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Introduction. Primary mediastinal lymphoma (PML) is an aggressive lymphoid tumor treatment success of which is determined by induction therapy. To date, none of the standard chemotherapy regimens (CT) have demonstrated an advantage in efficacy. Intensive therapy programs are associated with high toxicity. Aim - to evaluate the efficacy and toxicity of two pilot prospective treatment protocols PML-16 and PML-19 as well as the possibility of using the analysis of freely circulating tumor DNA (ctDNA) to assess MRD in patients with PML. Materials and methods. From January 2016 to January 2022, 34 previously untreated PML patients were included in the study;average age - 32;stage > I - in 60 %;extramediastinal lesions - in 14.7 %;bulky disease - in 73.5 % of patients. Positron emission tomography combined with computed tomography (PET-CT) was performed;ctDNA was determined to assess the completeness of remission. Results. Eighteen patients received treatment according to the PML-16 protocol (6 courses of chemotherapy;2 blocks of RmNHL-BFM-90 + 4 courses of R-EPOCH). After the end of therapy, all 18 patients achieved PET-negative remission. The next 16 patients received treatment according to the PML-19 protocol (4 courses of chemotherapy;2 blocks of R-mNHL-BFM-90 + 2 courses of R-EPOCH) in combination with lenalidomide. After the end of therapy, 9 (56 %) patients achieved PET-negative remission;7 (44 %) retained pathological activity (D4-5 points). After 3 and 6 months 15 (94 %) patients achieved normalization of metabolic activity. Considering the high frequency of false-positive results in patients with PML, a ctDNA study was performed to determine the depth of remission in 15 patients. After the end of therapy, all 15 patients had complete elimination of ctDNA. Of these, 5 (33 %) remained PET-positive at the end of treatment. During further observation, after 3-6 months, in 4 patients the level of metabolic activity decreased to physiological without the use of consolidating therapy. After the end of therapy, one patient suffered the new coronavirus infection, COVID-19. A month later, residual formation of SUVmax 14.2 remained in the mediastinum. The patient is currently under observation. With a median follow-up of 36 months (9 to 76 months) all 34 patients are in remission. Conclusion. The effectiveness of PML-16 made it possible to abandon the consolidation therapy and refuted the idea of the need for 6 courses of CT. The combination of programs based on the application of the principle of high-dose short-pulse induction of remission (R-mNHL-BFM-90) in combination with the prolonged administration of medium doses (R-EPOCH) was crucial in achieving a successful result. The inclusion of lenalidomide in the "PML-19" program made it possible to achieve complete remission in 100 % of cases after 4 courses. The possibility of using DNA analysis to assess MRD in patients with PML was shown.Copyright © 2022 Izdatel'stvo Meditsina. All rights reserved.
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Ziel/Aim We aimed at evaluating the incidence of SARS-CoV2 vaccine-related axillary and supraclavicular hypermetabolic lymphadenopathy (HLA) and evaluate which timepoint produces the least number of false-positive findings in HLA. Methodik/Methods For this retrospective, multi-center imaging study patients with any form of SARS-CoV2 vaccination prior to 18F-FDG-PET/CT between January 2021 and December 2021 were included. Patients were divided into six groups according to the timepoint of vaccination prior to 18F-FDG-PET/CT imaging: Group 1 (0-6 Days), Group 2 (7-13 Days), Group 3 (14-20 Days), Group 4 (21-27 Days), Group 5 (28-34 Days) and Group 6 (35-80 Days). As reference SUVmax of mediastinal blood pool (MBP) and SUVmax contralateral reference lymph node (RL) were determined. For each group, the following parameters were assessed. A) absolute SUVmax of HLA B) incidence of HLA [defined as the ratio of SUVmaxHLA/ SUVmax Mediastinal Blood Pool (rHLA/MBP)] greater than 1,5 C) rHLA/MBP D) ratio SUVmax HLA vs. SUVmax contralateral reference lymph node (rHLA/RL). Ergebnisse/Results HLA showed the highest incidence in Group 1(day 0-6) 16/23 (70 %). Similarly, SUVmax HLA and rHLA/MBP were highest in this group, SUVmax 4.97 +/- 4.1 and 2.58 +/- 2.1 respectively. The incidence of HLA, SUVmax HLA, and rHLA/MBP were higher in Group 3 (14-20 days) than in Group 2 (7- 13days);57 % vs 44 %;5.05 +/- 4.33vs 3.9 +/- 2.81 (p = 0.723 and 2.32 +/- 1.8 vs 1.83 +/- 1.38(p = 0.788). All parameters for HLA dropped markedly after at least 21 days of vaccination. There were no significant differences in SUVmax HLA, rHLA/MBP and rHLA/RL in group 4 (21-27 days), group 5 (28-34 days) and group 6 (35-80 Days). [1] Schlussfolgerungen/Conclusions It is crucial for diagnostic physicians to assess the recent history of COVID-19 vaccination prior to FDG-PET/CT scan to reduce the risk of false-positive calls. If feasible, FDG PET should be postponed by at least 3 weeks after SARS-CoV2 vaccination especially if an accurate evaluation of axillary status is required.
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Objectives: In the Covid-19 era, there was a surge in the cases of a life-threatening infection of rhinosinonasal mucormycosis. Mucormycosis, popularly known as black fungus, is an infection caused by mycetes mucorales, an aseptate hyphae. Presently, computed tomography (CT) and magnetic resonance imaging (MRI) are commonly used imaging modalities for the management of patients with rhinosinonasal mucormycosis. The present study was aimed to evaluate the role of 18F- FDG PET/CT in the detection of recurrent or residual disease in post-surgical or post antifungal therapy in these patients for further management. Method(s): A total of 10 patients were included in this pilot study of Covid-19 positive patients and histologically proven mucormycosis (by KOH mount). 18F- FDG PET/CT was performed to assess the disease status in 6 postoperative/ post debridement patients and response to antifungal therapy in 4 patients, at an interval of 40 (range = 27-66) days post intervention. Result(s): The mean age of the patients was 45.0 +/- 11.65 years. The male: female ratio was 9:1. The common clinical presentation was ipsilateral facial or orbital pain and swelling. Covid-19 infection was positive in all the patients except one who had CT finding with HRCT score of 10/25 and hence was considered as post Covid-19 infection. Six out of 10 patients were diabetic on oral hypoglycaemic agents or insulin. All patients had a baseline CT/MRI for staging the initial extent of the disease. Surgical debridement was done in 6 out of the 10 patients followed by antifungal therapy (Liposomal Amphotericin B and Pozaconazole). Remaining four patients were treated with antifungal therapy. PET/CTwas performed after an average of 40 days of surgical/medical intervention, in whom clinical symptoms persisted or worsened even on antifungal therapy. 18F-FDG PET/CT showed metabolically active residual disease in all the patients with a mean SUVmax of 9.78 +/- 4.03. Conclusion(s): In the era of ongoing Covid-19 infection, black fungus has been a debilitating disease with high mortality and morbidity. Present study demonstrated that 18F-FDG PET/CT can be an efficient imaging tool for an early surgical/ medical treatment response assessment and restaging.
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Introduction. Primary mediastinal lymphoma (PML) is an aggressive lymphoid tumor treatment success of which is determined by induction therapy. To date, none of the standard chemotherapy regimens (CT) have demonstrated an advantage in efficacy. Intensive therapy programs are associated with high toxicity. Aim - to evaluate the efficacy and toxicity of two pilot prospective treatment protocols PML-16 and PML-19 as well as the possibility of using the analysis of freely circulating tumor DNA (ctDNA) to assess MRD in patients with PML. Materials and methods. From January 2016 to January 2022, 34 previously untreated PML patients were included in the study;average age - 32;stage > I - in 60 %;extramediastinal lesions - in 14.7 %;bulky disease - in 73.5 % of patients. Positron emission tomography combined with computed tomography (PET-CT) was performed;ctDNA was determined to assess the completeness of remission. Results. Eighteen patients received treatment according to the PML-16 protocol (6 courses of chemotherapy;2 blocks of RmNHL-BFM-90 + 4 courses of R-EPOCH). After the end of therapy, all 18 patients achieved PET-negative remission. The next 16 patients received treatment according to the PML-19 protocol (4 courses of chemotherapy;2 blocks of R-mNHL-BFM-90 + 2 courses of R-EPOCH) in combination with lenalidomide. After the end of therapy, 9 (56 %) patients achieved PET-negative remission;7 (44 %) retained pathological activity (D4-5 points). After 3 and 6 months 15 (94 %) patients achieved normalization of metabolic activity. Considering the high frequency of false-positive results in patients with PML, a ctDNA study was performed to determine the depth of remission in 15 patients. After the end of therapy, all 15 patients had complete elimination of ctDNA. Of these, 5 (33 %) remained PET-positive at the end of treatment. During further observation, after 3-6 months, in 4 patients the level of metabolic activity decreased to physiological without the use of consolidating therapy. After the end of therapy, one patient suffered the new coronavirus infection, COVID-19. A month later, residual formation of SUVmax 14.2 remained in the mediastinum. The patient is currently under observation. With a median follow-up of 36 months (9 to 76 months) all 34 patients are in remission. Conclusion. The effectiveness of PML-16 made it possible to abandon the consolidation therapy and refuted the idea of the need for 6 courses of CT. The combination of programs based on the application of the principle of high-dose short-pulse induction of remission (R-mNHL-BFM-90) in combination with the prolonged administration of medium doses (R-EPOCH) was crucial in achieving a successful result. The inclusion of lenalidomide in the "PML-19" program made it possible to achieve complete remission in 100 % of cases after 4 courses. The possibility of using DNA analysis to assess MRD in patients with PML was shown.Copyright © 2022 Izdatel'stvo Meditsina. All rights reserved.
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A 56-year-old woman with new-onset aphasia and mood changes was diagnosed with a left temporal mass. The surgery was done. She was referred for a trial of post-operative study of in vivo evaluation of CXCR4 expression using [68Ga]Ga-Pentixafor (Pars-CixaforTM) PET/CT in high-grade glioma. The imaging from the brain revealed no evidence of tumoral remnant. Furthermore, the patient represented positive COVID-19 PCR about 4 weeks prior to the study. Surprisingly, mild diffuse uptake was noted in the base and periphery of both lungs with ground glass opacities (GGO) and consolidations (SUVmax = 2.60) with CXCR4-avid hilar lymph nodes (SUVmax up to 3.42).Copyright © 2023 The Authors.
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Aim/Introduction: Austria started its COVID-19-vaccination program in December 2020 with three different vaccines. As the vaccination program continues, we encountered increased F-18- FDG-activity not only in axillary lymph nodes ipsilateral to the injection site but also in other organs. The aim of this retrospective study is to present results of the metabolic activity of ipsilateral axillary lymph nodes, liver, blood pool, spleen, and bone marrow after three different vaccines. Material(s) and Method(s): The data of 220 eligible vaccinated patients (127 with BioNTech/Pfizer, 61 with Moderna, and 32 with AstraZeneca) examined with F18-FDG-PET/ CT were enrolled. The PET/CT examinations were evaluated from day 1 to day 120 (SD: 23.2, Median: 26) after different vaccinations. Seventy out of these 220 patients were at least once examined with F18-FDG-PET/CT before vacciantion. SUVmax of axillary node(s), and blood pool, liver, spleen, and bone marrow as reference organs were calculated. Relation of SUVmax activity of axillary lymph node to reference organs was also compared in all patients. Result(s): Ten days after BioNTech/Pfizer and AstraZeneca vaccination the axillary FDG uptake was at its highest activity. This was with Moderna vaccination after 30 days. There was no significant statistical difference of SUVmax of lymph nodes or its ratios to other reference organs between three groups of vaccines. SUVmax in lymph nodes in relation to SUVmax in the liver, spleen, and bone marrow was statistically significant with p-values of <.001, 0.044, and 0.001, respectively. In the group of 70 patients with a pre-vaccination PET/CT examination, the SUVmax of lymph nodes (median: 0.820, standard deviation 1.233) changed significantly after vaccination (p <.001). A significant change of tracer activity in the liver was also observed (p = 0.032). There was no significant change of tracer activity after vaccination in other reference regions or between different types of vaccines. Conclusion(s): Local site and ipsilateral axillary lymph node activity in F18-FDG PET/CT after COVID19-vaccination is suggested in many studies. The main challenge is recognizing the changes in lymph nodes after vaccination to minimize false interpretation, foremost in patients with oncological diagnoses. Moreover, different vaccines cause different system metabolic changes. The knowledge of vaccine type, the time interval between vaccination and PET/CT scan is essential, especially in therapy evaluation.
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Aim/Introduction: Although pulmonary findings of COVID-19 on PET/CT have been previously described, a comprehensive metabolic characterization of diagnostic lung parenchyma changes of COVID-19 pneumonia is still lacking. Our purpose is to evaluate the metabolic uptake of different tomographic signs observed in patients with incidental structural findings suggesting COVID-19 pneumonia through 18F-FDG PET/CT. Material(s) and Method(s): We retrospectively analyzed 596 PET/CT studies performed from February 21, 2020 to April 17, 2020. After excluding 37 scans (PET with non-18F-FDG tracers and brain studies), we analyzed the metabolic activity of several individual structural changes integrated and beyond CO-RADS score through SUVmax of multimodal studies with18F-FDG. Result(s): 43 patients with 18F-FDG PET/CT findings suggestive of COVID-19 pneumonia were included (mean age: 68+/-12.3 years, 22 male). SUVmax values were higher in patients with CO-RADS categories 5-6 than in those with lower, nonspecific CO-RADS categories (6.1+/-3.0 vs. 3.6+/-2.1, p=0.004). Groundglass opacities, bilaterality, consolidations, patchy distribution and crazy paving pattern were associated with higher SUVmax values in patients with CO-RADS 5-6 scores (p-values of 0.01, 0.02, 0,01, 0.002 and 0.01, respectively). SUVmax was significantly associated with a positive structural diagnosis of COVID-19 pneumonia (odds ratio=0.63, 95% confidence interval=0.41-0.90;p=0.02). The ROC curve of the regression model aimed to confirm or discard the structural diagnosis of COVID-19 pneumonia showed an AUC of 0.77 (standard error=0.072, p=0.003). Conclusion(s): Multimodal18F-FDG PET/CT is a useful tool during the incidental detection of COVID-19 pneumonia in patients referred for standard oncological and nononcological indications (43/559;7.7%). CT findings characteristic of COVID-19 pneumonia, specifically CO-RADS 5-6, were associated with higher SUVmax.
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Aim/Introduction: Austria started its COVID-19-vaccination program in December 2020 with three different vaccines. As the vaccination program continues, we encountered increased F-18- FDG-activity not only in axillary lymph nodes ipsilateral to the injection site but also in other organs. The aim of this retrospective study is to present results of the metabolic activity of ipsilateral axillary lymph nodes, liver, blood pool, spleen, and bone marrow after three different vaccines. Material(s) and Method(s): The data of 220 eligible vaccinated patients (127 with BioNTech/Pfizer, 61 with Moderna, and 32 with AstraZeneca) examined with F18-FDG-PET/ CT were enrolled. The PET/CT examinations were evaluated from day 1 to day 120 (SD: 23.2, Median: 26) after different vaccinations. Seventy out of these 220 patients were at least once examined with F18-FDG-PET/CT before vacciantion. SUVmax of axillary node(s), and blood pool, liver, spleen, and bone marrow as reference organs were calculated. Relation of SUVmax activity of axillary lymph node to reference organs was also compared in all patients. Result(s): Ten days after BioNTech/Pfizer and AstraZeneca vaccination the axillary FDG uptake was at its highest activity. This was with Moderna vaccination after 30 days. There was no significant statistical difference of SUVmax of lymph nodes or its ratios to other reference organs between three groups of vaccines. SUVmax in lymph nodes in relation to SUVmax in the liver, spleen, and bone marrow was statistically significant with p-values of <.001, 0.044, and 0.001, respectively. In the group of 70 patients with a pre-vaccination PET/CT examination, the SUVmax of lymph nodes (median: 0.820, standard deviation 1.233) changed significantly after vaccination (p <.001). A significant change of tracer activity in the liver was also observed (p = 0.032). There was no significant change of tracer activity after vaccination in other reference regions or between different types of vaccines. Conclusion(s): Local site and ipsilateral axillary lymph node activity in F18-FDG PET/CT after COVID19-vaccination is suggested in many studies. The main challenge is recognizing the changes in lymph nodes after vaccination to minimize false interpretation, foremost in patients with oncological diagnoses. Moreover, different vaccines cause different system metabolic changes. The knowledge of vaccine type, the time interval between vaccination and PET/CT scan is essential, especially in therapy evaluation.
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Aim/Introduction: During the COVID 19 pandemic, mass vaccination campaign has played an important role, with a special importance in oncological and immunosuppressed patients, who form a large part of our [18F]FDG-PET/CT studies. Unexpected findings in the form of reactive lymphadenopathy were commonly detected in [18F]FDG-PET/CT studies. It is essential to recognize them and adapt their interpretation to the current epidemiological context. Material(s) and Method(s): Retrospective study of consecutive [18F] FDG-PET/CT studies performed at our center in 219 patients with oncological pathology from June 15 to September 20, 2021. A structured interview was conducted on all the patients who came to undergo [18F]FDG-PET/CT, in which they were asked about the type, date and arm of administration of the vaccine. The frequency of appearance of reactive lymphadenopathy, its relationship with the type of vaccine, sex, age and the importance of a detailed clinical interview prior to the isotope injection and/ or study interpretation were analyzed. Patients that presented ipsilateral axillary lymphadenopathies following vaccination and presented increased metabolic activity regardless of node size were considered positive, size and SUVmax were assessed. Result(s): From De 219 patients reviewed, 32% presented positive [18F]FDG-PET/CT axillary lymph nodes ipsilateral to the arm where the vaccine was inoculated. There was a relationship (p=0.01) between the mean size of the lymph nodes (11+/-9mm) and its mean metabolic activity (3.7+/-2.6 SUVmax). The appearance of lymphadenopathy was more frequent in women (40.5% vs 21% p<0.001), in younger patients (mean age 53+/-14 years vs 68.5+/-13 years p<0.001), in patients who had received the Moderna vaccine (58.5% p<0.001) and in which the time elapsed between vaccination and the performance of [18F]FDG-PET/CT was shorter. Conclusion(s): The appearance of post SARS-CoV2-vaccination reactive lymphadenopathies has been a frequent finding in [18F]FDG-PET/CT despite the main oncological indication of the study. Knowing the circumstances of these findings in oncological patients is important when interpreting them, so the use of a structured directed clinical interview has been very useful to help the physician understand and differentiate these findings.
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Introducao: O linfoma da celula do manto (LCM) e uma doenca rara e agressiva com poucas alternativas terapeuticas. Mas com a introducao de inibidores de tirosina kinase de Bruton tem mudado a sobrevida a longo prazo. Objetivo: descricao de um caso clinico em portadora da doenca com insuficiencia renal cronica. Material e metodos: Descricao do caso clinico: Paciente feminina, 65 anos de idade, queixa de cansaco, dor abdominal, hepatoesplenomegalia, presenca de linfonodomegalias, emagrecimento de 5 kg em 6 meses, sudorese noturna, Hb = 8.8 g/dL, plaquetopenia de 118.000/mm3, albumina = 2.5 g/dL. Antecedente de HAS e DPOC. Diagnostico de Linfoma de celulas do manto em maio de 2021 por biopsia de adenomegalia inguinal. Tratamento instituido foi R-CHOP e RDHAP em meses alternados, porem apos o segundo ciclo evoluiu com edema agudo de pulmao volumoso, insuficiencia renal com necessidade dialitica diaria (IRA- KDIGO III multifatorial), intubacao orotraqueal e tratamento em unidade intensiva por quadro de choque septico (KPC). Realizou terceiro ciclo de QT com RCHOP, mas com a piora clinica foi aventada hipotese de cuidados paliativos. Mas com a melhora recebeu mais 3 tratamentos com rituximabe mensal, persistiu com falencia renal e necessidade de hemodialise. Recebeu alta hospitalar e introduzido ibrutinibe 560 mg ao dia em 09/11/2021 sem muitos efeitos adversos. Resultados: PETScan do diagnostico 26/05/2021 mostra linfonodos axilares, volumosa esplenomegalia, linfonodos mediastinais, retroperitoneais e inguinais, area focal de intensa concentracao na transicao retossigmoide e na pelve (SUVmax:12.5), moderado derrame pleural bilateral. PETScan antes da introducao do ibrutinibe 10/11/202: reducao do metabolismo dos linfonodos axilares bilaterais, das dimensoes do baco, mas persistencia da area focal na transicao do retossigmoide (SUVmax:10.15). 6 meses apos o tratamento: 23/06/2022, nao se observam areas focais de atividade metabolica glicolitica anomala (Score 1 de Deauville), persiste com esplenomeagalia homogenea. A paciente segue em tratamento, no momento com ibrutinibe e em hemodialise de segunda a sexta. Apresentou infeccao pelo coronavirus em janeiro de 2022 sem sequelas. Atualmente clinicamente assintomatica, ECOG=0 e exames laboratoriais normais exceto pelo aumento de ureia e creatinina. Discussao: A causa da insuficiencia renal desenvolvida durante a internacao pode ser explicada por varios fatores como a sindrome de lise tumoral, uso da medicamento cisplatina, historia de HAS previa e ao quadro septico. A paciente evoluiu com regressao do quadro de esplenomegalia, adenomegalias e da massa em retrossigmoide ao longo dos 6 primeiros meses e atualmente se encontra sem evidencia de doenca em uso de ibrutinibe ha 10 meses. A dose da medicacao nao foi ajustada em vigencia de realizacao de hemodialise se acreditando que a droga apresenta depuracao renal minima. Ha poucos casos descritos na literatura do uso de ibrutinibe em pacientes com insuficiencia renal grave com clearance < 30 mL/minuto avaliando a seguranca e eficacia de tratamento. Conclusao: Tratamento em paciente portador de Linfoma de celulas do manto com insuficiencia renal grave pode ser tratado com ibrutinibe. Em nosso caso houve sucesso terapeutico, mas e imprescindivel acompanhar a resposta pois o tratamento e continuo ate a progressao da doenca ou eventos adversos graves. Copyright © 2022
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SESSION TITLE: Lung Cancer Imaging Case Report Posters 2 SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: The Coronavirus disease 2019 (COVID-19) pandemic affected millions of people globally, prompting the emergent need for an effective vaccine. Lymphadenopathy associated with COVID-19 vaccine is a recognized phenomenon that can present a diagnostic dilemma for staging thoracic malignancies. We present a case of post COVID-19 vaccination axillary lymphadenopathy complicating the staging process for a patient with newly diagnosed lung adenocarcinoma. CASE PRESENTATION: A 64-year-old-male with chronic obstructive pulmonary disease, former smoker with a 20-pack-year smoking history was found to have a 1.7 cm solid nodule in the left upper lobe with irregular margins on low dose computed tomography (CT) scan of the chest for lung cancer screening. Fine needle aspiration of the nodule was done, and histopathology results were consistent with the diagnosis of adenocarcinoma. Patient then underwent fluorodeoxyglucose-positron emission tomography (FDG-PET) scan that showed a 16 mm nodule in the left upper pulmonary lobe with maximum standardized uptake value (SUVmax) of 5.3 and left axillary nodes measuring up to 8 mm with SUVmax of 4.4 concerning for metastatic disease. On further history, patient had received the Pfizer mRNA vaccination booster three days prior to undergoing the FDG-PET scan. Patient was evaluated by oncology and decision was made to treat with a 7-day course of prednisone 20 mg daily and to repeat FDG-PET scan. FDG-PET scan done four weeks later showed resolution of axillary lymphadenopathy. Patient was clinically staged as T1bN0M0 stage 1A and underwent robotic left upper lobe lingular-sparing lobectomy. DISCUSSION: In patients with thoracic malignancies, lymphadenopathy related to COVID-19 vaccination with avid FDG uptake on PET scan was reported in 29% of patients (2). The presentation of FDG avid lymphadenopathy creates a clinical challenge by confounding accurate cancer staging and leading to unnecessary workup (3). More importantly, detection of lymphadenopathy while staging lung cancer has crucial implications in the process of triaging patients to oncologic management in terms of candidacy for surgical resection (3). Currently, no consensus is available to guide management for incidental lymphadenopathy associated with COVID-19 vaccination in lung cancer patients. For this patient, we chose to treat with steroids and to obtain repeat imaging within 4 weeks of the original FDG-PET to not delay treatment planning. Repeat imaging showed resolution of the axillary lymphadenopathy and patient was able to undergo definitive treatment promptly. CONCLUSIONS: This case highlights the diagnostic challenge posed by COVID-19 lymphadenopathy in patients with newly diagnosed lung cancer and delineates our approach to navigating this challenge to avoid malignancy up-staging and treatment delay. Reference #1: Polack FP, Thomas SJ, Kitchin N, et al. Safety and Efficacy of the BNT162b2 mRNA Covid-19 Vaccine. N Engl J Med. 2020;383(27):2603-2615. doi:10.1056/NEJMoa2034577 Reference #2: Nishino M, Hatabu H, Ricciuti B, Vaz V, Michael K, Awad MM. Axillary Lymphadenopathy After Coronavirus Disease 2019 Vaccinations in Patients with Thoracic Malignancy: Incidence, Predisposing Factors, and Imaging Characteristics. J Thorac Oncol. 2022;17(1):154-159. doi:10.1016/j.jthoCH.2021.08.761 Reference #3: Lehman CD, D'Alessandro HA, Mendoza DP, Succi MD, Kambadakone A, Lamb LR. Unilateral Lymphadenopathy After COVID-19 Vaccination: A Practical Management Plan for Radiologists Across Specialties. J Am Coll Radiol. 2021;18(6):843-852. doi: 10.1016/j.jacr.2021.03.001 DISCLOSURES: No relevant relationships by Hadya Elshakh No relevant relationships by Stephen Karbowitz No relevant relationships by Gina Villani
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SESSION TITLE: Rare Malignancies SESSION TYPE: Case Reports PRESENTED ON: 10/17/2022 03:15 pm - 04:15 pm INTRODUCTION: SMARCA4 deficient undifferentiated tumors (SMARCA4-DUT) are rare and aggressive neoplasms that are most commonly encountered in young male smokers and portend a poor prognosis (1,2). They are characterized by loss of SMARCA4, a subunit of chromatin remodeling complexes, and loss of the tumor suppressor brahma-related gene 1 (BRG1). We present a case of an elderly female with an extensive smoking history who was diagnosed with SMARCA4-DUT. CASE PRESENTATION: An 84 year old female with approximately 70 pack year smoking history, emphysema, ischemic cardiomyopathy, and coronary artery disease, presented to the emergency room with upper abdominal pain which started one day prior to admission. She endorsed an unintentional 10 pound weight loss in the past two months. The patient was admitted for an incarcerated ventral hernia for which she underwent repair. Of note, one and a half years ago, she was found to have a right lower lobe 7mm nodule but was unable to follow up due to the COVID pandemic. On this admission, a CT chest revealed a 4.2 x 3.8 x 3.7cm mediastinal mass and subcarincal lymphadenopathy. She underwent an EBUS with biopsy of the mediastinal mass and subcarinal lymph node. Cytology showed highly atypical epitheloid cells, concerning for a neoplasm with neuroendocrine differentiation and granulomas. Given the high suspicion for malignancy, she had a PET CT (figure 1) which showed FDG activity (SUV 11) in the mass with areas of necrosis and was referred to thoracic surgery. She underwent thoracoscopy with mediastinal mass resection and lymph node dissection and pathology showed diffuse sheets of epithelioid cells with large foci of necrosis. Neoplastic cells showed preserved INI (SMARCB1) expression, non-reactivity for NUT, and complete loss of BRG1 (SMARCA4) expression, consistent with a SMARCA4-DUT with positive margins (figure 2). She was referred to Radiation Oncology with plans to pursue further therapy thereafter. DISCUSSION: SMARCA4-DUT is a new and distinctive clinicopathological entity of aggressive thoracic tumors (1). The novelty of this class of tumors poses challenges in terms of treatment. Immune checkpoint inhibitors have shown compelling outcomes in case reports (3), however larger studies are needed to delineate optimal treatment regimens. CONCLUSIONS: SMARCA4-DUT are are rare but highly aggressive thoracic neoplasms. They present as large tumors and are smoking related. Prompt recognition may aid in early diagnosis. No definitive therapy exists but immunotherapy has shown promising results. Reference #1: Chatzopoulos, K., Boland, J.M. Update on genetically defined lung neoplasms: NUT carcinoma and thoracic SMARCA4-deficient undifferentiated tumors. Virchows Arch 478, 21–30 (2021). Reference #2: Roden AC. Thoracic SMARCA4-deficient undifferentiated tumor-a case of an aggressive neoplasm-case report. Mediastinum. 2021;5:39. Published 2021 Dec 25. Reference #3: Henon C, Blay JY, Massard C, Mir O, Bahleda R, Dumont S, Postel-Vinay S, Adam J, Soria JC, Le Cesne A. Long lasting major response to pembrolizumab in a thoracic malignant rhabdoid-like SMARCA4-deficient tumor. Ann Oncol. 2019 Aug 1;30(8):1401-1403. DISCLOSURES: No relevant relationships by Sathya Alekhya Bukkuri No relevant relationships by Erin Meier No relevant relationships by Mangalore Amith Shenoy No relevant relationships by Alexandra Zavin
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SESSION TITLE: Using Imaging for Diagnosis Case Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Vaccine-related lymphadenopathy (VRL) is a local reaction like pain and swelling and has been associated with mRNA Pfizer/Moderna COVID-19 vaccines more than other vaccines (1). VRL can lead to false positives on nuclear imaging studies and confound the evaluation of patients during cancer screenings or treatments. The first COVID-19 VRL seen on imaging was reported in January 2021 in two patients undergoing breast mammogram (1). Since then, more cases have been reported in other nuclear imaging studies (1). Here, we report a case of subclinical unilateral VRL by FDG-PET 3 days after the patient received the Moderna COVID-19 booster. CASE PRESENTATION: 73-year-old male smoker returned for a 6 month follow up low dose CT for a 7 mm left upper lobe (LUL) nodule. He received the Moderna COVID-19 booster in the left deltoid the same day. The LUL nodule was found to be slightly larger at 8 mm and ipsilateral axillary nodes were not enlarged (Figure 1). He returned 3 days later for FDG-PET which showed mild uptake in the LUL nodule (SUV 1.8) and hypermetabolic left axillary nodes (Figure 2). COVID booster date/laterality was documented, and the FDG-PET summary included a comment about a possible inflammatory response to the booster. A repeat low dose chest CT in 3 months was recommended. DISCUSSION: After the first reported cases of COVID-19 VRL, recommendations were published to aid providers in evaluating clinical and imaging abnormalities. The Society of Breast Imaging recommended the "wait and watch” approach for unilateral COVID-19 VRL within the preceding 4 weeks only if appropriate in the clinical context;repeat exam in 4-12 weeks and lymph node sampling if VRL persists (1). All other screening exams should be scheduled prior to the first dose of the COVID-19 vaccine or 4-6 weeks after the second dose (1). Radiology experts recommended: 1) imaging screening exam to be scheduled at least 6 weeks after the final vaccination, 2) administer the vaccine in the arm contralateral to any primary or suspected cancer, and 3) record the vaccine date, injection site, and type (1). Months later, they recommended that in patients with a known vaccination history, ipsilateral VRL can be managed conservatively without further imaging (1). CONCLUSIONS: The current recommended COVID-19 Pfizer/Moderna vaccination consists of a two-dose primary series and a booster dose 5 months later. In a recent single-center study in oncologic patients in Israel who had FDG-PET after the Pfizer booster, the duration of unilateral axillary VRL was found to be shorter than the first and second dose (2). Therefore it has been suggested that FDG-PET can be scheduled 2 weeks after the third dose (3). Whether there will be any changes in the guidelines to accommodate this finding remains to be seen. More studies are needed to best inform clinicians because COVID-19 vaccinations will continue for the foreseeable future. Reference #1: Lehman CD, D'Alessandro HA, Mendoza DP, Succi MD, Kambadakone A, Lamb LR. Unilateral Lymphadenopathy After COVID-19 Vaccination: A Practical Management Plan for Radiologists Across Specialties. J Am Coll Radiol. 2021;18(6):843-852. doi:10.1016/J.JACR.2021.03.001 Reference #2: Cohen D, Hazut Krauthammer S, Wolf I, Even-Sapir E. A sigh of relief: vaccine-associated hypermetabolic lymphadenopathy following the third COVID-19 vaccine dose is short in duration and uncommonly interferes with the interpretation of [18F]FDG PET-CT studies performed in oncologic patients. Eur J Nucl Med Mol Imaging. 2021. doi:10.1007/S00259-021-05579-7 Reference #3: Thaweerat W. Optimization of FDG PET study after mRNA COVID-19 vaccination to reduce the interference of vaccine-associated hypermetabolic lymphadenopathy. Ann Nucl Med 2021 363. 2022;36(3):327-328. doi:10.1007/S12149-021-01712-6 DISCLOSURES: No relevant relationships by Anh Nguyen No relevant relationships by Perry Nystrom
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Background: Estrogen receptors (ER) are predictive of endocrine responsiveness. However, 30% of ER+ BC patients will relapse despite adjuvant ET and 10 to 20% of metastatic lesions loose the expression of ER. The early identification of endocrine resistant patients may help to improve treatment strategies, especially in the light of innovative drugs recently approved. In the ET-FES trial we evaluated 18F-FES CT/PET as a prediction tool for endocrine responsiveness in ER+ MBC. The ET-FES study was funded by the ERANET-Transcan project. Methods: MBC patients with ER+/HER2- disease, were eligible for the ET/FES study. All patients underwent a baseline [18]F-FES PET/CT in addition to conventional procedures. Patients were classified as endocrine sensitive if overall Standardized Uptake Value (SUV) ≥ 2 and received ET;patients with SUV <2 were randomized to receive ET or chemotherapy (CT). The prognostic role of [18]F-FES PET/CT was assessed for PFS and OS by univariate and multivariate analyses. The primary endpoint was disease progression rate (DPR) at 6 months. Results: From April 2015 to October 2020 146 patients, from 7 EU centers were enrolled: of them, 115 with a mean SUV >2 received ET and 30 with SUV <2 were included in the randomized study. Median follow up was 18.4 months (range 8.0 to 38.3 months) in endocrine sensitive patients (SUV > 2) versus 10.1 months (range 8.0 to 36.8) in patients with SUV <2. Overall, at the time of this analysis 67 patients (45.9%) had disease progression and 37 (25.3%) died. DPR at 6 months was 57% in patients with SUV >2 vs 50% in SUV <2 randomized to ET and 57% in case of CT. DPR at 12 months was 35% vs 17% and 14%, respectively. Median PFS was 7.3 months (IQR 3.8 – 17.3) vs 5.2 (IQR 3.1 – 9.4) vs 7.7 months (IQR 3.0 – 14.0), respectively. OS rate at 12 months was 31% versus 17% versus 14%. Conclusions: The ET-FES clinical trial was prematurely interrupted, due to COVID-19 pandemic. The discriminating ability of this assay was high, leading to a personalized endocrine approach;a considerable proportion of patients with a mean SUV >2 is still on ET. Clinical trial identification: EudraCT 2013-000287-29. Legal entity responsible for the study: Alessandra Gennari - Università del Piemonte Orientale. Funding: AIRC. Disclosure: All authors have declared no conflicts of interest.
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Introduction Phaeochromocytoma and paraganglioma (PPGL) are rare tumors with up to 40% associated with inherited germline mutations. SHDB mutation is associated with an increased risk of metastasis. Case A 36-year-old male presented with hypertensive emergency. He was diagnosed to have a bladder paraganglioma at age 32 when he presented with hypertensive crisis. Ga-68 DOTANOC PET/CT scan then showed a localized 4.7 x 5.3 cm bladder paraganglioma and he underwent complete surgical resection with resolution of his symptoms. Genetic testing done showed SHDB, deletion (exon 1), heterogenous pathogenic variant. He remained asymptomatic and was lost to follow-up due to COVID-19 until his recent admission. During this admission, he had labile blood pressure with symptoms of palpitations and lethargy. He was found to have a 4.3x elevated urine normetanephrine (1639 ug/day, N<374.7). Metanephrine and 3-methoxytyramine levels were normal. His blood pressure was controlled with phenoxybenzamine 20 mg TDS (1 mg/kg), telmisartan 40 mg OM and carvedilol 25 mg BD with improvement in his symptoms. Subsequent anatomical imaging with CT and functional imaging with Ga-68 DOTATATE showed a small recurrence at the bladder wall with metastatic lesions at the left sacral ala measuring 4.5 x 5.1 cm, and multiple lytic lesions over the spine, ribs and also the left acetabulum with the highest uptake of Ga-68 DOTATATE at the C2 vertebra (SUV max 93). He is now planned for peptide receptor radionuclide therapy (PRRT). SHDB mutation is associated with a higher risk of metastatic disease which has remained unexplained. Treatment for metastatic disease include surgical resection where possible, targeted therapy such as PRRT, meta-iodobenzylguanidine (MIBG) therapy, radiotherapy and also systemic therapy such as chemotherapy and tyrosine kinase inhibitors. Conclusion Patients with PPGL, especially those with SHDB mutation, require monitoring at regular intervals to screen and detect metastasis to reduce mortality and morbidity.
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Background: The risk of developing COVID-19 in patients with cancer has increased, directly influenced by age and the magnitude of comorbidities. In this population, the estimated mortality is 10.9%. With this, the urgent need for patients with cancer to get vaccinated against SARS COV 2 has generated an international response. With the ongoing vaccination campaign, experts in nuclear medicine have observed an increment in lymph node uptake in PET CT with 18 FDG. Increased uptake in lymph nodes in patients with a neoplastic diagnosis on PET CT 18 FDG must be closely followed and well-studied to differentiate disease progression from an inflammatory, fleeting reaction. Methods: Amongst the inclusion criteria were patients over 18 years of age with solid tumors, including lymphomas, who were on active oncologic treatment with chemotherapy, immune therapy, radiotherapy or under surveillance between April 2021 and July 2021 who underwent a PET CT scan and had at least one dose of a COVID 19 vaccine, and a prior PET CT to the vaccine for comparison. Patients were excluded who showed evidence of progression or disease recurrence of the primary tumor. We evaluated lymph node size and metabolism measured by SUV max in the PET CT scan prior to being vaccinated and posterior to, as well as patients' clinical characteristics. Results: A total of 92 patients who met inclusion criteria were included in the study. Amongst those, 54.3% were women, the median age was 68 years (27 - 95 years), the most common neoplastic diagnoses were breast cancer (19.6%), gastrointestinal tumors (17.4%), urothelial tumors (9.8%), lymphomas (9.8%) and ovarian cancer (8.7%). 52.2% of patients were under surveillance and 47.8% were under active treatment. 79% of patients had at least 2 vaccine doses. 59% had received Pfizer vaccines and the measurable adenopathies were axillary in 32.7% and mediastinal in 27%. The medium size of the measured lymph nodes prior to receiving the vaccine was 2.86 mm with an SUV max of 1.24, while after vaccination were 6.01 and 2.27 respectively. A Kruskal Wallis test was conducted to compare median results according to histopathologic reports, with no statistical difference. A Mann Whitney U test was conducted to compare breast cancer to other cancer histologies, where a statistical difference was found for SUV max, p = 0.003 and size with p = 0.033. Conclusions: This work details significant differences between lymph node size and SUV max in oncologic patients pre and post vaccination for COVID 19, showing a statistical difference in patients with breast cancer. This increment in lymph node uptake in patients with a neoplastic diagnosis PET CT 18 FDG must be closely followed and well-studied to differentiate disease progression from an inflammatory reaction.
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Background: Induction FOLFOX followed by PET-directed CRT prior to surgery demonstrated positive results in the CALGB 80803 study. We investigated the safety and efficacy of adding D, an anti-PD-L1 antibody, to PET-directed CRT. Methods: Patients (pts) with locally advanced esophageal/GEJ adenocarcinoma were enrolled. Pts received 2 cycles of mFOLFOX6 prior to repeat PET/CT. PET responders (≥35% reduction in SUV (PETr)) received 5-FU/capecitabine and oxaliplatin with RT to 50.4Gy, while induction PET non-responders (PETnr) received carboplatin/paclitaxel with RT. All Pts received D 1,500 mg q4W ×2 starting 2 weeks prior to CRT. Esophagectomy was planned 6-8 weeks after CRT. Pts with R0 resections received adjuvant D 1,500mg q4W ×6. The primary endpoint was the pathologic complete response (pCR) rate. Results: 36 pts were enrolled. Clinical ≥T3 disease was seen in 32 pts (88.9%, cT4 = 3) and ≥N1 in 23 (63.9%) pts. PD-L1 CPS was ≥1 in 25 (71.4%) of 35 tested with 14 (40%) ≥5. Microsatellite instability (MSI) was identified in 3 (8.3%) pts. 25 (70%) pts were PETr. Preop treatment was well tolerated with no new safety signals. Three pts had disease progression prior to surgery. pCR was identified in 8 (22.2%) pts and 22 (64.7%) had major pathologic response (MPR;ypTanyN0 + ≥90% response). Those with MSI tumors had ≥90% treatment response (1 pCR, 1: ypT1aN0 99% response, 1: ypT2N0, 90% response). 17 (73.9%) of 23 cN+ pts had ypN0 disease. MPR was associated with PD-L1 ≥1 (p = 0.03) and with a higher tumor mutational burden (TMB;p = 0.016) on MSK-IMPACT testing. Adjuvant D was commenced in 27 pts, with a median number of 6 cycles. Early discontinuation was due to risks of visits due to COVID19 (4, 15%), progressive disease (3, 11%), late surgical complications (2, 7%) and immune toxicity (1, 4%). With a median follow-up of 30 months, OS rates were 92% [95%CI: 83%-100%] and 85 % [95%CI: 74%-98%] at 12 and 24 months post induction. 12 and 24-month PFS rates were 81% [95%CI: 69%-95%] and 71% [95%CI: 58%-88%] respectively. In the 33 operated pts, 12 and 24-month disease free survival was 82% [95%CI: 70%-96%] and 78% [95%CI: 65%-94%], respectively. In addition to SUV on PET, total lesion glycolysis (TLG) was correlated with pathologic response. In cases with borderline change in SUV, TLG could predict response to treatment. One PETnr with 30.8% reduction in SUV had 88.1% reduction in TLG and pCR. Conversely, a PETr (-36.3%) who had an increase in TLG (39.3%) had only 40% treatment response on pathology. Conclusions: The addition of D to induction FOLFOX and PETdirected CRT prior to surgery is safe and appears effective with a high rate of pathologic response, as well as encouraging survival data. PD-L1 CPS≥1 and higher TMB may be associated with MPR. TLG is a novel PET variable that should be studied prospectively. Additional correlatives and comparison to a cohort treated with standard PET-directed CRT will be presented.
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Background-Aim: The aim of the present study was to investigate the occurrence and characteristics of axillary lymph node hypermetabolism (ALNH) after COVID-19 vaccination in a large series of cancer patients undergoing 18F-FDG PET/CT. Methods: We retrospectively reviewed a consecutive series of 500 cancer patients (267 males and 233 females, aged 22-91 years, mean age: 64.9 years) who underwent 18F-FDG PET/CT after COVID-19 vaccination (period: March-October 2021). Twenty of these patients were studied twice for a total of 520 PET/CT studies;135/520 studies were carried out after the first dose of vaccine and the remaining 385/520 studies after the second dose. All FDG PET/CT studies were acquired at the same nuclear medicine Centre according to standardized acquisition procedure protocols, using a Discovery 710 system (GE Healthcare). PET images were analysed both qualitatively and semiquantitatively calculating SUV max at the level of hypermetabolic lymph nodes. Results: ALNH ipsilateral to COVID-19 vaccination was observed in 176/520 studies (33.8%). Among the 176 positive studies, HALN was considered vaccine-related (Group 1) in 130/176 cases (74%), metastatic (Group 2) in 34/176 cases (19.3%) and equivocal (Group 3) in the remaining 12/176 cases (6.8%). SUV max was 3.5 ± 2.21 in Group 1, 8.95 ± 5.83 in Group 2 and 3.912 ± 1.66 in Group 3 (p<0.0001). Among the 130 Group 1 cases, 31 were studied after vaccine dose 1 (subgroup 1A) and 99 after vaccine dose 2 (subgroup 1B) with SUV max equal to 3.12 ± 1.72 in the former subgroup and 3.62 ± 2.34 in the second subgroup (p = 0.27). Furthermore, in the subgroup 1A, SUV max was 3.68 ± 2.01 in the first week after vaccination, 2.76 ± 1.57 in the second week and 2.52 ± 1.2 in the third week (p = 0.567), while in the subgroup 1B the corresponding SUV max values were 5.51 ± 3.03, 3.81 ± 2.01 and 3.17 ± 1.96 (p<0.001). After third week post-vaccination, FDG lymph node avidity was observed in 2/31 subgroup 1A cases and in 27/99 subgroup 1B cases. Conclusions: In our series, the overall prevalence of vaccine-related ALNH was 25% (130/520). Vaccine-related hypermetabolic lymph nodes showed a significantly lower SUV max than that observed in metastatic lymph nodes. Equivocal findings were seen in<7% of cases. No statistically significant difference in SUV max was seen after dose 1 and dose 2 vaccinations. However, after the second vaccination, the SUV max was statistically higher in the first week rather than later. Finally, FDG lymph node uptake may persist beyond the third week, mainly after the second vaccination.
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Background-Aim: Vaccination is an established but uncommon cause of unilateral axillary lymphadenopathy. Early clinical experience with coronavirus disease (COVID-19) vaccination suggests that such vaccines cause a significantly higher incidence of lymphadenopathy detected on 18F-FDG PET/CT than other vaccines. Guidelines are needed to properly manage unilateral axillary lymphadenopathy in the era of COVID-19 vaccination and to avoid benign reactive node biopsies. The differential diagnosis for unilateral axillary lymphadenopathy is broad and includes benign and malignant etiologies: among the malignant causes, most cases are due to lymphoma or breast cancer. Methods: Shortly after the initiation of vaccination of frail cancer patients, a significant number of cases of unilateral axillary lymphadenopathy were incidentally detected in asymptomatic cancer patients who underwent 18F-FDG PET/CT for disease diagnosis or follow-up. Results: After deltoid vaccination, significant uptake of 18F-FDG can be observed in the axillary (level 1, 2 and 3), supraclavicular and cervical lymph nodes. The extent of FDG absorption varies with temporal proximity to vaccination, from intense immediately after administration to barely noticeable after a longer period of time (SUVmax range: 2.1-16.2). Also, after vaccination, lymph nodes may show variable morphology on CT, although they are usually normal or show only a slightly thickened cortex with retained fat hilum. In our department, we have added questions regarding the date and laterality of COVID-19 vaccine administration to our intake form prior to all PET/CT exams, to avoid misjudgment in cancer patients. Conclusions: We believe that isolated unilateral axillary lymphadenopathy detected on PET and associated with the ipsilateral vaccine arm is related to the COVID-19 vaccine, if within a few weeks of either dose. As data from clinical trials of the COVID-19 vaccine suggest that the first two FDA-approved vaccines are highly immunogenic, there is a higher percentage of patients who notice both local and systemic reactions than other vaccines. Careful management should avoid unnecessary biopsies of vaccine-related benign reactive lymphadenopathy. Vaccine ipsilateral axillary adenopathy of the arm should be considered as a potential reactive process that nuclear physicians should be familiar with. If a patient has known cancer with laterality, such as breast cancer, most melanomas, sarcoma of the extremities, lung cancer (particularly in the upper lobe), or head and neck cancer, the vaccine should be given in the arm. contralateral to avoid potentially confounding FDG uptake into lymph nodes on the cancer side. However, if active axillary lymph nodes are identified in the ipsilateral vaccinated arm, axillary ultrasound at 4 weeks is recommended.