Use of [18F]fluorocholine PET/CT in the detection of primary hyperparathyroidism in paediatrics: a case report.

OBJECTIVES: The most common cause of primary hyperparathyroidism (PPH) in children is a parathyroid adenoma. Among this population, PPH exhibits higher levels of morbidity, severity and target organ involvement compared to adults. When there is suspicion of PPH, cervical ultrasound and 99mTc-sestamibi SPECT/CT are the imaging test traditionally indicated. Among adults, the use of [18F]fluorocholine PET/CT has shown a higher sensitivity than ultrasound and [99mTc]sestamibi SPECT/CT, leading to an expanding adoption in recent years. However, its role in paediatrics has not been clearly defined yet. CASE PRESENTATION: The patient is an adolescent female aged 13 years presented with lithiasis. The analytical study revealed elevated PTH, hipovitaminosis D, hypercalcaemia and hypophosphataemia. Due to the suspicion of PPH, cervical ultrasound and 99mTc-sestamibi SPECT/C were performed, failing to identify hyperfunctioning parathyroid glands. We proceeded to carry out a [18F]fluorocholine PET/CT where a hypermetabolic nodular image was identified, compatible with a hyperfunctioning parathyroid adenoma. The patient underwent surgery, resulting in the normalisation of PTH levels. Pathological anatomy confirmed the presence of a parathyroid adenoma. CONCLUSIONS: In cases where conventional imaging tests yield negative results or discrepancies, we suggest the possibility of the use of [18F]fluorocholine PET/CT for the detection of hyperfunctioning parathyroid adenomas.

Impact of amyloid-PET in daily clinical management of patients with cognitive impairment fulfilling appropriate use criteria.

To evaluate the use of amyloid-positron emission tomography (PET) in routine clinical practice, in a selected population with cognitive impairment that meets appropriate use criteria (AUC).A multicenter, observational, prospective case-series study of 211patients from 2 level-3 hospitals who fulfilled clinical AUC for amyloid-PET scan in a naturalistic setting. Certainty degree was evaluated using a 5-point Likert scale: 0 (very low probability); 1 (low probability); 2 (intermediate probability); 3 (high probability); and 4 (practically sure), before and after amyloid PET. The treatment plan was considered as cognition-specific or noncognition-specific.Amyloid-PET was positive in 118 patients (55.9%) and negative in 93 patients (44.1%). Diagnostic prescan confidence according amyloid-PET results showed that in both, negative and positive-PET subgroup, the most frequent category was intermediate probability (45.7% and 55.1%, respectively). After the amyloid-PET, the diagnostic confidence showed a very different distribution, that was, in the negative-PET group the most frequent categories are very unlikely (70.7%) and unlikely (29.3%), while in the positive-PET group were very probable (57.6%) and practically sure (39%). Only in 14/211 patients (6.6%) the result of the amyloid-PET did not influence the diagnostic confidence, while in 194 patients (93.4%), the diagnostic confidence improved significantly after amyloid-PET results. The therapeutic intention was modified in 93 patients (44.1%). Specific treatment for Alzheimer disease was started, before amyloid-PET, in 80 patients (37.9%).This naturalistic study provides evidence that the implementation of amyloid-PET is associated with a significant improvement in diagnostic confidence and has a high impact on the therapeutic management of patients with mild cognitive impairment fulfilled clinical AUC.

Pan-Costochondritis Caused by Aspergillus Diagnosed by 18F-FDG PET/CT.

Thoracic pain is an entity that can be difficult to diagnose etiologically. Once the cardiac origin has been ruled out, the rheumatologic, neoplastic, and infectious causes have to be taken into account. We present the case of a patient with atypical chest pain after triple-bypass surgery in whom F-FDG PET/CT scan showed an important uptake of the radiopharmaceutical in costal cartilages, in relation to pan-costochondritis due to Aspergillus.

Usefulness of Dual-Point Amyloid PET Scans in Appropriate Use Criteria: A Multicenter Study.

BACKGROUND: Biomarkers of neurodegeneration play a major role in the diagnosis of Alzheimer's disease (AD). Information on both amyloid-ß accumulation, e.g., from amyloid positron emission tomography (PET), and downstream neuronal injury, e.g., from 18F-fluorodeoxyglucose (FDG) PET, would ideally be obtained in a single procedure. OBJECTIVE: On the basis that the parallelism between brain perfusion and glucose metabolism is well documented, the objective of this work is to evaluate whether brain perfusion estimated in a dual-point protocol of 18F-florbetaben (FBB) PET can be a surrogate of FDG PET in appropriate use criteria (AUC) for amyloid PET. METHODS: This study included 47 patients fulfilling international AUC for amyloid PET. FDG PET, early FBB (pFBB) PET (0-10 min post injection), and standard FBB (sFBB) PET (90-110 min post injection) scans were acquired. Results of clinical subjective reports and of quantitative region of interest (ROI)-based analyses were compared between procedures using statistical techniques such as Pearson's correlation coefficients and t-tests. RESULTS: pFBB and FDG visual reports on the 47 patients showed good agreement (k  >  0.74); ROI quantitative analysis indicated that both data modalities are highly correlated; and the t-test analysis does not reject the null hypothesis that data from pFBB and FDG examinations comes from independent random samples from normal distributions with equal means and variances. CONCLUSIONS: A good agreement was found between pFBB and FDG data as obtained by subjective visual and quantitative analyses. Dual-point FBB PET scans could offer complementary information (similar to that from FDG PET and FBB PET) in a single procedure, considering pFBB as a surrogate of FDG.

Using CT Data to Improve the Quantitative Analysis of 18F-FBB PET Neuroimages.

18F-FBB PET is a neuroimaging modality that is been increasingly used to assess brain amyloid deposits in potential patients with Alzheimer's disease (AD). In this work, we analyze the usefulness of these data to distinguish between AD and non-AD patients. A dataset with 18F-FBB PET brain images from 94 subjects diagnosed with AD and other disorders was evaluated by means of multiple analyses based on t-test, ANOVA, Fisher Discriminant Analysis and Support Vector Machine (SVM) classification. In addition, we propose to calculate amyloid standardized uptake values (SUVs) using only gray-matter voxels, which can be estimated using Computed Tomography (CT) images. This approach allows assessing potential brain amyloid deposits along with the gray matter loss and takes advantage of the structural information provided by most of the scanners used for PET examination, which allow simultaneous PET and CT data acquisition. The results obtained in this work suggest that SUVs calculated according to the proposed method allow AD and non-AD subjects to be more accurately differentiated than using SUVs calculated with standard approaches.

Bone marrow biopsy superiority over PET/CT in predicting progression-free survival in a homogeneously-treated cohort of diffuse large B-cell lymphoma.

Several studies have reported uneven results when evaluating the prognostic value of bone marrow biopsy (BMB) and PET/CT as part of the staging of diffuse large B-cell lymphoma (DLBCL). The heterogeneity of the inclusion criteria and not taking into account selection and collinearity biases in the analysis models might explain part of these discrepancies. To address this issue we have carried a retrospective multicenter study including 268 DLBCL patients with a BMB and a PET/CT available at diagnosis where we estimated both the prognosis impact and the diagnostic accuracy of each technique. Only patients treated with R-CHOP/21 as first line (n = 203) were included in the survival analysis. With a median follow-up of 25 months the estimated 3-year progression-free survival (PFS) and overall survival (OS) were 76.3% and 82.7% respectively. In a multivariate analysis designed to avoid a collinearity bias with IPI categories, BMB-BMI [bone marrow involvement](+) (HR: 3.6) and ECOG PS > 1 (HR: 2.9) were independently associated with a shorter PFS and three factors, age >60 years old (HR: 2.4), ECOG PS >1 (HR: 2.4), and abnormally elevated B2-microglobulin levels (HR: 2.2) were independently associated with a shorter OS. In our DLBCL cohort, treated with a uniform first-line chemotherapy regimen, BMI by BMB complemented performance status in predicting those patients with a higher risk for relapse or progression. In this cohort BMI by PET/CT could not independently predict a shorter PFS and/or OS.

The role of bone marrow biopsy and FDG-PET/CT in identifying bone marrow infiltration in the initial diagnosis of high grade non-Hodgkin B-cell lymphoma and Hodgkin lymphoma. Accuracy in a multicenter series of 372 patients.

Bone marrow infiltration (BMI), categorized as an extra-nodal site, affects stage and is associated with poor prognosis in newly diagnosed lymphoma patients. We have evaluated the accuracy of PET/CT and bone marrow biopsy (BMB) to assess BMI in 372 lymphoma patients [140 Hodgkin Lymphoma (HL) and 232 High Grade B-cell non-Hodgkin Lymphoma (HG B-NHL), among them 155 Diffuse Large B-Cell Lymphoma (DLCL)]. For HL cases, and taking into account PET/CT, sensitivity, negative predictive value (NPV) and accuracy were 96.7, 99.3, and 99.3% while those of BMB were 32.3, 83.8, and 85%, respectively. For HG B-NHL and considering PET/CT, sensitivity, NPV, and accuracy were 52.7, 81.7, and 84.1%, while those of BMB were 77.6, 90.2, and 90.7%, respectively. In the HG B-NHL group, 25 patients would have been under-staged without BMB. These results lead us to recommend PET/CT and the avoidance of BMB to assess BMI in HL. In the case of HG B-NHL, bone marrow status should be assessed firstly by means of PET/CT; only in either focal or diffuse PET/CT with low borderline SUV max values or in negative cases, should BMB be carried out afterwards. In the HG B-NHL setting and at the present moment, both techniques are complementary.

[Diabetic retinopathy and mortality in type 2 diabetic patients]. / Relación entre la presencia de retinopatía diabética y la mortalidad en pacientes con diabetes tipo 2.

BACKGROUND AND OBJECTIVE: This study was intended to assess the independent contribution of retinopathy to mortality in type 2 diabetic patients. PATIENTS AND METHOD: Prospective cohort study. Type 2 diabetic patients with available fundus were included. The clinical end-point was total mortality. The main independent variable was baseline presence of background or proliferative retinopathy. Cox regression models were adjusted for age, sex, duration of diabetes, classical risk factors and baseline presence of nephropathy and cardiovascular disease. RESULTS: 458 patients were included (181 male, 277 females), with a median follow-up of 8 years (inter-quartile range, 6.7-9). There were 125 patients (27.3%) with background retinopathy and 46 (10%) with proliferative retinopathy. Mortality incidence rates per 1,000 patients-year were 20/1,000 (non retinopathy), 36.8/1,000 (background retinopathy) and 45.9/1,000 (proliferative retinopathy) with p = 0.0021. In the multivariate analysis, background retinopathy (HR = 1.87; 95% CI, 1.1-3.1; p = 0.019) and proliferative retinopathy (HR = 2.6; 95% CI, 1.3-5.1; p = 0.0048) were independent predictors of mortality. Other independent predictors were age (HR [1 year] = 1.13; 95% CI, 1.1-1.17; p < 0.0001), total cholesterol (HR [1 mmol/l] = 0.76; 95% CI, 0.6-0.97; p = 0.026), baseline insulin treatment (HR = 1.9; 95% CI, 1,1-3.2; p = 0.017) and baseline proteinuria (HR = 4.1; 95% CI, 2-8.5; p = 0.0001). CONCLUSIONS: The presence of retinopathy increases the mortality risk in type 2 diabetic patients.

Relación entre la presencia de retinopatía diabética y la mortalidad en pacientes con diabetes tipo 2 / Diabetic retinopathy and mortality in type 2 diabetic patients

Fundamento y objetivo: Evaluar la contribución independiente de la retinopatía diabética a la mortalidad de los pacientes con diabetes tipo 2. Pacientes y método: Estudio de cohortes prospectivo. Se incluyó a los pacientes con diabetes tipo 2 y fondo de ojo visualizable. Como variable dependiente, se evaluó la mortalidad total. La variable independiente principal fue la presencia de retinopatía simple o proliferativa, con ajuste para edad, sexo, tiempo de evolución de la diabetes, factores de riesgo clásicos y presencia de otras complicaciones crónicas (nefropatía y macroangiopatía). Se realizaron curvas de supervivencia y regresión de Cox multivariable, con cálculo de cocientes de riesgo (CR). Resultados: Se incluyó a 458 pacientes (181 varones y 277 mujeres), con seguimiento mediano de 8 años (intervalo intercuartil, 6,7-9). Hubo 125 (27,3%) pacientes con retinopatía simple y 46 (10%) con proliferativa. Las tasas de incidencia de mortalidad fueron 20/1.000 pacientes-año (ausencia de retinopatía), 36,8/1.000 pacientes-año (retinopatía simple) y 45,9/1.000 pacientes-año (retinopatía proliferativa); p = 0,0021. En el análisis multivariable, la presencia de retinopatía simple (CR = 1,87; intervalo de confianza [IC] del 95%, 1,1-3,1; p = 0,019) y de retinopatía proliferativa (CR = 2,6; IC del 95%, 1,3-5,1; p = 0,0048) predijeron de modo independiente la mortalidad. Otros predictores independientes fueron la edad (CR [1 año] = 1,13; IC del 95%, 1,1-1,17; p < 0,0001), el colesterol total (CR [1 mmol/l] = 0,76; IC del 95%, 0,6-0,97; p = 0,026), el tratamiento con insulina (CR = 1,9; IC del 95%, 1,1-3,2; p = 0,017) y la proteinuria (CR = 4,1; IC del 95%, 2-8,5; p = 0,0001). Conclusiones: La presencia de retinopatía diabética se relaciona con un incremento de mortalidad en los pacientes con diabetes tipo 2

Background and objective: This study was intended to assess the independent contribution of retinopathy to mortality in type 2 diabetic patients. Patients and method: Prospective cohort study. Type 2 diabetic patients with available fundus were included. The clinical end-point was total mortality. The main independent variable was baseline presence of background or proliferative retinopathy. Cox regression models were adjusted for age, sex, duration of diabetes, classical risk factors and baseline presence of nephropathy and cardiovascular disease. Results: 458 patients were included (181 male, 277 females), with a median follow-up of 8 years (inter-cuartile range, 6.7-9). There were 125 patients (27.3%) with background retinopathy and 46 (10%) with proliferative retinopathy. Mortality incidence rates per 1,000 patients-year were 20/1,000 (non retinopathy), 36.8/1,000 (background retinopathy) and 45.9/1,000 (proliferative retinopathy) with p = 0.0021. In the multivariate analysis, background retinopathy (HR = 1.87; 95% CI, 1.1-3.1; p = 0.019) and proliferative retinopathy (HR = 2.6; 95% CI, 1.3-5.1; p = 0.0048) were independent predictors of mortality. Other independent predictors were age (HR [1 year] = 1.13; 95% CI, 1.1-1.17; p < 0.0001), total cholesterol (HR [1 mmol/l] = 0.76; 95% CI, 0.6-0.97; p = 0.026), baseline insulin treatment (HR = 1.9; 95% CI, 1,1-3.2; p = 0.017) and baseline proteinuria (HR = 4.1; 95% CI, 2-8.5; p = 0.0001). Conclusions: The presence of retinopathy increases the mortality risk in type 2 diabetic patients

Microalbuminuria presents the same vascular risk as overt CVD in type 2 diabetes.

OBJECTIVES: We attempted to assess whether microalbuminuria conferred the same cardiovascular risk as overt CVD in type 2 diabetic patients. MATERIAL AND METHODS: A prospective cohort study including 436 type 2 diabetic patients (64.8+/-9.2 years old) without proteinuria, with follow-up until any cardiovascular event occurred, was performed. Patients were classified into four groups: group 0, non baseline CVD and normoalbuminuria; group 1, non baseline CVD and microalbuminuria; group 2, baseline CVD and normoalbuminuria; group 3, baseline CVD and microalbuminuria. Cox's multivariate regression models were used to assess the risk ratio (RR) associated with each variable. RESULTS: The median follow-up time was 7.6 years. Incidence rates of cardiovascular events per 1000 patient-years increased from groups 0 to 3 (23.8, 63.4, 74.1, 85.6; p<0.0001). Multivariate RR for incident CVD in groups 1, 2 and 3 in relation to group 0 were 2.8 (95% confidence interval (CI) 1.7-4.6; p<0.0001), 2.7 (95% CI 1.6-4.6; p<0.0001) and 2.9 (95% CI 1.6-5.4; p=0.001), respectively. No significant differences were seen between groups 1 and 2. CONCLUSIONS: We suggest that patients with microalbuminuria are at very high vascular risk and should share the same objectives of a vascular risk-factor control as patients with overt CVD.