First foods in a packaged world: Results from the COMMIT consortium to protect young child diets in Southeast Asia.

Although commercially produced complementary foods (CPCFs) are increasingly sold throughout Southeast Asia, concerns have been raised about CPCFs nutritional quality, labelling practices and the strength and scope of national CPCF regulations. The Consortium for Improving Complementary Foods in Southeast Asia (COMMIT), composed of UN agencies and civil society organizations, was formed to assess the nutrient gap in the diets of young children and the consumer, product and policy landscapes for CPCFs in seven Southeast Asian countries. Results from a nutrient gap assessment indicate that the diets of children aged 6-23 months are suboptimal and deficient in micronutrients. A consumer survey revealed that caretakers commonly use CPCFs, are conscious of the importance of nutrition and are influenced by label claims. Results from a CPCF benchmarking showed that many products sold in Southeast Asia contained added sugar or sweeteners, had a high total sugar and/or high sodium content and that no CPCF product adhered to all recommended labelling practices. Further, a legal review of national binding legal measures relevant to CPCFs showed minimal alignment with available global guidance. Urgent actions are necessary to strengthen national regulations related to CPCF nutrient composition and labelling practices. To speed progress, COMMIT developed a compendium of existing standards and global guidance to help countries align their national regulations with CPCF composition, labelling and production recommendations. Advocacy to garner public support for new or improved CPCF regulations, as well as strong government monitoring and enforcement of regulations, is crucial to support efforts to safeguard and improve the diets of older infants and young children in Southeast Asia.

Micronutrient gaps during the complementary feeding period in seven countries in Southeast Asia: A Comprehensive Nutrient Gap Assessment.

The complementary feeding period is a critical stage of child development when micronutrient needs are high and challenging to meet. Understanding if specific micronutrient gaps exist during this period is critical for effective programming. A Comprehensive Nutrient Gap Assessment (CONGA) was conducted in seven countries in Southeast Asia to estimate gaps in micronutrients commonly lacking in the diets of children aged 6-23 months and to establish the certainty of available evidence for each identified gap. Sixty-eight evidence sources were identified during this analysis, and 310 micronutrient-specific data points were identified across all seven countries. Data points varied in recency, representativeness and evidence type. The CONGA methodology enabled the estimation of a gap burden rating for each micronutrient in each country, as well as a rating of their evidence certainty. Micronutrient gaps were identified in vitamin D, zinc and iron and a potential gap was identified in calcium during the complementary feeding period in the region. Evidence relevant to intake and deficiency of folate, vitamin B12 , thiamine, niacin, vitamin C and vitamin B6 was limited across the region. Proven strategies to address these gaps include increasing the availability and consumption of nutrient-dense foods, micronutrient supplementation, large-scale fortification of staple foods and condiments and point-of-use fortification through multiple micronutrient powders and fortified speciality foods. More recent data on micronutrient availability, intake and deficiency is urgently needed in Southeast Asia.

Behavior Change Interventions Delivered through Interpersonal Communication, Agricultural Activities, Community Mobilization, and Mass Media Increase Complementary Feeding Practices and Reduce Child Stunting in Ethiopia.

BACKGROUND: Appropriate infant and young child feeding practices are critical for optimal child growth and development, but in Ethiopia, complementary feeding (CF) practices are very poor. Alive & Thrive (A&T) provided intensive behavior change interventions through 4 platforms: interpersonal communication (IPC), nutrition-sensitive agricultural activities (AG), community mobilization (CM), and mass media (MM). OBJECTIVES: The aim of this study was to evaluate the impact of A&T intensive compared with nonintensive interventions (standard nutrition counseling and agricultural extension service and less intensive CM and MM) on CF practices and knowledge and child anthropometric outcomes. METHODS: We used a cluster-randomized evaluation design with cross-sectional surveys among households with children aged 6-23.9 mo [n = 2646 at baseline (2015) and n = 2720 at endline (2017)]. We derived difference-in-difference impact estimates (DDEs) and conducted dose-response and path analyses to document plausibility of impacts. RESULTS: At endline, exposure to IPC was 17.8-32.3%, exposure to AG was 22.7-36.0%, exposure to CM was 18.6-54.3%, and exposure to MM was 35.4% in the intensive group. Minimum dietary diversity and minimum acceptable diet increased significantly in the intensive group but remained low at endline (24.9% and 18.2%, respectively). Significant differential declines in stunting prevalence were observed (DDE: -5.6 percentage points; P < 0.05) in children aged 6-23.9 mo, decreasing from 36.3% to 22.8% in the intensive group. Dose-response analyses showed higher odds of minimum dietary diversity (OR: 3.3; 95% CI: 2.2, 4.8) and minimum meal frequency (OR: 1.9; 95% CI: 1.4, 2.6) and higher height-for-age z score (HAZ) (ß: 0.24; 95% CI: 0.04, 0.4) among women exposed to 3 or 4 platforms. Path analyses showed a strong relation between AG and egg consumption, which led to increased child dietary diversity and HAZ. CONCLUSIONS: Delivery of social and behavior change interventions using multiple platforms was feasible and effective, resulting in improvements in CF practices and child stunting within a 2-y period. There is a need for continued efforts, however, to expand intervention coverage and to improve CF practices in Ethiopia. This trial was registered at clinicaltrials.gov as NCT02775552.

64Cu-SARTATE PET Imaging of Patients with Neuroendocrine Tumors Demonstrates High Tumor Uptake and Retention, Potentially Allowing Prospective Dosimetry for Peptide Receptor Radionuclide Therapy.

Imaging of somatostatin receptor expression is an established technique for staging of neuroendocrine neoplasia and determining the suitability of patients for peptide receptor radionuclide therapy. PET/CT using 68Ga-labeled somatostatin analogs is superior to earlier agents, but the rapid physical decay of the radionuclide poses logistic and regulatory challenges. 64Cu has attractive physical characteristics for imaging and provides a diagnostic partner for the therapeutic radionuclide 67Cu. Based on promising preclinical studies, we have performed a first-time-in-humans trial of 64Cu-MeCOSar-Tyr3-octreotate (64Cu-SARTATE) to assess its safety and ability to localize disease at early and late imaging time-points. Methods: In a prospective trial, 10 patients with known neuroendocrine neoplasia and positive for uptake on 68Ga-DOTA-octreotate (68Ga-DOTATATE) PET/CT underwent serial PET/CT imaging at 30 min, 1 h, 4 h, and 24 h after injection of 64Cu-SARTATE. Adverse reactions were recorded, and laboratory testing was performed during infusion and at 1 and 7 d after imaging. Images were analyzed for lesion and normal-organ uptake and clearance to assess lesion contrast and perform dosimetry estimates. Results:64Cu-SARTATE was well tolerated during infusion and throughout the study, with 3 patients experiencing mild infusion-related events. High lesion uptake and retention were observed at all imaging time-points. There was progressive hepatic clearance over time, providing the highest lesion-to-liver contrast at 24 h. Image quality remained high at this time. Comparison of 64Cu-SARTATE PET/CT obtained at 4 h to 68Ga-DOTATATE PET/CT obtained at 1 h indicated comparable or superior lesion detection in all patients, especially in the liver. As expected, the highest early physiologic organ uptake was in the kidneys, liver, and spleen. Conclusion:64Cu-SARTATE is safe and has excellent imaging characteristics. High late-retention in tumor and clearance from the liver suggest suitability for diagnostic studies and for prospective dosimetry for 67Cu-SARTATE peptide receptor radionuclide therapy, and the half-life of 64Cu would also facilitate good-manufacturing-practice production and distribution to sites without access to 68Ga.

The role of positron emission tomography/computed tomography in planning radiotherapy in endometrial cancer.

OBJECTIVE: The optimal method of assessing disease distribution in endometrial cancer is widely debated. Knowledge of disease distribution assists in planning adjuvant radiotherapy; in this study we used positron emission tomography/computed tomography (PET/CT) to assess disease distribution before radiotherapy. METHODS: Seventy-three consecutive patients referred to the Peter MacCallum Cancer Centre for adjuvant radiotherapy for endometrial cancer, with either high-risk disease after a hysterectomy or recurrent disease, had a PET/CT before treatment. The findings on PET/CT and clinical course were recorded. RESULTS: PET/CT found additional disease in 35% of postoperative patients, changing planned treatment in 31%. In the group with known recurrence, additional disease was found in 72%, changing management in 36%. CONCLUSIONS: PET/CT is a valuable tool for planning radiotherapy in endometrial cancer.

The utility of 18 F-FDG PET/CT for suspected recurrent breast cancer: impact and prognostic stratification.

BACKGROUND: The incremental value of 18FDG PET/CT in patients with breast cancer (BC) compared to conventional imaging (CI) in clinical practice is unclear. The aim of this study was to evaluate the management impact and prognostic value of 18 F-FDG PET/CT in this setting. METHODS: Sixty-three patients who were referred to our institution for suspicion of BC relapse were retrospectively enrolled. All patients had been evaluated with CI and underwent PET/CT. At a median follow-up of 61 months, serial clinical, imaging and pathologic results were obtained to validate diagnostic findings. Overall Survival (OS) was estimated using Kaplan Meier methods and analyzed using the Cox proportional hazards regression models. RESULTS: Forty-two patients had a confirmed relapse with 37 (88%) positive on CI and 40 (95%) positive on PET/CT. When compared with CI, PET/CT had a higher negative predictive value (86% versus 54%) and positive predictive value (95% versus 70%). The management impact of PET/CT was high (change of treatment modality or intent) in 30 patients (48%) and medium (change in radiation treatment volume or dose fractionation) in 6 patients (9%). Thirty-nine patients (62%) died during follow-up. The PET/CT result was a highly significant predictor of OS (Hazard Ratio [95% Confidence Interval] =4.7 [2.0-10.9] for PET positive versus PET negative for a systemic recurrence; p = 0.0003). In a Cox multivariate analysis including other prognosis factors, PET/CT findings predicted survival (p = 0.005). In contrast, restaging by CI was not significant predictor of survival. CONCLUSION: Our study support the value of 18 F-FDG PET/CT in providing incremental information that influence patient management and refine prognostic stratification in the setting of suspected recurrent breast cancer.

Evaluation of a new visual uptake scoring scale for 18F-fluorothymidine positron emission tomography in the diagnosis of pulmonary lesions.

PURPOSE: The aim of this analysis was to evaluate a new visual scoring scale developed to facilitate the qualitative appraisal of lesion uptake on (18)F-fluorothymidine PET ((18)F-FLT-PET). METHODS: Sixty-two patients with a pulmonary lesion of unknown aetiology who had undergone an F-fluorodeoxyglucose-PET/computed tomography (CT) suspicious for malignancy prospectively underwent an (18)F-FLT-PET/CT. Three nuclear medicine physicians independently reviewed each (18)F-FLT-PET/CT scan with knowledge of the location of the pulmonary lesion but blinded to the final diagnosis. They scored the lesion (18)F-FLT uptake as follows: (0) no visible uptake; (1) liver and >marrow. Lesion mean (SUV(mean)) and maximum (SUV(max)) standardized uptake values were measured in a separate session. RESULTS: In all, 35 lesions were malignant and 27 were benign, as assessed on the basis of surgery, biopsy or follow-up of at least 12 months. Visual score, SUV(mean) and SUV(max) were statistically different between benign and malignant lesions. The visual scoring scale showed substantial to almost-perfect interobserver agreement with a weighted κ value of 0.84, 0.67 and 0.65 for each observer pair. The visual score was highly correlated to SUV(mean) and SUV(max) (r=0.83 and 0.87, respectively) and described a logarithmic pattern in relation to SUV(mean) and SUV(max) (r =0.67 and 0.72, respectively). The area under the receiver-operating characteristic curve for the visual score was 0.86 and was statistically different from that for SUV(mean) (0.77; P=0.026) and SUV(max) (0.79; P=0.047). CONCLUSION: The (18)F-FLT scoring scale we propose is easy to use with high interobserver agreement and a significantly better discriminative capacity compared with SUV measurements. It has the potential to harmonize the qualitative interpretation of (18)F-FLT-PET/CT in lung cancer diagnosis.

18F-FDG PET/CT has a high impact on patient management and provides powerful prognostic stratification in the primary staging of esophageal cancer: a prospective study with mature survival data.

UNLABELLED: The aim of this study is to evaluate the incremental staging information, management impact, and prognostic stratification of PET/CT in the primary staging of esophageal cancer in a cohort of patients with mature survival data. METHODS: Between July 2002 and June 2005, 139 consecutive patients with newly diagnosed esophageal cancer underwent conventional staging investigations (CSI), followed by PET/CT. Disease stage was classified according to the American Joint Committee on Cancer staging system (6th edition) and grouped as stage I-IIA, stage IIB-III, and stage IV reflecting broad groupings that determine therapeutic choice. Validation of results was performed when PET/CT and CSI stage groups were discordant and in those patients where PET/CT changed management. Management impact was determined by comparing prospectively recorded pre-PET/CT management plans with post-PET/CT management plans. Survival after follow-up of at least 5 y in patients was analyzed using the Kaplan-Meier product limit method and the Cox proportional hazards regression model. RESULTS: PET/CT changed the stage group in 56 of 139 (40%) patients and changed management in 47 of 139 (34%) patients. In 22 patients, therapy was changed from curative to palliative and in 3 from palliative to curative; in 11, treatment modality was changed without a change in treatment intent, and in 11 the delivery of therapy or diagnostic procedure was changed. Of the 47 patients with management change, imaging results could be validated in 31 patients, and PET/CT correctly changed management in 26 (84%) of these. Of the remaining 5 patients, CSI stage was also incorrect in 4 and correct in 1. Median survival was 23 mo. PET/CT stages I-IIA, IIB-III, and IV had a 5-y survival of 40%, 38%, and 6%, respectively. Post-PET/CT stage group and treatment intent were both strongly associated with survival (P < 0.001). CONCLUSION: PET/CT provides incremental staging information compared with CSI, changes management in one third of patients, and has powerful prognostic stratification in the primary staging of esophageal cancer.

Impact of fluorine-18 fluorodeoxyglucose positron emission tomography on diagnosis and antimicrobial utilization in patients with high-risk febrile neutropenia.

Early and targeted antimicrobial therapy improves outcomes in patients with febrile neutropenia (FN). We evaluated the impact of fluorine-18 fluorodeoxyglucose positron emission tomography (FDG-PET) on antimicrobial utilization in the management of FN. A cohort of patients with FN and hematological malignancy was identified. Cases (in whom FDG-PET was performed, n = 37) were compared with controls (in whom conventional investigations excluding FDG-PET were performed, n = 76). An underlying cause for FN was determined in 94.6% of cases, compared to 69.7% of controls. FDG-PET had a significant impact on antimicrobial utilization compared to conventional imaging (35.1% vs. 11.8%; p = 0.003), and was associated with shorter duration of liposomal amphotericin-B therapy for systemic fungal infection (median 4.0 days cases vs. 10.0 days controls; p = 0.001). Cases had a longer length of hospitalization (p = 0.016). In the management of patients with high-risk FN, FDG-PET improves diagnostic yield and allows rationalization of antifungal therapy. The impact upon healthcare costs associated with antimicrobial therapy for FN requires further evaluation.

The utility of PET/CT in staging and assessment of treatment response of nasopharyngeal cancer.

INTRODUCTION: The aim of this study was to evaluate the impact of positron emission tomography/computerised tomography (PET/CT) as an adjunct to conventional imaging (CI) in the management of nasopharyngeal cancer (NPC) both for initial staging and assessment of post-treatment response. METHODS: All NPC cases referred to the Peter MacCallum Centre for Metabolic Imaging between January 2002 and December 2007 were identified. In patients undergoing initial staging, any differences between the pre-PET/CT management plan based on CI and that following performance of the PET/CT scan were noted. Clinical impact was scored using the Centre's published criteria: 'high' if PET/CT changed the primary treatment modality or intent, 'medium' if treatment modality was unchanged but the radiotherapy technique or dose was altered, and 'low' if there was no change in treatment modality or intent. Patients undergoing PET/CT following definitive treatment were scored according to whether or not they achieved a complete metabolic response. RESULTS: Forty-eight patients underwent a staging PET/CT. The clinical impact was high in 8%, medium in 25% and low in 66% of patients. Twenty-one patients were scanned for post-treatment response. PET/CT was less frequently equivocal than MRI (3 vs 8/21). A complete metabolic response on PET/CT was associated with a 93% negative predictive value for subsequent recurrence. CONCLUSION: PET/CT is a valuable staging tool for the detection of occult metastatic disease and defining the extent of neck nodal disease. Post-treatment, a complete metabolic response on PET/CT has a very high negative predictive value with fewer equivocal results than MRI.

Limitations on coupling of bimanual movements caused by arm dominance: when the muscle homology principle fails.

Studies of bimanual movements typically report interference between motions of the two arms and preference to perform mirror-symmetrical patterns. However, recent studies have demonstrated that the two arms differ in the ability to control interaction torque (INT). This predicts limitations in the capability to perform mirror-symmetrical movements. Here, two experiments were performed to test this prediction. The first experiment included bimanual symmetrical and asymmetrical circle drawing at two frequency levels. Unimanual circle drawing was also recorded. The increases in cycling frequency caused differences between the two arms in movement trajectories in both bimanual modes, although the differences were more pronounced in the asymmetrical compared with the symmetrical mode. Based on torque analysis, the differences were attributed to the nondominant arm's decreased capability to control INT. The intraarm differences during the symmetrical pattern of bimanual movements were similar (although more pronounced) to those during unimanual movements. This finding was verified in the second experiment for symmetrical bimanual oval drawing. Four oval orientations were used to provide variations in INT. Similar to the first experiment, increases in cycling frequency caused spontaneous deviations from perfect bimanual symmetry associated with inefficient INT control in the nondominant arm. This finding supports the limitations in performing mirror-symmetrical bimanual movements due to differences in joint control between the arms. Based on our results and previous research, we argue that bimanual interference occurs during specification of characteristics of required motion, whereas lower-level generation of muscle forces is independent between the arms. A hierarchical model of bimanual control is proposed.

Comparative PET study using F-18 FET and F-18 FDG for the evaluation of patients with suspected brain tumour.

The aim of this prospective pilot study in patients with suspected or known brain tumour was to establish the diagnostic value of O-(2-[(18)F]-fluoroethyl)-L-tyrosine (FET) positron emission tomography (PET) when compared to fluorine-18 fluorodeoxyglucose (FDG) PET. Twenty-five FET PET and FDG PET scans were performed on 21 consecutive patients within 24 months. Final malignant pathology included 11 glioma (eight low-grade, three high grade), two lymphoma, one olfactory ganglioneuroblastoma, one anaplastic meningioma. Benign pathology included two encephalitis and one cortical dysplasia. Definitive pathology was not available in three patients. The accuracy of PET was determined by subsequent surgical histopathology in 12 and clinical/imaging course in nine patients. Median follow-up period was 20 months. FET sensitivity was 93%, specificity 100%, accuracy 96%, positive predictive value (PPV) 100% and negative predictive value (NPV) 91%. FDG sensitivity was 27%, specificity 90%, accuracy 52%, PPV 80% and NPV 45%. FET PET is more accurate than FDG PET for detecting malignant brain lesions, especially low-grade gliomas.

Local control and survival following concomitant chemoradiotherapy in inoperable stage I non-small-cell lung cancer.

PURPOSE: Concomitant chemoradiotherapy (CRT) increases survival rates compared with radical radiotherapy alone (RT) in Stage III non-small-cell lung cancer (NSCLC), as a result of improved local control. The effect of CRT on local control in Stage I NSCLC is less well documented. We retrospectively reviewed local control and survival following CRT or RT for inoperable Stage I NSCLC patients. METHODS AND MATERIALS: Eligible patients had histologically/cytologically proved inoperable Stage I NSCLC and had undergone complete staging investigations including an F-18 fluorodeoxyglucose positron emission tomography (FDG-PET) scan. Radiotherapy was planned as (1) 60 Gy in 30 fractions over 6 weeks with or without concomitant chemotherapy or (2) 50-55 Gy in 20 fractions without chemotherapy. RESULTS: Between 2000 and 2005, 73 patients met the eligibility criteria and were treated as follows: CRT (60 Gy)-39; RT (60 Gy)-23; RT (50-55 Gy)-11. The median follow-up time for all patients was 18 months (range, 1-81 months). Survival analysis was based on intent to treat. Local progression-free survival (PFS) at 2 years was 66% with CRT and 55% with RT. The 2-year distant PFS was 60% following CRT and 63% after RT. The 2-year PFS rates were 57% and 50%, respectively. The 2-year survival rate for patients treated with CRT was 57% and 33% in patients receiving RT. CONCLUSIONS: Despite the use of CRT and routine staging with FDG-PET, both local and distant recurrences remain important causes of treatment failure in patients with inoperable stage I NSCLC.

Radiation changes do not interfere with postchemoradiation restaging of patients with rectal cancer by FDG PET/CT before curative surgical therapy.

PURPOSE: Changes in F-18 fluorodeoxyglucose (FDG) uptake in normal tissues after chemoradiation therapy (CRT) potentially limit the ability of positron emission tomography (PET) to provide early assessment of therapeutic response. This study evaluated whether such changes negatively impact interpretation of posttherapy PET performed within 6 weeks of CRT completion and before definitive surgery in patients with locally advanced rectal cancer. The positive predictive value (PPV) and specificity of post-CRT PET, read clinically, was determined in 63 consecutive rectal cancer patients who had undergone preoperative CRT. METHODS AND MATERIALS: A schema for identifying and scoring postradiation effects on PET was prospectively defined and applied in a blinded manner. This was compared with initial clinical reporting of response. Histologic assessment of the operative specimens was used as the reference standard. Correlation between clinical proctitis during CRT and radiation changes on subsequent PET was also assessed. RESULTS: Clinical reporting of post-CRT PET yielded a high PPV (94%; 95% confidence interval, 89--100%) but may have been exaggerated by the low prevalence of complete tumor clearance (16%). The specificity was 80% with only two false-positive results. On blinded reading, significant post-CRT effects on PET were recorded in 4 of 63 patients (6% 95% confidence interval, 0-13%), but pattern recognition converted both false-positive PET results to a complete metabolic response. Clinical CRT proctitis was not correlated with PET findings. CONCLUSION: Postradiation effects do not appear to significantly compromise the interpretation of PET for therapeutic response assessment. The proposed PET pattern of response may further improve the specificity of PET.

[Clinical application of (18)F-FDG PET/CT to staging and treatment effectiveness monitoring of nasopharyngeal carcinoma].

BACKGROUND & OBJECTIVE: Fluorine-18 fluorodeoxyglucose ((18)F-FDG) PET/CT could increase the accuracy of diagnosis, staging, and treatment effectiveness monitoring of many malignant diseases, such as lung cancer and esophageal cancer. This study was to evaluate the clinical application of (18)F-FDG PET/CT to the staging, restaging, and treatment effectiveness monitoring of nasopharyngeal carcinoma (NPC). METHODS: The reports of whole body (18)F-FDG PET/CT scans, performed from Feb. 2002 to Dec. 2005 on 43 NPC patients (26 men and 17 women with median age of 52 years) in Peter MacCallum Cancer Center, were reviewed. The final diagnoses were made according to medical records, pathologic reports and follow-up information. The accuracy, specificity, sensitivity, positive predictive value (PPV), and negative predictive value (NPV) of (18)F-FDG PET/CT, CT and MRI were calculated and analyzed. RESULTS: The accuracy, specificity, sensitivity, PPV, and NPV of (18)F-FDG PET/CT were 95.3%, 100.0%, 85.7%, 93.8%, and 100.0%, respectively; those of CT and MRI were 65.5%, 79.4%, 64.7%, 81.8%, and 57.9%, respectively. The results of (18)F-FDG PET/CT led to changes in the medical management of 2 staged patients, and 7 restaged patients and 5 patients in monitoring group. (18)F-FDG PET/CT scan affected the therapy plan of 3 restaged patients and 11 patients in monitoring group. Two cases of second primary malignancies(1 case of thyroid carcinoma and 1 case of low grade gastric carcinoma) were detected by (18)F-FDG PET/CT scan. CONCLUSION: (18)F-FDG PET/CT is better than conventional imaging in N and M staging and treatment effectiveness monitoring of NPC.

How do oncologists deal with incidental abnormalities on whole-body fluorine-18 fluorodeoxyglucose PET/CT?

BACKGROUND: Combined positron emission tomography (PET)/computed tomography (CT) using fluorine-18 fluorodeoxyglucose (FDG) is an exciting technique for cancer evaluation, but false-positive results are a recognized limitation. The aim of the study was to evaluate how oncologists deal with focal extrathyroidal FDG abnormalities considered by imaging specialists to be unrelated to the referral indication. METHODS: PET scan reports from a 12-month period from August 2002 to July 2003 in 1727 consecutive patients (mean age, 63 years) were reviewed. Incidental, nonphysiologic FDG abnormalities were classified based on the report conclusion. The frequency with which such abnormalities were investigated by oncologists and the final diagnosis were compared with the imaging diagnosis with a minimum potential follow-up of 2 years (mean, 27.5 months). RESULTS: Incidental FDG abnormalities were reported in 199 (12%) of 1727 patients, including 181 with adequate follow-up. Of 59 cases with a suspected second malignancy, 34 (58%) were actively investigated, with 14 confirmed, 7 unexpected metastatic sites, and 10 other active pathologies. Only 1 further cancer was subsequently detected in the 25 (42%) patients not actively investigated. Conversely, of 122 sites presumed to be benign, only 10 (8%) were actively investigated. Only 2 were proven to relate to malignancy. CONCLUSIONS: Although incidental abnormalities were common, most were benign and appropriately categorized by experienced readers. For actively investigated extrathyroidal abnormalities, a neoplastic basis was confirmed in over 60% of cases. Conversely, for cases deemed most likely benign by the PET/CT report or after review of readily available clinical information by the referring oncologist, the rate of malignancy was less than 2%.

FDG-PET status following chemoradiotherapy provides high management impact and powerful prognostic stratification in oesophageal cancer.

PURPOSE: The purpose of this study was to evaluate the impact of FDG-PET following chemoradiotherapy (CRT) on treatment planning and survival in patients with oesophageal cancer (OC). METHODS: Fifty-three consecutive OC patients had a post-treatment PET scan to evaluate tumour response to CRT prior to possible surgery. Baseline pre-CRT PET was performed in 33 patients. Prospectively recorded post-CRT management plans were compared with post-PET treatment. High impact was defined as a change in treatment intent or modality. Survival was analysed using the Kaplan-Meier product limit method and Cox proportional hazards regression model. RESULTS: After completion of CRT, 23/53 patients (43%) achieved complete metabolic response (CMR), as compared with only four (8%) with complete response on computed tomography. High PET impact was observed in 19 patients (36%). CMR was strongly predictive of survival (p<0.008) on multivariate analysis. CMR patients in whom resection was not performed had comparable survival to those (CMR and non-CMR) who underwent resection. CONCLUSION: The use of post-treatment FDG-PET for assessment of tumour response after CRT changed the clinical management of more than one-third of OC patients. CMR status as assessed by PET powerfully stratified prognosis. Even in the absence of a baseline study, normalisation of uptake at all sites of known tumoral involvement carries a good medium-term prognosis.

Findings on 18F-FDG PET scans after neoadjuvant chemoradiation provides prognostic stratification in patients with locally advanced rectal carcinoma subsequently treated by radical surgery.

UNLABELLED: Predicting outcome after aggressive therapy for advanced rectal cancer remains difficult. (18)F-FDG PET has emerged as a valid method for predicting patient outcomes after therapy in an increasing number of cancers. We evaluated the prognostic information obtained from the degree of change in tumor (18)F-FDG PET uptake induced by chemoradiation before radical curative surgery in patients with T3/T4 rectal cancer. METHODS: The study included 34 consecutive patients with T3/T4 Nx M0 rectal cancer on structural imaging, who underwent staging and postchemoradiation (18)F-FDG PET before planned curative surgery. Change in (18)F-FDG uptake was graded visually as complete (CMR), partial (PMR), or no (NoMR) metabolic response. Pre- and postchemoradiation (18)F-FDG PET-derived standardized uptake values (SUVs) were then obtained for PMR patients to determine whether SUV further stratified this subgroup. Operative findings were available in 30 patients (3 excluded because of (18)F-FDG PET-defined M1 disease, 1 refused surgery). Clinical status at study closeout (alive free from disease, FFD; alive with disease, AWD; or died of disease, DOD) was available for all patients. RESULTS: A pathologic complete response was found in only 6 of 30 patients (5 CMR, 1 false-positive PMR). However, after an estimated median 3.1 y of follow-up, all 17 CMR patients were FFD, 6 of 10 PMR patients were FFD, 2 of 10 had DOD, and 2 of 10 were AWD. All 3 NoMR patients DOD. PET response was highly significantly associated with overall survival duration (P < 0.0001) and time to progression (P < 0.0001). Pathologic complete response was the only other statistically significant prognostic factor (P < 0.03). The percentage of maximum SUV change after chemoradiation was not predictive of survival in PMR patients. CONCLUSION: Using a simple qualitative assessment, postchemoradiation (18)F-FDG PET scintigraphy provides good medium-term prognostic information in patients with advanced rectal cancer undergoing radical surgery with curative intent.

Carotid endarterectomy at the millennium: what interventional therapy must match.

OBJECTIVES: Carotid endarterectomy (CEA) is supported by level 1 evidence as the standard treatment of severe carotid stenosis in both symptomatic and asymptomatic patients. As interventional techniques are emerging for treatment of this disease, this study was undertaken to provide a contemporary surgical standard for comparison to carotid stenting. PATIENTS AND METHODS: During the interval 1989 to 1999, 2236 isolated CEAs were performed on 1897 patients (62% male, 36% symptomatic, 4.6% reoperative procedures). Study endpoints included perioperative events, patient survival, late incidence of stroke, anatomic durability of CEA, and resource utilization changes during the study. Variables associated with complications, long-term and stroke free survival, restenosis, and resource utilization were analyzed by univariate and multivariate analysis. RESULTS: Perioperative complications occurred in 5.5% of CEA procedures, including any stroke/death (1.4%), neck hematoma (1.7%), cardiac complications (0.5%), and cranial nerve injury (0.4%). Actuarial survival at 5 and 10 years was 72.4% (95% confidence interval [CI] 69.3-73.5) and 44.7% (95% CI 41.7-47.9) respectively, with coronary artery disease (P < 0.0018), chronic obstructive pulmonary disease (P < 0.00018) and diabetes mellitus (P < 0.0011) correlating with decreased longevity. The age- and sex-adjusted incidence of any stroke during follow-up was reduced by 22% (upper 0.35, lower 0.08) of predicted with the patient classification of hyperlipidemia (P < 0.0045) as the only protective factor. Analysis of CEA anatomic durability during a median follow-up period of 5.9 years identified a 7.7% failure rate (severe restenosis/occlusion, 4.5%; or reoperative CEA, 3.2%) with elevated serum cholesterol (P < 0.017) correlating with early restenosis. Resource utilization diminished (first versus last 2-year interval periods) for average hospital length of stay from 10.3 +/- 1.5 days to 4.3 +/- 0.7 days (P < 0.01) and preoperative contrast angiography from 87% +/- 1.4% to 10.3% +/- 4%. CONCLUSIONS: These data delineate the safety, durability, and effectiveness in long-term stroke prevention of CEA. They provide a standard to which emerging catheter-based therapies for carotid stenosis should be compared.

Does positron emission tomography change management in primary rectal cancer? A prospective assessment.

PURPOSE: The influence of positron emission tomography in the management of recurrent rectal cancer is well established but its role in primary rectal cancer remains uncertain. This study therefore prospectively assesses the impact of position emission tomography scanning on the management of primary rectal cancer. METHODS: Forty-six patients with advanced primary rectal cancer referred for consideration of adjuvant preoperative therapy underwent position emission tomography scanning. The referring physicians prospectively recorded each patient's stage following conventional imaging and the proposed treatment plan prior to position emission tomography scanning. This was then compared with subsequent stage and actual management implemented, and the appropriateness of position emission tomography-induced changes was noted by subsequent clinical follow-up. RESULTS: The surgical management of 36 of 46 patients (78 percent) was unchanged as a result of position emission tomography, even though position emission tomography upstaged disease in 3 of 36 cases (8 percent) and downstaged disease in 5 of 36 cases (14 percent). In 8 of 46 cases (17 percent), management was altered because of the position emission tomography scan findings, including 6 cases (13 percent) in which surgery was cancelled and 2 other cases (4 percent) in which the radiotherapy field was changed. Where available, follow-up confirmed the appropriateness of position emission tomography-induced management change in each case. Two patients had a change in therapy independent of the position emission tomography scan due to clinical circumstances. Overall tumor stage was changed following position emission tomography in 18 of 46 patients (39 percent). CONCLUSION: Position emission tomography scanning appears to accurately change the stage or appropriately alter the therapy of almost a third of patients with advanced primary rectal cancer. In view of this, we suggest that position emission tomography scanning be considered part of standard workup for such patients, particularly if neoadjuvant chemoradiation is being considered as part of primary management.