False-Negative 68 Ga-FAPI PET/CT in Pediatric Thyroid Medullary Carcinoma Seen With 68 Ga-DOTATOC PET/CT and 18 F-FDG PET/CT.

ABSTRACT: In adults, 68 Ga-FAP inhibitor ( 68 Ga-FAPI) PET/CT outperforms 68 Ga-radiolabeled somatostatin analog peptides ( 68 Ga PET/CT) and 18 F-FDG PET/CT in detecting thyroid lesions. This is the case of a 13-year-old boy newly diagnosed with medullary thyroid cancer with high calcitonin level. 68 Ga PET/CT revealed the presence of only a primary thyroid lesion. Proven to be superior in detecting metastasis, 68 Ga-FAPI PET/CT was performed. The results came out negative for primary and potential metastatic lesions. This case sheds shed light on false-negatives reported in 68 Ga-FAPI PET/CT scans in pediatric patients, emphasizing the need for alternate radiotracers when a negative study is met.

Unmasking Coincident Hodgkin Lymphoma and Giant Cell Tumor: Insights from [18F] FDG PET/CT.

Tenosynovial giant cell tumors represent a group of typically non-malignant tumors found within the joints and soft tissues. The occurrence of tenosynovial giant cell tumor alongside hematologic malignancies is an infrequent finding. Herein, we report a patient who presented with coinciding Hodgkin Lymphoma (HL) and tenosynovial giant cell tumor before chemotherapy initiation. The case was discovered during initial assessment using [18F]fluorodeoxyglucose ([18F]FDG) positron emission tomography/computed tomography (PET/CT) imaging for HL staging. An unrelated hypermetabolic mass within the left knee joint led to the discovery of this unusual case, which led to a CT-guided biopsy and tenosynovial giant cell tumor discovery. This was clearly demonstrated in interim and end-of-therapy PET/CT studies when all lymphomatous lesions had resolved but the tenosynovial giant cell tumor remained. This case serves as a reminder of the intricate nature of oncological pathology and emphasizes the need for thorough and vigilant diagnostic evaluation for optimal management plan.

The role of 18 F-FDG-PET/CT in the management of differentiated thyroid cancer.

INTRODUCTION: In previous literature, 18 F-FDG-PET/ CT imaging significantly impacted differentiated thyroid cancer (DTC) therapy. Low thyroglobulin (Tg) levels and negative Iodine-131 (131I) whole-body scan (WBS), along with negative 18 F-FDG-PET/ CT, suggested a lesser likelihood of active illness. Positive 18 F-FDG-PET/CT findings, however, were associated with a variety of signs of local recurrence and regional or distant metastases in patients with suspected WBS. We aim to evaluate the utility of 18 F-FDG-PET/CT in managing DTC patients with negative 131I post-therapy WBS and elevated Tg. MATERIAL AND METHODS: We retrospectively reviewed 55 patients with DTC (76% papillary and 24% follicular). Patients underwent total thyroidectomy or several radioactive iodine (RAI) treatments or both. WBS was performed 5-7 days after RAI treatment. Inclusion criteria were elevated serum Tg, negative anti-Tg auto-antibodies (AbTg) during long-term follow-up, presence of 18F-FDG-PET/CT images, and negative or suspicious WBS. RESULTS: 54% of 18 F-FDG-PET/CTs detected at least one lesion, mainly, cervical lymph nodes (49.9%), mediastinal lymph nodes (40.4%), local recurrence (34%), and bone or tissue metastasis (36.2%). The three major sites of metastasis were lung, bone, and liver. 18 F-FDG-PET/CT identified recurrence or metastasis in 45% of patients with high serum Tg and negative WBS, modifying therapeutic management in half the patients for suitable treatment modality (surgery vs. tyrosine kinase inhibitor). CONCLUSION: The findings redemonstrate that elevated Tg with negative or suspicious WBS necessitates 18 F-FDG-PET/CT for localization of recurrence. 18 F-FDG-PET/CT is useful in managing locally recurrent or metastatic DTC with high Tg levels. It influences treatment and accurately assesses disease severity.

The Clinical Significance of Incidental GIT Uptake on PET/CT: Radiologic, Endoscopic, and Pathologic Correlation.

Incidental gastrointestinal tract (GIT) [18F]-Fluorodeoxyglucose (FDG) uptake in positron emission technology/computed tomography (PET/CT) is an unexpected and often complicated finding for clinicians. This retrospective study reviewed 8991 charts of patients who underwent PET/CT: 440 patients had incidental GIT uptake, of which 80 underwent endoscopy. Patient characteristics, imaging parameters, and endoscopic findings were studied. Of the 80 patients, 31 had cancer/pre-cancer lesions (16 carcinomas; 15 pre-malignant polyps). Compared to patients with benign/absent lesions, patients with cancer/pre-cancer lesions were significantly older (p = 0.01), underwent PET/CT for primary evaluation/staging of cancer (p = 0.03), had focal GIT uptake (p = 0.04), and had lower GIT uptake (p = 0.004). Among patients with focal uptake, an SUVmax of 9.2 had the highest sensitivity (0.76) and specificity (0.885) in detecting cancer/pre-cancerous lesions. Lower GIT uptake was most common in the sigmoid colon, and upper GIT uptake was most frequent in the stomach. In a bivariate analysis, predictors of cancer/pre-cancer were older age, PET/CT indicated for primary evaluation, focal uptake, uptake in the lower GIT, and higher SUVmax. Further endoscopic investigation is warranted for patients with incidental GIT uptake, especially in the elderly or those presenting for primary evaluation with PET/CT, with the following findings on imaging: lower GIT uptake, focal uptake, or high SUVmax.

Findings of cholangitis in a kidney transplant patient with Caroli disease on FDG PET/CT and MRI.

Caroli disease is a rare congenital disorder of segmental cystic dilatations of the intrahepatic biliary ducts that maintain communication with the rest of the biliary tree. Its typical clinical presentation is recurrent episodes of cholangitis. The diagnosis is usually made using abdominal imaging modalities. We present a patient with Caroli disease showing atypical presentation of acute cholangitis with ambiguous labs and initial negative imaging findings, which was later diagnosed by [18F]-fluorodeoxyglucose positron emission tomography/computed tomography and confirmed by magnetic resonance imaging and tissue pathology. The use of such imaging modalities in moments of doubt or clinical suspicion provide the patient with accurate diagnosis, proper management, and better clinical outcome, thus obviating the need for further invasive investigations.

Well-differentiated gastro-entero-pancreatic neuroendocrine tumors with positive FDG-PET/CT: a retrospective chart review.

PURPOSE: Rarely, well-differentiated gastro-entero-pancreatic neuroendocrine tumors (GEP NETs) can have positive uptake on 18F-fluorodeoxyglucose-PET/computerized tomography ( 18 F-FDG-PET/CT), with or without a positive 68 Ga-PET/CT. We aim to evaluate the diagnostic role of 18 F-FDG-PET/CT in patients with well-differentiated GEP NETs. METHODS: We retrospectively reviewed a chart of patients diagnosed with GEP NETs between 2014 and 2021, at the American University of Beirut Medical Center, who have low (G1; Ki-67 ≤2) or intermediate (G2; and Ki-67 >2-≤20) well-differentiated tumors with positive findings on FDG-PET/CT. The primary endpoint is progression-free survival (PFS) compared to historical control, and the secondary outcome is to describe their clinical outcome. RESULTS: In total 8 out of 36 patients with G1 or G2 GEP NET met the inclusion criteria for this study. The median age was 60 years (range 51-75 years) and 75% were male. One patient (12.5%) had a G1 tumor whereas 7 (87.5%) had G2, and seven patients were stage IV. The primary tumor was intestinal in 62.5% of the patients and pancreatic in 37.5%. Seven patients had both 18 F-FDG-PET/CT and 68 Ga-PET/CT positive and one patient had a positive 18 F-FDG-PET/CT and negative 68 Ga-PET/CT. Median and mean PFS in patients positive for both 68 Ga-PET/CT and 18 F-FDG-PET/CT were 49.71 months and 37.5 months (95% CI, 20.7-54.3), respectively. PFS in these patients is lower than that reported in the literature for G1/G2 NETs with positive 68 Ga-PET/CT and negative FDG-PET/CT (37.5 vs. 71 months; P = 0.0217). CONCLUSION: A new prognostic score that includes 18 F-FDG-PET/CT in G1/G2 GEP NETs could identify more aggressive tumors.

Prone versus Supine FDG PET/CT in the Staging of Breast Cancer.

Supine [18F]Fluorodeoxyglucose (FDG) positron emission technology/computed tomography (PET/CT) is a commonly used modality for the initial staging of breast cancer, and several previous studies have shown superior sensitivity and specificity of prone FDG PET/CT in comparison to its supine counterpart. This retrospective study included 25 females with breast cancer referred for staging. They underwent supine FDG PET/CT followed by prone FDG PET/CT. The outcomes were: number of primary breast lesions, anatomical site of FDG-avid lymph nodes (LNs), and number and type of bone lesions, with SUVmax of all corresponding parameters. Performance was superior in prone acquisition compared to supine acquisition, with the respective results: 29 vs. 22 breast tumor lesions detected, 62 vs. 27 FDG-avid axillary LNs detected, sensitivity of 68% vs. 57%, specificity of 64% vs. 53%. The detection rate of axillary LNs in the prone position was significantly higher (p = 0.001). SUVmax for breast tumor lesions (p = 0.000) and number of detected axillary LNs (p = 0.002) were significantly higher in prone acquisition. Five patients were upstaged after experts read the prone acquisition. Prone FDG PET/CT acquisition is a promising technique in detecting primary breast lesions and metastatic LNs possibly missed in supine acquisition, which may lead to change in patient staging and management.

68Ga-PSMA PET/CT in early relapsed prostate cancer patients after radical therapy.

Biochemical recurrence (BCR) of prostate cancer (PCa) occurs in about 25% of patients treated with radical prostatectomy (RP) and up to 45% in patients who receive external beam radiotherapy (RT). Early diagnosis of PCa recurrence is of high importance for successful salvage therapy. The aim of the present study is to analyze the efficacy of 68 Ga-PSMA PET/CT in detecting the presence of local and/or systemic disease in patients with a history of PCa who have BCR. A total of 52 PCa patients with BCR referred for 68 Ga-PSMA PET/CT were recruited from the American University of Beirut Medical Center between November 2017 and December 2019. We compared the performance of PSMA PET/CT to the results and clinical factors based on follow up: PSA, PSA kinetics, primary treatment, and Gleason score. The relationship between the PET/CT findings and clinical indicators of disease were assessed by univariate and multivariate logistic regression. From a total of 52 patients, 34 (65.4%) had positive PSMA-PET/CT scans. Among those, 8/34 (23.5%) received primary RT. For all patients with a positive PSMA-PET: the detection rate was 2/4 (50%) for PSA < 0.2, 5/10 (50%) for PSA 0.2-0.49, 3/6 (50%) for PSA 0.5-0.99, 6/12 (50%) for PSA 1-1.99, 8/9 (88.9%) for PSA 2-3.99, and 10/11 (90.9%) for PSA 4-10.PSMA-PET/CT positivity was significantly associated with PSA level at time of PET scan, PSA doubling time, Gleason score and TNM staging. However, it did not show a significant correlation with radiotherapy as primary treatment, ongoing androgen deprivation therapy (ADT), time to relapse, and initial PSA before therapy. In our single center prospective trial, 68 Ga-PSMA PET/CT successfully detected the recurrence of PCa in patients with BCR. Scan positivity was significantly associated with PSA level at time of PET scan, PSA doubling time, Gleason score, and TNM staging. PSMA- PET/CT is a highly promising modality in the work up of patients with PCa in the setting of BCR for earlier detection of disease recurrence.

Management of Patients with Relapsed and/or Refractory Multiple Myeloma Treated with Novel Combination Therapies in Routine Clinical Practice in Germany.

INTRODUCTION: Multiple myeloma remains an incurable plasma cell malignancy which, despite improvements in overall survival over the last decade, is characterized by recurrent relapse and is associated with a poor prognosis. This study investigates the use of novel agents in current real-world clinical practice in the management of relapsed and/or refractory multiple myeloma (RRMM) in Germany over different lines of therapy. METHODS: A retrospective chart review was conducted for patients with RRMM treated at multiple centers across Germany between May 2017 and June 2018. Variables included patient demographics and clinical characteristics, current and prior treatment regimens, treatment response, cytogenetic abnormalities, testing methodology, and resource utilization. RESULTS: Data were analyzed from 484 patients from 47 centers across Germany (60% male; average age over 70 years; majority at International Staging System stage 2 or 3). Bone pain and anemia were the most common symptoms at diagnosis, with 63% of patients receiving osteoprotective drugs. Approximately one-third (32%) of patients had received autologous stem cell transplantation and approximately 70% underwent cytogenetic testing. After failure to respond to first-line treatment, most patients received regimens containing second-generation proteasome inhibitors and monoclonal antibodies, with overall response rates greater than 90% in second line (95% and 90% for daratumumab-based and carfilzomib-based therapies, respectively). The incidence of unplanned hospitalization ranged from 11% to 16% across all treatment lines, with longer hospital stays required for treatment administration than for treatment-related toxicity. CONCLUSION: Although treatment patterns for RRMM in Germany differ by line of therapy and are adapted as disease progresses, patients mostly receive combination regimens with carfilzomib or daratumumab in second and third lines, with high overall response rates achieved in all lines.

Hepatic granuloma mimicking recurrent lymphoma on 18F-FDG PET/CT in a patient with primary mediastinal diffuse large B-cell lymphoma.

18F-Flurodeoxyglucose (FDG) PET/CT has been considered the modality of choice in detecting, staging, restaging and following-up with lymphoma patients. However, it has an uncertain role in differentiating hepatic lymphomatous relapse from other granulomatous diseases such as in candidiasis or sarcoidosis. Therefore, it is important to correlate the imaging findings with other modalities such as ultrasound, CT scan, MRI, and histology to direct the diagnosis and treatment. We present a case of a 33-year-old woman with large B-cell lymphoma in complete remission following treatment presenting with neutropenic fever following her final cycle of chemotherapy. Ultrasound of the abdomen and enhanced CT scan of the abdomen and pelvis were negative. The FDG PET/CT scan showed multiple FDG-avid hypodense hepatic lesions that were suggestive either of lymphoproliferative involvement or nonmalignant process. However, MRI of the abdomen performed four days later was suggestive of an infectious process, rather than a lymphoproliferative disorder. A subsequent CT-guided biopsy of a hepatic lesion showed granulomatous inflammation, with no evidence of malignancy or Tuberculosis. The patient was started on Caspofungin followed by Fluconazole. After 5 weeks, the clinical condition resolved, and the subsequent FDG PET/CT showed complete resolution of the FDG-avid multiple hepatic lesions.

Diagnostic Performance of FDG-PET/CT Scan as Compared to US-Guided FNA in Prediction of Axillary Lymph Node Involvement in Breast Cancer Patients.

PURPOSE: The aim of this study was to evaluate the diagnostic ability of 2-deoxy-2-[fluorine-18]fluoro-d-glucose (18F-FDG) PET/non-contrast CT compared with those of ultrasound (US)-guided fine needle aspiration (FNA) for axillary lymph node (ALN) staging in breast cancer patients. PATIENTS AND METHODS: Preoperative 18F-FDG PET/non-contrast CT was performed in 268 women with breast cancer, as well as ALN dissection or sentinel lymph node (SLN) biopsy. One hundred sixty-four patients underwent US-guided FNA in combination with 18F-FDG PET/CT. The diagnostic performance of each modality was evaluated using histopathologic assessments as the reference standard. The receiver operating characteristic (ROC) curves were compared to evaluate the diagnostic ability of several imaging modalities. RESULTS: Axillary 18F-FDG uptake was positive in 180 patients, and 125 patients had axillary metastases according to the final pathology obtained by ALN dissection and/or SLN dissection. Of the patients with positive 18F-FDG uptake in the axilla, 21% had false-positive results, whereas 79% were truly positive. Eighty-eight patients had negative 18F-FDG uptake in the axilla, among which 25% were false-negative. 18F-FDG-PET/CT had a sensitivity of 86.59% and a specificity of 63.46% in the assessment of ALN metastasis; on the other hand, US-guided FNA had a sensitivity of 91.67% and a specificity of 87.50%. The mean primary cancer size (p = 0.04) and tumor grade (p = 0.04) in combination were the only factors associated with the accuracy of 18F-FDG PET/CT for detecting metastatic ALNs. CONCLUSION: The diagnostic performance of 18F-FDG PET/CT for the detection of axillary node metastasis in breast cancer patients was not significantly different from that of US-guided FNA. Combining 18F-FDG PET/CT with US-guided FNA or SLN biopsy could improve the diagnostic performance compared to 18F-FDG PET/CT alone.

Ictal and interictal FDG-PET in anti-NMDAR encephalitis with mutism.

We report a case of a 27-year-old right-handed gentleman with mutism and seizures diagnosed with Anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis without evidence of underlying malignancy. Brain MRI was unremarkable. Clinical seizures were controlled but long-term video-EEG monitoring was needed for better characterization of his clinical manifestations especially that language partially improved. It was crucial to identify whether this mutism was ictal in origin or not. Ictal brain Positron Emission Tomography with 18 F-fluorodeoxyglucose (FDGPET) scan combined with EEG was done. It revealed left fronto-temporal, parietal, and crossed cerebellar hypermetabolism (or diaschisis) concomitant to the underlying rhythmic focal delta activity on EEG. Beside anti-epileptic drugs he was treated with escalating immunotherapy (intravenous solumedrol then immunoglobulins then full rituximab course). Six months later, EEG combined to FDG-PET scan were repeated, and were normal. At 3 years follow up the patient remains neurologically stable and seizure-free, off anti-epileptics drugs. Performing the FDGPET scan combined to EEG was useful to identify non-convulsive status epilepticus and should be performed early in anti-NMDAR encephalitis to guide treatment.

Radiation levels following the Beirut seaport explosion: environmental survey and public dose exposure.

On August 4, 2020, an explosion at the Port of Beirut, Lebanon, ripped the city to shreds, killing more than 200 people, wounding 6500 others, and leaving about 300,000 residents temporarily homeless. The explosion raised many concerns regarding the possible presence of radioactive material and the associated public health risks. Accordingly, and after opening the affected sites for public access, an external radiological survey of the hit area was conducted. The dose rate reading in Beirut's seaport (ground zero) varied between 58 and 100 nSv/h. The detected levels were within the average worldwide annual gamma dose rate of 50 to 53 nSv/h set by the United Nations Scientific Committee on the Effects of Atomic Radiation. The recorded values were not significantly different from those measured by the Lebanese Atomic Energy Commission (LAEC) at the National Council for Scientific Research (CNRS-L) in 2009 and 2010 at three locations in Beirut's seaport (minimum value 50 nSv/h and maximum value 140 nSv/h). Besides, in the surveyed area, radiological scans were conducted on 360 injured patients reported to the American University of Beirut Medical Center (AUBMC), showing no signs of radiation exposure due to the explosion.

Can SUVmax of 68Ga-labeled PSMA Ligand and 18F-choline PET/CT Be Used to Predict the Radiation Dose in Prostate Cancer Patients?

Gallium-68 (Ga)-PSMA and F-Choline are two radionuclides that have already shown high potential for the detection of prostate cancer. The comparison between these two radionuclides has several advantages in radiation protection. The aim of this prospective study was to identify which of these two radionuclides can help in predicting the equivalent dose using the maximum standard uptake value (SUVmax) of normal organs, the kidneys. Two groups of 40 patients (total n = 80) who underwent PET/CT using Ga or F for diagnosis of prostate cancer between April 2018 and December 2018 at the American University of Beirut Medical Center were included. First, the dose rates were measured after 1 h of radionuclide uptake at 1 m distance with background of 0.015 µSv h. Then, SUVmax for kidneys were determined from images obtained with PET/CT 1 h after injection of both radionuclides. The ratios of the equivalent doses to the SUVmax for kidneys were compared for both Ga-PSMA and F-Choline. There is a positive moderate relationship between the SUVmax for kidneys and the Ga dose rate after 1 h of injection at 1 m distance from the abdomen (p-value = 0.023 < 0.05). This relationship is statistically significant. However, there is a very low negative relationship between the SUVmax kidney and F dose rate after 1 h of injection at 1 m distance from the abdomen (p-value = 0.93 > 0.05). This relationship is not statistically significant. This leads to the suggestion that we can predict the equivalent dose due to Ga by indicating the SUVmax from the PET/CT images.

Myers-Briggs Type Indicator Personality Types of Ophthalmology Residents.

Objective This study attempts to use the Myers-Briggs Type Indicator (MBTI) to analyze personality types among current and recent ophthalmology residents. We aimed to evaluate the prevalence rates of each specific personality type in ophthalmology, and whether these changed by level of training, training program, or fellowship selection. The study aimed to evaluate whether certain personality types are more prevalent in ophthalmology as a unique medical specialty. This can help understand specialty choice and potentially predict trends in specialty selection. Study Design After obtaining institutional review board approval from Howard University Hospital, an electronic version of the MBTI questionnaire, form M, was sent to participants. In addition to the questionnaire, participants responded to four questions inquiring about home program, postgraduate training level, subspecialty interest, and work environment (if applicable). The anonymous responses of the surveys were automatically scored on google forms, and the results were analyzed by using StatView statistical analysis. Setting This study was conducted at Howard University, Georgetown University, George Washington University, University of Texas Medical Branch at Galveston, and Kresge Eye Institute. Participants A total of 66 current residents and recent graduates of five residency programs were involved in this study. Main Outcomes and Measures This study evaluated four-letter personality type from each participant. Results Ophthalmology residents were statistically more likely to be identified in the categories of extroversion (E) than introversion (I) ( p = 0.049), thinking (T) than feeling (F) ( p = 0.027), and judging (J) than perceiving (P) ( p = 0.007), with no statistically significant difference between sensing (S) and intuition (N). ENTP, ESTJ, and ISTJ were the most common personality types, each comprising 13.6% of the sample population. The ratio of J:P was found to increase as training level increased, beginning with postgraduate 2nd year until graduate level. Conclusion Certain personality types are more common among ophthalmology residents in our cohort from five different training programs. It is possible that individual types change over the course of residency training and career. Understanding that these findings exist can be used as a baseline for future research in terms of potential predictors for applicants, of resident knowledge base, and personality changes over the course of one's training.

Early Sialadenitis After Radioactive Iodine Therapy for Differentiated Thyroid Cancer: Prevalence and Predictors.

INTRODUCTION: Sialadenitis is a frequent occurrence after radioactive iodine therapy (RAI). However, reports on its predictors and risk factors in the Eastern Mediterranean Region (EMRO) are scarce. AIM: This study aimed to identify risk factors for early sialadenitis in patients receiving RAI for differentiated thyroid cancer (DTC) at the American University of Beirut Medical Center. It also aimed to determine the prevalence and characteristics of such patients receiving RAI at our institution. METHODS: This was a retrospective study conducted at the American University of Beirut Medical Center. Medical charts were reviewed for all patients 18-79 years of age admitted to receive RAI for DTC between 01/01/2012 and 31/12/2015. Sialadenitis was deemed present if there were any records of neck swelling/pain, dry mouth, or difficulty swallowing within 48 hours of RAI administration. Characteristics between patients with sialadenitis and those without were compared to determine predictors. RESULTS: There were 174 patients admitted to receive RAI, predominantly females (71.3%), with papillary thyroid cancer (93.1%). The majority had lymph node involvement (64.5%). Pretreatment thyroid stimulating hormone (TSH) was greater than 75 mIU/ml in most patients (72.6%). The prevalence of sialadenitis was 20.1% (95% CI (15-27)). Being non-Lebanese and having a positive whole-body scan were associated with sialadenitis and persisted after adjustments (OR = 2.34 and 3.99). Non-Lebanese patients had higher rates of lymph nodes involvement (p value 0.005) and were kept off levothyroxine for longer periods (p value 0.02). CONCLUSION: The prevalence of sialadenitis at our institution was similar to other reported studies from the world. However, risk factors allude to more iodine exposure in the neck with positive whole-body scan uptake, lymph node involvement, and prolonged period of hypothyroidism.

Neoadjuvant chemotherapy and Avelumab in early stage resectable nonsmall cell lung cancer.

Multiple randomized studies have shown that combination of chemotherapy and immune checkpoint inhibitors (ICIs) leads to better response rates and survival as compared to chemotherapy alone in the advanced stage of NSCLC. Data suggesting a benefit to using ICIs in the neoadjuvant therapy of patients with early stage NSCLC are emerging. Eligible subjects were treatment naïve patients with stage IB, II, and resectable IIIA NSCLC. Patients received three cycles of neoadjuvant chemotherapy with four doses of avelumab every 2 weeks. Patients with squamous cell cancer received cisplatin or carboplatin on day 1 and gemcitabine on days 1 and 8 of each cycle of chemotherapy. Patients with nonsquamous histology received cisplatin or carboplatin with pemetrexed on day 1 of each cycle. Patients then proceeded to their planned surgery. Out of 15 patients accrued as part of stage 1 of the study, four had a radiologic response (1 complete response), lower than the minimum of six responses needed to continue to phase 2 of the study. The study was therefore terminated. Majority had adenocarcinoma histology and stage IIIA disease. The treatment was well tolerated with no unexpected side effects. Four patients (26.7%) had grade III/IV CTCAE toxicity. This study confirms that the preoperative administration of chemotherapy and avelumab is safe. There was no indication of increased surgical complications. The benefit of adding immunotherapy to chemotherapy did not appear to enhance the overall response rate of patients in the neoadjuvant setting in patients with resectable NSCLC because this study failed to meet its primary endpoint.