Simultaneous assessment of microcalcifications and morphological criteria of vulnerability in carotid artery plaque using hybrid 18F-NaF PET/MRI.

BACKGROUND: Previous studies have suggested the role of microcalcifications in plaque vulnerability. This exploratory study sought to assess the potential of hybrid positron-emission tomography (PET)/magnetic resonance imaging (MRI) using 18F-sodium fluoride (18F-NaF) to check simultaneously 18F-NaF uptake, a marker of microcalcifications, and morphological criteria of vulnerability. METHODS AND RESULTS: We included 12 patients with either recently symptomatic or asymptomatic carotid stenosis. All patients underwent 18F-NaF PET/MRI. 18F-NaF target-to-background ratio (TBR) was measured in culprit and nonculprit (including contralateral plaques of symptomatic patients) plaques as well as in other arterial walls. Morphological criteria of vulnerability were assessed on MRI. Mineral metabolism markers were also collected. 18F-NaF uptake was higher in culprit compared to nonculprit plaques (median TBR 2.6 [2.2-2.8] vs 1.7 [1.3-2.2]; P = 0.03) but was not associated with morphological criteria of vulnerability on MRI. We found a positive correlation between 18F-NaF uptake and calcium plaque volume and ratio but not with circulating tissue-nonspecific alkaline phosphatase (TNAP) activity and inorganic pyrophosphate (PPi) levels. 18F-NaF uptake in the other arterial walls did not differ between symptomatic and asymptomatic patients. CONCLUSIONS: 18F-NaF PET/MRI may be a promising tool for providing additional insights into the plaque vulnerability.

[Adenomatoid tumor of the adrenal gland: Clinicopathologic characteristics and differential diagnosis on two tumors of exceptional adrenal location]. / Tumeur adénomatoïde de la surrénale : aspects clinico-pathologiques et diagnostics différentiels de deux tumeurs de localisation surrénaliennes exceptionnelles.

Adenomatoid tumors are benign tumors from mesothelial origin, usually occurring in the genital tract. Extragenital locations, especially in the adrenal gland are extremely rare. Here we are reporting two cases of a 28-year-old and 50-year-old men with an adenomatoid tumor of the right adrenal gland. Usual morphological aspects join scattered and microcystic pattern with epithelioid or signet-ring cells. According to the morphological features, main differential diagnoses are adenocarcinoma metastasis, vascular tumors or mesotheliomas. Immunohistochemistry provides precious help to confirm the mesothelial origin thanks to positivity of epithelial markers (CK7, AE1-AE3, CK5/6) coupled to mesothelial markers (D2-40, Calretinin, WT1). On the other hand, there is no loss of BAP1 by immunohistochemistry and usually a surexpression of P16. Adrenal gland adenomatoid tumor is a benign tumor, which can be promoted by iatrogenous or constitutive immunodepression.

Commercial anti-CD19 CAR T cell therapy for patients with relapsed/refractory aggressive B cell lymphoma in a European center.

Two autologous anti-CD19 chimeric antigen receptors (CAR) T cells (axicabtagene ciloleucel [axi-cel] and tisagenlecleucel [tisa-cel]) are commercially approved in Europe for relapsed/refractory (R/R) diffuse large B cell lymphoma (DLBCL). We performed a retrospective study to evaluate patterns of use, efficacy and safety for axi-cel and tisa-cel. Data from 70 patients who underwent apheresis for commercial CAR T cells between January 2018 and November 2019 in our institution were retrospectively collected. Sixty-one patients were infused. The median age at infusion was 59 years old (range 27-75 years). The median number of prior therapies was 3 (range, 2-6). The overall response rates (ORRs) at 1 month and 3 months were 63% and 45%, respectively, with 48% and 39% achieving a complete response (CR), respectively. After a median follow-up after infusion of 5.7 months, the median progression-free survival (PFS) was 3.0 months (95% CI, 2.8-8.8 months), and the median overall survival (OS) was 11.8 months (95% CI, 6.0-12.6 months). In multivariate analysis, factors associated with poor PFS were the number of previous lines of treatment before CAR T cells (≥4) (P = .010) and a C reactive protein (CRP) value >30 mg/L at the time of lymphodepletion (P < .001). Likewise, the only factor associated with a shorter OS was CRP >30 mg/L (P = .009). Cytokine release syndrome (CRS) of any grade occurred in 85% of patients, including 8% of patients with CRS of grade 3 or higher. Immune cell-associated neurotoxicity syndrome (ICANS) of any grade occurred in 28% of patients, including 10% of patients with ICANS of grade 3 or higher. Regarding efficacy and safety, no significant difference was found between axi-cel and tisa-cel. This analysis describes one of the largest real-life cohorts of patients treated with axi-cel and tisa-cel for R/R aggressive B cell lymphoma in Europe.

Estimated Fetal Radiation Dose From 18 F-FDG PET/CT During the Second and Third Trimesters of Pregnancy.

PURPOSE: Data published in the literature concerning the doses received by fetuses exposed to a 18 F-FDG PET are reassuring but were obtained from small and heterogeneous cohorts, and very few data are available concerning the fetal dose received after exposure to both PET and CT. The present study aimed to estimate the fetal dose received following a PET/CT exposure using methods that include anthropomorphic phantoms of pregnant women applied on a large cohort. PATIENTS AND METHODS: This retrospective multicenter study included 18 pregnant patients in the second and third trimesters. For PET exposure, the fetal volume and mean concentration of radioactivity in the fetus were measured by manually drawing regions of interest. Those data, combined with the time-integrated activities of the fetus and the mother's organs, were entered into the OLINDA/EXM software 2.0 to assess the fetal dose due to PET exposure. To estimate the fetal dose received due to CT exposure, 2 softwares were used: CT-Expo (based on geometric phantom models of nonpregnant patients) and VirtualDose (using pregnant patient phantoms). RESULTS: The fetal dose exposure for PET/CT examination in the second trimester ranged from 5.7 to 15.8 mGy using CT-Expo (mean, 11.6 mGy) and from 5.1 to 11.6 mGy using VirtualDose (mean, 8.6 mGy). In the third trimester, it ranged from 7.9 to 16.6 mGy using CT-Expo (mean, 10.7 mGy) and from 6.1 to 10.7 mGy using VirtualDose (mean, 7.6 mGy). CONCLUSIONS: The estimated fetal doses were in the same range of those previously published and are well below the threshold for deterministic effects. Pregnancy does not constitute an absolute contraindication for a clinically justified hybrid 18 F-FDG PET/CT.

Outcome on Mesenteric Mass Response of Small-Intestinal Neuroendocrine Tumors Treated by 177Lu-DOTATATE Peptide Receptor Radionuclide Therapy: The MesenLuth Study, a National Study from the French Group of Endocrine Tumors and Endocan-RENATEN Network.

A mesenteric mass (MM), characterized by fibrotic reaction, is present in most small-intestinal neuroendocrine tumors (SI-NETs). 177Lu-DOTATATE peptide receptor radionuclide therapy (PRRT) has shown its efficacy in patients with progressive SI-NETs. However, because of specific tissue characteristics of desmoplastic MMs, we hypothesize that these lesions may be refractory to 177Lu-DOTATATE PRRT. Methods: From the national French Groupe d'étude des Tumeurs Endocrines database, we identified patients with an advanced SI-NET and a MM (≥2 cm with a retractile aspect) of a SI-NET treated by at least 1 course of 177Lu-DOTATATE PRRT. The primary endpoint was a MM objective response rate (ORR) of less than 5%. Secondary endpoints were metabolic response, MM-related safety, and clinical response, as well as MM progression-free survival (PFS) and non-MM PFS. Results: In total, 52 patients were included. The MM ORR was 4% (n = 2), and the non-MM ORR was 8% (n = 4). No patient had a MM metabolic response, and the non-MM metabolic response rate was 12% (n = 6). Among the 26 patients with baseline MM-related symptoms, 46% had a clinical response. Four patients presented with gastrointestinal complications during PRRT. The median MM-related PFS was not reached, and the non-MM PFS was 50.3 mo (95% CI, 38.2-61.7 mo). Conclusion: This study confirms that 177Lu-DOTATATE PRRT does not lead to morphologic response on MMs (ORR < 5%). However, it allows MM stability, with few MM-related side effects, and has a relevant impact on MM-related symptoms.

Cervix Abscess Mimicking Cervical Cancer Explored With 18 F-FDG PET/CT and MRI.

ABSTRACT: We report the case of a 32-year-old woman gravida 2 para 2 with pelvic pain evolving for 2 months, who underwent imaging examinations, including 18 F-FDG PET/CT and MRI, which showed a tumor-like cervix tissular mass with pathological lymph nodes and pelviperitonitis. An endocervical curettage with conization revealed a bacterial infection with cervical abscess and without neoplastic component. The follow-up 18 F-FDG PET/CT 3 months after starting antibiotherapy confirmed a complete metabolic and morphological response of the cervical abscess.

Randall-Type Monoclonal Immunoglobulin Deposition Disease in Bone Scintigraphy.

ABSTRACT: Bone scintigraphy is recognized as a noninvasive alternative to endomyocardial biopsy for the diagnostic of wild-type (wATTR) and hereditary ATTR amyloidosis (hATTR). Light chain amyloidosis (AL), Randall-type monoclonal immunoglobulin deposition disease , sarcoidosis, hemochromatosis, Fabry disease, and mucopolysaccharidoses are differential diagnosis of ATTR amyloidosis. Bone scintigraphy allows visualization of extracardiac involvements of AL amyloidosis: pleural, retroperitoneal, liver, spleen, and soft tissue. We report the case of a patient who underwent bone scintigraphy for suspected ATTR amyloidosis. Bone scan showed cardiac (Perugini score 2), hepatic, and renal hyperfixation. A cardiac biopsy demonstrated a Randall-type deposit, without amyloid deposit.

Morbidity, mortality, and prognostic factors in gestational trophoblastic neoplasia with liver metastasis.

BACKGROUND: Liver metastases of gestational trophoblastic neoplasia (GTN) are rare, but associated with poor prognosis. The additional concomitant presence of brain or intra-abdominal metastases, with liver metastases has been described as worsening factors, but the literature on this topic is reduced. OBJECTIVE: To estimate the overall mortality, specific hepatic morbidity, and mortality, and to identify prognostic factors for patients with GTN and liver metastases. METHOD: The medical records of 26 GTN patients with liver metastases registered in the French Center for Trophoblastic Diseases and treated between November 1999 and December 2019 were reviewed. Overall survival was described using Kaplan-Meier estimates. Prognostic factors were identified using univariate and multivariate Cox analyses. RESULTS: The 5-year overall survival rate was 60.7% for all patients with liver metastasis. The survival rate was higher in patients who achieved complete remission after first-line chemotherapy than in those who did not (100% vs 20%, p = 0.001). The only factor independently associated with prognosis was the presence of 6 or more liver metastases (5-year survival, 16.7% vs. 82.4% otherwise; HR =11.1, 95%CI, 2.3-53.1; p = 0.003). None of the five patients with a single liver metastasis died. CONCLUSION: GTN with liver metastasis is very rare (1.6%). The prognosis of patients seems to be improving. The results of this study are also reassuring for patients with complete remission after first-line combination chemotherapy, as well as for those with a single liver metastasis.

HLA-DR expression on monocytes and outcome of anti-CD19 CAR T-cell therapy for large B-cell lymphoma.

Despite their unprecedented success in relapsed/refractory (R/R) large B-cell lymphoma (LBCL), anti-CD19 CAR T cells are associated with significant toxicity, and more than half of patients relapse. As monocytes emerged as key players in CAR therapy, we sought to evaluate the evolution of HLA-DR expression on monocytes (mHLA-DR) before and after commercial anti-CD19 CAR T-cell infusion in a large cohort (n = 103) of patients with R/R LBCL and its association with adverse events and treatment response. Cy-Flu-based lymphodepletion (LD) upregulated mHLA-DR in 79% of the cases, whereas in 2l% of cases (15 patients), the mHLA-DR level decreased after LD, and this decrease was associated with poorer outcome. Low mHLA-DR at day minus 7 (D-7) (<13 500 antibodies per cell) before CAR T-cell infusion correlated with older age, poorer performance status, higher tumor burden, and elevated inflammatory markers. With a median follow-up of 7.4 months, patients with low mHLA-DR D-7 exhibited a poorer duration of response and survival than the higher mHLA-DR D-7 group. For toxicity management, tocilizumab was more frequently used in the low-mHLA-DR D-7 group. These data suggest that monocyte dysregulation before LD, characterized by the downregulation of mHLA-DR, correlates with an inflammatory and immunosuppressive tumor environment and is associated with failure of anti-CD19 CAR T cells in patients with R/R LBCL. Modulation of these myeloid cells represents a promising field for improving CAR therapy.

Metabolic Activity of Neurogenic Heterotopic Ossification on 18F-FDG PET/CT Matching with Ongoing Osteoblastic Activity on Bone Scan.

A 54-year-old man, with previous history of neurogenic heterotopic ossification (HO) in muscles around the left hip following a spinal cord injury ten months earlier, was referred to our nuclear medicine center for an 18fluorine-fluorodeoxyglucose (18F-FDG) positron emission tomography/computed tomography (PET/CT) to rule out a spondylodiscitis. No sign of spondylodiscitis was found on 18F-FDG PET/CT, but images revealed an increased 18F-FDG uptake in HO areas, matching with ongoing osteoblastic activity on a following bone scan.

Peptide Receptor Radionuclide Therapy by 177Lu-DOTATATE of a Secreting Cervical Paraganglioma.

ABSTRACT: A 59-year-old man with a parapharyngeal paraganglioma incidentally discovered on a cervical swelling was referred to our nuclear medicine department for a morpho-metabolic assessment. An 18F-FDG PET/CT was initially performed and found an intense hypermetabolism of the lesion and a hypermetabolism of the periadrenal brown fat evoking catecholamine secretion. An additional 68Ga-DOTATOC PET/CT was performed, showing an overexpression of the somatostatin receptors of this isolated paraganglioma. After multidisciplinary discussion, a peptide receptor radionuclide therapy with somatostatin analogs using 177Lu-DOTATATE as a compassionate measure was carried out.

Evaluating the Effectiveness of Yttrium-90 Glass Microspheres in the Treatment of Hepatocellular Carcinoma, Intrahepatic Cholangiocarcinoma, and Metastatic Colorectal Cancer in Practice: Protocol for the Prospective PROACTIF Phase IV Registry Study in France.

PRIMARY OBJECTIVE: Recently, selective internal radiation therapy using yttrium-90 (Y90) glass microspheres (TheraSphere™) was approved for reimbursement by health authorities in France. The PROACTIF study aims to gather data on effectiveness, patient quality of life, and safety with use of Y90 glass microspheres in real-world clinical settings in France. INCLUSION CRITERIA: Patient with a diagnosis of hepatocellular carcinoma (HCC), intrahepatic cholangiocarcinoma (iCC), and/or metastatic colorectal cancer (mCRC) who was treated with a dose of Y90 glass microspheres that has been reimbursed in France and who do not oppose use of their personal medical data. EXCLUSION CRITERIA: If data collection is opposed, treatment is reimbursed but not administered, or treatment is administered but not reimbursed. OUTCOME MEASURES: Primary outcome measures include overall survival from time of Y90 glass microsphere treatment and quality of life, as assessed using the Functional Assessment of Cancer Therapy- Hepatobiliary questionnaire. ESTIMATED NUMBER OF PATIENTS TO BE INCLUDED: This is an open study and there is no set number of patients; 115 have already been enrolled. PLANNED SUBGROUP ANALYSES: Analyses will be stratified by disease state (HCC, iCC, or mCRC). Subgroups to be analyzed include age group, unilobar/bilobar disease at baseline, Eastern Cooperative Oncology Group (ECOG) status at baseline, liver tumor burden at baseline, target lesion size, and standard versus multi-compartment personalized dosimetry treatment. PLANNED RECRUITMENT AND OBSERVATION PERIOD: Recruitment includes patients who are prescribed and treated with a commercial vial of Y90 glass microspheres between 01 January 2019 and 31 December 2024. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT04069468.

Paraneoplastic Multicentric Reticulohistiocytosis on 18F-FDG PET/CT Breast Carcinoma Follow-up.

ABSTRACT: We report the case of a 60-year-old woman who underwent 18F-FDG PET/CT to evaluate a metastatic breast carcinoma. Follow-up 18F-FDG PET/CT showed progressive disease with 18F-FDG increased in primary tumor, axillary lymph nodes, and pleural and bone diffuse metastases but also a concomitant uptake in multiples joints. The anatomopathological analysis from skin biopsy revealed a multicentric reticulohistiocytosis, considered paraneoplastic in the context. Second follow-up PET/CT after treatment showed a decrease of 18F-FDG uptake in previously affected joints, consistent with the symptoms evolution. 18F-FDG PET/CT could be helpful in the detection and the evaluation of such rare systemic disorder.

Diagnosis of Ectopic Pancreas in Small Intestine With 18F-DOPA PET/CT.

ABSTRACT: A 77-year-old man was referred for a PET/CT 18F-FDG after incidental discovery of a lobulated jejunal lesion during surgery for an abdominal aortic aneurysm. The lesion was not removed due to the risk of digestive perforation. PET/CT 18F-FDG did not show pathologic hypermetabolism. Subsequently, we decided to perform PET/CT 18F-DOPA to better characterize this incidentaloma. A moderate uptake was showed, less than the pancreas. After multidisciplinary discussion, taking into account macroscopic and imaging aspects, the hypothesis of an ectopic pancreas was retained, allowing the exclusion of surgical excision.

99mTc-white blood cell SPECT/CT to assess diabetic foot osteomyelitis remission: contribution of semi-quantitative scoring system.

AIMS: We previously reported that 99mTc-White blood cell (WBC) single-photon emission computed tomography (SPECT/CT) could be a useful tool to assess diabetic foot osteomyelitis (DFO) remission and guide the duration of antibiotic treatment. The aim of the present study was to evaluate the performance and reproducibility of two analysis methods to diagnose DFO remission using 99mTc-WBC-SPECT/CT. METHODS: 99mTc-WBC-SPECT/CT performed for patients with DFO at the end of antibiotic treatment were retrospectively read by two nuclear physicians (one senior and one junior). Assessment by conventional visual analysis and by the use of a semi-quantitative scoring system, the composite score index (CSI), was performed. The performance and reproducibility of methods were compared between the two nuclear physicians. Successful treatment of DFO was defined by the absence of DFO relapse at the same site within 1 year. RESULTS: A total of 68 patients with 74 DFO were included. Three were excluded from the analysis due to the low quality of SPECT/CT; among the 71 DFO analyzed, 11 (15.5%) had a relapse during follow-up. Performances of 99mTc-WBC-SPECT/CT to predict DFO remission with conventional visual assessment were significantly lower for junior than for senior nuclear physician with moderate inter-rater agreement (Kappa: 0.417). Performances with the use of CSI were similar between the two readers with good inter-rater agreement (Kappa: 0.756). CONCLUSION: The study found that conventional visual assessment of 99mTc-WBC-SPECT/CT to assess DFO remission requires experience, and supported that CSI could be useful for junior nuclear physician to discriminate residual infections and inflammatory post-treatment uptake.

Unexpected Vertebral Bodies Trapping of 99mTc-Macroaggregated Albumin During Lung Perfusion Scintigraphy in a Patient With Collateral Paravertebral Venous System.

ABSTRACT: A 35-year-old woman was referred to our nuclear medicine center for a ventilation and perfusion (VQ) pulmonary scintigraphy to detect pulmonary embolism. She was treated with low-molecular-weight heparin following a proximal venous thrombosis of the right upper limb and had a previous history of an infiltrating ductal carcinoma of the right breast. Surprisingly, the VQ scintigraphy showed uptake of 99mTc-MAA in several superior vertebrae. A contrast-enhanced CT scan revealed a dilated collateral paravertebral venous system due to the deep vein thrombosis extended from superior vena cava to brachiocephalic trunk. 99mTc-MAA was trapped through the dilated vertebral venous system.

Lymphoscintigraphy for Sentinel Node Mapping in Head and Neck Cancer.

The aim of this comprehensive review is to describe and analyze the role of the sentinel node mapping in head and neck cancers. For this purpose, head and neck neoplasms have been categorized in cutaneous malignancies and neoplasms of the upper aerodigestive tract. A concise description of lymphatic drainage will be the "prelude" for each section, as well as the description of the injection techniques, when specific. Concisely, the attention has been focused on detection rate of the sentinel node by lymphoscintigraphy for each cancer, and for those patients in which the sentinel lymph node has been identified, true-positives rates, false-negative rates, and overall accuracy has been pointed out. Overall, in cutaneous neoplasms of the head and neck, the detection rate is higher than 90%, however the false-negative rate is still an issue, in particular in melanoma, inducing the need for newer developments. In fact, new tracers and techniques are already available, while prospective multicenter trials exploring the outcome impact are needed in the near future. For the upper aerodigestive tract and in particular oral cavity and oropharynx, sentinel lymph node identification by lymphoscintigraphy allows avoiding unnecessary neck dissection and/or node irradiation. Even in this case, the main limit remains the risk of false-negative rates. While, for patients affected by laryngeal and hypopharyngeal cancers the data seem very limited and, although the feasibility has been demonstrated, performances of this lymphoscintigraphy still need to be confirmed by multicenter studies.

Prognostic Impact of 18F-FDG PET/CT in Patients With Aggressive B-Cell Lymphoma Treated With Anti-CD19 Chimeric Antigen Receptor T Cells.

PURPOSE OF THE REPORT: We aimed to evaluate the role of 18F-FDG PET/CT in predicting patient outcome following chimeric antigen receptor T (CAR T) cells infusion in aggressive B-cell lymphoma. METHODS: 18F-FDG PET/CT data before leukapheresis, before CAR T-cell infusion and 1 month (M1) after CAR T-cell infusion, from 72 patients were retrospectively analyzed. SUVmax, total lesion glycolysis (TLG), metabolic tumor volume (MTV), and parameters describing tumor kinetics were calculated for each 18F-FDG PET/CT performed. The aim was to evaluate the prognostic value of 18F-FDG PET/CT metabolic parameters for predicting progression-free survival (PFS) and overall survival (OS) following CAR T-cell therapy. RESULTS: Regarding PFS, ∆MTVpre-CAR and ∆TLGpre-CAR were found to be more discriminating compared with metabolic parameters at preinfusion. Median PFS in patients with a ∆MTVpre-CAR of less than 300% was 6.8 months (95% confidence interval [CI], 2.8 months to not reached) compared with 2.8 months (95% CI, 0.9-3.0 months) for those with a value of 300% or greater (P = 0.004). Likewise, median PFS in patients with ∆TLGpre-CAR of less than 420% was 6.8 months (95% CI, 2.8 months to not reached) compared with 2.7 months (95% CI, 1.3-3.0 months) for those with a value of 420% or greater (P = 0.0148). Regarding OS, metabolic parameters at M1 were strongly associated with subsequent outcome. SUVmax at M1 with a cutoff value of 14 was the most predictive parameter in multivariate analysis, outweighing other clinicobiological variables (P < 0.0001). CONCLUSIONS: Disease metabolic volume kinetics before infusion of CAR T cells seems to be superior to initial tumor bulk itself for predicting PFS. For OS, SUVmax at M1 might adequately segregate patients with different prognosis.