Node Lesions Research Articles

Evaluation of Benign and Malignant Cervical Lymphadenopathy: A Comparative Study of Shear Wave Elastography and Grayscale Ultrasound

Abstract Objectives The aim of the study was to evaluate role of shear wave elastography (SWE) using a novel methodology for differentiation of benign and malignant cervical lymph nodes. Methods SWE was performed on 38 patients who presented with cervical lymph adenopathy. Color-coded elasticity maps were obtained, from which the stiffest region of interest (ROI) with a diameter of 2 mm was chosen. Maximum and mean Young's modulus values (Kpa) were calculated in selected 2-mm ROI. Finally, the results were correlated with the fine needle aspiration cytology findings in all patients to assess the diagnostic accuracy, sensitivity, and specificity at a defined cutoff value for distinguishing between benign and malignant lymphadenopathies. Results There were 20 malignant cervical lymph nodes and 18 benign cervical lymph nodes. Malignant nodes showed significantly higher mean Young's modulus value (154.2 ± 46.19 kPa) compared with benign nodes (70.39 ± 30.76 kPa), with a p-value of less than 0.0001. Our findings indicate that the mean Young modulus value within a standardized 2-mm ROI outperformed grayscale ultrasound in terms of diagnostic accuracy (92.1 vs. 78.9%), sensitivity (100 vs. 80%), and specificity (83.3 vs. 77.7%), with the established cutoff values for high diagnostic accuracy indicating malignancy as greater than 92 for mean Young's modulus with an area under the curve of 0.964. Conclusion SWE using a standardized 2-mm ROI provides improved sensitivity and diagnostic accuracy for differentiation of benign and malignant lymph node lesions.

Diagnostic Value of Endobronchial Ultrasound-Guided Intranodal Forceps Biopsies Combined with Rapid On-Site Evaluation for Mediastinal/Hilar Lymph Node Disease

Aims/Background Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is the standard method for sampling mediastinal/hilar lymph node disease. However, the smaller samples obtained via needle aspiration have a lower diagnostic rate for benign compared to malignant diseases. The low diagnostic rates have been reported to be improved through using endobronchial ultrasound-guided intranodal forceps biopsy (EBUS-IFB), but the implementation of IFB presents technical challenges, as described with variable results in certain studies. The main objective of this study was to investigate the diagnostic value and safety of EBUS-IFB for mediastinal/hilar lymph node disease. Methods A retrospective analysis was conducted on 150 patients with mediastinal/hilar lymph node disease at Tianjin Medical University General Hospital. EBUS-TBNA was performed using a rigid bronchoscope on the same lymph node of each patient under general anesthesia, with rapid on-site evaluation (ROSE) conducted to determine the presence of pathological tissue. Following this, a tunnel was established, and a 1.5 mm biopsy forceps was employed for EBUS-IFB. Subsequently, diagnostic rates and safety of the methods used were determined. Results EBUS-IFB + EBUS-TBNA (the combined strategy) exhibited the highest diagnostic rates, with the addition of bronchial mucosa biopsy/transbronchial lung biopsy/neoplasm biopsy contributing to a successful diagnostic rate of 97.2% (139/143). The combined strategy (90.2%) and EBUS-IFB alone (88.1%) contributed to successful diagnosis for all diseases, with rates significantly higher than that of EBUS-TBNA (60.1%) (p < 0.001). The diagnostic rates for malignant disease detected with the combined strategy (97.4%) and EBUS-IFB alone (93.6%) were significantly higher than that with EBUS-TBNA alone (71.8%) (p < 0.001). Both the diagnostic rates for sarcoidosis detected with the combined strategy and EBUS-IFB alone were 87.8%, which was significantly higher than that with EBUS-TBNA alone (46.9%) (p < 0.001). The procedures implemented did not engender major complications. Conclusion Routine EBUS-TBNA followed by ROSE to acquire pathological tissue, followed by tunnel formation and EBUS-IFB, can enhance the overall diagnostic rate for mediastinal/hilar lymph node lesions. This approach is particularly valuable for diagnosing malignant diseases and sarcoidosis. EBUS-IFB serves as a safe and feasible complement to EBUS-TBNA, despite the fact that the procedure was extended in duration.

Challenges in developing response evaluation criteria for peptide receptor radionuclide therapy: A consensus report from the European Neuroendocrine Tumor Society Advisory Board Meeting 2022 and the ENETS Theranostics Task Force.

Assessing the response to systemic therapy in neuroendocrine tumors (NET) is challenging since morphological imaging response is often delayed and not necessarily reflective of clinical benefit. Peptide receptor radionuclide therapy (PRRT) has a complex mechanism of action, further complicating response assessment. In response to these challenges, the European Neuroendocrine Tumor Society (ENETS) Theranostics Task Force conducted a statement-based survey among experts to identify the current landscape and unmet needs in PRRT response assessment. The survey, presented at the 2022 ENETS Advisory Board (AB) meeting in Vienna, was completed by 70% of AB members, most of whom (81%) were from ENETS Centers of Excellence (CoE). It comprised a set of 13 questions with two substatements in three questions. Six (46%) of the statements achieved more than 75% agreement, while five (39%) additional statements reached over 60% consensus. Key points from the survey include: AB members agreed that lesions deemed equivocal on computed tomography (CT) or magnetic resonance imaging (MRI) should be characterized by somatostatin receptor (SST) positron emission tomography (PET)/CT before being designated as target lesions. It was agreed that interim response assessments should occur after the second or third PRRT cycle. Over half (54%) preferred using both conventional cross-sectional imaging (CT and/or MRI) and hybrid imaging (SST PET/CT) for this purpose. Almost all AB members supported further response assessment 3 months after the final PRRT cycle. A majority (62%) preferred using a combination of conventional cross-sectional imaging and SST PET/CT. For cases showing equivocal progression (ambiguous lesions or nontarget lesions) on CT and/or MRI, further confirmation using SST PET/CT was recommended. A significant majority (74%) preferred assessing pseudo-progression and delayed response by combining SST PET with diagnostic CT and/ or MRI. Though just below the 75% consensus threshold, there was substantial agreement on selecting target lesions based on SST PET/CT uptake intensity and homogeneity. Sixty-nine percent noted the importance of documenting and closely following heterogeneity in lesions in liver, lymph nodes, primary tumors, or other organs. As to the statement on parameters for new response criteria, AB members recommended exploring maximum standard unit value, tumor-to-background ratio, Hounsfield Unit (Choi Criteria), total tumor burden, and novel serum or molecular markers for future response evaluation criteria. Sixty-five percent supported the use of a single SST PET/CT for response assessment of NET lesions treated with PRRT. These findings highlight the importance of integrating advanced imaging techniques and recognizing the need for more nuanced criteria in assessing the efficacy of PRRT in NET patients. This approach aims to enhance the accuracy of treatment monitoring and improve patient outcomes.

Evaluation of Gross and Histopathological Lesions in Pneumonic Lungs and Mediastinal Lymph Nodes of Small Ruminants Slaughtered at Mosul Abattoirs

Evaluation of Gross and Histopathological Lesions in Pneumonic Lungs and Mediastinal Lymph Nodes of Small Ruminants Slaughtered at Mosul Abattoirs

Detection and quantification of small and low-uptake lesions for differentiated thyroid carcinoma using non-time-of-flight iodine-124 PET/MRI.

124-iodine (124I) is used for positron emission tomography (PET) diagnostics and therapy planning in patients with differentiated thyroid cancer (DTC). Small lesion sizes(<10mm) and low 124I uptake are challenging conditions for the detection of DTC lymph node lesions. The aim of this study was to systematically investigate the lesion detectability and quantification performance under clinically challenging imaging conditions using non-time-of-flight (TOF) PET/magnetic resonance imaging (MRI) in the clinical context of radionuclide therapy planning of DTC patients. PET/MR measurements were performed on the Siemens Biograph mMR using a small lesion NEMA-like phantom (six glass spheres, diameters 3.7-9.7mm). 60 min list-mode data were acquired for nine activity concentrations (AC) ranging from 25kBq/mL to 0.25kBq/mL using a sphere-to-background ratio of 20:1. PET list-mode data were divided into five timeframes (60, 30, 16, 8, and 4min) and reconstructed using either ordered-subsets expectation maximization (OSEM) or OSEM+ point spread function (PSF) algorithm. For all reconstructions, the smallest detectable sphere size was investigated in a human observer study. Partial volume effect (PVE) corrected PET images (contour and oversize-based approach) were analyzed considering a±30% deviation range between imaged and true AC as acceptable. Clinical data of eight DTC patients with small lymph node lesions were evaluated to assess agreement between the PVE correction approaches. Longer PET acquisition times, higher ACs, and PSF reconstructions resulted in improved PET image quality and overall improved lesion detectability. The smallest 3.7mm sphere was only visible under the best imaging conditions. Using a typical clinical 124I whole-body PET/MRI protocol with an acquisition time of 8 min using OSEM reconstructions, all lesions of ≥6.5mm in diameter could be detected and the quantification provided reliable results approximately above 5.0kBq/mL. An accurate quantification of ACs in the 4.8mm sphere was not feasible in this study. In the clinical evaluation of 10 lesions, a good agreement between oversize- and contour-based PVE corrections was observed(<15% deviation). The results showed that a reliable quantification of 124I uptake with PET/MRI is feasible and, therefore, could be used to perform radioiodine pre-therapy lesion dosimetry and individualized therapy planning in DTC patients.

Generalizability of lesion detection and segmentation when ScaleNAS is trained on a large multi-organ dataset and validated in the liver.

Tumor assessment through imaging is crucial for diagnosing and treating cancer. Lesions in the liver, a common site for metastatic disease, are particularly challenging to accurately detect and segment. This labor-intensive task is subject to individual variation, which drives interest in automation using artificial intelligence (AI). Evaluate AI for lesion detection and lesion segmentation using CT in the context of human performance on the same task. Use internal testing to determine how an AI-developed model (ScaleNAS) trained on lesions in multiple organs performs when tested specifically on liver lesions in a dataset integrating real-world and clinical trial data. Use external testing to evaluate whether ScaleNAS's performance generalizes to publicly available colorectal liver metastases (CRLM) from The Cancer Imaging Archive (TCIA). The CUPA study dataset included patients whose CT scan of chest, abdomen, or pelvis at Columbia University between 2010-2020 indicated solid tumors (CUIMC, n=5011) and from two clinical trials in metastatic colorectal cancer, PRIME (n=1183) and Amgen (n=463). Inclusion required ≥1 measurable lesion; exclusion criteria eliminated 1566 patients. Data were divided at the patient level into training (n=3996), validation (n=570), and testing (n=1529) sets. To create the reference standard for training and validation, each case was annotated by one of six radiologists, randomly assigned, who marked the CUPA lesions without access to any previous annotations. For internal testing we refined the CUPA test set to contain only patients who had liver lesions (n=525) and formed an enhanced reference standard through expert consensus reviewing prior annotations. For external testing, TCIA-CRLM (n=197) formed the test set. The reference standard for TCIA-CRLM was formed by consensus review of the original annotation and contours by two new radiologists. Metrics for lesion detection were sensitivity and false positives. Lesion segmentation was assessed with median Dice coefficient, under-segmentation ratio (USR), and over-segmentation ratio (OSR). Subgroup analysis examined the influence of lesion size ≥ 10mm (measurable by RECIST1.1) versus all lesions (important for early identification of disease progression). ScaleNAS trained on all lesions achieved sensitivity of 71.4% and Dice of 70.2% for liver lesions in the CUPA internal test set (3,495 lesions) and sensitivity of 68.2% and Dice 64.2% in the TCIA-CRLM external test set (638 lesions). Human radiologists had mean sensitivity of 53.5% and Dice of 73.9% in CUPA and sensitivity of 84.1% and Dice of 88.4% in TCIA-CRLM. Performance improved for ScaleNAS and radiologists in the subgroup of lesions that excluded sub-centimeter lesions. Our study presents the first evaluation of ScaleNAS in medical imaging, demonstrating its liver lesion detection and segmentation performance across diverse datasets. Using consensus reference standards from multiple radiologists, we addressed inter-observer variability and contributed to consistency in lesion annotation. While ScaleNAS does not surpass radiologists in performance, it offers fast and reliable results with potential utility in providing initial contours for radiologists. Future work will extend this model to lung and lymph node lesions, ultimately aiming to enhance clinical applications by generalizing detection and segmentation across tissue types.

Abstract A004: E2F5 conditional knockout in mammary epithelium drives organotropic metastasis in breast cancer

Abstract Breast cancer ranks as the most commonly diagnosed cancer in women with 90% of associated deaths caused by distant metastasis. The metastatic lesions in brain, lung, liver, bone and lymph nodes in human breast cancer are not arbitrary, but rather are a complex mechanism of extrinsic and intrinsic regulatory factors controlling organ-specific colonization. Specialized mechanisms driving bone, brain and lung cancer have been described. However, the studies of liver and lymph node metastatic drivers are limited despite the prevalence of metastases in these organs. A significant limitation is the lack of genetically engineered mouse models that develop mammary tumors that spontaneously metastasize to liver and lymph nodes. Our previous research identified the role for E2F5 in both mammary gland development and breast cancer. Loss of E2F5 resulted in tumorigenesis after a latency of one year and 70% of mice showed metastatic lesions in lung, lymph node and liver. Transplantation of these spontaneous tumors into FVB MMTV Cre mice recapitulated the metastatic pattern observed in the primary tumors. We propose that E2F5 regulates drivers of metastasis and potentiates organ tropism to lymph nodes and the liver. To address this hypothesis, we conducted serial transplantations of tumors originating from the lymph nodes and liver back into the mammary gland. This enrichment study led to a significant increase in organ-specific metastasis, with 60% and 77% of penetrance observed in two distinct mouse lineages with liver (LVM) and lymph node tropism (LNM). Immunohistochemical studies confirmed a complete epithelial-mesenchymal transition (EMT) phenotype in LVM that is conserved in the cell lines generated. LNM showed a partial EMT with a more epithelial phenotype in cell lines. We observed the presence of an immune enriched environment in primary and metastatic tumors in both lineages. Bulk-RNA sequencing studies uncovered the presence of unique organotropic pathways associated with liver and lymph node metastasis. We observed enriched pathways from the primary tumor as major component of our organotropic drivers with a clear distinction between liver and lymph node enriched lineages. Additionally, a gradual acquisition of distant organ-specific markers and signaling pathways suggests that phenotypic mimicry and tumor plasticity are key for successful events of colonization to liver and lymph nodes in our model. With these results, we unravel potential mechanisms responsible for the organotropic metastases in breast cancer under the absence of the transcription factor E2F5. Citation Format: Jesus A. Garcia Lerena, Briana To, Jing-Ru Jhan, Eran Andrechek. E2F5 conditional knockout in mammary epithelium drives organotropic metastasis in breast cancer [abstract]. In: Proceedings of the AACR Special Conference in Cancer Research: Tumor-body Interactions: The Roles of Micro- and Macroenvironment in Cancer; 2024 Nov 17-20; Boston, MA. Philadelphia (PA): AACR; Cancer Res 2024;84(22_Suppl):Abstract nr A004.

Distinguishing lymphoma from benign lymph node diseases in fever of unknown origin using PET/CT radiomics

BackgroundA considerable portion of patients with fever of unknown origin (FUO) present concomitant lymphadenopathy. Diseases within the spectrum of FUO accompanied by lymphadenopathy include lymphoma, infections, and rheumatic diseases. Particularly, lymphoma has emerged as the most prevalent etiology of FUO with associated lymphadenopathy. Distinguishing between benign and malignant lymph node lesions is a major challenge for physicians and an urgent clinical concern for patients. However, conventional imaging techniques, including PET/CT, often have difficulty accurately distinguishing between malignant and benign lymph node lesions. This study utilizes PET/CT radiomics to differentiate between lymphoma and benign lymph node lesions in patients with FUO, aiming to improve diagnostic accuracy.ResultsData were collected from 204 patients who underwent 18F-FDG PET/CT examinations for FUO, including 114 lymphoma patients and 90 patients with benign lymph node lesions. Patients were randomly divided into training and testing groups at a ratio of 7:3. A total of 15 effective features were obtained by the least absolute shrinkage and selection operator (LASSO) algorithm. Machine learning models were constructed using logistic regression (LR), support vector machine (SVM), random forest (RF), and k-nearest neighbors (KNN) algorithms. In the training group, the area under the curve (AUC) values for predicting lymphoma and benign cases by LR, SVM, RF, and KNN models were 0.936, 0.930, 0.998, and 0.938, respectively. There were statistically significant differences in AUC between the RF and other models (all P < 0.001). In the testing group, the AUC values for the four models were 0.860, 0.866, 0.915, and 0.891, respectively, with no statistically significant differences observed among them (all P > 0.05). The decision curve analysis (DCA) curves of the RF model outperformed those of the other three models in both the training and testing groups.ConclusionsPET/CT radiomics demonstrated promising performance in discriminating lymphoma from benign lymph node lesions in patients with FUO, with the RF model showing the best performance.

Giant pelvic dermoid cyst in a 17-year-old girl

BACKGROUND: Dermoid cysts in the presacral and retrorectal space in children are relatively rare. However, even more rarely, they have clinical manifestations at patient’s early age and so, can be silent for a long time. CLINICAL CASE DESCRIPTION: The article describes a rare clinical observation — a giant dermoid cyst in the retrorectal space in a 17-year-old girl. The child had a tendency to constipation from her early childhood. Menses started at age 13, painful. During the last year, disorders in her menstrual cycle were noticed. The girl was examined by a gynecologist. Ultrasound examination revealed a cystic formation in the pelvic cavity up to 9 cm in diameter. Non-malignant nature of the process was confirmed by: normal level of cancer markers (α-fetoprotein, β-human chorionic gonadotropin), single node, clearly defined formation capsule, homogeneous nature of its contents, no invasive growth and lesions in the regional lymph nodes. Magnetic resonance imaging with intravenous contrasting defined a true relationship of the cystic formation with other organs and structures of the pelvic cavity. The cystic formation caused deformation of the cervix, vagina, and rectum. The obtained findings allowed to plan surgical intervention correctly. Surgical access-transverse in the coccyx projection up to 10 cm long. The cystic formation was a thin-walled connective tissue capsule with a yellowish content. Due to very large cyst dimensions, first it was opened in a limited area and emptied. Then the capsule was isolated and completely removed. The cyst intimately adhere to rectum, vagina, and cervix walls. Histological conclusion: "Capsule of a dermoid cyst with hemorrhages". The postoperative period was smooth. The patient recovered, all disease manifestations disappeared. She was discharged home in a satisfactory state. Follow-up visits were in 6 and 12 months after surgery. No evidence of possible relapse. CONCLUSION: There are only few descriptions of such cases in the available literature. Ultrasound and MRI examinations allowed to have a full picture of dermoid cyst position and its connection with other pelvic organs due to which surgeons could develop a correct plan for surgical intervention.

Neoadjuvant chemotherapy with FLOT scheme in surgical treatment of gastric cancer: short- and long-term outcomes. A retrospective cohort study

Aim. To compare the results of surgical treatment of patients with gastric adenocarcinoma and esophagogastric junction cancer (EGJC) who received neoadjuvant chemotherapy (NCT) FLOT with primary operated patients. Materials and methods. A retrospective cohort study included 177 patients who underwent radical surgical treatment at the Burdenko Faculty Surgery Clinic of Sechenov University for gastric cancer (GC) and/or EGJC Sievert Type II–III in the period from January 2018 to December 2022. The main group consisted of patients (n=28) who received NCT FLOT. Patients in both groups did not statistically significantly differ in average age (p=0.110), ASA status (p=0.541), ECOG status 0–3 (p=0.12), localization (p=0.063), depth of invasion (p=0.099) and histological structure of the tumor (p=0.787). In the main group, more patients with lesion of the regional lymph nodes were expected (p0.001). According to the most significant indicators [postoperative complications, the presence of a "positive" edge of resection (R1), recurrence and/or progression of GC], we performed a quasi-randomization by the matching procedure, taking into account the selection of the nearest neighbors. Results. In 92.9% of patients in the main group and in 94.9% of the control group, R0 resection (p=0.750) was achieved. The number of removed lymph nodes was statistically significantly higher in the main group (average 26 vs 21; p=0.010). There was no difference in intraoperative blood loss (p=0.294) and hospital stay (p=0.992). The average duration of surgery in the main group was 319 minutes, compared to 250 minutes in the control group (p0.001). In the early postoperative period, the total number of complications (CD I–IV) was higher in the main group (p=0.031), however, there was no difference in the number of small (CD I–II; p=0.094) and significant (CD III–V; p=0.142) complications. Postoperative mortality in the first 30 days after surgical treatment was 3.6 and 2.5% in the main and control groups, respectively (p=0.764). The overall 6-month survival rate in the control group was 95.9% vs 90.9% in the main group, and the 12-month survival rate was 88.8% vs 75.7%, respectively. The reccurence-free 6-month survival rate in the control group was 96%, in the main group – 100%; the reccurence-free 12-month survival rate in the control group was 92.1%, in the NCT group – 93.3%. Conclusion. NCT FLOT in the treatment of GC and EGJC Sievert Type II–III does not increase the level of intraoperative blood loss, the number of postoperative complications and the duration of hospitalization. The 6-month and one-year survival rates did not differ in the two groups. Considering that the majority of patients in the NCT group belonged to the cN+ category, with an initially less favorable treatment prognosis, it can be assumed that comparable survival results were achieved thanks to NCT.

Multivariable models of outcomes with [177Lu]Lu-PSMA-617: analysis of the phase 3 VISION trial

[177Lu]Lu-PSMA-617 (177Lu-PSMA-617) prolonged life in patients with metastatic castration-resistant prostate cancer (mCRPC) in VISION (NCT03511664). However, distinguishing between patients likely and unlikely to respond remains a clinical challenge. We present the first multivariable models of outcomes with 177Lu-PSMA-617 built using data from VISION, a large prospective phase 3 clinical trial powered for overall survival. Adults with progressive post androgen receptor pathway inhibitor and taxane prostate-specific membrane antigen (PSMA)-positive mCRPC received 177Lu-PSMA-617 plus protocol-permitted standard of care (SoC) or SoC alone. In this post hoc analysis, multivariable Cox proportional hazards models of overall survival (OS) and radiographic progression-free survival (rPFS), and a logistic regression model of prostate-specific antigen response (≥50% decline; PSA50) were constructed and evaluated using C-index or receiver operating characteristic (ROC) analyses with bootstrapping validation. Nomograms were constructed for visualisation. Patients were randomised between June 2018 and October 2019. Data from all 551 patients in the 177Lu-PSMA-617 arm were analysed in multivariable modelling. The OS nomogram (C-index, 0.73; 95% confidence interval [CI], 0.70-0.76) included whole-body maximum standardised uptake value (SUVmax), time since diagnosis, opioid analgesic use, aspartate aminotransferase, haemoglobin, lymphocyte count, presence of PSMA-positive lesions in lymph nodes, lactate dehydrogenase (LDH), alkaline phosphatase (ALP), and neutrophil count. The rPFS nomogram (C-index, 0.68; 0.65-0.72) included SUVmax, time since diagnosis, opioid analgesic use, lymphocyte count, presence of liver metastases by computed tomography, LDH, and ALP. The PSA50 nomogram (area under ROC curve, 0.72; 95% CI, 0.68-0.77) included SUVmax, lymphocyte count and ALP. Performances of the OS and rPFS models were maintained when they were reconstructed excluding SUVmax. These models of outcomes with 177Lu-PSMA-617 are the first built using prospective phase 3 data. They show that a combination of pretreatment laboratory, clinical, and imaging parameters, reflecting both patient and tumour status, influences outcomes. These models are important for aiding treatment selection, patient management, and clinical trial design. Novartis.

Cytological diagnosis of follicular dendritic cell sarcoma with a unique pattern of D2-40 immunoexpression.

Fine needle aspiration procedure is routinely used for cytological diagnosis of nodal or extra nodal lesions. Follicular dendritic cell sarcoma (FDCS) is a rare mesenchymal neoplasm arising from follicular dendritic cells of lymphoid follicles at nodal and extranodal sites. Multimodal therapies have emerged for FDCS, necessitating its accurate pathologic diagnosis with additional ancillary testing for directing clinical management. By immunohistochemical analysis, FDCS is positive for the complement receptors CD21, CD23, and CD35. In addition, D2-40 is reported to be highly sensitive for FDCS with a strong membranous pattern of expression. In this study, we present the cytological diagnosis of a case of FDCS in retroperitoneal lymph nodes with an emphasis on a unique staining pattern of D2-40 which showed a strong nuclear pattern in tumor cells comparable to the membranous pattern of D2-40 on the control tissue and other surgical cases of FDCS in our comparative study.

Head-to-head comparison of 68Ga-FAPI-46 PET/CT, 18F-FDG PET/CT, and contrast-enhanced CT for the detection of various tumors.

FAPI-PET/CT exhibits high tumor uptake and low background accumulation, enabling high-sensitivity tumor detection. We compared the diagnostic performance of 68Ga-FAPI-46 PET/CT plus contrast-enhanced CT (CE-CT), 18F-FDG PET/CT plus CE-CT, and standalone CE-CT in patients with various malignancies. 232 patients underwent 68Ga-FAPI-46 PET/CT,18F-FDG PET/CT, and CE-CT each within 4weeks. Detection rates were assessed by a blinded reader, with ≥ 2weeks between scans of the same patient to avoid recall bias. A sub-analysis of diagnostic performance was performed for 490 histopathologically validated lesions. Detection rates were compared using McNemar's test. Lesion-based detection rates in 68Ga-FAPI-46 PET/CT plus CE-CT, 18F-FDG PET/CT plus CE-CT, and CE-CT alone were 91.2% (1540/1688), 82.5% (1393/1688) and 60.2% (1016/1688). The detection rates were significantly higher for 68Ga-FAPI-46 PET/CT plus CE-CT than for 18F-FDG PET/CT plus CE-CT (p < 0.02 for primary lesions and p < 0.001 for total, abdominopelvic nodal, liver and other visceral lesions) and CE-CT (p < 0.0001 for total, primary, cervicothoracic nodal, abdominopelvic nodal, liver, other visceral, and bone lesions). In the sub-analysis, sensitivity, specificity, positive and negative predictive value, and accuracy were 61.3%, 96.7%, 81.4%, 91.4% and 90.0% for 68Ga-FAPI-46 PET/CT plus CE-CT, 57.0%, 95.7%, 75.7%, 90.5% and 88.4% for 18F-FDG PET/CT plus CE-CT, and 51.6%, 97.2%, 81.4%, 89.6% and 88.6% for CECT, respectively. 68Ga-FAPI-46 PET/CT plus CE-CT demonstrates a higher tumor detection rate than 18F-FDG PET/CT plus CE-CT and CE-CT in a diverse spectrum of malignancies, especially for primary, abdominopelvic nodal, liver, and other visceral lesions. Further studies on which entities draw particular benefit from 68Ga-FAPI-46 PET/CT are warranted to aid appropriate diagnostic workup. A total of N = 232 patients were analyzed. Of these, N = 50 patients were included in a prospective interventional trial (NCT05160051), and N = 175 in a prospective observational trial (NCT04571086) for correlation and clinical follow-up of PET findings; N = 7 patients were analyzed retrospectively.

Application of 18 F-fluorodeoxyglucose PET/computed tomography in the diagnosis of infiltrative subsolid nodules in lung adenocarcinoma.

To investigate the diagnostic value of 18 F-fluorodeoxyglucose(FDG) PET/computed tomography (CT) for infiltrative subsolid nodules at different stages of lung adenocarcinoma and to explore predictive factors for invasive adenocarcinoma, providing compelling evidence for timely intervention. A retrospective analysis was conducted on PET/CT imaging data of 170 subsolid nodules lesions confirmed postoperatively as lung adenocarcinoma or precursor glandular lesions. Lesions were categorized into preinvasive lesions including atypical adenomatous hyperplasia and adenocarcinoma in situ, microinvasive adenocarcinoma, and invasive adenocarcinoma. Compared the differences in imaging features and metabolic parameters among different groups and used a multifactor logistic regression model and receiver operating characteristic curve analysis to identify predictive factors for invasive adenocarcinoma. From preinvasive lesions through microinvasive adenocarcinoma to invasive adenocarcinoma, there was a gradual increase in nodule diameter, nodule area, and proportion of part-solid nodule. Statistical significance ( P < 0.05) was observed in the rates of spiculation and pleural indentation between preinvasive lesions versus microinvasive adenocarcinoma and invasive adenocarcinoma groups. The maximum standardized uptake value and maximum standardized uptake ratio show statistically significant differences ( P < 0.05) between the invasive adenocarcinoma group and the other groups. Logistic regression analysis indicated that nodule composition, nodule diameter, and maximum standardized uptake ratio were predictive factors for invasive adenocarcinoma ( P < 0.05). For part-solid nodules, the longest diameter of the solid component has a high diagnostic value. The imaging features of 18 F-FDG PET/CT contribute to the diagnosis of infiltrative subsolid nodules at different stages of lung adenocarcinoma, providing robust evidence for timely intervention.

8078 TERT Positive Thyroid Nodule in the Setting of Metastatic Melanoma

Abstract Disclosure: E. Langnas: None. S. Chao: None. K.M. Gomes: None. A. Bhan: None. Metastatic disease to the thyroid gland is uncommon with a reported incidence of up to 4% in post-surgical specimens. Lung cancer is the most common primary tumor site in autopsy series. Clinically, renal cell carcinoma is the most common primary tumor site. Metastatic melanoma to the thyroid gland is clinically rare, however, in autopsy series, it has been reported with incidence of up to 39%. A 61-year-old man presented to the endocrinology clinic for an incidentally detected thyroid nodule. He had recently presented with a chronic cough, prompting a chest x-ray that revealed pulmonary nodules. Subsequent computed tomography (CT) showed numerous bilateral lung nodules measuring up to 2.5 cm and an incidental thyroid nodule. Ultrasound of the thyroid identified a 2.7 cm mixed cystic-solid right thyroid nodule. No risk factors for thyroid cancer were identified. His TSH was 3.51uIU (0.45 - 5.33 uIU/mL). The thyroid nodule was biopsied, and pathology revealed atypical spindle cells with irregular nuclear membranes and scattered histiocytes. A further review with cytopathology suggested non-thyroidal origin of the cells. Molecular testing with AFIRMA reported a telomerase reverse transcriptase (TERT) promoter mutation at C228T. The sequencing was negative for TERT C250T, BRAF, RET, PETC1, PTC3 and MTC. Due to concerns about metastatic disease, a positron-emission tomography (PET)-CT was conducted, revealing hypermetabolic lesions in numerous bilateral lung nodules, right thyroid nodule, porta hepatis lymph node, and a soft tissue nodule within the greater curvature of the gastric body. Subsequent biopsies of the right lung and gastric body confirmed the diagnosis of metastatic melanoma. On further questioning, it was found that the patient had a history of a skin lesion on his back that was excised several years ago with pathology reporting tumoral melanosis. Malignant melanoma has a poor prognosis due to high recurrence and metastatic rates. In melanoma, TERT promoter mutations are the most common mutations in noncoding regulatory regions. TERT C228T mutations and C250T mutations are seen in malignant melanoma and studies have shown that TERT promoter mutations are associated with aggressive clinical behavior. These TERT promoter mutations can also be seen in various other cancers including primary thyroid cancers with a similar association with more aggressive thyroid tumor characteristics. Our case describes a patient with a thyroid nodule and molecular testing noting a TERT promoter mutation. Both primary thyroid cancer and metastatic disease to the thyroid should be considered in these cases. This case also highlights the importance of obtaining a thorough history of prior malignancy in patients with thyroid nodules to assess the risk of metastatic disease. Presentation: 6/1/2024

Variable Tracer Avidity and Interlesional Heterogeneity on 18 F-FDG, 68 Ga-DOTATATE, and 68 Ga-DOTA-FAPi-04 PET/CT Imaging in a Single Individual Patient With Progressive Metastatic Medullary Thyroid Carcinoma.

In medullary thyroid carcinoma (MTC), distant metastases have few therapeutic options with low success rates and substantial toxicity in many patients, warranting exploration of alternate systemic treatments with fewer adverse effects. The fibroblast activation protein inhibitor (FAPI)-based PET/CT opens new avenues for several cancers, including MTC. A case of MTC with varying tracer avidity and interlesional heterogeneity on 18 F-FDG, 68 Ga-DOTATATE, and 68 Ga-DOTA-FAPI-04 PET/CT imaging is presented. 68 Ga-DOTA-FAPI-04 PET/CT exhibited superior efficacy in terms of visualization of metastatic soft tissue, lymph nodal, and skeletal lesions, with enhanced target-to-background ratio compared with the other two, facilitating the detection of these lesions, thereby demonstrating the potential for theranostic translation.

Head to head comparison of 18F-FDG and Al18F-NOTA-FAPI-04 PET/CT imaging used in diagnosis of autoimmune rheumatic diseases.

The aim of this study was to determine the performance of radionuclide-labeled fibroblast activation protein inhibitors (Al18F-NOTA-FAPI-04) PET/CT in patients with autoimmune rheumatic diseases (ARDs) and compare it with fluorine-18 (18F) labeled fluorodeoxyglucose (FDG) imaging. Fifty-eight participants with ARDs were prospectively enrolled from April 2022 to February 2024 and underwent dual-tracer PET/CT imaging. For both 18F-FDG and Al18F-NOTA-FAPI-04 PET/CT, imaging findings were interpreted and compared. The clinical significance was compared between18F-FDG PET/CT and Al18F-NOTA-FAPI-04 PET/CT imaging. 18F-FDG imaging was positive in 53 out of 58 cases (91.4%) while Al18F-NOTA-FAPI-04 imaging was positive in 55 out of 58 cases (94.8%). Overall positive rate of Al18F-NOTA-FAPI-04 imaging was as high as 18F-FDG imaging (P = 0.625). 18F-FDG imaging detected more lesions in lymph node, spleen, and bone marrow. Al18F-NOTA-FAPI-04 imaging detected more lesions in the lung, muscle, and tendon/ligament. There was no statistical difference of composing ratio of grades of clinical significance between two imaging modalities (χ2 = 2.875, P = 0.238). The superior rate of Al18F-NOTA-FAPI-04 PET/CT imaging was higher than 18F-FDG imaging (P = 0.020). In subgroup of adult-onset Still's disease, 18F-FDG imaging showed better performance than Al18F-NOTA-FAPI-04 imaging. In most of the other subgroup of ARDs, Al18F-NOTA-FAPI-04 PET/CT imaging overperformed 18F-FDG imaging. Both 18F-FDG and Al18F-NOTA-FAPI-04 PET/CT imaging have excellent sensitivity in ARDs. The detection capabilities of two tracers varied according to the involving organs of ARDs. In most of ARDs except adult-onset Still's disease, Al18F-NOTA-FAPI-04 PET/CT imaging overperformed 18F-FDG imaging. Key Points • 18F-FDG and Al18F-NOTA-FAPI-04 PET/CT imaging have excellent sensitivity in diagnosing of ARDs. • 18F-FDG PET/CT imaging detected more lesions in lymph node, spleen, and bone marrow. • 18F-NOTA-FAPI-04 PET/CT imaging detected more lesions in the lung, muscle, and tendon/ligament. • 18F-NOTA-FAPI-04 PET/CT imaging overperformed18F-FDG in most subgroups of ARDs.

Coexistence of papillary thyroid carcinoma and sarcoidosis: a case report and literature review.

Papillary thyroid carcinoma is a differentiated thyroid cancer that arises from thyroid follicular epithelial cells. Sarcoidosis is a multisystem disease of unknown cause, characterized by monocytic infiltration and granuloma formation. We herein report a case of thyroid carcinoma complicated by sarcoidosis. When thyroid nodules and lymph node lesions are suspected, it is essential to avoid fixed thinking, conduct a comprehensive preoperative evaluation, and select the appropriate surgical approach. This can help reduce the likelihood of postoperative complications and improve the patient's quality of life. Therefore, comprehensive diagnosis of the coexistence of papillary thyroid carcinoma and sarcoidosis is crucial.

Flourine-18 Prostate-Specific Membrane Antigen-1007 Positron Emission Tomography Imaging in Staging of Primary and Secondary Prostate Cancer—A Retrospective Observational Cohort Study

Background: Detection of metastatic disease is important to inform prostate cancer management. Objectives: Evaluate local and distant staging by initial 18F-PSMA-1007 PET in primary and secondary prostate cancer. Design, Setting, and Participants: We retrospectively identified a consecutive series of 18F-PSMA-1007 PET scans from the date of introduction of 18F-PSMA-1007 PET in September 2019 until April 2022 at a single UK tertiary referral center. Our protocol was registered in advance (OSF registration ID: KTE3R). Results: We identified 1335 PSMA-PET scans, from 1220 men. Across 623 initial scans for primary staging, we observed PSMA-PET avidity in 97.6% cases positive for local disease, 29.5% for nodal disease, and 26.5% for metastatic disease. PSMA-PET identified a 13.2% absolute increase in nodal lesions compared with MRI and a 24.0% absolute increase in metastatic lesions compared with MRI marrow. The sensitivity for detection of local disease among 79 patients who had radical prostatectomy was 96.2% for PSMA-PET vs 89.4% for multiparametric MRI. Across 612 scans for secondary staging, we observed PSMA-PET positive avidity in 51.2% of cases for local recurrence, 46.6% for nodal disease, and 43.0% for metastatic disease. When evaluated by the PSA range for patients receiving secondary staging, using the PSA values of 0.2 to 0.49, 0.5 to 0.99, 1 to 1.99, and ≥ 2 ng/mL, PSMA-PET scans were positive in 57.8%, 75.0%, 83.8%, and 95.5% of cases, respectively. PSMA-PET identified a 26.2% absolute increase in metastatic lesions compared with MRI marrow or other skeletal MRI (n = 61) and a 14.7% absolute increase in metastatic lesions compared with the bone scan (n = 42). Conclusion: 18F-PSMA-1007 PET identifies a higher number of nodal and metastatic lesions compared with conventional cross-sectional imaging. However, the high number of indeterminate lesions and stage migration necessitates discussion of 18F-PSMA-1007 PET imaging within a multidisciplinary team and places a higher burden on these teams.

Remifentanil Target-controlled Infusion Versus Standard of Care for Conscious Sedation During Ultrasound-guided Transbronchial Needle Aspiration and Biopsy: A Randomized, Prospective, Control Study.

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a minimally invasive procedure that has become an important tool in the diagnosis and staging of mediastinal lymph node lesions in lung cancer. Adequate sedation is an important part of the procedure as it provides patient comfort and potentially increases diagnostic yield. The sedation modality varies among centers and includes moderate sedation/conscious sedation, deep sedation, and general anesthesia. The object of this study will be the evaluation of patient's comfort and level of satisfaction with the involved health care providers (bronchoscopist and anesthesiologist) of remifentanil administration in target-controlled infusion (TCI) for conscious sedation in patients undergoing EBUS‑TBNA, with a prospective randomized study design versus the of standard sedation protocol with midazolam and/or fentanest and/or propofol. This study was carried out at the "Campus Biomedico di Roma" University Hospital between September 2021 and November 2021, with a total number of 30 patients enrolled who met the eligibility criteria, randomly divided into 2 groups: group 1 "REMIFENTANIL TCI" (experimental group) where the patients performed the EBUS-TBNA procedure under conscious sedation with infusion of remifentanil TCI with a target between 3 ng/mL and 6ng/mL and group 2 "STANDARD" (control group) with patients undergoing conscious sedation with the association of midazolam and/or fentanest and/or propofol in refracted boluses based on clinical needs. Complications, safety, and level of satisfaction of the operator, the anesthesiologist, and the patient were evaluated. The results show that sedation with remifentanil in TCI can improve the comfort level of patients, reducing the risks associated with the procedure (lower frequency of oversedations and hypotension), allowing for greater intraprocedural safety. Furthermore, the level of satisfaction of the anesthesiologist and that of the operator appears to be significantly higher in the Remifentanil group. The execution of a mild to moderate sedation with Remifentanil in TCI in patients undergoing EBUS is safe, tolerated, and allows to obtain greater intraprocedural comfort. Further studies and larger and more representative samples are obviously needed to confirm and strengthen the validity of a remifentanil TCI-based sedation in endoscopic diagnostics.