Correlations between maximum standardized uptake value measured via 18F-fluorodeoxyglucose positron emission tomography/computed tomography and clinical variables and biochemical indicators in adult lymphoma

Objectives

The aim of the current study was to investigate whether the maximum standardized uptake value (SUVmax) measured by ¹⁸F-fluorodeoxyglucose (¹⁸F-FDG) positron emission tomography (PET)/computed tomography (CT) could discriminate between aggressive and indolent non-Hodgkin lymphomas (NHLs) and correlations between the SUVmax and clinical variables and serum biochemical indicators in adult lymphoma.

Methods

A total of 103 patients with lymphoma confirmed by biopsy, pretreatment ¹⁸F-FDG PET/CT scans, and a complete medical record were retrospectively enrolled in the study. Clinical variables that were evaluated included stage, pathological subtype, International Prognostic Index (IPI) score, and Ki-67 index, as well as serum biochemical indicators (e.g., lactate dehydrogenase [LDH] and erythrocyte sedimentation rate [ESR]) and metabolic parameters (e.g., SUVmax of the biopsy site on PET/CT). Correlations between SUVmax and clinical variables and serum biochemical indicators were investigated.

Results

Of the 103 patients, 84 had NHL and 19 had Hodgkin lymphoma. The area under the receiver operating characteristic curve for examining the accuracy of SUVmax with regard to distinguishing between aggressive and indolent NHLs was 0.94 (95% confidence interval: 0.89-0.99), suggesting that SUVmax was a useful predictor of diagnosis. A cutoff value of 8.5 yielded a sensitivity of 76.3% and specificity of 92.0%. The SUVmax mean ± standard deviation of NHL (9.8 ± 6.0, range: 1.8-28.1) was higher than that of HL (7.5 ± 2.8, range: 3.5-13.9) (P = 0.016), but there was no statistically significant difference in SUVmax between NHL and HL (P > 0.05). SUVmax of the biopsy site was strongly positively correlated with Ki-67 index (r = 0.813, P < 0.001) and moderately positively correlated with IPI score (r = 0.332, P = 0.002), but it was not significantly correlated with clinical stage, LDH, or ESR (P > 0.05).

Conclusions

¹⁸F-FDG PET/CT may yield reliable measurements of tumor proliferation, and an SUVmax >8.5 may distinguish between aggressive and indolent NHLs. In adults with newly diagnosed lymphoma, SUVmax correlates with Ki-67 index and IPI score.

Positron Emission Tomography (PET) Radiopharmaceuticals in Multiple Myeloma

Multiple myeloma (MM) is a plasma cell disorder, characterized by clonal proliferation of malignant plasma cells in the bone marrow. Bone disease is the most frequent feature and an end-organ defining indicator of MM. In this context, imaging plays a pivotal role in the management of the malignancy. For several decades whole-body X-ray survey (WBXR) has been applied for the diagnosis and staging of bone disease in MM. However, the serious drawbacks of WBXR have led to its gradual replacement from novel imaging modalities, such as computed tomography (CT), magnetic resonance imaging (MRI) and positron emission tomography/computed tomography (PET/CT). PET/CT, with the tracer ¹⁸F-fluorodeoxyglucose (¹⁸F-FDG), is now considered a powerful diagnostic tool for the detection of medullary and extramedullary disease at the time of diagnosis, a reliable predictor of survival as well as the most robust modality for treatment response evaluation in MM. On the other hand, ¹⁸F-FDG carries its own limitations as a radiopharmaceutical, including a rather poor sensitivity for the detection of diffuse bone marrow infiltration, a relatively low specificity, and the lack of widely applied, established criteria for image interpretation. This has led to the development of several alternative PET tracers, some of which with promising results regarding MM detection. The aim of this review article is to outline the major applications of PET/CT with different radiopharmaceuticals in the clinical practice of MM.

Metastatic large cell neuroendocrine carcinoma of larynx: Individualizing tumor biology by dual tracer positron emission tomography/computed tomography (68Ga-DOTATATE and 18F-fluorodeoxyglucose) molecular imaging and disease stabilization following 177Lu-DOTATATE peptide receptor radionuclide therapy after initial progression on chemoradiotherapy

Debate exists on the disease biology and course of primary large cell neuroendocrine carcinoma (LCNEC) of larynx, being classified as a variant of atypical carcinoid by the World Health Organisation-2005 classification, while literature of its aggressive behavior indicating poorly differentiated neuroendocrine carcinoma (akin to pulmonary LCNEC) exists. The utility of dual tracer positron emission tomography/computed tomography (⁶⁸Ga-DOTATATE and ¹⁸F-fluorodeoxyglucose) in deciphering the dynamic tumor biology and feasibility of peptide receptor radionuclide therapy (PRRT) is illustrated in metastatic LCNEC of epiglottis after disease progression following conventional chemoradiotherapy. Relatively, atypical sites of soft-tissue metastases (subcutaneous tissue of arm, scrotal sac, peritoneum, and lamina of thyroid cartilage) and xiphisternum and disease stabilization following ¹⁷⁷Lu-DOTATATE PRRT were other noteworthy unique aspects of this report.

Molecular imaging of carotid artery atherosclerosis with PET: a systematic review

PURPOSE

To conduct a systematic review of articles on PET imaging of carotid atherosclerosis with emphasis on clinical usefulness and comparison with other imaging modalities.

METHODS

Research articles reporting carotid artery PET imaging with different radiotracers until 30 November 2018 were systematically searched for in Medline/PubMed, Scopus, Embase, Google Scholar, and Cochrane Library. Duplicates were removed, and editorials, case studies, and investigations on feasibility or reproducibility of PET imaging and of patients with end-stage diseases or immunosuppressive medications were omitted. After quality assessment of included articles using Joanna Briggs Institute checklists, all eligible articles were reviewed.

RESULTS

Of 1718 primary hits, 53 studies comprising 4472 patients, aged 47-91 years (78.8% males), were included and grouped under the following headlines: diagnostic performance, risk factors, laboratory findings, imaging modalities, and treatment. ¹⁸F-fluorodeoxyglucose (FDG) (49/53) and ¹⁸F-sodium fluoride (NaF) (5/53) were the most utilized tracers to visualize carotid wall inflammation and microcalcification, respectively. Higher carotid FDG uptake was demonstrated in patients with than without symptomatic carotid atherosclerosis. Normal carotid arteries presented with the lowest FDG uptake. In symptomatic atherosclerosis, carotid arteries ipsilateral to a cerebrovascular event had higher FDG uptake than the contralateral carotid artery. FDG uptake was significantly associated with age, male gender, and body mass index in healthy individuals, and in addition with arterial hypertension, hypercholesterolemia, and diabetes mellitus in patients. Histological assessment indicated a strong correlation between microcalcification and NaF uptake in symptomatic patients. Histological evidence of calcification correlated inversely with FDG uptake, which was associated with increased macrophage and CD68 count, both accounting for increased local inflammatory response.

CONCLUSION

FDG-PET visualizes the inflammatory part of carotid atherosclerosis enabling risk stratification to a certain degree, whereas NaF-PET seems to indicate long-term consequences of ongoing inflammation by demonstrating microcalcification allowing discrimination of atherosclerotic from normal arteries and suggesting clinically significant carotid atherosclerosis.

Association of metabolic and genetic heterogeneity in head and neck squamous cell carcinoma with prognostic implications: integration of FDG PET and genomic analysis

Purpose

The linkage between the genetic and phenotypic heterogeneity of the tumor has not been thoroughly evaluated. Herein, we investigated how the genetic and metabolic heterogeneity features of the tumor are associated with each other in head and neck squamous cell carcinoma (HNSC). We further assessed the prognostic significance of those features.

Methods

The mutant-allele tumor heterogeneity (MATH) score (n = 508), a genetic heterogeneity feature, and tumor glycolysis feature (GlycoS) (n = 503) were obtained from the HNSC dataset in the cancer genome atlas (TCGA). We identified matching patients (n = 33) who underwent 18F-fluorodeoxyglucose positron emission tomography (FDG PET) from the cancer imaging archive (TCIA) and obtained the following information from the primary tumor: metabolic, metabolic-volumetric, and metabolic heterogeneity features. The association between the genetic and metabolic features and their prognostic values were assessed.

Results

Tumor metabolic heterogeneity and metabolic-volumetric features showed a mild degree of association with MATH (n = 25, ρ = 0.4~0.5, P < 0.05 for all features). The patients with higher FDG PET features and MATH died sooner. Combination of MATH and tumor metabolic heterogeneity features showed a better stratification of prognosis than MATH. Also, higher MATH and GlycoS were associated with significantly worse overall survival (n = 499, P = 0.002 and 0.0001 for MATH and GlycoS, respectively). Furthermore, both MATH and GlycoS independently predicted overall survival after adjusting for clinicopathologic features and the other (P = 0.015 and 0.006, respectively).

Conclusion

Both tumor metabolic heterogeneity and metabolic-volumetric features assessed by FDG PET showed a mild degree of association with genetic heterogeneity in HNSC. Both metabolic and genetic heterogeneity features were predictive of survival and there was an additive prognostic value when the metabolic and genetic heterogeneity features were combined. Also, MATH and GlycoS were independent prognostic factors in HNSC; they can be used for precise prognostication once validated.

The effect of different segmentation methods on primary tumour metabolic volume assessed in 18F-FDG-PET/CT in patients with cervical cancer, for radiotherapy planning

Introduction

Gynaecological cancers, including cervical cancer, often require a multidisciplinary approach that includes external beam radiotherapy, chemotherapy, and/or surgical treatment. Biological parameters of the tumour evaluated in ¹⁸F-FDG-PET/CT are used for target volume delineation in radiotherapy planning. The choice of segmentation method may affect the assessment of metabolic tumour volume (MTV) in ¹⁸F-FDG-PET/CT.

Aim of the study

To find the optimal segmentation method for the assessment of primary MTV in ¹⁸F-FDG-PET/CT in cervical cancer patients for radiotherapy planning.

Material and methods

Retrospective analysis was performed on a group of 30 patients with newly diagnosed, histologically confirmed cervical cancer. The primary MTVs were assessed by SUV_max and SUV_mean values; three segmentation methods were used to assess the primary MTV: constant threshold of SUV_max of 2.5, threshold of SUV_max 35%, and threshold of SUV _max 45%. The MTVs were compared with the tumour volumes obtained in magnetic resonance imaging (MRI), which was the "gold standard", to select the best optimal segmentation method reflecting the tumour size. Wilcoxon-Mann-Whitney and t-test were used for statistical analysis.

Results

Depending on the segmentation method chosen, significant differences in the MTVs were obtained (p < 0.001). The highest volumes were obtained using the method based on constant SUV_max of 2.5, while the smallest in case of threshold of SUV_max of 45%. Regarding the volume determined by MRI, a 35% SUV_max threshold was chosen as the most reliable method.

Conclusions

The choice of appropriate segmentation method has a significant impact on the primary MTV assessment in ¹⁸F-FDG-PET/CT in patients with cervical cancer.

Local and Global Changes in Brain Metabolism during Deep Brain Stimulation for Obsessive-Compulsive Disorder

Recent approaches have suggested that deep brain stimulation (DBS) for obsessive-compulsive disorder relies on distributed networks rather than local brain modulation. However, there is insufficient data on how DBS affects brain metabolism both locally and globally. We enrolled three patients with treatment-refractory obsessive-compulsive disorder with ongoing DBS of the bilateral ventral capsule/ventral striatum. Patients underwent resting-state ¹⁸F-fluorodeoxyglucose and positron emission tomography in both stimulation ON and OFF conditions. All subjects showed relative hypometabolism in prefronto-basal ganglia-thalamic networks compared to a healthy control cohort when stimulation was switched OFF. Switching the stimulation ON resulted in differential changes in brain metabolism. Locally, volumes of activated tissue at stimulation sites (n = 6) showed a significant increase in metabolism during DBS ON compared to DBS OFF (Mean difference 4.5% ± SD 2.8; p = 0.012). Globally, differential changes were observed across patients encompassing prefrontal increase in metabolism in ON vs. OFF condition. Bearing in mind limitations of the small sample size, we conclude that DBS of the ventral capsule/ventral striatum for obsessive-compulsive disorder increases brain metabolism locally. Across distributed global networks, DBS appears to exert differential effects, possibly depending on localization of stimulation sites and response to the intervention.

Assessment of biological parameters in head and neck cancer based on in vivo distribution of 18F-FDG-FLT-FMISO-PET/CT images

OBJECTIVE

Several genetic analyses have identified tumor diversity not only among tumors from different patients (intertumor heterogeneity) but also within individual tumors (intratumor heterogeneity). The aim of this study was to analyze the intratumor heterogeneity and other biological parameters based on in vivo distribution in triple-tracer positron emission tomography with computed tomography (PET/CT) study in patients with newly diagnosed head and neck (H&N) cancer.

METHODS

Thirty-six patients with newly diagnosed H&N cancer were included in the study. Institutional Bioethical Committee approved the study protocol and informed consent was received from every participant. All patients underwent series of 3 PET/CT scans with [¹⁸F]Fluorodeoxyglucose (¹⁸F-FDG-PET), [¹⁸F]Fluorothymidine (¹⁸F-FLT-PET), and [¹⁸F]Fluoromisonidazole (¹⁸F-FMISO-PET) before treatment. Scans were performed on separate days, within a timeframe of 2 weeks. Several PET/CT parameters grading tumor biology including maximum standardized uptake value (SUV_max), total lesion glycolysis (TLG), its equivalent (total hypoxic lesion [TLH] and total proliferative lesion [TLP]), and heterogeneity (area under the curve-cumulative SUV histogram) for the primary tumor were compared.

RESULTS

All patients showed increased uptake of ¹⁸F-FDG in primary tumor, ranging from 2.29 to 14.89 SUV_max. Respectively, SUV_max values for ¹⁸F-FLT ranged from 0.93 to 16.11 and for ¹⁸F-FMISO 0.36-4.07. Based on 3-year follow-up, we divided patients in terms of survival forecasts (first with good prognosis and second with worse). Higher values of TLG/TLP/TLH and SUV_max were observed in the second group in all 3 tracers (for ¹⁸F-FDG: 167.40 vs 100.32, 11.15 vs 8.95; for ¹⁸F-FLT: 116.61 vs 60.67, 7.09 vs 5.47; for ¹⁸F-FMISO: 37.34 vs 22.30, 1.70 vs 1.61 respectively). Statistically significant differences were shown in SUV_max in ¹⁸F-FDG and ¹⁸F-FLT (P<0.034, P<0.034, respectively; in TLG, P=0.05; TLP, P=0.04; and TLH, P=0.05).

CONCLUSION

Our preliminary results suggest worse prognosis in patients with higher heterogeneity values of primary tumor in proliferation and hypoxia images and combination of metabolic and volumetric parameters in TLG and its equivalent and heterogeneity of primary tumor seems to be a prognostic factor.

Usefulness of positron emission tomography for differentiating gliomas according to the 2016 World Health Organization classification of tumors of the central nervous system

OBJECTIVE

Positron emission tomography (PET) is important in the noninvasive diagnostic imaging of gliomas. There are many PET studies on glioma diagnosis based on the 2007 WHO classification; however, there are no studies on glioma diagnosis using the new classification (the 2016 WHO classification). Here, the authors investigated the relationship between uptake of 11C-methionine (MET), 11C-choline (CHO), and 18F-fluorodeoxyglucose (FDG) on PET imaging and isocitrate dehydrogenase (IDH) status (wild-type [IDH-wt] or mutant [IDH-mut]) in astrocytic and oligodendroglial tumors according to the 2016 WHO classification.

METHODS

In total, 105 patients with newly diagnosed cerebral gliomas (6 diffuse astrocytomas [DAs] with IDH-wt, 6 DAs with IDH-mut, 7 anaplastic astrocytomas [AAs] with IDH-wt, 24 AAs with IDH-mut, 26 glioblastomas [GBMs] with IDH-wt, 5 GBMs with IDH-mut, 19 oligodendrogliomas [ODs], and 12 anaplastic oligodendrogliomas [AOs]) were included. All OD and AO patients had both IDH-mut and 1p/19q codeletion. The maximum standardized uptake value (SUV) of the tumor/mean SUV of normal cortex (T/N) ratios for MET, CHO, and FDG were calculated, and the mean T/N ratios of DA, AA, and GBM with IDH-wt and IDH-mut were compared. The diagnostic accuracy for distinguishing gliomas with IDH-wt from those with IDH-mut was assessed using receiver operating characteristic (ROC) curve analysis of the mean T/N ratios for the 3 PET tracers.

RESULTS

There were significant differences in the mean T/N ratios for all 3 PET tracers between the IDH-wt and IDH-mut groups of all histological classifications (p < 0.001). Among the 27 gliomas with mean T/N ratios higher than the cutoff values for all 3 PET tracers, 23 (85.2%) were classified into the IDH-wt group using ROC analysis. In DA, there were no significant differences in the T/N ratios for MET, CHO, and FDG between the IDH-wt and IDH-mut groups. In AA, the mean T/N ratios of all 3 PET tracers in the IDH-wt group were significantly higher than those in the IDH-mut group (p < 0.01). In GBM, the mean T/N ratio in the IDH-wt group was significantly higher than that in the IDH-mut group for both MET (p = 0.034) and CHO (p = 0.01). However, there was no significant difference in the ratio for FDG.

CONCLUSIONS

PET imaging using MET, CHO, and FDG was suggested to be informative for preoperatively differentiating gliomas according to the 2016 WHO classification, particularly for differentiating IDH-wt and IDH-mut tumors.

Clinical significance of quantitative assessment of right ventricular glucose metabolism in patients with heart failure with reduced ejection fraction

PURPOSE

Dynamic ¹⁸F-fluorodeoxyglucose (FDG) PET can be used to quantitatively assess the rate of myocardial glucose uptake (MRGlu). The aim of this study was to evaluate the clinical significance and prognostic value of right ventricular (RV) MRGlu in patients with coronary artery disease and heart failure with reduced ejection fraction.

METHODS

Patients with left ventricular ejection fraction (LVEF) ≤ 40% were consecutively enrolled for FDG PET between November 2012 and May 2017. Global LV and RV MRGlu (μmol/min/100 g) were analyzed. Outcome events were independently assessed using electronic medical records to determine hospitalization for revascularization, new-onset ischemic events, heart failure, cardiovascular, and all-cause death. Differences between LV and RV MRGlu and associations with clinical characteristics and echocardiographic data were evaluated. Associations among FDG PET findings and outcomes were analyzed using Kaplan-Meier survival analysis.

RESULTS

Seventy-five patients (mean age 62.2 ± 12.7 years, male 85.3%, LVEF 19.3 ± 8.6%) were included for analysis. The mean glucose utilization ratio of RV-to-LV (RV/LV MRGlu) was 89.5 ± 264.9% (r = 0.77, p < 0.001). Positive correlations between RV MRGlu and maximal tricuspid regurgitation peak gradient (r = 0.28, p = 0.033) and peak tricuspid regurgitation jet velocity (r = 0.29, p = 0.021) were noted. LVEF was positively correlated with LV MRGlu (r = 0.27, p = 0.018), but negatively correlated with end-diastolic volume (r = - 0.37, p = 0.001), end-systolic volume (r = - 0.54, p < 0.001), and RV/LV MRGlu (r = - 0.40, p < 0.001). However, RV MRGlu was not well correlated with LVEF. Forty-three patients received revascularization procedures after FDG PET, and 13 patients died in a mean follow-up period of 496 ± 453 days (1-1788 days), including nine cardiovascular deaths. Higher RV and LV MRGlu values, LVEF ≤ 16% and LV end-diastolic volume ≥ 209 ml of gated-PET were associated with poor overall survival and cardiac outcomes.

CONCLUSIONS

In patients with coronary artery disease and ischemic cardiomyopathy, RV glucose utilization was positively correlated with RV pressure overload, but not LVEF. Global LV and RV MRGlu, LVEF, and LV end-diastolic volume showed significant prognostic value.

Tumefactive Demyelination versus Primary Central Nervous System Lymphoma on 18F-Fluorodeoxyglucose Positron Emission Tomography Magnetic Resonance Imaging: A Twist in the Tale

Demyelinating lesions of the central nervous system (CNS) are classically known to be hypometabolic on ¹⁸F-Flurodeoxyglucose Positron Emission Tomography (¹⁸F-FDG PET). However, demyelinating lesions may show increased tracer uptake on ¹⁸F-FDG PET and can radiologically mimic neoplasm. Delayed tracer uptake on FDG PET is one of the diagnostic hallmarks of primary CNS lymphoma (PCNSL). Here, we present two cases in which the brain lesions showed increased FDG uptake on delayed integrated PET Magnetic Resonance Imaging (MRI), which were pathologically proven as CNS demyelination. Such demyelinating lesions may also act as "sentinel lesions" and potential harbinger of PCNSL on follow-up.

Predictive Value of Interim and End-of-Therapy 18F-FDG PET/CT in Patients with Follicular Lymphoma

Purpose

¹⁸F-fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) is the standard imaging modality for response evaluation in FDG-avid lymphoma, but the prognostic value is not established in follicular lymphoma (FL). This study investigated the prognostic value of Deauville 5-point scale (D5PS) from paired interim PET/CT (PET_Interim) and end-of-induction therapy PET/CT (PET_EOI) in patients with FL.

Methods

FL staging and response assessment PET/CT images from 2013 to 2015 were retrospectively reviewed. PET_Interim was performed 3 or 4 cycles after chemotherapy and PET_EOI after 6 or 8 cycles. D5PS scores of 1, 2, and 3 were considered as negative (-), and scores 4 and 5 were considered as positive (+). Statistical analysis was done using Cox regression analysis, Kaplan-Meier survival analysis, and the log-rank test.

Results

Thirty-three patients with set of baseline, interim, and end-of-induction therapy PET/CT studies were included. Ten patients (30.3%) had progression. The median progression-free survival (PFS) was 38.8 months (range 3.5-72.7 months). On PET_Interim, 23 patients were negative and 10 were positive. On PET_EOI scans, 29 patients were negative, and 4 were positive. On multivariate analysis, PET_EOI(-) was associated with longer PFS. PET_Interim(+) and PET_EOI(+) patients had a significantly shorter PFS than PET_Interim(-) patients (39.9 months, 95% confidence interval [CI] 23.0-56.9, versus 55.5 months, 95% CI 49.7-61.2, p = 0.005) and PET_EOI(-) patients (14.2 months, 95% CI 8.5-19.8, versus 60.5 months, 95% CI 52.1-69.0, p < 0.001).

Conclusion

For patients with FL, PET_Interim and PET_EOI response is predictive of PFS, and PET_EOI(+) is an independent prognostic factor for progression of FL.

Diagnostic value of surveillance 18F-fluorodeoxyglucose PET/CT for detecting recurrent esophageal carcinoma after curative treatment

PURPOSE

Esophageal carcinoma recurs within two years in approximately half of patients who receive curative treatment and is associated with poor survival. While ¹⁸F-fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) is a reliable method of detecting recurrent esophageal carcinoma, in most previous studies FDG PET/CT scans were performed when recurrence was suspected. The aim of this study was to evaluate FDG PET/CT as a surveillance modality to detect recurrence of esophageal carcinoma after curative treatment where clinical indications of recurrent disease are absent.

METHODS

A total of 782 consecutive FDG PET/CT studies from 375 patients with esophageal carcinoma after definitive treatment were reviewed. Abnormal lesions suggestive of recurrence on PET/CT scans were then evaluated. Recurrence was determined by pathologic confirmation or other clinical evidence within two months of the scan. If no clinical evidence for recurrence was found at least 6 months after the scan, the case was considered a true negative for recurrence.

RESULTS

The diagnostic sensitivity and specificity of PET/CT for detecting recurrent esophageal carcinomas were 100% (64/64) and 94.0% (675/718), respectively. There were no significant differences in the diagnostic performance of PET/CT for detecting recurrence according to initial stage or time between PET/CT and curative treatments. Unexpected second primary cancers were detected by FDG PET/CT in seven patients.

CONCLUSIONS

Surveillance FDG PET/CT is a useful imaging tool for detection of early recurrence or clinically unsuspected early second primary cancer in patients with curatively treated esophageal carcinoma but without clinical suspicion of recurrence.

Subclinical Lesions of the Primary Clinical Target Volume Margin in Esophageal Squamous Cell Carcinoma and Association With FDG PET/CT

Background and Objectives: An accurate delineation of the primary clinical target volume (CTVp) in esophageal squamous cell carcinoma (ESCC) significantly affects the outcomes of radiotherapy. However, when basing the CTVp on the primary gross tumor volume, there are no consistent guidelines for the size of the margin. We compared preoperative ¹⁸F-fluorodeoxyglucose (FDG) PET/CT images and large slices of resected pathological ESCC specimens for evidence and prediction of subclinical lesions. We also investigated associations between the maximum standardized uptake value (SUVmax), metabolic tumor volumes (MTVs), and lesions to improve estimates of the CTVp.

Methods:55 patients underwent FDG PET/CT before surgery, and the SUVmax and MTVs were determined. To ensure that the in situ distances between the primary and secondary tumors were preserved, the esophageal specimens collected during radical surgery were processed to minimize shrinkage, and subclinical lesions were characterized by pathological examination. A 2-dimensional logistic regression model was used to assess the associations between clinicopathological features and microscopic spread of the lesions.

Results: Subclinical lesions in pathological specimens were characterized as direct invasion, multicentric occurrence lesions, intra-mural metastasis, vascular invasion, and perineural invasion in 56.4, 40.0, 30.9, 21.8, and 18.2% of patients, respectively. The mean distances of the subclinical lesions from the primary tumor were 0.79 ± 1.28 cm and 0.87 ± 1.00 cm in the cranial and caudal directions, respectively. Together the SUVmax and MTV values could predict the presence of subclinical lesions that were not detectable in PET/CT images.

Conclusions: To cover 94.5% of ESCC subclinical lesions in the CTVp, a 3-cm margin along the cranial-caudal axis should be added to the primary gross tumor volume as defined by FDG-PET/CT, as well as a cutoff SUVmax value of 2.5. Although preoperative FDG PET/CT images may not reveal lesions directly, the SUVmax and MTV measurements together could predict their presence.

Positron Emission Tomography/Computed Tomography Predicts and Detects Complications After Endovascular Repair of Abdominal Aortic Aneurysms

Purpose: To assess if aortic 18F-fluorodeoxyglucose (FDG) uptake on positron emission tomography/computed tomography (PET/CT) could play a role in predicting complications after endovascular aneurysm repair (EVAR). Materials and Methods: This study involved 2 cohorts of men with abdominal aortic aneurysm treated by EVAR: those who underwent a PET/CT scan before EVAR (n=17) and those who had a PET/CT during follow-up (n=34). Uptake of FDG was measured as the standardized uptake value (SUV). D-dimer, a marker of fibrinolysis, was measured in blood drawn concomitantly with the PET/CT. Results: A significant uptake of FDG in the aneurysm wall was detected by PET/CT before EVAR in 6 of 17 patients. During the first year after EVAR, type II endoleaks developed in 5 of these FDG+ patients vs 3 of 11 FDG- patients (p=0.04). Two of the FDG+ patients had continued sac growth and required conversion to open repair. A significant association between sac growth rate, SUV, and the presence of endoleak was found in the 34 patients who underwent PET/CT after EVAR. Finally, D-dimer was significantly increased in patients with both endoleak and positive PET/CT in the post-EVAR group. Conclusion: This study suggests that the presence of FDG uptake in the aortic wall might be a useful tool to predict patients at high risk of developing post-EVAR complications.

18F-Fluorodeoxyglucose Positron Emission Tomography/Computed Tomography in the Assessment of Occult Involvement in Widespread Granulomatosis with Polyangiitis (Wegener's Granulomatosis)

Granulomatosis with polyangiitis (GPA) can be classified as classic triad of organ involvement consisting of lungs, upper respiratory tract/sinuses, and kidneys; limited which is not having the full triad; or widespread with additional organ involvement for example prostate, spleen, skin, eyes or peripheral nervous system and occasionally other organs. GPA is associated with increased 18F-fluorodeoxyglucose (FDG) uptake on positron emission tomography/computed tomography (PET/CT). PET/CT has the advantages of whole-body imaging and detecting metabolic abnormality before structural changes. FDG PET/CT is used to assess the extent of the disease in GPA and can detect site of occult disease involvement where there are metabolic evidence of defined organ involvement with no CT or clinical evidence. This may result in upgrading of the disease from limited to classic triad or from classic triad to widespread.

Differences of articular and extra-articular involvement in polymyalgia rheumatica: A comparison by whole-body FDG-PET/CT

Objectives: To clarify differences in incidences of articular and extra-articular involvement in patients with polymyalgia rheumatica (PMR) using FDG-PET/CT.Methods: Twenty PMR patients were enrolled in this retrospective study. We compared frequency, degree, and patterns (diffuse or non-diffuse) of abnormal FDG accumulation in the proximal and distal articular structures (PAS, DAS), and extra-articular synovial structures (ESS). Regional analyses were performed for the large joints (shoulder, hip, and knee).Results: The incidences of positive FDG accumulation were significantly higher in the PAS (96.7%) and ESS (91.4%) than in the DAS (31.8%, p < .0001), although, the incidence in the knees (96.2%) was exceptionally high. PAS (2.79 ± 0.61) and ESS (2.52 ± 0.85) had significantly higher visual scores than DAS (0.89 ± 1.33, p < .0001). Shoulder, hip, and knee joints each had a different accumulation pattern. Strong FDG accumulation was frequently observed in the medial-to-subscapular part of the shoulder joints, the lateral part of the hip joints, and the medial part of the knee joints.Conclusion: ESS were found to be the main affected areas in PMR patients as well as PAS. DAS involvement occurred with low frequency except in the knee joints. Each large joint showed a different accumulation pattern and its own characteristically strongly affected areas.

Positron Emission Tomography-Computed Tomography in a Case of POEMS Syndrome

The POEMS syndrome is a rare and multisystemic disease characterized by the presence of polyneuropathy, organomegaly, endocrinopathy, presence of M protein, and alterations in the skin. The existence of bone lesions is frequent, being generally blastic or mixed and rarely lytic. We present the case of a 54-year-old male patient diagnosed with POEMS syndrome, with atypical presence of lytic lesions, who was referred for an 18F-fluorodeoxyglucose positron emission tomography-computed tomography (PET-CT) study for initial staging of the process. There were several hypermetabolic foci coinciding with bone lesions, reaching a maximum standardized uptake value of 15 at the level of the right iliac bone with associated soft-tissue mass. PET-CT is an adequate tool for evaluation, diagnosis, and monitoring of the pathology. The scan allows the detection and selection for its biopsy of bone lesions and lymphadenopathies.

Glucose metabolism in the brain in LMNB1-related autosomal dominant leukodystrophy

OBJECTIVE

LMNB1-related autosomal dominant leukodystrophy is caused by an overexpression of the protein lamin B1, usually due to a duplication of the LMNB1 gene. Symptoms start in 5th to 6th decade. This slowly progressive disease terminates with death. We studied brain glucose metabolism in this disease using 18 F-fluorodeoxyglucose positron emission tomography (PET).

METHODS

We examined 8 patients, aged 48-64 years, in varying stages of clinical symptomatology. Two patients were investigated with quantitative PET on clinical indications after which six more patients were recruited. Absolute glucose metabolism was analyzed with the PVElab software in 6 patients and 18 healthy controls. A semiquantitative analysis using the CortexID software was performed in seven investigations, relating local metabolism levels to global glucose metabolism.

RESULTS

The clinical quantitative PET revealed low global glucose metabolism, with the most marked reduction in the cerebellum. In the PVElab analysis, patients presented low mean glucose metabolism in the cerebellum, brainstem and global grey matter. In the semiquantitative analysis, 2 patients showed a decreased metabolism in the cerebellum and 4 patients a relatively higher metabolism in parts of the temporal lobes. Since none of the patients showed an increased metabolism in the quantitative analysis, we interpret these increases as "pseudo-increases" related to a globally reduced metabolism.

CONCLUSIONS

Global reduction of grey matter glucose metabolism in this white matter disease most likely depends on a combination of cortical afferent dysfunction and, in later stages, neuronal loss. The lowest metabolism in the cerebellum is consistent with histopathological findings and prominent cerebellar symptoms.

Incidental Detection of Urinary Bladder Herniation in 18F-Fluorodeoxyglucose Positron Emission Tomography/Computed Tomography Mimicking as Metastatic Deposit in the Inguinal Canal

Although ¹⁸F-fluorodeoxyglucose (FDG) is the most extensively used tracer in oncological positron emission tomography/computed tomography (PET/CT) studies, various physiological as well as benign pathological conditions are known to cause false-positive results. This report describes ¹⁸F-FDG PET/CT done in an elderly man with primary hepatocellular carcinoma, revealing a metastasis mimicking lesion in the left inguinal canal, which was identified as the herniated portion of the urinary bladder. Though rare, bladder herniation, especially with a narrow neck, can be a pitfall in the evaluation for metastatic disease. The study also highlights the utility of delayed imaging in the evaluation of pelvic pathology.

Evaluation of recurrent parathyroid carcinoma: A new imaging tool in uncommon entity

Parathyroid carcinoma (PTC) is a rare endocrine tumor and uncommon cause for primary hyperparathyroidism. ¹⁸F-fluorocholine (FCH) positron emission tomography and computed tomography (PET/CT) has shown promising results in the detection of parathyroid adenoma, though its role in PTC is undefined due to the paucity of incidence. The authors in this case report discuss the possible complimentary role of FCH PET/CT with ¹⁸F-fluorodeoxyglucose PET/CT in the evaluation of the management of suspected recurrence, since this rare entity has high loco-regional and distant recurrence of the disease.

Multi-level otsu method to define metabolic tumor volume in positron emission tomography

This study was to validate reliability and clinical utility of a PET tumor segmentation method using multi-level Otsu (MO-PET) in standard National Electrical Manufacturers Association (NEMA) image quality (IQ) phantom and patients with osteosarcoma. The NEMA IQ phantom was prepared with a lesion-to-background ratio (LBR) of either 8:1, 4:1, or 1.5:1. The artificial lesions in the phantom were segmented using MO-PET, gradient-based method (PETedge), relative threshold methods, and background threshold methods. Metabolic tumor volumes (MTVs) using MO-PET and PETedge were named as MTV (MO-PET) and MTV (PETedge), respectively. Among the MTVs using multiple methods, only MTV (MO-PET) and MTV (PETedge) showed excellent agreements with the actual volume of NEMA IQ phantom across the different LBRs (intraclass correlation coefficient, ICC = 0.987, 0.985 in LBR 8:1, 0.981, 0.993 in LBR 4:1 and 0.947, 0.994 in LBR 1.5:1). Repeated measurements of MTV (MO-PET) of the primary tumors showed excellent reproducibility with ICC of 0.994 (0.989-0.997) in patients with osteosarcoma. Also, MTV (MO-PET) was found to be predictive of Event Free Survival (EFS) [Hazard ratio (95% CI) = 6.1 (2.1-17.2), log rank P = 0.0003] in patients with osteosarcoma. We have validated in NEMA IQ phantom that the MTV (MO-PET) is accurate, and importantly, stable and consistent across a range of lesion sizes and LBRs representative of clinical tumor lesions. Furthermore, MTV (MO-PET) showed excellent reproducibility and was predictive for EFS in patients with osteosarcoma.

Whole-body 18F-fluorodeoxyglucose positron emission tomography-computed tomography (18F-FDG PET/CT) for staging locally advanced breast cancer: A prospective study from a tertiary cancer centre in south India

Background & objectives:

Locally advanced breast cancer (LABC) is associated with substantial risk of occult metastases. The patients with LABC have high rate of systemic relapse, suggesting inadequacy of the current conventional staging in detecting the occult metastatic spread. ¹⁸F-fluorodeoxyglucose (FDG) positron emission tomography-computed tomography (PET/CT) is a new modality in the staging of breast cancer patients. Hence, this study was conducted to evaluate the role of ¹⁸F-FDG PET/CT in initial staging of LABC and to compare it with conventional methods.

Methods:

This prospective study included biopsy-confirmed female patients diagnosed with LABC meeting the selection criteria and attending surgical, medical and radiation oncology departments of a tertiary care centre in south India, from April 2013 to December 2014. Conventional workup included serum chemistry, mammogram, bone scan, contrast-enhanced CT (CECT) chest and upper abdomen and ultrasound abdomen and pelvis. All patients following conventional workup underwent ¹⁸F-FDG PET/CT.

Results:

In this study, 61 women with LABC underwent both conventional workup and ¹⁸F-FGD PET/CT. The ¹⁸F-FDG PET/CT, in comparison to conventional workup, revealed unsuspected N3 nodal disease in 11 more patients, revealed distant metastasis in seven more patients and also detected extra sites of metastasis in five patients. The sensitivity, specificity, positive predictive value, negative predictive value and accuracy of PET/CT to detect distant metastasis were 95, 98, 95, 98 and 97 per cent, respectively, whereas the sensitivity, specificity, positive predictive value, negative predictive value and accuracy of conventional imaging to detect distant metastasis were 65, 93, 81, 84 and 84 per cent, respectively.

Interpretation & conclusions:

The ¹⁸F-FDG PET/CT was found to be more accurate than conventional imaging for staging and modified stage and treatment in 30 and 38 per cent of patients, respectively. It was particularly useful in detecting occult distant metastasis and N3 nodal disease with an added advantage of examining whole body in single session. However, CECT chest was superior over ¹⁸F-FDG PET/CT for detecting pulmonary metastasis.

Standardized uptake values in FDG PET/CT for prosthetic heart valve endocarditis: a call for standardization

BACKGROUND

The significance of and threshold values for the standardized uptake value (SUV) in FDG PET/CT to diagnose prosthetic heart valve (PHV) endocarditis (PVE) are unclear at present.

METHODS

A literature search was performed in the PubMed and EMBASE medical databases, comprising the following terms: (FDG OR *fluorode* OR *fluoro-de*) AND (endocarditis OR prosthetic heart valve OR valve replacement). Studies reporting SUVs correlated to the diagnosis of PVE were selected for analysis.

RESULTS

8 studies were included, with a total of 330 PHVs assessed. SUVs for PVE varied substantially across studies due to differences in acquisition, reconstruction, and measurement protocols, with median SUVmax values for rejected PVE ranging from 0.5 to 4.9 and for definite PVE ranging from 4.2 to 7.4.

CONCLUSION

Reported SUV values for PVE are not interchangeable between sites, and further standardization of quantification is desirable. To this end, optimal protocols for patient preparation, image acquisition, and reconstruction and measurement methods need to be standardized across centers.