Risk-related 18F-FDG PET/CT and new diagnostic strategies in patients with solitary pulmonary nodule: the ITALIAN multicenter trial.

PURPOSE: Diagnosis of solitary pulmonary nodule (SPN) is an important public health issue and 18F-FDG PET/CT has proven to be more effective than CT alone. Pre-test risk stratification and clinical presentation of SPN could affect the diagnostic strategy. A relevant issue is whether thoracic segmental (s)-PET/CT could be implemented in patients with SPN. This retrospective multicenter study compared the results of FDG whole-body (wb)-PET/CT to those of s-PET/CT. METHODS: 18F-FDG PET/CT of 502 patients, stratified for pre-test cancer risk, were retrospectively analyzed. The thoracic part of wb-PET/CT, considered s-PET/CT, was compared to wb-PET/CT. Clinical and PET/CT variables were investigated for SPN characterization as well as for identification of patients in whom s-PET/CT could be performed. Histopathology or follow-up data were used as a reference. RESULTS: In the study population, 36% had malignant, 35% benign, and 29% indeterminate SPN. 18F-FDG uptake indicative of thoracic and extra-thoracic lesions was detectable in 13% and 3% of the patients. All patients with extra-thoracic metastases (n = 13) had thoracic lymph node involvement and highest 18F-FDG uptake at level of SPN (negative predictive value 100%). Compared to wb-PET/CT, s-PET/CT could save about 2/3 of 18F-FDG dose, radiation exposure or scan-time, without affecting the clinical impact of PET/CT. CONCLUSION: Pre-test probability of malignancy can guide the diagnostic strategy of 18FDG-PET/CT in patients with SPN. In subjects with low-intermediate pretest probability s-PET/CT imaging might be planned in advance, while in those at high risk and with thoracic lymph node involvement a wb-PET/CT is necessary.

Correction to: Predictive and prognostic value of 18F-DOPA PET/CT in patients affected by recurrent medullary carcinoma of the thyroid.

The following affiliation should be added to the authors Agostino Chiaravalloti and Orazio Schillaci.

Oligometastatic recurrent prostate cancer detects by fluorine-18-choline positron emission tomography/computed tomography in patients with prostate-specific antigen levels of up to 5 ng/ml.

PURPOSE: The aim of this study was to assess the ability of fluorine-18-fluorocholine (F-FCH) PET/computed tomography (CT) to detect oligometastatic disease (OMD) in patients with early recurrence of prostate cancer (PC) [prostate-specific antigen (PSA)≤5 ng/ml]. PATIENTS AND METHODS: Between 2010 and 2016, 324 patients with PC and PSA levels of less than or equal to 5 ng/ml were recruited. The mean (SD) age of the patients was 71 (10) years. All patients were treated with a radical prostatectomy±lymphadenectomy. One-hundred and twenty-one patients were under hormonal therapy at the time of PET/CT, whereas 203 were not. The mean (SD) PSA at the time of PET/CT was 1.33 (1.19) ng/ml, the mean (SD) PSA doubling time (PSAdt) was 10 (12) months, and the mean (SD) PSA velocity (PSAvel) was 1.94 (3.31) ng/ml/year. The correlation between continuous and categorical data was assessed using Student's t-test or by analysis of variance and by the χ-test, respectively. Univariate and multivariate analysis was carried out for the identification of clinical variables able to predict the presence of OMD. RESULTS: One-hundred and ninety-three patients had a negative F-FCH PET/CT, whereas 131 (40.4%) had a positive scan. Of these latter patients, 35 had a significant F-FCH uptake in the prostatic fossae, 59 in the lymph nodes, and 37 in bone. PSA levels were significantly different between patients with a positive than those with a negative scan (P<0.001). F-FCH PET/CT was negative in the majority of patients with a PSA of less than or equal to 1 (63.2%) ng/ml. More than 60% of patients with a PSAdt of less than or equal to 6 months had a positive F-FCH PET/CT scan for OMD. PSAvel was higher in patients with a positive scan than those with a negative finding. At univariate analysis, PSA level, PSAdt, and PSAvel were predictors of a positive F-FCH PET/CT for OMD, whereas on multivariate analysis, only PSA level and PSAdt were independent predictors (both P<0.01). Furthermore, PSAdt was the only independent predictor of OMD at the lymph node level. CONCLUSION: In patients with early recurrence of PC, F-FCH PET/CT is able to detect OMD in 40% of cases. This finding has an important impact on the detection of PC recurrent lesions that could be treated by local therapy to achieve long-term survival or cure.

Predictive and prognostic value of 18F-DOPA PET/CT in patients affected by recurrent medullary carcinoma of the thyroid.

INTRODUCTION: Medullary thyroid carcinoma (MTC) is a malignancy accounting for about 5-8% of thyroid cancers. Serum calcitonin and carcinoembryonic antigen (CEA) levels are widely used to monitor disease progression. However, prognostic factors able to predict outcomes are highly desirable. We, therefore, aimed to assess the prognostic role of 18F-DOPA PET/CT in patients with recurrent MTC. MATERIALS AND METHODS: 60 patients (mean age 64 ± 13 years, range 44-82) with recurrent MTC were eligible from a multicenter database. All patients underwent a restaging 18F-DOPA PET/CT, performed at least 6 months after surgery. CEA/calcitonin levels, local recurrences, nodal involvement and metastases at PET/CT were recorded. SUVmax, SUVmean (also normalized to mediastinal uptake) and metabolic tumor volume were automatically calculated for each lesion, by placing a volume of interest around the lesion with 40% of peak activity as threshold for the automatic contouring. The patients were clinically and radiologically followed up for 21 ± 11 months. Rate of progression-free survival (PFS), disease-specific survival (DSS) and incremental prognostic value of 18F-DOPA PET/CT over conventional imaging modalities were assessed by Kaplan-Meier curves and Log-Rank test. Cox regression univariate and multivariate analyses were performed for assessing predictors of prognosis. RESULTS: 18F-DOPA PET/CT showed abnormal findings in 27 patients (45%) and resulted unremarkable in 33 (55%). PFS was significantly longer in patients with an unremarkable PET/CT scan (p = 0.018). Similarly, an unremarkable PET/CT study was associated with a significantly longer DSS (p = 0.04). 18F-DOPA PET/CT added prognostic value over other imaging modalities both for PFS and for DSS (p < 0.001 and p = 0.012, respectively). Neither semiquantitative PET parameters nor clinical or laboratory data were predictive of a worse PFS and DSS in patients with recurrent MTC. CONCLUSION: 18F-DOPA PET/CT scan has an important prognostic value in predicting disease progression and mortality rate.

Diagnostic and prognostic impact of fluorine-18-fluorodeoxyglucose PET/CT in preoperative and postoperative setting of breast cancer patients.

PURPOSE: The aim of this study was to assess the diagnostic and prognostic value of fluorine-18-fluorodeoxyglucose (F-FDG) PET/CT in patients with breast cancer (BC) in the preoperative and the postoperative setting. PATIENTS AND METHODS: Between 2011 and 2015, we prospectively enrolled 275 patients (mean age: 53 years) with BC (stage I-III; triple-negative or HER2-positive cancer). One-hundred and forty-nine (54.2%) patients underwent F-FDG PET/CT before neoadjuvant therapy and 126 (45.8%) after surgery and before any additional adjuvant therapy. The patients were followed for a median period of 44 (2-57) months. The different effects of PET/CT on the presetting and postsetting phase form a therapeutic and prognostic point of view were assessed by χ, by Kaplan-Meier, and Cox-regression analyses. RESULTS: In the preoperative setting, PET/CT provided additional diagnostic information in 42/149 (28%) patients. In particular, 17/70 (24%) patients at stage III were converted into stage IV and 4/68 (6%) at stage II were upstaged to IV. In the postoperative setting, PET/CT upstaged the disease in both stage IIIC and stage IV in 14/126 (11%) cases. At the end of follow-up, 28/271 (10%) patients died from BC and 40 (15%) had a recurrence of disease. On Kaplan-Meier analysis, patients with a positive PET/CT other than the primary tumor site showed both a worse overall survival and a worse disease-free survival compared with their counterpart (76 vs. 92%; P=0.063 and 65 vs. 100%; P<0.001). Conversely, in the postoperative setting, no differences in overall survival and disease-free survival were found between patients with positive and negative PET/CT findings (both P>0.05). On multivariate Cox-regression analysis, a positive PET/CT was a significant predictive factor of a poor prognosis in the preoperative setting. The significance was lost in the postoperative setting. CONCLUSION: In the preoperative setting, PET/CT can provide additional diagnostic and prognostic information. Conversely, in the postoperative setting, PET/CT adds diagnostic information, but does not provide any adjunctive prognostic assessment.

Predictive value of (18)F-FDG PET/CT in restaging patients affected by ovarian carcinoma: a multicentre study.

PURPOSE: Ovarian cancer is the eighth most common malignancy among women and has a high mortality rate. Prognostic factors able to drive an effective therapy are essential. (18)F-Fluoro-2-deoxyglucose positron emission tomography/computed tomography ((18)F-FDG PET/CT) has been investigated in patients with epithelial ovarian cancer and showed promise in diagnosing, staging, detecting recurrent lesions and monitoring treatment response. Conversely, its prognostic role remains unclear. We aimed at assessing the prognostic value of (18)F-FDG PET/CT performed in the restaging process in a multicentre study. METHODS: We evaluated 168 patients affected by ovarian carcinoma, who underwent a restaging (18)F-FDG PET/CT. The presence of local recurrences, lymph node involvement and distant metastasis was recorded as well as lesion dimensions, maximum and mean standardized uptake values (SUVmax and SUVmean, respectively). Progression-free survival (PFS) and overall survival (OS) at 3 and 4 years were computed by using Kaplan-Meier curves. Increased odds ratio was assessed using Cox regression analysis testing all lesion parameters measured by PET/CT. RESULTS: PFS was significantly longer in patients with a negative than a positive restaging PET/CT study (3- and 4-year PFS 64 and 53% vs 23 and 12%, respectively; p < 0.001). Similarly, a negative study was associated with a significantly higher OS rate after 4 years of follow-up (67 vs 25% in negative and positive groups, respectively; p < 0.001). Lymph node or distant involvement were also independently associated with an increased risk of disease progression [hazard ratio (HR) 1.6 and 2.2, respectively; p = 0.003]. Moreover, PET/CT showed an incremental prognostic value compared to the International Federation of Gynecology and Obstetrics (FIGO) staging system. In the analysis of patient subsets, individuals with the same FIGO stage I-II but with negative PET had a significantly better 4-year OS than patients with low FIGO stage but positive PET. This implies that patients with the same FIGO stage can be further prognostically stratified using PET (p = 0.01). At receiver-operating characteristic (ROC) analysis, no thresholds for semiquantitative parameters were predictive of a worse outcome. CONCLUSION: (18)F-FDG PET/CT has an important prognostic value in assessing the risk of disease progression and mortality rate. An efficacious therapy planning might therefore effectively rely on (18)F-FDG PET/CT findings. Semiquantitative data were not proven to be an effective tool to predict disease progression.

Recurrent renal cell carcinoma: clinical and prognostic value of FDG PET/CT.

PURPOSE: The purpose of our study was 1) to evaluate the diagnostic performance of 18F-fluorodeoxyglucose (FDG) positron emission tomography (PET)/computed tomography (CT), 2) to assess the impact of FDG PET/CT on treatment decision-making, and 3) to estimate the prognostic value of FDG PET/CT in the restaging process among patients with renal cell carcinoma (RCC). METHODS: From the FDG PET/CT databases of San Raffaele Hospital in Milan, Italy, and the Veneto Institute of Oncology in Padua, Italy, we selected 104 patients with a certain diagnosis of RCC after surgery, and for whom at least 24 months of post-surgical FDG PET/CT, clinical, and instrumental follow-up data was available. The sensitivity and specificity of FDG PET/CT were assessed by histology and/or other imaging as standard of reference. Progression-free survival (PFS) and overall survival (OS) were computed using the Kaplan-Meier method. Univariate and multivariate Cox proportional hazards models were used to identify predictors of outcome. RESULTS: FDG PET/CT resulted in a positive diagnosis in 58 patients and a negative diagnosis in 46 patients. Sensitivity and specificity were 74% and 80%, respectively. FDG PET/CT findings influenced therapeutic management in 45/104 cases (43%). After a median follow-up period of 37 months (± standard deviation 12.9), 51 (49%) patients had recurrence of disease, and 26 (25%) had died. In analysis of OS, positive versus negative FDG PET/CT was associated with worse cumulative survival rates over a 5-year period (19% vs. 69%, respectively; p <0.05). Similarly, a positive FDG PET/CT correlated with a lower 3-year PFS rate. In addition, univariate and multivariate analysis revealed that a positive scan, alone or in combination with disease stage III-IV or nuclear grading 3-4, was associated with high risk of progression (multivariate analysis = hazard ratios [HRs] of 4.01, 3.7, and 2.8, respectively; all p < 0.05). CONCLUSIONS: FDG PET/CT is a valuable tool both in treatment decision-making and for predicting survival and progression in patients affected by RCC.

Diagnostic and Prognostic Value of 18F-FDG PET/CT in Male Breast Cancer: Results From a Bicentric Population.

PURPOSE: We aim to assess the diagnostic and prognostic values of 18Ffluorodeoxyglucose (FDG) positron emission tomography (PET)/computed tomography (CT) in a small population with male breast cancer (MBC). MATERIALS AND METHODS: From May 2005 to Jul 2013, we retrospectively reinterpreted 31 FDG PET/CT scans of 25 men (mean age: 67 years; range: 51-81 years) with a proven breast cancer diagnosis, from two Italian centers. In the majority of patients, an invasive ductal cancer was present (68%). PET/CT scan was performed for initial staging in 5 (16%), restaging in 18 (58%), restaging for the increase of tumor markers in 4 (13%), response to therapy in 2 (6%) and during follow-up in 2 cases (6%). The prognostic impact of PET/CT in this male breast cancer population was assessed by using Kaplan-Meier analysis. RESULTS: Nuclear medicine imaging was negative in 10 subjects while it resulted positive in the residual 15 patients (60%). At initial staging, in four out of five cases, PET/CT showed a significant uptake in the primary cancer and of those three had also a loco-regional lymphatic and distant metastatic involvement. In restaging setting, PET/CT was more accurate than conventional imaging for detection of distant metastases, resolving two false-positive findings. Finally, a positive PET/CT scan was demonstrated to be prognostically unfavorable as compared to a negative exam. CONCLUSIONS: MBC is a rare tumor with similar biological and metabolic characteristics of female breast cancer. FDG PET/CT seems to be useful, particularly in the restaging setting, to delineate the correct therapeutic approach and to predict the prognosis.

Comparison between conventional imaging (abdominal-pelvic computed tomography and bone scan) and [(18)F]choline positron emission tomography/computed tomography imaging for the initial staging of patients with intermediate- tohigh-risk prostate cancer: A retrospective analysis.

OBJECTIVE: The aim of this study was to evaluate the efficiency of [(18)F]fluorocholine positron emission tomography/computed tomography (FCH PET/CT) in detecting lymph-node and bone involvement in comparison with conventional imaging, such as abdominal-pelvic CT and bone scan, in the initial staging of prostate cancer (PCa). MATERIALS AND METHODS: The study retrospectively evaluated 48 patients who had FCH PET/CT for the initial staging of PCa. At the same time, 32 of the 48 patients had a bone scan and 26 of the 48 patients had abdominal-pelvic diagnostic CT. Diagnostic performance of FCH PET/CT, i.e. sensitivity, specificity and accuracy, was evaluated on a per-patient basis for the whole population and then separately on a per-risk classification, and later in comparison with conventional imaging. Histological specimens or follow-up data were used as the standard of reference. RESULTS: The overall accuracy of FCH PET/CT for lymph-node involvement was 83.3%. The sensitivity of FCH was higher in the high-risk subset (83.3%) than in the intermediate-risk group (33.3%), whereas FCH specificity was similar. In comparison with dedicated CT scan, FCH PET/CT showed a higher sensitivity and a similar specificity (46.2% vs 69.2% and 92.3% vs 92.3%, respectively). Moreover, the sensitivity and specificity of PET/CT were higher than those of bone scan (100% vs 90% and 86.4% vs 77.2%, respectively). In contrast with conventional imaging, PET/CT changed the staging of the PCa in 33.3% patients. CONCLUSIONS: The efficiency of FCH PET/CT in detecting both bone and lymph-node involvement of PCa at initial staging was found to be higher than that of conventional imaging. Prospective clinical trials are needed to confirm these findings.

Gleason score at diagnosis predicts the rate of detection of 18F-choline PET/CT performed when biochemical evidence indicates recurrence of prostate cancer: experience with 1,000 patients.

UNLABELLED: The objective of this study was to explore the ability of the initial Gleason score (GS) to predict the rate of detection of recurrent prostate cancer (PCa) with (18)F-choline PET/CT in a large cohort of patients. METHODS: Data from 1,000 patients who had undergone (18)F-choline PET/CT because of biochemical evidence of relapse of PCa between 2004 and 2013 were retrieved from databases at 4 centers. Continuous data were compared by the Student t test or ANOVA, and categoric variables were compared by the χ(2) test. Univariable and multivariable analyses were performed by logistic regression. RESULTS: The GS at diagnosis was less than or equal to 6 in 257 patients, 7 in 347 patients, and greater than 7 in 396 patients. The results of 645 PET/CT scans were positive for PCa recurrence. Eighty-one percent of the positive PET/CT results were found in patients with a PSA level of greater than or equal to 2 ng/mL, 43% were found in patients with a PSA level of 1-2 ng/mL, and 31% were found in patients with a PSA level of less than or equal to 1 ng/mL; 78.8% of patients with positive PET/CT results had a GS of greater than 7. The results of (18)F-choline PET/CT scans were negative in 300 patients; 44% had a GS of less than or equal to 6, 35% had a GS of 7, and 17% had a GS of greater than 7. PET/CT results were rated as doubtful in only 5.5% of patients (median PSA, 1.8 ng/mL). When the GS was greater than 7, the rates of detection of (18)F-choline PET/CT were 51%, 65%, and 91% for a PSA level of less than 1 ng/mL, 1-2 ng/mL, and greater than 2 ng/mL, respectively. In univariable and multivariable analyses, both a GS of 7 and a GS of greater than 7 were independent predictors for positive (18)F-choline PET/CT results (odds ratios, 0.226 and 0.330, respectively; P values for both, <0.001). CONCLUSION: A high GS at diagnosis is a strong predictive factor for positive (18)F-choline PET/CT scan results for recurrent PCa, even when the PSA level is low (i.e., ≤1 ng/mL).

Use of a portable gamma camera for guiding surgical treatment in locally advanced breast cancer in a post-neoadjuvant therapy setting.

The aim of the present study was to assess the feasibility of a portable gamma camera (PGC) for guiding surgical treatment in locally advanced breast cancer (LABC) after neoadjuvant therapy (NT). Since January 2012, a PGC (Sentinella 102, ONCOVISION) has been available in our center. We planned to perform a feasibility monocentric prospective study involving 15-20 patients with LABC for assessing the diagnostic performance of this PGC after NT (Breast Cancer Surgery-S102). Before the surgical treatment and at the end of NT an injection of 99mTc-Sestamibi (100-150 MBq) was made. Conventional scintimmamography (SMM) and Sentinella 102 images were obtained from 18 patients. 10 (55.5 %) patients showed a focal uptake of tracer in the breast or lymph nodes before or after the surgical excision (on histological specimen), while 8 did not. The histological specimen concluded for a complete response to NT in 4 (22.2 %) patients and for a partial or no response to treatment in the remnant 14 subjects. The specificity and false-negative rate of the Sentinella 102 compared to SMM were 100 % for both and 38 % vs. 60 %, respectively. The global diagnostic accuracy of Sentinella 102 was: 66.7 % (95 % confidence interval: 44.88-88.44 %). The present feasibility study shows how a new nuclear imaging device can be useful in the operating theatre for guiding a radical surgery approach in patients with LABC after NT.

Correlation between cancer antigen 15.3 value and qualitative and semiquantitative parameters of positron emission tomography/computed tomography in breast cancer patients.

BACKGROUND: The association of PET/CT and tumor markers can be considered complementary, since any significant increases of tumor markers can indicate the presence of disease while PET/CT is able to detect and describe the tumor sites. In this retrospective, single-institution study, we determine the correlation between cancer antigen (CA) 15.3 value and qualitative and semi-quantitative PET/CT data in breast cancer (BC) patients. METHODS: 193 BC patients (median age 61 yrs) already treated with primary treatment (surgery and others) were identified through institutional databases. All patients underwent PET/CT for increase in tumor markers, post-therapy evaluation, restaging and doubtful conventional imaging for disease relapse. The CA15.3 values before PET/CT scan were collected for all patients. Clinical outcome was defined as presence or absence of disease recurrence based on follow-up data (histological or imaging findings). CA15.3 quartile values and qualitative and semi-quantitative (maximum Standardized Uptake Value - SUVmax) PET/CT findings were compared with chi-square test and linear regression analysis. RESULTS: The mean value of CA15.3 was significantly higher in patients with positive than negative PET/CT (67.51±120.92 vs. 25.54±17.54, p<0.005). PET/CT was positive in 107 (55%) and negative in 86 (45%) patients; CA15.3 value was considered abnormal (≥ 31 UI/mL) in 85 (44%) patients; 57 of them showed positive PET/CT while 28 a negative scan (67 vs. 33%, p<0.05). In all 193 patients, the disease recurrence was found in 71 (37%), whereas 122 (63%) were disease-free. The diagnostic accuracy of PET/CT in all 193 patients was 74%. Among patients with normal CA15.3 value (n=108), 50 showed positive PET/CT; 24 out of these latter 50 patients (48%) had recurrence of disease. The combination of the highest quartile of CA15.3 (value>45 UI/ml) and FDG PET/CT determined high sensitivity and accuracy (92% and 82%, respectively) but a low specificity (50%) for restaging BC patients. The highest specificity (~ 70%) was found when PET/CT and 2nd quartile of CA15.3 (value: 12.95-25) were associated. No correlation between CA15.3 values and SUVmax was found (p=0.489); whereas a trend in increase of the CA15.3 value and SUVmax in the presence of visceral and no-visceral site of disease (22.4±16.2, 64.9±108 and 6.4±4.2, 8.2±5.1, respectively) was identified. CONCLUSIONS: The value of CA15.3 and PET/CT findings are consistently complementary. About 25% of BC patients with a negative CA15.3 value had a positive PET/CT and disease relapse. SUVmax and CA15.3 values are not correlated.

FDG avidity at PET/CT during adjuvant hormonal therapy in patients with breast cancer.

BACKGROUND: We aim to retrospectively evaluate the impact of hormone therapy (HT) on FDG avidity of metastatic lesions in patients with breast cancer (BC) undergoing PET/CT. PATIENTS AND METHODS: Three hundred eight patients with BC were scanned with PET/CT at 2 Italian institutions (mean time from diagnosis 4 yrs, range: 1-24 yrs). Main indications for PET/CT were elevation of tumor markers (34.4%) and clinical or radiological suspicion of relapse (65.6%). The diagnostic accuracy of FDG PET/CT was computed according to the standard method. Student t test was used to assess the mean differences between the study groups, whereas categorical data were compared with chi-square test. Significance was set at P <0.05. RESULTS: Two hundred sixty-four patients with positive estrogen receptor and who had received adjuvant HT were included in the analysis. At the time of PET/CT scan, HT was ongoing in 176 patients (66.7%) and 88 (33.3%) had completed adjuvant HT. Ninety-eight (55.7%) patients on HT and 59 (67%) off HT had a positive PET/CT; therefore, the scan resulted negative in the remaining 107 patients, 78 and 29 on and off HT, 44.3% and 33%, respectively (P < 0.001). At a median follow-up of 7 months (range 1-48 mos), disease recurrence was confirmed in either clinical or radiological examinations in 126 (47.7%) patients; 72 (40.9%) versus 54 (61.4%) patients on and off HT, respectively (P < 0.005). True-positive PET/CT results were found in 82% and 91% of patients on and off HT, respectively, whereas it failed to identify disease relapse in 13 (18%) and 5 (9%) patients on and off HT, respectively. CONCLUSIONS: In our series, FDG PET/CT shows a similar diagnostic accuracy in detecting disease relapse between patients with BC on adjuvant HT versus those who have completed therapy. These preliminary results suggest that the glucose metabolism is not altered by hormonal suppression at the time of the scan.

Choline PET or PET/CT and biochemical relapse of prostate cancer: a systematic review and meta-analysis.

AIM: The increase of prostate-specific antigen (PSA) after radical retropubic prostatectomy (RP) or external beam radiotherapy (EBRT) is the most sensitive tool for detecting prostate cancer (PCa) recurrence, although this measure cannot distinguish between local, regional, or distant recurrence. The aim of this meta-analysis was to evaluate the diagnostic performance of 18F-choline and 11C-choline PET or PET/CT in detection of locoregional or distant metastases in PCa. MATERIALS AND METHODS: Medline, Web of Knowledge, and Google Scholar search was carried out in order to select English-language articles dealing with diagnostic performance of both 18F-choline and 11C-choline PET for the detection of PCa recurrence after RP or EBRT. Articles were included only if absolute numbers of true-positive, true-negative, false-positive, and false-negative test results were available or derivable from the text and regarded local, lymph node, and distant metastases. Reviews, clinical reports, and editorial articles were excluded. All complete studies were re-analyzed thus performing a quantitative analysis. RESULTS: From the years 2000 to 2012, we found 53 complete articles that critically evaluated the role of choline PET in restaging patients with PCa recurrence. The meta-analysis was carried out and dealt with 19 selected studies (12 studies for all sites of disease, 3 for lymph node metastases, and 4 for local recurrence), with a total of 1555 patients. The meta-analysis provided a pooled sensitivity of 85.6% (95% CI: 82.9%-88.1%) and pooled specificity of 92.6% (95% CI: 90.1%-94.6%) for all sites of disease (prostatic fossa, lymph nodes, and bone), a pooled sensitivity of 75.4% (95% CI: 66.9%-82.6%) and pooled specificity of 82% (95% CI: 68.6%-91.4%) for prostatic fossa recurrence, and a pooled sensitivity of 100% (95% CI: 90.5%-100%) and pooled specificity of 81.8% (95% CI: 48.2%-97.7%) for lymph node metastases. The heterogeneity ranged between 0.00% and 88.6%. The diagnostic odds ratios were 62.123 (95% CI: 24.783-155.72), 5.869 (95% CI: 1.818-18.946), and 138.57 (95% CI: 11.27-1703.8), respectively, for all sites of disease, local recurrence, and lymph node disease. CONCLUSIONS: Choline PET and PET/CT represent high sensitivity and specificity techniques for the detection of locoregional and distant metastases in PCa patients with recurrence of disease. Moreover, a high diagnostic odds ratio was found for the identification of lymph node disease in patients with biochemical recurrence of PCa.

Risk stratification and prognostic assessment by myocardial perfusion-gated SPECT in patients with left bundle-branch block and low-intermediate cardiac risk.

OBJECTIVE: In high-risk patients with left bundle-branch block (LBBB), functional but not perfusion parameters yield incremental prognostic information. The aim of our study was to evaluate the prognostic value of gated single photon emission computed tomography (SPECT) in low-intermediate risk LBBB patients. METHODS: One hundred seventy-six subjects underwent stress-rest dual-day protocol 99mTc sestamibi-gated SPECT and were dichotomized in two groups: without LBBB (Group 1, n = 86) and with LBBB (Group 2, n = 90). Patients were followed for 32 ± 18 months. Cox regression multivariate analysis was used to determine which variable was the best predictor of cardiac event. Event-free survival curves were computed by Kaplan-Meier method. RESULTS: Myocardial perfusion scintigraphy was abnormal in 32 and 60 patients for Groups 1 and 2, respectively (37 vs. 67 %, p < 0.001). In Groups 1 and 2, the mean summed stress score (SSS) was 3.7 ± 5.6 versus 6.7 ± 6.4, while the mean summed difference score (SDS) was 1.6 ± 2.5 versus 2.7 ± 3.3 (both p < 0.005); therefore 34 % of patients in Group 1 and 53 % of those in Group 2 presented myocardial ischemia. All functional parameters were significantly different between the two subsets (all p < 0.005). Follow-up was completed in 161 patients (92 %); 10 events occurred in Group 1 and 20 in Group 2 (14 vs. 25 %). The event-free survival was significantly higher in patients with normal than in those with abnormal scan (85 vs. 63 %, p < 0.005); moreover, the prognosis of patients with LBBB was significantly worse. At multivariate analysis, SDS was found to be the only independent predictor of cardiac events both in all patients and in LBBB population (HR 3.08, and HR 4.99, p < 0.05). CONCLUSIONS: This is the first study to assess the prognostic value of gated SPECT in patients with LBBB and low-intermediate cardiac risk. Both perfusion and functional data obtained by gated SPECT are different between patients with and without LBBB. However, SDS is the only predictor of events. Thus, the amount of reversible ischemia at gated SPECT has a discriminative power in stratifying the cardiac risk of LBBB population.

Prognostic value of myocardial perfusion scintigraphy in elderly patients with hypertension: a 10-year follow-up analysis.

PURPOSE: The aim of the study was to assess the role of myocardial perfusion scintigraphy (MPS) in the prediction of future cardiac events in elderly hypertensive patients and to investigate if its prognostic value is maintained during a 10-year follow-up period. METHODS: A total of 229 consecutive patients ≥ 65 years old (range 65-88 years) with arterial hypertension, who were referred to our institution for stress/rest (99m)Tc-sestamibi MPS between January 2000 and November 2001, were followed up for 10-12 years. Cardiac death, myocardial infarction and a coronary revascularization procedure were considered as events. Survival curves were computed by the Kaplan-Meier method. A stepwise Cox proportional hazards analysis was used to identify predictors of events. RESULTS: Follow-up was completed in 221 (96.5 %) patients; 26 patients experienced cardiac death, 29 myocardial infarction and 51 coronary revascularization. Annual event rates for cardiac death, cardiac death/myocardial infarction and cardiac death/myocardial infarction/coronary revascularization were, respectively, 0, 0.2 and 0.4 % for patients with a normal scan and 1.5, 3.0 and 5.3 % after an abnormal MPS. Event-free survival was significantly different according to extent and severity of perfusion defects (all p < 0.01). An increase in global chi-square in predicting cardiac events occurred when MPS data were added to pre-scan information (from 47.28 to 88.87; p < 0.001). CONCLUSION: MPS provides incremental prognostic information for the prediction of cardiac events in elderly patients with hypertension. Subjects with a normal scan have an excellent 10-year outcome, and the risk of experiencing a cardiac event increases with extension and severity of stress perfusion defect.

Diagnostic and prognostic value of gated myocardial perfusion single-photon emission computed tomography in low-risk patients with left bundle-branch block.

BACKGROUND: The abnormal left ventricular activation pattern in patients with a left bundle-branch block (LBBB) frequently induces myocardial perfusion defects, decreasing the specificity of noninvasive coronary-risk stratification with stress testing. We assessed the diagnostic and prognostic impact of gated single-photon emission computed tomography (SPECT) in low-risk patients with LBBB. METHODS: A total of 114 patients underwent dual-day protocol Tc-99m sestamibi gated SPECT and were divided into two subsets: without LBBB (group 1, n = 57) and with LBBB (group 2, n = 57). Sixty-eight (60%) patients had negative coronary angiography and 46 (40%) were at a low risk for coronary artery disease. The variables incorporating the extent and severity of perfusion defects were calculated: summed stress score, summed rest score and summed difference score, end-diastolic volume (EDV), end-systolic volume (ESV), and left ventricular ejection fraction. The mean variations in EDV and ESV were computed as follows: rest volume-poststress volume. Cardiac events were classified as major and minor. RESULTS: Gated SPECT was positive in eight (14%) patients of group 1 and 33 (58%) patients of group 2 (P<0.001). The summed stress score was significantly higher in group 2 than in group 1 (4.7 ± 4.8 vs. 0.9 ± 1.8, P<0.001); similarly, EDV and ESV were significantly higher in LBBB patients (P<0.05 in both). The mean variation in EDV was -2.21 ml for group 1 and 1.32 ml for group 2 (P<0.05). After a mean follow-up period of 32 ± 19 months, cardiac events occurred in 22 (23%) patients, six of group 1 and 16 of group 2 (12 vs. 35%, P<0.01). CONCLUSION: Functional and perfusion parameters obtained by gated SPECT are different between patients with and without LBBB. In LBBB patients, the decrease in EDV between rest and poststress could be considered an early marker of diastolic dysfunction that might anticipate left ventricular ejection fraction reduction and may have an impact on prognosis.

PET/CT imaging in gynecologic malignancies: a critical overview of its clinical impact and our retrospective single center analysis.

Gynecologic cancers represent a major global healthcare problem since they are associated with a significant mortality and morbidity. Over the last decade, considerable efforts have been spent in the development and optimization of novel diagnostic modalities to achieve an early diagnosis, aid in choosing appropriate treatment, improving long term surveillance, with the ultimate goal of increasing survival of gynecologic cancer patients. A growing body of evidence defines PET/CT as one of the most powerful tools for tumor, nodal and metastasis (TNM) cancer staging both in pre-treatment and in post treatment follow-up settings. At any phase of cancer evaluation, detection of metastasis represents one of the most critical impediments to the cure of tumor; traditional diagnostic imaging modalities, such as computed tomography (CT), are frequently found to inadequately stage the tumor, based on subsequent outcomes. As a consequence, patients may undergo pointless surgery for disease that could be treated with local medical therapies. In the setting of restaging, the ability to describe primary lesion, lymph nodes, possible metastases to peritoneum, bone, liver, lungs and brain renders PET/CT a potential alternative for a series of tests, including bone scanning, MRI or ultrasound, diagnostic CT, lymph node surgical sampling, that need to be used in combination in order to obtain a level of clinical confidence. In this review, we describe, the theoretical advantage and prognostic implications of PET/CT in the management of gynecologic cancer patients.