Impact of solitary pulmonary nodule size on qualitative and quantitative assessment using 18F-fluorodeoxyglucose PET/CT: the SPUTNIK trial.

PURPOSE: To compare qualitative and semi-quantitative PET/CT criteria, and the impact of nodule size on the diagnosis of solitary pulmonary nodules in a prospective multicentre trial. METHODS: Patients with an SPN on CT ≥ 8 and ≤ 30 mm were recruited to the SPUTNIK trial at 16 sites accredited by the UK PET Core Lab. Qualitative assessment used a five-point ordinal PET-grade compared to the mediastinal blood pool, and a combined PET/CT grade using the CT features. Semi-quantitative measures included SUVmax of the nodule, and as an uptake ratio to the mediastinal blood pool (SURBLOOD) or liver (SURLIVER). The endpoints were diagnosis of lung cancer via biopsy/histology or completion of 2-year follow-up. Impact of nodule size was analysed by comparison between nodule size tertiles. RESULTS: Three hundred fifty-five participants completed PET/CT and 2-year follow-up, with 59% (209/355) malignant nodules. The AUCs of the three techniques were SUVmax 0.87 (95% CI 0.83;0.91); SURBLOOD 0.87 (95% CI 0.83; 0.91, p = 0.30 versus SUVmax); and SURLIVER 0.87 (95% CI 0.83; 0.91, p = 0.09 vs. SUVmax). The AUCs for all techniques remained stable across size tertiles (p > 0.1 for difference), although the optimal diagnostic threshold varied by size. For nodules < 12 mm, an SUVmax of 1.75 or visual uptake equal to the mediastinum yielded the highest accuracy. For nodules > 16 mm, an SUVmax ≥ 3.6 or visual PET uptake greater than the mediastinum was the most accurate. CONCLUSION: In this multicentre trial, SUVmax was the most accurate technique for the diagnosis of solitary pulmonary nodules. Diagnostic thresholds should be altered according to nodule size. TRIAL REGISTRATION: ISRCTN - ISRCTN30784948. ClinicalTrials.gov - NCT02013063.

Accuracy and cost-effectiveness of dynamic contrast-enhanced CT in the characterisation of solitary pulmonary nodules-the SPUtNIk study.

INTRODUCTION: Solitary pulmonary nodules (SPNs) are common on CT. The most cost-effective investigation algorithm is still to be determined. Dynamic contrast-enhanced CT (DCE-CT) is an established diagnostic test not widely available in the UK currently. METHODS AND ANALYSIS: The SPUtNIk study will assess the diagnostic accuracy, clinical utility and cost-effectiveness of DCE-CT, alongside the current CT and 18-flurodeoxyglucose-positron emission tomography) (18FDG-PET)-CT nodule characterisation strategies in the National Health Service (NHS). Image acquisition and data analysis for 18FDG-PET-CT and DCE-CT will follow a standardised protocol with central review of 10% to ensure quality assurance. Decision analytic modelling will assess the likely costs and health outcomes resulting from incorporation of DCE-CT into management strategies for patients with SPNs. ETHICS AND DISSEMINATION: Approval has been granted by the South West Research Ethics Committee. Ethics reference number 12/SW/0206. The results of the trial will be presented at national and international meetings and published in an Health Technology Assessment (HTA) Monograph and in peer-reviewed journals. TRIAL REGISTRATION NUMBER: ISRCTN30784948; Pre-results.

The appropriate whole-body index on which to base standardized uptake value in 2-deoxy-2-[(18)F]fludeoxyglucose PET.

OBJECTIVE: Tissue uptake of 2-deoxy-2-fluorine-18 fludeoxyglucose ((18)F-FDG) is routinely quantified as standardized uptake value (SUV), which in general is the fraction (F) of administered activity per millilitre of tissue multiplied by an index of body size, usually weight (W), i.e. F/ml × W = SUV or F/ml = SUV × (1/W). Other indices have been suggested as preferable to W, especially lean body mass (LBM) and body surface area (BSA). The second equation mentioned above shows that the reciprocal of the ideal index should correlate closely with F/ml and give a regression line through the origin. The purpose of this study was to determine which of these three indices best meets these criteria. METHODS: Data were evaluated from 49 males and 51 females undergoing routine (18)F-FDG positron emission tomography/CT. A 3 cm diameter region of interest was drawn over the liver and F/ml recorded. LBM and BSA were estimated from height and weight. RESULTS: Based on all patients, the reciprocals of the three indices gave similar correlation coefficients with F/ml, but only 1/LBM gave regressions close to the origin. Intercepts were significantly higher for females for 1/W and 1/BSA, consistent with females having more body fat, but there was no significant difference with 1/LBM. CONCLUSION: LBM is the best index on which to base SUV because adipose tissue accumulates less (18)F-FDG than other soft tissues. ADVANCES IN KNOWLEDGE: The value of this study lies in its use of a novel, more rational approach than previously to confirm that SUV should be based on LBM.

Imaging of multidrug resistance in cancer.

Primary intrinsic and/or acquired multidrug resistance (MDR) is the main obstacle to successful cancer treatment. Functional molecular imaging of MDR in cancer using single photon or positron emitters may be helpful to identify multidrug-resistant tumours and predict not only those patients who are resistant to treatment, with a clinically unfavourable prognosis, but also those who are susceptible to the development of drug toxicity or even certain tumours . Variations in the mdr1 gene product may directly affect the therapeutic effectiveness, and single nucleotide polymorphisms for the mdr1 gene may be associated with altered oral bioavailability of MDR1 substrates, drug resistance, and a susceptibility to some human diseases. The challenge of translating the concept of MDR modulation in vivo involves a complex cellular interplay between both malignant and normal cells. Integration and correlation of functional single photon emission tomography or positron emission tomography imaging findings with mdr1 genotype and clinical data may contribute to efficient management by selecting cancer patients with the appropriate molecular phenotype for maximal individual therapeutic benefit, as well as those who are non-responders. This review describes a role for functional imaging of classical mechanisms of MDR with an emphasis on readily available [(99m)Tc]MIBI scintigraphy. MIBI scintigraphy has been shown to be a non-invasive cost-effective in vivo assay of ATP-binding cassette transporters associated with MDR in cancer, including P-glycoprotein, multidrug-resistant protein 1 and breast cancer resistant protein. New imaging agents for molecular targets such as vascular endothelial growth factor and HER2 receptors, may potentially be combined with MDR imaging substrates to more accurately predict the therapeutic response to anticancer drugs, guiding individualised treatment while minimising the economic health costs of ineffective therapy in an era of personalised medicine.

[Neurosarcoidosis presenting with transitory neurodeficit and generalized epileptic seizures associated with migraine]. / Neurosarkoidoza prezentirana tranzitornim neurodeficitom i generaliziranim epileptickim napadima i udruzena sa migrenom.

Sarcoidosis is a multi-system disease of unknown etiology with abnormal immune response. Neurosarcoidosis affects 3 to 5% of all patients with sarcoidosis. A case of the patient with neurosarcoidosis, has been presented in this article. He has had leptomeningeal involvement and white matter lesions of the left cerebral hemisphere and clinically, transient neurological deficit, generalised epileptic seizures and migraine headache.

[Our approach to the treatment of burns]. / Nas pristup lijecenju opekotina.

The treatment of the burns is successful in situation when there is a separate department for burns with well-educated and highly skilled surgeons. The adequate reanimation during the first 48 hours is essential for the patients with burns to survive. Burns patients with circumferential burns of the body or the bower extremities should have at least three longitudinal incisions (escharotomy) prior to the development of the arterial ischaemia. The early tangential necrectomy should be performed between third and fifth day. The early grafting of the necrotic surfaces reduces the possibility of septicemic complications with deep burns and thus decreases the mortality rate.

[Percutaneous drainage of abdominal fluid collections guided by computer tomography]. / Perkutana drenaza tecnih kolekcija u abdomenu vodena kompjuteriziranom tomografijom.

During the war, June 1992,-August 1994, at the Institute 20 percutaneous fluid collections and abscesses drainages in the belles were done, controlled by the CT. The percutaneous drainage we started in 1984, until now we had 141 cases, 20 cases in the war time, 14 of them were wounded, while the rest was suffering from a malignant process in stomach, pancreas, kidneys. Both groups had post-operative complications after liver injuries. 7 underwent the percutaneous drainage. The length was 1-64 days, drainage contents quantity was 60-5.000 m. The drainage was successful with 14 patients, while in 5 cases we had to repeat, change the catheter place. Only with 1 patients the drainage was not done, but an aspiration. The contents were send to microbiologic analysis. It was a retro-peritoneal abscess collection. Based on our ten-years experience, we are of an opinion that the CT controlled percutaneous drainage is a very efficient, simple and acurata urgent radiology procedure. According to our experiences, nearly all cases were successful.

[Correction of hypospadias with a preputial flap--personal experience]. / Korekcija hipospadije prepucijalnim reznjem--nasa iskustva.

In the period 1985-1989 correction of hypospadia was performed in 187 children aged 2-14 yrs. Praeputial flap was used in 54 patients with penile and scrotal hypospadia. Ombrédanne's operation in one or two stages was used in 35 cases, while Perovis's method vas used in 19 patients. Fistulas occurred in 8% of the cases. However, the achieved results did not differ significantly. Cases of meatal or neourethral stenosis were not recorded. Both techniques resulted in satisfactory cosmetic and functional outcome.

[Abdominal injuries in our patients during the past 10 years]. / Povrede abdomena kod nasih bolesnika u zadnjih 10 godina.

The authors bring forward results in the medical treatment of the abdominal injuries encompassing period of the last ten years. From the 46 patients that have been treated those having spleen-, guts-, and liver injuries prevailed. The authors describe two cases with the abdominal and one with the injury of the pancreas.

[Injuries of the pelvis associated with injuries to other organs]. / Povrede karlice sa povredama drugih organa.

In polytraumatized patients with fracture of the pelvis and injury to the other organs, the clinical picture is dominated by a hypovolemic shock, which is difficult to control. Surgical intervention must be quick in cases of external or internal bleeding. The importance of reaching a quick diagnosis cannot be emphasized enough, upon which the life of the patient is greatly dependent. During the seven year period 23 patients with injury to the pelvis were treated. 10 had injuries to the surrounding organs (brain commotion, injury to the urethra and vagina, as well as the lower extremities). The causes were: automobile accidents (8), falling during play (6), from height (5), during sports (4). Two injured girls are individually described (2 1/2 and 8 years old), who were surgically treated successfully. There was no mortality.