How to Perform FAPI PET? An Expedited Systematic Review Providing a Recommendation for FAPI PET Imaging With Different FAPI Tracers.

This expedited systematic review aims to provide the first overview of the different Fibroblast activation protein inhibitor (FAPI) PET scan procedures in the literature and discuss how to efficiently obtain optimal FAPI PET images based on the best available evidence. The PubMed, Embase, Cochrane Library, and Web of Science databases were systematically searched in April 2023. Peer-reviewed cohort studies published in English and used FAPI tracers were included. Articles were excluded if critical scan procedure information was missing, or the article was not retrievable from a university library within 30 days. Data were grouped according to the FAPI tracer applied. Meta-analysis with proper statistics was deemed not feasible based on a pilot study. A total of 946 records were identified. After screening, 159 studies were included. [68Ga]Ga-FAPI-04 was applied in 98 studies (61%), followed by [68Ga]Ga-FAPI-46 in 19 studies (12%). Most studies did not report specific patient preparation. A mean/median administered activity of 80-200 MBq was most common; however, wide ranges were seen in [68Ga]Ga-FAPI-04 PET studies (56-370 MBq). An injection-to-scan-time of 60 minutes was dominant for all FAPI PET studies. A possible trend toward shorter injection-to-scan times was observed for [68Ga]Ga-FAPI-46. Three studies evaluated [68Ga]Ga-FAPI-46 PET acquisition at multiple time points in more than 593 cancer lesions, all yielding equivalent tumor detection at 10 minutes vs later time points despite slightly lower tumor-to-background Ratios. Despite the wide ranges, most institutions administer an average of 80-200 MBq [68Ga]Ga-FAPI-04/46 and scan patients at 60 minutes postinjection. For [68Ga]Ga-FAPI-46, the present evidence consistently supports the feasibility of image acquisition earlier than 30 minutes. Currently, data on the optimal FAPI PET scan procedure are limited, and more studies are encouraged. The current review can serve as a temporary guideline for institutions planning FAPI PET studies.

Intravenous Pyogenic Granuloma in the Inguinal Canal Mimicking Lymph Node Metastasis on PSMA PET/CT.

ABSTRACT: We present a 68-year-old man with newly diagnosed high-risk prostate cancer who was referred for PSMA PET/CT after the initial CT showed a contrast-enhanced structure resembling a lymph node in the left inguinal canal. No other findings suggesting metastatic disease were seen on CT or bone scintigraphy. PSMA PET/CT showed moderate PSMA uptake in the inguinal tissue, substantiating an unexpected location of lymph node metastasis. The uncommon location warranted an excision biopsy, and an IV pyogenic granuloma was diagnosed on histological examination, emphasizing the importance of biopsy of unexpected findings.

Clinical significance of atypical 68Ga-DOTATOC prostatic uptake on PET/CT: A ten-year review.

OBJECTIVE: Gallium-68-DOTA-D-Phe1-Try3-Octreotide (68Ga-DOTATOC) is a radiolabeled somatostatin receptor (SSTR) analog that is widely used in the imaging of neuroendocrine tumors (NET). Benign and malignant prostate tumors have been observed to express SSTR. Diffuse symmetric DOTATOC uptake in the prostate is a normal positron emission tomography (PET) finding. The aim of this study was to evaluate the frequency and clinical significance of incidental atypical prostatic uptake in men undergoing 68Ga-DOTATOC PET/computed tomography(CT). SUBJECTS AND METHODS: A retrospective review of consecutive male patients who underwent 68Ga-DOTATOC PET/CT studies at Aalborg University Hospital, Denmark, from November 2010 to April 2020 was performed. Positron emission tomography/CT reports were searched for text words or phrases indicating incidental atypical prostatic uptake. In the resulting cohort, PET/CT were re-evaluated, and DOTATOC uptake in the prostate gland was categorized as focal, diffuse or mixed. The intensity of the uptake was visually graded using the Krenning visual score. Follow-up was based on all available clinical, biochemical, imaging, and pathology follow-up. RESULTS: A total of 178 male patients underwent 193 68Ga-DOTATOC PET/CT scans. Incidental atypical uptake of 68Ga-DOTATOC on PET/CT in the prostatic bed was observed in eight patients (4.5%) (mean age 67 years, range 58-85 years). Six patients (75%) had diffuse uptake; two (25%) patients had focal uptake. Four patients out of eight with incidental findings (50%) had uptake less than or equal to that of the liver (Krenning score 2); four patients (50%) had uptake greater than that of the liver (score 3). All patients had measurements of serum prostate-specific antigen and were referred for urological evaluation. Five patients (62%) underwent a transrectal ultrasound, and three required a biopsy of the prostate. No cases of prostate malignancy (including prostatic cancer) were diagnosed. CONCLUSION: During a 10-year period, we found that 4.5% of men exhibited prostate incidentalomas on 68Ga-DOTATOC PET/CT. No malignancy was found in the prostate in this population. Our data indicate absent malignancy among incidental 68Ga-DOTATOC findings in the prostate.

Designing clinical trials based on modern imaging and metastasis-directed treatments in patients with oligometastatic breast cancer: a consensus recommendation from the EORTC Imaging and Breast Cancer Groups.

Breast cancer remains the most common cause of cancer death among women. Despite its considerable histological and molecular heterogeneity, those characteristics are not distinguished in most definitions of oligometastatic disease and clinical trials of oligometastatic breast cancer. After an exhaustive review of the literature covering all aspects of oligometastatic breast cancer, 35 experts from the European Organisation for Research and Treatment of Cancer Imaging and Breast Cancer Groups elaborated a Delphi questionnaire aimed at offering consensus recommendations, including oligometastatic breast cancer definition, optimal diagnostic pathways, and clinical trials required to evaluate the effect of diagnostic imaging strategies and metastasis-directed therapies. The main recommendations are the introduction of modern imaging methods in metastatic screening for an earlier diagnosis of oligometastatic breast cancer and the development of prospective trials also considering the histological and molecular complexity of breast cancer. Strategies for the randomisation of imaging methods and therapeutic approaches in different subsets of patients are also addressed.

The diagnostic accuracy of radiolabeled PSMA-ligand PET for tumour staging in newly diagnosed prostate cancer patients compared to histopathology: a systematic review and meta-analysis.

PURPOSE: The current clinical recommendations posit the deployment of specific approved radiolabeled prostate-specific membrane antigen-ligand positron emission tomography (PSMA PET) for detecting metastatic prostate cancer during primary staging. Nevertheless, the precise efficacy of such ligands in localizing intraprostatic tumours (index tumour) and T-staging is not well established. Consequently, the objective of this inquiry is to ascertain the diagnostic accuracy of PSMA-PET in the tumour staging of newly diagnosed prostate cancer by means of a meta-analysis that integrates studies utilizing histological confirmation as the reference standard. METHODS: In this study, we conducted a systematic literature search of the PubMed, Embase, Web of Science, and Cochrane Library databases using a predefined collection of search terms. These terms included 'PSMA PET', 'primary staging', and 'prostate cancer'. Subsequently, two independent reviewers evaluated all the studies based on predetermined inclusion criteria, extracted pertinent data, and assessed the quality of evidence. Any disparities were resolved by a third reviewer. A random effects Sidik-Jonkman model was applied to conduct a meta-analysis and estimate the diagnostic accuracy on a per-patient basis, along with 95% confidence intervals. Moreover, an appraisal regarding the likelihood of publication bias and the impact of small-study effects was performed utilizing both Egger's test and a graphical examination of the funnel plot. RESULTS: The present analysis comprised a total of twenty-three scientific papers encompassing 969 patients and involved their analysis by both qualitative and quantitative approaches. The results of this study demonstrated that the estimated diagnostic accuracy of PSMA PET/CT and PSMA PET/MRI, for the detection of intraprostatic tumours, regardless of the type of PSMA-ligand, was 86% (95% CI: 76-96%) and 97% (95% CI: 94-100%), respectively. Furthermore, the diagnostic accuracy for the detection of extraprostatic extension (EPE) was 73% (95% CI: 64-82%) and 77% (95% CI: 69-85%), while the diagnostic accuracy for the detection of seminal vesicle involvement (SVI) was 87% (95% CI: 80-93) and 90% (95% CI: 82-99%), respectively. CONCLUSION: The present investigation has demonstrated that PSMA PET/MRI surpasses currently recommended multiparametric magnetic resonance imaging (mpMRI) in terms of diagnostic accuracy as inferred from a notable data trajectory, whereas PSMA-PET/CT exhibited comparable diagnostic accuracy for intraprostatic tumour detection and T-staging compared to mpMRI. Nevertheless, the analysis has identified certain potential limitations, such as small-study effects and a potential for publication bias, which may impact the overall conclusions drawn from this study.

A Case of Penile Metastasis from Prostate Cancer, Identified by 68Ga-PSMA PET/CT, Mimicking Peyronie's Disease: A Diagnostic Challenge.

A 70-year-old man with high-risk prostate cancer (PCa) received radiation therapy and androgen deprivation therapy (ADT). The patient developed penile tenderness, compatible with Peyronie's disease upon physical examination. An ultrasound revealed a matching hypoechoic plaque and a thrombus in the vena dorsalis profunda, which were treated with anticoagulants. A follow-up ultrasound showed no abnormalities. Despite the use of analgesics, the patient suffered from persistent pain, later accompanied by an increasing PSA level of up to 7.5 ng/mL, despite ADT. 68Ga-PSMA PET/CT showed a PSMA uptake consistent with PCa penile metastasis. Due to severe pain and the presence of metastatic PCa, the patient was referred for penectomy. Histopathological analysis confirmed metastases originating from the PCa. This case underscores the importance of 68Ga-PSMA PET/CT in diagnosing PCa metastases and vigilance towards urogenital symptoms as potential indicators of metastases, despite the rarity of penile metastases.

Presurgical 68Ga-PSMA-11 Positron Emission Tomography for Biochemical Recurrence Risk Assessment: A Follow-up Analysis of a Multicenter Prospective Phase 3 Imaging Trial.

BACKGROUND: In the initial staging of patients with high-risk prostate cancer (PCa), prostate-specific membrane antigen positron emission tomography (PSMA-PET) has been established as a front-line imaging modality. The increasing number of PSMA-PET scans performed in the primary staging setting might be associated with decreases in biochemical recurrence (BCR)-free survival (BCR-FS). OBJECTIVE: To assess the added prognostic value of presurgical PSMA-PET for BCR-FS compared with the presurgical Cancer of the Prostate Risk Assessment (CAPRA) and postsurgical CAPRA-Surgery (CAPRA-S) scores in patients with intermediate- to high-risk PCa treated with radical prostatectomy (RP) and pelvic lymph node dissection. DESIGN, SETTING, AND PARTICIPANTS: This is a follow-up study of the surgical cohort evaluated in the multicenter prospective phase 3 imaging trial (n = 277; NCT03368547, NCT02611882, and NCT02919111). OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Each 68Ga-PSMA-11-PET scan was read by three blinded independent readers. PSMA-PET prostate uptake (low vs high), PSMA-PET extraprostatic disease (N1/M1), and CAPRA and CAPRA-S scores were used to assess the risk of BCR. Patients were followed after RP by local investigators using electronic medical records. BCR was defined by a prostate-specific antigen (PSA) level increasing to ≥0.2 ng/ml after RP or initiation of PCa-specific secondary treatment (>6 mo after surgery). Univariate and multivariable Cox models, and c-statistic index were performed to assess the prognostic value of PSMA-PET and for a comparison with the CAPRA and CAPRA-S scores. RESULTS AND LIMITATIONS: From December 2015 to December 2019, 277 patients underwent surgery after PSMA-PET. Clinical follow-up was obtained in 240/277 (87%) patients. The median follow-up after surgery was 32.4 (interquartile range 23.3-42.9) mo. Of 240 BCR events, 91 (38%) were observed. PSMA-PET N1/M1 was found in 41/240 (17%) patients. PSMA-PET prostate uptake, PSMA-PET N1/M1, and CAPRA and CAPRA-S scores were significant univariate predictors of BCR. The addition of PSMA-PET N1/M1 status to the presurgical CAPRA score improved the risk assessment for BCR significantly in comparison with the presurgical CAPRA score alone (c-statistic 0.70 [0.64-0.75] vs 0.63 [0.57-0.69]; p < 0.001). The C-index of the postsurgical model utilizing the postsurgical CAPRA-S score alone was not significantly different from the presurgical model combining the presurgical CAPRA score and PSMA-PET N1/M1 status (p = 0.19). CONCLUSIONS: Presurgical PSMA-PET was a strong prognostic biomarker improving BCR-FS risk assessment. Its implementation in the presurgical risk assessment with the CAPRA score improved the performance and reduced the difference with the reference standard (postsurgical CAPRA-S score). PATIENT SUMMARY: The use prostate-specific membrane antigen positron emission tomography improved the assessment of biochemical recurrence risk in patients with intermediate- and high-risk prostate cancer who were treated with radical prostatectomy and pelvic lymph node dissection.

Intense PSMA Uptake in a Vertebral Hemangioma Mimicking a Solitary Bone Metastasis in the Primary Staging of Prostate Cancer via 68Ga-PSMA PET/CT.

A 78-year-old man with newly diagnosed high-risk prostate cancer underwent 68Ga-PSMA PET/CT for primary staging. This showed a single, very intense PSMA uptake in the vertebral body of Th2, without discrete morphological changes on low-dose CT. Thus, the patient was considered oligometastatic and underwent MRI of the spine for stereotactic radiotherapy planning. MRI demonstrated an atypical hemangioma in Th2. A bone algorithm CT scan confirmed the MRI findings. The treatment was changed, and the patient underwent a prostatectomy with no concomitant therapy. At three and six months after the prostatectomy, the patient had an unmeasurable PSA level, confirming the benign etiology of the lesion.

Frequency of superscan on bone scintigraphy: A systematic review.

INTRODUCTION: Bone scintigraphy (BS) is an important tool for detecting bone metastasis. BS with diffuse increased skeletal radioisotope uptake with absent or faint urinary tract and soft tissue activity is defined as a superscan. In this review, we investigate the different etiologies causing superscan and the reported frequency of superscan among different disease entities. MATERIALS AND METHODS: The search terms were 'bone' AND 'superscan' OR 'superscan' in the PubMed database from 1980 to November 2020. Eligibility criteria included the following: Peer-reviewed studies containing original data using 99mTc-phosphate-analogue BS reporting a superscan pattern. Unretrievable papers, imaging modalities other than BS or with insufficient information to assess the aetiology were excluded. The abstracts of every paper and full texts of potentially eligible papers were assessed independently by three observers. RESULTS: Sixty-seven papers were included (48 case reports and 19 cohort studies). Studies conducted in patients with osteomalacia or skeletal fluorosis revealed superscan in all patients. Other benign causes of superscan were hyperparathyroidism and kidney disease. Among papers with malignant cause, prostate cancer was the most common cause, followed by gastric cancer. The frequency of superscans ranged from 1.3% in a cohort of mixed cancer types up to 2.6% in patients with gastric cancer and up to 23% in a cohort of prostate cancer patients. CONCLUSION: Superscan is most frequently seen in prostate cancer, but numerous other cancers and metabolic bone diseases can cause superscan, which should be kept in mind when encountering an unexpected superscan on BS.

Multiparametric dynamic whole-body PSMA PET/CT using [68Ga]Ga-PSMA-11 and [18F]PSMA-1007.

BACKGROUND: Routine prostate-specific membrane antigen (PSMA) positron emission tomography (PET) performed for primary staging or restaging of prostate cancer patients is usually done as a single static image acquisition 60 min after tracer administration. In this study, we employ dynamic whole-body (D-WB) PET imaging to compare the pharmacokinetics of [68Ga]Ga-PSMA-11 and [18F]PSMA-1007 in various tissues and lesions, and to assess whether Patlak parametric images are quantitative and improve lesion detection and image readability. METHODS: Twenty male patients with prostate cancer were examined using a D-WB PSMA PET protocol. Ten patients were scanned with [68Ga]Ga-PSMA-11 and ten with [18F]PSMA-1007. Kinetic analyses were made using time-activity curves (TACs) extracted from organs (liver, spleen, bone, and muscle) and lesions. For each patient, three images were produced: SUV + Patlak parametric images (Ki and DV). All images were reviewed visually to compare lesion detection, image readability was quantified using target-to-background ratios (TBR), and Ki and DV values were compared. RESULTS: The two PSMA tracers exhibited markedly different pharmacokinetics in organs: reversible for [68Ga]Ga-PSMA-11 and irreversible for [18F]PSMA-1007. For both tracers, lesions kinetics were best described by an irreversible model. All parametric images were of good visual quality using both radiotracers. In general, Ki images were characterized by reduced vascular signal and increased lesion TBR compared with SUV images. No additional malignant lesions were identified on the parametric images. CONCLUSION: D-WB PET/CT is feasible for both PSMA tracers allowing for direct reconstruction of parametric Ki images. The use of multiparametric PSMA images increased TBR but did not lead to the detection of more lesions. For quantitative whole-body Ki imaging, [18F]PSMA-1007 should be preferred over [68Ga]Ga-PSMA-11 due to its irreversible kinetics in organs and lesions.

Indeterminate thyroid cytology in an iodine-deficient population: Prevalence, operation rate, risk of malignancy anddiagnostic value of thyroid scintigraphy and 18F-FDG PET imaging parameters.

OBJECTIVE: Patients with indeterminate thyroid cytology often have a diagnostic hemithyroidectomy. The role of molecular imaging, particularly fluorine-18-fluorodeoxyglucose (18F-FDG) positron emission tomography (PET), is controversial, and demographic variations in tumor prevalence and histology influence test performance and clinical utility. We retrospectively assessed the prevalence of indeterminate thyroid cytology and the malignancy rate in patients from an iodine deficient area, and evaluated the diagnostic value of preoperative thyroid scintigraphy and 18F-FDG PET/CT among operated patients. SUBJECTS AND METHODS: From 2006-2018, all patients with indeterminate thyroid cytology from the North Denmark region were included in the study (population 600,000).Clinical data, including operation rate, preoperative molecular imaging, and histopathological diagnosis, were retrieved. The results from preoperative thyroid scintigraphy and 18F-FDG PET/CT-scanning were compared to the final histopathological diagnosis. RESULTS: Four hundred and thirty-three patients were found with indeterminate thyroid cytology.The main registered reasons for conducting a fine needle aspiration biopsy (FNAB) were "cold nodule", goiter or a palpable nodule (n=312). In 40 patients (9%), FNAB was registered as conducted due to a PET incidentaloma. Four hundred and two patients (93%) underwent diagnostic lobectomy, and this population formed the study population for the following explorative study: One-hundred and two patients (25%) had a malignant diagnosis. In 226 (56%) and 51 (25%) patients, respectively, preoperative thyroid scintigraphy and 18F-FDG PET/computed tomography (CT) was performed. Among patients with a final malignant disease who had a thyroid scintigraphy (40 patients), a cold nodule was seen in 90% of cases; one (atypical) patient presented a warm nodule. Among patients with a final malignant disease 16 patients (16%) had a 18F-FDG PET (incl. 3 missing PET scans). Among the 51 patients with preoperative 18F-FDG PET/CT, no difference in the PET-derived parameters was found between benign (n=33) and malignant tumors (n=13). CONCLUSION: The prevalence of malignancy (25%) was comparable with that in other studies. In patients with a preoperative thyroid scintigraphy, 90% of malignant cases had a cold nodule on scintigraphy. In patients with a preoperative PET/CT-scanning presenting focal 18F-FDG-uptake, PET-derived parameters had no diagnostic value. However, the diagnostic value of 18F-FDG-avidity vs. non-avidity needs to be addressed prospectively.

Not All Glittering Bone Lesions Are Gold: A Case of Sclerotic Bone Lesions with Elevated 68 Ga PSMA and 99m Tc HDP Uptake with No Signs of Malignancy.

Gallium-68 prostate-specific membrane antigen positron emission tomography/computed tomography ( 68 Ga PSMA PET/CT) outperforms CT and bone scintigraphy in terms of diagnostic accuracy for the primary staging of prostate cancer and has become widely used. However, 68 Ga PSMA uptake is also encountered in nonprostatic tissue. We present a 63-year-old male with newly diagnosed high-risk prostate cancer who underwent bone scintigraphy with single-photon emission computed tomography/computed tomography (SPECT/CT), which showed inhomogeneous elevated uptake in sclerotic bone lesions in the pelvis. Likewise, 68 Ga PSMA PET/CT revealed inhomogeneous uptake in the same areas. Subsequent biopsy revealed hyperplastic bone marrow without signs of malignancy. The patient underwent radical prostatectomy, and the prostate-specific antigen level dropped to less than 0.1 ng/mL.

FAPI-avid nonmalignant PET/CT findings: An expedited systematic review.

Fibroblast activation protein inhibitor (FAPI) is a promising tracer in oncologic positron emission tomography/computed tomography (PET/CT). Numerous studies have demonstrated the superior sensitivity of FAPI PET/CT over fluorodeoxyglucose (FDG) PET/CT in several types of cancer. However, the cancer specificity of FAPI uptake remains understudied, and several cases of false-positive FAPI PET/CT findings have been reported. A systematic search of PubMed, Embase, and Web of Science was conducted for studies published prior to April 2022 reporting nonmalignant FAPI PET/CT findings. We included original peer-reviewed articles of studies in humans using FAPI tracers radiolabeled with 68Ga or 18F that were published in English. Papers without original data and studies with insufficient information were excluded. Nonmalignant findings were presented on a per-lesion basis and grouped according to the type of organ or tissue involved. The search identified a total of 1.178 papers, of which 108 studies were eligible. Eighty studies were case reports (74%), and the remaining 28 were cohort studies (26%). A total of 2.372 FAPI-avid nonmalignant findings were reported, with the most frequent being uptake in the arteries, e.g., related to plaques (n = 1178, 49%). FAPI uptake was also frequently related to degenerative and traumatic bone and joint lesions (n = 147, 6%) or arthritis (n = 92, 4%). For organs, diffuse or focal uptake was often seen in cases of inflammation, infection, fibrosis, and IgG4-related disease (n = 157, 7%). FAPI-avid inflammatory/reactive lymph nodes (n = 121, 5%) and tuberculosis lesions (n = 51, 2%) have been reported and could prove to be potential pitfalls in cancer staging. Periodontitis (n = 76, 3%), hemorrhoids (n = 47, 2%), and scarring/wound healing (n = 35, 2%) also presented as focal uptake on FAPI PET/CT. The present review provides an overview of the reported FAPI-avid nonmalignant PET/CT findings to date. A large number of benign clinical entities may show FAPI uptake and should be kept in mind when interpreting FAPI PET/CT findings in patients with cancer.

Deep learning based identification of bone scintigraphies containing metastatic bone disease foci.

PURPOSE: Metastatic bone disease (MBD) is the most common form of metastases, most frequently deriving from prostate cancer. MBD is screened with bone scintigraphy (BS), which have high sensitivity but low specificity for the diagnosis of MBD, often requiring further investigations. Deep learning (DL) - a machine learning technique designed to mimic human neuronal interactions- has shown promise in the field of medical imaging analysis for different purposes, including segmentation and classification of lesions. In this study, we aim to develop a DL algorithm that can classify areas of increased uptake on bone scintigraphy scans. METHODS: We collected 2365 BS from three European medical centres. The model was trained and validated on 1203 and 164 BS scans respectively. Furthermore we evaluated its performance on an external testing set composed of 998 BS scans. We further aimed to enhance the explainability of our developed algorithm, using activation maps. We compared the performance of our algorithm to that of 6 nuclear medicine physicians. RESULTS: The developed DL based algorithm is able to detect MBD on BSs, with high specificity and sensitivity (0.80 and 0.82 respectively on the external test set), in a shorter time compared to the nuclear medicine physicians (2.5 min for AI and 30 min for nuclear medicine physicians to classify 134 BSs). Further prospective validation is required before the algorithm can be used in the clinic.

Improvement of the splanchnic blood flow and hepatic vein oxygenation following revascularization in patients with chronic mesenteric ischaemia.

OBJECTIVES: Chronic mesenteric ischaemia (CMI) is an underdiagnosed but severe condition. Access to functional testing is often limited and the diagnosis is usually based primarily on symptoms and imaging. One of the functional tests available is measurement of the splanchnic blood flow (SBF). The purpose of the present investigation was to evaluate if changes in the splanchnic perfusion after revascularization can be detected by measuring the SBF and hepatic vein oxygenation. MATERIALS AND METHODS: The SBF was measured in 10 patients before and after revascularization of the mesenteric arteries by either percutaneous transluminal angioplasty (n = 9) or open revascularization (n = 1). The SBF was measured indirectly using Fick's principle and using the tracer Tc-99m Mebrofenin along with assessment of hepatic blood oxygenation, before and after a standard meal, following catheterization of a hepatic vein and the femoral artery. RESULTS: Nine of 10 patients (90%) achieved a profound increase in SBF after revascularization (mean increase in postprandial response to meal stimulation from 71 ± 95 to 531 ± 295 ml/min, p = 0.001), and an increase in postprandial hepatic vein oxygen saturation (from 52 ± 14% to 59 ± 13%, p = 0.006). The symptoms of the patients diminished accordingly. One patient had no symptom relief, and no increase in postprandial SBF, but an angiographic result with no significant stenosis postrevascularization. CONCLUSIONS: Revascularization increased the SBF and hepatic vein oxygen saturation significantly concurrent with symptom relief and according with the angiographic successful result in the vast majority of patients. A satisfying angiographic result post vascular intervention does not rule out CMI.

Giant Parathyroid Tumor: Parathyroid Adenoma versus Parathyroid Carcinoma.

Parathyroid adenoma is the most common cause of primary hyperparathyroidism (PHPT). We present the preoperative detection of a giant parathyroid adenoma (GPA) using (99mTc)-sestamibi parathyroid scintigraphy in a patient presenting with severely elevated parathyroid hormone, hypercalcemia, hypophosphatemia, and vitamin D insufficiency. The patient complained of cerebral symptoms and intermittent abdominal discomfort without constipation. After surgical removal of the hyperactive parathyroid gland and D vitamin supplementation, all blood tests were normalized. The clinical and paraclinical characteristics of GPA may raise the suspicion of parathyroid carcinoma, but not absolutely in this case.

The clinical consequences of routine 68Ga-PSMA-11 PET/CT in patients with newly diagnosed prostate cancer, ISUP grade 5 and no metastases based on standard imaging - preliminary results.

AIM: To evaluate the clinical consequences of prostate specific membrane antigen (PSMA) PET/CT for primary staging in patients with ISUP grade 5 (Gleason score ≥9) prostate cancer (PCa), and no definitive distant metastases based on standard imaging. METHODS: At our tertial referral center, PSMA PET/CT became standard of care from August 2018 for primary staging of prostate cancer given the following criteria: (1) no prior treatment for prostate cancer, (2) ISUP grade 5, (3) no definitive metastases on standard imaging (contrast enhanced CT and bone scintigraphy), and (4) deemed suitable for treatment with curative intent based on comorbidity and life expectancy. We present the preliminary results of first six months recruitment with 12 months of follow-up. RESULTS: Forty-eight patients (mean age 69 years, median PSA 13.0 ng/mL, 20 patients with locally advanced PCa) were included. CT was positive in pelvic lymph nodes in two patients, bone scintigraphy was equivocal in three patients. PSMA PET/CT showed pathological uptake outside the prostatic bed in 22 patients (46%) of which 13 patients (27%) showed lesions confined to regional lymph nodes, and nine patients (19%) showed nonregional lymph node metastases and/or bone metastases. PSMA PET/CT changed the treatment strategy from curatively intended treatment to palliative treatment in 18 patients (38%). CONCLUSION: PMSA PET/CT revealed pathological uptake in a large proportion of high-risk patients at primary staging among patients with no definite metastases on standard imaging leading to change of patient management in 38% of the patients.

The value of 68 Ga-PSMA-11 PET/CT in patients with prostate cancer and inconclusive standard imaging at primary staging.

OBJECTIVE: The current standard imaging recommended for primary staging of intermediate- and high-risk prostate cancer (PCa) consists of bone scintigraphy (BS) and computed tomography (CT). Some patients will have equivocal lesions or divergent findings on BS and CT, leading to inconclusive disease staging. Our aim was to investigate the value of 68 Ga-PSMA-11 PET/CT in PCa with inconclusive disease stage based on standard imaging. METHODS: We made a single-center study of patients with newly diagnosed PCa who underwent a 68 Ga-PSMA-11 PET/CT due to equivocal findings or discrepancies between BS and CT from 1 January 2017 to 31 December 2020. The value of 68 Ga-PSMA-11 PET/CT was evaluated for each location of equivocal findings (regional lymphnode, nonregional lymphnodes, bones and other metastases) and on a patient level. RESULTS: Seventy-six patients were included in the study (62 patients with 72 equivocal lesions, 14 with discrepancy between BS and CT). Equivocal lesions were predominately in the bones (61%, 44/72), or in the regional lymph nodes (17%, 12/72). 68 Ga-PSMA-11 PET/CT provided a conclusive diagnosis in 90% (65/72) of the equivocal lesions. All patients with discrepancies between BS and CT had definite answers after 68 Ga-PSMA-11 PET/CT. 68 Ga-PSMA-11 PET/CT also uncovered 32 additional sites of metastasis in 25 patients not visible by standard imaging. CONCLUSION: 68 Ga-PSMA-11 PET/CT provides a definite disease stage in more than 90% of newly diagnosed patients with inconclusive standard imaging. Furthermore, it revealed additional sites of metastasis in 25 patients not detected by standard imaging.

Influence of Prior Imaging Information on Diagnostic Accuracy for Focal Skeletal Processes-A Retrospective Analysis of the Consistency between Biopsy-Verified Imaging Diagnoses.

INTRODUCTION: Comparing imaging examinations with those previously obtained is considered mandatory in imaging guidelines. To our knowledge, no studies are available on neither the influence, nor the sequence, of prior imaging and reports on diagnostic accuracy using biopsy as the reference standard. Such data are important to minimize diagnostic errors and to improve the preparation of diagnostic imaging guidelines. The aim of our study was to provide such data. MATERIALS AND METHODS: A retrospective cohort of 216 consecutive skeletal biopsies from patients with at least 2 different imaging modalities (X-ray, CT and MRI) performed within 6 months of biopsy was identified. The diagnostic accuracy of the individual imaging modality was assessed. Finally, the possible influence of the sequence of imaging modalities was investigated. RESULTS: No significant difference in the accuracy of the imaging modalities was shown, being preceded by another imaging modality or not. However, the sequence analyses indicate sequential biases, particularly if MRI was the first imaging modality. CONCLUSION: The sequence of the imaging modalities seems to influence the diagnostic accuracy against a pathology reference standard. Further studies are needed to establish evidence-based guidelines for the strategy of using previous imaging and reports to improve diagnostic accuracy.