The EANM guideline for radiosynoviorthesis.

PURPOSE: Radiosynoviorthesis (RSO) using the intraarticular application of beta-particle emitting radiocolloids has for decades been used for the local treatment of inflammatory joint diseases. The injected radiopharmaceuticals are phagocytized by the superficial macrophages of the synovial membrane, resulting in sclerosis and fibrosis of the formerly inflamed tissue, finally leading to reduced joint effusion and alleviation of joint pain. METHODS: The European Association of Nuclear Medicine (EANM) has written and approved these guidelines in tight collaboration with an international team of clinical experts, including rheumatologists. Besides clinical and procedural aspects, different national legislative issues, dosimetric considerations, possible complications, and side effects are addressed. CONCLUSION: These guidelines will assist nuclear medicine physicians in performing radiosynoviorthesis. Since there are differences regarding the radiopharmaceuticals approved for RSO and the official indications between several European countries, this guideline can only give a framework that must be adopted individually.

18F-sodium fluoride bone PET-CT in symptomatic lumbosacral transitional vertebra.

AIM: To analyse the relationship between 18F-labelled sodium fluoride (NaF) uptake and lumbar back pain in patients with lumbosacral transitional vertebra (LSTV) a congenital malformation of the lumbosacral spine. MATERIALS AND METHODS: The study population comprised 55 patients (mean age, 51.42 years; median age 52 years) with LSTV. All patients underwent integrated positron-emission tomography (PET)/computed tomography (CT) by injecting 0.06 mCi/kg of 18F-NaF. A three-point grading system was used to evaluate 18F-NaF uptake (grade 0, no uptake; grade 1, mild uptake; and grade 2, marked increase uptake. RESULTS: In total, 55 cases of LSTV (34 symptomatic and 21 asymptomatic) were included. Asymptomatic patients had no uptake in the majority of cases, i.e., grade 0 (n=18) and grade 1 (n=3), whereas symptomatic patients demonstrated focal increase tracer uptake of grade 2 (n=24), grade 1 (n=4), and grade 0 (n=6). There is a strong linear trend between the intensity of 18F-NaF uptake and presence of symptoms (p<0.0001). The sensitivity and specificity of 18F-NaF uptake at LSTV as a cause of pain were 82% (95% confidence interval [CI]: 65-93%) and 86% (95% CI: 64-97%). The positive and negative predictive values were 90% (95% CI: 74-98%) and 75% (95% CI: 53-90%). CONCLUSIONS: 18F-NaF PET/CT can be useful in evaluating back pain and 18F-NaF may be used as an adjunctive biological maker for assessing LSTV as a potential cause of pain.

The clinical significance of incidental soft tissue uptake on whole body 18F-sodium fluoride bone PET-CT.

18F-sodium fluoride (NaF) is a PET bone imaging agent and is commonly used in imaging patients with cancer; however, similar to technetium-99m medronic acid (99mTc-MDP), it can be useful in the evaluation of benign bone and joint conditions. NaF is an excellent bone-seeking agent with high bone uptake due to rapid single-pass extraction. It has negligible plasma protein binding, rapid blood, renal clearance, high bone uptake and almost all NaF delivered is retained by bone after a single pass of blood; however, uptake of NaF can be observed in non-osseous structures such as the arterial vasculature, gastrointestinal tract, genitourinary tract, and viscera. In this article, we present a spectrum of clinical cases with non-osseous NaF uptake in patients referred for cancer staging.

The role of hybrid bone SPECT/CT imaging in the work-up of the limping patient: a symptom-based and joint-oriented review.

A vast spectrum of lower limb bone and joint disorders (hip, knee, ankle, foot) present with a common clinical presentation: limping. Too often this symptom generates an inefficient cascade of imaging studies. This review attempts to optimise the diagnostic effectiveness of bone scintigraphy using the hybrid SPECT/CT technique in relation to the diagnostic clues provided by other imaging modalities, discusses the appropriate clinical indications, optimal scintigraphic procedures and illustrates updated image pattern-oriented reporting. Frequent lower limb bone and joint pathologies that can now be reliably diagnosed using hybrid bone SPECT/CT imaging will be reviewed. Bone SPECT/CT can be an effective problem-solving tool in patients with persistent limping when careful history taking, clinical examination, and first-line imaging modalities fail to identify the underlying cause.

Correction to: 18F-NaF PET/CT: EANM procedure guidelines for bone imaging.

The original version of this article unfortunately contained an error. The name and affiliation of "Frédéric Paycha" needs to be corrected. Given in this article is the correct author name and affiliation.

Effect of isotonic versus hypotonic maintenance fluid therapy on urine output, fluid balance, and electrolyte homeostasis: a crossover study in fasting adult volunteers.

BACKGROUND.: Daily and globally, millions of adult hospitalized patients are exposed to maintenance i.v. fluid solutions supported by limited scientific evidence. In particular, it remains unclear whether fluid tonicity contributes to the recently established detrimental effects of fluid, sodium, and chloride overload. METHODS.: This crossover study consisted of two 48 h study periods, during which 12 fasting healthy adults were treated with a frequently prescribed solution (NaCl 0.9% in glucose 5% supplemented by 40 mmol litre -1 of potassium chloride) and a premixed hypotonic fluid (NaCl 0.32% in glucose 5% containing 26 mmol litre -1 of potassium) at a daily rate of 25 ml kg -1 of body weight. The primary end point was cumulative urine volume; fluid balance was thus calculated. We also explored the physiological mechanisms behind our findings and assessed electrolyte concentrations. RESULTS.: After 48 h, 595 ml (95% CI: 454-735) less urine was voided with isotonic fluids than hypotonic fluids ( P <0.001), or 803 ml (95% CI: 692-915) after excluding an outlier with 'exaggerated natriuresis of hypertension'. The isotonic treatment was characterized by a significant decrease in aldosterone ( P <0.001). Sodium concentrations were higher in the isotonic arm ( P <0.001), but all measurements remained within the normal range. Potassium concentrations did not differ between the two solutions ( P =0.45). Chloride concentrations were higher with the isotonic treatment ( P <0.001), even causing hyperchloraemia. CONCLUSIONS.: Even at maintenance rate, isotonic solutions caused lower urine output, characterized by decreased aldosterone concentrations indicating (unintentional) volume expansion, than hypotonic solutions and were associated with hyperchloraemia. Despite their lower sodium and potassium content, hypotonic fluids were not associated with hyponatraemia or hypokalaemia. CLINICAL TRIAL REGISTRATION.: ClinicalTrials.gov (NCT02822898) and EudraCT (2016-001846-24).

The EANM practice guidelines for bone scintigraphy.

PURPOSE: The radionuclide bone scan is the cornerstone of skeletal nuclear medicine imaging. Bone scintigraphy is a highly sensitive diagnostic nuclear medicine imaging technique that uses a radiotracer to evaluate the distribution of active bone formation in the skeleton related to malignant and benign disease, as well as physiological processes. METHODS: The European Association of Nuclear Medicine (EANM) has written and approved these guidelines to promote the use of nuclear medicine procedures of high quality. CONCLUSION: The present guidelines offer assistance to nuclear medicine practitioners in optimizing the diagnostic procedure and interpreting bone scintigraphy. These guidelines describe the protocols that are currently accepted and used routinely, but do not include all existing procedures. They should therefore not be taken as exclusive of other nuclear medicine modalities that can be used to obtain comparable results. It is important to remember that the resources and facilities available for patient care may vary.

(18)F-NaF PET/CT: EANM procedure guidelines for bone imaging.

The aim of this guideline is to provide minimum standards for the performance and interpretation of (18)F-NaF PET/CT scans. Standard acquisition and interpretation of nuclear imaging modalities will help to provide consistent data acquisition and numeric values between different platforms and institutes and to promote the use of PET/CT modality as an established diagnostic modality in routine clinical practice. This will also improve the value of scientific work and its contribution to evidence-based medicine.

Prospective observational study of treatment pattern, effectiveness and safety of zoledronic acid therapy beyond 24 months in patients with multiple myeloma or bone metastases from solid tumors.

PURPOSE: To study the treatment patterns, effectiveness and safety of zoledronic acid (ZOL) beyond 2 years of therapy, given the paucity of data on long-term treatment in daily clinical practice. METHODS: Patients with multiple myeloma (MM) or solid tumor bone metastases (STM) and at least 24 months of regular q3-4w ZOL therapy were followed prospectively for an additional 18 months beyond the 24 months required for study entry. End-points included ZOL exposure, incidence of skeletal related events (SRE), and safety. RESULTS: In all, 298 evaluable patients were enrolled. The mean continuation rate of ZOL was 90.6%. Exposure to ZOL decreased with time in all patients, but was lower (50.0% vs. 67.6%; p<0.001) and with higher discontinuation rates (incidence rate ratio [IRR]=1.95; p=0.002) in MM compared to the STM group. ZOL suppressed the rate of SREs similarly during the study as compared to before inclusion (0.12 vs. 0.13 events per person-year; p=0.7). At 18 months, 84.5% remained SRE-free. In STM patients, persistent ZOL therapy was associated with lower SRE risk (hazard ratio [HR]=0.42; p=0.01), but not in MM. Renal deterioration occurred in 3.7% and osteonecrosis of the jaw (ONJ) developed in 6.0%, with dental trauma increasing ONJ risk (HR=4.67; p=0.002). CONCLUSIONS: Beyond 2 years of therapy, treatment patterns of ZOL were heterogeneous and SRE rates were low. The safety profile of ZOL was acceptable, and interrupting ZOL in patients with solid tumors was associated with a higher risk of SREs.

Initial experience with conservative treatment in cancer patients with osteonecrosis of the jaw (ONJ) and predictors of outcome.

BACKGROUND: Overall survival (OS) and outcome of cancer patients with bisphosphonate-associated osteonecrosis of the jaw (ONJ) using conservative treatment (chlorhexidine 0.12% rinse, intermittent antibiotics, and careful sequestrectomy) are unknown. DESIGN: In all, 33 ONJ patients were studied for OS and ONJ outcome. RESULTS: Median duration of bisphosphonate treatment was 27 months (range 4-115) and was stopped in 25 (76%) patients. Nine (27%) cases presented with stage 1, 21 (64%) with stage 2, and 3 (9%) with stage 3 disease. During median follow-up of 23 months, 11 patients (33%) died (median survival 39 months), with no ONJ-related fatalities. Out of 30 assessable patients, 53% no longer had exposed bone, 37% had stable lesions, and 10% showed progressive necrosis. The hazard ratio for healing with doubling of bisphosphonate exposure was 0.419 [95% confidence interval (CI) 0.178-0.982; P = 0.045], stage 2 versus stage 1 disease 0.216 (95% CI 0.063-0.738; P = 0.015), and stage 3 versus stage 1 disease 0.084 (95% CI 0.008-0.913; P = 0.042). Cessation of bisphosphonate treatment did not influence outcome. CONCLUSIONS: Conservative treatment of ONJ leads to mucosal closure in 53% of patients. Doubling the exposure time to bisphosphonates and higher stages of ONJ significantly reduce ONJ healing rates.

Bisphosphonates and osteonecrosis of the jaw: cause and effect or a post hoc fallacy?

BACKGROUND: An increasing amount of reports are being published suggesting a relationship between the use of bisphosphonates (BPs) and the development of osteonecrosis of the jaw (ONJ). We reviewed the currently available evidence and explore the potential mechanisms of action based on the known effects of the concerned BP. DESIGN: The MEDLine, Current Contents and Science Citation Index Expanded databases were queried and the results augmented by analyzing cited references and recent congress proceedings. RESULTS: 22 papers were included detailing 225 patients, all based on retrospective chart review without control groups. The prevalence of ONJ was estimated at 1.5%. The involved BPs were pamidronate, zoledronic acid, alendronate and risedronate, all potent nitrogen-containing agents. The most common symptom was pain (81.7%), although 12.2% of cases were asymptomatic. In 69.3% of patients ONJ was preceded by a dental extraction. At the time of diagnosis, 74.5% of patients were receiving chemotherapy and in 38.2% of cases corticosteroids were administered. Although various conservative and surgical treatment modalities were reported, residual sites of ONJ persisted in 72.5% of cases. CONCLUSION: Although not enough evidence is available to prove a causal link, it seems that under specific circumstances local defenses can become overwhelmed resulting in ONJ.