Salvage radiotherapy in prostate cancer patients. Planning, treatment response and prognosis using (11)C-choline PET/CT

OBJECTIVE

To assess the prognostic value of the therapeutic response by (11)C-choline PET/CT in prostate cancer patients with biochemical recurrence in which (11)C-choline PET/CT indicated radio-guided radiotherapy.

METHODS

The study included 37 patients initially treated with prostatectomy, who were treated due to biochemical recurrence. (11)C-choline PE/CT detected infra-diaphragmatic lymph-node involvement. All were selected for intensity modulated radiation therapy, escalating the dose according to the PET findings. One year after treatment patients underwent PSA and (11)C-choline PET/CT categorizing response (complete/partial/progression). Clinical/biochemical/image monitoring was performed until appearance of second relapse or 36 months in disease-free patients.

RESULTS

(11)C-choline PET/CT could detect lymph nodes in all 37 patients. They were 18 (48.6%) of more than a centimetre in size and 19 (51.3%) with no pathological CT morphology: 9 (24.3%) with positive lymph nodes of around one centimetre and 10 (27.0%) only less than a centimetre in size. The response by (11)C-choline PET/CT was categorised one year after radiotherapy: 16 patients (43.2%) complete response; 15 (40.5%) partial response, and 6 (16.2%) progression. The response was concordant between the PSA result and (11)C-choline PET/CT in 32 patients (86.5%), and discordant in five (13.5%). New recurrence was detected in 12 patients (80%) with partial response, and 5 (31.2%) with complete response. The mean time to recurrence was 9 months after partial response, and 18 months after complete response (significant difference, p<.0001).

CONCLUSION

(11)C-choline PET/CT allows the selection of patients with recurrent prostate cancer candidates for radiotherapy and to plan the technique. The evaluation of therapeutic response by (11)C-choline PET/CT has prognostic significance.

Diagnosis by (18)F-FDG PET/CT of infective endocarditis, staging and monitoring of antibiotic treatment after transposition of surgically corrected great arteries

Infective endocarditis is one of the leading causes of fever of unknown origin in those patients with intravascular catheters, prosthetic valves or cardiovascular implantable electronic devices. The diagnosis of infective endocarditis is made according to modified Duke criteria, which are based on blood culture and echocardiographic findings. Demonstration of vegetation with the transoesophageal echocardiography may be difficult in these cases with previous anatomical changes, especially in early phases. Positron emission tomography with (18)F-fluorodeoxyglucose ((18)F-FDG PET/CT) is well known to show an increased glucidic metabolism in malignant, inflammatory, and infectious processes. Thus, it provides useful functional imaging that enables the disease causing the fever of unknown origin to be detected well before structural changes are evident. Moreover, (18)F-FDG PET/CT helps to detect infectious extra-cardiac involvement, since the whole body is imaged with this technique. (18)F-FDG PET/CT may have an additional promising role for the monitoring of response to antimicrobial therapy in patients with established infective endocarditis, thus evaluating standard treatment outcome, as well as evaluating the need for alternative/intensified treatment options.

Assessment of medial coronoid disease in 180 canine lame elbow joints: a sensitivity and specificity comparison of radiographic, computed tomographic and arthroscopic findings

Background

Diagnostic imaging is essential to assess the lame patient; lesions of the elbow joint have traditionally been evaluated radiographically, however computed tomography (CT) has been suggested as a useful technique to diagnose various elbow pathologies. The primary objective of this study was to determine the sensitivity and specificity of CT to assess medial coronoid disease (MCD), using arthroscopy as gold standard. The secondary objective was to ascertain the radiographic sensitivity and specificity for MCD compared with CT.

Methods

For this study 180 elbow joints were assessed, of which 141 had been examined with radiography, CT and arthroscopy; and 39 joints, had radiographic and CT assessment. Sensitivity and specificity were calculated for CT and radiographic findings using available statistical software.

Results

Sensitivity and specificity of CT using arthroscopy as gold standard resulted in high values for sensitivity (100 %) and specificity (93 %) for the assessment of MCD. For the radiographic evaluation, a sensitivity of 98 % and specificity of 64 - 69 % using CT as the technique of reference, were found.

Discussion

These results suggest that in case of doubt during radiographic assessment, CT could be used as a non-invasive technique to assess the presence of MCD.

Conclusion

Based on the high sensitivity and specificity obtained in this study it has been considered that CT, rather than arthroscopy, is the preferred noninvasive technique to assess MCD lesions of the canine elbow joint.

11C-Choline PET/CT in the primary diagnosis of prostate cancer: impact on treatment planning

AIM

Aim of the present study was to evaluate the usefulness of 11C-choline PET/CT for detecting lymphatic or haematogenous spread and for planning radiotherapy in patients with medium-to-high risk prostate cancer.

METHODS

We have included 61 consecutive patients recently diagnosed with cancer prostate by biopsy. All patients were classified as medium-to-high risk: Gleason: 7-9; PSA: 6.3-30.4 ng/mL; stage T2c (N.=20) or stage T3 (N.=41). Image acquisition began 5 min after intravenous injection of 11C-choline (656+119 MBq), starting at the pelvis and continuing craniocaudally. Images were interpreted visually to evaluate uptake by the prostate gland. Lymph nodes with 11C-choline uptake were considered invaded, regardless of their size. Bone lesions were considered positive when they showed greater focal uptake than the surrounding bone. In patients with evidence of lymph-node invasion or bone metastases (15 patients), disease was classified as locoregional, oligometastatic, or multimetastatic.

RESULTS

All patients had prostate gland uptake (20 focal, 8 bifocal, and 33 multifocal). Extraprostatic disease was present in 15 patients (24.6%), as follows: 9 (60%) in a single location: in an infradiaphragmatic lymph node (N.=6), in a supradiaphragmatic lymph node (N.=1), and in bone (M1) (N.=2). Six (40%) as multifocal invasion: with both infra- and supradiaphragmatic lymph node involvement (N.=2); with infradiaphragmatic lymph node involvement and M1 bone metastases (N.=3); and infra- and supradiaphragmatic lymph node involvement plus M1 bone metastases (N.=1). Disease was classified as locoregional (N.=6), oligometastatic (N.=5), and multimetastatic (N.=4). The 11 (73.3%) patients with locoregional and oligometastatic disease were selected to undergo intensity-modulated radiation therapy with dose escalation based on the PET findings.

CONCLUSION

Our results suggest that 11C-choline PET/CT is a useful one-stop diagnostic procedure for evaluating patients with medium/high risk prostate cancer scheduled for radical treatment. 11C-choline PET/CT can reliably rule out lymph node involvement and remote metastases, allowing to select candidates for radiotherapy and to plan their treatment.

(11)C-choline PET/CT and multiparametric MRI in patients with biochemical relapse of prostate cancer

CLINIC PROBLEM AND CASE SERIES

To assess the diagnostic usefulness of (11)C-choline PET/CT vs. multi-parametric MRI in the prostate cancer relapse. A retrospective study of 21 patients with prostate cancer treated initially with surgery (n=12), radiotherapy (n=9). PSA levels were increased (post-surgery: .3-3.6 ng/ml; post-radiotherapy: 2.4-8.8 ng/ml). In an interval of time of 15 days all patients were underwent to: whole-body-dual-modality PET-CT carried out early after (11)C-choline (296 ± 29 MBq) injection, and multiparametric prostate MRI with paramagnetic intravenous contrast (using anatomical imaging sequences, diffusion-weighted imaging and dynamic contrast-enhanced imaging). On the basis of our results, all patients were underwent to directed diagnosis and/or clinical, analytic and imaging follow-up. In 15 patients (71.4%) both procedures showed concordant results: 4 negative and 11 positive cases [7 local recurrences, 3 isolated pelvic lymph nodes (2 infracentimetric), 1 local relapse and only one M1 bone metastases]. The results were discordant in 6 patients (28.6%): 3 local relapses in MRI with no PET significance, 1 local relapse in PET with no MRI significance. 2 bone metastases were identified with PET (out of the field-of-view of MRI).

COMMENT

(11)C-choline PET/CT and multi-parametric MRI play a complementary role in the detection of local relapse in prostate cancer patients, with similar sensitivity for the detection of lymph involvement. Whole-body 11C-choline PET/CT technique is also useful for bone staging.

[Diagnostic performance of bone scintigraphy and (11)C-Choline PET/CT in the detection of bone metastases in patients with biochemical recurrence of prostate cancer]

AIM

To compare bone scan (BS) with (11)C-Choline PET/CT for the detection of bone metastases in patients with biochemical recurrence of prostate cancer (PC).

MATERIAL AND METHODS

A total of 169 patients with biochemical recurrence of PC(PSA:2.4-58 ng/ml) who were referred for both exams (0-15 days-in-between) were included. Lesion-detection-rate per patients and lesions were analyzed for both BS and (11)C-Choline PET/CT. Metastasis diagnosis was reached by: biopsy, CT/(18)F-Fluoride PET/MRI confirmation, or evidence of progression in subsequent imaging procedures.

RESULTS

A total of 91 lesions were found to be active in BS and/or (11)C-choline PET/CT (40 patients), with 78 of which were metastatic. BS detected 38 blastic, 2 lytic and 10 non-CT-evident lesions. (11)C-Choline PET/CT detected 41 blastic, 4 lytic and 29 non-CT-evident lesions. BS and (11)C-Choline PET/CT sensitivities were 65.4% and 96.1%; specificities ere 38.5 and 92.3% (χ(2) 8.27, p<0.04). Both imaging techniques were negative in 118 patients. Tracer avid lesions were found in 51 patients: with 30/51 being BS and (11)C-Choline PET/CT concordant; in 21/51 patients had discordant lesions (kappa 0.712, p=0.00). Lesions were absolutely discordant in 10/19 patients,: 5 FN BS, 2 FP BS (degenerative changes; dysplasia), 1 FN (11)C-Choline PET/CT (blastic), 1 FP (11)C-Choline PET/CT (degenerative), 1 out of field-of-view lesion with (11)C-Choline PET/CT (tibia alone). (11)C-Choline PET/CT showed extraosseous involvement in 26/51 patients with bone metastases: 9 local recurrences, 5 infra-diaphragmatic-lymph-nodes, 2 supra-diaphragmatic, 5 local and infra-diaphragmatic, 4 infra- and supra-diaphragmatic, 1 supra-diaphragmatic and lung metastases.

CONCLUSION

(11)C-Choline PET/CT yielded better sensitivity and specificity than BS for the detection of bone involvement in patients with biochemical recurrence of PC and allowed extraosseous restaging, with an impact in the clinical management of these patients.

[Variability in the implementation of health-promoting community activities in Spain]

BACKGROUND

To describe the variability in the application of community activities (CA) promoting health, in support received, in training, and in evaluation of the participation of professionals, administration and social partners in these.

METHODS

Survey to key informants identified in each region with the help of the Spanish Society of Family and Community Medicine. The questionnaire included a definition of a health promotion community activity. The study was conducted in 2008.

RESULTS

There was variability in community activities by region. The most involved professionals are nurses and social workers. Most of the regions (15 of 17) offer training in these issues to their professionals, especially in health education. It is less frequent to offer training to family medicine residents (10 of 17 regions) and to the different nursing specialties (6 of 17). The main institutional support comes from primary health care management, regional health services, municipalities, and public health services, and non-institutional support from scientific societies, civic associations and NGOs. On the evaluation of the involvement of different organizations and institutions in these activities, the only entities receiving pass grades were NGOs (3 out of 5) and primary health care (2.5 out of 5).

CONCLUSIONS

There is a high variability in the ways of supporting and promoting community activities in each region and consequently in their dissemination and implementation by primary health care teams. Nurses and social workers are key players in this process.

Recognizing odd smells and ejection of brood parasitic eggs. An experimental test in magpies of a novel defensive trait against brood parasitism

One of the most important defensive host traits against brood parasitism is the detection and ejection of parasitic eggs from their nests. Here, we explore the possible role of olfaction in this defensive behaviour. We performed egg-recognition tests in magpie Pica pica nests with model eggs resembling those of parasitic great spotted cuckoos Clamator glandarius. In one of the experiment, experimental model eggs were exposed to strong or moderate smell of tobacco smoke, whereas those of a third group (control) were cleaned with disinfecting wipes and kept in boxes containing odourless cotton. Results showed that model eggs with strong tobacco scent were more frequently ejected compared with control ones. In another experiment, models were smeared with scents from cloacal wash from magpies (control), cloacal wash or uropygial secretions from cuckoos, or human scents. This experiment resulted in a statistically significant effect of treatment in unparasitized magpie nests in which control model eggs handled by humans were more often rejected. These results provide the first evidence that hosts of brood parasites use their olfactory ability to detect and eject foreign eggs from their nests. These findings may have important consequences for handling procedures of experimental eggs used in egg-recognition tests, in addition to our understanding of interactions between brood parasites and their hosts.

[Extension study and evaluation of the therapeutic response in a patient with metastatic lung adenocarcinoma using sequential study with ¹⁸F-FDG PET-CT and ¹⁸F-fluoride PET-CT]

We report a case of a patient with lung adenocarcinoma and bone and extraosseus metastases studied with (18)F-FDG PET-CT, (99m)Tc-HMDP and (18)F-fluoride PET-CT. It assesses the usefulness of (18)F-FDG PET-CT for initial staging of the disease and monitoring response to therapy. For the study of the sclerotic bone metastases it shows the superiority of 99mTc-HMDP bone scintigraphy and (18)F-fluoride PET-CT over (18)F-FDG PET-CT, and (18)F-fluoride PET-CT over bone scintigraphy. It also shows the usefulness of (18)F-fluoride PET-CT for monitoring the bone metastases.