Restaging Of Patients Research Articles

Role of 18F-fluorodeoxyglucose positron emission tomography/computed tomography in the detection of recurrence and peritoneal metastasis from ovarian cancer in correlation with cancer antigen-125 tumor marker levels

BackgroundThe chronic nature of ovarian cancer and disease recurrence has a considerable impact on the assessment of follow-up strategies and treatment planning for both oncologists and radiologists. It is imperative to conduct adequate follow-up in ovarian cancer to detect and treat recurrence as early as possible. Presently, surveillance of patients with this malignancy involves the combination of serial CA-125 assay and diverse imaging procedures, yet normal CA-125 levels cannot entirely rule out disease relapse. PET/CT provides whole-body functional imaging that does not necessities contrast injection, and allows for precise diagnosis and restaging of patients with suspected ovarian cancer recurrence, thereby strongly impacting disease management decisions. Our study aims to evaluate the value of FDG-PET/CT as a follow-up imaging tool in detecting and localizing recurrence of ovarian cancer, in conjunction with CA-125 tumor markers.ResultsIn our study, it was demonstrated that recurrent disease manifested in FDG-PET/CT in 24 cases, with 9 of those cases exhibiting CA-125 levels within the normal range. There were two instances of false negative results and one instance of false positive results in FDG-PET/CT. Additionally, three cases were found to be free of disease relapse in FDG-PET/CT and exhibited normal CA-125 levels throughout the follow-up period (true negative). The prevalence of disease recurrent sites was 12% for local recurrence, 60% for peritoneal metastasis, 64% for nodal deposits and 28% for distant metastatic disease. The accuracy of FDG-PET/CT was 88.8%, with a sensitivity of 91.3% and specificity of 75%. Furthermore, FDG-PET/CT showed a positive predictive value of 95.5% and a negative predictive value of 60.3%.ConclusionsPET/CT imaging provides a comprehensive and functional view of the entire body, which can accurately diagnose and restage cases with ovarian cancer recurrence. This approach plays a critical role in identifying peritoneal carcinomatosis and is considered a more dependable method than CA-125 tumor markers for detecting and monitoring ovarian cancer recurrence. Additionally, PET/CT imaging has the potential to decrease the number of second-look laparotomies and can thus significantly impact the management plan.

Serum CEA as a Prognostic Marker for Overall Survival in Patients with Localized Pancreatic Adenocarcinoma and Non-Elevated CA19-9 Levels Treated with FOLFIRINOX as Initial Treatment: A TAPS Consortium Study.

About 25% of patients with localized pancreatic adenocarcinoma have non-elevated serum carbohydrate antigen (CA) 19-9 levels at baseline, hampering evaluation of response to preoperative treatment. Serum carcinoembryonic antigen (CEA) is a potential alternative. This retrospective cohort study from five referral centers included consecutive patients with localized pancreatic adenocarcinoma (2012-2019), treated with one or more cycles of (m)FOLFIRINOX, and non-elevated CA19-9 levels (i.e., < 37U/mL) at baseline. Cox regression analyses were performed to assess prognostic factors for overall survival (OS), including CEA level at baseline, restaging, and dynamics. Overall, 277 patients were included in this study. CEA at baseline was elevated (≥5ng/mL) in 53 patients (33%) and normalized following preoperative therapy in 14 patients (26%). In patients with elevated CEA at baseline, median OS in patients with CEA normalization following preoperative therapy was 33 months versus 19 months in patients without CEA normalization (p = 0.088). At time of baseline, only elevated CEA was independently associated with (worse) OS (hazard ratio [HR] 1.44, 95% confidence interval [CI] 1.04-1.98). At time of restaging, elevated CEA at baseline was still the only independent predictor for (worse) OS (HR 1.44, 95% CI 1.04-1.98), whereas elevated CEA at restaging (HR 1.16, 95% CI 0.77-1.77) was not. Serum CEA was elevated in one-third of patients with localized pancreatic adenocarcinoma having non-elevated CA19-9 at baseline. At both time of baseline and time of restaging, elevated serum CEA measured at baseline was the only predictor for (worse) OS. Therefore, serum CEA may be a useful tool for decision making at both initial staging and time of restaging in patients with non-elevated CA19-9.

OP82 Positron Emission Tomography Combined With Computed Tomography Using 18F-Sodium Fluoride

IntroductionPositron emission tomography combined with computed tomography (PET/CT) using 18F-sodium fluoride (18F-NaF) is used for functional imaging in diseases to detect abnormally altered osteogenic activity, such as benign and malignant bone diseases and inflammatory or traumatic changes in skeletal bones.MethodsA systematic search of literature using keywords in the MEDLINE database was conducted to identify literature on the clinical and cost effectiveness of using PET/CT with 18F-NaF-based radiopharmaceuticals in the diagnosis of bone and cartilage cancer. The search retrieved 323 publications. The analysis included 11 publications that met the selection criteria, including one meta-analysis and ten literature reviews.ResultsThe pooled sensitivity, specificity, diagnostic odds ratio (DOR) and area under the receiver operating characteristic curve of 18F-NaF-based PET/CT for the detection of bone metastases were 0.98 (95% confidence interval [CI]: 0.95, 0.99), 0.90 (95% CI: 0.86, 0.93), 123.2, and 0.97, respectively. 18F-NaF-based PET/CT was highly effective in detecting bone metastases during staging and restaging of patients with high-risk prostate cancer. The effectiveness of 18F-NaF-based PET/CT was superior to bone scintigraphy with technetium-99m and single-photon emission computed tomography (SPECT) and was comparable to diffusion-weighted imaging.ConclusionsPET/CT with 18F-NaF is a more accurate method of localizing and characterizing malignant bone lesions than SPECT. This method has improved clinical accuracy and provides greater convenience for patients and referring physicians. PET/CT with 18F-NaF in malignant neoplasms is a more specific, sensitive study than 18F-fluorodeoxyglucose PET/CT. These results were submitted to the Ministry of Health for a decision on the inclusion of 18F-NaF-based PET/CT in the state reimbursement system.

Artificial intelligence and radiomics in magnetic resonance imaging of rectal cancer: a review.

Rectal cancer (RC) is one of the most common tumours worldwide in both males and females, with significant morbidity and mortality rates, and it accounts for approximately one-third of colorectal cancers (CRCs). Magnetic resonance imaging (MRI) has been demonstrated to be accurate in evaluating the tumour location and stage, mucin content, invasion depth, lymph node (LN) metastasis, extramural vascular invasion (EMVI), and involvement of the mesorectal fascia (MRF). However, these features alone remain insufficient to precisely guide treatment decisions. Therefore, new imaging biomarkers are necessary to define tumour characteristics for staging and restaging patients with RC. During the last decades, RC evaluation via MRI-based radiomics and artificial intelligence (AI) tools has been a research hotspot. The aim of this review was to summarise the achievement of MRI-based radiomics and AI for the evaluation of staging, response to therapy, genotyping, prediction of high-risk factors, and prognosis in the field of RC. Moreover, future challenges and limitations of these tools that need to be solved to favour the transition from academic research to the clinical setting will be discussed.

The Role of Whole-Body Magnetic Resonance Imaging in Assessing Extrapulmonary Metastases in Osteosarcoma Staging and Restaging: A Pilot Study.

The aim of the study is to investigate the role of whole-body magnetic resonance imaging (MRI) in assessing extrapulmonary metastases in primary osteosarcoma staging. We retrospectively reviewed medical data to identify primary osteosarcoma patients with available preoperative whole-body MRI obtained in the staging or restaging. Histopathology was the reference test for assessing the diagnostic performance, if available. Otherwise, oncology board decisions were used as the reference. In addition, the benefits of whole-body MRI to F-fluorodeoxyglucose positron emission tomography-computed tomography (18F-FDG PET-CT) and bone scintigraphy were investigated. In all, 36 patients with osteosarcoma (24 staging, 12 restaging) with a mean age of 16.36 ± 5.63 years (range, 9-29 years) were included in the study. The median follow-up duration was 26.61 months (interquartile range, 33.3 months). Of 36 patients, 8 had skeletal, 1 had a lymph node, and 1 had a subcutaneous metastasis. Whole-body MRI correctly identified all patients with metastatic disease but incorrectly classified a bone infarct in one patient as a skeletal metastasis, equating a scan-level sensitivity, specificity, accuracy, negative predictive value, and positive predictive value of 100%, 96.3%, 97.3%, 100%, and 90.91%. Whole-body MRI contributed to bone scintigraphy by identifying a skeletal metastasis in one patient and positron emission tomography-computed tomography by ruling out a skeletal metastasis in another. Whole-body MRI could accurately identify extrapulmonary metastases in primary osteosarcoma patients for staging or restaging. In addition, it might contribute to the standard whole-body imaging methods.

Added value of digital FDG-PET/CT in disease staging and restaging in patients with resectable or borderline resectable pancreatic cancer

BackgroundWe studied the added value of digital FDG-PET/CT in disease staging and restaging compared to the standard work-up with contrast enhanced CT (ceCT) and CA19-9 in patients with resectable or borderline resectable pancreatic cancer who received neo-adjuvant therapy. Primary endpoints were tumor response compared to ceCT and CA19.9 as well as the ability to detect distant metastatic disease. Methods35 patients were included in this dual-center prospective study. FDG-PET using digital photon counting technology combined with CT scans were acquired before (T1) and after neo-adjuvant therapy (T2). Patients were staged and restaged based on standard protocol with ceCT and CA 19.9, while all PET/CT scans were stored securely and not included in clinical decision making. After the pancreatic resection, an expert team retrospectively assessed the CT tumor diameter, CA19-9, tumor FDG-uptake, and appearance of metastatic disease of all patients for both time points. ResultsCA19-9 levels, CT tumor diameter, and tumor FDG-uptake on PET significantly decreased from T1 to T2 (p = 0.017, p = 0.001, and p < 0.0001). The change in FDG-uptake values showed a strong positive correlation with the change in CT tumor diameter and change in CA19-9 (R = 0.75 and R = 0.73, respectively). In addition, small-volume liver lesions were detected on digital PET/CT in 5/35 patients (14%), 4 of which were pathology confirmed at laparotomy. Only one of these five cases was detected on baseline staging ceCT (3%). ConclusionWe found that adding digital PET/CT strengthens restaging after neo-adjuvant therapy based on the observed strong correlation with ceCT tumor diameter and Ca19.9. Also, digital PET/CT was found to detect occult metastatic disease not visualized on ceCT, that would have resulted in altered disease staging and therapeutic strategy in a substantial proportion of patients.

Patterns of breast cancer second recurrences in patients after mastectomy.

Little is known about second recurrences in breast cancer patients, especially in patients with mastectomy. We aimed to determine the risk factors, prevalence and patterns of second recurrence in mastectomy patients after first recurrence. Stage I-III breast cancer patients treated at a tertiary institution from 1st September 2005 to 31st October 2017 and developed first and second recurrences after mastectomy were retrospectively reviewed. We excluded patients with bilateral cancers and patients who were lost to follow-up. The demographics, pathological and recurrence data were collected from a prospectively maintained database and analysed. Of the 1619 mastectomy patients, 214 (13.2%) patients developed recurrences at a mean 39.9months from primary cancer diagnosis. 23, 8 and 183 had isolated chest wall recurrences (CWR), regional and systemic metastases, respectively. Excluding 2 CWR patients without surgery, second recurrences occurred in 3/21 (14.3%) and 3/8 (37.5%) in patients with CWR and regional metastasis at 27.7months (range: 5-42) and 32months (range: 18-40), respectively. In both groups, systemic metastasis as second recurrence occurred within 2years after first recurrence, whilst locoregional second recurrences occurred later. No risk factors for second recurrence were identified. In patients with mastectomy, second recurrences occurred in 20.7% of patients with treated locoregional first recurrence, with no risk factors identified. Systemic metastases manifesting as second recurrence occurred in the first 2years after first recurrence. Continued clinical surveillance and restaging patients in the first 2years after first locoregional recurrence may enable early prognostication and treatment with the newer metastatic drugs.

Contribution of Open Mouth Technique in 18F-FDG PET/CT Imaging in Patients with Malignant Lip Neoplasm.

Objectives: 18F-fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) plays an important role in evaluating head and neck cancers. However, localization and size evaluation in this region can be rough due to the multitude of the anatomic structures and physiologic uptakes. The aim of this study was to evaluate malignant lip lesions with the contribution of open mouth (OM) imaging technique at PET/CT.Methods:Fifty-six patients with malignant lip neoplasm underwent 18F-FDG PET/CT imaging. Each patient was imaged twice as whole-body PET/CT with routine closed mouth (CM) position; and OM head and neck image, standardized with a special device. Lesion maximum standard uptake value (SUVmax), localization, size, and involvement of lymph nodes were evaluated.Results:Lesion localization was correctly detected in 100% of the OM images. Lesion size in PET/CT was compared with clinical, radiological (magnetic resonance imaging and CT) and/or histopathological results and the size measurement was coherent at 47.1% and 95.6% for CM and OM images, respectively. It was observed that OM acquisition did not contribute additionally in detecting regional lymph node metastasis. Forty-one PET/CT scans with CT artifacts due to dental amalgams were evaluated and 46.3% dimensional and 53.7% localization errors were detected in the CM position. There was no statistically significant difference between OM and CM SUVmax (p>0.05).Conclusion:We concluded that additional OM head and neck imaging is useful and necessary to accurately determine the localization and size of the tumor, thus enhancing the value of PET/CT in staging, treatment response assessment, and restaging of patients with malignant lip cancer with or without dental amalgam

Laparoscopic and Laparotomic Restaging in Patients With Apparent Stage I Epithelial Ovarian Cancer: A Comparison of Surgical and Oncological Outcomes.

ObjectiveTo assess the surgical and oncological outcomes of laparoscopic restaging compared with laparotomy for apparent early-stage epithelial ovarian cancer.MethodsA retrospective chart review was undertaken of patients who underwent laparoscopic (laparoscopy group) or laparotomic (laparotomy group) restaging at the Peking Union Medical College Hospital, China, between January 2012 and December 2017. All patients had apparent stage I epithelial ovarian cancer that was incompletely staged at the initial surgery.ResultsA total of 157 patients were included, with 50 in the laparoscopy group and 107 in the laparotomy group. Baseline characteristics were similar between the groups. No cases were converted from laparoscopy to laparotomy. The laparoscopy group had a significantly shorter operating time (p<0.001), less estimated blood loss (p<0.001), and a shorter postoperative hospitalization duration (p<0.001) than the laparotomy group. Transfusions were required in only eight laparotomy patients. No significant differences in postoperative complications were observed between the two groups (p=0.55). Eighteen (11.5%) patients were upstaged to stage II or stage III after surgery. A total of 123 (78.3%) patients received postoperative platinum-based chemotherapy. During the follow-up period, 15 (9.6%) patients experienced disease recurrence, and 3 patients died of disease progression. Five-year disease-free survival (p = 0.242, log-rank test) and overall survival (p = 0.236, log-rank test) were not affected by the surgical approach.ConclusionsLaparoscopic restaging showed more favorable operative outcomes than laparotomy. Surgical restaging via laparoscopy versus laparotomy was not associated with worse survival in women with apparent stage I epithelial ovarian cancer.

The role of fluorine-18-fluorodeoxyglucose-positron emission tomography/computed tomography (18F-FDG-PET/CT) in staging and restaging of patients with uterine sarcomas: a systematic review

The role of fluorine-18-fluorodeoxyglucose-positron emission tomography/computed tomography (18F-FDG-PET/CT) in staging and restaging of patients with uterine sarcomas: a systematic review

Normal Variants, Pitfalls and Artifacts in Ga-68 DOTATATE PET/CT Imaging.

Indium 111 DTPA Octreotide (Octreoscan) has been the pillar of Somatostatin receptor (SSTRs) imaging in nuclear medicine for over three decades. The advent of PET/CT brought new analogs of somatostatin that have higher affinity and improved resolution due to their labeling to Gallium 68 for positron imaging. The most used analogs include DOTATATE, DOTATOC and DOTANOC. However, Gallium 68-1,4,7,10-tetraazacyclododecane-1,4,7,10-tetraacetic acid (DOTA)-octreotate (DOTATATE) is probably the most common non-FDG (fluoro-2-deoxy glucose) PET tracer alongside PSMA (prostate specific membrane antigen). In contrast to F18-labeled FDG, it does not require proximity to a cyclotron due to the availability of the Ga68 generator. DOTATATE is a somatostatin analog which allows whole body imaging of somatostatin receptors on cell surfaces. 68Ga-DOTA compounds provide the imaging standard for well-differentiated (Grade 1 and low grade 2) neuro-endocrine tumors (NETs) and is utilized in the staging and characterization and restaging of patients with NETs. 68Ga DOTATATE has a complementary role with 18F-FDG where tumors may exhibit varying degrees of differentiation. It furthermore has application as a prelude to therapy in selecting patients for peptide receptor radionuclide therapy using a theranostic approach. A sound knowledge of the normal biodistribution of the radiotracer is imperative for optimal patient outcome and to avoid potential false positives such as inflammation, normal pancreatic uncinate process uptake and osteoblastic activity. In this review, we will describe the normal appearances of the 68Ga DOTATATE and the potential pitfalls with the support of images to aid in improving interpretation of this crucial innovative tool in the management of individuals with tumors expressing SSTRs.

Tumor Imaging With 68Ga-DOTA-FAPI-04 PET/CT: Comparison With 18F-FDG PET/CT in 22 Different Cancer Types.

Cancer-associated fibroblasts, which are densely found in tumor tissue, express high levels of fibroblast activation protein (FAP), and FAP inhibitors (FAPIs) labeled with radionuclides can be used in the diagnosis and treatment of cancer. In this study, the role of 68Ga-DOTA-FAPI-04 PET/CT in imaging of primary, metastatic, and recurrent cancers was investigated. A total of 42 patients (16 females, 26 males; mean age, 58.5 years; range, 31-84 years) with 22 different types of malignant diseases were included in the study. 68Ga-DOTA-FAPI-04 PET/CT imaging was performed 1 to 7 days after 18F-FDG PET/CT. Pathological uptake levels in primary tumoral lesions, lymph nodes, skeletal system, liver, peritoneal surfaces, and other body parts were compared between 2 PET/CTs. In addition, physiological uptake levels of 18F-FDG and 68Ga-FAPI were defined measuring the liver, thoracic aorta, gluteal muscle activities, and uterus activity in female patients. Of the 42 patients in the study group, 33 patients were included for staging, 8 patients for restaging, and 1 patient for evaluation of treatment response. 68Ga-DOTA-FAPI-04 PET/CT showed intense uptake in 94.2% of primary tumoral lesions. In patients with multiple myeloma, 18F-FDG uptake in the bone marrow was significantly higher than 68Ga-FAPI uptake, whereas in gastric signet ring cell tumors, 68Ga-FAPI uptake was found to be significantly higher than 18F-FDG uptake. It was observed that 68Ga-DOTA-FAPI-04 PET/CT detected bone, liver, and peritoneum metastases with higher sensitivity and accuracy compared 18F-FDG PET/CT. The preliminary findings of this study showed that 68Ga-DOTA-FAPI-04 PET/CT can contribute to the diagnostic process in solid tumors. Especially in malignancies with mild uptake on 18F-FDG PET/CT, it stands out in diagnosis, staging, and restaging. It is also predicted that FAPI molecules can be used for radionuclide therapy in patients with metastatic disease and unresponsive to other treatments showing intense uptake on 68Ga-DOTA-FAPI-04 PET/CT.

Preoperative T and N Restaging of Rectal Cancer After Neoadjuvant Chemoradiotherapy: An Accuracy Comparison Between MSCT and MRI.

BackgroundIt is well established that magnetic resonance imaging (MRI) is better than multi-slice computed tomography (MSCT) for the accurate diagnosis of pretreatment tumor (T) and node (N) staging of rectal cancer. However, the diagnostic value of MRI and MSCT in local restaging of rectal cancer after neoadjuvant chemoradiotherapy (NCRT) is controversial. The aim of this study is to investigate the performance of the two imaging exams in restaging of patients with rectal cancer.MethodsPatients with rectal cancer from April 2015 to April 2021 were analyzed retrospectively. The inclusion criteria are as follows: 1) diagnosis of rectal cancer through pathology; 2) NCRT had been performed; 3) all patients had undergone both MSCT and MRI examination before the surgery. Exclusion criteria are as follows: 1) incomplete clinical and imaging data; 2) previous history of pelvic surgery. Two radiologists performed T and N staging of patient images. Diagnostic accuracy, consistency analysis, and error restaging distribution of the two imaging exams for T and N restaging of rectal cancer were assessed using postoperative pathological staging as the gold standard.ResultsA total of 62 patients (49 men; mean age: 59 years; age range 29–83 years) were included in the study. The diagnostic accuracy of MSCT and MRI for T restaging was 51.6% (95% CI 39.3%–63.9%) and 41.9% (95% CI 29.6%–54.2%), respectively, and no statistical difference was found between them (p > 0.05). The diagnostic accuracy of MSCT and MRI for N restaging was 56.5% (95% CI 44.2%–68.8%) and 53.2% (95% CI 40.8%–65.6%), respectively, and no statistical difference was found between them (p > 0.05). The consistency analysis showed that T restaging (κ = 0.583, p < 0.001) and N restaging (κ = 0.644, p < 0.001) were similar between MSCT and MRI. There was no significant difference in the distribution of over, accurate, or low staging in T restaging (p > 0.05) and N restaging (p > 0.05) between MSCT and MRI.ConclusionsMSCT and MRI have similarly poor performance in the diagnosis of preoperative T and N restaging of rectal cancer after NCRT. Neither of them cannot effectively stage the ypT0-1 of rectal cancer. These findings may be of clinical relevance for planning less imaging exam.

Adapting Imaging Protocols for PET-CT and PET-MRI for Immunotherapy Monitoring.

Simple SummaryIn this review, we discuss the possible advantages and methods to overcome potential obstacles of applying combined imaging protocols of PET-CT and PET-MRI, within the context of staging and restaging of patients under immunotherapy, in order to achieve “multi-hybrid imaging” in one single visit.Hybrid imaging with positron emission tomography (PET) in combination with computer tomography (CT) is a well-established diagnostic tool in oncological staging and restaging. The combination of PET with magnetic resonance imaging (MRI) as a clinical scanner was introduced approximately 10 years ago. Although MRI provides superb soft tissue contrast and functional information without the radiation exposure of CT, PET-MRI is not as widely introduced in oncologic imaging as PET-CT. One reason for this hesitancy lies in the relatively long acquisition times for a PET-MRI scan, if the full diagnostic potential of MRI is exploited. In this review, we discuss the possible advantages of combined imaging protocols of PET-CT and PET-MRI, within the context of staging and restaging of patients under immunotherapy, in order to achieve “multi-hybrid imaging” in one single patient visit.

Clinical value of 18FDG PET/MRI in muscle-invasive, locally advanced, and metastatic bladder cancer

ObjectiveMetastatic bladder cancer is an aggressive disease that can often be difficult to diagnose and stage with conventional cross-sectional imaging. The primary objective of this study was to determine the clinical value of fluorine-18 2-fluoro-2-deoxy-D-glucose (18F-FDG) PET/MRI for surveillance and restaging of patients with muscle-invasive, locally advanced, and metastatic bladder cancer compared to conventional imaging methods. Materials and MethodsThis retrospective study enrolled patients with muscle-invasive, locally advanced and metastatic bladder cancer in a single institute evaluated with 18F-FDG PET/MRI. All patients also underwent conventional imaging with CT. Additional imaging may also have included 18F-FDG PET/CT (18F-FDG PET), or sodium fluoride (NaF) PET/CT in some patients. Images were reviewed by a diagnostic radiologist/nuclear medicine physician. Number of lesions and sites of disease were captured and compared between 18F-FDG PET/MRI and conventional imaging. Lesions were confirmed by sequential imaging or lesion biopsy. All patients were followed for survival. ResultsFifteen patients (4 for surveillance; 11 for restaging) underwent 34 18F-FDG PET/MRI scans. Each patient received a corresponding conventional CT around the time of the 18F-FDG PET/MRI (median 6 days). The 15 patients (11 male; 4 female) had a median age of 61.5 years (range 37–73) and histologies of urothelial carcinoma (n = 13) and small-cell carcinoma of the bladder (n = 2) diagnosed as stage 4 (n = 13), stage 3 (n = 1), or stage 2 (n = 1). 18F-FDG PET/MRI detected 82 metastatic malignant lesions involving lymph nodes (n = 22), liver (n = 10), lung (n = 34), soft tissue (n = 12), adrenal glands (n = 1), prostate (n = 1), and bone (n = 2) with a resultant advantage of 36% for lesion visibility in comparison with CT. Serial imaging or biopsy confirmed these lesions as malignant. Conclusion18F-FDG PET/MRI can detect metastatic lesions which cannot be identified on conventional CT, and this can allow for better treatment planning and improved disease monitoring during therapy.

Whole-body MRI versus an [18F]FDG-PET/CT-based reference standard for early response assessment and restaging of paediatric Hodgkin\u2019s lymphoma: a prospective multicentre study

ObjectivesTo compare WB-MRI with an [18F]FDG-PET/CT-based reference for early response assessment and restaging in children with Hodgkin’s lymphoma (HL).MethodsFifty-one children (ages 10–17) with HL were included in this prospective, multicentre study. All participants underwent WB-MRI and [18F]FDG-PET/CT at early response assessment. Thirteen of the 51 patients also underwent both WB-MRI and [18F]FDG-PET/CT at restaging. Two radiologists independently evaluated all WB-MR images in two separate readings: without and with DWI. The [18F]FDG-PET/CT examinations were evaluated by a nuclear medicine physician. An expert panel assessed all discrepancies between WB-MRI and [18F]FDG-PET/CT to derive the [18F]FDG-PET/CT-based reference standard. Inter-observer agreement for WB-MRI was calculated using kappa statistics. Concordance, PPV, NPV, sensitivity and specificity for a correct assessment of the response between WB-MRI and the reference standard were calculated for both nodal and extra-nodal disease presence and total response evaluation.ResultsInter-observer agreement of WB-MRI including DWI between both readers was moderate (κ 0.46–0.60). For early response assessment, WB-MRI DWI agreed with the reference standard in 33/51 patients (65%, 95% CI 51–77%) versus 15/51 (29%, 95% CI 19–43%) for WB-MRI without DWI. For restaging, WB-MRI including DWI agreed with the reference standard in 9/13 patients (69%, 95% CI 42–87%) versus 5/13 patients (38%, 95% CI 18–64%) for WB-MRI without DWI.ConclusionsThe addition of DWI to the WB-MRI protocol in early response assessment and restaging of paediatric HL improved agreement with the [18F]FDG-PET/CT-based reference standard. However, WB-MRI remained discordant in 30% of the patients compared to standard imaging for assessing residual disease presence.Key Points• Inter-observer agreement of WB-MRI including DWI between both readers was moderate for (early) response assessment of paediatric Hodgkin’s lymphoma.• The addition of DWI to the WB-MRI protocol in early response assessment and restaging of paediatric Hodgkin’s lymphoma improved agreement with the [18F]FDG-PET/CT-based reference standard.• WB-MRI including DWI agreed with the reference standard in respectively 65% and 69% of the patients for early response assessment and restaging.

The role of 18F-Fluorodeoxyglucose PET/CT in restaging patients with small cell lung cancer: a systematic review.

18F-Fluorodeoxyglucose (FDG) PET imaging may play an important role in the restaging of patients with small-cell lung cancer (SCLC),, nevertheless, a systematic review of literature was still missing in this setting. The aim of this review was to summarize the evidence on literature regarding the utility of 18F-FDG PET imaging in restaging patients with SCLC. A literature search was performed to retrieve original studies using 18F-FDG PET or 18F-FDG PET/computed tomography (CT) in a minimum of 10 patients with SCLC at restaging. The selected literature (17 studies) was discussed in four sections: detection rate, impact on management, prediction of prognosis and evaluation of the response to therapy. According to the literature, PET imaging may result in discordance with conventional imaging, mainly contrast-enhanced CT (ceCT), and detect additional lesions in a certain proportion of cases, leading to upstaging or downstaging. A variable level of disagreement between PET and conventional imaging has been reported also in the evaluation of response to therapy. A positive PET study is associated with shorter survival, especially in the presence of distant metastases. According to some studies, semiquantitative parameters are also inversely associated with overall survival and progression-free survival. Although the retrieved articles proved the utility of 18F-FDG PET imaging in each clinical setting, literature is still limited. This review encourages the use of 18F-FDG PET imaging, especially in conjunction with ceCT in recurrent SCLC patients. Further level I evidence is needed to further assess the diagnostic and prognostic capability of 18F-FDG PET/ceCT findings in SCLC.

18F-FDG PET/MR versus MR Alone in Whole-Body Primary Staging and Restaging of Patients with Rectal Cancer: What Is the Benefit of PET?

Background: To investigate and compare the diagnostic performance of 18F-Fluorodeoxyglucose (18F-FDG) PET/MR and MR alone in whole-body primary staging and restaging of patients with rectal cancer. Methods: A retrospective analysis was performed to evaluate diagnostic accuracies of combined reading of PET/MR and MR alone in T, N and M staging against the reference standard. Inter-observer agreement regarding TNM staging was calculated separately for PET/MR and MR alone. Results: A total of 39 studies of 34 patients could be evaluated. Diagnostic accuracies of PET/MR and MR alone were the same in locoregional T staging. For predicting N+ stage, the specificity of combined reading of PET and MR (0.917 and 0.833 for reader 1 and 2, respectively) was slightly higher than MR alone (0.833 and 0.75) without significantly increasing the overall accuracy (0.783 vs. 0.783 and 0.783 vs. 0.739). For detecting distant metastasis, the sensitivities of PET/MR and MR alone were shown equal (1.0 vs. 1.0 and 0.938 vs. 0.938), while the specificity of PET/MR was marginally lower (0.87 vs. 0.913 and 0.826 vs. 0.87). The inter-observer agreements were good to excellent in M (κ = 0.64 and 0.637 for PET/MR and MR alone, p < 0.001) and N staging (0.819 and 0.738, p < 0.001).Conclusion: PET did not yield a significant improvement in diagnostic accuracy of PET/MR in TNM staging of rectal cancer, since MR alone facilitated accurate classification of disease stage with good to excellent inter-observer agreement.

Evaluation of Second-Look Transurethral Resection in Re-Staging of Patients With Superficial Bladder Cancer

Objective: The Objective of this study was to evaluate the second-look transurethral resection (TUR) from the base of the previously resected bladder tumour in avoidance of staging errors, possibility of changing treatment strategy, and determination of risk factors of up-staging in patients with a diagnosis of superficial bladder cancer. Materials and Methods: In this cross sectional study, 50 cases of superficial bladder cancers (pTa and pT1) were included where muscle coat were absent in histopathologic report of first TURBT. A second-look TUR from the tumour site were done after 4 weeks following the initial resection. At the second-look TUR, resection from the base of the previously resected area was performed for restaging. Finally, histopathologic findings of the second TURBT were compared with those of the initial one by appropriate statistical analysis. Results: Out of 50 patients, 27 (54%) had residual malignant tissue in histopathological report of second-look TUR, while 23 (46%) were tumour free (no residual malignant tissue) at second-look TUR. In this study, total up-staging of tumour found in 18 (36%) patients. Out of them, 6 (12%) and 2(4%) patients were up-staged from pTa to pT1 and PT2 respectively. 10 (20%) were up-staged from PT1 to muscle-invasive (pT2). So, total percentage of staging errors (under staging) detected in second-look TUR was 36% cases. Appearance (sessile), size (&gt;3 cm) and stage (pT1) of the tumour at the initial resection were independent risk factors for up-staging to muscle invasive disease detected at second-look TURBT. Conclusions: Second-look TURBT is a valuable procedure for detection of residual tumour and accurate staging of non-muscle invasive bladder tumour. It also changed the treatment strategy of a significant proportion of patients. It is useful for tumours at high risk of recurrence and progression such as large size, sessile, multiple and T1 high grade tumours, particularly when there is inadequate or no muscularis propria in the specimen. Bangladesh Journal of Urology, Vol. 18, No. 1, Jan 2015 p.16-22

PET/CT in restaging, prognosis, and recurrence in patients with malignant melanoma

BackgroundCutaneous malignant melanoma (CMM) is a highly aggressive tumor with high tendency of return despite complete surgical removal. It has a high risk of dissemination to regional lymph nodes and visceral organs. The prognosis is highly dependent on lymph node involvement and distant metastases. Positron Emission Tomography with Computed Tomography (PET/CT) is a valuable non-invasive tool for the diagnosis and staging of patients with MM. The purpose of the present study was to evaluate the role of integrated (PET/CT) in staging, restaging, prognosis, and prediction of recurrence in patients with malignant melanoma.ResultsFifty malignant melanoma patients with age ranged from 28 to74 years (mean age 55.94 + 13.40 years) were 28 males (mean age 56.71 + 12.82) and 22 females (mean age 54.95 + 14.34). All our patients were histopathologically proven to have malignant melanoma. Twenty-one patients came for initial staging by 18F-FDG PET/CT. Their findings were compared with the reference standards and showed the sensitivity of 93.33%, specificity of 60%, and accuracy of 85.71% for primary staging. 18F-FDG PET/CT scan in 11 clinical suspicion patients of relapse after treatment showed the sensitivity of 100%, specificity of 66.66%, positive predictive value of 88.88%; negative predictive value of 100%; and accuracy of 90.90%. FDG-PET/CT of whole body scan in 18 cases of stage IV melanoma showed sensitivity of 100%, specificity of 66.66%, and overall accuracy of 94.44% for detection of distant metastases. SUVmean and SUVmax in all studied groups were significantly higher in true positive more than true negative or false-positive patients diagnosed by PET/CT with high sensitivity (82.88–100%).ConclusionPET/CT imaging enhanced diagnostic performance in detection of the primary malignancy, in follow-up of high-risk patients and patients with suspected or known local or distant recurrence, and in restaging of patients with known distant metastatic disease to assess tumor response.