Precision radiotherapy by SPECT lung functional imaging in NSCLC

Background: Single Photon Emission Computed Tomography (SPECT) could be used to avoid the non-affected perfusion areas in patients with non-small-cell lung cancer (NSCLC) and to potentially reduce lung toxicity. The aim of this study is to compare dosimetric differences between two different 3D-conformal treatment plans, with and without CT/SPECT contribution. Methods: Simulation Computed tomography (CT) scans were accurately co-registered with SPECT scans and three different areas, based on SPECT intensity perfusion, were contoured: low perfusion (LP), medium perfusion (MP) and high perfusion (HP). Two different 3D-conformal plans, with co-planar and nonco-planar fields, were generated; one without SPECT information (anatomic plan), and one using the perfusion area identified with functional imaging (functional plan). Results: 9 patients were planned and a total of 18 plans were available for analysis. Anatomical and functional plans resulted in comparable planning target volume (PTV) coverage. In the functional plans, a significant reduction of dose in high perfusion areas was reported. The reduction of HP-V20 Gy values ranged from 15% to 8% (p = 0.046), the ipsiHP-V20 Gy from 38% to 22% (p = 0.028) and ipsiHP-Dmean reduction from 16 Gy to 12 Gy (p = 0.039). No significant differences in other organs at risk (OARs) metrics were reported between anatomical and functional plans. Conclusions: Despite the few cases reported, the strength of our study lies in the reported benefit of functional lung information in 3D conformal radiation planning, without compromising target coverage or worsening dose distribution to the OARs. There is an urgent need for prospective clinical and randomized trials in order to define the role of lung functional imaging in reducing toxicity in clinical practice

Long-term treatment of severe sapho syndrome with adalimumab and isotretinoin

SAPHO (synovitis, acne, pustulosis, hyperostosis, and osteitis) syndrome defines an association of inflammatory cutaneous disorders with osteoarticular manifestations and represents a clinical and therapeutic challenge. We report a case of severe SAPHO syndrome with acne conglobata and a diffuse involvement of the anterior chest wall and sacroiliac joints that required treatment with isotretinoin and adalimumab, a new fully human anti-tumor necrosis factor (TNF)-α monoclonal antibody. Combination treatment determined a complete clinical remission of cutaneous and osteoarticular manifestations after 48 weeks. Despite maintenance of clinical remission, follow-up imaging studies after 24 months of adalimumab monotherapy revealed osteoarticular disease progression, with features of inflammatory osteitis. TNFα antagonists have been used as third-line therapy for SAPHO syndrome in single case reports or case series, but these lack consistent long-term follow-up. SAPHO syndrome can present an intermittent-favorable course in the majority of cases as well as a chronic-progressive course, the latter requiring aggressive combination treatment with TNFα antagonists and conventional systemic agents