Utilidad de los radioligandos PSMA en el diagnóstico y tratamiento del carcinoma de próstata / The role of PSMA radioligands in the diagnosis and treatment of prostate carcinoma

El cáncer de próstata (CP) es el tumor más frecuente en varones en Occidente y la quinta causa de muerte relacionada con el cáncer. El uso de radioligandos antígeno prostático específico de membrana (PSMA) ha supuesto un importante avance tanto en su diagnóstico, a través de la imagen molecular de tomografía por emisión de positrones (PET), como en su tratamiento en fases avanzadas de la enfermedad. En este artículo, se hace una revisión de la aportación de los estudios PET con radioligandos PSMA en la estadificación inicial, en la detección tumoral en la recidiva bioquímica (elevación del antígeno prostático específico [PSA]) tras un tratamiento con intención curativa, y en los estadios más avanzados de la enfermedad (CP resistente a la castración o CPRC). Se analiza, además, la aportación de la terapia con radioligandos PSMA (PSMA-TRL) en pacientes con CPRC que progresan a la terapia estándar (AU)

Prostate cancer (PC) is the most common tumor in men in the West and the fifth leading cause of cancer-related death. The use of prostate-specific membrane antigen (PSMA) radioligands has represented an important advance in both in the diagnosis by positron emission tomography (PET) molecular imaging and the treatment of advanced stages of the disease. This article reviews the contribution of PET studies with PSMA radioligands in the initial staging, tumor detection in biochemical recurrence (elevation of PSA) after treatment with curative intent, and in the more advanced stages of the disease (castration-resistant PC [CRPC]). The contribution of PSMA radioligand therapy in CRPC patients who progress to standard therapy is also analyzed (AU)

Cancer screening in idiopathic inflammatory myopathies: Ten years experience from a single center.

OBJECTIVE: There is a well-recognized association between cancer and myositis, so cancer screening at diagnosis is recommended. We aim to report the results of our cancer screening strategy and to ascertain the reliability of using PET/CT to identify cancer-associated myositis (CAM) in a large cohort of patients with myositis from a single center over 10 years. METHODS: This retrospective observational study included all patients diagnosed with any type of myositis except for inclusion body myositis. Cancer screening strategy was individualized according to clinical and serological data, including PET/CT as the main test to detect occult cancer (OC). Procedures derived from a positive PET/CT were registered. Qualitative data expressed as percentages, and quantitative data as the median with the interquartile range were analyzed. A ROC curve was used to estimate the reliability of PET/CT for CAM diagnosis. RESULTS: Seventy-seven out of 131 patients underwent a PET/CT for OC screening. The performance of the PET/CT in patients with myositis at disease onset yielded an area under the curve ROC of 0.87 (0.73-0.97) for CAM diagnosis. Invasive procedures in 7 (9%) patients without a final diagnosis of cancer did not cause derived complications. Patients not evaluated for OC did not develop cancer after a median follow-up of 3.3 years (1.7-6.7). CONCLUSION: Cancer screening strategy should be individualized. PET/CT at myositis onset seems to be an efficient approach to rule out CAM. This practice does not seem to significantly increase harm to patients related to the additional tests needed to clarify inconclusive results.

Immunotherapy, cancer and PET. / Inmunoterapia, cáncer y PET.

The treatment of cancer by immunotherapy has been a revolution, as it is the first strategy that manages to control the disease for prolonged periods of time. Its efficacy is associated with different imaging response patterns and the appearance of new toxicities. We would highlight two patterns of tumour response: pseudoprogression, or growth of tumour lesions after the start of immunotherapy treatment, followed by a significant reduction in lesions, and hyperprogression, acceleration of tumour progression and metastasis early after the start of treatment. The emergence of such patterns has generated new metabolic response criteria, such as PECRIT, PERCIMT, imPERCIST and IPERCIST. Of particular interest are the new immunoPET-specific biomarkers, as they allow the identification of patients presenting the tumour target and are useful for predicting response to immunotherapy.

A multidisciplinary consensus on the morphological and functional responses to immunotherapy treatment

The implementation of immunotherapy has radically changed the treatment of oncological patients. Currently, immunotherapy is indicated in the treatment of patients with head and neck tumors, melanoma, lung cancer, bladder tumors, colon cancer, cervical cancer, breast cancer, Merkel cell carcinoma, liver cancer, leukemia and lymphomas. However, its efficacy is restricted to a limited number of cases. The challenge is, therefore, to identify which subset of patients would benefit from immunotherapy. To this end, the establishment of immunotherapy response criteria and predictive and prognostic biomarkers is of paramount interest. In this report, a group of experts of the Spanish Society of Medical Oncology (SEOM), the Spanish Society of Medical Radiology (SERAM), and Spanish Society of Nuclear Medicine and Molecular Imaging (SEMNIM) provide an up-to-date review and a consensus guide on these issues (AU)

IgG4 related disease. / Enfermedad relacionada con IgG4.

IgG4-related disease (ER-IgG4) is a recognised systemic disease. It was described after patients diagnosed with autoimmune pancreatitis showed signs of extra-pancreatic disease. The clinical manifestation of these patients is subacute and is manifested by the appearance of pseudotumoral lesions, or inflammatory or fibrous tumours. Sometimes it can be serious as in the case of patients with cholangitis or large vessel vasculitis. Diagnostic criteria include, among others, serum IgG4 elevation and/or histological parameters. The 18F-FDG-PET/CT is useful in the initial diagnosis, biopsy guidance as well as in the assessment of response to therapy. It usually responds to steroid therapy.

A multidisciplinary consensus on the morphological and functional responses to immunotherapy treatment.

The implementation of immunotherapy has radically changed the treatment of oncological patients. Currently, immunotherapy is indicated in the treatment of patients with head and neck tumors, melanoma, lung cancer, bladder tumors, colon cancer, cervical cancer, breast cancer, Merkel cell carcinoma, liver cancer, leukemia and lymphomas. However, its efficacy is restricted to a limited number of cases. The challenge is, therefore, to identify which subset of patients would benefit from immunotherapy. To this end, the establishment of immunotherapy response criteria and predictive and prognostic biomarkers is of paramount interest. In this report, a group of experts of the Spanish Society of Medical Oncology (SEOM), the Spanish Society of Medical Radiology (SERAM), and Spanish Society of Nuclear Medicine and Molecular Imaging (SEMNIM) provide an up-to-date review and a consensus guide on these issues.

Imagen funcional en sarcomas de partes blandas: actualización de las indicaciones de la 18F-FDG-PET/TC / Functional image in soft tissue sarcomas: An update of the indications of 18F-FDG-PET/CT

Los sarcomas de partes blandas (SPB) son un grupo heterogéneo y poco frecuente de tumores. Suponen el 1% de los tumores malignos sólidos en adultos y el 7% en niños, y son responsables del 2% de la mortalidad por cáncer. Requieren un abordaje multidisciplinar en centros con experiencia. Esta colaboración pretende actualizar la evidencia científica para fortalecer, junto con la experiencia clínica, las bases del uso y las limitaciones de la 18F-FDG-PET/TC en los SPB. Las recomendaciones generales del uso de la PET/TC en SPB en la actualidad se resumen en la valoración inicial de lesiones de partes blandas cuando la imagen convencional no establece con certeza benignidad y ello condiciona el abordaje; en la guía de biopsia en casos seleccionados; en la estadificación inicial, como prueba adicional, del rabdomiosarcoma y SPB de extremidades o superficiales del tronco y cabeza y cuello; en la sospecha de recurrencia local cuando la TC o la RM no son concluyentes y ante la presencia de material de osteosíntesis o protésico, y en la valoración de respuesta a la terapia local/sistémica en SPB estadios ii/iii. Además, la PET/TC tiene el valor añadido de ser un marcador subrogado de la respuesta histopatológica en la pieza quirúrgica y de aportar información pronóstica tanto en el estudio basal como postratamiento

Soft tissue sarcomas (STS) are a rare and heterogeneous group of tumors. They account for 1% of solid malignant tumors in adults and 7% in children and are responsible for 2% of cancer mortality. They require a multidisciplinary approach in centers with experience. This collaboration aims to update the scientific evidence to strengthen, together with clinical experience, the bases for the use and limitations of 18F-FDG-PET/CT in STSs. The general recommendations for the use of PET/CT in STS at present are summarized as the initial evaluation of soft tissue tumours when conventional image does not establish benignity with certainty and this determines the approach; in biopsy guiding in selected cases; in the initial staging, as additional tool, for rhabdomyosarcoma and STS of extremities or superficial trunk and head and neck tumours; in the suspicion of local recurrence when the CT or MRI are inconclusive and in the presence of osteosynthesis or prosthetic material and in assessment of therapy response to local/systemic therapy in stages ii/iii. In addition, PET/CT has the added value of being a surrogate marker of the histopathological response and it provides prognostic information, both in the baseline study and after treatment

Functional image in soft tissue sarcomas: An update of the indications of 18F-FDG-PET/CT. / Imagen funcional en sarcomas de partes blandas: actualización de las indicaciones de la 18F-FDG-PET/TC.

Soft tissue sarcomas (STS) are a rare and heterogeneous group of tumors. They account for 1% of solid malignant tumors in adults and 7% in children and are responsible for 2% of cancer mortality. They require a multidisciplinary approach in centers with experience. This collaboration aims to update the scientific evidence to strengthen, together with clinical experience, the bases for the use and limitations of 18F-FDG-PET/CT in STSs. The general recommendations for the use of PET/CT in STS at present are summarized as the initial evaluation of soft tissue tumours when conventional image does not establish benignity with certainty and this determines the approach; in biopsy guiding in selected cases; in the initial staging, as additional tool, for rhabdomyosarcoma and STS of extremities or superficial trunk and head and neck tumours; in the suspicion of local recurrence when the CT or MRI are inconclusive and in the presence of osteosynthesis or prosthetic material and in assessment of therapy response to local/systemic therapy in stages ii/iii. In addition, PET/CT has the added value of being a surrogate marker of the histopathological response and it provides prognostic information, both in the baseline study and after treatment.

Unilateral breast metastasis from alveolar rhabdomyosarcoma in adult detected by 18F-FDG PET/CT / Metástasis mamaria unilateral de rabdomiosarcoma alveolar en un adulto, detectada por 18F-FDG PET/TAC

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18F-FDG PET-CT usefulness in extra-pancreatic involvement in IgG4 related diseases / Utilidad de la 18F-FDG PET-TC en las manifestaciones extrapancreáticas de las enfermedades relacionadas con IgG4

IgG4-related diseases are a group of recently identified entities that include disorders that were previously known by other names, such as Mikulicz disease, Küttner's tumor, Riedel thyroiditis, among others, as well as some new ones described in the last years. These pathologies are a challenge for the medical community in terms of diagnosis and characterization due to their wide spectrum of clinical presentation. Functional imaging can provide a new approach to the comprehension of physiopathology, staging and targeting site of biopsy of IgG4-related diseases. In this clinical note, we describe five patients who underwent 18F-FDG PET-CT and correlate their findings with previous reports (AU)

Las enfermedades relacionadas con IgG4 son un grupo de entidades recientemente identificadas; que engloban a patologías anteriormente conocidas como la enfermedad de Mikulicz, el tumor de Küttner y la tiroiditis de Riedel entre otras, las cuales se creían que eran entidades diferentes, y otras descritas en los últimos años. Estas patologías plantean un reto diagnóstico para el clínico y el médico nuclear, dado su amplio espectro de presentación clínica. La imagen funcional puede brindar un nuevo abordaje con respecto a la fisiopatología, estudio de extensión y optimización de los sitios de biopsia, en las enfermedades relacionadas con IgG4. En esta nota clínica presentamos cinco 5 casos clínicos, valorados mediante 18F-FDG PET-TC y correlacionamos hallazgos con la literatura médica reciente (AU)

¹8F-FDG PET-CT usefulness in extra-pancreatic involvement in IgG4 related diseases.

IgG4-related diseases are a group of recently identified entities that include disorders that were previously known by other names, such as Mikulicz disease, Küttner's tumor, Riedel thyroiditis, among others, as well as some new ones described in the last years. These pathologies are a challenge for the medical community in terms of diagnosis and characterization due to their wide spectrum of clinical presentation. Functional imaging can provide a new approach to the comprehension of physiopathology, staging and targeting site of biopsy of IgG4-related diseases. In this clinical note, we describe five patients who underwent ¹8F-FDG PET-CT and correlate their findings with previous reports.

A propósito de un caso: falso positivo en pelvis en un estudio PET-TAC debido a una reimplantación ovárica / False positive in pelvis in a PET-CT scan due to ovarian reimplantation: a case report

Presentamos el caso de una mujer de 36 años con antecedente de una neoplasia de cérvix, tratada quirúrgicamente, a la que se le realiza un estudio PET-TAC para caracterizar unas adenopatías inguinales de nueva aparición. La PET mostró 2 nódulos hipermetabólicos pélvicos, sugestivos de corresponder a un implante y a una adenopatía tumoral, respectivamente. Tras una reevaluación clínica y con un nuevo estudio PET-TAC, se evidenció que dichos focos de captación correspondían a actividad fisiológica de fluordesoxiglucosa secundaria a la ovulación en una paciente con reimplantación ovárica. Este artículo muestra la importancia de disponer de una información clínica exhaustiva de los pacientes antes de valorar los estudios. Asimismo, realizamos una revisión bibliográfica sobre el carcinoma de cérvix y el comportamiento metabólico de los anejos en relación con el ciclo menstrual en mujeres premenopáusicas(AU)

We present the case of a 36-year-old premenopausal woman with a background of surgically-treated cervical neoplasm. She underwent a positron emission tomography-computed tomography (PET-CT) for evaluation of the new appearance of abnormal inguinal lymph nodes. The study showed two hypermetabolic nodules in the pelvic region suggestive of corresponding to an implant and to tumor involvement of the lymph node, respectively. After a clinical evaluation and a new PET-CT scan, it was considered that these uptake foci corresponded to physiological activity of the FDG secondary to ovarian activity in a patient with ovariopexy. This article shows the importance of having complete clinical information about the patients before evaluating the studies. We also present a review of the medical literature on the cervical neoplasm and metabolic behavior of the adnexa in relationship with the menstrual cycle of pre-menopausal women(AU)

[False positive in pelvis in a PET-CT scan due to ovarian reimplantation: a case report]. / A propósito de un caso: falso positivo en pelvis en un estudio PET-TAC debido a una reimplantación ovárica.

We present the case of a 36-year-old premenopausal woman with a background of surgically-treated cervical neoplasm. She underwent a positron emission tomography-computed tomography (PET-CT) for evaluation of the new appearance of abnormal inguinal lymph nodes. The study showed two hypermetabolic nodules in the pelvic region suggestive of corresponding to an implant and to tumor involvement of the lymph node, respectively. After a clinical evaluation and a new PET-CT scan, it was considered that these uptake foci corresponded to physiological activity of the FDG secondary to ovarian activity in a patient with ovariopexy. This article shows the importance of having complete clinical information about the patients before evaluating the studies. We also present a review of the medical literature on the cervical neoplasm and metabolic behavior of the adnexa in relationship with the menstrual cycle of pre-menopausal women.

[PET/CT with (18F)FDG in the initial staging of a pelvic kidney neoplasm. A case report]. / PET-TAC con (18)F-FDG en la estadificación inicial de una neoplasia de pelvis renal. A propósito de un caso.

We report a case of 58-year-old woman referred to our service for an (18)FFDG PET/CT study of initial staging after being diagnosed of a pelvic kidney mass consistent with malignancy. The FDG-PET showed an abnormal mass in the right kidney, a suspicious metastasis versus a second primary tumor in the cortex of the kidney and lymph node infiltration in the paracaval nodes. The histological analysis verification after exeresis of the lesions confirmed the diagnosis of renal metastases. In this article, we present a brief review of the literature published on the role of PET in the characterization and initial staging of kidney and urinary tract tumors. We also stress the clinical importance of carefully evaluating any low attenuation lesion or focal glucose uptake detected in these structures in a PET/CT study with (18)FFDG.

PET-TAC con 18F-FDG en la estadificación inicial de una neoplasia de pelvis renal. A propósito de un caso / PET/CT with 18FFDG in the initial staging of a pelvic kidney neoplasm. A case report

Presentamos el caso de una mujer de 58 años remitida a nuestro servicio para la realización de un estudio PET-TAC con 18F-FDG de estadificación inicial tras ser diagnosticada de una masa en la pelvis de riñón derecho compatible con un proceso neoproliferativo. La PET-FDG mostró una masa en riñón derecho, una lesión sospechosa de metástasis versus un segundo tumor primario en la cortical del propio riñón y signos de infiltración adenopática tumoral en situación paracaval. El estudio histológico tras la exéresis de las lesiones confirmó dichos hallazgos como metastásicos. En este artículo realizamos un breve repaso de la bibliografía publicada al respecto, valorando la utilidad de la PET en la caracterización y estadificación inicial de las neoplasias de riñón y vías urinarias. Asimismo enfatizamos la importancia de valorar cuidadosamente cualquier imagen hipodensa o depósito de glucosa en riñones y vías urinarias visualizado en un estudio PET-TAC con 18F-FDG(AU)

We report a case of 58-year-old woman referred to our service for an 18FFDG PET/CT study of initial staging after being diagnosed of a pelvic kidney mass consistent with malignancy. The FDG-PET showed an abnormal mass in the right kidney, a suspicious metastasis versus a second primary tumor in the cortex of the kidney and lymph node infiltration in the paracaval nodes. The histological analysis verification after exeresis of the lesions confirmed the diagnosis of renal metastases. In this article, we present a brief review of the literature published on the role of PET in the characterization and initial staging of kidney and urinary tract tumors. We also stress the clinical importance of carefully evaluating any low attenuation lesion or focal glucose uptake detected in these structures in a PET/CT study with 18FFDG(AU)

[Utility of inspiratory diagnostic CT scan after CT/PET study in the detection of pulmonary nodules]. / Utilidad de la TC diagnóstica inspiratoria tras la realización del estudio PET/TC en la detección de nódulos pulmonares.

We present the case of a 57-year old woman diagnosed of papillary thyroid carcinoma and treated with thyroidectomy followed by radioiodine (I-131) on two occasions. Follow-up radioiodine scan showed disease in right cervical region, confirmed by fine needle aspiration (FNA) and treated with lymphadenectomy. Due to thyroglobulin elevation, I-131 scan negative and inconclusive cervical ultrasonography/CT scan, we conducted a CT/PET study that confirmed cervical disease. An additional CT scan that was performed on maximum-inspiration showed four micro-nodules, one of which was not detected by the CT scan on shallow breathing (CT/PET). Post-treatment (I-131) scan confirmed uptake in these localizations. Good fusion between PET and CT images that avoids the errors of attenuation correction, especially in the lung bases, is necessary for correct image interpretation of the CT/PET study. Shallow breathing is necessary in order to obtain optimal image fusion with the CT/PET study, although this is not the best to evaluate pulmonary parenchyma in which an additional inspiratory CT scan improves detection of the pulmonary nodules.

Utilidad de la TC diagnóstica inspiratoria tras la realización del estudio PET/TC en la detección de nódulos pulmonares / Presentamos el caso de una mujer de 57 años diagnosticada de carcinoma papilar de tiroides, tratada con tiroidectomía y radioyodo en dos ocasiones. Un rastreo de control muestra captación cervical derecha, confirmada por punción aspiración con aguja fina, tratada con linfadenectomía. Ante la elevación de tiroglobulina, el rastreo negativo y la ecografía/TC cervical inespecífica se realiza un estudio tomográfico por emisión de positrones/tomográfico computarizado (PET/TC) que confirma infiltración del lecho cervical. Adicionalmente se le realiza una TC en máxima inspiración que muestra cuatro micronódulos, uno de ellos no detectado por la TC del estudio PET/TC. El rastreo posterapéutico (I-131) confirma captación en estas localizaciones. Para la correcta interpretación de las imágenes PET/TC se necesita una fusión óptima de la PET y la TC, que minimice errores de corrección de atenuación, especialmente en las bases pulmonares. La fusión más óptima se consigue en respiración suave, aunque no es la más adecuada para la evaluación del parénquima pulmonar, para la que es necesaria realizar una segunda TC en máxima inspiración

Presentamos el caso de una mujer de 57 años diagnosticada de carcinoma papilar de tiroides, tratada con tiroidectomía y radioyodo en dos ocasiones. Un rastreo de control muestra captación cervical derecha, confirmada por punción aspiración con aguja fina, tratada con linfadenectomía. Ante la elevación de tiroglobulina, el rastreo negativo y la ecografía/TC cervical inespecífica se realiza un estudio tomográfico por emisión de positrones/tomográfico computarizado (PET/TC) que confirma infiltración del lecho cervical. Adicionalmente se le realiza una TC en máxima inspiración que muestra cuatro micronódulos, uno de ellos no detectado por la TC del estudio PET/TC. El rastreo posterapéutico (I-131) confirma captación en estas localizaciones. Para la correcta interpretación de las imágenes PET/TC se necesita una fusión óptima de la PET y la TC, que minimice errores de corrección de atenuación, especialmente en las bases pulmonares. La fusión más óptima se consigue en respiración suave, aunque no es la más adecuada para la evaluación del parénquima pulmonar, para la que es necesaria realizar una segunda TC en máxima inspiración

We present the case of a 57-year old woman diagnosed of papillary thyroid carcinoma and treated with thyroidectomy followed by radioiodine (I-131) on two occasions. Follow-up radioiodine scan showed disease in right cervical region, confirmed by fine needle aspiration (FNA) and treated with lymphadenectomy. Due to thyroglobulin elevation, I-131 scan negative and inconclusive cervical ultrasonography/CT scan, we conducted a CT/PET study that confirmed cervical disease. An additional CT scan that was performed on maximum-inspiration showed four micro-nodules, one of which was not detected by the CT scan on shallow breathing (CT/PET). Post-treatment (I-131) scan confirmed uptake in these localizations. Good fusion between PET and CT images that avoids the errors of attenuation correction, especially in the lung bases, is necessary for correct image interpretation of the CT/PET study. Shallow breathing is necessary in order to obtain optimal image fusion with the CT/PET study, although this is not the best to evaluate pulmonary parenchyma in which an additional inspiratory CT scan improves detection of the pulmonary nodules