PSMA-Avid Desmoid Tumor of the Abdominal Wall on 18 F-Piflufolastat PET/CT.

ABSTRACT: Prostate-specific membrane antigen (PSMA) PET/CT is widely used in the evaluation of suspected metastasis for initial definitive therapy and suspected recurrence of prostate cancer. We outline a case report of a 62-year-old man with history of prostate cancer treated with surgery, salvage radiation, and hormonal therapy presenting with rising PSA levels. There was incidental detection of a PSMA-avid subcutaneous abdominal wall mass on PSMA PET/CT study, which was consistent with desmoid fibromatosis on an ultrasound-guided biopsy.

Enchondroma on Bone Scan and PSMA PET/CT in a Patient With Prostate cancer.

ABSTRACT: A 54-year-old man with Gleason 9 prostate cancer with reported nodal and skeletal metastases was referred to us. Outside hospital reports described abnormal left proximal humerus activity on bone scan concerning for metastasis; however, concurrent PSMA PET/CT did not show activity in this lesion. Further review of the PET/CT images revealed characteristic features of enchondroma in the left humeral lesion.

Vapocoolant Analgesia for Breast Lymphoscintigraphy: A Prospective Clinical Trial.

Breast lymphoscintigraphy is commonly performed before initial surgical intervention and surgical staging in the setting of breast cancer. Breast lymphoscintigraphy injections can often be quite painful and are routinely performed without any anesthesia or analgesia, thus representing a significant unmet need for the breast cancer population. Although vapocoolants have been previously available, they have typically been used on intact skin and not been recommended for sterile procedures. Methods: Thirty consecutive patients were enrolled in our prospective study of which 29 received vapocoolant analgesia in the setting of breast lymphoscintigraphy. Patients were given a postinjection questionnaire that included a self-reported pain score and boolean question regarding whether they would recommend vapocoolant for future patients. Results: The lymposcintigraphy procedure was successful in 100% of cases with an ipsilateral axillary node identified on average within 2.4 h of injection (median, 1 h; range 1-4.5 h). The average self-reported pain score was 1.98 (median, 1; range, 1-10). Conclusion: Vapocoolant analgesia in the setting of breast lymphoscintigraphy is feasible, does not appear to compromise lymphoscintigraphy, and appears to be associated with generally low self-reported pain scores.

Pitfall of 18 F-PSMA PyL PET/CT Imaging of a Displaced Urinary Bladder as Recurrent Prostate Malignancy.

ABSTRACT: We herein present a potential pitfall in the setting of restaging PSMA PyL PET/CT. In this case, there is large non-PSMA-avid cystic structure in the mid pelvis, probably representing a postprostatectomy lymphocele, which was mistaken for the urinary bladder, resulting in the displaced and somewhat crescentic urinary bladder to be deemed recurrence. Subsequently, biopsy and retrospective review of images confirms displaced urinary bladder containing physiologic excreted activity.

Comparison of PSMA-based 18F-DCFPyL PET/CT and Tc-99m MDP bone scan in detection of bone metastasis in prostate cancer.

While Tc-99m MDP bone scan (BS) remains the conventional standard for detection of bone metastasis in prostate cancer, newly FDA-approved imaging with PSMA-based 18F-DCFPyL PET/CT has shown promise for early detection of metastatic disease. However, a paucity of data remains in the diagnostic accuracy of PSMA PET/CT in detecting bone metastasis compared to BS. This retrospective study included 91 patients who received both BS and PSMA PET/CT within a 3-month interval from August 2021 to February 2022. Separate concurrent primary cancer, interval PSA levels greater than a 2-fold difference (or absolute difference >1 ng/ml) between the two studies were excluded. All abnormal bone lesions on either scan were compared. The findings were verified by pathological findings and/or 6-month clinical follow-up. High concordance (78%) was found between modalities with discordant findings (20/91, 22%) demonstrating more false positives (4/20, 20%) and false negatives (3/20, 15%) on BS compared to PET/CT. Additionally, more bone metastases were detected on PSMA PET/CT (13/20, 65%) with all true positive BS lesions also detected PET/CT. The sensitivity, specificity, PPV and NPV for BS were 89%, 91%, 80%, and 95% respectively; and 100%, 97%, 93%, and 100% for 18F-DCFPyL PET/CT respectively. Our results demonstrate that 18F-DCFPyL PET/CT identified more bone metastases while also identifying all bone metastases identified on BS. With the added diagnostic value of detecting primary tumor and soft tissue metastasis, 18F-DCFPyL PET/CT may render BS unnecessary to investigate bone metastases in patients with prostate cancer.

Smart Start: Rituximab, Lenalidomide, and Ibrutinib in Patients With Newly Diagnosed Large B-Cell Lymphoma.

PURPOSE: Chemoimmunotherapy for patients with newly diagnosed diffuse large B-cell lymphoma (DLBCL) is largely unchanged for decades. Both preclinical models and clinical data suggest the combination of lenalidomide and ibrutinib may have synergy in DLBCL, particularly in the non-germinal center B-cell-like subset. METHODS: We enrolled 60 patients with newly diagnosed non-germinal center B-cell-like DLBCL in this investigator-initiated, single-arm phase II trial of rituximab, lenalidomide, and ibrutinib (RLI) with the sequential addition of chemotherapy (ClinicalTrials.gov identifier: NCT02636322). Patients were treated with rituximab 375 mg/m2 intravenous once on day 1, lenalidomide 25 mg once per day on days 1-10, and ibrutinib 560 mg once daily continuously of each 21-day cycle (RLI). After two cycles, standard chemotherapy was added to RLI for six additional cycles. The primary end points were overall response rate (ORR) after two cycles of RLI alone and complete response rate after completion of RLI with chemotherapy. In evaluable samples, circulating tumor DNA and DLBCL90 assays were performed. RESULTS: The median age was 63.5 years (range, 29-83 years) with 28% age 70 years or older. The revised international prognostic index identified 42% as high risk, and 62% were double expressor of MYC and BCL2 protein. The ORR after two cycles of RLI was 86.2%, and the complete response rate at the end of RLI-chemotherapy was 94.5%. With a median follow-up of 31 months, the progression-free survival and overall survival were at 91.3% and 96.6% at 2 years, respectively. CONCLUSION: Smart Start is the first study, to our knowledge, to treat newly diagnosed DLBCL with a targeted therapy combination before chemotherapy. RLI produced a high ORR, and RLI with chemotherapy resulted in durable responses. This establishes the potential for developing biologically driven and noncytotoxic first-line therapies for DLBCL.

Complications of Ileal Conduits after Radical Cystectomy: Interventional Radiologic Management.

Since their introduction into clinical practice in the 1950s, ileal conduits have been the most common type of urinary diversion used after radical cystectomy worldwide. Although ileal conduits are technically simpler to construct than other forms of urinary diversion, a variety of complications can occur in the early and late postoperative periods. Early complications include urine leakage, urinary obstruction, postoperative fluid collection (eg, urinoma, hematoma, lymphocele, or abscess), and fistula formation. Late complications include ureteroileal anastomotic stricture, stomal stenosis, conduit stenosis, and urolithiasis. Although not directly related to ileal conduits, ureteroarterial fistula can occur in patients with an ileal conduit. Interventional radiologists can play a pivotal role in diagnosis and management of these complications by performing image-guided minimally invasive procedures. In this article, the authors review the surgical anatomy of an ileal conduit and the underlying pathophysiology of and diagnostic workup for complications related to ileal conduits. The authors also discuss and illustrate current approaches to interventional radiologic management of these complications, with emphasis on a collaborative approach with urologists or endourologists to best preserve patients' renal function and maintain their quality of life. ©RSNA, 2020.

CT-guided cryoablation for post-thoracotomy pain syndrome: a retrospective analysis.

PURPOSE Post-thoracotomy pain syndrome is a common condition affecting up to 50% of post-thoracotomy patients. However, percutaneous computed tomography (CT)-guided intercostal nerve cryoablation may provide symptomatic benefit in chronic and/or refractory cases. METHODS A retrospective review of our institution's comprehensive case log from October 2017 to September 2018 for patients who underwent cryoablation was analyzed. Thirteen patients with post-thoracotomy pain syndrome, refractory to medical management, were treated with CT-guided intercostal nerve cryoablation. Most patients had treatment of the intercostal nerve at the level of their thoracotomy scar, two levels above and below. The safety and technical success of this technique and the clinical outcomes of the study population were then retrospectively reviewed. RESULTS Of the patients, 69% experienced significant improvement in their pain symptoms with a median pain improvement score of 3 points (range, -1 to 8 points) over a median follow-up of 11 months (range, 2-18.6 months). Complications included pneumothorax in 8% and pseudohernia in 23% of patients. CONCLUSION CT-guided intercostal nerve cryoablation may be an effective technique in the treatment of post-thoracotomy pain syndrome and requires further study.

Transarterial embolization of a hyperfunctioning aldosteronoma in a patient with bilateral adrenal nodules.

Primary hyperaldosteronism often results in resistant hypertension and hypokalemia, which may lead to cardiovascular and cerebrovascular complications. Although surgery is first line treatment for unilateral functioning aldosteronomas, minimally invasive therapies may be first line for certain patients such as those who cannot tolerate surgery. We present a case of transarterial embolization (TAE) of an aldosteronoma. The patient presented with a cerebrovascular accident, and subsequently developed uncontrolled hypertension, hypokalemia, and a myocardial infarction. Following TAE, potassium returned to normal levels and blood pressure control was improved. There were no postoperative complications. TAE thus may be a safe and effective alternative to surgery.

Safety and efficacy of percutaneous cecostomy/colostomy for treatment of large bowel obstruction in adults with cancer.

PURPOSE: To assess the safety and efficacy of image-guided percutaneous cecostomy/colostomy (PC) in the management of colonic obstruction in patients with cancer. MATERIALS AND METHODS: Twenty-seven consecutive patients underwent image-guided PC to relieve large bowel obstruction at a single institution between 2000 and 2012. Colonic obstruction was the common indication. Patient demographics, diagnosis, procedural details, and outcomes including maximum colonic distension (MCD; ie, greatest transverse measurement of the colon on radiograph or scout computed tomography image) were recorded and retrospectively analyzed. RESULTS: Following PC, no patient experienced colonic perforation; pain was relieved in 24 of 27 patients (89%). Catheters with tip position in luminal gas rather than mixed stool/gas or stool were associated with greater decrease in MCD (-40%, -12%, and -16%, respectively), with the difference reaching statistical significance (P = .002 and P = .013, respectively). Catheter size was not associated with change in MCD (P = .978). Catheters were successfully removed from six of nine patients (67%) with functional obstructions and two of 18 patients (11%) with mechanical obstructions. One patient underwent endoscopic stent placement after catheter removal. Three patients required diverting colostomy after PC, and their catheters were removed at the time of surgery. One major complication (3.7%; subcutaneous emphysema, pneumomediastinum, and sepsis) occurred 8 days after PC and was successfully treated with cecostomy exchange, soft-tissue drainage, and intravenous antibiotic therapy. CONCLUSIONS: Image-guided PC is safe and effective for management of functional and mechanical bowel obstruction in patients with cancer. For optimal efficacy, catheters should terminate within luminal gas.

Cholecystokinin-assisted hydrodissection of the gallbladder fossa during FDG PET/CT-guided liver ablation.

A 68-year-old female with colorectal cancer developed a metachronous isolated fluorodeoxyglucose-avid (FDG-avid) segment 5/6 gallbladder fossa hepatic lesion and was referred for percutaneous ablation. Pre-procedure computed tomography (CT) images demonstrated a distended gallbladder abutting the segment 5/6 hepatic metastasis. In order to perform ablation with clear margins and avoid direct puncture and aspiration of the gallbladder, cholecystokinin was administered intravenously to stimulate gallbladder contraction before hydrodissection. Subsequently, the lesion was ablated successfully with sufficient margins, of greater than 1.0 cm, using microwave with ultrasound and FDG PET/CT guidance. The patient tolerated the procedure very well and was discharged home the next day.

Hill-Sachs lesion on FDG PET/CT.

A woman with colon cancer underwent FDG PET/CT. Images demonstrated an FDG-avid lytic defect in the posterosuperior right humeral head, without other suspicious lesions. Because it is rare for bone to be the first metastatic site in patients with colon cancer, additional clinical history was sought. The patient experienced chronic right-shoulder anterior dislocations. The diagnosis of Hill-Sachs lesion was made. A Hill-Sachs lesion is a depression in the posterosuperior aspect of the humeral head caused by impaction of the humeral head against the anterior scapular glenoid during anterior shoulder dislocation. FDG-avid Hill-Sachs lesions must be distinguished from malignancy.