Unusual Prostate-Specific Membrane Antigen (PSMA) Splenic Uptake in a Patient With Prostate Cancer.

There are many benefits to early detection of prostate cancer, including improved survival rates, less invasive treatment options, and better quality of life. Apart from traditional tests and imaging (including the prostate-specific antigen (PSA) test, digital rectal exam, biopsy, computed tomography (CT), and magnetic resonance imaging (MRI)), an imaging technique called prostate-specific membrane antigen positron emission tomography (PSMA PET) is more specific and sensitive, targeting PSMA expressed by prostate cancer cells on their surface. This case report describes a 62-year-old male with metastatic prostate adenocarcinoma and unusual PSMA uptake in the spleen. Elevated PSA levels and MRI indicated aggressive prostate cancer, confirmed by a Gleason score of 7 from biopsies. A PSMA PET/CT scan showed intense activity in both the prostate and spleen, initially suggesting metastasis. However, further imaging identified the splenic lesion as a benign hemangioma. This case showcases the importance of thorough diagnostic evaluations for distinguishing metastatic disease from benign conditions to ensure accurate diagnosis and appropriate treatment.

Comparison of staging using [68Ga]Ga-PSMA-11 PET/CT and histopathological results in intermediate- and high-risk prostate cancer patients treated with radical prostatectomy and pelvic lymph node dissection.

OBJECTIVE: To evaluate the diagnostic accuracy of [68Ga]Ga-PSMA-11 PET/CT (PET-PSMA) in local and loco-regional nodal staging compared with histopathological results in intermediate- and high-risk prostate cancer patients treated with radical prostatectomy (RP) and pelvic lymph node dissection (PLND). MATERIALS Y METHODS: A total of 122 intermediate- and high-risk prostate cancer (PCa) patients staged with PET-PSMA and treated with RP (36/122) and RP plus PLND (86/122) from December 2018 to December 2023 were included. Visual and semiquantitative analysis findings using the SUVmax of the molecular imaging were correlated with histopathological results. RESULTS: The primary tumor was visible by PET-PSMA in 96.7% of the patients. A positive correlation was found between PSA levels and SUVmax (Spearman's r: 0.303, p < 0.001). PET-PSMA detected nodal involvement in 25/89 patients (28.08%). The sensitivity, specificity, and diagnostic accuracy of PET-PSMA for detecting nodal involvement were 75%, 82.2%, and 80.9%, respectively. Patients with PSA levels >20 ng/ml, Gleason score ≥7b, ISUP grade >2, and extracapsular extension showed significantly higher SUVmax values. No differences were observed in SUVmax between risk groups or in other histopathological variables. CONCLUSIONS: PET-PSMA is an effective tool for the initial staging of intermediate- and high-risk PCa. SUVmax values were significantly higher in patients with unfavorable clinical features.

18F-FDG PET/CT versus bone marrow biopsy in detecting bone marrow infiltration in initial staging of pediatric lymphoma.

BACKGROUND: To evaluate the efficacy of PET/CT using18F-FDG (18F-fluorodeoxyglucose) as a radiotracer compared to conventional bone marrow biopsy (BMB) in detecting infiltration to bone marrow (BM) in pediatric patients with lymphoma at the time of initial diagnosis. METHODS: 66 pediatric patients with lymphoma (47Hodgkin's and 19non-Hodgkin's lymphoma) were referred for initial staging by18F-FDG PET/CT study. All patients underwent bilateral iliac BMB and 18F-FDG PET/CT scan with no more than 2 weeks interval in-between. Follow-up for at least 6 months was used as a reference standard to compare diagnostic performance between two modalities in detecting bone marrow infiltration (BMI). RESULTS: Sensitivity, specificity, accuracy, as well as positive and negative predictive values of 18F-FDG PET/CT in detecting BMI were (80%, 86%, 85%, 63%, and 94%) in contrast to BMB (80%, 53%, 59%, 33%, and 90%) respectively. 18F-FDG PET/CT was concordant to BMB in 39/66 patients (59%). CONCLUSION: 18F-FDG PET/CT was more accurate and specific, with higher predictive values than BMB in detecting BMI during initial staging of pediatric lymphoma. In most pediatric lymphoma patients, 18F-FDG PET/CT can be used instead of BMB to determine BMI during their initial staging process.

Head-to-head comparison of 18F-FDG and 18F-FES PET/CT for initial staging of ER-positive breast cancer patients.

PURPOSE: To compare the diagnostic performance of 18F-fluorodeoxyglucose (18F-FDG) and 18F-fluoroestradiol (18F-FES) positron emission tomography/computed tomography (PET/CT) for initial staging of estrogen receptor (ER) positive breast cancer. METHODS: Twenty-eight patients with ER-positive breast cancer underwent 18F-FDG and 18F-FES PET/CT for initial staging. Diagnostic performance and concordance rates were analyzed for both radiotracers. Semiquantitative parameters of maximum standardized uptake value (SUVmax) and tumor-to-normal ratio (T/N ratio) were compared using Wilcoxon signed-rank test. Factors potentially affecting the degree of radiotracer uptake were analyzed by multi-level linear regression analysis. RESULTS: The overall diagnostic performance of 18F-FES was comparable to 18F-FDG, except for higher specificity and NPV, with sensitivity, specificity, PPV, NPV, and accuracy of 87.56%, 100%, 100%, 35.14%, and 88.35%, respectively, for 18F-FES and 83.94%, 30.77%, 94.74%, 11.43%, and 95.37%, respectively, for 18F-FDG. Diagnostic performance of strong ER expression was better in 18F-FES but worse for 18F-FDG. There was a correlation of mucinous cell type and Allred score 7-8 with 18F-FES uptake, with correlation coefficients of 26.65 (19.28, 34.02), 5.90 (- 0.005, 11.81), and p-value of < 0.001, 0.05, respectively. Meanwhile, luminal B and Ki-67 were related to 18F-FDG uptake, with correlation coefficients of 2.76 (1.10, 0.20), 0.11 (0.01, 0.2), and p-value of 0.018, 0.025, respectively. CONCLUSION: Diagnostic performance of 18F-FES is comparable to 18F-FDG, but better for strongly ER-positive breast cancer. Combination of 18F-FES and 18F-FDG would potentially overcome the limitations of each tracer with more accurate staging.

Do Bone Scans Overstage Disease Compared with PSMA PET at Initial Staging? An International Multicenter Retrospective Study with Masked Independent Readers.

Prostate-specific membrane antigen (PSMA) PET has a higher accuracy than CT and bone scans to stage patients with prostate cancer. We do not understand how to apply clinical trial data based on conventional imaging to patients staged using PSMA PET. Therefore, we aimed to evaluate the ability of bone scans to detect osseous metastases using PSMA PET as a reference standard. Methods: In this multicenter retrospective diagnostic study, 167 patients with prostate cancer, who were imaged with bone scans and PSMA PET performed within 100 d, were included for analysis. Each study was interpreted by 3 masked readers, and the results of the PSMA PET were used as the reference standard. Endpoints were positive predictive value (PPV), negative predictive value (NPV), and specificity for bone scans. Additionally, interreader reproducibility, positivity rate, uptake on PSMA PET, and the number of lesions were evaluated. Results: In total, 167 patients were included, with 77 at initial staging, 60 in the biochemical recurrence and castration-sensitive prostate cancer setting, and 30 in the castration-resistant prostate cancer setting. In all patients, the PPV, NPV, and specificity for bone scans were 0.73 (95% CI, 0.61-0.82), 0.82 (95% CI, 0.74-0.88), and 0.82 (95% CI, 0.74-0.88), respectively. In patients at initial staging, the PPV, NPV, and specificity for bone scans were 0.43 (95% CI, 0.26-0.63), 0.94 (95% CI, 0.85-0.98), and 0.80 (95% CI, 0.68-0.88), respectively. Interreader agreement for bone disease was moderate for bone scans (Fleiss κ, 0.51) and substantial for the PSMA PET reference standard (Fleiss κ, 0.80). Conclusion: In this multicenter retrospective study, the PPV of bone scans was low in patients at initial staging, with 57% of positive bone scans being false positives. This suggests that a large proportion of patients considered low-volume metastatic by the bone scan actually had localized disease, which is critical when applying clinical data from trials such as the STAMPEDE M1 radiation therapy trial to patients being staged with PSMA PET.

Diagnostic and therapeutic impact of PET/CT with 18F-DCFPyL versus 18F-Fluorocholine in initial staging of intermediate-/high-risk prostate cancer: a pilot study.

AIM: To assess the diagnostic and therapeutic impact of PET/CT with 18F-DCFPyL with respect to 18F-Fluorocholine in initial staging of intermediate-/high-risk prostate cancer (PCa). MATERIAL AND METHODS: Patients with recent diagnosis of intermediate-/high-risk PCa without androgen deprivation therapy and previous 18F-Fluorocholine-PET/CT (negative for extraprostatic disease or with oligometastatic disease) were referred to 18F-DCFPyL-PET/CT. Patients' disease characteristic as grade group, D'Amico risk category (intermediate/high), prostate-specific antigen (PSA) closest to PET/CTs and its kinetics were obtained. The overall detection rate (DR) and molecular imaging TNM (miTNM) stage according to the prostate cancer molecular imaging standardized evaluation (PROMISE) criteria were assessed for both radiotracers, and their concordance (Kappa coefficient) was analyzed. The diagnostic and therapeutic impact of 18F-DCFPyL with respect to 18F-Fluorocholine was evaluated. RESULTS: Fifty-eight patients were analyzed (84.5% high-risk). 18F-Fluorocholine showed a higher DR than 18F-DCFPyL of prostate gland involvement (100% versus 93.1%) and pelvic node disease (37.9% versus 31%; k = 0.436, p = 0.001). On the other hand, 18F-DCFPyL-PET/CT showed a higher DR of metastatic disease than 18F-Fluorocholine-PET/CT, 9/58 patients (15.5%): 3 M1a, 5 M1b and 1 M1c) versus 5/58 (8.6%) patients: 1 M1a and 4 M1b), k = 0.426; p = 0.001. No significant association was found between clinical characteristics (grade group, risk category, PSA level and kinetic) and 18F-Fluorocholine or 18F-DCFPyL results. The results of 18F-DCFPyL-PET/CT modified the previously planned treatment compared to 18F-Fluorocholine-PET/CT in 13 patients (22.4%). CONCLUSIONS: 18F-Fluorocholine and 18F-DCFPyL PET/CT showed a similar DR of prostate gland and lymph node involvement, although with moderate concordance for the latter. 18F-DCFPyL was superior to 18F-Fluorocholine in detecting regional and distant metastasis with a therapeutic impact in one of every five patients.

18F-JK-PSMA-7 PET/CT for staging intermediate- or high-risk prostate cancer patients before radical prostatectomy: a pilot study.

BACKGROUND: Positron emission tomography/computed tomography (PET/CT) using radiotracers that bind to the prostate-specific membrane antigen (PSMA) is mainly used in biochemical recurring prostate cancer. The aim of our study was to assess the usefulness of 18F-JK-PSMA-7 PET/CT for local and nodal staging in patients with intermediate- and high-risk prostate cancer (PCa) prior to radical prostatectomy, as compared to conventional imaging techniques. METHODS: We enrolled a total of 10 patients with intermediate- and high-risk PCa diagnosed by multiparametric-MRI followed by systematic and targeted biopsies, eligible for radical prostatectomy with extended lymph node dissection. Clinical team was blind to the results of the pre-surgery 18F-JK-PSMA-7 PET/CT at times of clinical decision and surgery. One month post-surgery, 18F-JK-PSMA-7 PET/CT was repeated and the results of both scans were unblinded. A third 18F-JK-PSMA-7 PET/CT could be acquired at a later time point depending on PSA progression. RESULTS: All pre-surgery 18F-JK-PSMA-7 PET/CT was positive in the prostatic region, while MRI was negative in the prostate in one patient. We also detected positive pelvic lymph nodes in two patients (one high-risk, one intermediate-risk PCa) on pre-surgery and post-surgery 18F-JK-PSMA-7 PET/CT. No positive pelvic lymph nodes were reported on pre-surgical CT and MRI. 18F-JK-PSMA-7 PET/CT detected bladder involvement in one patient and seminal vesicles involvement in two patients; this malignant extension was undetected by the conventional imaging techniques. SUVmax in prostate lesions had an average value of 11.51 (range 6.90-21.49). SUVmean in prostate lesions had an average value of 7.59 (range 5.26-14.02). CONCLUSION: This pilot study indicates that pre-surgery 18F-JK-PSMA-7 PET/CT provides valuable information in intermediate- and high-risk PCa, for surgery planning with curative intent.

Role of 18F-Choline PET/CT in the Initial Staging of High Risk Prostate Cancer and Comparison with Conventional Imaging Techniques.

OBJECTIVE: To assess the diagnostic accuracy of 18F-Choline PET/CT in the initial staging of high-risk prostate cancer (PC), and to compare it with conventional imaging techniques and to assess the changes in therapeutic attitude derived from its results. SECONDARY OBJECTIVES: To assess the concordance between 18F-Choline PET/CT and conventional study and to find related prognostic factors. MATERIAL AND METHODS: Retrospective observational study of 78 patients with high-risk PC undergoing 18F-Choline PET/CT after conventional initial staging (CT + BS). Sensitivity, specificity and predictive values of 18F-Choline PET/CT and CT + BS were calculated. The golden standard was histological result or follow-up. Tumor characteristics were collected and univariate and multivariate analyzes were performed. RESULTS: The median age was 67 years old and mean PSA was 42.39 ng/mL. The sensitivity, specificity and NPV in global initial staging for PET/CT 18F-Choline and conventional imaging were: 92.9% vs 38.5%, 83.3% vs 42.3%, and 90.9% vs 40.7%, respectively. Lymph node staging: sensitivity 96.3% vs 61.5% and specificity 80% vs 76%, respectively. Bone staging: sensitivity 91.7% vs 21.4% and specificity 97.4% vs 83.8%, respectively. There was agreement in 25 patients (32%) (p = 0.004), Kappa index 0.134 (p = 0.011). The treatment was modified in 47.4% patients. PSA, PSADT% positive cores and cT were related to PET results. PSA level <8.9 ng/mL was considered an independent protective factor for positive PET (OR 0.03) (95% CI: 0.002-0.435, p 0.010). CONCLUSIONS: 18F-Choline PET/CT seems to be superior to CT + BS for initial staging in high-risk PC. It could be considered because its results can change the treatment decision in almost half of the patients.

Utility of 18F-FDG PET/CT in Management of Pancreatic and Periampullary Masses-Prospective Study from a Tertiary Care Center.

Characterizing a pancreatic or periampullary mass lesion as benign or malignant on conventional imaging is difficult due to overlapping morphological features. 18F-FDG PET/CT is a molecular imaging technique with reportedly higher sensitivity and specificity in the differentiation of benign and malignant pancreatic and periampullary masses. In this prospective study, we evaluated the utility of 18F-FDG PET/CT in patients with recently diagnosed pancreatic and periampullary masses. Based on FDG uptake pattern, diffuse or absent uptake was considered benign and focal increased uptake as malignant. Among the 32 patients included in the study, pathological examination confirmed 25 as positive for malignancy and the remaining 7 as benign etiology. Based on FDG uptake pattern, sensitivity, specificity, PPV, NPV, and accuracy of the study were 92%, 42.8%, 85.2%, 60%, and 81.3% respectively. 18F-FDG PET/CT had a statistically significant higher detection rate in the evaluation of regional lymph nodes and distant organ metastases compared to radiological imaging. In 7/25 (14%) malignant cases, 18F-FDG PET/CT detected additional distant metastases which were not detected by conventional imaging and thus resulting in change in management from curative resection to palliative therapy. To conculde, 18F-FDG PET/CT uptake pattern can characterize pancreatic and periampullary masses as benign or malignant with a relatively good accuracy. Using 18F-FDG PET/CT for initial staging of pancreatic and periampullary cancer helps in appropriate staging and optimal selection of treatment modality compared to conventional imaging techniques.

[Place of molecular imaging in the management of prostate cancer]. / Place de l'imagerie moléculaire dans la prise en charge du cancer de la prostate.

In the management of prostate cancer in recent years, innovative therapies have appeared requiring precise and reliable disease detection. In 2021, new generation imaging (PET/CT, multiparametric MRI, PET/MRI) have their place at all stages of the prostate cancer natural history to help target the lesion(s) and guide therapy and improve the results obtained. PSMA PET/CT is currently the leader in this type of imaging with a complete offer during the disease: both from diagnosis, to recurrence or in the oligo-metastatic and metastatic stage resistant to castration with a pivotal role in the PSMA theranostic approach. However, multiparametric MRI also has many detection advantages when the prostate is left in place, which suggests the potential major benefit of hybrid PSMA PET/MRI imaging.

A Joint Statement from the American Thyroid Association, the European Association of Nuclear Medicine, the European Thyroid Association, the Society of Nuclear Medicine and Molecular Imaging on Current Diagnostic and Theranostic Approaches in the Management of Thyroid Cancer.

Background: The American Thyroid Association (ATA), the European Association of Nuclear Medicine, the European Thyroid Association, and the Society of Nuclear Medicine and Molecular Imaging have established an intersocietal working group to address the current controversies and evolving concepts in thyroid cancer management and therapy. The working group annually identifies topics that may significantly impact clinical practice and publishes expert opinion articles reflecting intersocietal collaboration, consensus, and suggestions for further research to address these important management issues. Summary: In 2019, the intersocietal working group identified the following topics for review and interdisciplinary discussion: (i) perioperative risk stratification, (ii) the role of diagnostic radioactive iodine (RAI) imaging in initial staging, and (iii) indicators of response to RAI therapy. Conclusions: The intersocietal working group agreed that (i) initial patient management decisions should be guided by perioperative risk stratification that should include the eighth edition American Joint Committee on Cancer staging system to predict disease specific mortality, the modified 2009 ATA risk stratification system to estimate structural disease recurrence, with judicious incorporation of molecular theranostics to further refine management recommendations; (ii) diagnostic RAI scanning in ATA intermediate risk patients should be utilized selectively rather than being considered mandatory or not necessary for all patients in this category; and (iii) a consistent semiquantitative reporting system should be used for response evaluations after RAI therapy until a reproducible and clinically practical quantitative system is validated.

The Relationship of SUV Value in PET-CT with Tumor Differentiation and Tumor Markers in Gastric Cancer.

OBJECTIVE: We aimed to investigate the relationship between the use of fluoro-2-deoxyglucose (FDG)-positron emission tomography (PET)/computed tomography (CT), maximized standardized uptake value (SUVmax) values of tumors, and tumor differentiation and tumor markers during the initial staging of patients with gastric cancer. MATERIALS AND METHODS: The study included 50 patients (14 women and 36 men; mean age: 63±11 years; age range: 31-80 years) who had undergone initial staging with FDG-PET/CT after the diagnosis of gastric cancer with endoscopic biopsy between January and June 2013. Serum alpha fetoprotein (AFP), carcinogenic antigen 19-9 (CA 19.9), carcinoembryonic antigen (CEA), and C-reactive protein (CRP) levels were measured in patients prior to imaging. PET/CT images were evaluated for primary tumors, locoregional spread, and distant organ metastases, and classified by tumor-node-metastasis staging. Semiquantitative data were collected by SUVmax measurements in pathological regions of involvement. Data were analyzed statistically. RESULTS: FDG-PET/CT showed primary gastric cancer with a sensitivity of 87%. Imaging findings were normal in 3 patients (1/3; mucinous adenocarcinoma, 2/3; signet-ring cell adenocarcinoma). With FDG-PET/CT, 3/50 patients were classified into Stage 1B, 3/50 patients into Stage 2, 5/50 patients into Stage 3A, 5/50 patients into Stage 3B, 5/50 patients into 3C and 29/50 patients into Stage 4. The mean SUVmax was calculated as 11.35±4.3 (poorly differentiated adenocarcinoma: 5.4±1.7; moderately differentiated adenocarcinoma: 10.3±4.8) for the primary tumor and 14.9±6.3 for tumor metastasis. A positive correlation was evident between the measured SUVmax and stage and the grade of primary tumor (p<0.05). While the relationship between SUVmax and levels of serum AFP and CRP was statistically significant (p<0.05), the relationship between SUVmax and levels of serum CA 19-9 and CEA was not statistically significant (p>0.05). CONCLUSION: The SUVmax of primary tumors was associated with the degree of differentiation of primary tumors and the biochemical tumor markers CRP and AFP. The fact that SUVmax of primary tumors is high supplies clues about the presence of the factors affecting prognosis of the disease.

Potential Impact of 68Ga-PSMA-11 PET/CT on the Planning of Definitive Radiation Therapy for Prostate Cancer.

Standard-of-care imaging for initial staging of prostate cancer (PCa) underestimates disease burden. Prostate-specific membrane antigen (PSMA) PET/CT detects PCa metastasis with superior accuracy, having a potential impact on the planning of definitive radiation therapy (RT) for nonmetastatic PCa. Our objectives were to determine how often definitive RT planning based on standard target volumes covers 68Ga-PSMA-11 PET/CT-defined disease and to assess the potential impact of 68Ga-PSMA-11 PET/CT on definitive RT planning. Methods: This was a post hoc analysis of an intention-to-treat population of 73 patients with localized PCa without prior local therapy who underwent 68Ga-PSMA PET/CT for initial staging as part of an investigational new drug trial. Eleven of the 73 were intermediate-risk (15%), 33 were high-risk (45%), 22 were very-high-risk (30%), and 7 were N1 (9.5%). Clinical target volumes (CTVs), which included the prostate, seminal vesicles, and (in accord with the Radiation Therapy Oncology Group consensus guidelines) pelvic lymph nodes (LNs), were contoured on the CT portion of the PET/CT images by a radiation oncologist masked to the PET findings. 68Ga-PSMA-11 PET/CT images were analyzed by a nuclear medicine physician. 68Ga-PSMA-11-positive lesions not covered by planning volumes based on the CTVs were considered to have a major potential impact on treatment planning. Results: All patients had one or more 68Ga-PSMA-11-positive primary prostate lesions. Twenty-five (34%) and 7 (9.5%) of the 73 patients had 68Ga-PSMA-11-positive pelvic LN and distant metastases, respectively. The sites of LN metastases in decreasing order of frequency were external iliac (20.5%), common iliac (13.5%), internal iliac (12.5%) obturator (12.5%), perirectal (4%), abdominal (4%), upper diaphragm (4%), and presacral (1.5%). The median size of the LN lesions was 6 mm (range, 4-24 mm). RT planning based on the CTVs covered 69 (94.5%) of the 73 primary lesions and 20 (80%) of the 25 pelvic LN lesions, on a per-patient analysis. Conclusion:68Ga-PSMA-11 PET/CT had a major impact on intended definitive RT planning for PCa in 12 (16.5%) of the 73 patients whose RT fields covered the prostate, seminal vesicles, and pelvic LNs and in 25 (37%) of the 66 patients whose RT fields covered the prostate and seminal vesicles but not the pelvic LNs.

Role of Fluorodeoxyglucose-Positron Emission Tomography/Computed Tomography in the Evaluation of Head and Neck Carcinoma.

Fluorodeoxyglucose (FDG)-positron emission tomography-computed tomography (PET-CT) has been playing a pivotal role in tumor imaging for the past 20 years. Head and neck (HN) cancers are a good example that can illustrate such unique role of FDG imaging contributing to the patient's management. In this review article, we will describe the normal physiological distribution of FDG within HN structures focusing on its limitations and pitfalls. In addition, we will be also describing its role in the initial staging and restaging of the disease, particularly with regard to therapy response assessment. Furthermore, its role in the evaluation of patients with malignant cervical adenopathy from an unknown primary will be described. In 2016, the Royal College of Radiologists in its third edition published evidence-based guidelines for PET-CT use in HN cancer emphasizing its rule in all these clinical scenarios that are being described in this review. Finally, we will be highlighting future directions in the field of molecular imaging of HN tumors with a special emphasis on the new PET tracers.

Limitations in the use of 18F-FDG PET in the pre-operative staging of gastric cancer: A case series.

INTRODUCTION: Positron emission tomography (PET) is a mainstay in the preoperative evaluation of various cancers. In gastric cancer however, its role in the initial staging remains contentious. Presented is a case series of three gastric patients wherein the use of fluorodeoxyglucose (18F-FDG) PET/CT (computer tomography) as part of the initial staging was inconsequential to treatment, demonstrating its limited role in the staging of primary gastric cancer. METHODS: We analyzed retrospective data from 12/1/2010 to 10/31/2016 of patient with gastric cancer whose initial staging included a PET/CT. Only patients 18 years and older with gastric and gastro-oesophageal junction cancers were included. The data was derived from a single institution. Management of patients involved both an academic institution and a community practice. RESULTS: Of the three cases reported, an FDG-avid mass with minimal FDG uptake was reported in a single case and no FDG-avid lesion was reported in the other two. Neither of the patients underwent an endoscopic ultrasound for lack of availability. CONCLUSION: While various imaging studies such as endoscopic ultrasound have an established role in the initial staging, the role of FDG-PET is yet to be established and its routine use remains contentious. Based on our clinical experience and review of the literature, we believe FDG-PET/CT imaging is of limited clinical and cost effective value in the initial staging workup of gastric cancer.

[Initial management of advanced ovarian cancer: What radiological, pathological and surgical information are important for optimal therapeutic strategy?]. / Prise en charge initiale du cancer de l'ovaire avancé : quelles sont les informations radiologiques, anatomo-pathologiques et chirurgicales importantes pour une stratégie thérapeutique optimale ?

Because the majority of patients present advanced disease at diagnosis, the management of epithelial ovarian cancer needs specialist multidisciplinary teamwork. Expertise in surgery, chemotherapy, imaging and histopathology is essential to achieve optimum outcomes. Computed tomography scans are routinely used to determine the extent of disease and to aid in surgical planning. The histologic classification is crucial to plan the best therapeutic strategy and to define the prognosis of disease. Pathological prognostic factors, such as degree of differentiation, FIGO-stage, and histological type have to be described. This report is fundamental to assessing prognosis and selection of appropriate treatment strategy. An adequate staging procedure is an extensive staging by an experienced gynecological oncologist, exploring the entire upper abdomen, and the pelvic and para-aortic lymph node regions to define the Peritoneal Cancer Index (PCI). The final assessment is the completeness of cytoreduction (CC) score, which is an assessment of residual disease after a maximal surgical effort. Initial management of advanced ovarian cancer is best provided by a specialist multidisciplinary team, including a radiologist, a pathologist, a gynecologic oncologist and a medical oncologist.

Impact of (18)f-fluorodeoxyglucose positron emission tomography/computed tomography scan on initial evaluation of head and neck squamous cell carcinoma: our experience at a tertiary care center in India.

The efficacy of the whole body (WB) (18)F-fluorodeoxyglucose ((18)F-FDG) positron emission tomography-computed tomography (PET-CT) as a part of conventional initial staging in all cases of head and neck squamous cell carcinoma (HNSCC) is still controversial with various studies in literature giving contradictory reports. We conducted this study at a government tertiary care oncology center in India to identify the impact of WB (18)F-FDG PET-CT scan on HNSCC staging and treatment. A prospective clinical study of patients of HNSCC who were evaluated and treated at our center was performed. The patients included in the study were HNSCC of the oral cavity, oropharynx, hypopharynx, larynx, nasopharynx, and carcinoma of unknown primary site (CUPS) with cervical metastasis. The study design was to evaluate the cases of HNSCC initially by staging with conventional investigations followed by staging with the information derived from WB (18)F-FDG PET-CT scan. At the end of the conventional investigations, a tumor, node, metastasis (TNM) staging as per AJCC 7(th) edition, and a detailed treatment plan as per NCCN 2012 guidelines was decided in consultation with the multidisciplinary oncology team of the hospital. WB (18)F-FDG PET-CT scan was carried out in all these patients. The findings of WB (18)F-FDG PET-CT were then interpreted with the staging with conventional investigations to identify the cases with change in staging and also those in whom the treatment protocol would be affected. Descriptive analysis of demographic data and analytical analysis of the sensitivity and specificity of WB (18)F-FDG PET-CT scan and also the change in staging and treatment plan after WB (18)F-FDG PET-CT scan was analyzed using SPSS version 18. A total of 131 patients met the inclusion criteria, which included 123 males and 8 females. The various sites involved among the study group are oral cavity 11 (8.3%), oropharyn × 39 (29.7%), hypopharyn × 31 (23.6%), laryn × 34 (25.9%), nasopharyn × 4 (3%), and CUPS 12 (9.1%). The majority of cases studied were of T2 and T3 stage, and changes in T staging after WB (18)F-FDG PET-CT scan were minimal and not statistically significant (P > 0.5). In the nodal staging after WB (18)F-FDG PET-CT scan, there was a statistically significant change in identification of nodal metastasis in N0 group and also identification of additional multiple/bilateral nodes (N2b and N2c). 3 (2.2%) patients had a change in M status with identification of distant metastasis in lungs (2 patients) and in the liver and lung (1 patient). Of the 131 patients, 75 (57.25%) underwent surgical management with or without adjuvant treatment (Group I) and 56 (42.74%) patients underwent nonsurgical management (Group II). There was no significant statistical difference in sensitivity and specificity of (18)F-FDG PET-CT scan in detecting cancer among the two groups. Considering all the patients in this study, WB (18)F-FDG PET-CT scan showed an overall sensitivity of 95.2% and specificity of 80%. In this study, change in TNM staging after WB (18)F-FDG PET-CT was seen in 22 (16.8%) patients and an alteration in the treatment in 21 (16.1%) patients, which were both found to be statistically significant (P < 0.5). In our study, WB (18)F-FDG PET-CT scan has shown to have an impact on initial staging of disease affecting the change in treatment protocol in a significant number of patients. The effect of this change in staging and treatment on the eventual morbidity and mortality rates is not known. In practice, the use of (18)F-FDG PET-CT scan is limited, owing to the high cost and low availability. A realistic evaluation of cost versus benefit needs to be undertaken to identify the impact of using (18)F-FDG PET-CT scan as a mode for initial evaluation of HNSCC.

Can Initial (18)F-FDG PET-CT Imaging Give Information on Metastasis in Patients with Primary Renal Cell Carcinoma?

PURPOSE: The aim of this study was to investigate the relationship between the maximum standardized uptake values (SUVmax) of primary renal cancers with and without metastatic lesions, if any. We also studied the relationship between the size of primary renal cancers and their SUVmax, and tried to find a clinical value of (18)F-FDG PET-CT for the initial evaluation of renal cell carcinoma (RCC). METHODS: The cases of 23 patients, 16 men and 7 women, who underwent PET-CT examination before operation were retrospectively reviewed. We measured the SUVmax of the primary renal cancers and those of any existing metastatic lesions, and the size of the primary renal cancers. We compared the SUVmax of primary RCCs with metastases and those without metastases, SUVmax of primary RCC and those of metastases, and studied the correlation between the size and SUVmax of primary RCCs. RESULTS: The SUVmax of primary RCC of the 16 patients without metastasis ranged from 1.1 to 5.6 with a median value of 2.6. Those of the patients with metastasis ranged from 2.9 to 7.6 with a median of 5.0. The size of the all 23 primary renal cancers ranged from 1.7 cm to 13.5 cm, with a median of 4.5 cm, and their SUVmax ranged from 1.1 to 7.6, with a median of 2.9. There was a statistically significant difference between the SUVmax of the primary RCC with metastasis (5.3 ± 1.7) and those without metastasis (2.9 ± 1.0). There was a moderate positive correlation between the sizes and SUVmax of all 23 primary RCCs. However, there was no statistically significant correlation between the sizes and SUVmax of primary RCCs with metastatic lesions and the same for RCCs without metastasis. The cutoff value of SUVmax for predicting extra-renal lesion was 4.4 and that for size was 5.8 cm according to the receiver operating characteristic curves. CONCLUSIONS: Those who have primary RCC with high SUVmax are suggested to have a likelihood of metastasis. Also, there was a moderate trend of increasing value of SUVmax of primary RCC as their size increases. Physicians should beware of missing extra-renal lesions elsewhere.

Three-dimensional Doppler ultrasonography in assessing nodal metastases and staging head and neck cancer.

OBJECTIVES/HYPOTHESIS: This study built a simple prediction system by three-dimensional (3D) Doppler ultrasonography to evaluate the metastases of cervical lymph nodes and the preoperative initial stage of head and neck cancer. STUDY DESIGN: Retrospective review of cervical lymph node ultrasound features and prospective nodal staging of head and neck cancer. METHODS: One hundred thirty-nine suspicious cervical lymph nodes, receiving 3D Doppler ultrasonography, were used to establish a predictive model. Then nodal metastasis was initially staged from 27 patients with head and neck cancer by this model. RESULTS: The prediction system was constructed by major (internal matting, vascularity pattern) and minor (age ≥ 40 years, short/long ratio ≥ 0.5) sign categories. Cervical lymph node was regarded as metastasis with the presence of one major and any of the other factors. The predictive model resulted in sensitivity of 91.9%, specificity of 88.2%, and accuracy of 89.2%. Then we evaluated the initial staging of patients with head and neck cancer by this model, and the rate of correct N staging was 92.6%. CONCLUSIONS: According to this prediction system, 3D Doppler ultrasonography definitely provides a rapid and reliable method for initial staging of head and neck cancer.

Detection of bone metastases in initial staging of orbital embryonal rhabdomyosarcoma by fluorodeoxyglucose positron emission tomography/computed tomography.

UNLABELLED: Rhabdomyosarcoma is the most common form of soft tissue sarcoma in young children. In soft tissue sarcomas, isolated metastases are seen in the lung, soft tissue, and bone. The optimal management of these tumors depends on the site, size, and grade of the local growth, and accurate staging of the disease when first seen. Although detection of the primary site of disease is usually accomplished well with conventional techniques, the performance of fluorodexyglucose (FDG) positron emission tomography/computed tomography (PET/CT) may be useful to determine metastases that are not clinically evident. We describe a case of early detection of distant metastases by FDG PET/CT in a young patient diagnosed with orbital embryonal rhabdomyosarcoma. CONFLICT OF INTEREST: None declared.