Positron emission tomography in the management of documented or suspected recurrent ovarian cancer.

BACKGROUND: To prospectively evaluate the value of positron emission tomography (PET) or integrated computed tomography (CT) and PET (PET/CT) in the management of documented or suspected recurrent ovarian cancer. METHODS: Patients with ovarian cancer who had completed primary cytoreductive surgery and standard adjuvant chemotherapy were studied to evaluate the following indications: (1) CA125 elevation after complete remission with negative CT or magnetic resonance imaging (MRI) result; (2) post-therapy surveillance CT/MRI-detected suspicious lesions that guided biopsy was not feasible; (3) documented relapse for restaging prior to or after curative salvage therapy. The clinical impact of PET, as compared with those of CT/MRI, was determined on a per scan basis. RESULTS: From 2002 to 2009, 73 patients were recruited, and 92 PET scans were performed. Up to June 2015, 53 patients had died of disease, four were alive with disease, and the remaining 16 were alive without disease. Among the 92 scans, PET had positive impacts in 72.8%, no clinical impacts in 21.7%, and negative impacts in 5.4%. For indication 1, the sensitivity and positive predictive value of PET in detecting recurrence were 80.0% and 92.3%, respectively. For indication 2, the sensitivity, specificity, positive predictive value, and negative predictive value of PET were 91.2%, 62.5%, 91.2%, and 62.5%, respectively. For indication 3, PET provided positive impact in 85.3% and negative impact in 2.9% of the 34 scans. CONCLUSION: PET has value in the management of suspected or documented recurrent ovarian cancer, with positive impacts on confirming recurrent status and offering a better treatment plan.

Evaluation of response after SBRT for liver tumors.

Stereotactic body radiotherapy (SBRT) has developed over the last few years for the treatment of primary and metastatic hepatic tumors. The tumoral and adjacent peritumoral modifications caused by this radiosurgery limit the evaluation of response by anatomic imaging and dimensional criteria alone, such as with RECIST. This suggests that it is of interest to also take into account the residual enhancement and hyper metabolism of these hepatic targets. We have reviewed the English language literature regarding the response of hepatic lesions treated by SBRT, and found that only seven articles were specifically concerned with this problem. The response of the hepatocellular carcinoma after SBRT has been studied specifically with multiphase enhanced CT-scan. Criteria set by the European Association of Study of the Liver better estimate response at each time point of follow up than RECIST does. Non-enhancement, reflecting tumor necrosis, is additionally an early indicator of response with extended response in time and a best non-enhancement percentage is observed at 12 months. The response after treatment by SBRT of cholangiocarcinoma has not yet generated a specific report. Use of RECIST criteria is also inadequate in the evaluation of response after SBRT for hepatic metastases. Response of liver metastases to SBRT is better assessed with a combination of size and enhancement pattern. The occurrence of a lobulated enhancement during follow up is efficient to predict local progression in a specific, reproducible, and sensitive way. Patients with FDG-avid hepatic metastases are also better evaluated with PET-CT and functional criteria than routine imaging and metric evaluation alone.

Exercise Influences the Brain's Metabolic Response to Chronic Cocaine Exposure in Male Rats.

Cocaine use is associated with negative health outcomes: cocaine use disorders, speedballing, and overdose deaths. Currently, treatments for cocaine use disorders and overdose are non-existent when compared to opioid use disorders, and current standard cocaine use disorder treatments have high dropout and recidivism rates. Physical exercise has been shown to attenuate addiction behavior as well as modulate brain activity. This study examined the differential effects of chronic cocaine use between exercised and sedentary rats. The effects of exercise on brain glucose metabolism (BGluM) following chronic cocaine exposure were assessed using Positron Emission Tomography (PET) and [18F]-Fluorodeoxyglucose (FDG). Compared to sedentary animals, exercise decreased metabolism in the SIBF primary somatosensory cortex. Activation occurred in the amygdalopiriform and piriform cortex, trigeminothalamic tract, rhinal and perirhinal cortex, and visual cortex. BGluM changes may help ameliorate various aspects of cocaine abuse and reinstatement. Further investigation is needed into the underlying neuronal circuits involved in BGluM changes and their association with addiction behaviors.

Comparison of FDG-PET/CT and CT for evaluation of tumor response to nivolumab plus ipilimumab combination therapy and prognosis prediction in patients with unresectable malignant pleural mesothelioma.

OBJECTIVES: Results for malignant pleural mesothelioma (MPM) patients following first-line treatment with nivolumab plus ipilimumab obtained with immunotherapy-modified PERCIST (imPERCIST), shown by [18F]fluorodeoxyglucose positron emission tomography/computed tomography (FDG-PET/CT), and modified RECIST (mRECIST), shown by CT, were compared for response evaluation and prognosis prediction. RESULTS: imPERCIST indicated nine progressive metabolic disease (PMD), eight stable metabolic disease (SMD), four partial metabolic response (PMR), and five complete metabolic response (CMR) cases. mRECIST showed nine with progressive disease (PD), nine stable disease (SD), seven partial response (PR), and one complete response (CR). Although high concordance was noted (κ = 0.827), imPERCIST correctly judged a greater percentage with CMR (15.4%). Following a median 10.0 months, 15 patients showed progression and eight died from MPM. With both, progression-free survival (PFS) and overall survival (OS) were significantly longer in patients without progression (CMR/PMR/SMD, CR/PR/SD, respectively) as compared to PMD/PD patients (imPERCIST p < 0.0001 and p = 0.015, respectively; mRECIST p < 0.0001 and p = 0.015, respectively). METHODS: Twenty-six patients (23 males, 3 females; median 73.5 years) with histologically proven MPM and no curative surgery received nivolumab plus ipilimumab combination therapy. FDG-PET/CT and diagnostic CT scanning at the baseline, and after 2-4 cycles (2 in three, 3 in 17, 4 in six patients) were performed. Therapeutic response findings evaluated using imPERCIST and mRECIST were compared. PFS and OS analyses were done using log-rank and Cox methods. CONCLUSION: For unresectable MPM patient examinations, FDG-PET and CT provide accurate findings for evaluating tumor response and also prognosis prediction following first-line nivolumab plus ipilimumab immunotherapy (approximately three cycles).

A Comparative Study of 18F-FAPI-42 and 18F-FDG PET/CT for Evaluating Acute Kidney Injury in Cancer Patients.

PURPOSE: Compare the value of imaging using positron 18F-labeled fibroblast activation protein inhibitor-42 (18F-FAPI-42) and 18F-labeled deoxyglucose (18F-FDG) for assessment of AKI. PROCEDURES: This study analyzed cancer patients who received 18F-FAPI-42 and 18F-FDG PET/CT imaging. Eight patients had AKI with bilateral ureteral obstruction (BUO), eight had BUO (CKD1-2) with no acute kidney disease (AKD), and eight had no ureteral obstruction (UO) with normal renal function. The average standardized uptake value (SUVave) of the renal parenchyma (RP-SUVave), the blood pool SUVave (B- SUVave), SUVave in the highest region of the renal collective system (RCS-SUVave), and the highest serum creatinine level (top SCr) were recorded. RESULTS: The 18F-FAPI-42 and 18F-FDG results showed that radiotracer of renal parenchyma was more concentrated in the AKI group than in the other two groups, whereas the RP-SUVave from 18F-FAPI-42 was higher than that from 18F-FDG in the AKI group (all P < 0.05). 18F-FAPI-42 imaging in the AKI group showed uptake by the renal parenchyma with a diffuse increase, but very little radiotracer in the renal collecting system, similar to a "super kidney scan." The renal parenchyma also had an increase of SUVave, with accumulation of radiotracer in the renal collecting system. AKI was more severe when a patient had a "super kidney scan" in both kidneys (P < 0.05). The B-SUVave level was higher in the AKI group than in the other two groups in 18F-FAPI-42 (both P < 0.05). CONCLUSIONS: 18F-FAPI-42 imaging had higher RP-SUVave than 18F-FDG imaging in cancer patients who had BUO with AKI. An increased renal parenchyma uptake in both kidneys and low radiotracer distribution in the collecting system suggest more severe AKI.

Exercise Modifies the Brain Metabolic Response to Chronic Cocaine Exposure Inhibiting the Stria Terminalis.

It is well known that exercise promotes health and wellness, both mentally and physiologically. It has been shown to play a protective role in many diseases, including cardiovascular, neurological, and psychiatric diseases. The present study examined the effects of aerobic exercise on brain glucose metabolic activity in response to chronic cocaine exposure in female Lewis rats. Rats were divided into exercise and sedentary groups. Exercised rats underwent treadmill running for six weeks and were compared to the sedentary rats. Using positron emission tomography (PET) and [18F]-Fluorodeoxyglucose (FDG), metabolic changes in distinct brain regions were observed when comparing cocaine-exposed exercised rats to cocaine-exposed sedentary rats. This included activation of the secondary visual cortex and inhibition in the cerebellum, stria terminalis, thalamus, caudate putamen, and primary somatosensory cortex. The functional network of this brain circuit is involved in sensory processing, fear and stress responses, reward/addiction, and movement. These results show that chronic exercise can alter the brain metabolic response to cocaine treatment in regions associated with emotion, behavior, and the brain reward cascade. This supports previous findings of the potential for aerobic exercise to alter the brain's response to drugs of abuse, providing targets for future investigation. These results can provide insights into the fields of exercise neuroscience, psychiatry, and addiction research.

Acute cervicitis resembling gastric-type mucinous adenocarcinoma that was definitively diagnosed by cervical conization: A case report.

Although imaging studies are not typically performed for clinical diagnosis of cervicitis, in this case magnetic resonance imaging (MRI) was performed because a lesion with a tumor-like gross appearance was found in the uterine cervix. We present a case of cervicitis in which clinical, imaging and pathological features overlapped with those of gastric-type mucinous adenocarcinoma (GAS). The patient, a 30-year-old woman, was referred to a gynecologist with a complaint of watery vaginal discharge. On visual examination, the uterine cervix was irregularly enlarged and bled easily, suggesting cervical cancer. The next day, the patient had a fever of 39°C and blisters appeared on her vulva due to herpes simplex virus type II infection. MRI showed a diffusely enlarged cervix with poorly marginated high signal intensity on T2-weighted imaging (WI) and apparent diffusion coefficient map as well as strong enhancement on contrast-enhanced T1WI, which are findings consistent with GAS. Although a punch biopsy showed only mild atypia of the cervical glands, this was not enough to completely rule out GAS. Consequently, laser conization of the lesion was performed for definitive diagnosis, and the diagnosis of cervicitis was made. Acute cervicitis can be difficult to differentiate from GAS based on symptoms, results of cervical biopsy and MR imaging because of their overlapping features. Even when a patient presents with a lesion with tumor-like gross appearance, acute cervicitis should be included in the differential diagnosis if the result of cervical biopsy is negative, especially when accompanied by infection-like fever.

Semi-automated 18F-FDG PET segmentation methods for tumor volume determination in Non-Hodgkin lymphoma patients: a literature review, implementation and multi-threshold evaluation.

In the treatment of Non-Hodgkin lymphoma (NHL), multiple therapeutic options are available. Improving outcome predictions are essential to optimize treatment. The metabolic active tumor volume (MATV) has shown to be a prognostic factor in NHL. It is usually retrieved using semi-automated thresholding methods based on standardized uptake values (SUV), calculated from 18F-Fluorodeoxyglucose Positron Emission Tomography (18F-FDG PET) images. However, there is currently no consensus method for NHL. The aim of this study was to review literature on different segmentation methods used, and to evaluate selected methods by using an in house created software tool. A software tool, MUltiple SUV Threshold (MUST)-segmenter was developed where tumor locations are identified by placing seed-points on the PET images, followed by subsequent region growing. Based on a literature review, 9 SUV thresholding methods were selected and MATVs were extracted. The MUST-segmenter was utilized in a cohort of 68 patients with NHL. Differences in MATVs were assessed with paired t-tests, and correlations and distributions figures. High variability and significant differences between the MATVs based on different segmentation methods (p < 0.05) were observed in the NHL patients. Median MATVs ranged from 35 to 211 cc. No consensus for determining MATV is available based on the literature. Using the MUST-segmenter with 9 selected SUV thresholding methods, we demonstrated a large and significant variation in MATVs. Identifying the most optimal segmentation method for patients with NHL is essential to further improve predictions of toxicity, response, and treatment outcomes, which can be facilitated by the MUST-segmenter.

Brain Mapping the Effects of Chronic Aerobic Exercise in the Rat Brain Using FDG PET.

Exercise is a key component to health and wellness and is thought to play an important role in brain activity. Changes in brain activity after exercise have been observed through various neuroimaging techniques, such as functional magnetic resonance imaging (fMRI) and positron emission tomography (PET). The precise impact of exercise on brain glucose metabolism (BGluM) is still unclear; however, results from PET studies seem to indicate an increase in regional metabolism in areas related to cognition and memory, direction, drive, motor functions, perception, and somatosensory areas in humans. Using PET and the glucose analog [18F]-Fluorodeoxyglucose (18F-FDG), we assessed the changes in BGluM between sedentary and chronic exercise in rats. Chronic treadmill exercise treatment demonstrated a significant increase in BGluM activity in the following brain regions: the caudate putamen (striatum), external capsule, internal capsule, deep cerebellar white matter, primary auditory cortex, forceps major of the corpus callosum, postsubiculum, subiculum transition area, and the central nucleus of the inferior colliculus. These brain regions are functionally associated with auditory processing, memory, motor function, and motivated behavior. Therefore, chronic daily treadmill running in rats stimulates BGluM in distinct brain regions. This identified functional circuit provides a map of brain regions for future molecular assessment which will help us understand the biomarkers involved in specific brain regions following exercise training, as this is critical in exploring the therapeutic potential of exercise in the treatment of neurodegenerative disease, traumatic brain injury, and addiction.

Exercise Modulates Brain Glucose Utilization Response to Acute Cocaine.

Exercise, a proven method of boosting health and wellness, is thought to act as a protective factor against many neurological and psychological diseases. Recent studies on exercise and drug exposure have pinpointed some of the neurological mechanisms that may characterize this protective factor. Using positron emission tomography (PET) imaging techniques and the glucose analog [18F]-Fluorodeoxyglucose (18F-FDG), our team sought to identify how chronic aerobic exercise modulates brain glucose metabolism (BGluM) after drug-naïve rats were exposed to an acute dose of cocaine. Using sedentary rats as a control group, we observed significant differences in regional BGluM. Chronic treadmill exercise treatment coupled with acute cocaine exposure induced responses in BGluM activity in the following brain regions: postsubiculum (Post), parasubiculum (PaS), granular and dysgranular insular cortex (GI and DI, respectively), substantia nigra reticular (SNR) and compact part dorsal tier (SNCD), temporal association cortex (TeA), entopenduncular nucleus (EP), and crus 1 of the ansiform lobule (crus 1). Inhibition, characterized by decreased responses due to our exercise, was found in the ventral endopiriform nucleus (VEn). These areas are associated with memory and various motor functions. They also include and share connections with densely dopaminergic areas of the mesolimbic system. In conclusion, these findings suggest that treadmill exercise in rats mediates brain glucose response to an acute dose of cocaine differently as compared to sedentary rats. The modulated brain glucose utilization occurs in brain regions responsible for memory and association, spatial navigation, and motor control as well as corticomesolimbic regions related to reward, emotion, and movement.

Sclerotic lumbar chordoma: A case report.

Chordoma is a rare tumor, often occurring in the cervical spine and sacrococcygeal spine with a lytic appearance, but rarely in the thoracolumbar spine. Chordomas can occasionally be sclerotic and are included in the differential diagnosis for an ivory vertebra. We present a case of a sclerotic chordoma in an upper lumbar vertebral body with corresponding multimodality imaging. This case demonstrates that chordoma should be a concern for an older adult with a sclerotic vertebral lesion, particularly if it is a solitary lesion. Knowledge of the variable location and appearance of chordomas is critical so it is not mistaken for a metastasis.

Cerebral Embolic Protection During Transseptal Biopsy of Left Atrial Mass.

Diagnostic biopsy of a left atrial mass is technically feasible but has the risk of tumor embolization causing stroke or seeding. In this case report, we highlight the technical steps for left atrial mass biopsy under transesophageal echocardiography guidance by using cerebral embolic protection. Pathologic examination disclosed low-grade B-cell lymphoma. (Level of Difficulty: Advanced.).

F-FDG18PET/CT incidental detection of tumor-to-tumor metastasis in patients investigated for squamous cell lung cancer.

Tumor-to-tumor metastasis (TTM) is a well-known entity, although this is still an extremely rare phenomenon. The lung cancers are considered the most frequent metastatic donors while kidney cancers are the most common recipient. The finding of TTM is often incidental during a biopsy of metastases or on surgical specimens but never suspected on radiological assessment of tumor extension. The finding of an unexpected region of Fluorodeoxyglucose (FDG) uptake can occur when performing whole body Positron Emission Tomography/computed tomography (PET/CT) scan and potentially raises the possibility of a second primary tumor. However, PET/CT scan incidental detection of tumor-to-tumor metastasis has never been reported in English literature. We report here a case of clear cell renal carcinoma, receptor of metastases originating from an oligometastatic squamous cell lung cancer detected on the PET/CT scan performed as part of the extension workup. Morphological and immunohistochemical analysis of a percutaneous biopsy of the renal mass were consistent with the diagnosis of a metastasis of lung cancer into renal cell carcinoma. This is the first case of oligometastatic lung cancer with the occurrence of TTM suspected in PET/CT scan. Although this is a rare setting, it should be considered in daily practice, as it could potentially modify the oncological management offered to the patients.

Pericardiectomy for Constrictive Pericarditis in a Young Patient With Erdheim-Chester Disease.

Erdheim-Chester Disease (ECD) is an extremely rare non-Langerhans histiocytosis that most often presents in the fifth to seventh decades of life. In this case report, we present a 34-year-old woman who underwent successful pericardiectomy for constrictive pericarditis secondary to ECD, which is the youngest reported patient with ECD to undergo pericardiectomy. (Level of Difficulty: Advanced.).

Inflammatory Cardiomyopathies: A Need to Identify Indolent Inflammation.

We present 3 cases of inflammatory cardiomyopathies illustrating the need for a multimodality imaging and multidisciplinary approach for diagnosis and treatment. (Level of Difficulty: Intermediate.).

A First Suspected Case of Fibrosing Mediastinitis After Anti-PD-1 Therapy.

We describe a first suspected case of fibrosing mediastinitis following anti-programmed death (PD)-1 therapy, pembrolizumab. Multimodality imaging, including cardiac magnetic resonance imaging, and a multidisciplinary team approach were integral to the diagnosis. If further substantiated, systematic surveillance after anti-PD-1 therapy for fibrosing mediastinitis may be warranted. (Level of Difficulty: Intermediate.).

Role of Multimodality Imaging and Preoperative Management in Intrapericardial Paragangliomas: Experience From a Case Series.

Intrapericardial paragangliomas are rare, highly vascular tumors that frequently adhere to adjacent structures and blood vessels, making surgical resection challenging. In this case series, we discuss the role of multimodality imaging and preoperative embolization in the management of 3 patients presenting with intrapericardial paragangliomas. (Level of Difficulty: Advanced.).

The Heart Team for Coronary Revascularization Decisions: 2 Illustrative Cases.

The 2021 ACC/AHA/SCAI coronary artery disease revascularization guideline highlights the importance of the multidisciplinary heart team in making patient-centered, evidence-based clinical decisions for patients considered for coronary revascularization. We present 2 cases highlighting aspects of heart team decision making for complex patients with coronary artery disease. (Level of Difficulty: Intermediate.).

Combining concurrent radiotherapy and immunotherapy for synergistic effects in recurrent endometrial cancer - A case report.

Endometrial cancer, also known as uterine cancer, is the second most common cancer affecting women globally and the fourth most prevalent in the United States (US). Treatment often involves a combination of surgery, radiotherapy and chemotherapy depending on the severity. In this case report, we present two patients with relapsed endometrial carcinomas, who responded positively to combined radiotherapy and immunotherapy followed by maintenance immunotherapy. Given the worsening prognoses associated with recurrent endometrial cancers, these two cases warrant the further exploration of the concurrent administration of immunotherapy and radiation therapy in the context of clinical trials.

Tumor response evaluation in patients with malignant melanoma undergoing immune checkpoint inhibitor therapy and prognosis prediction using 18F-FDG PET/CT: multicenter study for comparison of EORTC, PERCIST, and imPERCIST.

OBJECTIVE: In malignant melanoma patients treated with immune checkpoint inhibitor (ICI) therapy, three different FDG-PET criteria, European Organization for Research and Treatment of Cancer (EORTC), PET Response Criteria in Solid Tumors (PERCIST), immunotherapy-modified PERCIST (imPERCIST), were compared regarding response evaluation and prognosis prediction using standardized uptake value (SUV) harmonization of results obtained with various PET/CT scanners installed at different centers. MATERIALS AND METHODS: Malignant melanoma patients (n = 27) underwent FDG-PET/CT examinations before and again 3 to 9 months after therapy initiation (nivolumab, n = 21; pembrolizumab, n = 6) with different PET scanners at five hospitals. EORTC, PERCIST, and imPERCIST criteria were used to evaluate therapeutic response, then concordance of the results was assessed using Cohen's κ coefficient. Log-rank and Cox methods were employed to determine progression-free (PFS) and overall (OS) survival. RESULTS: Complete metabolic response (CMR)/partial metabolic response (PMR)/stable metabolic disease (SMD)/progressive metabolic disease (PMD) with harmonized EORTC, PERCIST, and imPERCIST was seen in 3/5/4/15, 4/5/3/15, and 4/5/5/13 patients, respectively. Nearly perfect concordance between each pair of criteria was noted (κ = 0.939-0.972). Twenty patients showed progression and 14 died from malignant melanoma after a median 19.2 months. Responders (CMR/PMR) showed significantly longer PFS and OS than non-responders (SMD/PMD) (harmonized EORTC: p < 0.0001 and p = 0.011; harmonized PERCIST: p < 0.0001 and p = 0.0012; harmonized imPERCIST: p < 0.0001 and p = 0.0012, respectively). CONCLUSIONS: All harmonized FDG-PET criteria (EORTC, PERCIST, imPERCIST) showed accuracy for response evaluation of ICI therapy and prediction of malignant melanoma patient prognosis. Additional studies to determine their value in larger study populations will be necessary.