CT scan showing the enhancing tumour (yellow arrow) in close proximity to the lower pole of the right kidney (red arrow) and inferior venacava. There was evidence of fat stranding all around the tumour. (b) The lower part of the ... [Table/Fig-2]: (a) At surgery, the tumour could be separated from the kidney. (b) The tumour, after mobilisation following blunt and sharp dissection. (c) The tumour after excision. (d) The cut section of the tumour [Table/Fig-3]: The histopathological picture of the tumour revealing polymorphic cells composed of lymphocytes and plasma cells along with plump spindle cells arranged in fasicular pattern (Haematoxylin & Eosin, 100X) Inflammatory myofibroblastic tumour, also known as pseudo tumour, plasma cell granuloma is a rare neoplasm. It is presumed to occur as a result of trauma, infection, previous surgical intervention, etc [1,2] and most often involves the bladder [3]. The patients usually present with non specific symptoms like pain abdomen, loss of weight, fever. Anaemia, elevated counts and erythrocyte sedimentation rate can also be seen. At imaging, the tumour usually shows heterogeneous enhancement but again, there are no specific features. Of late, Positron emission tomography has also been reported to be helpful. The tumour, by the virtue of associated inflammation, has been found to have high standardized uptake value on a 18F- fluorodeoxyglucose positron emission tomography. Though these findings support the diagnosis, histopathological examination along with immunohistochemistry remains the confirmatory investigation [4,5]. The retroperitoneal inflammatory myofibroblastic tumours are extremely rare neoplasms having non-specific symptoms and imaging findings. Surgical removal remains the mainstay of treatment.

Prognostic value of pretreatment (18)F-FDG PET-CT in radiotherapy for patients with hepatocellular carcinoma.

PurposeThe purpose of this study was to investigate the predictable value of pretreatment 18F-fluorodeoxyglucose positron emission tomography-computed tomography (18F-FDG PET-CT) in radiotherapy (RT) for patients with hepatocellular carcinoma (HCC) or portal vein tumor thrombosis (PVTT).Materials and MethodsWe conducted a retrospective analysis of 36 stage I-IV HCC patients treated with RT. 18F-FDG PET-CT was performed before RT. Treatment target was determined HCC or PVTT lesions by treatment aim. They were irradiated at a median prescription dose of 50 Gy. The response was evaluated within 3 months after completion of RT using the Response Evaluation Criteria in Solid Tumors (RECIST). Response rate, overall survival (OS), and the pattern of failure (POF) were analyzed.ResultsThe response rate was 61.1%. The statistically significant prognostic factor affecting response in RT field was maximal standardized uptake value (maxSUV) only. The high SUV group (maxSUV ≥ 5.1) showed the better radiologic response than the low SUV group (maxSUV < 5.1). The median OS were 996.0 days in definitive group and 144.0 days in palliative group. Factors affecting OS were the %reduction of alpha-fetoprotein (AFP) level in the definitive group and Child-Pugh class in the palliative group. To predict the POF, maxSUV based on the cutoff value of 5.1 was the only significant factor in distant metastasis group.ConclusionThe results of this study suggest that the maxSUV of 18F-FDG PET-CT may be a prognostic factor for treatment outcome and the POF after RT. A %reduction of AFP level and Child-Pugh class could be used to predict OS in HCC.

Prediction of Pathologic Grade and Prognosis in Mucoepidermoid Carcinoma of the Lung Using ¹⁸F-FDG PET/CT.

ObjectiveThe maximum standardized uptake value (SUVmax) of pulmonary mucoepidermoid carcinoma (PMEC) in fluorine-18fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT) was evaluated as a preoperative predictor of pathologic grade and survival rate.Materials and MethodsTwenty-three patients who underwent preoperative PET/CT and complete resection for PMEC were enrolled. The optimal cut-off SUVmax for tumor grade was calculated as 6.5 by receiver operating characteristic curve. The patients were divided into a high SUV group (n = 7) and a low SUV group (n = 16). Clinicopathologic features were compared between the groups by χ2 test and overall survival was determined by Kaplan-Meier analysis.ResultsThe mean SUVmax was 15.4 ± 11.5 in the high SUV group and 3.9 ± 1.3 in the low SUV group. All patients except one from the low SUV group had low grade tumors and all had no nodal metastasis. The sensitivity and specificity of SUVmax from PET/CT for predicting tumor grade was 85.7% and 93.8%, respectively. During the follow-up period (mean, 48.6 ± 38.7 months), four patients from the high SUV group experienced cancer recurrence, and one died of cancer. In contrast, none of the low SUV group had recurrence or mortality. Five-year overall survival rate was significantly higher in the low SUV group (100% vs. 71.4%, p = 0.031).ConclusionPulmonary mucoepidermoid carcinoma patients with high SUVmax in PET/CT had higher tumor grade, more frequent lymph node metastasis and worse long-term outcome. Therefore, PMEC patients with high uptake on PET/CT imaging might require aggressive mediastinal lymph node dissection and adjuvant therapies.

Utilization of 18F-FDG PET/CT as a staging tool in patients with newly diagnosed lymphoma

The aim of this study was to investigate the role of 2-fluorine-18-fluoro-2-deoxy-D-glucose (18F-FDG) positron emission tomography/computed tomography (PET/CT) in the initial staging and prediction of bone marrow involvement in patients with newly diagnosed lymphoma. A total of 185 patients with newly diagnosed lymphoma were enrolled. All patients received PET/CT and bone marrow biopsy as part of a staging work-up. At the initial staging, 17 patients (9.2%) with occult nodal or extranodal lesions were upstaged after a review of the PET/CT studies. PET/CT was found to be useful in the differentiation of aggressive lymphoma subtypes from the indolent subtype based on higher standardized uptake value (SUV) (16.67 vs. 7.98, p < 0.001). The results of bone marrow biopsy and PET/CT in the detection of bone marrow involvement were concordant in 152 patients (82.1%); positive concordance was observed in 21 patients, and negative concordance was observed in 131 patients. A high concordance rate was found between aggressive B cell lymphoma and Hodgkin's lymphoma (88.1% and 93.8%, respectively). High negative predictive values (NPVs) for excluding bone marrow involvement were observed in aggressive B-cell lymphoma (93.2%) and Hodgkin's lymphoma (100%). Diffuse bone marrow FDG uptake accurately predicted bone marrow in aggressive B-cell lymphoma with a positive predictive value (PPV) of 100%. The concordance rate was lower in indolent B-cell lymphoma (66.0%). In conclusion, PET/CT resulted in the upstaging of patients with occult extranodal or nodal lesions. A high SUV level can predict aggressive subtype of lymphoma and detect aggressive components in indolent lymphoma. PET/CT had a high PPV for aggressive B-cell lymphoma with diffuse bone marrow FDG uptake and high NPVs for excluding bone marrow involvement in aggressive B-cell lymphoma and Hodgkin's lymphoma. Bone marrow biopsy may be omitted for the above subgroups of patients with medical conditions not suitable for this procedure. For patients with indolent B-cell lymphoma, bone marrow biopsy is still an indispensable procedure for staging.

Staging of locally advanced breast cancer and the prediction of response to neoadjuvant chemotherapy: complementary role of scintimammography and 18F-FDG PET/CT.

The primary endpoint of the study was to established the role of sestamibi scintimammography and PET/CT findings in locally advanced breast cancer (LABC) before neoadjuvant systemic therapy (NST) in different histological subtypes. The secondary endpoint was to determine the role of FDG PET/CT as multi-drug resistance marker. From January 2012, we prospectively enrolled 51 consecutive women (median age: 49 years; range: 27-76 yrs) with a biopsy-proven LABC. All patients underwent both sestamibi scintimammography and FDG PET/CT within one week before to start NST. Both examinations were qualitatively and semiquantitatively analysed. For scintimammography we calculated the tumor to background ratio (T/B) and the most intense uptake of the tumor to background ratio (I/B) according the following formula: T/B=[cntsT-cntsB]/ [cntsB] and I/B [cntsI-cntsB]/[cntsB]. Furthermore, the percentage washout index (WO) for T and I were obtained, according to: WOT,I= [cntsT,I]early image-[cntsT,I]delayed image/[cntsT,I]early image. Maximum and average (avg) standardized uptake value (SUV) was computed by PET/CT, using a region of interest. Patients who had an evidence of systemic metastases or a second active cancer at imaging scans, were excluded. At the end of pre-operative therapy, the response to therapy was assessed by the analysis of surgical specimen and then correlated with both scintimammographic and PET/CT data. Based on the inclusion criteria, the final analysis was performed in 49 patients. Scintimammography and PET/CT showed a sensitivity of 100% for the evaluation of primary cancer, while PET/CT showed a slightly higher detection rate for axillary lymph node than scintimammography. According to the biological pattern, SUVmax and SUVavg resulted significantly different among histological subtypes, whereas scintimammographic data did not. At the end of neo-adjuvant therapy, pathological complete response was obtained in 12 (24.4%) patients, while 37 had a partial or no response to NST (identified as no-responders). On the basis of histopathological response to NST, median WOI resulted significantly lower in responders than non-responders (30.5% vs. 44%; P=0.027). Conversely, SUVmax and SUVavg were significantly higher in responders than non-responders (all P<0.05). In this latter subset of patients, high WOTs were associated with low SUVs. On the contrary, in responder group, high SUVs were reported particularly for high WOT values. Scintimammography with sestamibi did not accurately determine the responsiveness to therapy. FDG PET/CT is more accurate in the prediction of response to therapy, particularly in the aggressive LABC subtype. Moreover, semiquantitative data by FDG PET seems to be linked with the chemosensitivity to NST.

Differentiation of an adrenal mass in patients with non-small cell lung cancer by means of a normal range of adrenal standardized uptake values on FDG PET/CT.

The aim of this study was to assess the range of normal adrenal FDG uptake, and to determine the diagnostic criteria of FDG PET-CT to differentiate adrenal nodule. A total of 117 healthy subjects who underwent FDG PET/CT for cancer screening, and 106 lung cancer patients who underwent FDG PET/CT for cancer staging without adrenal abnormality were enrolled to determine the normal range of adrenal standardized uptake value (SUV). In addition, another 24 lung cancer patients with suspicious adrenal masses were enrolled to evaluate the diagnostic performance of the different diagnostic criteria from FDG PET/CT. The adrenal maximal SUV (SUVmax) of the healthy group was 1.66 ± 0.21 in the right and 1.86 ± 0.30 in the left. The adrenal SUVmax of lung cancer group was 1.79 ± 0.30 in the right and 1.90 ± 0.37 in the left. Lung cancer group had a higher ratio of adrenal gland to liver (AL ratio) when compared with healthy subjects (0.77 ± 0.13 vs. 0.61 ± 0.10 on the right, 0.82 ± 0.12 vs. 0.68 ± 0.12 on the left: p < 0.001). The upper normal limits of adrenal SUVmax were calculated as the mean plus 2 standard deviations (right: 2.08 vs. 2.39, left: 2.46 vs. 2.64, in the normal group and lung cancer group, respectively). Using the upper limit from the lung cancer group, we achieved a sensitivity of 87 % and specificity of 100 %. We demonstrated that left adrenal gland had higher SUV than right adrenal gland both in healthy group and lung cancer group. Using the different normal range of bilateral adrenal SUVmax, we could successfully differentiate adrenal masses.

SUVmax on Pre-Treatment FDG PET Scan Is Not Predictive of Outcome in Follicular Lymphoma after R-CHOP Threapy

Introduction: High standardized uptake value (SUV) on FDG PET scan in follicular lymphoma (FL) suggests aggressive disease and possible transformation to diffuse large B-cell lymphoma. Schoder et al, J Clin Oncol, 2005, reported that SUV >10 predicted aggressive lymphoma with >80% certainty and SUV >13 with >90% certainty. However, it is unknown whether the maximum SUV (SUVmax) on FDG PET scan at baseline, suggesting the possibility of focal aggressive or transformed disease, has prognostic value in FL. Here, we determined the prognostic value of SUVmax on baseline FDG PET scan in patients with advanced stage FL treated uniformly with R-CHOP chemoimmunotherapy at initial diagnosis.Methods: We reviewed medical records of all patients with stage III or IV FL who had FDG PET scan at initial diagnosis and were treated with R-CHOP chemoimmunotherapy at MD Anderson Cancer Center between January 2001 and December 2012. Patients with histological diagnosis of concurrent diffuse large B-cell lymphoma were excluded. Results: For the 225 patients studied, the median age was 57 years (range, 20-82). 83 (37%) patients were >= age 60, 137 (61%) had grade 1 or 2 FL, and 88 (39%) had grade 3A (n=57, 25%) or 3B (n=31, 14%). The Ki-67 score was <=40% for 85 (60%) patients and >40% for 56 (40%) patients. FLIPI risk groups were 54 patients (24%) low, 74 (33%) intermediate, and 97 (43%) high. GELF criteria were met in 133 (59%) patients. Tumor bulk of >= 6 cm was seen in 97 (43%) patients. The absolute lymphocyte count (ALC) was normal or high in 155 (69%) patients and low in 70 (31%). Sixty-nine (31%) patients received rituximab maintenance. There was no correlation between baseline SUVmax on FDG PET scan and Ki-67 score (Pearson correlation co-efficient of 0.168). The overall and complete response rates were 96% and 87%, respectively. The median follow-up time was 66 months. At 5 years, progression-free survival (PFS) was 85% and overall survival (OS) was 90%. Male gender, stage IV, high risk FLIPI, presence of GELF criteria, high beta-2 microglobulin, and low ALC were associated with significantly inferior PFS and OS (p<0.05). Histological grade was not associated with PFS or OS. Age >= 60 was associated with inferior OS but not PFS. Rituximab maintenance was associated with improved PFS but not OS. On baseline FDG PET scan, median SUVmax was 13.7 and the SUVmax range was 1.5-42.1. 105 (47%) patients had SUVmax <=13 and 120 (53%) had SUVmax >13. Patient characteristics including age, gender, histological grade, Ki-67 score, and FLIPI risk groups were not significantly different between the two SUVmax populations (p>0.05). The overall response rates were 94% and 96% for the SUVmax <=13 and SUVmax >13 groups, respectively. The complete response rate was 87% in both groups. At 5 years, the PFS and OS were not significantly different between the low and high SUVmax groups (61% vs 63% for PFS, p=0.98 and 90% vs 89% for OS, p=0.63). PFS and OS were not significantly different even when the patients were grouped into SUVmax <=10 vs >10 (p=0.9 and 0.61, respectively) or when other cut-offs were used. SUVmax was also not predictive of PFS and OS when only the patients meeting GELF criteria were analyzed.Conclusions: In this large cohort of advanced stage FL patients treated uniformly with R-CHOP chemoimmunotherapy, SUVmax on baseline FDG PET scan was not predictive of clinical outcome or correlated with other features. It is possible that the doxorubicin-based chemotherapy regimen may have benefited patients with high SUVmax who may have underlying aggressive or undiagnosed transformed disease. It remains to be determined whether SUVmax is predictive of clinical outcome in FL patients treated with other commonly used therapies such as rituximab monotherapy, rituximab and bendamustine, or R-CVP. [Display omitted] DisclosuresWang:Pharmacyclics, Janssen: Honoraria, Research Funding. Westin:Novartis: Research Funding.