18F-FDG PET/CT for invasive fungal infection in immunocompromised patients.

BACKGROUND: Opportunistic invasive fungal infections (IFIs) comprise a heterogeneous spectrum of pathogens, whose early diagnosis remains challenging. Candida spp. and Aspergillus spp, the most frequent pathogens in immunocompromised patients, frequently affect lungs, liver, bone and skin. AIM: To evaluate the impact of 18F-FDG PET/CT in the management of immunocompromised patients with IFI. DESIGN: A single-center retrospective study included 51 immunocompromised patients with IFI diagnosis undergoing 83 18F-FDG PET/CTs. METHODS: Twenty-nine 18F-FDG PET/CTs were performed for primary work-up in 29 treatment-naïve patients. Fifty-four PET/CTs were performed during follow-up to confirm IFI suspicion in 22 patients who had anti-fungal drug therapy before PET/CT. When available, histological and/or microbiological criteria were used to assess IFI diagnosis. RESULTS: Aspergillus spp. and Candida spp. were the most frequent microorganisms responsible for IFI in our population. 18F-FDG PET/CT sensitivity, specificity, positive and negative predictive values, and global accuracy were 93%, 81%, 95%, 72% and 90%, respectively. 18F-FDG PET/CT influenced the diagnostic work-up at primary staging in 16/29 patients (55%) by assessing the extent of infection and targeting the diagnostic procedure. 18F-FDG PET/CT results during treatment induced anti-fungal drugs dosage increase and/or new drugs addition in 8/54 cases (15%) and contributed to the reduction of anti-fungal drugs dosage or treatment withdraws in 17 cases (31%). CONCLUSIONS: We recommend the utilization of 18F-FDG PET/CT to improve the primary staging work-up of immunocompromised patients with IFI and to assess treatment effectiveness or disease relapse. Both 18F-FDG PET/CT and conventional imaging should be integrated into a well-defined imaging diagnostic algorithm considering the clinical context and both strengths and limitations of each diagnostic modality.

Imaging sphenoid diseases.

In this review we provide comprehensive analysis of the imaging features of diseases affecting the sphenoid sinus, including a large and heterogeneous spectrum of pathologies such as sinusitis, pseudotumours, bony pathologies, and tumours. Clinical symptomatology related to sphenoid pathologies is often non-specific and patient clinical examination and endoscopic investigations are not definitive; thus, radiological imaging is mandatory for diagnosis. Strengths and limitations of both morphological and functional imaging methods such as computed tomography (CT), magnetic resonance imaging (MRI), and combined positron-emission tomography/computed tomography (PET/CT) have been considered and integrated into a well-defined clinical context in order to recognise specific imaging features and to underline their clinical relevance for an early and accurate diagnosis. An overview of several sphenoid conditions is herein selected with a didactic objective including both common and less common diseases.

Erratum to: One-level step section histological analysis is insufficient to confirm complete pathological response after neoadjuvant chemoradiation for rectal cancer.

Unfortunately, one of the author name was wrongly published in the original publication. The complete correct name should read as follows "Beatriz Camargo Azevedo". The original article was updated.

One-level step section histological analysis is insufficient to confirm complete pathological response after neoadjuvant chemoradiation for rectal cancer.

BACKGROUND: Neoadjuvant chemoradiation therapy (nCRT) for rectal cancer may lead to cure. As we currently lack reliable methods to clinically confirm the absence of disease, some patients undergo radical resection and have pathological complete response (pCR) still undergo surgery. Furthermore, it is uncertain if conventional one-level histopathological analysis is accurate enough to determine complete response. Confirming pCR is essential to determine the prognosis and to consider the patient's inclusion in trials of adjuvant therapy. The aim of this study was to determine whether the current 1-level approach is sufficient to confirm pCR. METHODS: Four hundred and thirty-five patients with rectal cancer who received nCRT followed by radical resection were analyzed. All cases identified as pCR by 1-level step section histological evaluation were reassessed with 3-level step sections and immunohistochemical analysis to verify the presence of residual disease. RESULTS: Out of 435 patients, 75 (17.2%) were staged as ypT0. Of these, 6 had lymph node involvement and 1 had distant metastasis, leaving 68 (15.6%) who had pCR. After the additional step sections, residual tumor was detected in 12 (17.6%) of these 68. The final pCR rate was 12.9%. Distant recurrence was detected in 7.1% of real-pCR patients compared to 16.7% in the false-pCR group (p = 0.291). Sensitivity of clinical assessment for detecting pCR was 35.7%, and the accuracy of 1-section histological evaluation to identify pCR was 82.4%. CONCLUSIONS: Histopathological analysis with 1-level step section is insufficient to determine complete tumor eradication. The 3-level sections methodology revealed residual tumor cells in patients initially classified as ypT0. Further studies with larger sample size are required to verify the clinical relevance of these residual tumor cells. Caution should continue to be applied to watch and wait strategies following nCRT.

Metabolomics approaches in pancreatic adenocarcinoma: tumor metabolism profiling predicts clinical outcome of patients.

BACKGROUND: Pancreatic adenocarcinomas (PAs) have very poor prognoses even when surgery is possible. Currently, there are no tissular biomarkers to predict long-term survival in patients with PA. The aims of this study were to (1) describe the metabolome of pancreatic parenchyma (PP) and PA, (2) determine the impact of neoadjuvant chemotherapy on PP and PA, and (3) find tissue metabolic biomarkers associated with long-term survivors, using metabolomics analysis. METHODS: 1H high-resolution magic angle spinning (HRMAS) nuclear magnetic resonance (NMR) spectroscopy using intact tissues was applied to analyze metabolites in PP tissue samples (n = 17) and intact tumor samples (n = 106), obtained from 106 patients undergoing surgical resection for PA. RESULTS: An orthogonal partial least square-discriminant analysis (OPLS-DA) showed a clear distinction between PP and PA. Higher concentrations of myo-inositol and glycerol were shown in PP, whereas higher levels of glucose, ascorbate, ethanolamine, lactate, and taurine were revealed in PA. Among those metabolites, one of them was particularly obvious in the distinction between long-term and short-term survivors. A high ethanolamine level was associated with worse survival. The impact of neoadjuvant chemotherapy was higher on PA than on PP. CONCLUSIONS: This study shows that HRMAS NMR spectroscopy using intact tissue provides important and solid information in the characterization of PA. Metabolomics profiling can also predict long-term survival: the assessment of ethanolamine concentration can be clinically relevant as a single metabolic biomarker. This information can be obtained in 20 min, during surgery, to distinguish long-term from short-term survival.

[A rare case of bone metastasis from gastro-intestinal stromal tumour: place of radiotherapy]. / À partir d'un cas rare de métastases osseuses d'une tumeur stromale gastro-intestinale : intérêt de la radiothérapie.

Gastro-intestinal stromal tumours are the most common mesenchymal neoplasms of the gastrointestinal tract. Their usual metastatic sites are the liver and the peritoneum, but gastro-intestinal stromal tumours rarely metastasize to the bones. We report the case of a 56-year-old male presenting with bone lesions six years after initial surgical resection. We discuss through this paper the possibilities of management of these lesions and the place of radiotherapy.

Interest of [18F]FDG PET/CT for treatment efficacy assessment in aggressive phenotype of sarcoidosis with special emphasis on sinonasal involvement.

AIM: The aim of this paper was to evaluate the clinical usefulness of [18F]FDG PET/CT for treatment efficacy assessment in patients with severe multisystemic phenotype of sarcoidosis with special emphasis on sinonasal involvement. METHODS: Thirteen patients with biopsy-proven sinonasal sarcoidosis (SNS) who underwent two [18F]FDG-PET/CT were selected. PET/CT results were correlated with nasal endoscopy, biology and conventional imaging techniques (CT, MRI). Four and nine patients underwent first PET/CT before beginning treatment and during CS therapy, respectively. On the other hand, ten and three patients underwent second PET/CT during CS and after treatment withdrawal, respectively. The mean duration of clinical and endoscopic follow-up after the second scintigraphic examination was 51 months. RESULTS: Eleven out of 13 selected patients presented with pathological nasal endoscopy at inclusion. Among them: 1) 5 showed persistent endoscopic abnormalities at follow-up evaluation. Radiological and PET/CT imaging was consistent with these results in 4 and 5 patients, respectively; 2) 2 showed a complete endoscopic, radiologic and PET/CT normalization after CS treatment; 3) 4 showed important alterations of the sinonasal structures preventing a definitive diagnosis by endoscopic and radiologic techniques. PET/CT suggested a residual inflammatory disease in two cases. No scintigraphic abnormalities were detected in the other 2 patients. Scintigraphic results were finally confirmed by a mean follow-up of 51 months. No pathologic sinonasal [18F]FDG uptake was observed in the remaining 2/13 patients who showed doubtful endoscopic and radiologic results during primary evaluation. The stability of endoscopic results without clinical and biological evolution was observed during 39 and 38 months of follow-up after the second PET/CT. CONCLUSION: [18F]FDG PET/CT seems to be a valuable non-invasive imaging technique able to evaluate the response to treatment in aggressive SNS, identifying persistent active disease even in those patients with destructive sinonasal aftereffects and/or with atypical therapeutic evolution. Finally, [18F]FDG PET/CT could be clinically useful to modulate CS treatment eventually integrating immunosuppressive drugs.

[Morpho-functional imaging in a patient with hyperparathyroidism and multifocal maxillary brown tumor]. / Imagerie morphologique et fonctionnelle des tumeurs brunes. À propos d'un cas de localisation maxillo-mandibulaire.

INTRODUCTION: Brown tumors are uncommon osteolytic lesions directly related to the increased osteoclastic activity due to hyperparathyroidism. CASE REPORT: A 37-year-old woman presented with hypercalcemia related to primary hyperparathyroidism. Multiple and bilateral maxillary osteolytic lesions showing intense fluorodesoxyglucose (FDG) uptake were noted in a positron emission tomography computed tomography (PET-CT). Diagnosis of maxillary brown tumors was discussed and confirmed by both orthopantomogram and magnetic resonance imaging. Left inferior parathyroid adenoma was detected by both cervical ultrasonography and parathyroid scintigraphy, and then surgically treated with consequent improvement of hyperparathyroidism. CONCLUSION: Our case emphasizes the necessity of a multidisciplinary diagnostic approach to optimize the interpretation of the available imaging, especially in unusual and unrecognized pathology as brown tumors.

[Sarcoidosis of the upper respiratory tract]. / Sarcoïdose des voies aérodigestives supérieures.

INTRODUCTION: Sarcoidosis is a non-caseating granulomatous disease of unknown origin, principally affecting the respiratory tract. BACKGROUND: Sarcoidosis of the upper respiratory tract (SURT) includes sino-nasal sarcoidosis (SNS) and pharyngo-laryngeal sarcoidosis (PLS). SURT may be isolated or, more often, part of multisystemic sarcoidosis. Its clinical symptomatology is protean and non specific. The natural history, course and prognosis are poorly understood and unpredictable. The treatment has not yet been standardised and the long-term therapeutic results are often disappointing. VIEWPOINT: In this work, we try to make a synthesis of our experience and publications, and the data in the existing international literature, to improve the diagnosis and therapeutic management of SURT. The usefulness of both morphological and functional imaging techniques, in particular 18F-fluorodeoxyglucose positron emission tomography (18F-FDG PET/CT), is evaluated for use in the management of the severe phenotypes of sarcoidosis such as SURT. CONCLUSIONS: Even if guided biopsy remains necessary for confirmation of SURT, medical imaging plays an important role in the management of this disease: CT imaging allows the description of SNS and classification into two stages that correlate well with the severity, reversibility and course of the sino-nasal involvement, 18F-FDG PET/CT, providing a complete morpho-functional mapping of active inflammatory lesions, could be a useful technique in patients with biopsy-proven SURT, for both diagnosis and follow up of medical treatment.

Recurrent form of neurogenic stunned myocardium: is myocardial adrenergic receptor distribution a dynamic process?

Neurogenic stunned myocardium mediated by stress-induced catecholamine acute release is considered as the central causative mechanism of transient left ventricular dysfunction syndrome (TVLDS). Interindividual differences in both LV ß-adrenergic receptor density and sympathetic innervation were proposed to explain the atypical forms of TVLDS. Whether this distribution is independent of age or may vary during ageing still remains unclear. We report a recurrent form of TLVDS characterized by two different patterns. Whilst myocardial receptor distribution or sympathetic innervation appears to follow a dynamic process, the precise determinants of these variations remain largely unknown.

Value of (18)F-FDG-PET/CT in patients with fever of unknown origin and unexplained prolonged inflammatory syndrome: a single centre analysis experience.

OBJECTIVE: The aim of our study was to evaluate the diagnostic contribution of (18)F-fluoro-deoxyglucose ((18)F-FDG)-positron emission tomography (PET)/computed tomography (CT) in patients with fever of unknown origin (FUO) or unexplained prolonged inflammatory syndrome (UPIS) in real life. PATIENTS AND METHODS: We performed a retrospective study including 14 patients with FUO or UPIS hospitalised in our institution (Strasbourg University Hospital, France) between January 2005 and July 2006. (18)F-FDG-PET/CT was considered helpful when abnormal results allowed an accurate diagnosis. RESULTS: (18)F-FDG-PET/CT was helpful in half the patients (7/14) for final diagnosis. A diagnosis was reached in 87.5% of the patients (7/8) with an abnormal (18)F-FDG-PET/CT but only in 50% of the patients (3/6) with a normal (18)F-FDG-PET/CT. Conventional chest and abdominal CT was performed in 13 patients before ordering (18)F-FDG-PET/CT. We considered that (18)F-FDG-PET/CT was essential to establish the final diagnosis in only 23% of the patients (3/13) since neither chest nor abdominal CT identified abnormalities consistent with the final diagnosis. However, among the three patients, two were diagnosed with large vessel vasculitis and one patient with local prosthetic infection. CONCLUSIONS: Our study supports the potential interest of (18)F-FDG-PET/CT in the diagnostic workup of FUO and UPIS as it helped establish a fine diagnosis in half of the cases. However, (18)F-FDG-PET/CT appeared to be essential to the final diagnosis in only 23% of the cases. In our opinion, this protocol should be performed as a second level test, especially when conventional CT is normal or is unable to discriminate between active and silent lesions.

Imaging in sinonasal sarcoidosis: CT, MRI, 67Gallium scintigraphy and 18F-FDG PET/CT features.

OBJECTIVES: Attempt to describe and analyse the radiological and nuclear medicine patterns of sinonasal sarcoidosis (SNS) still poorly reported in the literature. MATERIAL AND METHODS: Retrospective single institution study of 22 consecutive patients with symptomatic biopsy-proven SNS to evaluate the interest of CT, MRI, (67)Ga scintigraphy and (18)F-FDG PET/CT for diagnosis and therapeutic follow-up. RESULTS: Nodules of the septum and turbinates are the most suggestive CT and MRI features. Other CT features such as sinusal filling, mucosal thickening, osteosclerosis or destructive sinonasal lesions are not specific and depend on clinical context and evolutive stage of SNS. (18)F-FDG PET/CT provides complete morphofunctional mapping of active inflammatory sites related to sarcoidosis with a better diagnostic sensitivity (100%) compared to (67)Gallium scintigraphy (75%). The changes in (18)F-FDG uptake intensity could reflect the efficacy of treatment. CONCLUSION: SNS is an uncommon and probably underdiagnosed phenotype of sarcoidosis. Even if guided biopsy remains necessary for SNS confirmation, medical imaging plays an important role in diagnosis and therapeutic follow-up. CT features with nodules of the septum and/or turbinates are suggestive of SNS contrary to other nonspecific CT findings. CT imaging is directly related severity, reversibility and course of SNS and provide an original radiological staging system in order to predict patient clinical outcome. PET/CT may be used for diagnosis assessement but also to monitor treatment response in a given clinical context, in a patient with histopathologically-proven SNS. Prospective and long term studies are necessary to validate these preliminary results.

Tomographic evaluation of [131I] 6beta-iodomethyl-norcholesterol standardised uptake trend in clinically silent monolateral and bilateral adrenocortical incidentalomas.

AIM: The aim of this study was three-fold: 1) to quantify [131I]-6beta-iodomethyl-norcholesterol ([131I]-NP-59) adrenal uptake trend in patients with incidentalomas, 2) to identify a specific uptake trend (TREND) capable of characterising pre-clinical Cushing syndrome (PC-CS) patients, 3) to assess the clinical availability of TREND as a prognostic factor of late clinical outcome in a cohort of patients with bilateral adrenal adenomas. METHODS: Fifty-seven consecutive patients were examined using three-head SPECT at 24, 48, 72 hours following intravenous injection of [131I ]-NP-59. On the basis of the absence or presence of hormonal abnormalities, the selected population was classified as GR1 or GR2, respectively. Adrenal glands were classified into 4 groups taking into account both the patient group (GR1, GR2) and the presence (+) or absence (-) of the adenoma (AD) on CT scan. Using ROI technique, adrenal-liver uptake ratio (A/L) was estimated bilaterally at 24, 48 and 72 hours. For each adrenal group, mean [131I]-NP-59 uptake trends were derived. RESULTS: TREND was significantly different between GR1/AD+ and GR2/AD+. Among GR2/AD+ patients, TREND correctly identified PC-CS with a global accuracy of 74%. Two patients with bilateral incidentaloma developed an overt CS. In both patients, TREND correctly identified the hyperfunctioning adrenal, thus permitting an effective sparing adrenalectomy. CONCLUSIONS: TREND seems to be a parameter which closely reflects adrenal physiological behaviour, especially in the case of bilateral adrenal involving. The possibility to quantify even contralateral adrenal uptake as standardised index provides additional useful information about normal adrenal parenchyma and, indirectly, about adenoma functional autonomy.