Positron emission tomography/computed tomography in the management of Hodgkin and B-cell non-Hodgkin lymphoma: An update.

18 F-fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) is now an integral part of lymphoma staging and management. Because of its greater accuracy compared with CT alone, PET/CT is currently routinely performed for staging and for response assessment at the end of treatment in the vast majority of FDG-avid lymphomas and is the cornerstone of response classification for these lymphomas according to the Lugano classification. Interim PET/CT, typically performed after 2 to 4 of 6 to 8 chemotherapy/chemoimmunotherapy cycles with or without radiation, is commonly performed for prognostication and potential treatment escalation or de-escalation early in the course of therapy, a concept known as response-adapted or risk-adapted treatment. Quantitative PET is an area of growing interest. Metrics, such as the standardized uptake value, changes (Δ) in the standardized uptake value, metabolic tumor volume, and total lesion glycolysis, are being investigated as more reproducible and potentially more accurate predictors of response and prognosis. Despite the progress made in standardizing the use of PET/CT in lymphoma, challenges remain, particularly with respect to its limited positive predictive value, emphasizing the need for more specific molecular probes. This review highlights the most relevant applications of PET/CT in Hodgkin and B-cell non-Hodgkin lymphoma, its strengths and limitations, as well as recent efforts at implementing PET/CT-based metrics as promising tools for precision medicine.

Endovascular Rescue Treatment for Delayed Cerebral Ischemia After Subarachnoid Hemorrhage Is Safe and Effective.

Background: The implementation of rescue efforts for delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage remains largely empirical for a lack of supporting evidence, while the associated risk profile is also unclear. Objective: The present study evaluates the safety and efficacy of endovascular rescue treatment (ERT, continuous intraarterial nimodipine; IAN, transcutaneous balloon angioplasty, TBA). Methods: In this prospective observational study, we assessed periprocedural complications and side effects in context of ERT. We evaluated neurological status, multimodal neuromonitoring (ptiO2, lactate/pyruvate ratio, transcranial doppler), and cranial imaging (CTP, DSA). All parameters were included into multivariate analysis to determine predictors for the need of retreatment. Results: We included 33 consecutive patients with 54 ERT (IAN n = 35; TBA n = 13; TBA + IAN n = 6). We recorded no serious complications and initial improvement in all parameters (neurostatus 72.3% of patients; ptiO2 15.0 ± 11.7 to 25.8 ± 15.5 mmHg, p < 0.0001; lactate/pyruvate ratio 46.3 ± 27.5 to 31.0 ± 9.7, p <0.05; transcranial doppler 139.0 ± 46.3 to 98.9 ± 29.6 cm/s, p < 0.05; CTP 81.6% of patients; DSA 93.1% of patients). Retreatment (n = 16, 48.5%) was independently associated with preinterventional ptiO2 < 5 mmHg (p <0.01) and early (<72 h) discontinuation of IAN treatment (p = 0.08). DCI related cerebral infarction was noted in n = 8 patients (24.2%). At 3 months after discharge, favorable outcome was noted for n = 11 (35.5%) patients. Conclusion: Provided a detailed decision tree, timely ERT can provide a relatively safe and effective treatment option in those highly-selected patients undergoing multimodality monitoring where conservative treatment options are exhausted. Continuous treatment in particular may be suitable to surpass sustained DCI and was associated with a low rate of DCI related infarction and comparably high percentage of good outcome.

Retinal Vessel Analysis (RVA) in the Context of Subarachnoid Hemorrhage - A Proof of Concept Study.

BACKGROUND: Timely detection of impending delayed cerebral ischemia after subarachnoid hemorrhage (SAH) is essential to improve outcome, but poses a diagnostic challenge. Retinal vessels as an embryological part of the intracranial vasculature are easily accessible for analysis and may hold the key to a new and non-invasive monitoring technique. This investigation aims to determine the feasibility of standardized retinal vessel analysis (RVA) in the context of SAH. METHODS: In a prospective pilot study, we performed RVA in six patients awake and cooperative with SAH in the acute phase (day 2-14) and eight patients at the time of follow-up (mean 4.6±1.7months after SAH), and included 33 age-matched healthy controls. Data was acquired using a manoeuvrable Dynamic Vessel Analyzer (Imedos Systems UG, Jena) for examination of retinal vessel dimension and neurovascular coupling. RESULTS: Image quality was satisfactory in the majority of cases (93.3%). In the acute phase after SAH, retinal arteries were significantly dilated when compared to the control group (124.2±4.3MU vs 110.9±11.4MU, p<0.01), a difference that persisted to a lesser extent in the later stage of the disease (122.7±17.2MU, p<0.05). Testing for neurovascular coupling showed a trend towards impaired primary vasodilation and secondary vasoconstriction (p = 0.08, p = 0.09 resp.) initially and partial recovery at the time of follow-up, indicating a relative improvement in a time-dependent fashion. CONCLUSION: RVA is technically feasible in patients with SAH and can detect fluctuations in vessel diameter and autoregulation even in less severely affected patients. Preliminary data suggests potential for RVA as a new and non-invasive tool for advanced SAH monitoring, but clinical relevance and prognostic value will have to be determined in a larger cohort.

Development of a Performance Improvement Program: A Workplace-Based Educational Intervention on Magnetic Resonance Imaging in Spinal Trauma.

OBJECTIVE: Performance improvement (PI) programs are an educational tool used to analyze clinical performance of clinicians. The effect of this tool has not been fully explored in orthopedic and trauma surgery. DESIGN AND SETTING: A needs assessment was conducted in connection with a worldwide webinar on magnetic resonance imaging in spinal injuries to identify the clinical need for an educational intervention. A 3-step PI process was defined and implemented over a 6-month period in 1 hospital department. Opportunities for improvement were identified by applying a 10-item quality checklist to 26 cases. A focused educational intervention was delivered to address the identified gaps, and a set of 22 posteducation cases was compared. PARTICIPANTS: The department of radiology and the department of trauma surgery of a level I university hospital participated in this study. RESULTS: A total of 26 cases collected before the educational intervention showed several areas for potential improvement. Important information was not provided by the surgeons in their communication with the radiologist. The educational intervention outlined the data and suggested actions. Comparing the information transfer of the preintervention and postintervention data, there was a significant improvement following the intervention (p = 0.0013). CONCLUSION: Our PI program was able to demonstrate a significant influence on the behavior and the attitude of surgeons and radiologists.