Six country vignettes: Strengthening radiotherapy and theranostics.

BACKGROUND: For cancer patient populations worldwide, the synchronous scale-up of diagnostics and treatments yields meaningful gains in survival and quality of life. Among advanced cancer therapies, radiotherapy (RT) and theranostics are key to achieving practical, high-quality, and personalized precision medicine - targeting disease manifestations of individual patients and broad populations, alike. Aiming to learn from one another across different world regions, the six country vignettes presented here depict both challenges and victories in de novo establishment or improvement of RT and theranostics infrastructure. METHODS: The International Atomic Energy Agency (IAEA) convened global RT and theranostics experts from diverse world regions and contexts to identify relevant challenges and report progress in their own six countries: Belgium, Brazil, Costa Rica, Jordan, Mongolia, and South Africa. These accounts are collated, compared, and contrasted herein. RESULTS: Common challenges persist which could be more strategically assessed and addressed. A quantifiable discrepancy entails personnel. The estimated radiation oncologists (ROs), nuclear medicine physicians (NMPs), and medical physicists (MPs for RT and nuclear medicine) per million inhabitants in the six collective countries respectively range between 2.69-38.00 ROs, 1.00-26.00 NMPs, and 0.30-3.45 MPs (Table 1), reflecting country-to-country inequities which largely match World Bank country-income stratifications. CONCLUSION: Established goals for RT and nuclear medicine advancement worldwide have proven elusive. The pace of progress could be hastened by enhanced approaches such as more sustainably phased implementation; better multinational networking to share lessons learned; routine quality and safety audits; as well as capacity building employing innovative, resource-sparing, cutting-edge technologic approaches. Bodies such as ministries of health, professional societies, and the IAEA shall serve critical roles in convening and coordinating more innovative RT and theranostics translational research, including expanding nuanced global database metrics to inform, reach, and potentiate milestones most meaningfully. POLICY SUMMARY: Aligned with WHO 25×25 NCDs target; WHA70.12 and WHA76.5 resolutions.

Association of Income Level and Ischemic Heart Disease: Potential Role of Walkability. / Associação de Nível de Renda e Doença Isquêmica do Coração: Papel Potencial da Caminhabilidade.

BACKGROUND: Association of Income Level and Ischemic Heart Disease: Potential Role of Walkability Association of ischemic heart disease (adjusted for traditional risk factors and socioeconomics variables) and income level (A), and walkability z-score (B), and association of walkability z-score and income level (C). BACKGROUND: Socioeconomic status has been linked to ischemic heart disease (IHD). High-income neighborhoods may expose individuals to a walking-promoting built environment for daily activities (walkability). Data from the association between income and IHD is lacking in middle-income countries. It is also uncertain whether walkability mediates this association. OBJECTIVES: To investigate whether income is associated with IHD in a middle-income country and whether neighborhood walkability mediates the income-IHD association. METHODS: This cross-sectional study evaluated 44,589 patients referred for myocardial perfusion imaging (SPECT-MPI). Income and walkability were derived from participants' residential census tract. Walkability quantitative score combined 4 variables: street connectivity, residential density, commercial density, and mixed land use. IHD was defined by abnormal myocardial perfusion during a SPECT-MPI study. We used adjusted mixed effects models to evaluate the association between income level and IHD, and we performed a mediation analysis to measure the percentage of the income-IHD association mediated by walkability. We considered p values below 0.01 as statistically significant. RESULTS: From 26,415 participants, those living in the lowest-income tertile census tract were more physically inactive (79.1% versus 75.8% versus 72.7%) when compared to higher-income tertile census tracts (p < 0.001). Income was associated with IHD (odds ratio: 0.91 [95% confidence interval: 0.87 to 0.96] for each 1,000.00 international dollars increase in income) for both men and women equally (p for interaction = 0.47). Census tracts with a higher income were associated with better walkability (p < 0.001); however, walkability did not mediate the income-IHD association (percent mediated = -0.3%). CONCLUSIONS: Income was independently associated with higher prevalence of IHD in a middle-income country irrespective of gender. Although walkability was associated with census tract income, it did not mediate the income-IHD association.

Associação de Nível de Renda e Doença Isquêmica do Coração: Papel Potencial da Caminhabilidade / Association of Income Level and Ischemic Heart Disease: Potential Role of Walkability

Resumo Fundamento O nível socioeconômico tem sido associado à doença isquêmica do coração (DIC). Bairros de alta renda podem expor os indivíduos a um ambiente construído que promova caminhadas para atividades diárias (caminhabilidade). Faltam dados sobre a associação entre renda e DIC em países de renda média. Também é incerto se a caminhabilidade medeia essa associação. Objetivos Investigar se a renda está associada à DIC em um país de renda média e se a caminhabilidade dos bairros medeia a associação entre renda e DIC. Métodos O presente estudo transversal avaliou 44.589 pacientes encaminhados para imagem de perfusão miocárdica (SPECT-MPI). A renda e a caminhabilidade foram derivadas do setor censitário residencial dos participantes. A pontuação quantitativa da caminhabilidade combinou as seguintes 4 variáveis: conectividade viária, densidade residencial, densidade comercial e uso misto do solo. A DIC foi definida pela presença de perfusão miocárdica anormal durante um estudo SPECT-MPI. Utilizamos modelos ajustados com efeitos mistos para avaliar a associação entre nível de renda e DIC e realizamos uma análise de mediação para medir o percentual da associação entre renda e DIC mediada pela caminhabilidade. Consideramos valores de p abaixo de 0,01 como estatisticamente significativos. Resultados Dos 26.415 participantes, aqueles que residiam no setor censitário do tercil de menor renda eram mais fisicamente inativos (79,1% versus 75,8% versus 72,7%) quando comparados aos setores censitários do tercil de maior renda (p < 0,001). A renda foi associada à DIC (odds ratio: 0,91 [intervalo de confiança de 95%: 0,87 a 0,96] para cada aumento de 1000,00 dólares internacionais na renda), para homens e mulheres igualmente (p para interação = 0,47). Os setores censitários com maior renda estiveram associados a uma melhor caminhabilidade (p < 0,001); no entanto, a caminhabilidade não mediou a associação entre renda e DIC (porcentagem mediada = −0,3%). Conclusões A renda foi independentemente associada a maior prevalência de DIC em um país de renda média, independentemente de gênero. Embora a caminhabilidade tenha sido associada à renda do setor censitário, ela não mediou a associação entre renda e DIC.

Abstract Background Socioeconomic status has been linked to ischemic heart disease (IHD). High-income neighborhoods may expose individuals to a walking-promoting built environment for daily activities (walkability). Data from the association between income and IHD is lacking in middle-income countries. It is also uncertain whether walkability mediates this association. Objectives To investigate whether income is associated with IHD in a middle-income country and whether neighborhood walkability mediates the income-IHD association. Methods This cross-sectional study evaluated 44,589 patients referred for myocardial perfusion imaging (SPECT-MPI). Income and walkability were derived from participants' residential census tract. Walkability quantitative score combined 4 variables: street connectivity, residential density, commercial density, and mixed land use. IHD was defined by abnormal myocardial perfusion during a SPECT-MPI study. We used adjusted mixed effects models to evaluate the association between income level and IHD, and we performed a mediation analysis to measure the percentage of the income-IHD association mediated by walkability. We considered p values below 0.01 as statistically significant. Results From 26,415 participants, those living in the lowest-income tertile census tract were more physically inactive (79.1% versus 75.8% versus 72.7%) when compared to higher-income tertile census tracts (p < 0.001). Income was associated with IHD (odds ratio: 0.91 [95% confidence interval: 0.87 to 0.96] for each 1,000.00 international dollars increase in income) for both men and women equally (p for interaction = 0.47). Census tracts with a higher income were associated with better walkability (p < 0.001); however, walkability did not mediate the income-IHD association (percent mediated = −0.3%). Conclusions Income was independently associated with higher prevalence of IHD in a middle-income country irrespective of gender. Although walkability was associated with census tract income, it did not mediate the income-IHD association.

PSMA PET for the Evaluation of Liver Metastases in Castration-Resistant Prostate Cancer Patients: A Multicenter Retrospective Study.

Background: To evaluate the diagnostic performance of PSMA-PET compared to conventional imaging/liver biopsy in the detection of liver metastases in CRPC patients. Moreover, we evaluated a PSMA-PET/CT-based radiomic model able to identify liver metastases. Methods: Multicenter retrospective study enrolling patients with the following inclusion criteria: (a) proven CRPC patients, (b) PSMA-PET and conventional imaging/liver biopsy performed in a 6 months timeframe, (c) no therapy changes between PSMA-PET and conventional imaging/liver biopsy. PSMA-PET sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy for liver metastases were calculated. After the extraction of radiomic features, a prediction model for liver metastases identification was developed. Results: Sixty CRPC patients were enrolled. Within 6 months before or after PSMA-PET, conventional imaging and liver biopsy identified 24/60 (40%) patients with liver metastases. PSMA-PET sensitivity, specificity, PPV, NPV, and accuracy for liver metastases were 0.58, 0.92, 0.82, 0.77, and 0.78, respectively. Either number of liver metastases and the maximum lesion diameter were significantly associated with the presence of a positive PSMA-PET (p < 0.05). On multivariate regression analysis, the radiomic feature-based model combining sphericity, and the moment of inverse difference (Idm), had an AUC of 0.807 (95% CI:0.686-0.920). Conclusion: For liver metastases assessment, [68Ga]Ga-PSMA-11-PET demonstrated moderate sensitivity while high specificity, PPV, and inter-reader agreement compared to conventional imaging/liver biopsy in CRPC patients.

Radiation exposure after myocardial perfusion imaging with Cadmium-Zinc-Telluride camera versus conventional camera.

BACKGROUND: Patient exposure to radiation during the management of coronary heart disease (CHD) can be reduced with more efficient technologies in nuclear medicine, such as the Cadmium-Zinc-Telluride (CZT) gamma-camera for myocardial perfusion imaging (MPI) studies. However, it has been suggested that CZT has lower specificity, which might lead to more downstream radiological procedures, particularly among obese individuals. METHODS AND RESULTS: We evaluated 244 patients with suspected CHD who underwent CZT-SPECT and matched 1:1 according to sex, age, and body mass index (BMI) with those undergoing MPI study with the Anger gamma-camera (Anger-SPECT). The outcome was the total radiation exposure from the MPI study added to the radiation exposure from all subsequent cardiac examinations during a 90-day follow-up. The total radiation dose after 90 days was significantly lower in the CZT-SPECT group (6.4 ± 4.8 vs 9.5±4.9 mSv, P < .001). After adjusting for potential confounders, CZT-SPECT remained associated with lower total radiation dose, but it significantly attenuated among obese individuals (Beta coefficient - 3.73 ± 0.86 for BMI < 30 vs - 2.30 ± 0.92 for BMI ≥ 30 Kg/m2, P for interaction < 0.032). CONCLUSIONS: CZT-SPECT was associated with lower total radiation doses compared to Anger-SPECT, albeit this benefit may be attenuated in obese individuals.

Fluorodeoxyglucose-positron emission tomography staging can replace bone marrow biopsy in Hodgkin's lymphoma. Results from Brazilian Hodgkin's Lymphoma Study Group

ABSTRACT Objective: To investigate, in a large prospective multicenter study, whether 2-[18F]-fluoro-2-deoxy-D-glucose-positron emission tomography is sufficiently accurate to identify clinically important bone marrow involvement by Hodgkin's lymphoma to replace routine bone marrow biopsy in a developing tropical country. Methods: Patients newly diagnosed with Hodgkin's lymphoma were recruited from six cancer centers in Brazil. All were staged by the results of positron emission tomography/computed tomography that were centrally reviewed and by iliac crest bone marrow biopsy. Patients were classified as having marrow disease if they had lymphoma identified by marrow biopsy histology or had focal 2-[18F]-fluoro-2-deoxy-D-glucose marrow uptake that resolved following chemotherapy. Results: A total of 246 participants were recruited from six different centers and 62 (25.2%) were judged to have Hodgkin's lymphoma in the bone marrow. Positron emission tomography and biopsies were concordant in 206 patients (83%). Positron emission tomography correctly identified marrow disease in 59/62 patients (95.1%) and marrow biopsy in 25/62 patients (40.3%). In 22/62 (35.4%) patients, the two techniques were concordant in the diagnosis of marrow involvement. Of the forty discordant results, positron emission tomography found bone marrow involvement in 37 patients, upstaging 22 to stage IV and having an impact on therapeutic decision in nine cases given their reallocation from early to advanced stage. Three false negative positron emission tomography results were obtained with bone marrow biopsy giving positive findings. All three cases were classified as stage IV regardless of bone marrow findings implying no modification in the clinical management. The sensitivity, specificity and accuracy of positron emission tomography for detecting bone marrow disease were 95%, 100% and 98% and for bone marrow biopsy they were 40%, 100% and 84%, respectively. Conclusion: We conclude that positron emission tomography can replace marrow biopsy in Brazilian patients with Hodgkin's lymphoma without compromising clinical management.

Fluorodeoxyglucose-positron emission tomography staging can replace bone marrow biopsy in Hodgkin's lymphoma. Results from Brazilian Hodgkin's Lymphoma Study Group.

OBJECTIVE: To investigate, in a large prospective multicenter study, whether 2-[18F]-fluoro-2-deoxy-d-glucose-positron emission tomography is sufficiently accurate to identify clinically important bone marrow involvement by Hodgkin's lymphoma to replace routine bone marrow biopsy in a developing tropical country. METHODS: Patients newly diagnosed with Hodgkin's lymphoma were recruited from six cancer centers in Brazil. All were staged by the results of positron emission tomography/computed tomography that were centrally reviewed and by iliac crest bone marrow biopsy. Patients were classified as having marrow disease if they had lymphoma identified by marrow biopsy histology or had focal 2-[18F]-fluoro-2-deoxy-d-glucose marrow uptake that resolved following chemotherapy. RESULTS: A total of 246 participants were recruited from six different centers and 62 (25.2%) were judged to have Hodgkin's lymphoma in the bone marrow. Positron emission tomography and biopsies were concordant in 206 patients (83%). Positron emission tomography correctly identified marrow disease in 59/62 patients (95.1%) and marrow biopsy in 25/62 patients (40.3%). In 22/62 (35.4%) patients, the two techniques were concordant in the diagnosis of marrow involvement. Of the forty discordant results, positron emission tomography found bone marrow involvement in 37 patients, upstaging 22 to stage IV and having an impact on therapeutic decision in nine cases given their reallocation from early to advanced stage. Three false negative positron emission tomography results were obtained with bone marrow biopsy giving positive findings. All three cases were classified as stage IV regardless of bone marrow findings implying no modification in the clinical management. The sensitivity, specificity and accuracy of positron emission tomography for detecting bone marrow disease were 95%, 100% and 98% and for bone marrow biopsy they were 40%, 100% and 84%, respectively. CONCLUSION: We conclude that positron emission tomography can replace marrow biopsy in Brazilian patients with Hodgkin's lymphoma without compromising clinical management.

Hodgkin's lymphoma unmet medical needs in Brazil: experts' perspective / Necessidades médicas não atendidas no tratamento de linfoma de Hodgkin no Brasil: perspectiva de médicos

Background: In 2016, Hodgkin's Lymphoma (HL) was responsible for 2,470 new cases in Brazil and, despite recent scientific advances, there are unmet medical needs that affects patients' outcome. Therefore, we aimed to explore the unmet medical needs in the management of HL patients in Brazil, based on experts' perspective. Methods: A questionnaire was developed to address the unmet medical needs including barriers for the diagnosis and treatment of HL in Brazil. The questionnaire results were presented in a panel discussion to validate participants' responses and to collect additional data. Main results: Eight experts participated in the panel. On both healthcare systems, public and private, a slight majority of patients was women and most of them were under 60 yearsold. In addition, the majority of patients were referred from another specialty on both systems. The time from onco-hematologist appointment to diagnosis was different between public and private sector (median of 30 and 12.5 days, respectively). Most patients in the public sector were on stage III (33%) and IV (33%); in the private sector, most patients were on stages II (36%) and III (24%). The most common barriers were the delayed diagnosis and the unavailability of diagnostic procedures and treatment options. Conclusion: According to participants, issues related to infrastructure and healthcare resource allocation affects the management of HL. Improvements in the infrastructure and educational measures for physicians and patients may contribute to minimize the barriers.

Introdução: Em 2016, o Linfoma de Hodgkin (LH) foi responsável por 2.470 novos casos no Brasil e, apesar dos recentes avanços científicos, há necessidades médicas não atendidas que afetam os pacientes. Portanto, o estudo teve como objetivo explorar as necessidades médicas não atendidas no manejo de pacientes com LH no Brasil, com base na perspectiva de especialistas. Métodos: Um questionário foi desenvolvido para abordar as necessidades médicas não atendidas, incluindo as barreiras para o diagnóstico e tratamento do LH no Brasil. Os resultados do questionário foram apresentados em um painel de discussão para validar as respostas dos participantes e coletar dados adicionais. Principais resultados: Oito especialistas participaram do painel. De acordo com os especialistas, em ambos os sistemas de saúde público e privado, uma pequena maioria dos pacientes era mulher e a maioria tinha menos de 60 anos. Além disso, a maioria dos pacientes foi encaminhada por outra especialidade em ambos os sistemas. O tempo entre a consulta com o onco-hematologista até o diagnóstico foi diferente entre o setor público e privado (mediana de 30 e 12,5 dias, respectivamente). A maioria dos pacientes do setor público apresenta estádios III (33%) e IV (33%); no setor privado, a maioria dos pacientes apresenta estádios II (36%) e III (24%). As barreiras mais comuns foram o atraso no diagnóstico e a indisponibilidade de procedimentos diagnósticos, e opções de tratamento. Conclusão: De acordo com os participantes, as questões relacionadas à infraestrutura e à alocação de recursos de saúde afetam o gerenciamento do LH. Melhorias na infraestrutura e medidas educacionais para médicos e pacientes podem contribuir para minimizar as barreiras.

Treatment patterns of Hodgkin's lymphoma in Brazil: experts' perspective / Padrões de tratamento do linfoma de Hodgkin no Brasil: a perspectiva dos especialistas

Background: Hodgkin's Lymphoma (HL) is a curable type of cancer, with a wide variety of therapies, especially for refractory/relapsing cases. Therefore, the study aims to explore the treatment patterns used in the management of HL patients in Brazil. Methods: A survey was developed to explore the treatment patterns in Brazil, addressing topics such as clinical characteristics, lines of therapy, transplant information and cure rates. Then, results were presented in a panel discussion to validate participants' responses and gain additional insights. Main results: The eight experts reported that most patients are women and under 60 years old. In both private and public healthcare systems, ABVD was the most commonly used first-line therapy for patients of all stages. The median cure rates for patients in stages I and II were 80% and 87.5%, and for stages III and IV 60% and 67.5%, respectively, in public and private sectors. For the subsequent lines of therapy, different regimens such as DHAP, GVD, GEV, ICE and allogeneic transplant are used, among others. Brentuximab vedotin was present mainly in the private sector. In the public sector, 70% of the patients are eligible for autologous stem cell transplant; of them, 75% actually receive the transplant. In the private sector, 80% of the patients are eligible, and 100% of them receive the transplant. Conclusion: Similarities were found between the public and private sectors in first-line therapy and cure rates. However, barriers for subsequent lines of therapy are more evident in the public system.

Introdução: O linfoma de Hodgkin (LH) é um tipo de câncer curável, com ampla variedade de terapias, especialmente para casos refratários/recidivantes. Portanto, o estudo visa explorar os padrões de tratamento utilizados no manejo de pacientes com LH no Brasil. Métodos: Uma pesquisa foi desenvolvida para explorar os padrões de tratamento no Brasil, abordando tópicos como: características clínicas, linhas de terapia, informações sobre transplantes e taxas de cura. Em seguida, os resultados foram apresentados em um painel de discussão para validar as respostas dos participantes e coletar os insights adicionais. Principais resultados: Os oito especialistas relataram que maioria dos pacientes é composta por mulheres com idade menor de 60 anos. Em ambos os sistemas de saúde, privado e público, ABVD foi a terapia de primeira linha mais comumente usada para pacientes de todos os estágios. As medianas das taxas de cura para pacientes nos estágios I e II foram de 80% e 87,5%, e para os estádios III e IV, de 60% e 67,5%, nos setores público e privado, respectivamente. Para as linhas subsequentes de terapia, diferentes regimes como DHAP, GVD, GEV, ICE e transplante alogênico são utilizados, entre outros. Brentuximabe vedotina estava presente principalmente no setor privado. No setor público, 70% dos pacientes são elegíveis para transplante autólogo de células-tronco; deles, 75% recebem o transplante. No setor privado, 80% dos pacientes são elegíveis e 100% recebem o transplante. Conclusão: Foram encontradas semelhanças entre o setor público e privado na terapia de primeira linha, bem como nas taxas de cura. No entanto, as barreiras para as linhas subsequentes de terapia são mais evidentes no sistema público.

New treatment approaches for relapsing/refractory Hodgkin's lymphoma: An overview of the Brazilian scenario / Novas abordagens de tratamento para o linfoma de Hodgkin recidivante/refratário: uma revisão

Hodgkin's lymphoma (HL) is a B-cell malignancy with a classical bimodal distribution with incidence peaking in the third and sixth decades of life. The purpose of this review is to describe the current unmet medical need for relapsing/refractory HL and the main data of emerging treatments, including brentuximab vedotin, the immune checkpoint inhibitors nivolumab and pembrolizumab, as well as other compounds in development. Available guidelines for relapsing/refractory HL are discussed.

O linfoma de Hodgkin (LH) é uma neoplasia de células B com distribuição bimodal clássica com pico de incidência na terceira e sexta décadas de vida. O objetivo desta revisão é descrever as atuais necessidades médicas não atendidas dos pacientes com LH recidivante/refratário e os dados principais dos tratamentos emergentes, incluindo brentuximabe vedotina, os inibidores do ponto de verificação imunológico, nivolumabe e pembrolizumabe, bem como outros compostos em desenvolvimento. Além disso, discutem-se as diretrizes disponíveis para LH recidivante/refratário.

Protocol for qRT-PCR analysis from formalin fixed paraffin embedded tissue sections from diffuse large b-cell lymphoma: Validation of the six-gene predictor score.

As a part of an international study on the molecular analysis of Diffuse Large B-cell Lymphoma (DLBCL), a robust protocol for gene expression analysis from RNA extraction to qRT-PCR using Formalin Fixed Paraffin Embedded tissues was developed. Here a study was conducted to define a strategy to validate the previously reported 6-gene (LMO2, BCL6, FN1, CCND2, SCYA3 and BCL2) model as predictor of prognosis in DLBCL. To avoid variation, all samples were tested in a single centre and single platform. This study comprised 8 countries (Brazil, Chile, Hungary, India, Philippines, S. Korea, Thailand and Turkey). Using the Kaplan-Meier and log rank test on patients (n=162) and two mortality risk groups (with those above and below the mean representing high and low risk groups) confirmed that the 6-gene predictor score correlates significantly with overall survival (OS, p<0.01) but not with event free survival (EFS, p=0.18). Adding the International Prognostic Index (IPI) shows that the 6-gene predictor score correlates significantly with high IPI scores for OS (p<0.05), whereas those with low IPI scores show a trend not reaching significance (p=0.08). This study defined an effective and economical qRT-PCR strategy and validated the 6-gene score as a predictor of OS in an international setting.

The impact of coaxial core biopsy guided by FDG PET/CT in oncological patients.

OBJECTIVE: When deciding on therapy, FDG PET/CT-positive results should be confirmed by histology if possible. We evaluated the impact of percutaneous PET/CT-guided biopsies on histological confirmation of PET/CT-positive lesions. METHODS: We prospectively evaluated 126 patients who had undergone a PET/CT scan with positive results with an indication for histological evaluation of lesions. Imaging was performed in a PET/CT scanner with a fluoroscopic imaging system. A total of 130 lesions were accessed by PET/CT-guided biopsy. The technical feasibility, clinical success and complication rates of PET/CT-guided biopsies were evaluated. RESULTS: Of 130 PET/CT-positive lesions, 128 (98.5 %) were successfully accessed and representative tissue samples obtained. Two lesions were reaccessed due to inconclusive histological results. Histology showed that 99 of the 130 lesions (76.2 %) were malignant, and 31 lesions (23.8 %) were benign (inflammatory cells or necrotic tissue); these patients had no recurrence of disease after a minimum follow-up of 6 months. Also, in 23 of the 130 lesions (17.7 %), the patient was referred for the PET/CT-guided biopsy due to a previous nontumoral biopsy result, and of these 23 lesions, 21 were found to be malignant. The complication rates were: pneumothorax in 15/130 (11.5 %; resolved spontaneously), haemoptysis in 2/130 (1.5 %) and severe haemothorax in 1/130 (0.8 %); there was no procedure-related mortality. CONCLUSION: PET/CT-guided biopsy is feasible and may optimize the diagnostic yield of image-guided interventions. Also, PET/CT-positive lesions with no morphological correlation may now be accessible to percutaneous interventions.

Investigação municipal do paciente coronariano a ser tratado (IMPACT): relatório final / Municipal Research coronary patients to be treated (IMPACT): final report

Neste estudo retrospectivo foram quantificados os procedimentos utilizados no diagnóstico e tratamento invasivo dos pacientes com doença arterial coronariana (DAC) do Sistema Único de Saúde (SUS) com origem no nível de atenção secundária nos municípios de Curitiba, São Paulo e também no Instituto do Coração da Faculdade de Medicina da Universidade de São Paulo (Incor FMUSP), uma instituição terciária de ensino. Foi realizada uma comparação da população com diagnóstico ou supeita de DAC submetida ou não a diagnóstico não-invasivo prévio com exames funcionais (teste ergométrico, ecocardiograma de estresse e cintilografia de perfusão do miocárdio), além de cateterismo diagnóstico e tratamento com revascularização percutânea ou cirúrgica. Foi ainda analisado o impacto econômico das estratégias observadas sob a perspectiva do Sistema Único de Saúde. Os objetivos do presente estudo foram (1) avaliar e quantificar os procedimentos utilizados na investigação de pacientes com DAC no SUS nos município de Curitiba e (2) São Paulo, assim como (3) no Incor FMUSP e (4) analisar a incidência de óbito em cada grupo de investigação (5) assim, como o custo direto destas estratégias utilizadas. Existem diferenças importantes no manejo do paciente com DAC na região metropolitana de Curitiba, São Paulo e no InCor. Os testes funcionais são os exames mais frequentemente utilizados na avaliação de pacientes com DAC nos três cenários avaliados, porém os custos empregados são muito menores em Curitiba que nos demais cenários. Há uma priorização dos custos relacionados ao tratamento invasivo, representando 59,7% dos custos diretos relacionado ao diagnóstico e tratamento do SUS em São Paulo e chegando até a 87,2% dos custos diretos totais em Curitiba. Indicadores nominais e estudos longitudinais são necessários para uma melhor avaliação e planejamento do sistema (AU)

A tomografia por emissão de pósitrons com 2-[18F]-fluoro-2-desoxi-D-glicose é custo-efetiva em pacientes com câncer de pulmão não pequenas células no Brasil / 2-[18F]-fluoro-2-deoxy-D-glucose positron-emission tomography is cost-effective in the initial staging of non-small cell lung cancer patients in Brazil

OBJETIVO: Comparar a acurácia e a custo-efetividade do estadiamento metabólico (EM) com o FDG-PET em relação ao estadiamento convencional (EC) no estadiamento inicial de pacientes com câncer de pulmão não pequenas células (CPNPC). MATERIAIS E MÉTODOS: Noventa e cinco pacientes com diagnóstico inicial de CPNPC foram estadiados antes do início do tratamento. Os resultados do EC e EM foram comparados quanto a definição do tratamento e incidência de toracotomia fútil em cada estratégia. RESULTADOS: O EM com FDG-PET classificou 48,4% dos pacientes como estádio mais avançado e 5,3% como menos avançado. O resultado do EM modificaria o tratamento em 41% dos pacientes. A toracotomia foi considerada fútil em 47% dos pacientes com EC e em 19% dos casos com EM. O custo das toracotomias fúteis em oito pacientes no EM foi de R$ 79.720, enquanto em 31 pacientes no EC seria de R$ 308.915. Apenas esta economia seria mais que suficiente para cobrir os custos de todos os exames de FDG-PET nos 95 pacientes (R$ 126.350) ou de FDG-PET/CT (R$ 193.515). CONCLUSÃO: O EM com FDG-PET tem maior acurácia que o EC em pacientes com CPNPC. A FDG-PET e FDG-PET/CT são custo-efetivas e sua utilização se justifica economicamente na saúde pública no Brasil.

OBJECTIVE: To evaluate the accuracy and cost-effectiveness of metabolic staging (MS) with FDG-PET as compared with the conventional staging (CS) strategy in the preoperative staging of non-small cell lung cancer (NSCLC). MATERIALS AND METHODS: A total of 95 patients with initial diagnosis of NSCLC were staged before undergoing treatment. The MS and CS results were compared with regard to treatment definition and incidence of futile thoracotomies with both strategies. RESULTS: Metabolic staging with FDG-PET upstaged 48.4% and downstaged 5.3% of the patients, and would lead to change in the treatment of 41% of cases. Thoracotomy was considered as futile in 47% of the patients with CS, and in 19% of the patients with MS. The cost of futile thoracotomies in eight patients with MS was R$ 79,720, while in 31 patients with CS it would be R$ 308,915. Just such saving in costs would be more than enough to cover the costs of all FDG-PETs (R$ 126,350) or FDG-PET/CTs (R$ 193,515) for the 95 patients. CONCLUSION: The metabolic staging with FDG-PET is more accurate than CS in patients with NSCLC. Both FDG-PET and FDG-PET/CT are cost-effective methods and their utilization is economically justifiable in the Brazilian public health system.

FDG-PET in Lymphoma: Nuclear Medicine Perspective.

Positron emission tomography (PET) is a sectional molecular imaging procedure that allows evaluation of the metabolism at a molecular and cellular level. For a PET scan, the patient is injected with a radiotracer, such as (18)F-fluorodeoxyglucose (FDG). FDG PET-computed tomography has become an established modality for metabolic staging and plays an important role in the major steps of evaluation and treatment of most lymphoma subtypes, with significant impact in the initial staging, posttherapy evaluation, and suspect of relapse of disease. However, whenever the information of PET results is translated to changing treatment, especially in cases of further treatment, biopsy confirmation should always be made when possible.

Myocardial perfusion imaging is a strong predictor of death in women.

OBJECTIVES: We sought to assess the prognostic value and risk classification improvement using contemporary single-photon emission computed tomography myocardial perfusion imaging (SPECT-MPI) to predict all-cause mortality. BACKGROUND: Myocardial perfusion is a strong estimator of prognosis. Evidence published to date has not established the added prognostic value of SPECT-MPI nor defined an approach to detect improve classification of risk in women from a developing nation. METHODS: A total of 2,225 women referred for SPECT-MPI were followed by a mean period of 3.7 ± 1.4 years. SPECT-MPI results were classified as abnormal on the presence of any perfusion defect. Abnormal scans were further classified as with mild/moderate reversible, severe reversible, partial reversible, or fixed perfusion defects. Risk estimates for incident mortality were categorized as <1%/year, 1% to 2%/year, and >2%/year using Cox proportional hazard models. Risk-adjusted models incorporated clinical risk factors, left ventricular ejection fraction (LVEF), and perfusion variables. RESULTS: All-cause death occurred in 139 patients. SPECT-MPI significantly risk stratified the population; patients with abnormal scans had significantly higher death rates compared with patients with normal scans, 13.1% versus 4.0%, respectively (p < 0.001). Cox analysis demonstrated that after adjusting for clinical risk factors and LVEF, SPECT-MPI improved the model discrimination (integrated discrimination index = 0.009; p = 0.02), added significant incremental prognostic information (global chi-square increased from 87.7 to 127.1; p < 0.0001), and improved risk prediction (net reclassification improvement = 0.12; p = 0.005). CONCLUSIONS: SPECT-MPI added significant incremental prognostic information to clinical and left ventricular functional variables while enhancing the ability to classify this Brazilian female population into low- and high-risk categories of all-cause mortality.

Lista de recomendações do Exame PET/CT com 18F-FDG em Oncologia: consenso entre a Sociedade Brasileira de Cancerologia e a Sociedade Brasileira de Biologia, Medicina Nuclear e Imagem Molecular / Recommendations on the use of 18F-FDG PET/CT in Oncology: consensus between the Brazilian Society of Cancerology and the Brazilian Society of Biology, Nuclear Medicine and Molecular Imaging

Apresentamos uma lista de recomendações sobre a utilização de 18F-FDG PET em oncologia, no diagnóstico, estadiamento e detecção de recorrência ou progressão do câncer. Foi realizada pesquisa para identificar estudos controlados e revisões sistemáticas de literatura composta por estudos retrospectivos e prospectivos. As consequências e o impacto da 18F-FDG PET no manejo de pacientes oncológicos também foram avaliados. A 18F-FDG PET deve ser utilizada como ferramenta adicional aos métodos de imagem convencionais como tomografia computadorizada e ressonância magnética. Resultados positivos que sugiram alteração no manejo clínico devem ser confirmados por exame histopatológico. A 18F-FDG PET deve ser utilizada no manejo clínico apropriado para o diagnóstico de cânceres do sistema respiratório, cabeça e pescoço, sistema digestivo, mama, melanoma, órgão genitais, tireoide, sistema nervoso central, linfoma e tumor primário oculto.

The authors present a list of recommendations on the utilization of 18F-FDG PET/CT in oncology for the diagnosis, staging and detection of cancer, as well as in the follow-up of the disease progression and possible recurrence. The recommendations were based on the analysis of controlled studies and a systematic review of the literature including both retrospective and prospective studies regarding the clinical usefulness and the impact of 18F-FDG PET/CT on the management of cancer patients. 18F-FDG PET/CT should be utilized as a supplement to other conventional imaging methods such as computed tomography and magnetic resonance imaging. Positive results suggesting changes in the clinical management should be confirmed by histopathological studies. 18F-FDG PET should be utilized in the diagnosis and appropriate clinical management of cancer involving the respiratory system, head and neck, digestive system, breast, genital organs, thyroid, central nervous system, besides melanomas, lymphomas and occult primary tumors.

A tomografia por emissão de pósitron com 18F-fluoro-desoxi-glicose (PET-FDG) na avaliação de resposta precoce à quimioterapia em pacientes portadores de linfoma de Hodgkin / Positron emission tomography with 2-[18F]-fluoro-2-desoxy-D-glucose assessing response after 2 cycles of chemotherapy in Hodgkin lymphoma

Pacientes com linfoma de Hodgkin (LH) tratados com poliquimioterpia com adriamicina, bleomicina, vincristina e doxorrubicina (ABVD) apresentam resposta terapêutica distinta. Para aprimorar a avaliação prognóstica e a abordagem terapêutica em LH objetivamos avaliar o valor prognóstico da PET-FDG após 2 ciclos de ABVD (PET2) em pacientes com LH. Foram incluídos nesse estudo prospectivo 115 pacientes com diagnóstico recente de LH no período de agosto de 2005 a dezembro de 2007. Os pacientes foram estadiados com exame clínico, laboratorial, tomografia computadorizada e PET-FDG (PET0). Todos os pacientes foram tratados com ABVD e aqueles com massa tumoral extensa foram tratados com radioterapia associada. Após dois ciclos de ABVD os pacientes foram submetidos a PET2. Nenhum tratamento foi alterado baseado na PET2. Foi avaliado o valor prognóstico dos fatores clínicos, Índice Prognóstico Internacional (IPI) e PET2 em relação à sobrevida livre de eventos (SLE) em três anos. Dos 104 pacientes que foram avaliados, 82 atingiram remissão completa e 22 pacientes apresentaram falha de tratamento durante a mediana de 36 meses de acompanhamento. A SG e SLE em três anos foi de 94,2% e 74,2% respectivamente. A SLE em três anos da PET2 positiva foi de 54,3%, enquanto da PET2 negativa foi de 90,5% (p< 0.001). Na análise de subgrupos de pacientes com estádio precoce, avançado, IPI baixo e alto risco, a PET2 também apresentou correlação estatisticamente significativa com o prognóstico. Concluímos que a PET2 é o melhor fator prognóstico independente na avaliação de pacientes com LH.

Patients with Hodgkin lymphoma (HL) treated with poliquimioteraphy with adriamycin, bleomycin, vincristine and doxorubicin (ABVD) have distinct therapeutic response. In order to improve the prognostic assessment and therapeutic approach in HL we have evaluated the prognostic value of FDG-PET after 2 cycles of ABVD (PET2). Were included in this prospective study 115 patients with newly diagnosed LH in the period of August 2005 to December 2007. The patients were staged with physical examination, laboratory, CT and PET-FDG (PET0). All patients were treated with ABVD and those with extensive tumor were treated with radiotherapy associated. After two cycles of ABVD patients underwent PET2. No treatment was changed based on PET2. We assessed the prognostic value of clinical factors, international prognostic score (IPS) and PET2 in relation to event-free survival (EFS) in three years. Of the 104 patients who finalized the evaluation, 82 achieved complete remission and 22 patients experienced treatment failure during the median of 36 months of follow-up. The EFS at three years was 74.2%. EFS in three years of PET2 positive was 54.3%, while the PET2 negative was 90.5% (p <0.001). In subgroup analysis of patients with early stage, advanced, low and high risk IPS, PET2 also showed significant correlation with the prognosis. We conclude that the PET2 is the best independent prognostic factor in the evaluation of overall patients with LH, or in subgroups of early, advance; low and high risk of HL.