Whole-body nonenhanced PET/MR versus PET/CT in the staging and restaging of cancers: preliminary observations.

PURPOSE: To assess the diagnostic performance of whole-body non-contrast material-enhanced positron emission tomography (PET)/magnetic resonance (MR) imaging and PET/computed tomography (CT) for staging and restaging of cancers and provide guidance for modality and sequence selection. MATERIALS AND METHODS: This study was approved by the institutional review board and national government authorities. One hundred six consecutive patients (median age, 68 years; 46 female and 60 male patients) referred for staging or restaging of oncologic malignancies underwent whole-body imaging with a sequential trimodality PET/CT/MR system. The MR protocol included short inversion time inversion-recovery ( STIR short inversion time inversion-recovery ), Dixon-type liver accelerated volume acquisition ( LAVA liver accelerated volume acquisition ; GE Healthcare, Waukesha, Wis), and respiratory-gated periodically rotated overlapping parallel lines with enhanced reconstruction ( PROPELLER periodically rotated overlapping parallel lines with enhanced reconstruction ; GE Healthcare) sequences. Primary tumors (n = 43), local lymph node metastases (n = 74), and distant metastases (n = 66) were evaluated for conspicuity (scored 0-4), artifacts (scored 0-2), and reader confidence on PET/CT and PET/MR images. Subanalysis for lung lesions (n = 46) was also performed. Relevant incidental findings with both modalities were compared. Interreader agreement was analyzed with intraclass correlation coefficients and κ statistics. Lesion conspicuity, image artifacts, and incidental findings were analyzed with nonparametric tests. RESULTS: Primary tumors were less conspicuous on STIR short inversion time inversion-recovery (3.08, P = .016) and LAVA liver accelerated volume acquisition (2.64, P = .002) images than on CT images (3.49), while findings with the PROPELLER periodically rotated overlapping parallel lines with enhanced reconstruction sequence (3.70, P = .436) were comparable to those at CT. In distant metastases, the PROPELLER periodically rotated overlapping parallel lines with enhanced reconstruction sequence (3.84) yielded better results than CT (2.88, P < .001). Subanalysis for lung lesions yielded similar results (primary lung tumors: CT, 3.71; STIR short inversion time inversion-recovery , 3.32 [P = .014]; LAVA liver accelerated volume acquisition , 2.52 [P = .002]; PROPELLER periodically rotated overlapping parallel lines with enhanced reconstruction , 3.64 [P = .546]). Readers classified lesions more confidently with PET/MR than PET/CT. However, PET/CT showed more incidental findings than PET/MR (P = .039), especially in the lung (P < .001). MR images had more artifacts than CT images. CONCLUSION: PET/MR performs comparably to PET/CT in whole-body oncology and neoplastic lung disease, with the use of appropriate sequences. Further studies are needed to define regionalized PET/MR protocols with sequences tailored to specific tumor entities.

Discrimination and anatomical mapping of PET-positive lesions: comparison of CT attenuation-corrected PET images with coregistered MR and CT images in the abdomen.

PURPOSE: PET/MR has the potential to become a powerful tool in clinical oncological imaging. The purpose of this prospective study was to evaluate the performance of a single T1-weighted (T1w) fat-suppressed unenhanced MR pulse sequence of the abdomen in comparison with unenhanced low-dose CT images to characterize PET-positive lesions. METHODS: A total of 100 oncological patients underwent sequential whole-body (18)F-FDG PET with CT-based attenuation correction (AC), 40 mAs low-dose CT and two-point Dixon-based T1w 3D MRI of the abdomen in a trimodality PET/CT-MR system. PET-positive lesions were assessed by CT and MRI with regard to their anatomical location, conspicuity and additional relevant information for characterization. RESULTS: From among 66 patients with at least one PET-positive lesion, 147 lesions were evaluated. No significant difference between MRI and CT was found regarding anatomical lesion localization. The MR pulse sequence used performed significantly better than CT regarding conspicuity of liver lesions (p < 0.001, Wilcoxon signed ranks test), whereas no difference was noted for extrahepatic lesions. For overall lesion characterization, MRI was considered superior to CT in 40 % of lesions, equal to CT in 49 %, and inferior to CT in 11 %. CONCLUSION: Fast Dixon-based T1w MRI outperformed low-dose CT in terms of conspicuity and characterization of PET-positive liver lesions and performed similarly in extrahepatic tumour manifestations. Hence, under the assumption that the technical issue of MR AC for whole-body PET examinations is solved, in abdominal PET/MR imaging the replacement of low-dose CT by a single Dixon-based MR pulse sequence for anatomical lesion correlation appears to be valid and robust.

Complex cardiac anatomy and catheter access: the role of imaging in patients referred for catheter ablation.

A 66-year-old man with Kartagener's syndrome, situs inversus totalis, and recurrent supraventricular tachycardia and a 49-year-old man with atrial fibrillation and drug-refractory rapid ventricular rate response were referred for catheter ablation. In the first case, the mirrored anatomy of the right atrium was reconstructed using three-dimensional electroanatomical mapping, which guided successful ablation of a typical atrioventricular nodal reentrant tachycardia. In the second case, computerized tomography showed the presence of left atrial isomerism with interruption of the inferior vena cava and azygous continuation into the superior vena cava, guiding advancement of the ablation catheter for access into the positionally right atrial ablation site. These cases illustrate the role of imaging in patients with unusual anatomy of the cardiac chambers and major blood vessels guiding optimal catheter access for catheter ablation.

Triple rule-out CT in the emergency department: protocols and spectrum of imaging findings.

Triage decisions in patients suffering from acute chest pain remain a challenge. The patient's history, initial cardiac enzyme levels, or initial electrocardiograms (ECG) often do not allow selecting the patients in whom further tests are needed. Numerous vascular and non-vascular chest problems, such as pulmonary embolism (PE), aortic dissection, or acute coronary syndrome, as well as pulmonary, pleural, or osseous lesions, must be taken into account. Nowadays, contrast-enhanced multi-detector-row computed tomography (CT) has replaced previous invasive diagnostic procedures and currently represents the imaging modality of choice when the clinical suspicion of PE or acute aortic syndrome is raised. At the same time, CT is capable of detecting a multitude of non-vascular causes of acute chest pain, such as pneumonia, pericarditis, or fractures. Recent technical advances in CT technology have also shown great advantages for non-invasive imaging of the coronary arteries. In patients with acute chest pain, the optimization of triage decisions and cost-effectiveness using cardiac CT in the emergency department have been repetitively demonstrated. Triple rule-out CT denominates an ECG-gated protocol that allows for the depiction of the pulmonary arteries, thoracic aorta, and coronary arteries within a single examination. This can be accomplished through the use of a dedicated contrast media administration regimen resulting in a simultaneous attenuation of the three vessel territories. This review is intended to demonstrate CT parameters and contrast media administration protocols for performing a triple rule-out CT and discusses radiation dose issues pertinent to the protocol. Typical life-threatening and non-life-threatening diseases causing acute chest pain are illustrated.

Caerulein-induced acute pancreatitis in mice that constitutively overexpress Reg/PAP genes.

BACKGROUND: The cystic fibrosis (CF) mouse pancreas has constitutively elevated expression of the Reg/PAP cell stress genes (60-fold greater Reg3alpha, and 10-fold greater PAP/Reg3beta and Reg3gamma). These genes are suggested to be involved in protection or recovery from pancreatic injury. METHODS: To test this idea the supramaximal caerulein model was used to induce acute pancreatitis in wild type and CF mice. Serum amylase, pancreatic water content (as a measure of edema), pancreatic myeloperoxidase activity, and Reg/PAP expression were quantified. RESULTS: In both wild type and CF mice caerulein induced similar elevations in serum amylase (maximal at 12 h), pancreatic edema (maximal at 7 h), and pancreatic myeloperoxidase activity (MPO, a marker of neutrophil infiltration; maximal at 7 h). By immunohistochemistry, Reg3alpha was strongly expressed in the untreated CF pancreas but not in wild type. During pancreatitis, Reg3alpha was intensely expressed in foci of inflamed tissue in both wild type and CF. CONCLUSION: These data demonstrate that the severity of caerulein-induced pancreatitis is not ameliorated in the CF mouse even though the Reg/PAP stress genes are already highly upregulated. While Reg/PAP may be protective they may also have a negative effect during pancreatitis due to their anti-apoptotic activity, which has been shown to increase the severity of pancreatitis.

Exocrine meets endocrine: pancreatic stone protein and regenerating protein--two sides of the same coin.

BACKGROUND: Regenerating protein (reg) and pancreatic stone protein (PSP) have been discovered independently in the fields of diabetes and pancreatitis. MATERIALS AND METHODS: These proteins are identical; however, because of the gap between the endocrine and exocrine field, there was never a consensus and the nomenclature has not been rectified. Since the time of the initial discovery, more isoforms have been unified. Historically, PSP was discovered long before reg, yet, in many areas outside of the pancreatitis research field, reg is being used. RESULTS: For PSP/reg, a role in proliferation and regeneration of islet cells has been postulated. A hitherto insufficiently understood phenomenon is the massive up-regulation of PSP/reg in pancreatic tissue and juice under conditions of stress. Similarly, PAP (pancreatitis-associated protein)/reg III has been attributed various functional roles. Structurally, the ability to form fibrils after tryptic cleavage is a striking common features of both proteins. However, this biochemical transformation is in itself not enough to gain functional insight. Thus, physiological and genetic approaches are required to further characterize the role of these proteins in the pancreas. Recently, more evidence has been presented in support of the theory that PSP/reg plays a key role in islet neogenesis/regeneration. CONCLUSIONS: In this review we discuss the debate on the localization and functional roles of PSP/reg and PAP/regIII. Therefore, we have summarized hypotheses and experimental results supporting such hypotheses.