Low-Dose PET/CT and Full-Dose Contrast-Enhanced CT at the Initial Staging of Localized Diffuse Large B-Cell Lymphomas

Computed tomography (CT) has been used as the reference imaging technique for the initial staging of diffuse large B-cell lymphoma until recent days, when the introduction of positron emission tomography (PET)/CT imaging as a hybrid technique has become of routine use. However, the performance of both examinations is still common. The aim of this work was to compare the findings between low-dose 2-deoxy-2-(F-18) fluoro-D-glucose (F-18-FDG) PET/CT and full-dose contrast-enhanced CT (ceCT) in 28 patients with localized diffuse large B-cell lymphoma according to PET/CT findings, in order to avoid the performance of ceCT. For each technique, a comparison in the number of nodal and extranodal involved regions was performed. PET/CT showed more lesions than ceCT in both nodal (41 vs. 36) and extranodal localizations (16 vs. 15). Disease staging according to both techniques was concordant in 22 patients (79%) and discordant in 6 patients (21%), changing treatment management in 3 patients (11%). PET/CT determined a better staging and therapeutic approach, making the performance of an additional ceCT unnecessary

Comparison of different automatic methods for the delineation of the total metabolic tumor volume in I-II stage Hodgkin Lymphoma

Total metabolic tumor volume (TMTV) is a promising quantitative biomarker for therapy assessment and prognosis in Hodgkin Lymphoma affected patients that allows prediction of patient outcome. The aim of this study was to evaluate the TMTV reproducibility between different sources of variability in tumor delimitation such as SUV-based thresholds (2.5, 41% and 50%) and software tools (Beth Israel plugin (BI) and LIFEx). Effect of contouring procedure both including single and multiple regions of interest was also studied in patients with multiple lesions, and optimal cut-offs for each studied method were displayed to compare the effect on prognosis. Strong alikeness in TMTV was found for 2.5 under software choice. Best accuracy in contouring compared to visual assessment of the disease was found for BI multiple ROI and LIFEx single ROI drawing. Similar cut-offs were found between both software for all considered thresholds, but best resemblance and highest cut-off due to an overestimation of the TMTV was found for 2.5 SUV. Our findings suggest that optimal reproducibility in TMTV is found for SUV>2.5 threshold under choice of contouring methodology or software tool, meaning that overestimation of the TMTV threshold using 2.5 looks to be preferable than underestimation with 41% and 50%

SPECT-CT metabolic and morphological study of 2 types of cemented hip stem prostheses in primary total hip arthroplasty patients

Background: Cemented hip arthroplasty requires applying a layer of polymethylmethacrylate (cement) in the space between the bone and the prosthetic stem. This can be achieved using 2 techniques: the thick-layer technique (requires a layer of at least 2 mm to surround an undersized prosthetic stem), and the thin-layer technique (requires a thin layer of cement, so that the prosthetic stem fills the femoral medullary canal). Both approaches have excellent long-term clinical and radiological outcomes, although an implant's insertion into the bone generates inevitable bone mass and bone metabolic changes around it. Combination of single photon emission computed tomography and computed tomography scan (SPECT-CT) imaging combines the single photon emission computed tomography's ability to provide detailed bone metabolism assessment with the computed tomography scan's capacity to provide a meticulous anatomical study. Methods: This is a single center, open label, randomized clinical trial, performed in the premises of the Bellvitge University Hospital. Participants will be randomly assigned to the Thick-layer technique group (Exeter V40 Cemented Femoral Stem) or to the French paradox technique group (Müller Straight Stem). All participants will have a SPECT-CT scan study at 3, 6, 12, and 24 months after the surgery. Discussion: Surgical distress itself and the implant's insertion into the bone may cause microvascular changes that alter periprosthetic bone mass and bone metabolism. To the best of our knowledge, there are no studies using SPECT-CT to compare bone metabolism evolution in the postoperative period between these 2 surgical cementation techniques. We aim to provide information in this regard that could help decision making in complicated implant cases and, maybe, pave the way for larger, and methodologically improved studies

Usefulness of 18F-FDG PET-CT for assessing large-vessel involvement in patients with suspected giant cell arteritis and negative temporal artery biopsy

Objective: To investigate the usefulness of F-18-FDG PET-CT for assessing large-vessel (LV) involvement in patients with suspected giant cell arteritis (GCA) and a negative temporal artery biopsy (TAB).Methods: A retrospective review of our hospital databases was conducted to identify patients with suspected GCA and negative TAB who underwent an F-18-FDG PET-CT in an attempt to confirm the diagnosis. The gold standard for GCA diagnosis was clinical confirmation after a follow-up period of at least 12 months.Results: Out of the 127 patients included in the study, 73 were diagnosed with GCA after a detailed review of their medical records. Of the 73 patients finally diagnosed with GCA, F-18-FDG PET-CT was considered positive in 61 cases (83.5%). Among the 54 patients without GCA, F-18-FDG PET-CT was considered positive in only eight cases (14.8%), which included 1 case of Erdheim-Chester disease, 3 cases of IgG4-related disease, 1 case of sarcoidosis, and 3 cases of isolated aortitis. Overall, the diagnostic performance of F-18-FDG PET-CT for assessing LV involvement in patients finally diagnosed with GCA and negative TAB yielded a sensitivity of 83.5%, specificity of 85.1%, and a diagnostic accuracy of 84% with an area under the ROC curve of 0.844 (95% CI: 0.752 to 0.936). The sensitivity was 89% in occult systemic GCA and 100% in extracranial LV-GCA.Conclusion: Our study confirms the utility of F-18-FDG PET-CT in patients presenting with suspected GCA and a negative TAB by demonstrating the presence of LV involvement across different subsets of the disease

Gamma probe sentinel node localization and biopsy in breast cancer patients treated with a neoadjuvant chemotherapy scheme

The aim of this study was to analyse the accuracy of scintigraphic and gamma probe sentinel node (SN) localization in breast cancer patients who have been submitted to neoadjuvant chemotherapy (NC). Seventy-six patients with single breast cancer were included in the study, and were classified into two groups. Group 1 consisted of 40 women who had received NC, and Group 2 consisted of 36 women who did not receive NC. All patients received 111 MBq (3 mCi) of 99Tcm-nanocolloid in 3 ml, by peritumoural injection. Anterior and lateral thoracic scans were obtained 2 h post-injection. The following day (18-24 h post-injection) the patients underwent surgery and sentinel nodes were localized by using a gamma probe. Complete axillary lymph node dissection was performed in all patients. Histological analysis included haematoxylin-eosin in all cases and immunohistochemistry in 10 cases. In Group 1, SNs were localized in 36/40 patients, histological analysis was performed in 34 and there were four false negatives (22%). In Group 2, SNs were localized in 32/36 patients, histological analysis was performed in 29 and there were two false negatives (9%). Predictive negative values were 78% and 90% in Groups 1 and 2, respectively. In summary, sentinel node localization in breast cancer patients submitted to previous neoadjuvant chemotherapy is less accurate than in patients who do not receive this therapy. The procedure is not sufficiently accurate to localize the sentinel node, thus it cannot be recommended in these patients

2-[18F]FDG PET/CT as a Predictor of Microvascular Invasion and High Histological Grade in Patients with Hepatocellular Carcinoma

Hepatocellular carcinoma (HCC) generally presents a low avidity for 2-deoxy-2-[18F]fluoro-d-glucose (FDG) in PET/CT although an increased FDG uptake seems to relate to more aggressive biological factors. To define the prognostic value of PET/CT with FDG in patients with an HCC scheduled for a tumor resection, forty-one patients were prospectively studied. The histological factors of a poor prognosis were determined and FDG uptake in the HCC lesions was analyzed semi-quantitatively (lean body mass-corrected standardized uptake value (SUL) and tumor-to-liver ratio (TLR) at different time points). The PET metabolic parameters were related to the histological characteristics of the resected tumors and to the evolution of patients. Microvascular invasion (MVI) and a poor grade of differentiation were significantly related to a worse prognosis. The SULpeak of the lesion 60 min post-FDG injection was the best parameter to predict MVI while the SULpeak of the TLR at 60 min was better for a poor differentiation. Moreover, the latter parameter was also the best preoperative variable available to predict any of these two histological factors. Patients with an increased TLRpeak60 presented a significantly higher incidence of poor prognostic factors than the rest (75% vs. 28.6%, p = 0.005) and a significantly higher incidence of recurrence at 12 months (38% vs. 0%, p = 0.014). Therefore, a semi-quantitative analysis of certain metabolic parameters on PET/CT can help identify, preoperatively, patients with histological factors of a poor prognosis, allowing an adjustment of the therapeutic strategy for those patients with a higher risk of an early recurrence

18F-FDG PET/CT for early prediction of response to neoadjuvant lapatinib, trastuzumab, and their combination in HER2-positive breast cancer: results from Neo-ALTTO

Molecular imaging receives increased attention for selecting patients who will benefit from targeted anticancer therapies. Neo-ALTTO (Neoadjuvant Lapatinib and/or Trastuzumab Treatment Optimisation) enrolled 455 women with invasive human epidermal growth factor receptor 2 (HER2)-positive breast cancer and compared rates of pathologic complete response (pCR) to neoadjuvant lapatinib, trastuzumab, and their combination. Each anti-HER2 therapy was given alone for 6 wk, followed by 12 wk of the same therapy plus weekly paclitaxel. The early metabolic effects of the anti-HER2 therapies on the primary tumors and their predictive values for pCR were assessed in a subset of patients. Methods: eighty-six patients underwent (18)F-FDG PET/CT at baseline and weeks 2 and 6 of anti-HER2 treatment. An imaging core laboratory provided central validation, and 2 independent reviewers, masked to assigned treatment arm and clinical outcomes, performed consensus (18)F-FDG PET/CT readings. Maximum standardized uptake value (SUVmax) reductions from baseline were used to measure metabolic response. Results: seventy-seven of the 86 enrolled patients presented an evaluable baseline (18)F-FDG PET/CT scan; of these, 68 and 66 were evaluable at weeks 2 and 6, respectively. Metabolic responses in the primary tumors were evident after 2 wk of targeted therapy and correlated highly with metabolic responses at week 6 (R(2) = 0.81). pCRs were associated with greater SUVmax reductions at both time points. Mean SUVmax reductions for pCR and non-pCR, respectively, were 54.3% versus 32.8% at week 2 (P = 0.02) and 61.5% versus 34.1% at week 6 (P = 0.02). (18)F-FDG PET/CT metabolic response rates at weeks 2 and 6 were 71.6% and 60%, respectively using European Organization for Research and Treatment of Cancer criteria; pCR rates were twice as high for (18)F-FDG PET/CT responders than nonresponders (week 2: 42% vs. 21%, P = 0.12; week 6: 44% vs. 19%, P = 0.05). Conclusion: early metabolic assessment using (18)F-FDG PET/CT can identify patients with an increased likelihood of pCR after neoadjuvant trastuzumab, lapatinib, or their combination when given with chemotherapy

Efficacy and safety clinical trial with efavirenz in patients diagnosed with adult Niemann-pick type C with cognitive impairment

Background:Niemann-Pick disease Type C (NPC) is a genetic, incurable, neurodegenerative disorder. This orphan disease is most frequently caused by mutations in the NPC1 protein, resulting in intralysossomal cholesterol accumulation. NPC1 is found in neuronal cell bodies, axon terminals and synaptosomes, suggesting it plays a role in lysosomal degradation pathway and in synaptic transmission. Neuronal function is especially vulnerable to NPC1 deficiency and synaptic changes seem a key element in disease development. Currently, Miglustat (Zavesca (R)) is the only approved treatment for NPC. However, preclinical evidence showed that low-dose Efavirenz reverted synaptic defects through pharmacological activation of the enzyme CYP46. Methods:This is a single-center, phase II clinical trial to evaluate the efficacy and safety of Efavirenz in addition to standard of care in patients diagnosed with adult or late juvenile-onset NPC with cognitive impairment. All enrolled patients will be treated orally with 25 mg/d of Efavirenz for 52 weeks (1 year). Secondary objectives include evaluating clinical (neurological and neuropsychological questionnaires) and biological (imaging and biochemical biomarkers) parameters. Discussion:NPC is still an unmet medical need. Although different therapeutic approaches are under study, this is the first clinical trial (to the best of our knowledge) studying the effects of Efavirenz in adult- and late-juvenile-onset NPC. Despite the small sample size and the single-arm design, we expect the results to show Efavirenz's capacity of activating the CYP46 enzyme to compensate for NPC1 deficiency and correct synaptic changes, therefore compensating cognitive and psychiatric changes in these patients. This study may provide direct benefit to enrolled patients in terms of slowing down the disease progression

Ibrutinib in Combination With Rituximab for Indolent Clinical Forms of Mantle Cell Lymphoma (IMCL-2015): A Multicenter, Open-Label, Single-Arm, Phase II Trial

PURPOSE The need for an individualized management of indolent clinical forms in mantle cell lymphoma (MCL) is increasingly recognized. We hypothesized that a tailored treatment with ibrutinib in combination with rituximab (IR) could obtain significant responses in these patients. METHODS This is a multicenter single-arm, open-label, phase II study with a two-stage design conducted in 12 Spanish GELTAMO sites (ClinicalTrials.gov identifier: NCT02682641). Previously untreated MCL patients with indolent clinical forms defined by the following criteria were eligible: no disease-related symptoms, nonblastoid variants, Ki-67 < 30%, and largest tumor diameter <= 3 cm. Both leukemic non-nodal and nodal subtypes were recruited. Patients received ibrutinib 560 mg once daily and a total of eight doses of rituximab 375 mg/m(2). Ibrutinib could be discontinued after 2 years in the case of sustained undetectable minimal residual disease (MRD). The primary end point was the complete response (CR) rate achieved after 12 cycles according to Lugano criteria. RESULTS Fifty patients with MCL (male 66%; median age 65 years) were enrolled. After 12 cycles of treatment, 42 (84%; 95% CI, 74 to 94) patients had an overall response, including 40 (80%; 95% CI, 69 to 91) with CR. Moreover, undetectable MRD in peripheral blood was achieved in 87% (95% CI, 77 to 97) of cases. At 2 years, 24 of 35 evaluable patients (69%) could discontinue ibrutinib because of undetectable MRD. Four patients had disease progression; three were non-nodal MCL and carried high genomic complexity and TP53 mutations at enrollment. No unexpected toxicity was seen except one patient with severe aplastic anemia. CONCLUSION Frontline IR combination achieves a high rate of CRs and undetectable MRD in indolent clinical forms of MCL. Discontinuation seems appropriate in cases with undetectable MRD, except for TP53-mutated cases

Localización radioguiada de lesiones no palpables de mama y biopsia selectiva del ganglio centinela

INTRODUCCIÓN: La localización radioguiada de lesiones no palpables de mama, conocida internacionalmente como ROLL, es una alternativa al método convencional de marcaje (arpón). Se puede realizar simultáneamente con la biopsia selectiva del ganglio centinela (GC) en pacientes con tumores clínicamente ocultos, conocida como técnica SNOLL. OBJETIVOS: Primario: Demostrar la utilidad de ROLL y SNOLL en pacientes con lesiones no palpables de mama (LNPM). Secundarios: Valorar la correcta localización intralesional del radiofármaco y analizar los márgenes de resección; evaluar los porcentajes de detección gammagráfica y quirúrgica del GC; valor de la ROLL en el diagnóstico de las LNPM con biopsia indeterminada; valorar la utilidad de la localización simultánea ROLL y GC (técnica SNOLL) en pacientes con cáncer no palpable de mama; valorar la utilidad de la localización simultánea ROLL y GC en pacientes tratadas con quimioterapia neoadyuvante (QTNA). MATERIAL Y MÉTODOS: Pacientes. Se distinguen 3 grupos: Grupo A pacientes con LNPM (69); Grupo B pacientes con cáncer no palpable de mama (27). Grupo C pacientes con cáncer de mama tratadas con QTNA (31). Protocolo exploratorio: 1) Administración intralesional, guiada mediante ecografía o mamografía estereotáxica, de macroagregados de albúmina marcados con 99mTC. En caso de detección simultánea del GC se administran nanocoloides-99mTc intratumoral (en grupo B) o subdermal (en grupo C). 2) Adquisición de imágenes gammagráficas para comprobar correcta colocación del radiofármaco a nivel intralesional e identificar el GC. 3) Exéresis quirúrgica de la lesión y del GC con la ayuda de una sonda gammadetectora. 4) Comprobación de la pieza quirúrgica (mamografía o inspección). Análisis anatomopatológico de la lesión primaria y de los bordes de resección. Parámetros estadísticos evaluados: valor predictivo negativo (VPN) y porcentaje falsos negativos (FN). RESULTADOS: Hubo correcta colocación intralesional del radiofármaco en 66/69 casos (95.6 %) en el grupo A, en los 27 casos (100%) del grupo B y en 30/31 casos (97%) en el grupo C. En el grupo A: La ROLL permitió resecar completamente la lesión en 21/32 de las malignas (66%). En el grupo B: los bordes de resección en el grupo B fueron libres en el 67% y cercanos en el 25%. Se identificó el GC en 26 casos (96%). El VPN fue del 100%. En el grupo C: Se identificó el GC en 28 casos (90%). El VPN fue del 87.5 % y el porcentaje de FN fue de 9.6 %. CONCLUSIONES: La técnica ROLL es una técnica de marcaje sencilla, segura y precisa para localizar lesiones no palpables de mama. Permite seleccionar la mejor vía de abordaje quirúrgico. La técnica SNOLL facilita la localización y exéresis quirúrgica de la lesión primaria no palpable debido a la elevada retención del radiotrazador en el punto de inyección y la migración del mismo por las vías de drenaje linfático permite la identificación del GC en un elevado porcentaje de pacientes. La BSGC en pacientes tratadas con QTNA predice el estado ganglionar axilar en un 85% de los casos y permite un análisis anatomopatológico exhaustivo del GC mejorando la identificación de las micrometástasis en los ganglios con cambios post-quimioterapia, aunque presenta una elevada tasa de FN.INTRODUCTION: Radioguided non palpable breast lesion localization, known as ROLL, is an alternative to the standard preoperative method (wire-guide). Simultaneous SLNB and non palpable breast localization is feasible in patients with occult tumors, a procedure known as SNOLL. OBJECTIVES: Primary objective: To show the utility of ROLL and SNOLL in patients with non palpable breast lesions. Secondaries objectives: To assess the correct intralesional radiotracer localization and to analyze the status of surgical margins; to assess scintigraphic and intraoperative identification rates of sentinel lymph node (SLN); the utility of ROLL in the diagnoses of indeterminate non palpable breast lesions (NPBL); to assess the utility of the SNOLL in patients with non palpable breast tumors; to assess the utility of simultaneous of the ROLL and SLNB in patients with locally advanced breast cancer (LABC) treated with neoadjuvant chemotherapy (NC). MATERIAL AND METHODS: Patients. We have distinguished 3 groups: A patients with indeterminate NPBL (69); B patients with non palpable breast cancer (27). C patients with LABC treated with NC (31). Exploratory protocol: 1) Intralesional radiotracer injection guided by ultrasound or stereotactic mammography (human serum albumin macroaggregates labelled with 99mTc). Intratumoural (in group B) or subdermal (in group C) radiotracer (nanocolloids labelled with 99mmTc) injection was performed when simultaneous SLNB. 2) Scintigraphic scans were performed in order to verify the intralesional correct placement of radiotracer and to identify the SLN. 3) Surgical removal of the lesion and SLNB were performed using a gamma probe. 4) Removed specimen was verified by mammography control or macroscopic inspection. Anatomopathological analysis of the primary lesion and surgical margins was performed. Statistical parameters (negative predictive value-NPV- and false negative-FN rate) were evaluated. RESULTS: Intralesional placement of tracer was correct in 66/69 cases (95.6 %) of group A, in 27 cases of group B (100%) and in 30/31 cases (97%) of group C. ROLL allows complete removal of the lesion in 21/32 of the malign lesions (66%) in group A. In group B, surgical margins were free in 67% and closed in 25%. SLN was detected in 26 cases (96%). NPV was 100%. In group C: Intraoperative detection of SN was found in 28 cases (90%). NPV and FN were 87.5 % and 9.6 %. CONCLUSIONS: ROLL is a simple, safe and precise preoperative localization in non palpable breast lesions. ROLL allows the more appropriate surgical procedure. SNOLL allows the localization and surgical removal of the non palpable breast tumor due to high retention of tracer in the place of injection and its migration through the lymphatic channels allow the identification of SN in a high number of patients. The SLNB in patients with breast cancer treated with NC predicts the status of axillary region in 85% patients and allows an accurate anatomopathological analysis of SL, improving the identification of the micrometastases in nodes with chemotherapy changes, although it has a high rate of FN