All You Need to Know as an Authorized User.

OBJECTIVE: The purpose of this article is to review the training requirements for practicing nuclear radiology, the scope of licensing, how to start a new practice, and the key concepts an authorized user needs to know for responsible use of radiopharmaceuticals. CONCLUSION: Physicians responsible for the daily operations of nuclear medicine clinics often find the regulations concerning the safe handling and administration of radiopharmaceuticals daunting. Even experienced authorized users have concerns about handling many new therapeutic agents. Those studying for certifying and subspecialty examinations or for maintenance of certification for the American Board of Nuclear Medicine and the American Board of Radiology must clearly understand the overall process for becoming an authorized user.

Small cell lung cancer.

Neuroendocrine tumors account for approximately 20% of lung cancers; most (≈15%) are small cell lung cancer (SCLC). These NCCN Clinical Practice Guidelines in Oncology for SCLC focus on extensive-stage SCLC because it occurs more frequently than limited-stage disease. SCLC is highly sensitive to initial therapy; however, most patients eventually die of recurrent disease. In patients with extensive-stage disease, chemotherapy alone can palliate symptoms and prolong survival in most patients; however, long-term survival is rare. Most cases of SCLC are attributable to cigarette smoking; therefore, smoking cessation should be strongly promoted.

Non-small cell lung cancer.

Most patients with non-small cell lung cancer (NSCLC) are diagnosed with advanced cancer. These guidelines only include information about stage IV NSCLC. Patients with widespread metastatic disease (stage IV) are candidates for systemic therapy, clinical trials, and/or palliative treatment. The goal is to identify patients with metastatic disease before initiating aggressive treatment, thus sparing these patients from unnecessary futile treatment. If metastatic disease is discovered during surgery, then extensive surgery is often aborted. Decisions about treatment should be based on multidisciplinary discussion.

Radiation necrosis in the brain: imaging features and differentiation from tumor recurrence.

Radiation necrosis in the brain commonly occurs in three distinct clinical scenarios, namely, radiation therapy for head and neck malignancy or intracranial extraaxial tumor, stereotactic radiation therapy (including radiosurgery) for brain metastasis, and radiation therapy for primary brain tumors. Knowledge of the radiation treatment plan, amount of brain tissue included in the radiation port, type of radiation, location of the primary malignancy, and amount of time elapsed since radiation therapy is extremely important in determining whether the imaging abnormality represents radiation necrosis or recurrent tumor. Conventional magnetic resonance (MR) imaging findings of these two entities overlap considerably, and even at histopathologic analysis, tumor mixed with radiation necrosis is a common finding. Advanced imaging modalities such as diffusion tensor imaging and perfusion MR imaging (with calculation of certain specific parameters such as apparent diffusion coefficient ratios, relative peak height, and percentage of signal recovery), MR spectroscopy, and positron emission tomography can be useful in differentiating between recurrent tumor and radiation necrosis. In everyday practice, the visual assessment of diffusion-weighted and perfusion images may also be helpful by favoring one diagnosis over the other, with restricted diffusion and an elevated relative cerebral blood volume being seen much more frequently in recurrent tumor than in radiation necrosis.

A Guide to Writing Academic Portfolios for Radiologists.

The academic educator's portfolio is a collection of materials that document academic performance and achievements, supplementing the curriculum vitae, in order to showcase a faculty member's most significant accomplishments. A decade ago, a survey of medical schools revealed frustration in the nonuniform methods of measuring faculty's medical education productivity. A proposed solution was the use of an academic educator's portfolio. In the academic medical community, compiling an academic portfolio is always a challenge because teaching has never been confined to the traditional classroom setting and often involves active participation of the medical student, resident, or fellow in the ongoing care of the patient. Diagnostic radiology in addition requires a knowledge base that encompasses basic sciences, imaging physics, technology, and traditional and molecular medicine. Teaching and performing research that involves this complex mix, while providing patient care that is often behind the scenes, provides unique challenges in the documentation of teaching, research, and clinical service for diagnostic radiology faculty. An academic portfolio is seen as a way to explain why relevant academic activities are significant to promotions committee members who may have backgrounds in unrelated academic areas and may not be familiar with a faculty member's work. The academic portfolio consists of teaching, research, and service portfolios. The teaching portfolio is a collection of materials that document teaching performance and documents the educator's transition to a more effective educator. A research portfolio showcases the most significant research accomplishments. The service portfolio documents service responsibilities and highlight any service excellence. All portfolios should briefly discuss the educator's philosophy, activities, methods used to implement activities, leadership, mentoring, or committee roles in these respective areas. Recognizing that academic programs have differing needs, this article will attempt to provide some basic guidelines that may help junior faculty in diagnostic radiology develop their teaching, research, and service portfolios.

99mTc-Tilmanocept: A Novel Molecular Agent for Lymphatic Mapping and Sentinel Lymph Node Localization.

Preoperative lymphatic mapping in conjunction with intraoperative γ-probe detection is widely used for sentinel node localization in melanoma, breast cancer, and other malignancies. (99m)Tc-radiocolloids have been the standard radiotracers used for sentinel node mapping. (99m)Tc-tilmanocept is a receptor-binding molecular imaging agent approved by the U.S. Food and Drug Administration for lymphatic mapping and lymph node localization in breast cancer, melanoma, clinically node-negative squamous cell carcinoma of the oral cavity, and other solid tumors. It has several advantages over conventional radiocolloids, including rapid injection site clearance, high sentinel node extraction, and low distal node accumulation, which can lead to efficient resource use.

18F-FDG PET/CT Findings in Portal Vein Thrombosis and Liver Metastases.

(18)F-FDG PET/CT is a valuable noninvasive tool in oncologic imaging, and its application in the diagnosis of liver metastases has been very convincing. Both the sensitivity and the specificity of (18)F-FDG PET/CT are high for detecting liver metastases from various tumors including colorectal, breast, and lung. Such liver metastases are typically (18)F-FDG-avid. We present atypical (18)F-FDG PET findings in a lung cancer patient with known liver metastases and PVT.

Ovarian hyperstimulation and breast cancer on PET imaging with sonographic correlation.

We present interesting PET/CT and ultrasound findings in a 36-year-old lactating woman with stage T2 N0 M0 right breast cancer undergoing oocyte retrieval for fertility preservation. Her cancer treatment plan included neoadjuvant chemotherapy; therefore, the patient wanted to undergo an oocyte retrieval procedure for fertility preservation. She underwent a transvaginal ultrasound-guided oocyte retrieval procedure in the morning and a staging F-FDG PET/CT later the same day. At the time of PET imaging, she had been breast-feeding her 9-month-old infant with only her left breast.

¹8F-FDG PET and PET/CT patient preparation: a review of the literature.

For many types of cancer, (18)F-FDG PET/CT is commonly used in evaluation and management, including tumor diagnosis, staging, restaging, treatment monitoring, and radiation therapy planning. Meticulous patient preparation including restrictions of diet and activity and management of blood glucose levels in diabetic patients, as well as an awareness of the effect of medications and environmental conditions, plays an important role toward obtaining good-quality images, which are essential for accurate interpretation. Protocol guidelines for performing PET/CT have been proposed by various societies and groups, including the Society of Nuclear Medicine and Molecular Imaging, the European Association of Nuclear Medicine, the American College of Radiology, and the National Cancer Institute. Standardization of the PET/CT procedure is necessary to enable use of metabolic parameters as imaging biomarkers in routine clinical decision making and to ensure reproducibility and allow comparison examinations across different sites. Though several published articles, including various society guidelines, have addressed the relevant patient preparation variables individually, we believe there is need for further clarification. This article summarizes existing data and proposes a standard patient preparation protocol.

Evaluation of tumor-induced osteomalacia with 111In-pentetreotide scintigraphy.

In cases of nonhereditary osteomalacia associated with hypophosphatemia and inadequate response to vitamin D supplementation, one should consider the possibility of tumor-induced osteomalacia, a paraneoplastic syndrome caused by small mesenchymal tumors often found in obscure locations. We present a case of tumor-induced osteomalacia in which (111)In-pentetreotide scintigraphy aided in accurate localization of the culprit brachial plexus tumor and cure after resection.

Primary hyperparathyroidism-related brown tumors mimicking other giant cell-containing skeletal tumors: role of correlative imaging in diagnosis.

A patient initially suspected of having a giant cell granuloma was subsequently found-through additional imaging with (99m)Tc-sestamibi and ultrasound-to have osteolytic brown tumors caused by a parathyroid adenoma. Brown tumors that relate to primary hyperparathyroidism may mimic other skeletal tumors that contain giant cells, presenting difficulty with accurate diagnosis. Correlative imaging can have a valuable role in such cases, potentially avoiding the extensive work-up usually done for suspected bone metastases.

A phase I clinical trial of Ad5.SSTR/TK.RGD, a novel infectivity-enhanced bicistronic adenovirus, in patients with recurrent gynecologic cancer.

PURPOSE: Ad5.SSTR/TK.RGD is an infectivity-enhanced adenovirus expressing a therapeutic thymidine kinase suicide gene and a somatostatin receptor (SSTR) that allows for noninvasive gene transfer imaging. The purpose of this study was to identify the maximum tolerated dose (MTD), toxicities, clinical efficacy, and biologic effects of Ad5.SSTR/TK.RGD in patients with recurrent gynecologic cancer. EXPERIMENTAL DESIGN: Eligible patients were treated intraperitoneally for 3 days with 1 × 10(9) to 1 × 10(12) vp/dose of Ad5.SSTR/TK.RGD followed by intravenous ganciclovir for 14 days. Toxicity and clinical efficacy were assessed using Common Toxicity Criteria (CTC) Adverse Events grading and Response Evaluation Criteria in Solid Tumors (RECIST) criteria. Imaging using In-111 pentetreotide was obtained before and after treatment. Tissue samples were obtained to evaluate for gene transfer, generation of wild-type virus, viral shedding, and antibody response. RESULTS: Twelve patients were treated in three cohorts. The most common vector-related clinical toxicities were grade I/II constitutional or pain symptoms, experienced most often in patients treated at the highest dose. MTD was not identified. Five patients showed stable disease; all others experienced progressive disease. One patient with stable disease experienced complete resolution of disease and normalization of CA125 on further follow-up. Imaging detected increased In-111 pentetreotide retention in patients treated at the highest dose. Ancillary studies showed presence of Ad5.SSTR/TK.RGD virus and HSV1-tk expression in ascites samples collected at various time points in most patients treated within the higher dose cohorts. CONCLUSIONS: This study shows the safety, potential efficacy, and possible gene transfer imaging capacity of Ad5.SSTR/TK.RGD in patients with recurrent gynecologic cancer. Further development of this novel gene therapeutic appears to be warranted.

Pilot trial of preoperative (neoadjuvant) letrozole in combination with bevacizumab in postmenopausal women with newly diagnosed estrogen receptor- or progesterone receptor-positive breast cancer.

INTRODUCTION: Tumor content or expression of vascular endothelial growth factor (VEGF) is associated with impaired efficacy of antiestrogen adjuvant therapy. We designed a pilot study to assess the feasibility and short-term efficacy of neoadjuvant letrozole and bevacizumab (anti-VEGF) in postmenopausal women with stage II and III estrogen receptor/progesterone receptor-positive breast cancer. PATIENTS AND METHODS: Patients were treated with a neoadjuvant regimen of letrozole orally 2.5 mg/day and bevacizumab intravenously 15 mg/kg every 3 weeks for a total of 24 weeks before the surgical treatment of their breast cancer. Patients were followed for toxicity at 3-week intervals, and tumor assessment (a physical examination and ultrasound) was performed at 6-week intervals. Positron emission tomography (PET) scans were performed before therapy and 6 weeks after the initiation of therapy. RESULTS: Twenty-five evaluable patients were treated. The regimen was well-tolerated, except in 2 patients who were taken off the study for difficulties controlling their hypertension. An objective clinical response occurred in 17 of 25 patients (68%), including 16% complete responses (CRs) and 52% partial responses. The 4 patients with clinical CRs manifested pathologic CRs in their breasts (16%), although 1 patient had residual tumor cells in her axillary nodes. Eight of 25 patients (32%) attained stage 0 or 1 status. The PET scan response at 6 weeks correlated with clinical CRs and breast pathologic CRs at 24 weeks (P < .0036). CONCLUSION: Combination neoadjuvant therapy with letrozole and bevacizumab was well-tolerated and resulted in impressive clinical and pathologic responses. The Translational Breast Cancer Research Consortium has an ongoing randomized phase II trial of this regimen in this patient population.