68 Ga-prostate-specific membrane antigen (PSMA) PET/CT as a clinical decision-making tool in biochemically recurrent prostate cancer.

OBJECTIVE: PSMA PET/CT has demonstrated superior sensitivity over conventional imaging in the detection of local and distant recurrence in biochemically relapsed (BCR) prostate cancer. We prospectively investigated the management impact of 68 Ga-PSMA PET/CT imaging in men with BCR, with the aim of identifying baseline clinicopathological predictors for management change. PATIENTS AND METHODS: Men with BCR who met eligibility criteria underwent 68 Ga-PSMA-11 PET/CT at Monash Health (Melbourne, Australia). Intended management plans were prospectively documented before and after 68 Ga-PSMA PET/CT imaging. Binary logistic regression analysis was performed to identify potential clinicopathological predictors of management change. Descriptive statistics were used to characterize the nature of these changes. RESULTS: Seventy men underwent 68 Ga-PSMA-11 PET/CT imaging. Median age was 67 years (IQR 63-72) and median PSA was 0.48 ng/ml (IQR 0.21-1.9). PSMA-avid disease was observed in 56% (39/70) of patients. Pre-scan management plan was altered following scanning in 43% (30/70) of patients. Management changes were significantly more common in patients with higher baseline PSA levels (PSA≥2 ng/ml, p = 0.01). 18/36 (50%) of the patients initially planned for watchful waiting had their management changed, including the use of salvage pelvic radiotherapy (n = 7) and stereotactic ablative body radiotherapy to oligometastatic disease (n = 6). CONCLUSION: Management change after 68 Ga-PSMA PET/CT for BCR is common and typically resulted in treatment intensification strategies in those planned for a watchful waiting approach. This study adds to the growing pool of evidence supporting the clinical utility of PSMA PET/CT imaging in the care of patients with BCR after definitive therapy.

No needle to fear: An approach to needle phobic patients.

18F-FDG is the most commonly used radioisotope in PET scanning and is administered intravenously. When patients cannot cannulated, there are limited options available for functional tumour assessment. A fifty year old male presented for investigation of a suspected lung carcinoma identified during investigation of pneumonia. The patient had a severe needle phobia, intellectual disabilities and multiple co-morbidities which made cannulation impossible. An alternative administration method was sought, with successful oral administration occurring in both staging and restaging scans. The scans demonstrated resolution of a suspected lung cancer indicating it was an inflammatory/infective process, preventing the need for more invasive investigative approaches. A non-invasive and positive experience allowed for accurate diagnosis and repeat imaging for this patient, enabling follow up imaging to occur. It is reported that oral administration of 18F-FDG may be useful for assessment of suspected cancers for patients where cannulation isn't possible, when limitations are taken into consideration.

Extravascular closure for patients with high-risk femoral anatomy.

BACKGROUND: Vascular closure devices (VCDs) improve patient comfort and decrease time to ambulation. However, VCD studies have excluded patients with high-risk femoral artery anatomy; we examined the safety and efficacy of clip-based extravascular closure in this high-risk group. METHODS: We performed a prospective registry enrolling 98 consecutive patients undergoing diagnostic coronary angiography. Inclusion criteria were femoral artery calcification, moderate femoral artery stenosis, or non-femoral arterial sheath insertion. All patients underwent immediate vessel closure with the Starclose device (Abbott Vascular). Patients with severe femoral arterial disease or femoral arterial diameter < or = 4.0 mm were excluded. Hospital outcomes were assessed prospectively and femoral arterial stenosis was determined by quantitative angiography. RESULTS: Inclusion was mainly related to at least one of 3 main high-risk characteristics: moderate femoral arterial stenosis (30%), femoral arterial calcification (24%) or nonfemoral sheath insertion (46%). The average femoral stenosis was 35.3 +/- 5.1% among patients included for a significant femoral disease. There was a 100% procedural and 94% device success: 1 patient required manual compression for greater than or equal to 30 minutes. The average time from sheath removal to hemostasis was 0.76 +/- 1.3 minutes. Despite the higher-risk anatomy, there were no major vascular complications and only one minor vascular complication. The average time to ambulation was 78.1 +/- 47.3 minutes. CONCLUSIONS: In this prospective registry, the Starclose VCD was safe and effective for early ambulation of patients despite the presence of high-risk femoral arterial anatomy.

Elevated carboxy-terminal peptide of procollagen type I in elderly patients with diastolic dysfunction.

BACKGROUND: Diastolic dysfunction (DD) is common in elderly people. Myocardial fibrosis is a major determinant of diastolic function. Increased myocardial fibrosis has been observed with advancing age. We hypothesized that plasma levels of carboxy-terminal peptide of procollagen type I (PICP), a marker of fibrosis, is elevated in elderly subjects with DD compared to healthy control subjects. METHODS: PICP levels were measured in 29 elderly subjects with DD and 25 healthy control subjects. The relationship between PICP levels and age, gender, hypertension, and the presence of left ventricular hypertrophy were then assessed. RESULTS: PICP levels were significantly higher in elderly subjects with DD than in healthy control subjects (301.0 +/- 52.0 vs. 262.9 +/- 45.3 ng/mL; P = .006). PICP levels were higher in elderly with DD regardless of the presence of left ventricular hypertrophy. Additionally, PICP levels were not found to correlate with age. CONCLUSIONS: PICP levels are elevated in elderly people with DD. PICP may be a useful marker to determine the level of fibrotic activity in this population.

Spironolactone improves diastolic function in the elderly.

BACKGROUND: Diastolic dysfunction is common in the elderly. Increased myocardial fibrosis, a major determinant of diastolic function, has been observed with advancing age. Spironolactone prevents age-related increases in myocardial fibrosis in old normotensive rats. HYPOTHESIS: Spironolactone, via its antifibrotic activity, can improve diastolic function in the elderly with isolated diastolic dysfunction. METHODS: The study was a prospective, double-blind, randomized, placebo-controlled trial. Thirty elderly subjects between 60 and 85 years of age with isolated diastolic dysfunction and no contraindications for spironolactone were randomized to 25 mg/day of spironolactone or placebo for 4 months. Mitral E/A and deceleration time, plasma levels of carboxy-terminal of procollagen type I (PICP), and brain natriuretic peptide (BNP) were measured at baseline and at the end of 4 months. Plasma level of potassium was also monitored to prevent clinically significant hyperkalemia. RESULTS: There was no serious adverse event or clinically significant hyperkalemia in the spironolactone group. Compared with baseline values, spironolactone significantly improved mitral E/A ratio (0.71 +/- 0.08 vs. 0.84 +/- 0.19, p = 0.025) and deceleration time (285.5 +/- 73.1 vs. 230.0 +/- 54.7, p = 0.035). There were no significant differences in the magnitude of change in the levels of PICP and BNP between the two treatment groups. CONCLUSION: Spironolactone may improve diastolic function in the elderly.