Multimodal radionuclide shuntography for device patency: New procedural tips for anuncommon historical technique.

Cerebrospinal fluid (CSF) shunting is an established long-term treatment option for hydrocephalus, and is one of the most commonly performed neurosurgical procedures in western countries.Despite advances in CSF shunt design and management, its failure rates remain high and is most commonly due to obstruction and infection.Cerebrospinal fluidshunt failure diagnosis should be prompt and accurate in establishing timely if its revision is appropriate. Radionuclide shuntography with technetium-99m-diethylenetriaminepetaacetic acid (99mTc-DTPA) is a useful technique for evaluation CSF shunts and management of patients presenting with shunt-related problems, in particular it can avoid unnecessary replacement interventions. Although its execution and interpretation require specific skills, we suggest its execution for the evaluation of device's patency. We here describe the radionuclide shuntography performed with recent hybrid multimodal technologies, with a procedure customized to a complicated patient with hydrocefalus and neoplastic disease. We suggest considering radionuclide shuntography in association with conventional imaging and strongly recommend the additional performance of single photon emission computed tomography/computed tomography (SPECT/CT) because it also provides valuable information to complete the interpretation of planar images.

[18F]FDG PET/CT in head and neck squamous cell carcinoma: a head-to-head between visual point-scales and the added value of multi-modality imaging.

BACKGROUND: Head and neck squamous cell carcinoma (HNSCC) represents the 6th leading cancer worldwide. In most cases, patients present a locally advanced disease at diagnosis and non-surgical curative treatment is considered the standard of care. Nowadays, [18F]FDG PET/CT is a validated tool in post-treatment evaluation, with a high level of evidence. However, to standardize imaging response, several visual scales have been proposed with none of them approved yet. The study's aim is a head-to-head comparison between the diagnostic performance of the Hopkins criteria, the Deauville score, and the new proposed Cuneo score, to establish their prognostic role. Secondly, we investigate the possible value of semiquantitative analysis, evaluating SUVmax and ΔSUVmax of the lymph node with the highest uptake on the restaging PET scan. Moreover, we also considered morphological features using the product of diameters measured on the co-registered CT images to assess the added value of hybrid imaging. METHODS: We performed a retrospective analysis on histologically proven HNSCC patients who underwent baseline and response assessment [18F]FDG PET/CT. Post-treatment scans were reviewed according to Hopkins, Deauville, and Cuneo criteria, assigning a score to the primary tumor site and lymph nodes. A per-patient final score for each scale was chosen, corresponding to the highest score between the two sites. Diagnostic performance was then calculated for each score considering any evidence of locoregional progression in the first 3 months as the gold standard. Survival analysis was performed using the Kaplan-Meier method. SUVmax and its delta, as well as the product of diameters of the lymph node with the highest uptake at post-treatment scan, if present, were calculated. RESULTS: A total of 43 patients were finally included in the study. Sensitivity, specificity, PPV, NPV, and accuracy were 87%, 86%, 76%, 92%, and 86% for the Hopkins score, whereas 93%, 79%, 70%, 96%, and 84% for the Deauville score, respectively. Conversely, the Cuneo score reached the highest specificity and PPV (93% and 78%, respectively) but the lowest sensitivity (47%), NPV (76%), and accuracy (77%). Each scale significantly correlated with PFS and OS. The ROC analysis of the combination of SUVmax and the product of diameters of the highest lymph node on the restaging PET scan reached an AUC of 0.822. The multivariate analysis revealed the Cuneo criteria and the product of diameters as prognostic factors for PFS. CONCLUSIONS: Each visual score statistically correlated with prognosis thus demonstrating the reliability of point-scale criteria in HNSCC. The novel Cuneo score showed the highest specificity, but the lowest sensibility compared to Hopkins and Deauville criteria. Furthermore, the combination of PET data with morphological features could support the evaluation of equivocal cases.

18F-FDG PET/CT in GIST treatment response evaluation beyond Imatinib.

Positron emission tomography/computed tomography (PET/CT) represents a reliable promising tool in treatment response evaluation of new therapies beyond Imatinib in gastrointestinal stromal tumors (GIST). This narrative review aims to discuss the literature about the role of fluorine-18-fluorodeoxyglucose (18F-FDG) PET/CT in evaluating response in new tyrosine kinase inhibitors (TKI) and radiotherapy (RT) in GIST patients. A comprehensive literature search was performed to retrieve original studies published on PubMed, Scopus and Google Scholar databases. Eighteen studies including 382 patients with GIST were selected. Main findings of included studies are presented. Fluorine-18-FDG PET/CT may enhance performance in GIST management providing significant information in evaluation of treatment response and representing a strong predictor of clinical outcome.

Durable complete response to PET-CT driven stereotactic radiation therapy plus pembrolizumab for pleomorphic Pancoast cancer: Case report and literature review.

PET-driven SBRT plus pembrolizumab as first-line therapy against pleomorphic Pancoast cancer appears beneficial, probably due to high equivalent doses of SBRT on photopenic necrotic core and synergic immune system stimulation of immunoradiotherapy.

Selective internal radiation therapy segmentectomy: A new minimally invasive curative option for primary liver malignancies?

Transarterial radioembolization or selective internal radiation therapy (SIRT) has emerged as a minimally invasive approach for the treatment of tumors. This percutaneous technique involves the local, intra-arterial delivery of radioactive microspheres directly into the tumor. Historically employed as a palliative measure for liver malignancies, SIRT has gained traction over the past decade as a potential curative option, mirroring the increasing role of radiation segmentectomy. The latest update of the BCLC hepatocellular carcinoma guidelines recognizes SIRT as an effective treatment modality comparable to other local ablative methods, particularly well-suited for patients where surgical resection or ablation is not feasible. Radiation segmentectomy is a more selective approach, aiming to deliver high-dose radiation to one to three specific hepatic segments, while minimizing damage to surrounding healthy tissue. Future research efforts in radiation segmentectomy should prioritize optimizing radiation dosimetry and refining the technique for super-selective administration of radiospheres within the designated hepatic segments.

Role of 18F-FCH PET/CT in Detecting Recurrences of Prostate Cancer After Curative Treatments.

Objectives: To evaluate the role of 18F-fluorocholine (18F-FCH) positron emission tomography/computed tomography (PET/CT) in prostate cancer (PC) patients with biochemical recurrence who were submitted to different curative treatments. Methods: Seventy-five patients with PC who underwent 18F-FCH PET/CT for biochemical recurrence were retrospectively analyzed to distinguish patients who were submitted only to prostatectomy (PR group), only to radiotherapy (RT) on prostate with curative intent (RT group), and to both (PR + RT group). Correlations between 18F-FCH PET/CT and outcome and between prostate-specific antigen (PSA) values and sites and the number of metastases were analyzed. The performance of 18F-FCH PET/CT in relation to the PSA value and of maximum standardized uptake value (SUVmax) value in relation to patient outcome were assessed by receiver operating characteristic (ROC) curves. Results: 18F-FCH PET/CT relapses mostly involved lymph nodes, bones, and prostate bed. K-cohen test showed moderate agreement with the outcome in the whole population and in the PR group, whereas in the RT group it was perfect and in PR + RT fair. A statistically significant difference in PSA values was observed in the presence of lymph node metastases and with multiple metastases. ROC curves showed PSA cut-off values of 1.96 ng/dL, 1.95, 1.81, and 2.96, respectively, in the whole population, PR, RT and PR + RT group. SUVmax cut-off values of 3.75, 3.45, and 4.7 were described in the whole population, PR group, and PR + RT group. Conclusion: The study confirms that 18F-FCH PET/CT is still valid in PC patients with suspected biochemical recurrence. Therefore, we can affirm that it still makes sense to perform it both with high PSA values and with lower values when prostate-specific membrane antigen tracers are not available.

The Role of the 18F-FDG PET/CT in the Management of Patients Suspected of Cardiac Implantable Electronic Devices' Infection.

Background: Infection of Cardiac Implantable Electronic Devices (CIEDI) is a real public health problem. The main aim of this study was to determine the diagnostic performance of 18F-FDG PET/CT in the diagnosis of CIEDI. Methods: A total of 48 patients, who performed 18F-FDG PET/CT for the clinical suspicion of CIEDI were retrospectively analyzed; all patients were provided with a model with procedural recommendations before the exam. Sensitivity (Se), specificity (Sp), positive predictive value (PPV), negative predictive value (NPV) and diagnostic accuracy (DA) of 18F-FDG PET/CT were calculated; the reproducibility of qualitative analysis was assessed with Cohen's κ test. The semi-quantitative parameters (SUVmax, SQR and TBR) were evaluated in CIEDI+ and CIEDI- patients using the Student' t-test; ROC curves were elaborated to detect cut-off values. The trend of image quality with regards to procedural recommendation adherence was evaluated. Results: Se, Sp, PPV, NPV and DA were respectively 96.2%, 81.8%, 86.2%, 94.7% and 89.6%. The reproducibility of qualitative analysis was excellent (K = 0.89). Semiquantitative parameters resulted statistically different in CIEDI+ and CIEDI- patients. Cut-off values were SUVmax = 2.625, SQR = 3.766 and TBR = 1.29. Trend curves showed increasing image quality due to adherence to procedural recommendations. Conclusions:18F-FDG-PET/CT is a valid tool in the management of patients suspected of CIEDI and adherence to procedural recommendations improves its image quality.

Prognostic Role of Pre- and Post-Treatment [18F]FDG PET/CT in Squamous Cell Carcinoma of the Oropharynx in Patients Treated with Chemotherapy and Radiotherapy.

BACKGROUND: The prognostic role of imaging with [18F]fluorodeoxyglucose ([18F]FDG) positron emission tomography/computed tomography (PET/CT) in oropharynx cancer (OPC) has been demonstrated in the past. The aim of this study was to assess the prognostic impact of both baseline and post-treatment PET/CT in patients with OPC and treated with chemo- and/or radiotherapy. METHODS: The PET/CT parameters of scans performed before and after therapy were collected and analyzed to find significant prognosticators for progression-free survival (PFS) and overall survival (OS). Human papillomavirus (HPV) infection's influence on the prognosis was also taken into account. RESULTS: A total of 66 patients were included in the study. The staging volumetric parameters of PET/CT were significant prognosticators for OS, while the same parameters were affordable predictors for PFS at the restaging evaluation. No significant correlations between HPV infection and PET/CT parameters were reported. CONCLUSION: The prognostic role of volumetric [18F]FDG PET/CT parameters in patients with OPC was reported.

Radiomics and liver: Where we are and where we are headed?

Hepatic diffuse conditions and focal liver lesions represent two of the most common scenarios to face in everyday radiological clinical practice. Thanks to the advances in technology, radiology has gained a central role in the management of patients with liver disease, especially due to its high sensitivity and specificity. Since the introduction of computed tomography (CT) and magnetic resonance imaging (MRI), radiology has been considered the non-invasive reference modality to assess and characterize liver pathologies. In recent years, clinical practice has moved forward to a quantitative approach to better evaluate and manage each patient with a more fitted approach. In this setting, radiomics has gained an important role in helping radiologists and clinicians characterize hepatic pathological entities, in managing patients, and in determining prognosis. Radiomics can extract a large amount of data from radiological images, which can be associated with different liver scenarios. Thanks to its wide applications in ultrasonography (US), CT, and MRI, different studies were focused on specific aspects related to liver diseases. Even if broadly applied, radiomics has some advantages and different pitfalls. This review aims to summarize the most important and robust studies published in the field of liver radiomics, underlying their main limitations and issues, and what they can add to the current and future clinical practice and literature.

Genetic profiling in radiotherapy: a comprehensive review.

This comprehensive review explores the pivotal role of radiotherapy in cancer treatment, emphasizing the diverse applications of genetic profiling. The review highlights genetic markers for predicting radiation toxicity, enabling personalized treatment planning. It delves into the impact of genetic profiling on radiotherapy strategies across various cancer types, discussing research findings related to treatment response, prognosis, and therapeutic resistance. The integration of genetic profiling is shown to transform cancer treatment paradigms, offering insights into personalized radiotherapy regimens and guiding decisions in cases where standard protocols may fall short. Ultimately, the review underscores the potential of genetic profiling to enhance patient outcomes and advance precision medicine in oncology.

[Lung perfusion scintigraphy in pediatric patients with congenital malformations]. / La scintigrafia polmonare in età neonatale e pediatrica per patologie congenite.

Congenital malformations are an heterogeneous group of disorders that can lead changes in pulmonary perfusion and then can be evaluated with lung perfusion scintigraphy. We selected five patients in which the role of lung perfusion scintigraphy emerges as a reliable and non-invasive imaging technique. Lung perfusion scintigraphy is a useful tool in pediatric patients with congenital malformations allowing an accurate evaluation of the best therapeutic strategy and its results.

[18F-FDG PET/CT in a patient with clinical suspicion of giant cell arteritis]. / La gestione di un caso di arterite a cellule giganti con la 18F-FDG PET/TC.

We report the case of a 72 year old man with clinical suspicion of giant cell arteritis (GCA); in this case 18F-FDG PET/CT has been useful from the diagnosis to the control of the response to therapy. He performed the first 18F-FDG PET/CT that showed increased uptake of 18F-FDG in the aortic arch, brachial artery, common iliac and femoral arteries and in the temporal cerebral sites bilaterally. The patient then began a cortisonic therapy that led straight to the improvement of clinical symptoms, and repeated 18F-FDG PET/CT 3 months later the beginning of therapy that showed reduced uptake in the same sites of the first 18F-FDG PET/CT. This patient continued the cortisonic therapy, progressively reducing it until the definitive ending.

Lympho-SPECT/CT as a Key Tool in the Management of a Patient with Chylous Ascites.

Chylous ascites is a rare form of ascites usually associated with cirrhosis, abdominal malignancies, surgeries or infections. We presented a case of chylous ascites after robotic laparoscopic prostatectomy (PLDN-RALP), in which the correct diagnosis was achieved by SPECT/CT lymphoscintigraphy. A 72-year-old male developed chylous ascites after surgery and underwent lymphoscintigraphy with radiolabeled albumin nanocolloids for the supplementary study of the lymph flow and to detect a possible site of leakage. The scintigraphic imaging demonstrated the abdominal effusion and lymph stasis in the left iliac region. The combination of planar imaging with SPECT/CT can resolve the assessment of chylous disorders.

Correlation between Kidney Uptake at [18F]FDG PET/CT and Renal Function.

Different insights into the connection between kidney [18F]fluorodesoxyglucose ([18F]FDG) uptake at positron emission tomography/computed tomography (PET/CT) and renal function have been proposed in the past. The aim of this study was therefore to assess the presence of a correlation between these two parameters. Kidney uptakes were assessed and compared to the creatinine (Cr) values and estimated glomerular filtration rate (EGFR) among different classes of renal functional impairment or kidney status. A total of 339 patients and 385 different PET/CT scans were included in this study. Significant correlations between kidney uptakes and renal function parameters were reported in most of the groups studied, with the exception of patients with Cr < 1.2 mg/dL and subjects with a kidney transplantation. Strong concordance in the assessment of renal parenchymal uptakes between the different readers was reported. To conclude, strong correlations for renal [18F]FDG uptake with Cr levels and the EGFR were reported, with the exception of the group of patients with a Cr value < 1.2 mg/dL and for the group with a kidney transplantation.

Sex differences in 123I-mIBG scintigraphy imaging techniques in patients with heart failure.

BACKGROUND: 123I-mIBG-scintigraphy could be a useful stratifying tool for patients with heart failure (HF). The purpose of this retrospective study is to evaluate whether there are differences between men and women with HF in terms of the prediction of cardiac arrhythmic events (AE). RESEARCH AND METHODS: A total of 306 patients, before implantable-cardioverter-defibrillator (ICD) implantation, were evaluated. They underwent 123I-mIBG-scintigraphy and an evaluation of the results was performed after 85 months of follow-up. Early and late planar and SPECT cardiac images were acquired. Heart-to-mediastinum ratio (HM) for planar images and the sum of the segmental scores (SS) for SPECT were calculated. RESULTS: In the general population, age, early SS (ESS), late SS (LSS), and ejection fraction (EF) were statistically significant for the prediction of AE at Cox regression, while early and late HM (eHM,lHM) were not significative for the prediction of AE. Population was divided into females and males and univariate analysis was conducted separately for the two cohorts: no significant variables for prediction of AE were found in females. For males, ESS, LSS, EF, and late HM were statistically significant predictors of AE. The overall survival was similar in males and females, but the risk of AE is lower in males than in females. CONCLUSIONS: 123I-mIBG represents a more effective tool for the prediction of AE in male patients than in women.

Radiomics in colorectal cancer patients.

The main therapeutic options for colorectal cancer are surgical resection and adjuvant chemotherapy in non-metastatic disease. However, the evaluation of the overall adjuvant chemotherapy benefit in patients with a high risk of recurrence is challenging. Radiological images can represent a source of data that can be analyzed by using automated computer-based techniques, working on numerical information coded within Digital Imaging and Communications in Medicine files: This image numerical analysis has been named "radiomics". Radiomics allows the extraction of quantitative features from radiological images, mainly invisible to the naked eye, that can be further analyzed by artificial intelligence algorithms. Radiomics is expanding in oncology to either understand tumor biology or for the development of imaging biomarkers for diagnosis, staging, and prognosis, prediction of treatment response and diseases monitoring and surveillance. Several efforts have been made to develop radiomics signatures for colorectal cancer patient using computed tomography (CT) images with different aims: The preoperative prediction of lymph node metastasis, detecting BRAF and RAS gene mutations. Moreover, the use of delta-radiomics allows the analysis of variations of the radiomics parameters extracted from CT scans performed at different timepoints. Most published studies concerning radiomics and magnetic resonance imaging (MRI) mainly focused on the response of advanced tumors that underwent neoadjuvant therapy. Nodes status is the main determinant of adjuvant chemotherapy. Therefore, several radiomics model based on MRI, especially on T2-weighted images and ADC maps, for the preoperative prediction of nodes metastasis in rectal cancer has been developed. Current studies mostly focused on the applications of radiomics in positron emission tomography/CT for the prediction of survival after curative surgical resection and assessment of response following neoadjuvant chemoradiotherapy. Since colorectal liver metastases develop in about 25% of patients with colorectal carcinoma, the main diagnostic tasks of radiomics should be the detection of synchronous and metachronous lesions. Radiomics could be an additional tool in clinical setting, especially in identifying patients with high-risk disease. Nevertheless, radiomics has numerous shortcomings that make daily use extremely difficult. Further studies are needed to assess performance of radiomics in stratifying patients with high-risk disease.

Intracranial Solitary Fibrous Tumor: A "New" Challenge for PET Radiopharmaceuticals.

Solitary fibrous tumor (SFT) of the central nervous system, previously named and classified with the term hemangiopericytoma (HPC), is rare and accounts for less than 1% of all intracranial tumors. Despite its benign nature, it has a malignant behavior due to the high rate of recurrence and distant metastasis, occurring in up to 50% of cases. Surgical resection of the tumor is the treatment of choice. Radiotherapy represents the gold standard in the case of post-surgery residual disease, relapse, and distant metastases. In this context, imaging plays a crucial role in identifying the personalized therapeutic decision for each patient. Although the referring imaging approach in SFT is morphologic, an emerging role of positron emission tomography (PET) has been reported in the literature. However, there is still a debate on which radiotracers have the best accuracy for studying these uncommon tumors because of the histological or biological heterogeneity of SFT.

Sixteen-Year Follow-Up in a Cavernous Sinus Hemangiopericytoma: Improved Outcomes over Radiotherapy Advances.

Intracranial hemangiopericytomas are rare tumors, accounting for 1% of all central nervous system malignancies. This tumor is considered at high risk of local and also distant metastases. Surgical excision is the gold standard for treatment, but it is seldom curative by itself. Adjuvant radiotherapy is often recommended. We report an overview and update of the available literature on one such rare but aggressive mesenchymal tumor, using the case of a 46-year-old woman affected by hemangiopericytoma of the cavernous sinus surgically removed and treated with adjuvant radiotherapy at our institution. After seven years, the patient underwent a local recurrence and was treated with exeresis and Gamma Knife radiotherapy. Sixteen years after the initial diagnosis, she is still well with stable disease.

Multimodal study of pelvic splenosis: a rare cause of abdominal pain.

We present a rare case of pelvic splenosis, in a 46-year-old man, with a previous history of partial splenectomy, complaining of nonspecific pain in the lower abdominal quadrants. Splenosis is a benign acquired condition, defined as a heterotopic autotransplantation of splenic tissue in other compartments of the body, caused by rupture of the splenic capsule following trauma or splenectomy. Splenosis is often asymptomatic and incidentally found and does not require treatment. Surgery is indicated only in patients presenting with symptoms or complications. In our case, the multimodal imaging study (ultrasound, MRI, CT, and scintigraphy) allowed a correct differential diagnosis without resorting to invasive procedures, susceptible to complications.

Lesion-to-Liver SUVmax Ratio to Improve the Prognostic Value of the End of Treatment PET/CT in Diffuse Large B-Cell Lymphoma.

BACKGROUND: Diffuse large B-cell lymphoma (DLBCL) is the most common non-Hodgkin lymphoma worldwide. After first-line therapy, 30-40% of patients relapse or experiment with refractory disease. 18F-FDG PET/CT represents a validated diagnostic tool in post-treatment evaluation of FDG-avid lymphoma, and the Deauville Score (DS), a five-point visual scale, is usually used to assess response. However, the increased number of false positive findings suggested the need to search for new parameters. The aim of this study is to evaluate the prognostic value of End-of-Treatment-PET, comparing DS to the semi-quantitative Lesion-to-Liver ratio (LLR). METHODS: newly diagnosed DLBCL patients who underwent 18F-FDG PET/CT were retrospectively analyzed. End-of-Treatment PET findings were assessed first using DS; secondly, assigned the LLR. RESULTS: a total of 105 patients were finally enrolled. ROC analysis showed an LLR of 1.80 as the optimal cutoff value for predicting a disease progression (sensitivity 58%, specificity 95%). Both DS and LLR showed a statistically significant correlation with PFS and OS. LLR resulted in a better diagnostic performance than DS. CONCLUSIONS: LLR showed to be a reliable diagnostic method to assess treatment response in DLBCL. The integration of visual and semi-quantitative criteria could help in decision making, improving specificity and PPV.