Review of imaging techniques for evaluating morphological and functional responses to the treatment of bone metastases in prostate and breast cancer.

Bone metastases are very common complications associated with certain types of cancers that frequently negatively impact the quality of life and functional status of patients; thus, early detection is necessary for the implementation of immediate therapeutic measures to reduce the risk of skeletal complications and improve survival and quality of life. There is no consensus or universal standard approach for the detection of bone metastases in cancer patients based on imaging. Endorsed by the Spanish Society of Medical Oncology (SEOM), the Spanish Society of Medical Radiology (SERAM), and the Spanish Society of Nuclear Medicine and Molecular Imaging (SEMNIM) a group of experts met to discuss and provide an up-to-date review of our current understanding of the biological mechanisms through which tumors spread to the bone and describe the imaging methods available to diagnose bone metastasis and monitor their response to oncological treatment, focusing on patients with breast and prostate cancer. According to current available data, the use of next-generation imaging techniques, including whole-body diffusion-weighted MRI, PET/CT, and PET/MRI with novel radiopharmaceuticals, is recommended instead of the classical combination of CT and bone scan in detection, staging and response assessment of bone metastases from prostate and breast cancer.Clinical trial registration: Not applicable.

Contributions of nuclear medicine to malignant musculoskeletal tumor disease in children.

A diagnosis of cancer is frightening at any age, but especially when the patient is a child. Only what is suspected can be diagnosed, only what is known or at least known to exist is suspected, but musculoskeletal tumors are infrequent and therefore very difficult to diagnose or treat. Probably due to their infrequency, the complexity of the radiological images, histopathological appearance, as well as the serious consequences due to inadequate biopsies and treatments, musculoskeletal tumor pathology requires clinical management that must be carried out by a group of specialists with specific training, allowing an adequate diagnosis, introduction of adjuvant therapies, as well as surgical treatment, making multidisciplinary treatment essential today. Imaging studies provide essential information on the nature of each lesion, its size, its anatomical location, the effect on the surrounding bone or soft tissues and the involvement of adjacent joints and neurovascular structures. In this article the authors will discuss the advances in nuclear medicine techniques (scintigraphy, SPECT/CT and PET/CT) and their usefulness in the staging of pediatric malignant musculoskeletal tumors, as well as in the assessment of response, follow-up, and diagnosis of recurrence.

Contributions of nuclear medicine in paediatric non-tumour musculoskeletal pathology. / Aportaciones de la medicina nuclear en la enfermedad musculoesquelética no tumoral pediátrica.

Non-tumour musculoskeletal pathology in children represents a high percentage of the nuclear medicine studies requested by paediatricians. As these are immature bones and joints, in constant growth and remodelling, they present their own physiological and anatomical peculiarities that require a specific management for the paediatric age group. Using different clinical scenarios frequently observed in medical appointments (limping, back pain or fever, among others), we have summarised the possible findings or artefacts that can be obtained in the different Nuclear Medicine explorations, including bone scintigraphy and hybrid images such as PET/CT. To obtain high quality images requires careful attention to technique and positioning in children. Bone scintigraphy is a common paediatric nuclear medicine procedure and plays an important role in the diagnosis of musculoskeletal pathologies and can be complemented by techniques such as SPECT to improve localisation and diagnostic accuracy. In addition, 18F-FDG PET/CT is increasingly applied in the evaluation of children. This article reviews the usual indications of, mainly, bone scintigraphy and 18F-FDG PET/CT in paediatric non-tumour musculoskeletal diseases, how to interpret them properly, being essential to know the normal physiological distribution of each radiopharmaceutical, as well as the common variants of paediatric growth that can simulate disease, implying possible misinterpretations between normal and pathological structures.

Nuclear Medicine in the diagnosis of pathologies of the spine: role of hybrid imaging. / Medicina nuclear en el diagnóstico de las afecciones de la columna vertebral: papel de la imagen híbrida.

Clinical problems in the human spine are still common in our society, often causing pain and can also limit movement. Back pain is a very common clinical entity, although difficult to diagnose due to its multifactorial nature. There are multiple processes that can alter the structure of the spine, injure vertebrae and/or the surrounding tissue. For the study of the spine, image diagnosis is essential, and within this, molecular hybrid techniques play an important role by providing us with an image of functional and morphological fusion. Among these, SPECT/CT is key in the diagnosis of traumatic and stress pathology, allowing us to locate hidden vertebral fractures, and is also very useful in degenerative and post-surgical pathology. On the other hand, PET/CT with 18F-FDG also plays an important role in the management and monitoring of infectious and oncological processes. This review describes the application of these hybrid techniques in the different pathologies of the spine and the findings of their images, being very useful for the diagnostic assessment and therapeutic management of the patient.

[18F-FDG PET-CT in a case of solitary plasmacytoma of the soft palate]. / Tomografía por emisión de positrones con ¹8F-fluorodeoxy-glucosa en un caso de plasmocitoma solitario de paladar blando.

Solitary plasmacytoma is an uncommon tumor of plasma cells that can appear in the head and neck. It must be differentiated from multiple myeloma because of its initial presentation. A case of solitary plasmacytoma on the palate is presented. Furthermore, role of ¹8F-fluorodeoxyglucose Positron Emission Tomography (¹8F-FDG-PET) in its initial staging is analyzed.

[Quantitative evaluation of SPECT with FP-CIT. Importance of the reference area]. / Valoración cuantitativa del SPECT con FP-CIT. Importancia del área de referencia.

OBJECTIVE: The aim of this study is to compare several uptake indexes between specific and non-specific activity to determine the existence of degenerative Parkinsonism according to different reference areas. MATERIAL AND METHODS: A total of 46 patients (23 men and 23 women), randomly selected from individuals referred to our center with a movement disorder, were included in the study. Mean age was 70.2 ± 10.2 years (41-87). The uptake indexes were obtained through the areas of interest (ROIs) located in the striate (specific uptake) and other reference ROIs located in areas with different concentrations of serotonin receptors: low-cerebellum, medium-occipital cortex and high-midbrain. RESULTS: A high linear correlation was found between indexes having low and medium concentration of serotonin receptors. The ROC curve analysis shows an area under the curve of 0.874, 0.886 and 0.739 and regression coefficients of 5.41, 6.62 and 3.41, respectively for the striatum/cerebellum (E/C), striatum/occipital (E/O) and striatum midbrain (E/M) indexes. Optimal cutoff for E/O (1.35), index with the best behavior, provides a sensitivity of 0.84 and specificity of 0.89. CONCLUSION: The reference area selected may alter the predictive power of the different indexes to determine the existence of a degenerative Parkinsonism.

Role of Nuclear Medicine in the diagnosis of musculoskeletal infection: a review. / Revisión del papel de la Medicina Nuclear en el diagnóstico de la infección musculoesquelética.

Inflammatory and infectious osteoarticular diseases can cause serious consequences for the patient if they are not diagnosed on time. In the last decades, different modalities of nuclear medicine have allowed to study the physiopathology of these processes, and nowadays, they play an important role in diagnosis, characterization and monitoring of musculoskeletal infectious diseases. Therefore, it is essential that every nuclear medicine physician have a vision of the advantages and disadvantages of each method and know how to use them correctly in the diagnosis of the patient. This article highlights the role of nuclear medicine in standardizing the diagnostic approach in patients with infectious/inflammatory diseases, in particular in peripheral osteomyelitis, septic arthritis, prosthetic joint infections, infected diabetic foot and spinal infections. The authors reveal the role of the most common radionuclides tests, with their advantages and clinical indications, to achieve an adequate diagnosis of infection and inflammation.

Four years of clinical experience with Radium-223 for the treatment of castration-resistant prostate cancer. / Cuatro años de experiencia clínica con radio-223 para el tratamiento del cáncer de próstata resistente a la castración.

PURPOSE: Radium-223 is an alpha-emitting radiopharmaceutical that significantly prolongs overall survival in patients with castration-resistant prostate cancer and symptomatic bone metastases. We report a retrospective analysis of our clinical experience with Radium-223 in the first 68 patients treated. METHODS: The incidence of hematologic, gastrointestinal, and other adverse events was identified, including events that led to treatment discontinuation or delay. Alterations in bone pain and prostate-specific antigen and serum alkaline phosphatase levels were evaluated. Bone scan changes were identified and correlated with the clinical course. RESULTS: Sixty-eight patients were included in the study. The median number of radium-223 injections was 5 (range 1-6), with 69% of patients receiving 5 to 6 injections. The most common side effects were digestive alterations in 24 patients, anemia in 7 patients, and thrombocytopenia in 5 patients. Clear downward trends in serum alkaline phosphatase were seen, that were less clear in prostate-specific antigen. Mean serum alkaline phosphatase decreased from baseline in 77% of the patients, and prostate-specific antigen in less than 40%. The majority of patients (62) experienced an improvement in bone pain intensity or no increase in bone pain intensity. No prostate-specific antigen flare phenomenon was noted. CONCLUSIONS: Radium-223 was generally well tolerated and there were no safety concerns. The adverse events were mild and manageable. A decline in serum alkaline phosphatase was more common than a decline in prostate-specific antigen. Monitoring changes in serum alkaline phosphatase dynamics may be useful.

[Clinical impact of FDG-PET in patients with suspected recurrent ovarian cancer]. / Impacto clínico de la PET-FDG en pacientes con sospecha de recurrencia de cáncer de ovario.

AIM: To evaluate the efficacy and clinical impact of FDG-PET in patients with suspected recurrent ovarian cancer. METHODS: Between October 2001 and October 2006, we retrospectively studied 49 FDG-PET performed in 40 women (age: 52.4 +/- 12.2 years) with ovarian cancer, who had suspicion of recurrent disease by positive morphologic imaging tests (MIT) or increased tumour markers and negative MIT. All patients underwent whole body FDG-PET after the injection of 370-434 MBq of (18)FDG. The results were confirmed by histology in 31 cases, and by clinical-radiological follow-up in 18. RESULTS: Prevalence of disease was 79.6 %. We obtained a global sensitivity and positive predictive value of 87.2 % and 87.2 %, and an accuracy of 79.6 %. Results led to a change in the patient's management in 25 cases (51 %). Subgroup results were: Sensitivity of 81.8 % in patients with increased tumour markers and negative MIT, and 89.3 % in patients with operable malignant lesions. CONCLUSIONS: FDG-PET has high sensitivity and clinical impact in patients with suspicion of recurrent ovarian cancer. Better results were obtained in patients with increased tumour markers and negative MIT.

Review of imaging techniques for evaluating morphological and functional responses to the treatment of bone metastases in prostate and breast cancer

Bone metastases are very common complications associated with certain types of cancers that frequently negatively impact the quality of life and functional status of patients; thus, early detection is necessary for the implementation of immediate therapeutic measures to reduce the risk of skeletal complications and improve survival and quality of life. There is no consensus or universal standard approach for the detection of bone metastases in cancer patients based on imaging. Endorsed by the Spanish Society of Medical Oncology (SEOM), the Spanish Society of Medical Radiology (SERAM), and the Spanish Society of Nuclear Medicine and Molecular Imaging (SEMNIM) a group of experts met to discuss and provide an up-to-date review of our current understanding of the biological mechanisms through which tumors spread to the bone and describe the imaging methods available to diagnose bone metastasis and monitor their response to oncological treatment, focusing on patients with breast and prostate cancer. According to current available data, the use of next-generation imaging techniques, including whole-body diffusion-weighted MRI, PET/CT, and PET/MRI with novel radiopharmaceuticals, is recommended instead of the classical combination of CT and bone scan in detection, staging and response assessment of bone metastases from prostate and breast cancer.

Aportaciones de la medicina nuclear en la enfermedad musculoesquelética tumoral maligna en niños / Contributions of nuclear medicine to malignant musculoskeletal tumor disease in children

Un diagnóstico de cáncer es perturbador a cualquier edad, pero especialmente cuando el paciente es un niño. Solo se puede diagnosticar lo que se sospecha, solo se sospecha lo que se conoce o, al menos, se conoce su existencia, pero los tumores musculoesqueléticos son infrecuentes y, por tanto, muy difíciles de diagnosticar o tratar. Probablemente por su infrecuencia, por la complejidad de las imágenes radiológicas, por la apariencia histopatológica, así como por las serias consecuencias debido a biopsias y tratamientos inadecuados, la patología tumoral musculoesquelética necesita un manejo clínico que debe ser llevado a cabo por un grupo de especialistas con formación específica, que permita un adecuado diagnóstico, la introducción de terapias adyuvantes, así como un tratamiento quirúrgico, haciéndose hoy imprescindible un tratamiento multidisciplinar. Los estudios de imagen proporcionan información esencial sobre la naturaleza de cada lesión, su tamaño, su localización anatómica, el efecto sobre el hueso o los tejidos blandos circundantes y la afectación de las articulaciones adyacentes y las estructuras neurovasculares. En este artículo los autores analizan los avances de las técnicas de medicina nuclear (gammagrafías, PET/TC y SPECT/TC) y su utilidad en la estadificación de tumores musculoesqueléticos malignos pediátricos, así como en la valoración de la respuesta, el seguimiento y el diagnóstico de recidiva (AU)

A diagnosis of cancer is frightening at any age, but especially when the patient is a child. Only what is suspected can be diagnosed, only what is known or at least known to exist is suspected, but musculoskeletal tumors are infrequent and therefore very difficult to diagnose or treat. Probably due to their infrequency, the complexity of the radiological images, histopathological appearance, as well as the serious consequences due to inadequate biopsies and treatments, musculoskeletal tumor pathology requires clinical management that must be carried out by a group of specialists with specific training, allowing an adequate diagnosis, introduction of adjuvant therapies, as well as surgical treatment, making multidisciplinary treatment essential today. Imaging studies provide essential information on the nature of each lesion, its size, its anatomical location, the effect on the surrounding bone or soft tissues and the involvement of adjacent joints and neurovascular structures. In this article the authors will discuss the advances in nuclear medicine techniques (scintigraphy, SPECT/CT and PET/CT) and their usefulness in the staging of pediatric malignant musculoskeletal tumors, as well as in the assessment of response, follow-up, and diagnosis of recurrence (AU)

[Use of 18F FDG-PET in patients with suspicion of recurrent differentiated thyroid cancer by elevated antithyroglobulin antibodies levels and negative ¹³¹I scan]. / Uso de la PET-18F-FDG en pacientes con sospecha de recurrencia de cáncer diferenciado de tiroides por anticuerpos anti-tiroglobulina elevados y rastreo ¹³¹I negativo.

AIM: To evaluate the utility of (18F)FDG-PET for patients diagnosed of differentiated thyroid carcinoma who present risk of disease and invaluable levels of thyroglobulin (Tg) by the presence of antibodies antithyroglobulin (AbTg). MATERIAL AND METHODS: Retrospective study of 7 women of 40 years old and histological diagnosis of differentiated thyroid cancer (7 papillary tumours) that were sent to our department for the accomplishment of(18F)FDG-PET study because of suspicion of disease, due to ¹³¹I negative and high levels of AbTg, between the year 2002 and 2007. 11 PET scans were obtained after the intravenous injection of 370-434 MBq of (18F)FDG in normoglycemia conditions and previous administration of muscle relaxant, hydration and diuretic. The results of (18F)FDG-PET scans were confirmed by pathologic examination or clinical outcome and radiographic examination for more than 24 months. RESULTS: The prevalence of recurrence in our population was 57.14%. All patients presented levels of Tg lower than 3 ng/dl and AbTg superior to 200 UI/ml. Three patients had precedent thyroiditis. Out of 11 scans performed 3 of them were negative and 8 cases were found positive. It ruled out the existence of disease in three patients and localized the presence of recurrence in 4 patients. CONCLUSION: (18F)FDG-PET CONCLUSION: 18F-FDG-PET is a useful diagnostic tool for the detection of recurrence as well as to rule out the existence of disease with a high accuracy, in patients with differentiated thyroid carcinoma with ¹³¹I whole body scan negative but with pathological elevation of antithyroglobulin antibodies.

Revisión del papel de la Medicina Nuclear en el diagnóstico de la infección musculoesquelética / Role of Nuclear Medicine in the diagnosis of musculoskeletal infection: a review

Las enfermedades inflamatorias e infecciosas osteoarticulares pueden tener graves consecuencias para el paciente si no se diagnostican a tiempo. En las últimas décadas, diferentes modalidades de la Medicina Nuclear han permitido estudiar la fisiopatología de estos procesos y desempeñan un importante papel hoy en día en el diagnóstico, caracterización y monitorización de las enfermedades infecciosas musculoesqueléticas. Por lo tanto, es esencial que todos los especialistas de Medicina Nuclear tengan una visión de las ventajas y desventajas de cada método y saber cómo usarlos correctamente en el diagnóstico del paciente. Este artículo destaca el papel de la Medicina Nuclear en la estandarización del abordaje diagnóstico en pacientes con enfermedades infecciosas/inflamatorias, en particular en osteomielitis periférica, artritis séptica, infecciones de prótesis articulares, pie diabético infectado e infecciones de la columna vertebral. Los autores presentan las pruebas con radionúclidos más comunes, con sus ventajas e indicaciones clínicas, para lograr un diagnóstico adecuado de la infección y la inflamación

Inflammatory and infectious osteoarticular diseases can cause serious consequences for the patient if they are not diagnosed on time. In the last decades, different modalities of nuclear medicine have allowed to study the physiopathology of these processes, and nowadays, they play an important role in diagnosis, characterization and monitoring of musculoskeletal infectious diseases. Therefore, it is essential that every nuclear medicine physician have a vision of the advantages and disadvantages of each method and know how to use them correctly in the diagnosis of the patient. This article highlights the role of nuclear medicine in standardizing the diagnostic approach in patients with infectious/inflammatory diseases, in particular in peripheral osteomyelitis, septic arthritis, prosthetic joint infections, infected diabetic foot and spinal infections. The authors reveal the role of the most common radionuclides tests, with their advantages and clinical indications, to achieve an adequate diagnosis of infection and inflammation

Cuatro años de experiencia clínica con radio-223 para el tratamiento del cáncer de próstata resistente a la castración / Four years of clinical experience with Radium-223 for the treatment of castration-resistant prostate cancer

El dicloruro de radio-223 es un radiofármaco emisor alfa que prolonga la supervivencia global en pacientes con cáncer de próstata resistente a la castración y metástasis óseas sintomáticas. Presentamos un análisis retrospectivo de 68 pacientes tratados. MÉTODO: Se evaluó la incidencia de eventos adversos hematológicos, gastrointestinales y otros, incluidos aquellos que llevaron a la interrupción o el retraso del tratamiento. Se determinó la mejoría o empeoramiento del dolor óseo, los niveles de antígeno prostático específico y de fosfatasa alcalina sérica. Se valoró la gammagrafía ósea pre- y postratamiento y se correlacionó con la evolución clínica. RESULTADOS: Fueron incluidos 68 pacientes. La media del número de inyecciones de radio-223 fue de 5 (rango 1-6), el 69% de los pacientes recibieron 5 o 6 inyecciones. Los efectos secundarios más comunes fueron alteraciones digestivas en 24 pacientes, anemia en 7 y trombocitopenia en 5. Se observaron claras tendencias a la baja en la fosfatasa alcalina sérica. La fosfatasa alcalina sérica media disminuyó desde el inicio en el 77% de los pacientes y el antígeno prostático específico en menos del 40%. La mayoría de los pacientes (62) experimentaron una mejoría en la intensidad o estabilidad del dolor. No se observó ningún fenómeno de llamarada de antígeno prostático específico. CONCLUSIONES: El radio-223 fue generalmente bien tolerado y no hubo problemas de seguridad. Los eventos adversos fueron leves y manejables. Fue más común una disminución en la fosfatasa alcalina sérica que del antígeno prostático específico. La monitorización de la dinámica de la fosfatasa alcalina sérica puede ser útil

PURPUSE: Radium-223 is an alpha-emitting radiopharmaceutical that significantly prolongs overall survival in patients with castration-resistant prostate cancer and symptomatic bone metastases. We report a retrospective analysis of our clinical experience with Radium-223 in the first 68 patients treated. METHODS: The incidence of hematologic, gastrointestinal, and other adverse events was identified, including events that led to treatment discontinuation or delay. Alterations in bone pain and prostate-specific antigen and serum alkaline phosphatase levels were evaluated. Bone scan changes were identified and correlated with the clinical course. RESULTS: Sixty-eight patients were included in the study. The median number of radium-223 injections was 5 (range 1-6), with 69% of patients receiving 5 to 6 injections. The most common side effects were digestive alterations in 24 patients, anemia in 7 patients, and thrombocytopenia in 5 patients. Clear downward trends in serum alkaline phosphatase were seen, that were less clear in prostate-specific antigen. Mean serum alkaline phosphatase decreased from baseline in 77% of the patients, and prostate-specific antigen in less than 40%. The majority of patients (62) experienced an improvement in bone pain intensity or no increase in bone pain intensity. No prostate-specific antigen flare phenomenon was noted. CONCLUSIONS: Radium-223 was generally well tolerated and there were no safety concerns. The adverse events were mild and manageable. A decline in serum alkaline phosphatase was more common than a decline in prostate-specific antigen. Monitoring changes in serum alkaline phosphatase dynamics may be useful