Healthcare and Economic Impact of Lung Perfusion Scintigraphy in Patients Affected by Acute Pulmonary Embolism.

Acute pulmonary embolism (APE) is a cardiovascular emergency, representing the main cause of mortality, morbidity, and hospitalisation in Europe. We aim to evaluate the economic and healthcare impact of lung perfusion scintigraphy (LPS) used in patients with suspected APE, in the event of non-conclusive or contraindicated computed tomography pulmonary angiography (CTPA). We considered two alternative healthcare processes for APE diagnosis, with and without LPS. We performed a cost analysis with the aim of evaluating the average direct healthcare costs for diagnosis, risk assessment, and treatment of APE. We used data from a monocentric trial. Our economic model showed that the strategy with LPS was preferable in terms of costs. The average per-patient costs for the diagnosis and treatment of the acute phase of PE in low-risk patients with a non-conclusive or not-executable CTPA, with and without LPS, are EUR 2145.25 and EUR 4912.45, respectively. LPS is a simple, quick, and economic examination, useful in this setting of patients not only for an early diagnosis but also to exclude APE, demonstrating an advantage in terms of healthcare resources. To the best of our knowledge, this study is the first to analyse the economic and healthcare impact of the use of LPS in the diagnostic pathway of suspected APE.

Safety culture to improve accidental event reporting in radiotherapy.

BACKGROUND AND PURPOSE: The potential for unintended and adverse radiation exposure in radiotherapy (RT) is real and should be studied because RT is a highly complex, multistep process, which requires input from numerous individuals from different areas and steps of the RT workflow. The 'Incident' (I) is an event the consequence of which is not negligible from the point of view of protection or safety. A 'near miss' (NM) is defined as an event that is highly likely to happen but did not occur. The purpose of this work is to show that through systematic reporting and analysis of these adverse events, their occurrence can be reduced. MATERIALS AND METHODS: Staff were trained to report every type of unintended and adverse radiation exposure and to provide a full description of it. RESULTS: By 2018, 110 worksheets had been collected, with an average of 6.1 adverse events per year (with 780 patients treated per year, meaning an average incident rate of 0.78%). In 2001-2009, 37 events were registered (13 I and 24 NM), the majority of them were in the decision phase (12/37), while in 2010-2013, there were 42 (1 I and 41 NM) in both the dose-calculation and transfer phase (19/42). In 2014-2018, 31 events (1 I and 30 NM) were equally distributed across the phases of the RT process. In 9/15 cases of I, some checkpoint was introduced. CONCLUSION: The complexity of the RT workflow is prone to errors, and this must be taken into account by encouraging a safety culture. The aim of this paper is to present the collected incidents and near misses and to show how organization and practice were modified by the acquired knowledge.

Is whole body low dose CT still necessary in the era of 18F-FDG PET/CT for the assessment of bone disease in multiple myeloma patients?

OBJECTIVE: Whole body low dose computed tomography (WBLDCT) is the first-choice imaging modality to identify bone involvement in multiple myeloma (MM). Because the unenhanced LDCT co-registered to positron emission tomography (PET) (LDCT/PET) has similar technical characteristics to WBLDCT, we aimed to assess its reliability in the detection of bone disease, for employing fluorine-18-fluorodeoxyglucose (18F-FDG) PET/CT as unique multimodality imaging method in MM patients. SUBJECTS AND METHODS: Thirty three consecutive MM patients were prospectively enrolled and evaluated with WBLDCT to assess bone involvement. In addition, patients underwent 18F-FDG PET/CT using a disease-tailored optimized LDCT protocol. To compare both methods, skeletal anatomical regions were identified and a per-region and per-patient analysis were performed using Cohen's k test. Low dose computed tomography/PET sensitivity, specificity and accuracy were also calculated. RESULTS: The two imaging modalities resulted highly concordant considering both patient-based (k=0.841) and region-based analysis; some discrepancies were observed in dorsal spine (k=0.809) and thorax (k=0.756). Low dose computed tomography/PET sensitivity, specificity and accuracy were 89.4%, 98.3% and 93.5%, respectively. CONCLUSION: Low dose computed tomography co-registered PET has comparable performance to WBLDCT. If confirmed on a lager sample, these encouraging results suggest the possibility to use this multimodal hybrid imaging as the only method for MM evaluation, rather than both exams, providing both morphologic and metabolic information in one session with impact on patient compliance, health care spending and especially radiation exposure.

[Role of 18F-FDG PET/CT in comparison with CECT for whole-body assessment of patients with esophageal cancer.] / Il ruolo della 18F-FDG PET/CT nella stadiazione dei pazienti con carcinoma esofageo.

AIM: We aimed to evaluate the role of 18F-FDG PET/CT in the TNM staging of esophageal cancer in comparison with contrast-enhancement computed-tomography (CECT). Futhermore we set out to determine the role of semiquantitative PET parameters. METHODS: 55 patients performed 18F-FDG PET/CT and CECT. Values of Sensitivity (Se), specificity (Sp), accuracy and predictability (PPV and NPV) were evaluated. McNemar test was applied for comparison. Cohen's K was calculated to measure the agreement. 18F-FDG PET/CT semiquantitative parameters (SUVmax, SUVmean, MTV and TLG) in relation to site and histotype, were assessed by ANOVA test and post-hoc test. RESULTS: About T parameter, Se, Sp, accuracy, PPV and NPV of CECT and 18F-FDG PET/CT were respectively 82.35%, 94.48%, 85.00%, 93.33% and 76% for both the tecniques; the agreement resulted substantial. There were no statistically significant relationships between 18F-FDG PET/CT parameters and sites; MTV value differs in histotypes. About N parameter, Se, Sp, accuracy, PPV and NPV of CECT were respectively 82.35%, 57.89%, 65.00%, 46.67%, 88%; for 18F-FDG PET/CT were 88.23%, 60.53%, 61%, 50% and 92%; the agreement resulted fair. About M parameter, Se, Sp, accuracy, PPV and NPV PET/CT were equal for both techniques: 76.92%, 52.38%, 58.33%, 33%, 88%; the agreement resulted moderate. No statistical difference was observed in any comparison. CONCLUSION: 18F-FDG PET/CT is a useful tool for whole-body evaluation of patients with esophageal cancer, allowing an effective clinical TNM staging. In particular 18F-FDG PET/CT's ability in detecting distant metastases suggest its routinary performance as a second level of investigation.

Medical radiological procedures: which information would be chosen for the report?

AIMS AND OBJECTIVES: The aim of this study was to properly define the information regarding patient exposure to Ionizing Radiations in the radiological report, according to the European Directive 2013/59/EURATOM (EU 2013/59 art.58(b)). For this purpose, we evaluated the results from other Member States EU 2013/59 transpositions and from Guidelines recommendation published by International Organizations involved in diagnostic radiology. A practical way for implementing art.58 is also traced. MATERIALS AND METHODS: Dosimetric quantities, such as exposure, absorbed dose and effective dose which may be included in radiological report, were first analyzed; then, in order to define international state of art of Member States EU 2013/59 transposition, a Web research using French, English, Spanish and German key words was performed. RESULTS: EU 2013/59 transposition for 5 Member States was reported. Especially regarding art.58, a European project reports that few European countries (11 of 28) have identified the dose metrics to be used in radiological report. Scientific organizations supporting clinical radiologists and medical physicists have published Guidelines reporting parameters useful to quantify the radiation output and to assess patient dose. CONCLUSIONS: Our research revealed that there is not a shared interpretation of patient exposure information to be included in radiological report. Nevertheless, according to scientific community, authors believe that the exposure is the most appropriate information that could be included in radiological report. Alternatively, but with more expensiveness, a risk index based on effective dose could be used. Moreover, the systematic exposure information recorded could be useful for dose estimates of population from medical exposure.

Pediatric Hodgkin Lymphoma: Predictive value of interim 18F-FDG PET/CT in therapy response assessment.

We investigated the prognostic value of interim F-FDG PET/CT (PET-2) in pediatric Hodgkin lymphoma (pHL), evaluating both visual and semiquantitative analysis.Thirty pHL patients (age ≤16) underwent serial F-FDG PET/CT: at baseline (PET-0), after 2 cycles of chemotherapy (PET-2) and at the end of first-line chemotherapy (PET-T). PET response assessment was carried out visually according to the Deauville Score (DS), as well as semiquantitatively by using the semiquantitative parameters reduction from PET-0 to PET-2 (ΔΣSUVmax0-2, ΔΣSUVmean0-2). Final clinical response assessment (outcome) at the end of first-line chemotherapy was the criterion standard, considering patients as responders (R) or nonresponders (NR). Disease status was followed identifying patients with absence or relapsed/progression disease (mean follow-up: 24 months, range 3-78).Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of visual and semiquantitative assessment were calculated; furthermore, Fisher exact test was performed to evaluate the association between both visual and semiquantitative assessment and outcome at the end of the first-line chemotherapy. The prognostic capability of PET-2 semiquantitative parameters was calculated by ROC analysis and expressed as area under curve (AUC). Finally, progression-free survival (PFS) was analyzed according to PET-2 results based on the 5-point scale and semiquantitative criteria, using the Kaplan-Meier method.Based on the outcome at the end of first-line chemotherapy, 5 of 30 patients were NR, the remnant 25 of 30 were R. Sensitivity, specificity, PPV, NPV, and accuracy of visual analysis were 60%,72%,30%,90%,70%; conversely, sensitivity, specificity, PPV, NPV, and accuracy of semiquantitative assessment were 80%, 92%, 66.7%, 95.8%, 90%. The highest AUC resulted for ΔΣSUVmax0-2 (0.836; cut-off <12.5; sensitivity 80%; specificity 91%). The association between ΔΣSUVmax0-2 and outcome at the end of first-line chemotherapy resulted to have a strong statistical significance (P = 0.0026). Both methods demonstrated to influence PFS, even if the semiquantitative assessment allowed a more accurate identification of patients with a high risk of treatment failure (P = 0.005).Our preliminary results showed that PET-2 visual assessment, by using Deauville criteria, can be improved by using the semiquantitative analysis. The SUV max reduction (ΔΣSUVmax0-2) evaluation might provide a support for the interpretation of intermediate scores, predicting with good confidence those patients who will have a poor outcome and require alternative therapies.

Role of WB-MR/DWIBS compared to (18)F-FDG PET/CT in the therapy response assessment of lymphoma.

INTRODUCTION: This study prospectively evaluated whole-body magnetic resonance/diffusion-weighted imaging with body signal suppression (WB-MR/DWIBS) reliability compared to (18)F-FDG PET/CT in the treatment response assessment of classic Hodgkin lymphomas (HL) and aggressive non-Hodgkin lymphomas (aNHL). MATERIALS AND METHODS: Twenty-seven consecutive patients were prospectively enrolled at the time of diagnosis. Eighteen (11 HL and seven aNHL) were considered for the analysis. They received chemo/radiotherapy as induction and completed post-treatment evaluation performing both (18)F-FDG PET/CT and WB-MR/DWIBS. The revised response criteria for malignant lymphomas were used to assess the response to treatment. We evaluated the agreement between the two methods by Cohen's K test. Post-therapy WB-MR/DWIBS sensitivity, specificity, PPV, NPV and accuracy were then calculated, considering the 12 months of follow-up period as the gold standard. RESULTS: By using an evaluation on a lesion-by-lesion basis, WB-MR/DWIBS and (18)F-FDG PET/CT showed an overall good agreement (K = 0.796, 95% IC = 0.651-0.941), especially in the evaluation of the nodal basins in aNHL (K = 0.937, 95% IC = 0.814-1). In reference to the revised response criteria for malignant lymphomas, the two methods showed a good agreement (K = 0.824, 95% IC = 0.493-1). Post-therapy sensitivity, specificity, PPV, NPV and accuracy of WB-MR/DWIBS were 43, 91, 75, 71 and 72%, respectively. CONCLUSION: WB-MR/DWIBS seems to be an appropriate method for the post-treatment assessment of patients affected by HL and aNHL. The small discrepancies between the two methods found within HL could be due to the biological and metabolic behavior of this group of diseases. Larger prospective studies are necessary to better define the role of WB-MR/DWIBS in this setting of patients.

18F-FDG PET/CT metabolic activity assessment in infective and neoplastic diseases: a patient with systemic hydatidosis and concomitant Burkitt lymphoma.

We report a case of a 73-year-old-man with systemic hydatidosis and concomitant Burkitt lymphoma. He came at our attention for fever and weight loss suspected for parasitic cyst discharge and also for lymphoproliferative disorder. We performed US, which showed disseminated parasitic cysts. CECT showed parasitic cysts and also several abdominal and thoracic lymphnodes and adrenal hypodense tissue. 18F-FDG PET/CT was performed and showed lack of 18F-FDG uptake in cysts and high 18F-FDG uptake in lymphnodes and adrenal glands. These findings permitted us to exclude the cyst discharge, to localize a site for biopsy, and to define and stage the Burkitt lymphoma.

[Role of 18F-FDG-PET/CT in the assessment of carotid atherosclerosis]. / Ruolo della 18F-FDG-PET/TC nella valutazione delle placche aterosclerotiche carotidee.

The aim of this study was to determine the role of 18F-FDG-PET/CT in the evaluation of carotid plaques and its relationship with cardiovascular risk factors. 18F-FDG-PET/CT scan was performed in 25 patients with ultrasound diagnosis of carotid atherosclerosis and ≥70% stenosis, who were scheduled for carotid endoarterectomy. 18F-FDG uptake was measured by ROIs drawn on PET/CT carotid artery slices. A statistically significant difference in 18F-FDG uptake was observed in relation to body mass index values between 25 and 29 kg/m2. Our results suggest that PET/CT imaging has utility in risk stratification of atherosclerotic patients.

[Multidetector CT for the assessment of the groin region]. / La TC multidetettore nello studio del canale inguinale.

Assessment of the complex anatomy of the groin region using different imaging modalities is important to identify those pathological conditions that may present with atypical symptoms. In obese patients or in the presence of complications, physical examination may be unremarkable and instrumental studies based on non-invasive techniques (e.g., ultrasounds) do not allow accurate assessment of this region. Multidetector CT scanning and reconstruction can provide useful information on inguinal canal anatomy and its related diseases, contributing to timely therapeutic interventions.

[Striatal dopamine transporter levels in patients with REM sleep behavior disorder: assessment with 123I-FP-CIT SPECT]. / Livelli striatali del trasportatore della dopamina nei pazienti affetti da disturbo comportamentale del sonno REM: uno studio SPECT con 123I-FP-CIT.

REM sleep Behaviour Disorder (RBD) is a sleep disorder that can precedes the development of motor signs of Parkinson's disease by years. The aim of this study was to assess the functional integrity of nigrostriatal dopaminergic system in RBD patients using 123I-2b-carbomethoxy-3b-(4-iodophenyl)-N-(3-fluoropropyl) nortropane (123I-FP-CIT) Single-Photon Emission Computed Tomography (SPECT). 5 patients with RBD and 5 normal healthy controls were included in the study and underwent SPECT imaging 3 hours after injection of 111-185 MBq of 123I-FP-CIT. All RBD patients showed reduced 123I-FP-CIT striatal binding. 123I-FP-CIT SPECT is a useful diagnostic tool in RBD patients.

Brain F-18 Fluorocholine PET/CT for the assessment of optic pathway glioma in neurofibromatosis-1.

A 22-year-old man diagnosed with neurofibromatosis-I was admitted to the neurology department because of progressive hemianopsia and chronic headache. Magnetic resonance imaging, magnetic resonance spectroscopy (MRS), and F-18 fluorocholine revealed a splenial mass with imaging features compatible with malignant astrocytoma. At follow-up examination, the sharp decrease in F-18 fluorocholine uptake and in choline/creatine ratio supported a conservative management. Molecular imaging of optic pathway gliomas may be a valuable tool in the selection of therapeutic options.

Long-term functional assessment of antegrade colonic enema for combined incontinence and constipation using a modified Marsh and Kiff technique.

PURPOSE: Constipation and fecal incontinence can severely affect quality of life for patients, particularly when simultaneously present. Malone antegrade colonic enema enables periodic colonic emptying, thus preventing uncontrolled passage of feces and constipation. METHODS: Eleven patients with fecal incontinence and severe constipation or perineal colostomy after Miles' operation underwent a modified Marsh and Kiff ileostomy for antegrade colonic enema. Before and after surgery, the patients were fully evaluated for gastrointestinal functions, including gallbladder and stomach emptying time, H(2)-breath test, colonic transit time, dynamic defecography, and anorectal manometry. The severity of incontinence and constipation was scored preoperatively and postoperatively by using the American Medical System score and Cleveland Clinic Constipation scale, respectively, whereas the quality of life was measured by the Gastrointestinal Quality of Life Index. The surgical technique involved division of the terminal ileum 10 to 15 cm from the ileocecal valve, anastomosis and intussusception of the ileum with the cecum, narrowing of the ileal conduit with a linear stapler, and a small, introflexed ileostomy with an advanced skin flap. RESULTS: During the postoperative period, the mean American Medical System score decreased significantly from 77 to 11 (P<0.01) and the mean Cleveland Clinic Constipation score from 23 to 8.5 (P<0.01) with a significant improvement of quality of life. Antegrade colonic enema did not affect gallbladder, gastric, or orocecal transit time, which remained comparable with baseline. Colonic scintigraphy showed that antegrade colonic enema was efficient to clean the whole colon and rectum, leaving only 24 (range, 6-40) percent of the initial radioactivity after 30 minutes. Ileal manometry confirmed the presence of a high-pressure zone, preventing accidental reflux. CONCLUSIONS: Modified Marsh and Kiff technique is a safe and effective surgical option to treat patients with combined fecal incontinence and severe constipation and those with perineal colostomy after Miles. It should be recommended as a last option before colostomy.

Stress-rest myocardial perfusion SPECT for functional assessment of coronary arteries with anomalous origin or course.

UNLABELLED: Anomalous coronary arteries (ACAs) may be clinically silent and totally benign or associated with catastrophic and fatal presentations. It has been postulated that the proximal course of an ACA is a decisive factor in risk stratification and surgical approach. Particularly, a course between the aorta and pulmonary trunk carries a high risk of major adverse events. We sought to evaluate the anatomic course of documented ACAs by transesophageal echocardiography (TEE) and to study their functional importance using stress-rest (99m)Tc-sestamibi ((99m)Tc-MIBI) myocardial perfusion SPECT. METHODS: From a cohort of patients undergoing coronary angiography in our department between January 1997 and April 2003, we selected 14 with ACAs but without CAD (9 men and 5 women; mean age, 50.7 +/- 14.6 y). All patients underwent TEE and stress-rest (99m)Tc-MIBI myocardial perfusion SPECT. RESULTS: TEE correctly identified the origin of all ACAs and revealed an anomalous course between the great vessels in 5 patients. At exercise myocardial perfusion SPECT, 4 of 14 patients demonstrated a reversible myocardial perfusion defect. All these patients had an anomalous course between the aorta and pulmonary artery. CONCLUSION: In this study, 4 of 5 (80%) anomalous courses between the aorta and pulmonary artery were associated with the finding of a reversible perfusion defect on stress-rest SPECT. An integrated evaluation of anatomic course and hemodynamic importance could be useful in the management of ACA.