Clinical Trial Protocol for PRIMARY2: A Multicentre, Phase 3, Randomised Controlled Trial Investigating the Additive Diagnostic Value of [68Ga]Ga-PSMA-11 Positron Emission Tomography/Computed Tomography in Men with Negative or Equivocal Multiparametric Magnetic Resonance Imaging for the Diagnosis of Clinically Significant Prostate Cancer.

BACKGROUND: Multiparametric magnetic resonance imaging (mpMRI) has an established role for the diagnosis of clinically significant prostate cancer (sPCa). The PRIMARY trial demonstrated that [68Ga]Ga-PSMA-11 positron emission tomography/computed tomography (PET/CT) was associated with a significant improvement in sensitivity and negative predictive value for sPCa detection. OBJECTIVE: To demonstrate that addition of prostate-specific membrane antigen (PSMA) radioligand PET/CT will enable some men to avoid transperineal prostate biopsy without missing sPCa, and will facilitate biopsy targeting of PSMA-avid sites. DESIGN, SETTING, AND PARTICIPANTS: This multicentre, two-arm, phase 3, randomised controlled trial will recruit 660 participants scheduled to undergo biopsy. Eligible participants will have clinical suspicion of sPCa with a Prostate Imaging-Reporting and Data System (PI-RADS) score of 2 and red flags, or a PI-RADS score of 3 on mpMRI (PI-RADS v2). Participants will be randomised at a 1:1 ratio in permuted blocks stratified by centre. The trial is registered on ClinicalTrials.gov as NCT05154162. INTERVENTION: In the experimental arm, participants will undergo pelvic PSMA PET/CT. Local and central reviewers will interpret scans independently using the PRIMARY score. Participants with a positive result will undergo targeted transperineal prostate biopsies, whereas those with a negative result will undergo prostate-specific antigen monitoring alone. In the control arm, all participants undergo template transperineal prostate biopsies. Participants will be followed for subsequent clinical care for up to 2 yr after randomisation. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: sPCa is defined as Gleason score 3 + 4 (≥10%) = 7 disease (grade group 2) or higher on transperineal prostate biopsy. Avoidance of transperineal prostate biopsy will be measured at 6 mo from randomisation. The primary endpoints will be analysed on an intention-to-treat basis. CONCLUSIONS: Patient enrolment began in March 2022, with recruitment expected to take 36 mo. PATIENT SUMMARY: For patients with suspected prostate cancer who have nonsuspicious or unclear MRI (magnetic resonance imaging) scan findings, a different type of scan (called PSMA PET/CT; prostate-specific membrane antigen positron emission tomography/computed tomography) may identify men who could avoid an invasive prostate biopsy. This type of scan could also help urologists in better targeting of samples from suspicious lesions during prostate biopsies.

Underutilisation of gastric emptying studies and underrecognition of gastroparesis in people with diabetes treated in a hospital setting.

Delayed gastric emptying occurs in up to 30% of patients with long-standing diabetes and causes significant morbidity. We performed a retrospective cohort study of 341 patients who had participated in a gastric emptying study from 2018 to 2021 in a large teaching hospital. Given the expected prevalence of gastroparesis in people with diabetes, there were fewer studies than anticipated, which could lead to gastroparesis underrecognition.

Correlation of current myocardial perfusion imaging and previous coronary angiography to avert the need for repeat intervention - A case report.

INTRODUCTION: Evaluation of chest pain in an individual with prior coronary artery bypass graft (CABG) procedures can be complex. Stress myocardial perfusion imaging (MPI) demonstrates reasonable sensitivity for detection of ischemia following bypass grafting [1] but often requires multi-modality imaging correlation for knowledge of graft anatomy. CASE AND OUTCOME: We describe the findings of a reversible perfusion defect on myocardial perfusion scintigraphy in a person post-CABG. This was interpreted in combination with findings of coronary angiography, thereby identifying ischemia in a native un-grafted vessel territory and influencing management strategy. DISCUSSION: Myocardial perfusion scintigraphy is a sensitive technique for evaluation of inducible ischemia. It provides information on the extent and severity of ischemia. Integrating the knowledge of changes on coronary angiography with MPI provides a comprehensive picture that can guide management decisions, as in our case. CONCLUSION: Correlation of structural and functional imaging findings may be extremely helpful for management of patients with myocardial ischemia post-CABG.

Can 68 Ga-PSMA positron emission tomography and multiparametric MRI guide treatment for biochemical recurrence after radical prostatectomy?

OBJECTIVE: To evaluate the role of multiparametric magnetic resonance imaging (mpMRI) and Gallium-68 (68 Ga)-prostate-specific membrane antigen (PSMA) positron emission tomography (PET)/computed tomography (CT) in guiding salvage therapy for patients with biochemical recurrence (BCR) post-radical prostatectomy. PATIENTS AND METHODS: Patients were evaluated with paired mpMRI and 68 Ga-PSMA PET/CT scans for BCR (prostate-specific antigen [PSA] >0.2 ng/mL). Patient, tumour, PSA and imaging characteristics were analysed with descriptive statistics. RESULTS: A total of 117 patients underwent paired scans to investigate BCR, of whom 53.0% (62/117) had detectable lesions on initial scans and 47.0% (55/117) did not. Of those without detectable lesions, 8/55 patients proceeded to immediate salvage radiotherapy (sRT) and 47/55 were observed. Of patients with negative imaging who were initially observed, 46.8% (22/47) did not reach threshold for repeat imaging, while 53.2% were rescanned due to rising PSA levels. Of these rescanned patients, 31.9% (15/47) were spared sRT due to proven distant disease, or due to absence of disease on repeat imaging. Of the original 117 patients, 53 (45.3%) were spared early sRT due to absence of disease on imaging or presence of distant disease, while those undergoing delayed sRT still maintained good PSA responses. Of note, patients with high-risk features who underwent sRT despite negative imaging demonstrated satisfactory PSA responses to sRT. Study limitations include the observational design and absence of cause-specific or overall survival data. CONCLUSION: Our findings support the use of mpMRI and 68 Ga-PSMA PET/CT in guiding timing and necessity of salvage therapy tailored to detected lesions, with potential to reduce unnecessary sRT-related morbidity. Larger or randomized trials are warranted to validate this.

99m Tc-Sestamibi Thyroid Scintigraphy in Amiodarone-Induced Thyrotoxicosis : Functional Imaging-Histopathologic Correlation.

ABSTRACT: 99m Tc-sestamibi thyroid scintigraphy (STS) can aid in differentiating between types 1 and 2 amiodarone-induced thyrotoxicosis (AIT). We present a consecutive case series of 4 men (aged 56-75 years) in whom both 99m Tc-STS and thyroid histology were consistent with a diagnosis of type 2 AIT, representing the first reported histopathologic correlation for this diagnostic test. Median amiodarone treatment duration was 26 months (range, 10-39 months), and amiodarone was discontinued a median of 3 months preoperatively (range, 2-4 months) in all 4 cases. 99m Tc-STS is a promising functional imaging modality, which has the potential to aid clinicians in the diagnostic workup and treatment of AIT.

Empiric radioiodine for hyperthyroidism: Outcomes, prescribing patterns, and its place in the modern era of theranostics.

BACKGROUND: The modern era of radioiodine (I-131) theranostics for metastatic differentiated thyroid cancer requires us to rationalize the role of traditional empiric prescription in nonmalignant thyroid disease. We currently practice empiric I-131 prescription for treatment of hyperthyroidism. This study aims to assess outcomes after treatment of hyperthyroidism by empiric I-131 prescription at our centre, evaluate factors that impact on outcomes and prescribing practice, and gain insight into whether there is a place for theranostically-guided prescription in hyperthyroidism. PATIENTS AND METHODS: A retrospective review was undertaken of all patients with Graves' disease, toxic multinodular goitre (MNG) and toxic adenoma treated with I-131 between 2016 and 2021. Associations between clinical or scintigraphic variables and remission (euthyroid or hypothyroid) or persistence of hyperthyroidism at follow-up were performed using standard t test as well as Pearson's product correlation. RESULTS: Of 146 patients with a mean follow-up of 13.6 months, 80.8% achieved remission of hyperthyroidism. This was highest in toxic nodules (90.1%), compared with Graves' disease (73.8%) and toxic MNG (75.5%). In patients with Graves' disease, higher administered activity was associated with remission (p = .035). There was a weak inverse correlation between the Tc-99m pertechnetate uptake vs prescribed activity in Graves' disease (r = -0.33; p = .009). Only one patient (0.7%) had an I-131 induced flare of thyrotoxicosis. CONCLUSION: Traditional empiric I-131 prescription is a safe and effective treatment of hyperthyroidism and suitable for most patients. However, there may be a role for personalized I-131 prescription by theranostic guidance in selected patients with high thyroid hyperactivity.

Indirect Lung Absorbed Dose Verification by 90Y PET/CT and Complete Lung Protection by Hepatic Vein Balloon Occlusion: Proof of Concept.

Postradioembolization lung absorbed dose verification was historically problematic and impractical in clinical practice. We devised an indirect method using 90Y PET/CT. Methods: Conceptually, true lung activity is simply the difference between the total prepared activity minus all activity below the diaphragm and residual activity within delivery apparatus. Patient-specific lung mass is measured by CT densitovolumetry. True lung mean absorbed dose is calculated by MIRD macrodosimetry. Results: Proof of concept is shown in a hepatocellular carcinoma patient with a high lung shunt fraction of 26%, where evidence of technically successful hepatic vein balloon occlusion for radioembolization lung protection was required. Indirect lung activity quantification showed the postradioembolization lung shunt fraction to be reduced to approximately 1% with a true lung mean absorbed dose of approximately 1 Gy, suggesting complete lung protection by hepatic vein balloon occlusion. Conclusion: We discuss possible clinical applications such as lung absorbed dose verification, refining the limits of lung tolerance, and the concept of massive activity radioembolization.

68Ga-Prostate-Specific Membrane Antigen Positron Emission Tomography Maximum Standardized Uptake Value as a Predictor of Gleason Pattern 4 and Pathological Upgrading in Intermediate-Risk Prostate Cancer.

PURPOSE: Accurate risk stratification remains a barrier for the safety of active surveillance in patients with intermediate-risk prostate cancer. [68Ga]Ga-PSMA-11 prostate-specific membrane antigen positron emission tomography/computerized tomography (68Ga-PSMA PET/CT) and the maximum standardized uptake value (SUVmax) may improve risk stratification within this population. MATERIALS AND METHODS: We reviewed men with International Society for Urological Pathology Grade Group (GG) 2-3 disease on transperineal template biopsy undergoing 68Ga-PSMA PET/CT from November 2015 to January 2021. Primary outcome was the presence of high percentage Gleason pattern 4 (GP4) disease per segment at surgery at 3 thresholds: >/<50% GP4, >/<20% GP4, and >/<10% GP4. SUVmax was compared by GP4, and multivariable logistic regression examined the relationship between SUVmax and GP4. Secondary outcome was association between SUVmax and pathological upgrading (GG 1/2 to GG ≥3 from biopsy to surgery). RESULTS: Of 220 men who underwent biopsy, 135 men underwent surgery. SUVmax was higher in high GP4 groups: 5.51 (IQR 4.19-8.49) vs 3.31 (2.64-4.41) >/<50% GP4 (p <0.001); 4.77 (3.31-7.00) vs 3.13 (2.64-4.41) >/<20% GP4 (p <0.001); and 4.54 (6.10-3.13) vs 3.03 (2.45-3.70) >/<10% GP4 (p <0.001). SUVmax remained an independent predictor of >50% (OR=1.39 [95%CI 1.18-1.65], p <0.001) and >20% (OR=1.24 [1.04-1.47], p=0.015) GP4 disease per-segment, and of pathological upgrading (OR=1.22 [1.01-1.48], p=0.036). SUVmax threshold 4.5 predicted >20% GP4 with 58% specificity, 85% sensitivity, positive predictive value 75% and negative predictive value 72%. Threshold 5.4 predicted pathological upgrading with 91% specificity and negative predictive value 94%. CONCLUSIONS: SUVmax on 68Ga-PSMA PET/CT is associated with GP4. SUVmax may improve risk stratification for men with intermediate-risk prostate cancer.

Brain hypometabolism in rare genetic neurodegenerative disease: Niemann-Pick disease type C, spinocerebellar ataxia and Huntington disease assessed by FDG PET.

Brain metabolic imaging using 18F-fluorodeoxyglucose (FDG) Positron Emission Tomography (PET) with contemporaneous low-dose CT may be used to assess neurodegenerative diseases. In contrast to oncology whole-body FDG PET, qualitative assessment alone in brain FDG PET is subjective and vulnerable to visual interference due to high physiologic background activity. Therefore, mild changes in brain metabolism may be visually undetectable by qualitative interpretation alone, resulting in diagnostic inaccuracy. To overcome this, some institutions may employ an objective comparison to a normal reference database. To date, there is limited literature describing brain metabolic changes in rare genetic neurodegenerative diseases such as Niemann-Pick disease Type C, spinocerebellar ataxia and Huntington disease. In this case series, we illustrate the typical FDG PET findings in the cortex and deep grey matter for these rare diseases, utilising normal database comparison including three dimensional Stereotactic Surface Projection (3D-SSP) mapping. These comparisons can generate 3D-SSP maps where metabolic changes may be expressed in standard deviations from normal (z-score) and visually depicted in a scale of colours to improve diagnostic accuracy.

Brain hypometabolic changes in 14 adolescent-adult patients with Niemann-Pick disease type C assessed by 18F-fluorodeoxyglucose positron emission tomography.

OBJECTIVE: Niemann Pick disease type C (NPC) is a rare progressive neurovisceral lysosomal disorder caused by autosomal recessive mutations in the NPC1 or NPC2 genes. 18F-fluorodeoxyglucose (FDG) is a positron-emitting glucose analogue for non-invasive imaging of brain metabolism. FDG PET is commonly used for dementia imaging but its specific application to NPC is rarely described. METHODS: This is a retrospective study of all baseline brain FDG PET performed for NPC patients. Images were assessed using a normal database statistical comparison of metabolic changes expressed in standard deviations and three-dimensional Stereotactic Surface Projection maps. Typical hypometabolic patterns in NPC were identified. We further investigated any correlation between the degree of regional brain hypometabolism and the Iturriaga clinical severity scale. RESULTS: Brain FDG PET images of 14 adolescent-adult NPC patients were analysed, with mean age of 35 years. We found significant frontal lobe hypometabolism in 12 patients (86%), thalamic hypometabolism in eight patients (57%) and variable parietal lobe hypometabolism in 13 patients (93%). Hypometabolic changes were usually bilateral and symmetric. Ten out of 13 ataxic patients showed cerebellar or thalamic hypometabolism (sensitivity 77%, specificity 100%). Linear regression analysis showed frontal lobe hypometabolism to have the best correlation with the Iturriaga clinical scale (R2 = 0.439; p = 0.01). CONCLUSIONS: We found bilateral symmetric hypometabolism of the frontal lobes, thalami and parietal lobes (especially posterior cingulate gyrus) to be typical of adolescent-adult NPC. Ataxia was commonly associated with cerebellar or thalamic hypometabolism. Frontal lobe hypometabolism showed the best inverse correlation with clinical severity.

90Y PET for Qualitative and Quantitative Assessment of Residual Activity in Delivery Apparatus After Radioembolization.

Assessment of residual activity is critical for quality assurance after 90Y radioembolization. The resin microsphere manufacturer's indirect method of estimating the residual activity is laborious and vulnerable to inaccuracies. Furthermore, the method cannot localize the exact site of residual activity. 90Y PET/CT for qualitative and quantitative assessment of residual activity has not, to our knowledge, been described. We show an example of 90Y PET/CT of residual activity in the delivery apparatus and catheters packed inside the delivery box. Focally intense residual activity was clearly localized to the stopcock junction. Residual activity was directly quantified by setting the PET volume-of-interest isocontour threshold to 1%.

Utility of MAG3 scintigraphy with the use of a 2 min uptake parameter in the assessment of postsurgical renal transplant complications.

OBJECTIVE: Major complications including acute tubular necrosis or rejection may occur after renal transplantation. We use a semiquantitative parameter, 2 min uptake (2MU), as part of Tc mercaptoacetyltriglycine (MAG3) scintigraphy for transplant evaluation. The aim of this study were (a) to examine the utility of Tc MAG3 scintigraphy in the assessment of postsurgical complications using the renal biopsy as the gold standard and (b) examine for any correlation with 2MU with serum creatinine (sCr) at 3 and 12 months. MATERIALS AND METHODS: We retrospectively reviewed all Tc MAG3 studies at our institution between July 2015 and June 2016, alongside available renal ultrasound, biopsy, and sCr results. RESULTS: A total of 105 patients fulfilled the inclusion criteria. 30/105 patients underwent biopsy less than 7 days of the Tc MAG3 study. Within this 7 day cohort, the negative predictive value for rejection with normal perfusion on Tc MAG3 study was 79% and the positive predictive value for rejection with abnormal Tc MAG3 perfusion was 9%. There was a weak negative correlation between 2MU and 3-month sCr (R=-0.358, P<0.001), and 2MU and 12-month sCr (R=-0.348, P<0.001). CONCLUSION: Although normal perfusion on Tc MAG3 scintigraphy study has a reasonable negative predictive value for rejection, abnormal Tc MAG3 perfusion is not useful in the differentiation of rejection from moderate to severe acute tubular necrosis. The 2MU parameter showed no additional benefit in the identification of rejection, but appeared to have a weak negative correlation with the 3-month and 12-month sCr, and may thus play a role in the prediction of longer term graft function.

Quantitative assessment of thyroid-to-background ratio improves the interobserver reliability of technetium-99m sestamibi thyroid scintigraphy for investigation of amiodarone-induced thyrotoxicosis.

BACKGROUND: Amiodarone-induced thyrotoxicosis (AIT) is caused by excessive hormone synthesis and release (AIT I), a destructive thyroiditis (AIT II), or a combination of both (AIT Ind). Although no gold-standard diagnostic test is available, technetium-99m sestamibi thyroid scintigraphy (99mTc-STS) has been previously reported to be an accurate tool for differentiating subtypes with important therapeutic implications. However, the information to guide reporting of 99mTc-STS is qualitative and highly subjective. This study aims to compare the interobserver reliability of 99mTc-STS before and after the use of quantitative thyroid-to-background ratios (TBRs) displayed on a time-activity curve for differentiation of AIT subtypes. METHODS: A retrospective audit of Nuclear Medicine Departments at Royal Melbourne Hospital (Parkville, Victoria, Australia) and Cabrini Hospital (Malvern, Victoria, Australia) identified 15 consecutive 99mTc-STS studies performed for AIT. Four nuclear medicine physicians reported the studies according to previously established criteria (series 1). Quantitative TBR and estimated 'normal' range TBR were subsequently provided before the studies were reordered and reported again (series 2). Interobserver reliability was calculated using Fleiss' κ statistic for each assessment. RESULTS: The overall percentage of agreement (PoA) and κ statistics for use of conventional 99mTc-STS for diagnosis of AIT improved from 47 to 80% and from 0.30 to 0.67 following the use of quantitative TBR displayed on a time-activity curve with reference to a normal population. Interobserver reliability improved substantially under all diagnostic comparisons, particularly for differentiation of either AIT I (PoA 80% to 94%, κ: 0.48 to 0.84) or AIT Ind (PoA 47% to 82%, κ: -0.05 to 0.51) from other types of AIT. CONCLUSION: Use of quantitative TBR improves the interobserver reliability of reporting 99mTc-STS for investigation of different types of AIT. There is 'almost perfect' agreement upon differentiation of AIT I from AIT II and AIT Ind, with important implications for rationalizing the use of corticosteroid therapy. Prospective identification of AIT Ind is improved from 'poor' to a 'moderate' level of agreement to facilitate rational use of combination therapy at diagnosis.

Myocardial perfusion imaging (MPI) is superior to the demonstration of distal collaterals in predicting cardiac events in chronic total occlusion (CTO).

BACKGROUND: In chronic total occlusion (CTO), the evidence for revascularization is less robust than for stable angina. A medical therapy strategy is common and often based on distal collateralization, regardless of the presence of ischemia. AIM: The aim of this study was to examine the correlation between distal collateralization, myocardial perfusion imaging (MPI), and hard cardiac events (HCE) in CTO. METHOD: Retrospective analysis of consecutive patients undergoing coronary angiography revealed 21 non-revascularized patients with CTO and MPI, over a 24-month period. Blinded review of patient charts, MPI, and angiography was undertaken. HCE of death, myocardial infarct, and unstable angina were assessed. Mean follow up was 23 months. RESULTS: Summed difference scores were calculated on a 17-segment model and collaterals graded on the Rentrop scale. 43% of patients had HCE, and 62% had collaterals. Ischemia on MPI accurately predicted HCE in CTO (60% vs 0%, P = .01). Distal collateralization failed to predict freedom from ischemia on MPI (31% vs 25%, P = .53) or HCE (31% vs 62%, P = .15). CONCLUSION: MPI in patients with CTO accurately predicted HCE. This allows for accurate triage of patients by MPI for consideration of revascularization. Patients without ischemia can be safely managed with optimal medical therapy. The presence of collateralization did not predict either ischemia or HCE.

Fixed defect on rest/stress Tc-99m sestamibi study underestimates myocardial ischemia: comparison with 24-hour thallium-201 study for short- and intermediate-term follow-up.

PURPOSE: We assessed whether a same day rest/stress gated Tc-99m sestamibi (MIBI) SPECT myocardial study underestimates reversible ischemia in patients with fixed perfusion defects compared with a 24-hour thallium-201 (Tl-201) study. The short- and intermediate-term outcome with or without Tl-201 reversibility was assessed. METHODS: Forty-nine consecutive patients with fixed MIBI defects received an additional Tl-201 study and were evaluated. Tl-201 was given to patients with a high clinical suspicion of underestimation of reversibility. Images were interpreted semiquantitatively by 3 nuclear medicine physicians using a 17-segment, 5-point model. A summed stress score (SSS) from stress MIBI images, a summed rest score (SRS) from Tl images, and a summed difference (SDS = SSS - SRS) score were calculated. SDS >3 indicated significant Tl-201 redistribution. Composite end points included acute myocardial infarction, unstable angina needing admission, cardiac death, or revascularization within 3 and 6 months. RESULTS: Fifteen of 49 patients showed no Tl-201 redistribution. Thirty-four of 49 (69%) patients had significant Tl-201 redistribution, and these patients had significantly higher cardiac events (CE) at 3 months (29% vs. 7%; P = 0.039), and higher at 6 months (32% vs. 7%; P = 0.027). These patients with CE had a larger amount of Tl-201 redistribution, mean SDS 8.6 vs. 5.3 (P = 0.047). Patients with significant Tl-201 redistribution had a lower left ventricular ejection fraction (mean 37%; P = 0.001). CONCLUSION: With short- and intermediate-term follow-up, our study shows a significant association towards fixed defects on the rest/stress MIBI study underestimating CE risk when compared with a delayed Tl-201 study, especially in patients with a large amount of Tl-201 redistribution. Hence, the addition of a Tl-201 study may be useful in the management of patients with large fixed MIBI defects, especially with a depressed left ventricular ejection fraction.

Demonstrating time sequence and extent of sustained decrease in native heart ejection fraction after heterotopic transplantation.

BACKGROUND: In this study we investigate the time sequence and extent of the sustained decrease in native heart ejection fraction (EF) after heterotopic heart transplantation (HHTx) when using gated cardiac blood pool scanning (GCBPS) and transthoracic echocardiography (TTE) One case report of 2 patients used post-operative GCBPS and TTE and found a significant deterioration in native heart EF post-operatively over the course of several years. Comparison with pre-operative measurements using these techniques in a series of patients has not been performed previously. METHODS: Thirteen of 16 HHTx patients with adequate pre- and post-operative GCBPS follow-up were included in this study. All patients also underwent TTE post-operatively and the GCBPS results were correlated with the TTE findings. RESULTS: GCBPS demonstrated a marked (21.1 +/- 4.7% vs 10.5 +/- 3.7%, p < 0.0001) decrease in native EF post-HHTx. Spontaneous echo contrast in the native left ventricle and/or poor opening of the mitral/aortic valves was noted at Day 1 in 4 of 5 patients who had a TTE at this stage. No further decline was noted between the first and last post-operative GCBPS (10.8 +/- 3% vs 8.6 +/- 2.1%, p = NS). CONCLUSIONS: A dramatic decrease in native heart EF post-HHTx occurs as early as Day 1 post-transplant. Dissociation of ventricular contraction is the most likely cause. Studies have demonstrated that paced linkage (counterpulsation) between the ventricles results in improved hemodynamics. This may have clinical implications as to the timing of ejection of blood from a left ventricular assist device (LVAD) and for providing the best hemodynamics for the ventricle being assisted and for optimizing its chances of long-term recovery.