Role of Cardiovascular Magnetic Resonance in Cardiac Amyloidosis: A Narrative Review.

Amyloidosis is a rare infiltrative condition resulting from the extracellular accumulation of amyloid fibrils at the cardiac level. It can be an acquired condition or due to genetic mutations. With the progression of imaging technologies, a non-invasive diagnosis was proposed. In this study, we discuss the role of CMR in cardiac amyloidosis, focusing on the two most common subtypes (AL and ATTR), waiting for evidence-based guidelines to be published.

Multimodal radionuclide shuntography for device patency: New procedural tips for anuncommon historical technique.

Cerebrospinal fluid (CSF) shunting is an established long-term treatment option for hydrocephalus, and is one of the most commonly performed neurosurgical procedures in western countries.Despite advances in CSF shunt design and management, its failure rates remain high and is most commonly due to obstruction and infection.Cerebrospinal fluidshunt failure diagnosis should be prompt and accurate in establishing timely if its revision is appropriate. Radionuclide shuntography with technetium-99m-diethylenetriaminepetaacetic acid (99mTc-DTPA) is a useful technique for evaluation CSF shunts and management of patients presenting with shunt-related problems, in particular it can avoid unnecessary replacement interventions. Although its execution and interpretation require specific skills, we suggest its execution for the evaluation of device's patency. We here describe the radionuclide shuntography performed with recent hybrid multimodal technologies, with a procedure customized to a complicated patient with hydrocefalus and neoplastic disease. We suggest considering radionuclide shuntography in association with conventional imaging and strongly recommend the additional performance of single photon emission computed tomography/computed tomography (SPECT/CT) because it also provides valuable information to complete the interpretation of planar images.

Durable complete response to PET-CT driven stereotactic radiation therapy plus pembrolizumab for pleomorphic Pancoast cancer: Case report and literature review.

PET-driven SBRT plus pembrolizumab as first-line therapy against pleomorphic Pancoast cancer appears beneficial, probably due to high equivalent doses of SBRT on photopenic necrotic core and synergic immune system stimulation of immunoradiotherapy.

Role of 18F-FCH PET/CT in Detecting Recurrences of Prostate Cancer After Curative Treatments.

Objectives: To evaluate the role of 18F-fluorocholine (18F-FCH) positron emission tomography/computed tomography (PET/CT) in prostate cancer (PC) patients with biochemical recurrence who were submitted to different curative treatments. Methods: Seventy-five patients with PC who underwent 18F-FCH PET/CT for biochemical recurrence were retrospectively analyzed to distinguish patients who were submitted only to prostatectomy (PR group), only to radiotherapy (RT) on prostate with curative intent (RT group), and to both (PR + RT group). Correlations between 18F-FCH PET/CT and outcome and between prostate-specific antigen (PSA) values and sites and the number of metastases were analyzed. The performance of 18F-FCH PET/CT in relation to the PSA value and of maximum standardized uptake value (SUVmax) value in relation to patient outcome were assessed by receiver operating characteristic (ROC) curves. Results: 18F-FCH PET/CT relapses mostly involved lymph nodes, bones, and prostate bed. K-cohen test showed moderate agreement with the outcome in the whole population and in the PR group, whereas in the RT group it was perfect and in PR + RT fair. A statistically significant difference in PSA values was observed in the presence of lymph node metastases and with multiple metastases. ROC curves showed PSA cut-off values of 1.96 ng/dL, 1.95, 1.81, and 2.96, respectively, in the whole population, PR, RT and PR + RT group. SUVmax cut-off values of 3.75, 3.45, and 4.7 were described in the whole population, PR group, and PR + RT group. Conclusion: The study confirms that 18F-FCH PET/CT is still valid in PC patients with suspected biochemical recurrence. Therefore, we can affirm that it still makes sense to perform it both with high PSA values and with lower values when prostate-specific membrane antigen tracers are not available.

The Role of the 18F-FDG PET/CT in the Management of Patients Suspected of Cardiac Implantable Electronic Devices' Infection.

Background: Infection of Cardiac Implantable Electronic Devices (CIEDI) is a real public health problem. The main aim of this study was to determine the diagnostic performance of 18F-FDG PET/CT in the diagnosis of CIEDI. Methods: A total of 48 patients, who performed 18F-FDG PET/CT for the clinical suspicion of CIEDI were retrospectively analyzed; all patients were provided with a model with procedural recommendations before the exam. Sensitivity (Se), specificity (Sp), positive predictive value (PPV), negative predictive value (NPV) and diagnostic accuracy (DA) of 18F-FDG PET/CT were calculated; the reproducibility of qualitative analysis was assessed with Cohen's κ test. The semi-quantitative parameters (SUVmax, SQR and TBR) were evaluated in CIEDI+ and CIEDI- patients using the Student' t-test; ROC curves were elaborated to detect cut-off values. The trend of image quality with regards to procedural recommendation adherence was evaluated. Results: Se, Sp, PPV, NPV and DA were respectively 96.2%, 81.8%, 86.2%, 94.7% and 89.6%. The reproducibility of qualitative analysis was excellent (K = 0.89). Semiquantitative parameters resulted statistically different in CIEDI+ and CIEDI- patients. Cut-off values were SUVmax = 2.625, SQR = 3.766 and TBR = 1.29. Trend curves showed increasing image quality due to adherence to procedural recommendations. Conclusions:18F-FDG-PET/CT is a valid tool in the management of patients suspected of CIEDI and adherence to procedural recommendations improves its image quality.

Applications of new radiological scores: the Node-rads in colon cancer staging.

PURPOSE: The study focuses on the evaluation of the new Node Reporting and Data System 1.0 (Node-rads) scoring accuracy in the assessment of metastatic lymph nodes (LN) in patients with colon carcinoma. MATERIAL AND METHODS: From April 2021 to May 2022, retrospective chart reviews were performed on 67 preoperative CT (Computed Tomography) of patients undergoing excisional surgery for colon cancer at the Polyclinic of Bari, Italy. Primary endpoints were to assess lymph node size and configuration to express the likelihood of a metastatic site adopting the Node-rads score system, whose categories of risk are defined from 1 (very low) to 5 (very high). The nodal postsurgical histological evaluation was the gold standard. The relationship between Node-rads score, LN size, configuration criteria (texture, border and shape) and the presence of histological metastases was statistically evaluated. RESULTS: All surgical specimens examined had correlation with Node-rads score. They were significantly more likely to present nodes micrometastasis those patients with (a) spherical LN shape (82.8%), (b) with lymph node necrosis (100%), (c) irregular borders (87%) and (d) the LN short axis more than 10 mm (61.9%). CONCLUSIONS: Our experience highlights how the Node-rads system proposes an intuitive and effective definition of criteria to standardize the lymph node radiological reports in colon cancer disease. Further studies are needed to streamline the classification of the nodal and peripheral LN in all the oncological imaging.

Volumetric Modulated Arc Radiotherapy Efficacy After Double Recurrences of Cardiac Sarcoma.

BACKGROUND: Volumetric Modulated Arc Therapy (VMAT) has recently become a pivotal treatment of oncological diseases due to the high-precise delineation of target volume contours with sparing organs at risk. This procedure requires a high level of experience and precision and is achievable only with advanced diagnostic support. Magnetic Resonance (MRI) and multimodality imaging, such as 18F-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT), are fundamental in implementing radiotherapy guidance. CASE REPORT: A 54-year-old patient underwent surgery twice to remove primitive and recurrent cardiac sarcomas of the left atrium. The appearance of a further relapse required radiotherapy as the only possible treatment. Cardiac MRI was then performed to define the degree of atrial mass invasiveness, and 18F-FDG PET/CT was performed to assess the activity and staging of the cardiac lesion. It revealed high 18F-FDG uptake not only in the left atrium lesion but also in a pancreatic lesion with elevated 18F-FDG uptake (SUV max 5.5). The pancreatic biopsy performed a few days later confirmed the myxoid sarcoma metastasis, and surgeons defined it as not operable due to the patient's clinical condition. Radiotherapy was then urgently performed with the VMAT technique. After 40 days, a cardiac MRI showed a reduction in the cardiac mass with improvement in the respiratory and cardiac symptoms; then, the patient started chemotherapy. One year after diagnosis, the patient is still alive and is receiving chemotherapy with gemcitabine and docetaxel with good compliance. CONCLUSION: The correct and timely management of a patient suffering from a rare oncological disease has allowed a better and longer survival, especially due to VMAT, a sophisticated procedure that requires high expertise. This case also demonstrates that cardiac MRI and whole-body imaging procedures, such as 18FDG PET/CT, can be useful in staging patients with oncological diseases.

Lympho-SPECT/CT as a Key Tool in the Management of a Patient with Chylous Ascites.

Chylous ascites is a rare form of ascites usually associated with cirrhosis, abdominal malignancies, surgeries or infections. We presented a case of chylous ascites after robotic laparoscopic prostatectomy (PLDN-RALP), in which the correct diagnosis was achieved by SPECT/CT lymphoscintigraphy. A 72-year-old male developed chylous ascites after surgery and underwent lymphoscintigraphy with radiolabeled albumin nanocolloids for the supplementary study of the lymph flow and to detect a possible site of leakage. The scintigraphic imaging demonstrated the abdominal effusion and lymph stasis in the left iliac region. The combination of planar imaging with SPECT/CT can resolve the assessment of chylous disorders.

[18F]FDG PET/CT in head and neck squamous cell carcinoma: a head-to-head between visual point-scales and the added value of multi-modality imaging.

BACKGROUND: Head and neck squamous cell carcinoma (HNSCC) represents the 6th leading cancer worldwide. In most cases, patients present a locally advanced disease at diagnosis and non-surgical curative treatment is considered the standard of care. Nowadays, [18F]FDG PET/CT is a validated tool in post-treatment evaluation, with a high level of evidence. However, to standardize imaging response, several visual scales have been proposed with none of them approved yet. The study's aim is a head-to-head comparison between the diagnostic performance of the Hopkins criteria, the Deauville score, and the new proposed Cuneo score, to establish their prognostic role. Secondly, we investigate the possible value of semiquantitative analysis, evaluating SUVmax and ΔSUVmax of the lymph node with the highest uptake on the restaging PET scan. Moreover, we also considered morphological features using the product of diameters measured on the co-registered CT images to assess the added value of hybrid imaging. METHODS: We performed a retrospective analysis on histologically proven HNSCC patients who underwent baseline and response assessment [18F]FDG PET/CT. Post-treatment scans were reviewed according to Hopkins, Deauville, and Cuneo criteria, assigning a score to the primary tumor site and lymph nodes. A per-patient final score for each scale was chosen, corresponding to the highest score between the two sites. Diagnostic performance was then calculated for each score considering any evidence of locoregional progression in the first 3 months as the gold standard. Survival analysis was performed using the Kaplan-Meier method. SUVmax and its delta, as well as the product of diameters of the lymph node with the highest uptake at post-treatment scan, if present, were calculated. RESULTS: A total of 43 patients were finally included in the study. Sensitivity, specificity, PPV, NPV, and accuracy were 87%, 86%, 76%, 92%, and 86% for the Hopkins score, whereas 93%, 79%, 70%, 96%, and 84% for the Deauville score, respectively. Conversely, the Cuneo score reached the highest specificity and PPV (93% and 78%, respectively) but the lowest sensitivity (47%), NPV (76%), and accuracy (77%). Each scale significantly correlated with PFS and OS. The ROC analysis of the combination of SUVmax and the product of diameters of the highest lymph node on the restaging PET scan reached an AUC of 0.822. The multivariate analysis revealed the Cuneo criteria and the product of diameters as prognostic factors for PFS. CONCLUSIONS: Each visual score statistically correlated with prognosis thus demonstrating the reliability of point-scale criteria in HNSCC. The novel Cuneo score showed the highest specificity, but the lowest sensibility compared to Hopkins and Deauville criteria. Furthermore, the combination of PET data with morphological features could support the evaluation of equivocal cases.

Correlation between Kidney Uptake at [18F]FDG PET/CT and Renal Function.

Different insights into the connection between kidney [18F]fluorodesoxyglucose ([18F]FDG) uptake at positron emission tomography/computed tomography (PET/CT) and renal function have been proposed in the past. The aim of this study was therefore to assess the presence of a correlation between these two parameters. Kidney uptakes were assessed and compared to the creatinine (Cr) values and estimated glomerular filtration rate (EGFR) among different classes of renal functional impairment or kidney status. A total of 339 patients and 385 different PET/CT scans were included in this study. Significant correlations between kidney uptakes and renal function parameters were reported in most of the groups studied, with the exception of patients with Cr < 1.2 mg/dL and subjects with a kidney transplantation. Strong concordance in the assessment of renal parenchymal uptakes between the different readers was reported. To conclude, strong correlations for renal [18F]FDG uptake with Cr levels and the EGFR were reported, with the exception of the group of patients with a Cr value < 1.2 mg/dL and for the group with a kidney transplantation.

[18F]fluciclovine vs. [18F]fluorocholine Positron Emission Tomography/Computed Tomography: A Head-to-Head Comparison for Early Detection of Biochemical Recurrence in Prostate Cancer Patients.

Nowadays, there is still no consensus on the most accurate PET radiopharmaceutical to early detect prostate cancer (PCa) relapse. A tailored radiotracer choice based on a specific patient's profile could ensure prompt disease detection and an improvement in patients management. We aimed to compare the [18F]fluciclovine and [18F]fluorocholine PET/CT detection rate (DR) in PCa patients restaged for early biochemical recurrence (BCR), according to clinical and biochemical features. A cohort of 138 PCa patients with early BCR (mean age: 71 y, range: 50-87 y) were homogeneously randomized 1:1 to a [18F]fluciclovine or a [18F]fluorocholine PET/CT group. The respective PET/CT DR, according to per-patient and per-region analysis, and the impact of the biochemical, clinical, and histological parameters, were compared. The PSA cut-off values predictive of a positive scan were also calculated. Overall, the [18F]fluciclovine PET/CT DR was 64%, significantly higher than the [18F]fluorocholine PET/CT DR of 35% (p = 0.001). Similarly, in the per-region analysis, the [18F]fluciclovine PET/CT DR was 51% in the prostate region, significantly higher compared to 15% of [18F]fluorocholine (p < 0.0001). Furthermore, a statistically significant higher DR in per-patient and per-region (prostate/prostate bed) analysis was observed in the [18F]fluciclovine group for 0.5-1 ng/mL (p = 0.018, p = 0.049) and >1 ng/mL (p = 0.040, p < 0.0001) PSA values. A PSA of 0.45 ng/mL for [18F]fluciclovine and of 0.94 ng/mL for [18F]fluorocholine was identified as the optimal cut-off value in predicting a positive PET/CT scan. Our results demonstrated a better [18F]fluciclovine PET/CT DR compared to [18F]fluorocholine for restaging PCa patients in early BCR, particularly in the detection of locoregional recurrence. The significantly higher [18F]fluciclovine DR for low PSA values (PSA < 1 ng/mL) supports its use in this setting of patients.

[The role of oropharyngoesophageal scintigraphy in the assessment of dysphagia in neurological patients.] / Ruolo dello studio scintigrafico del transito orofaringoesofageo nella valutazione della disfagia nei pazienti affetti da patologia neurologica.

PURPOSE: The aim of this study was to assess the role of oropharingoesophageal scintigraphy (OPES) in the management of neurological patients, investigating the clinical value of semiquantitative analysis. MATERIALS AND METHODS: We enrolled 39 neurological patients clinically evaluated and scored according to the Dysphagia Outcome Severity Scale (DOSS) scale who underwent fibrolaryngoscopic swallowing examination (FEES) and OPES using a 99mTc-nanocolloid-radioblabelled semiliquid bolus. We calculated the following semiquantitative parameters: Oral Transit Time (OTT), Pharyngeal Transit Time (PTT), Esophageal Transit Time (ETT), Retention Index (RI), and Esophageal Emptying Rate (EER10s). Differences in OPES semiquantitative parameters between patients classified according to the DOSS scale were performed using the nonparametric Mann-Whitney U test. Optimal semiquantitative parameters cut-off values that correlated with DOSS classification were investigated with ROC curves. The agreement between OPES, FEES and DOSS results was measured using Cohen's Kappa test (K). RESULTS: A significantly higher OTT (p=0.028), PTT (p=0.011) and ETT (p=0.030) and lower EER10s (p=0.016) values were identified. Moderate agreement resulted between OPES and DOSS results (k=0.429, 95%CI: 0.143-0.715, p=0.002). CONCLUSIONS: Our study revealed a significant correlation between clinical dysphagia graded using DOSS scale and semiquantitative parameters obtained by OPES evaluation. Despite reliable and reproducible OPES results, allowing an adequate study also of the esophageal phase, nowadays scintigraphic study remains an underestimated method to be considered in the diagnosis of dysphagia and related complications.

Lesion-to-Liver SUVmax Ratio to Improve the Prognostic Value of the End of Treatment PET/CT in Diffuse Large B-Cell Lymphoma.

BACKGROUND: Diffuse large B-cell lymphoma (DLBCL) is the most common non-Hodgkin lymphoma worldwide. After first-line therapy, 30-40% of patients relapse or experiment with refractory disease. 18F-FDG PET/CT represents a validated diagnostic tool in post-treatment evaluation of FDG-avid lymphoma, and the Deauville Score (DS), a five-point visual scale, is usually used to assess response. However, the increased number of false positive findings suggested the need to search for new parameters. The aim of this study is to evaluate the prognostic value of End-of-Treatment-PET, comparing DS to the semi-quantitative Lesion-to-Liver ratio (LLR). METHODS: newly diagnosed DLBCL patients who underwent 18F-FDG PET/CT were retrospectively analyzed. End-of-Treatment PET findings were assessed first using DS; secondly, assigned the LLR. RESULTS: a total of 105 patients were finally enrolled. ROC analysis showed an LLR of 1.80 as the optimal cutoff value for predicting a disease progression (sensitivity 58%, specificity 95%). Both DS and LLR showed a statistically significant correlation with PFS and OS. LLR resulted in a better diagnostic performance than DS. CONCLUSIONS: LLR showed to be a reliable diagnostic method to assess treatment response in DLBCL. The integration of visual and semi-quantitative criteria could help in decision making, improving specificity and PPV.

Intracranial Solitary Fibrous Tumor: A "New" Challenge for PET Radiopharmaceuticals.

Solitary fibrous tumor (SFT) of the central nervous system, previously named and classified with the term hemangiopericytoma (HPC), is rare and accounts for less than 1% of all intracranial tumors. Despite its benign nature, it has a malignant behavior due to the high rate of recurrence and distant metastasis, occurring in up to 50% of cases. Surgical resection of the tumor is the treatment of choice. Radiotherapy represents the gold standard in the case of post-surgery residual disease, relapse, and distant metastases. In this context, imaging plays a crucial role in identifying the personalized therapeutic decision for each patient. Although the referring imaging approach in SFT is morphologic, an emerging role of positron emission tomography (PET) has been reported in the literature. However, there is still a debate on which radiotracers have the best accuracy for studying these uncommon tumors because of the histological or biological heterogeneity of SFT.

Multimodal study of pelvic splenosis: a rare cause of abdominal pain.

We present a rare case of pelvic splenosis, in a 46-year-old man, with a previous history of partial splenectomy, complaining of nonspecific pain in the lower abdominal quadrants. Splenosis is a benign acquired condition, defined as a heterotopic autotransplantation of splenic tissue in other compartments of the body, caused by rupture of the splenic capsule following trauma or splenectomy. Splenosis is often asymptomatic and incidentally found and does not require treatment. Surgery is indicated only in patients presenting with symptoms or complications. In our case, the multimodal imaging study (ultrasound, MRI, CT, and scintigraphy) allowed a correct differential diagnosis without resorting to invasive procedures, susceptible to complications.

[18F]Fluciclovine PET/CT Improves the Clinical Management of Early Recurrence Prostate Cancer Patients.

We investigated the [18F]Fluciclovine PET/CT reliability in the early detection of recurrent prostate cancer (PCa) and its impact on therapeutic decision making. We retrospectively analyzed 58 [18F]Fluciclovine PET/CT scans performed to identify early PCa recurrence. Detection rate (DR) and semiquantitative analysis were evaluated in relation to biochemical and clinical-histological features. Clinical follow-up data were collected and considered as gold standard to evaluate sensitivity, specificity, accuracy, positive and negative predictive value (PPV, NPV). The impact of [18F]Fluciclovine PET/CT on clinical management was also assessed. Overall DR resulted as 66%, while DR was 53%, 28%, and 7% in prostate/bed, lymph nodes, and bone, respectively. DR significantly increased with higher PSA values (p = 0.009) and 0.45 ng/mL was identified as the optimal cut-off value. Moreover, SUVmax and SUVmean resulted significant parameters in interpreting malignant from benign findings. [18F]Fluciclovine PET/CT reached a sensitivity, specificity, PPV, NPV, and accuracy of 87.10%, 80.00%, 87.10%, 80.00%, and 84.31%, respectively. Therapeutic strategy was changed in 51% of patients. Our results support [18F]Fluciclovine PET/CT as a reliable tool for early restaging of PCa patients, especially for local recurrence detection, leading to a significant impact on clinical management. Semiquantitative analysis could improve specificity in interpreting malignant from benign lesions.

18F-FDG PET/CT in GIST treatment response evaluation beyond Imatinib.

Positron emission tomography/computed tomography (PET/CT) represents a reliable promising tool in treatment response evaluation of new therapies beyond Imatinib in gastrointestinal stromal tumors (GIST). This narrative review aims to discuss the literature about the role of fluorine-18-fluorodeoxyglucose (18F-FDG) PET/CT in evaluating response in new tyrosine kinase inhibitors (TKI) and radiotherapy (RT) in GIST patients. A comprehensive literature search was performed to retrieve original studies published on PubMed, Scopus and Google Scholar databases. Eighteen studies including 382 patients with GIST were selected. Main findings of included studies are presented. Fluorine-18-FDG PET/CT may enhance performance in GIST management providing significant information in evaluation of treatment response and representing a strong predictor of clinical outcome.

The Day after Mass COVID-19 Vaccination: Higher Hypermetabolic Lymphadenopathy Detection on PET/CT and Impact on Oncologic Patients Management.

The widespread COVID-19 vaccination led to unexpected PET findings. Notably, axillary and interpectoral lymphadenopathies ipsilateral to the vaccine inoculation were observed. We aimed to assess the hypermetabolic lymphadenopathy (HLN) detection rate on PET/CT. Secondly, we investigated factors that might help in HLN differential diagnosis. A retrospective analysis on 1196 consecutive patients referred for a PET/CT was performed. All patients were asked about the date, type and site of vaccine injections. HLNs were recorded and categorized according to risk classes and SUVmax grades. A statistical analysis was performed to assess the correlation between HLN detection and different clinical/vaccine data. HLN detection rate was 15% and 27% in the No Vac- and vac-groups (p < 0.001), respectively. In the Vac-group, age (p < 0.001) and time interval from vaccine-to-PET (p = 0.010) were inversely correlated with HLN detection. Furthermore, SUVmax significantly changed during time intervals, with lower values beyond 20 days (p < 0.001). In the era of mass COVID-19 vaccination, a higher axillary and interpectoral lymphadenopathies detection ipsilateral to vaccine injection was observed. These PET findings can be wrongly interpreted, complicating cancer patients' management. To minimize these pitfalls, a detailed vaccination anamnesis must be recorded and should take into account the appropriate PET schedule.

Early Predictive Response to Multi-Tyrosine Kinase Inhibitors in Advanced Refractory Radioactive-Iodine Differentiated Thyroid Cancer: A New Challenge for [18F]FDG PET/CT.

Differentiated thyroid cancer (DTC) represents the most common thyroid cancer histotype. Generally, it exhibits a good prognosis after conventional treatments; nevertheless, about 20% of patients can develop a local recurrence and/or distant metastasis. In one-third of advanced DTC, the metastatic lesions lose the ability to take up iodine and become radioactive iodine-refractory (RAI-R) DTC. In this set of patients, the possibility to perform localized treatments should always be taken into consideration before the initiation of systemic therapy. In the last decade, some multi-tyrosine kinase inhibitor (MKI) drugs were approved for advanced DTC, impacting on patient's survival rate, but at the same time, these therapies have been associated with several adverse events. In this clinical context, the role of 2-deoxy-2-[18F]fluoro-D-glucose positron emission tomography/computed tomography ([18F]FDG PET/CT) in the early treatment response to these innovative therapies was investigated, in order to assess the potentiality of this diagnostic tool in the early recognition of non-responders, avoiding unnecessary therapy. Herein, we aimed to present a critical overview about the reliability of [18F]FDG PET/CT in the early predictive response to MKIs in advanced differentiated thyroid cancer.