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Jeeyavudeen MS, Mathiyalagan N, Fernandez James C, Pappachan JM. Tumor metabolism in pheochromocytomas: clinical and therapeutic implications. EXPLORATION OF TARGETED ANTI-TUMOR THERAPY 2024; 5:349-373. [PMID: 38745767 PMCID: PMC11090696 DOI: 10.37349/etat.2024.00222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Accepted: 12/27/2023] [Indexed: 05/16/2024] Open
Abstract
Pheochromocytomas and paragangliomas (PPGLs) have emerged as one of the most common endocrine tumors. It epitomizes fascinating crossroads of genetic, metabolic, and endocrine oncology, providing a canvas to explore the molecular intricacies of tumor biology. Predominantly rooted in the aberration of metabolic pathways, particularly the Krebs cycle and related enzymatic functionalities, PPGLs manifest an intriguing metabolic profile, highlighting elevated levels of oncometabolites like succinate and fumarate, and furthering cellular malignancy and genomic instability. This comprehensive review aims to delineate the multifaceted aspects of tumor metabolism in PPGLs, encapsulating genetic factors, oncometabolites, and potential therapeutic avenues, thereby providing a cohesive understanding of metabolic disturbances and their ramifications in tumorigenesis and disease progression. Initial investigations into PPGLs metabolomics unveiled a stark correlation between specific genetic mutations, notably in the succinate dehydrogenase complex (SDHx) genes, and the accumulation of oncometabolites, establishing a pivotal role in epigenetic alterations and hypoxia-inducible pathways. By scrutinizing voluminous metabolic studies and exploiting technologies, novel insights into the metabolic and genetic aspects of PPGLs are perpetually being gathered elucidating complex interactions and molecular machinations. Additionally, the exploration of therapeutic strategies targeting metabolic abnormalities has burgeoned harboring potential for innovative and efficacious treatment modalities. This review encapsulates the profound metabolic complexities of PPGLs, aiming to foster an enriched understanding and pave the way for future investigations and therapeutic innovations in managing these metabolically unique tumors.
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Affiliation(s)
| | - Navin Mathiyalagan
- Department of Medical Oncology, Nottingham University Hospitals NHS Trust, NG5 1PB Nottingham, UK
| | - Cornelius Fernandez James
- Department of Endocrinology & Metabolism, Pilgrim Hospital, United Lincolnshire Hospitals NHS Trust, PE21 9QS Boston, UK
| | - Joseph M. Pappachan
- Department of Endocrinology and Metabolism, Lancashire Teaching Hospitals NHS Trust, PR2 9HT Preston, UK
- Faculty of Science, Manchester Metropolitan University, M15 6BH Manchester, UK
- Faculty of Biology, Medicine, and Health, The University of Manchester, M13 9PL Manchester, UK
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2
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Marcus C, Subramaniam RM. Paragangliomas and Pheochromocytomas: Positron Emission Tomography/Computed Tomography Diagnosis and Therapy. PET Clin 2023; 18:233-242. [PMID: 36585340 DOI: 10.1016/j.cpet.2022.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Molecular imaging evaluation of pheochromocytomas and paragangliomas depends on multiple factors, such as localized versus metastatic disease, the genetic, and biochemical profile of tumors. Positron emission tomography/computed tomography (PET/CT) imaging of these tumors outperforms Meta-Iodo-Benzyl-Guanidine (MIBG) scintigraphy in most cases. A few PET radiotracers have been studied in evaluating these patients with somatostatin receptor PET imaging and have shown superior performance compared with other agents in most of these patients. 18F-fluorodeoxyglucose PET/CT imaging is useful in select patients, such as those with succinate dehydrogenase complex subunit B-associated disease. Treatment strategy depends on multiple factors and necessitates a multidisciplinary approach.
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Affiliation(s)
- Charles Marcus
- Division of Nuclear Medicine and Molecular Imaging, Department of Radiology and Radiological Sciences, Emory University School of Medicine, 1364 Clifton Road Northeast, 1st Floor #E163, Atlanta, GA 30322, USA.
| | - Rathan M Subramaniam
- Department of Medicine, Otago Medical School, University of Otago, 1st Floor, Dunedin Hospital, 201 Great King Street, Dunedin 9016, New Zealand; Duke University Medical Center, Department of Radiology, 2301 Erwin Road, Box 3808, Durham, NC 27710, USA
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Bamminger K, Raitanen J, Karanikas G, Rasul S, Nics L, Mitterhauser M, Wadsak W, Hacker M, Pichler V, Vraka C. Rapid, high-yield enzymatic synthesis of n.c.a. 6-[ 18F]fluorodopamine (6-[ 18F]FDA) for in vivo application. Nucl Med Biol 2022; 114-115:189-197. [PMID: 35820986 DOI: 10.1016/j.nucmedbio.2022.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Revised: 04/08/2022] [Accepted: 07/01/2022] [Indexed: 12/27/2022]
Affiliation(s)
- Karsten Bamminger
- Department of Biomedical Imaging and Image-guided Therapy, Division of Nuclear Medicine, Medical University of Vienna, Vienna, Austria; CBmed GmbH - Center for Biomarker Research in Medicine, Graz, Austria
| | - Julia Raitanen
- Department of Biomedical Imaging and Image-guided Therapy, Division of Nuclear Medicine, Medical University of Vienna, Vienna, Austria; Ludwig Boltzmann Institute Applied Diagnostics, Vienna, Austria; University of Vienna, Vienna Doctoral School in Chemistry (DoSChem), Währinger Str. 42, 1090 Vienna, Austria
| | - Georgios Karanikas
- Department of Biomedical Imaging and Image-guided Therapy, Division of Nuclear Medicine, Medical University of Vienna, Vienna, Austria
| | - Sazan Rasul
- Department of Biomedical Imaging and Image-guided Therapy, Division of Nuclear Medicine, Medical University of Vienna, Vienna, Austria
| | - Lukas Nics
- Department of Biomedical Imaging and Image-guided Therapy, Division of Nuclear Medicine, Medical University of Vienna, Vienna, Austria
| | - Markus Mitterhauser
- Department of Biomedical Imaging and Image-guided Therapy, Division of Nuclear Medicine, Medical University of Vienna, Vienna, Austria; Ludwig Boltzmann Institute Applied Diagnostics, Vienna, Austria
| | - Wolfgang Wadsak
- Department of Biomedical Imaging and Image-guided Therapy, Division of Nuclear Medicine, Medical University of Vienna, Vienna, Austria; CBmed GmbH - Center for Biomarker Research in Medicine, Graz, Austria
| | - Marcus Hacker
- Department of Biomedical Imaging and Image-guided Therapy, Division of Nuclear Medicine, Medical University of Vienna, Vienna, Austria
| | - Verena Pichler
- Department of Pharmaceutical Sciences, Division of Pharmaceutical Chemistry, University of Vienna, Vienna, Austria.
| | - Chrysoula Vraka
- Department of Biomedical Imaging and Image-guided Therapy, Division of Nuclear Medicine, Medical University of Vienna, Vienna, Austria
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Genetics of Pheochromocytomas and Paragangliomas Determine the Therapeutical Approach. Int J Mol Sci 2022; 23:ijms23031450. [PMID: 35163370 PMCID: PMC8836037 DOI: 10.3390/ijms23031450] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 01/21/2022] [Accepted: 01/24/2022] [Indexed: 02/06/2023] Open
Abstract
Pheochromocytomas and paragangliomas are the most heritable endocrine tumors. In addition to the inherited mutation other driver mutations have also been identified in tumor tissues. All these genetic alterations are clustered in distinct groups which determine the pathomechanisms. Most of these tumors are benign and their surgical removal will resolve patient management. However, 5–15% of them are malignant and therapeutical possibilities for them are limited. This review provides a brief insight about the tumorigenesis associated with pheochromocytomas/paragangliomas in order to present them as potential therapeutical targets.
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Pediatric issues in nuclear medicine therapy. Nucl Med Mol Imaging 2022. [DOI: 10.1016/b978-0-12-822960-6.00151-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Research progress of 18F labeled small molecule positron emission tomography (PET) imaging agents. Eur J Med Chem 2020; 205:112629. [PMID: 32956956 DOI: 10.1016/j.ejmech.2020.112629] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2020] [Revised: 06/07/2020] [Accepted: 06/28/2020] [Indexed: 01/12/2023]
Abstract
With the development of positron emission tomography (PET) technology, a variety of PET imaging agents labeled with radionuclide 18F have been developed and widely used in the diagnosis and treatment of various clinical diseases in recent years. For example, they have showed a great value of study in the field of tumor detection, tumor treatment and evaluation of tumor therapy in a non-invasive, qualitative and quantitative way. In this review, we highlight the recent development in chemical synthesis, structure and characterization, imaging characterization, and potential applications of these 18F labeled small molecule PET imaging agents for the past five years. The development and application of 18F labeled small molecules will expand our knowledge of the function and distribution of diseases-related molecular targets and shed light on the diagnosis and treatment of various diseases including tumors.
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Därr R, Kater J, Sekula P, Bausch B, Krauss T, Bode C, Walz G, Neumann HP, Zschiedrich S. Clinical decision making in small non-functioning VHL-related incidentalomas. Endocr Connect 2020; 9:834-844. [PMID: 32869749 PMCID: PMC7487196 DOI: 10.1530/ec-20-0208] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 08/06/2020] [Indexed: 01/26/2023]
Abstract
The optimal treatment strategy for patients with small non-functioning VHL-related incidentalomas is unclear. We searched the Freiburg VHL registry for patients with radiologic evidence of pheochromocytoma/paraganglioma (PHEO/PGL). In total, 176 patients with single, multiple, and recurrent tumours were identified (1.84 tumours/patient, range 1-8). Mean age at diagnosis was 32 ± 16 years. Seventy-four percent of tumours were localised to the adrenals. Mean tumour diameter was 2.42 ± 2.27 cm, 46% were <1.5 cm. 24% of tumours were biochemically inactive. Inactive tumours were significantly smaller than active PHEO/PGL at diagnosis (4.16 ± 2.80 cm vs 1.43 ± 0.45 cm; P < 0.025) and before surgery (4.89 ± 3.47 cm vs 1.36 ± 0.43 cm; P < 0.02). Disease was stable in 67% of 21 patients with evaluable tumours ≤1.5 cm according to RECIST and progressed in 7. Time till surgery in these patients was 29.5 ± 20.0 months. A total of 155 patients underwent surgery. PHEO/PGL was histologically excluded in 4 and proven in 151. Of these, one had additional metastatic disease, one harboured another tumour of a different type, and in 2 a second surgery for suspected disease recurrence did not confirm PHEO/PGL. Logistic regression analysis revealed 50% probability for a positive/negative biochemical test result at 1.8 cm tumour diameter. Values of a novel symptom score were positively correlated with tumour size (Rs = 0.46, P < 0.0001) and together with a positive biochemistry a linear size predictor (P < 0.01). Results support standardised clinical assessment and measurement of tumour size and metanephrines in VHL patients with non-functioning incidentalomas <1.5 cm at one year following diagnosis and at individualised intervals thereafter depending on evolving growth dynamics, secretory activity and symptomatology.
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Affiliation(s)
- Roland Därr
- Department of Cardiology and Angiology I, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Department of Medicine IV, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Correspondence should be addressed to R Därr:
| | - Jonas Kater
- Department of Medicine IV, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Peggy Sekula
- Institute of Genetic Epidemiology, University Medical Center Freiburg, Freiburg, Germany
| | - Birke Bausch
- Department of Medicine II, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Tobias Krauss
- Department of Radiology, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Christoph Bode
- Department of Cardiology and Angiology I, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Gerd Walz
- Department of Medicine IV, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Hartmut P Neumann
- Section for Preventive Medicine, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Stefan Zschiedrich
- Department of Medicine IV, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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Pauwels E, Van Aerde M, Bormans G, Deroose CM. Molecular imaging of norepinephrine transporter-expressing tumors: current status and future prospects. THE QUARTERLY JOURNAL OF NUCLEAR MEDICINE AND MOLECULAR IMAGING : OFFICIAL PUBLICATION OF THE ITALIAN ASSOCIATION OF NUCLEAR MEDICINE (AIMN) [AND] THE INTERNATIONAL ASSOCIATION OF RADIOPHARMACOLOGY (IAR), [AND] SECTION OF THE SOCIETY OF RADIOPHARMACEUTICAL CHEMISTRY AND BIOLOGY 2020; 64:234-249. [PMID: 32397701 DOI: 10.23736/s1824-4785.20.03261-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
The human norepinephrine transporter (hNET) is a transmembrane protein responsible for reuptake of norepinephrine in presynaptic sympathetic nerve terminals and adrenal chromaffin cells. Neural crest tumors, such as neuroblastoma, paraganglioma and pheochromocytoma often show high hNET expression. Molecular imaging of these tumors can be done using radiolabeled norepinephrine analogs that target hNET. Currently, the most commonly used radiopharmaceutical for hNET imaging is meta-[123I]iodobenzylguanidine ([123I]MIBG) and this has been the case since its development several decades ago. The γ-emitter, iodine-123 only allows for planar scintigraphy and single photon emission computed tomography imaging. These modalities typically have a poorer spatial resolution and lower sensitivity than positron emission tomography (PET). Additional practical disadvantages include the fact that a two-day imaging protocol is required and the need for thyroid blockade. Therefore, several PET alternatives for hNET imaging are actively being explored. This review gives an in-depth overview of the current status and recent developments in clinical trials leading to the next generation of clinical PET ligands for imaging of hNET-expressing tumors.
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Affiliation(s)
- Elin Pauwels
- Nuclear Medicine and Molecular Imaging, Department of Imaging and Pathology, University Hospitals Leuven, Leuven, Belgium.,Nuclear Medicine and Molecular Imaging, Department of Imaging and Pathology, KU Leuven, Belgium
| | - Matthias Van Aerde
- Nuclear Medicine and Molecular Imaging, Department of Imaging and Pathology, University Hospitals Leuven, Leuven, Belgium.,Nuclear Medicine and Molecular Imaging, Department of Imaging and Pathology, KU Leuven, Belgium
| | - Guy Bormans
- Radiopharmaceutical Research, Department of Pharmacy and Pharmacology, KU Leuven, Leuven, Belgium
| | - Christophe M Deroose
- Nuclear Medicine and Molecular Imaging, Department of Imaging and Pathology, University Hospitals Leuven, Leuven, Belgium - .,Nuclear Medicine and Molecular Imaging, Department of Imaging and Pathology, KU Leuven, Belgium
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Recent advances in radiotracers targeting norepinephrine transporter: structural development and radiolabeling improvements. J Neural Transm (Vienna) 2020; 127:851-873. [PMID: 32274584 PMCID: PMC7223405 DOI: 10.1007/s00702-020-02180-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Accepted: 03/21/2020] [Indexed: 12/13/2022]
Abstract
The norepinephrine transporter (NET) is a major target for the evaluation of the cardiac sympathetic nerve system in patients with heart failure and Parkinson's disease. It is also used in the therapeutic applications against certain types of neuroendocrine tumors, as exemplified by the clinically used 123/131I-MIBG as theranostic single-photon emission computed tomography (SPECT) agent. With the development of more advanced positron emission tomography (PET) technology, more radiotracers targeting NET have been reported, with superior temporal and spatial resolutions, along with the possibility of functional and kinetic analysis. More recently, fluorine-18-labelled NET tracers have drawn increasing attentions from researchers, due to their longer radiological half-life relative to carbon-11 (110 min vs. 20 min), reduced dependence on on-site cyclotrons, and flexibility in the design of novel tracer structures. In the heart, certain NET tracers provide integral diagnostic information on sympathetic innervation and the nerve status. In the central nervous system, such radiotracers can reveal NET distribution and density in pathological conditions. Most radiotracers targeting cardiac NET-function for the cardiac application consistent of derivatives of either norepinephrine or MIBG with its benzylguanidine core structure, e.g. 11C-HED and 18F-LMI1195. In contrast, all NET tracers used in central nervous system applications are derived from clinically used antidepressants. Lastly, possible applications of NET as selective tracers over organic cation transporters (OCTs) in the kidneys and other organs controlled by sympathetic nervous system will also be discussed.
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Schreiner F, Beuschlein F. Disease monitoring of patients with pheochromocytoma or paraganglioma by biomarkers and imaging studies. Best Pract Res Clin Endocrinol Metab 2020; 34:101347. [PMID: 31662271 DOI: 10.1016/j.beem.2019.101347] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Pheochromocytoma and paraganglioma (PPGL) are rare neuroendocrine tumors, a large proportion of which secrete catecholamines. PPGL are associated with a high cardiovascular morbidity and come with a risk of malignancy. The therapy of choice is surgical resection. Nevertheless, PPGL are associated with a lifelong risk of tumor persistence or recurrence. Currently, there are no clinical, biochemical, histopathological or imaging characteristics, which can predict or exclude malignant behavior or tumor recurrence. Therefore, long-term follow-up is recommended even after apparent complete surgical removal. Early detection of recurrence is essential to reduce cardiovascular morbidity and mortality due to catecholamine secretion, to prevent morbidity by mass effects of paraganglioma (PGL) or by metastatic spread of disease. Due to the rarity of these tumors, no prospective data on long-term surveillance exist. In fact, current recommendations are based on retrospective analyses, expert opinions and case studies. The aim of this review is to provide an overview on the current state of knowledge with regard to known factors that increase the risk of recurrence and might impact disease monitoring as well as the available possibilities for biochemical and imaging follow-up. Based on this overview, we aim to propose a practical approach for a patient-oriented follow-up after surgical removal of a PPGL.
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Affiliation(s)
- Florentine Schreiner
- Klinik für Endokrinologie, Diabetologie und Klinische Ernährung, UniversitätsSpital Zürich, Zurich, Switzerland
| | - Felix Beuschlein
- Klinik für Endokrinologie, Diabetologie und Klinische Ernährung, UniversitätsSpital Zürich, Zurich, Switzerland; Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Munich, Germany.
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Taïeb D, Hicks RJ, Hindié E, Guillet BA, Avram A, Ghedini P, Timmers HJ, Scott AT, Elojeimy S, Rubello D, Virgolini IJ, Fanti S, Balogova S, Pandit-Taskar N, Pacak K. European Association of Nuclear Medicine Practice Guideline/Society of Nuclear Medicine and Molecular Imaging Procedure Standard 2019 for radionuclide imaging of phaeochromocytoma and paraganglioma. Eur J Nucl Med Mol Imaging 2019; 46:2112-2137. [PMID: 31254038 PMCID: PMC7446938 DOI: 10.1007/s00259-019-04398-1] [Citation(s) in RCA: 183] [Impact Index Per Article: 36.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Accepted: 06/10/2019] [Indexed: 01/11/2023]
Abstract
PURPOSE Diverse radionuclide imaging techniques are available for the diagnosis, staging, and follow-up of phaeochromocytoma and paraganglioma (PPGL). Beyond their ability to detect and localise the disease, these imaging approaches variably characterise these tumours at the cellular and molecular levels and can guide therapy. Here we present updated guidelines jointly approved by the EANM and SNMMI for assisting nuclear medicine practitioners in not only the selection and performance of currently available single-photon emission computed tomography and positron emission tomography procedures, but also the interpretation and reporting of the results. METHODS Guidelines from related fields and relevant literature have been considered in consultation with leading experts involved in the management of PPGL. The provided information should be applied according to local laws and regulations as well as the availability of various radiopharmaceuticals. CONCLUSION Since the European Association of Nuclear Medicine 2012 guidelines, the excellent results obtained with gallium-68 (68Ga)-labelled somatostatin analogues (SSAs) in recent years have simplified the imaging approach for PPGL patients that can also be used for selecting patients for peptide receptor radionuclide therapy as a potential alternative or complement to the traditional theranostic approach with iodine-123 (123I)/iodine-131 (131I)-labelled meta-iodobenzylguanidine. Genomic characterisation of subgroups with differing risk of lesion development and subsequent metastatic spread is refining the use of molecular imaging in the personalised approach to hereditary PPGL patients for detection, staging, and follow-up surveillance.
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Affiliation(s)
- David Taïeb
- Department of Nuclear Medicine, La Timone University Hospital, CERIMED, Aix-Marseille University, 264 rue Saint-Pierre, 13005, Marseille Cedex 05, France
| | - Rodney J. Hicks
- Centre for Cancer Imaging, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Elif Hindié
- Department of Nuclear Medicine, Hôpital Haut-Lévêque, Bordeaux University Hospitals, Pessac, France
| | - Benjamin A. Guillet
- Department of Radiopharmacy, La Timone University Hospital, CERIMED, Aix-Marseille University, Marseille, France
| | - Anca Avram
- Nuclear Medicine/Radiology, University of Michigan, Ann Arbor, MI, USA
| | - Pietro Ghedini
- Nuclear Medicine Unit, Medicina Nucleare Metropolitana, University Hospital S.Orsola-Malpighi, Bologna, Italy
| | - Henri J. Timmers
- Department of Endocrinology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | | | - Saeed Elojeimy
- Department of Radiology, University of New Mexico, Albuquerque, NM, USA
| | - Domenico Rubello
- Department of Nuclear Medicine, Radiology, Neuroradiology, Medical Physics, Clinical Laboratory, Microbiology, Pathology, Transfusional Medicine, Santa Maria della Misericordia Hospital, Rovigo, Italy
| | - Irène J. Virgolini
- Department of Nuclear Medicine, Medical University Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria
| | - Stefano Fanti
- Nuclear Medicine Unit, Medicina Nucleare Metropolitana, University Hospital S.Orsola-Malpighi, Bologna, Italy
| | - Sona Balogova
- Department of Nuclear Medicine, Comenius University and St. Elisabeth Oncology Institute, Heydukova 10, 81250 Bratislava, Slovakia,Department of Nuclear Medicine, Hôpital Tenon Assistance Publique-Hôpitaux de Paris and Sorbonne University, Paris, France
| | - Neeta Pandit-Taskar
- Department of Radiology, Molecular Imaging and Therapy Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Karel Pacak
- Eunice Kennedy Shriver National Institutes of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA
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12
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11C-hydroxy-ephedrine-PET/CT in the Diagnosis of Pheochromocytoma and Paraganglioma. Cancers (Basel) 2019; 11:cancers11060847. [PMID: 31248124 PMCID: PMC6627429 DOI: 10.3390/cancers11060847] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Revised: 06/12/2019] [Accepted: 06/16/2019] [Indexed: 01/04/2023] Open
Abstract
Pheochromocytomas (PCC) and paragangliomas (PGL) may be difficult to diagnose because of vague and uncharacteristic symptoms and equivocal biochemical and radiological findings. This was a retrospective cohort study in 102 patients undergoing 11C-hydroxy-ephedrine (11C-HED)-PET/CT because of symptoms and/or biochemistry suspicious for PCC/PGL and/or with radiologically equivocal adrenal incidentalomas. Correlations utilized CT/MRI, clinical, biochemical, surgical, histopathological and follow-up data. 11C-HED-PET/CT correctly identified 19 patients with PCC and six with PGL, missed one PCC, attained one false positive result (nodular hyperplasia) and correctly excluded PCC/PGL in 75 patients. Sensitivity, specificity, positive and negative predictive values of 11C-HED-PET/CT for PCC/PGL diagnosis was 96%, 99%, 96% and 99%, respectively. In 41 patients who underwent surgical resection and for whom correlation to histopathology was available, the corresponding figures were 96%, 93%, 96% and 93%, respectively. Tumor 11C-HED-uptake measurements (standardized uptake value, tumor-to-normal-adrenal ratio) were unrelated to symptoms of catecholamine excess (p > 0.05) and to systolic blood pressure (p > 0.05). In PCC/PGL patients, norepinephrine and systolic blood pressure increased in parallel (R2 = 0.22, p = 0.016). 11C-HED-PET/CT was found to be an accurate tool to diagnose and rule out PCC/PGL in complex clinical scenarios and for the characterization of equivocal adrenal incidentalomas. PET measurements of tumor 11C-HED uptake were not helpful for tumor characterization.
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13
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Vāvere AL, Neumann KD, Butch ER, Hu B, DiMagno SG, Snyder SE. Improved, one-pot synthesis of 6-[18
F]fluorodopamine and quality control testing for use in patients with neuroblastoma. J Labelled Comp Radiopharm 2018; 61:1069-1080. [DOI: 10.1002/jlcr.3685] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2018] [Revised: 09/03/2018] [Accepted: 09/27/2018] [Indexed: 11/09/2022]
Affiliation(s)
- Amy L. Vāvere
- Division of Nuclear Medicine, Department of Diagnostic Imaging; St. Jude Children's Research Hospital; Memphis Tennessee USA
| | | | - Elizabeth R. Butch
- Division of Nuclear Medicine, Department of Diagnostic Imaging; St. Jude Children's Research Hospital; Memphis Tennessee USA
| | - Bao Hu
- Department of Medicinal Chemistry and Pharmacognosy; University of Illinois at Chicago; Chicago Illinois USA
| | - Stephen G. DiMagno
- Department of Medicinal Chemistry and Pharmacognosy; University of Illinois at Chicago; Chicago Illinois USA
| | - Scott E. Snyder
- Division of Nuclear Medicine, Department of Diagnostic Imaging; St. Jude Children's Research Hospital; Memphis Tennessee USA
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Agrawal A, Rangarajan V, Shah S, Puranik A, Purandare N. MIBG (metaiodobenzylguanidine) theranostics in pediatric and adult malignancies. Br J Radiol 2018; 91:20180103. [PMID: 30048149 DOI: 10.1259/bjr.20180103] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Metaiodobenzylguanidine, a guanithidine analog, labeled with 123I and 131I, is used for imaging and therapy of neuroblastomas and various neural crest tumors like paragangliomas, pheochromocytomas, medullary cancer of thyroid and carcinoids since the past three to four decades. In this review article, we shall revisit metaiodobenzylguanidine as a radiopharmaceutical and its various applications in neural crest tumors.
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Affiliation(s)
- Archi Agrawal
- 1 Department of Nuclear Medicine and Molecular Imaging, Tata Memorial Hospital , Mumbai , India
| | - Venkatesh Rangarajan
- 1 Department of Nuclear Medicine and Molecular Imaging, Tata Memorial Hospital , Mumbai , India
| | - Sneha Shah
- 1 Department of Nuclear Medicine and Molecular Imaging, Tata Memorial Hospital , Mumbai , India
| | - Ameya Puranik
- 1 Department of Nuclear Medicine and Molecular Imaging, Tata Memorial Hospital , Mumbai , India
| | - Nilendu Purandare
- 1 Department of Nuclear Medicine and Molecular Imaging, Tata Memorial Hospital , Mumbai , India
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Molecular imaging and theranostic approaches in pheochromocytoma and paraganglioma. Cell Tissue Res 2018; 372:393-401. [PMID: 29450723 DOI: 10.1007/s00441-018-2791-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Accepted: 01/06/2018] [Indexed: 10/18/2022]
Abstract
Pheochromocytomas and their extra-adrenal counterpart paragangliomas (PGLs; together called PPGLs), belong to the family of neural crest-derived tumors. Given the overexpression of a wide variety of specific targets in PPGLs, it seems that these tumors are optimally suited to be imaged by specific radiopharmaceuticals. Thus, theranostics approaches with somatostatin agonists and antagonists are rapidly evolving in the setting of these tumors and may be considered as the next step in the therapeutic arsenal of metastatic PPGLs.
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16
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Pandit-Taskar N, Modak S. Norepinephrine Transporter as a Target for Imaging and Therapy. J Nucl Med 2017; 58:39S-53S. [PMID: 28864611 DOI: 10.2967/jnumed.116.186833] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Accepted: 07/19/2017] [Indexed: 01/01/2023] Open
Abstract
The norepinephrine transporter (NET) is essential for norepinephrine uptake at the synaptic terminals and adrenal chromaffin cells. In neuroendocrine tumors, NET can be targeted for imaging as well as therapy. One of the most widely used theranostic agents targeting NET is metaiodobenzylguanidine (MIBG), a guanethidine analog of norepinephrine. 123I/131I-MIBG theranostics have been applied in the clinical evaluation and management of neuroendocrine tumors, especially in neuroblastoma, paraganglioma, and pheochromocytoma. 123I-MIBG imaging is a mainstay in the evaluation of neuroblastoma, and 131I-MIBG has been used for the treatment of relapsed high-risk neuroblastoma for several years, however, the outcome remains suboptimal. 131I-MIBG has essentially been only palliative in paraganglioma/pheochromocytoma patients. Various techniques of improving therapeutic outcomes, such as dosimetric estimations, high-dose therapies, multiple fractionated administration and combination therapy with radiation sensitizers, chemotherapy, and other radionuclide therapies, are being evaluated. PET tracers targeting NET appear promising and may be more convenient options for the imaging and assessment after treatment. Here, we present an overview of NET as a target for theranostics; review its current role in some neuroendocrine tumors, such as neuroblastoma, paraganglioma/pheochromocytoma, and carcinoids; and discuss approaches to improving targeting and theranostic outcomes.
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Affiliation(s)
| | - Shakeel Modak
- Memorial Sloan Kettering Cancer Center, New York, New York
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17
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Functional Imaging of Paragangliomas with an Emphasis on Von Hippel-Lindau-Associated Disease: A Mini Review. J Kidney Cancer VHL 2017; 4:30-36. [PMID: 28890865 PMCID: PMC5583378 DOI: 10.15586/jkcvhl.2017.92] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Accepted: 08/05/2017] [Indexed: 01/10/2023] Open
Abstract
Few reports have presented data and results on functional (i.e., nuclear medicine) imaging of paragangliomas and pheochromocytomas (PGLs/PHEOs) for von Hippel-Lindau (VHL) patients. Nuclear medicine localization modalities for chromaffin tumors can be specific or nonspecific. Specific methods make use of the expression of the human norepinephrine transporter (hNET) and vesicular monoamine transporters (VMATs) by these tumors. These permit the use of radiolabeled ligands that enter the synthesis and storage pathway of catecholamines. Nonspecific methods are not related to the synthesis, uptake, or storage of catecholamines but make use of the tumors' high glucose metabolism or expression of somatostatin receptors. Consensuses and guidelines suggest that metastatic and sporadic PHEOs/PGLs in VHL patients (as in patients with chromaffin tumors of yet unknown genotype) should be evaluated first with 18F-dihydroxyphenylalanine (18F-DOPA) positron emission tomography/computed tomography (PET/CT). The functional imaging of second choice is 123I-metaiodobenzylguanidine (123I-MIBG) for PHEOs in VHL patients. 123I-MIBG, 68Ga-DOTATATE/DOTATOC/DOTANOC PET/CT, or 18F-fluorodeoxyglucose (18F-FDG) PET/CT can be a second choice of functional imaging for PGLs in VHL patients.
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18
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Neumann KD, Qin L, Vāvere AL, Shen B, Miao Z, Chin FT, Shulkin BL, Snyder SE, DiMagno SG. Efficient automated syntheses of high specific activity 6-[18F]fluorodopamine using a diaryliodonium salt precursor. J Labelled Comp Radiopharm 2016; 59:30-4. [PMID: 26695865 PMCID: PMC4715522 DOI: 10.1002/jlcr.3367] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2015] [Revised: 11/25/2015] [Accepted: 12/01/2015] [Indexed: 11/08/2022]
Abstract
6-[(18)F]Fluorodopamine (6-[(18) F]F-DA) is a positron emission tomography radiopharmaceutical used to image sympathetic cardiac innervation and neuroendocrine tumors. Imaging with 6-[(18)F]F-DA is constrained, in part, by the bioactivity and neurotoxicity of 6-[(19)F]fluorodopamine. Furthermore, routine access to this radiotracer is limited by the inherent difficulty of incorporation of [(18)F]fluoride into electron-rich aromatic substrates. We describe the simple and direct preparation of high specific activity (SA) 6-[(18)F]F-DA from no-carrier-added (n.c.a.) [(18)F]fluoride. Incorporation of n.c.a. [(18)F]fluoride into a diaryliodonium salt precursor was achieved in 50-75% radiochemical yields (decay corrected to end of bombardment). Synthesis of 6-[(18)F]F-DA on the IBA Synthera® and GE TRACERlab FX-FN automated platforms gave 6-[(18)F]F-DA in >99% chemical and radiochemical purities after HPLC purification. The final non-corrected yields of 6-[(18)F]F-DA were 25 ± 4% (n = 4, 65 min) and 31 ± 6% (n = 3, 75 min) using the Synthera and TRACERlab modules, respectively. Efficient access to high SA 6-[(18)F]F-DA from a diaryliodonium salt precursor and n.c.a. [(18)F]fluoride is provided by a relatively subtle change in reaction conditions - replacement of a polar aprotic solvent (acetonitrile) with a relatively nonpolar solvent (toluene) during the critical radiofluorination reaction. Implementation of this process on common radiochemistry platforms should make 6-[(18)F]F-DA readily available to the wider imaging community.
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Affiliation(s)
- Kiel D. Neumann
- Department of Chemistry, University of Nebraska-Lincoln, Lincoln, Nebraska
| | - Linlin Qin
- Department of Chemistry, University of Nebraska-Lincoln, Lincoln, Nebraska
| | - Amy L. Vāvere
- Division of Nuclear Medicine, Department of Radiological Sciences, St. Jude Children’s Research Hospital, Memphis, Tennessee
| | - Bin Shen
- Department of Radiology, Stanford University School of Medicine, Stanford, California
| | - Zheng Miao
- Department of Radiology, Stanford University School of Medicine, Stanford, California
| | - Frederick T. Chin
- Department of Radiology, Stanford University School of Medicine, Stanford, California
| | - Barry L. Shulkin
- Division of Nuclear Medicine, Department of Radiological Sciences, St. Jude Children’s Research Hospital, Memphis, Tennessee
| | - Scott E. Snyder
- Division of Nuclear Medicine, Department of Radiological Sciences, St. Jude Children’s Research Hospital, Memphis, Tennessee
| | - Stephen G. DiMagno
- Department of Chemistry, University of Nebraska-Lincoln, Lincoln, Nebraska
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19
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Brito JP, Asi N, Gionfriddo MR, Norman C, Leppin AL, Zeballos-Palacios C, Undavalli C, Wang Z, Domecq JP, Prustsky G, Elraiyah TA, Prokop LJ, Montori VM, Murad MH. The incremental benefit of functional imaging in pheochromocytoma/paraganglioma: a systematic review. Endocrine 2015; 50:176-86. [PMID: 25663601 DOI: 10.1007/s12020-015-0544-7] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2014] [Accepted: 01/27/2015] [Indexed: 01/04/2023]
Abstract
Computed tomography (CT) and magnetic resonance imaging (MRI) are the major imaging modalities used for the localization of catecholamine-producing tumors (pheochromocytoma and paraganglioma). Functional imaging (FI) offers an alternative approach to localize, evaluate, and stage these tumors. Our objective was to describe the additive benefit of FI studies for patients with pheochromocytoma and paraganglioma (PPG) who have undergone MRI or CT scan evaluation. We searched MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Scopus from database inception through June 2012 for studies that included patients with biochemically proven PPGs who underwent CT or MRI and additional FI for the localization of PPGs. We included 32 studies enrolling a total of 1,264 patients with a mean age of 43-years old. The studies were uncontrolled and evaluated six FI modalities. FI tests provided small additive value to CT/MRI, aiding in the localization of only 24/1,445 primary cases (1.4 %) and 28/805 metastatic cases (3.5 %). In metastatic cases, 6-[F-18]fluoro-L-dihydroxyphenylalanine (DOPA) and fluorodopamine-PET (FDA) were the FI tests most successful at identifying disease missed by CT/MRI, providing additional benefit in 6/60 (10 %) and 5/78 (6.4 %) cases, respectively. No clinically significant findings were observed in any of the predefined subgroups. No study evaluated the impact of FI on the completeness of surgical resection or other patient-important outcomes. Observational evidence suggests that FI tests have a limited additional role in patients with PPGs who have undergone CT/MRI evaluation. However, the role of FI tests in specific subgroups of patients with atypical presentations (metastatic, extra-adrenal) as well as the use of hybrid FI tests should be explored. Further research should also evaluate the impact of FI tests on patient-important outcomes.
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Affiliation(s)
- Juan P Brito
- Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, MN, 55905, USA
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20
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van Berkel A, Rao JU, Lenders JW, Pellegata NS, Kusters B, Piscaer I, Hermus AR, Plantinga TS, Langenhuijsen JF, Vriens D, Janssen MJ, Gotthardt M, Timmers HJ. Semiquantitative 123I-Metaiodobenzylguanidine Scintigraphy to Distinguish Pheochromocytoma and Paraganglioma from Physiologic Adrenal Uptake and Its Correlation with Genotype-Dependent Expression of Catecholamine Transporters. J Nucl Med 2015; 56:839-46. [DOI: 10.2967/jnumed.115.154815] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2015] [Accepted: 03/25/2015] [Indexed: 01/15/2023] Open
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21
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Favier J, Amar L, Gimenez-Roqueplo AP. Paraganglioma and phaeochromocytoma: from genetics to personalized medicine. Nat Rev Endocrinol 2015; 11:101-11. [PMID: 25385035 DOI: 10.1038/nrendo.2014.188] [Citation(s) in RCA: 309] [Impact Index Per Article: 34.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Paragangliomas and phaeochromocytomas are neuroendocrine tumours whose pathogenesis and progression are very strongly influenced by genetics. A germline mutation in one of the susceptibility genes identified so far explains ∼40% of all cases; the remaining 60% are thought to be sporadic cases. At least one-third of these sporadic tumours contain a somatic mutation in a predisposing gene. Genetic testing, which is indicated in every patient, is guided by the clinical presentation as well as by the secretory phenotype and the immunohistochemical characterization of the tumours. The diagnosis of an inherited form drives clinical management and tumour surveillance. Different 'omics' profiling methods have provided a neat classification of these tumours in accordance with their genetic background. Transcriptomic studies have identified two main molecular pathways that underlie development of these tumours, one in which the hypoxic pathway is activated (cluster 1) and another in which the MAPK and mTOR (mammalian target of rapamycin) signalling pathways are activated (cluster 2). DNA methylation profiling has uncovered a hypermethylator phenotype in tumours related to SDHx genes (a group of genes comprising SDHA, SDHB, SDHC, SDHD and SDHAF2) and revealed that succinate acts as an oncometabolite, inhibiting 2-oxoglutarate-dependent dioxygenases, such as hypoxia-inducible factor prolyl-hydroxylases and histone and DNA demethylases. 'Omics' data have suggested new therapeutic targets for patients with a malignant tumour. In the near future, new 'omics'-based tests are likely to be transferred into clinical practice with the goal of establishing personalized medical management for affected patients.
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Affiliation(s)
- Judith Favier
- INSERM, UMR 970, Paris Cardiovascular Research Centre, F-75015 Paris, France
| | - Laurence Amar
- Assistance Publique-Hôpitaux de Paris, Hôpital Européen Georges Pompidou, Unité d'Hypertension Artérielle, F-75015 Paris, France
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22
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Menegaux F, Chéreau N, Peix JL, Christou N, Lifante JC, Paladino N, Sebag F, Ghander C, Trésallet C, Mathonnet M. Management of adrenal incidentaloma. J Visc Surg 2014; 151:355-64. [DOI: 10.1016/j.jviscsurg.2014.07.002] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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23
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van Berkel A, Pacak K, Lenders JWM. Should every patient diagnosed with a phaeochromocytoma have a ¹²³ I-MIBG scintigraphy? Clin Endocrinol (Oxf) 2014; 81:329-33. [PMID: 24796657 DOI: 10.1111/cen.12482] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2014] [Revised: 04/21/2014] [Accepted: 04/25/2014] [Indexed: 11/28/2022]
Abstract
Localization of phaeochromocytomas and paragangliomas (PPGLs) should involve functional imaging as anatomical imaging modalities can either fail to locate the tumour or can be suboptimal due to an anatomical abnormality or previous surgery. Functional imaging is particularly useful to fully delineate the extent of disease using the whole-body scan and the evaluation of multifocality, metastatic or recurrent disease. An increasing number of radiolabeled tracers have become available for tumour visualization during the past decade. (123) I-meta-iodobenzylguanidine scintigraphy is the most widely used functional imaging modality, and its sensitivity to identify chromaffin cell tumours varies from 85 to 88% for phaeochromocytomas and 56-76% for paragangliomas, while specificity ranges between 70 and 100% and 84-100%, respectively.
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Affiliation(s)
- A van Berkel
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
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24
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25
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FDG PET in the evaluation of phaeochromocytoma: a correlative study with MIBG scintigraphy and Ki-67 proliferative index. Clin Imaging 2013; 37:1084-8. [PMID: 24035263 DOI: 10.1016/j.clinimag.2013.07.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2013] [Accepted: 07/24/2013] [Indexed: 01/31/2023]
Abstract
To compare 123I-metaiodobenzylguanidine (MIBG) and [Fluorine-18]-2-fluoro-2-deoxy-D-glucose (FDG) positron emission tomography (PET) in 22 patients with phaeochromocytomas and paragangliomas (PGL) retrospectively and to evaluate the correlation between FDG uptake and Ki-67 proliferative index. Fourteen of 17 (82%) patients at initial diagnosis had positive FDG uptake, more intensely in PGL. Eleven of 12 (92%) patients had positive MIBG uptake. PET and MIBG scintigraphy were concordant in 10 patients, discordant in 6. Combined results yielded no false negative findings and are complementary. Neither maximum standardised uptake value nor visual scores on MIBG correlated with Ki-67.
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26
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Abstract
Laparoscopic procedures are preferred by surgeons and patients alike because of decreased pain, reduced perioperative morbidity, and an earlier return to self-reliance. During the last decade, laparoscopic adrenalectomy has become the technique most commonly used for the removal of benign adrenal tumors. The indications for laparoscopy in malignant adrenal tumors remains controversial, because oncologic resections have not been reproducible compared with open techniques.
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Affiliation(s)
- Jennifer Creamer
- Department of General Surgery, William Beaumont Army Medical Center, 5005 North Piedras, El Paso, TX 79920, USA
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27
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Lowery AJ, Walsh S, McDermott EW, Prichard RS. Molecular and therapeutic advances in the diagnosis and management of malignant pheochromocytomas and paragangliomas. Oncologist 2013; 18:391-407. [PMID: 23576482 DOI: 10.1634/theoncologist.2012-0410] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Pheochromocytomas (PCCs) and paragangliomas (PGLs) are rare catecholamine-secreting tumors derived from chromaffin cells originating in the neural crest. These tumors represent a significant diagnostic and therapeutic challenge because the diagnosis of malignancy is frequently made in retrospect by the development of metastatic or recurrent disease. Complete surgical resection offers the only potential for cure; however, recurrence can occur even after apparently successful resection of the primary tumor. The prognosis for malignant disease is poor because traditional treatment modalities have been limited. The last decade has witnessed exciting discoveries in the study of PCCs and PGLs; advances in molecular genetics have uncovered hereditary and germline mutations of at least 10 genes that contribute to the development of these tumors, and increasing knowledge of genotype-phenotype interactions has facilitated more accurate determination of malignant potential. Elucidating the molecular mechanisms responsible for malignant transformation in these tumors has opened avenues of investigation into targeted therapeutics that show promising results. There have also been significant advances in functional and radiological imaging and in the surgical approach to adrenalectomy, which remains the mainstay of treatment for PCC. In this review, we discuss the currently available diagnostic and therapeutic options for patients with malignant PCCs and PGLs and detail the molecular rationale and clinical evidence for novel and emerging diagnostic and therapeutic strategies.
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Affiliation(s)
- Aoife J Lowery
- Department of Surgery, St. Vincent's University Hospital, Dublin, Ireland
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28
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Rufini V, Treglia G, Perotti G, Giordano A. The evolution in the use of MIBG scintigraphy in pheochromocytomas and paragangliomas. Hormones (Athens) 2013; 12:58-68. [PMID: 23624132 DOI: 10.1007/bf03401287] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Radioiodinated metaiodobenzylguanidine (MIBG) was developed in the late 1970's, at the Michigan University Medical Center, for imaging of the adrenal medulla and its diseases. Soon after, MIBG was shown to depict a wide range of tumors of neural crest origin other than pheochromocytomas/paragangliomas (Pheo/PGL) with the result that its use rapidly spread to many countries. After more than 30 years of clinical application, MIBG continues to be the most widespread radiopharmaceutical for the functional imaging of Pheo/PGL in spite of the emergent role of PET agents for detection of these tumors. In this paper we review the evolution in the use of MIBG over more than 30 years of experimental and clinical applications, with particular focus on the uptake mechanisms, pharmacokinetics, biodistribution and drug interaction as well as on clinical studies in Pheo/PGL also in comparison to other gamma-emitters tracers and PET radiopharmaceuticals.
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Affiliation(s)
- Vittoria Rufini
- Institute of Nuclear Medicine, Università Cattolica del Sacro Cuore, Rome, Italy.
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29
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Sisson JC, Yanik GA. Theranostics: evolution of the radiopharmaceutical meta-iodobenzylguanidine in endocrine tumors. Semin Nucl Med 2012; 42:171-84. [PMID: 22475426 DOI: 10.1053/j.semnuclmed.2011.11.004] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Since 1981, meta-iodobenzylguanidine (MIBG), labeled with (131)I and later (123)I, has become a valuable agent in the diagnosis and therapy of a number of endocrine tumors. Initially, the agent located pheochromocytomas and paragangliomas (PGLs), both sporadic and familial, in multiple anatomic sites; surgeons were thereby guided to excisional therapies, which were previously difficult and sometimes impossible. The specificity in diagnosis has remained above 95%, but sensitivity has varied with the nature of the tumor: close to 90% for intra-adrenal pheochromocytomas but 70% or less for PGLs. For patients with neuroblastoma, carcinoid tumors, and medullary thyroid carcinoma, imaging with radiolabeled MIBG portrays important diagnostic evidence, but for these neoplasms, use has been primarily as an adjunct to therapy. Although diagnosis by radiolabeled MIBG has been supplemented and sometimes surpassed by newer scintigraphic agents, searches by this radiopharmaceutical remain indispensable for optimal care of some patients. The radiation imparted by concentrations of (131)I-MIBG in malignant pheochromocytomas, PGLs, carcinoid tumors, and medullary thyroid carcinoma has reduced tumor volumes and lessened excretions of symptom-inflicting hormones, but its value as a therapeutic agent is being fulfilled primarily in attacks on neuroblastomas, which are scourges of children. Much promise has been found in tumor disappearance and prolonged survival of treated patients. The experiences with therapeutic (131)I-MIBG have led to development of new tactics and strategies and to well-founded hopes for elimination of cancers. Radiolabeled MIBG is an exemplar of theranostics and remains a worthy agent for both diagnosis and therapy of endocrine tumors.
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Affiliation(s)
- James C Sisson
- Division of Nuclear Medicine, Department of Radiology, University of Michigan Health System, Ann Arbor, MI 48103-5028, USA.
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30
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Taïeb D, Timmers HJ, Hindié E, Guillet BA, Neumann HP, Walz MK, Opocher G, de Herder WW, Boedeker CC, de Krijger RR, Chiti A, Al-Nahhas A, Pacak K, Rubello D. EANM 2012 guidelines for radionuclide imaging of phaeochromocytoma and paraganglioma. Eur J Nucl Med Mol Imaging 2012; 39:1977-95. [PMID: 22926712 DOI: 10.1007/s00259-012-2215-8] [Citation(s) in RCA: 156] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2012] [Accepted: 07/31/2012] [Indexed: 10/27/2022]
Abstract
PURPOSE Radionuclide imaging of phaeochromocytomas (PCCs) and paragangliomas (PGLs) involves various functional imaging techniques and approaches for accurate diagnosis, staging and tumour characterization. The purpose of the present guidelines is to assist nuclear medicine practitioners in performing, interpreting and reporting the results of the currently available SPECT and PET imaging approaches. These guidelines are intended to present information specifically adapted to European practice. METHODS Guidelines from related fields, issued by the European Association of Nuclear Medicine and the Society of Nuclear Medicine, were taken into consideration and are partially integrated within this text. The same was applied to the relevant literature, and the final result was discussed with leading experts involved in the management of patients with PCC/PGL. The information provided should be viewed in the context of local conditions, laws and regulations. CONCLUSION Although several radionuclide imaging modalities are considered herein, considerable focus is given to PET imaging which offers high sensitivity targeted molecular imaging approaches.
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Affiliation(s)
- David Taïeb
- Department of Nuclear Medicine, La Timone University Hospital, CERIMED, Aix-Marseille University, France.
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31
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Naji M, AL-Nahhas A. ⁶⁸Ga-labelled peptides in the management of neuroectodermal tumours. Eur J Nucl Med Mol Imaging 2012; 39 Suppl 1:S61-7. [PMID: 22388623 DOI: 10.1007/s00259-011-1990-y] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Neuroectodermal tumours arise from chromaffin cells and possess the ability to secrete catecholamines. They are generally rare and may occur in association with a variety of hereditary syndromes such as MEN-2A and 2B, neurofibromatosis type 1 and von Hippel-Lindau disease. The most common types are phaeochromocytoma arising from the adrenal medulla and paraganglioma of extra-adrenal origin. Phaeochromocytomas tend to be benign and are often associated with a gene mutation if the disease is bilateral, while paragangliomas are often malignant, have a more aggressive nature and tend to metastasize. There are no specific histological or immunohistochemical features that indicate the malignant potential and the diagnosis of malignancy can only be established by the presence of distant metastases. Therefore, imaging can play a vital role in the diagnosis, localization, staging and assessment of spread. Traditionally, this is achieved with a combination of cross-sectional (CT and MRI) and functional ((123)I-MIBG or (111)In-octreotide) imaging. However, these modalities are not adequate and achieve moderate sensitivity. The introduction of (68)Ga-DOTA peptide in PET/CT imaging has led to improved receptor targeting and superb PET resolution, as well as accurate localization of lesions. The use of this technique in neuroectodermal tumours has been shown to be superior to all available modalities, but the available data are limited and larger studies are awaited to establish its role in the management of these tumours.
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Affiliation(s)
- Meeran Naji
- Departments of Nuclear Medicine and Radiology, Maidstone and Tunbridge Wells NHS Trust, Maidstone, UK
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32
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Chen CC, Carrasquillo JA. Molecular imaging of adrenal neoplasms. J Surg Oncol 2012; 106:532-42. [PMID: 22628250 DOI: 10.1002/jso.23162] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2012] [Accepted: 04/29/2012] [Indexed: 11/08/2022]
Abstract
The adrenal glands are complex structures from which a variety of benign and malignant tumors may arise and are a common site of metastatic disease. Several radiopharmaceuticals are used for imaging the adrenals, including I-123/I-131 metaiodobenzylguanidine (MIBG), norcholesterol derivatives, In-111 pentetreotide and Ga-68 somatostatin analogs, [F-18]fluorodeoxyglucose, [F-18]fluorodopa, [F-18]fluorodopamine, C-11 meta hydroxyephedrine, and C-11/F-18/I-123 Metomidate (MTO) or its analogs. In this review we focus on the role of these reagents in metastatic lesions, cortical neoplasms, pheochromocytoma/paraganglioma, and neuroblastoma (NB).
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Affiliation(s)
- Clara C Chen
- Division of Nuclear Medicine, Department of Radiology and Imaging Sciences, Clinical Center, National Institutes of Health, Bethesda, Maryland, USA
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33
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Timmers HJLM, Taieb D, Pacak K. Current and future anatomical and functional imaging approaches to pheochromocytoma and paraganglioma. Horm Metab Res 2012; 44:367-72. [PMID: 22399235 PMCID: PMC4714588 DOI: 10.1055/s-0031-1299712] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
After establishing a biochemical diagnosis, pheochromocytomas and extra-adrenal paragangliomas (PPGLs) can be localized using different anatomical and functional imaging modalities. These include computed tomography, magnetic resonance imaging, single-photon emission computed tomography (SPECT) using 123I-metaiodobenzylguanidine or 111In-DTPA-pentetreotide, and positron emission tomography (PET) using 6-[18F]-fluorodopamine (18F-FDA), 6-[18F]-fluoro-l-3,4-dihydroxyphenylalanine (18F-DOPA), and 2-[18F]-fluoro-2-deoxy-d-glucose. We review the currently available data on the performance of anatomical imaging, SPECT, and PET for the detection of (metastatic) PPGL as well as parasympathetic head and neck paragangliomas. We show that there appears to be no 'gold-standard' imaging technique for all patients with (suspected) PPGL. A tailor-made approach is warranted, guided by clinical, biochemical, and genetic characteristics. In the current era of a growing number of PET tracers, PPGL imaging has moved beyond tumor localization towards functional characterization of tumors.
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Affiliation(s)
- H. J. L. M. Timmers
- Department of Endocrinology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - D. Taieb
- Department of Nuclear Medicine, La Timone University Hospital, Aix-Marseille University, Marseille, France
| | - K. Pacak
- Program in Reproductive and Adult Endocrinology, Eunice Kennedy Shriver National Institutes of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA
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Oh JR, Kulkarni H, Carreras C, Schalch G, Min JJ, Baum RP. Ga-68 Somatostatin Receptor PET/CT in von Hippel-Lindau Disease. Nucl Med Mol Imaging 2012; 46:129-33. [PMID: 24900047 DOI: 10.1007/s13139-012-0133-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2011] [Revised: 02/26/2012] [Accepted: 03/15/2012] [Indexed: 01/16/2023] Open
Abstract
Von Hippel-Lindau (VHL) disease is a dominantly inherited familial cancer syndrome with a variety of benign and malignant tumors such as retinal and central nervous system hemangioblastomas, endolymphatic sac tumors, renal cysts and tumors, pancreatic cysts and tumors, pheochromocytomas, and epididymal cystadenomas. Cross-sectional modalities (computed tomography and magnetic resonance imaging) as well as ultrasound play a major role in the initial evaluation and follow-up of the various manifestations of VHL disease. Ga-68-labeled somatostatin receptor analogs already have a significant role in the diagnosis, staging, and therapy management of neuroendocrine neoplasms and neural crest tumors. Herein, we report a case presenting a variety of malignancies in VHL and showing the usefulness of Ga-68 somatostatin receptor PET/CT as a one-stop-shop imaging modality in the management of VHL disease.
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Affiliation(s)
- Jong-Ryool Oh
- Department of Nuclear Medicine, Chonnam National University Hwasun Hospital, Hwasun, South Korea
| | - Harshad Kulkarni
- Department of Nuclear Medicine and Center for PET/CT, Zentralklinik Bad Berka, 99437 Bad Berka, Germany
| | - Cecilia Carreras
- Department of Nuclear Medicine and Center for PET/CT, Zentralklinik Bad Berka, 99437 Bad Berka, Germany
| | - Georg Schalch
- Department of Nuclear Medicine and Center for PET/CT, Zentralklinik Bad Berka, 99437 Bad Berka, Germany
| | - Jung-Joon Min
- Department of Nuclear Medicine, Chonnam National University Hwasun Hospital, Hwasun, South Korea
| | - Richard P Baum
- Department of Nuclear Medicine and Center for PET/CT, Zentralklinik Bad Berka, 99437 Bad Berka, Germany
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Timmers HJLM, Chen CC, Carrasquillo JA, Whatley M, Ling A, Eisenhofer G, King KS, Rao JU, Wesley RA, Adams KT, Pacak K. Staging and functional characterization of pheochromocytoma and paraganglioma by 18F-fluorodeoxyglucose (18F-FDG) positron emission tomography. J Natl Cancer Inst 2012; 104:700-8. [PMID: 22517990 DOI: 10.1093/jnci/djs188] [Citation(s) in RCA: 176] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Pheochromocytomas and paragangliomas (PPGLs) are rare tumors of the adrenal medulla and extra-adrenal sympathetic chromaffin tissues; their anatomical and functional imaging are critical to guiding treatment decisions. This study aimed to compare the sensitivity and specificity of (18)F-fluorodeoxyglucose positron emission tomography with computed tomography ((18)F-FDG PET/CT) for tumor localization and staging of PPGLs with that of conventional imaging by [(123)I]-metaiodobenzylguanidine single photon emission CT ((123)I-MIBG SPECT), CT, and magnetic resonance imaging (MRI). METHODS A total of 216 patients (106 men, 110 women, aged 45.2 ± 14.9 years) with suspected PPGL underwent CT or MRI, (18)F-FDG PET/CT, and (123)I-MIBG SPECT/CT. Sensitivity and specificity were measured as endpoints and compared by the McNemar test, using two-sided P values only. RESULTS Sixty (28%) of patients had nonmetastatic PPGL, 95 (44%) had metastatic PPGL, and 61 (28%) were PPGL negative. For nonmetastatic tumors, the sensitivity of (18)F-FDG was similar to that of (123)I-MIBG but less than that of CT/MRI (sensitivity of (18)F-FDG = 76.8%; of (123)I-MIBG = 75.0%; of CT/MRI = 95.7%; (18)F-FDG vs (123)I-MIBG: difference = 1.8%, 95% confidence interval [CI] = -14.8% to 14.8%, P = .210; (18)F-FDG vs CT/MRI: difference = 18.9%, 95% CI = 9.4% to 28.3%, P < .001). The specificity was 90.2% for (18)F-FDG, 91.8% for (123)I-MIBG, and 90.2% for CT/MRI. (18)F-FDG uptake was higher in succinate dehydrogenase complex- and von Hippel-Lindau syndrome-related tumors than in multiple endocrine neoplasia type 2 (MEN2) related tumors. For metastases, sensitivity was greater for (18)F-FDG and CT/MRI than for (123)I-MIBG (sensitivity of (18)F-FDG = 82.5%; of (123)I-MIBG = 50.0%; of CT/MRI = 74.4%; (18)F-FDG vs (123)I-MIBG: difference = 32.5%, 95% CI = 22.3% to 42.5%, P < .001; CT/MRI vs (123)I-MIBG: difference = 24.4%, 95% CI = 11.3% to 31.6%, P < .001). For bone metastases, (18)F-FDG was more sensitive than CT/MRI (sensitivity of (18)F-FDG = 93.7%; of CT/MRI = 76.7%; difference = 17.0%, 95% CI = 4.9% to 28.5%, P = .013). CONCLUSIONS Compared with (123)I-MIBG SPECT and CT/MRI, both considered gold standards for PPGL imaging, metastases were better detected by (18)F-FDG PET. (18)F-FDG PET provides a high specificity in patients with a biochemically established diagnosis of PPGL.
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Affiliation(s)
- Henri J L M Timmers
- Department of Endocrinology and Department of Laboratory Medicine, Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands
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Weisbrod AB, Kitano M, Gesuwan K, Millo C, Herscovitch P, Nilubol N, Linehan WM, Kebebew E. Clinical utility of functional imaging with ¹⁸F-FDOPA in Von Hippel-Lindau syndrome. J Clin Endocrinol Metab 2012; 97:E613-7. [PMID: 22259055 PMCID: PMC3319180 DOI: 10.1210/jc.2011-2626] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
CONTEXT Von Hippel-Lindau (VHL) syndrome is an inherited cancer syndrome in which patients are at risk of developing multiple tumors in different organs. 6-L-¹⁸F-fluorodihydroxyphenylalanine (¹⁸F-FDOPA) positron emission tomography (PET) is a relatively new metabolic imaging tracer proposed for the use of localizing sites of neuroendocrine tumors. There are limited data on the clinical utility of using ¹⁸F-FDOPA PET for identifying neuroendocrine tumors in a high-risk population such as VHL. OBJECTIVE The aim of this prospective study was to evaluate the clinical utility of ¹⁸F-FDOPA PET in patients with VHL-related tumors. DESIGN Radiological findings were prospectively collected from four imaging modalities: computed tomography, magnetic resonance imaging (MRI), ¹⁸F-fluorodeoxyglucose PET, and ¹⁸F-FDOPA PET. ¹⁸F-FDOPA PET findings were compared with those from other imaging modalities, as well as with clinical and laboratory data, and pathology findings if patients underwent an operation. RESULTS In 52 patients with VHL, 390 lesions were identified by computed tomography (n = 139), MRI (n = 117), ¹⁸F-fluorodeoxyglucose PET (n = 94), and ¹⁸F-FDOPA PET (n = 40). ¹⁸F-FDOPA PET identified 20 pancreatic and 20 extrapancreatic tumors, including lesions in the adrenal gland (n = 11), kidney (n = 3), liver (n = 4), lung (n = 1), and cervical paraganglioma (n = 1). These tumor sites were not seen by conventional imaging studies in 9.6% of patients and 4.4% of lesions. Seven of eight patients who had an ¹⁸F-FDOPA PET-positive lesion underwent resection, and pathology showed a neuroendocrine tumor. Four of 10 patients with positive adrenal uptake had elevated catecholamine levels, and six of 10 patients had a discrete mass on axial imaging. CONCLUSIONS ¹⁸F-FDOPA PET is a useful complementary imaging study to detect neuroendocrine tumors in patients with VHL undergoing surveillance, especially in those suspected to have adrenal pheochromocytoma or unusual ectopic locations.
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Affiliation(s)
- Allison B Weisbrod
- Endocrine Oncology Section, Surgery Branch, National Cancer Institute, National Institutes of Health, Clinical Research Center, Building 10-CRC, Room 3-3940, 10 Center Drive, MSC 1201, Bethesda, Maryland 20892, USA
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Fonte JS, Robles JF, Chen CC, Reynolds J, Whatley M, Ling A, Mercado-Asis LB, Adams KT, Martucci V, Fojo T, Pacak K. False-negative ¹²³I-MIBG SPECT is most commonly found in SDHB-related pheochromocytoma or paraganglioma with high frequency to develop metastatic disease. Endocr Relat Cancer 2012; 19:83-93. [PMID: 22167067 PMCID: PMC3420013 DOI: 10.1530/erc-11-0243] [Citation(s) in RCA: 81] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
The purpose of this study was to present the characteristics and outcome of patients with proven pheochromocytoma or paraganglioma who had false-negative iodine-123 metaiodobenzylguanidine single photon emission computed tomography ((123)I-MIBG SPECT). Twenty-one patients with false-negative (123)I-MIBG SPECT (7 males, 14 females), aged 13-55 years (mean: 41.40 years), were included. We classified them as nonmetastatic or metastatic according to the stage of the disease at the time of false-negative (123)I-MIBG SPECT study, the location and size of the tumor, plasma and urinary catecholamine and metanephrine levels, genetic mutations, and outcome in terms of occurrence and progression of metastases and death. Thirteen patients were evaluated for metastatic tumors, while the remaining eight were seen for nonmetastatic disease. All primary tumors and multiple metastatic foci did not show avid (123)I-MIBG uptake regardless of the tumor diameter. The majority of patients had extraadrenal tumors with hypersecretion of normetanephrine or norepinephrine. SDHB mutations were present in 52% (n=11) of cases, RET mutation in 4% (n=1), and the rest were apparently sporadic. Twenty-four percent (n=5) had metastatic disease on initial presentation. Fourteen patients were followed for 3-7 years. Of them, 71% (n=10) had metastatic disease and the majority had SDHB mutations. Nine are still alive, while five (four with SDHB) died due to metastatic disease. We concluded that false-negative (123)I-MIBG SPECT is frequently related to metastatic tumors and usually due to SDHB mutations with unfavorable prognosis. We therefore recommend that patients with false-negative (123)I-MIBG SPECT be tested for SDHB mutations and undergo more regular and close follow-up.
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Affiliation(s)
- Jay S Fonte
- Program in Reproductive and Adult Endocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland 20892, USA
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Taïeb D, Neumann H, Rubello D, Al-Nahhas A, Guillet B, Hindié E. Modern Nuclear Imaging for Paragangliomas: Beyond SPECT. J Nucl Med 2012; 53:264-74. [DOI: 10.2967/jnumed.111.098152] [Citation(s) in RCA: 73] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
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Blanchet EM, Martucci V, Pacak K. Pheochromocytoma and paraganglioma: current functional and future molecular imaging. Front Oncol 2012; 1:58. [PMID: 22655253 PMCID: PMC3356140 DOI: 10.3389/fonc.2011.00058] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2011] [Accepted: 12/19/2011] [Indexed: 11/23/2022] Open
Abstract
Paragangliomas are neural crest-derived tumors, arising either from chromaffin sympathetic tissue (in adrenal, abdominal, intra-pelvic, or thoracic paraganglia) or from parasympathetic tissue (in head and neck paraganglia). They have a specific cellular metabolism, with the ability to synthesize, store, and secrete catecholamines (although most head and neck paragangliomas do not secrete any catecholamines). This disease is rare and also very heterogeneous, with various presentations (e.g., in regards to localization, multifocality, potential to metastasize, biochemical phenotype, and genetic background). With growing knowledge, notably about the pathophysiology and genetic background, guidelines are evolving rapidly. In this context, functional imaging is a challenge for the management of paragangliomas. Nuclear imaging has been used for exploring paragangliomas for the last three decades, with MIBG historically as the first-line exam. Tracers used in paragangliomas can be grouped in three different categories. Agents that specifically target catecholamine synthesis, storage, and secretion pathways include: 123 and 131I-metaiodobenzylguanidine (123/131I-MIBG), 18F-fluorodopamine (18F-FDA), and 18F-fluorodihydroxyphenylalanine (18F-FDOPA). Agents that bind somatostatin receptors include 111In-pentetreotide and 68Ga-labeled somatostatin analog peptides (68Ga-DOTA-TOC, 68Ga-DOTA-NOC, 68Ga-DOTA-TATE). The non-specific agent most commonly used in paragangliomas is 18F-fluorodeoxyglucose (18F-FDG). This review will first describe conventional scintigraphic exams that are used for imaging paragangliomas. In the second part we will emphasize the interest in new PET approaches (specific and non-specific), considering the growing knowledge about genetic background and pathophysiology, with the aim of understanding how tumors behave, and optimally adjusting imaging technique for each tumor type.
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Affiliation(s)
- Elise M Blanchet
- Department of Nuclear Medicine, Centre Hospitalo-Universitaire d'Angers Angers, France
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Malignant pheochromocytomas and paragangliomas: a diagnostic challenge. Langenbecks Arch Surg 2011; 397:155-77. [PMID: 22124609 DOI: 10.1007/s00423-011-0880-x] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2011] [Accepted: 11/14/2011] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Malignant pheochromocytomas (PCCs) and paragangliomas (PGLs) are rare disorders arising from the adrenal gland, from the glomera along parasympathetic nerves or from paraganglia along the sympathetic trunk. According to the WHO classification, malignancy of PCCs and PGLs is defined by the presence of metastases at non-chromaffin sites distant from that of the primary tumor and not by local invasion. The overall prognosis of metastasized PCCs/PGLs is poor. Surgery offers currently the only change of cure. Preferably, the discrimination between malignant and benign PCCs/PGLs should be made preoperatively. METHODS This review summarizes our current knowledge on how benign and malignant tumors can be distinguished. CONCLUSION Due to the rarity of malignant PCCs/PGLs and the obvious difficulties in distinguishing benign and malignant PCCs/PGLs, any patient with a PCC/PGL should be treated in a specialized center where a multidisciplinary setting with specialized teams consisting of radiologists, endocrinologist, oncologists, pathologists and surgeons is available. This would also facilitate future studies to address the existing diagnostic and/or therapeutic obstacles.
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Wong KK, Arabi M, Bou-Assaly W, Marzola MC, Rubello D, Gross MD. Evaluation of incidentally discovered adrenal masses with PET and PET/CT. Eur J Radiol 2011; 81:441-50. [PMID: 21295930 DOI: 10.1016/j.ejrad.2010.12.060] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2010] [Accepted: 12/23/2010] [Indexed: 12/21/2022]
Abstract
BACKGROUND AND PURPOSE Incidentally discovered adrenal masses are commonly seen with high resolution diagnostic imaging performed for indications other than adrenal disease. Although the majority of these masses are benign and non-secretory, their unexpected discovery prompts further biochemical and often repeated imaging evaluations, sufficient to identify hormonally active adrenal masses and/or primary or metastatic neoplasms to the adrenal(s). In the present paper we investigate the role of PET and PET/CT for the detection of adrenal incidentalomas in comparison with CT and MRI. MATERIALS AND METHODS a systematic revision of the papers published in PubMed/Medline until September 2010 was done. RESULTS The diagnostic imaging approach to incidentally discovered adrenal masses includes computed tomography (CT), magnetic resonance imaging (MRI) and more recently positron emission tomography (PET) with radiopharmaceuticals designed to exploit mechanisms of cellular metabolism, adrenal substrate precursor uptake, or receptor binding. CONCLUSION The functional maps created by PET imaging agents and the anatomic information provided by near-simultaneously acquired, co-registered CT facilitates localization and diagnosis of adrenal dysfunction, distinguishes unilateral from bilateral disease, and aids in characterizing malignant primary and metastatic adrenal disease.
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Affiliation(s)
- Ka Kit Wong
- Department of Nuclear Medicine, Veterans Affairs Hospital, and University of Michigan Health System, Department of Radiology, Division of Nuclear Medicine, Ann Arbor, MI 48105, USA.
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Abstract
Neuroendocrine tumors (NET) are a heterogeneous group of tumors that arise from neuroendocrine cells. These tumors may arise from various organs, including lung, thymus, thyroid, stomach, duodenum, small bowel, large bowel, appendix, pancreas, adrenal, and skin. Most are well differentiated and have the ability to produce biogenic amines and various hormones. NET usually occur sporadically but they also be associated with various familial syndromes. For the vast majority of NET, surgical resection is the treatment of choice whenever feasible. Localization of NET prior to surgery and for staging and follow-up relies on both anatomic and functional imaging modalities. In fact, the unique secretory characteristics of these tumors lend themselves to imaging by molecular imaging modalities, which can target specific metabolic pathways or receptors. Neuroendocrine cells have a variety of such target receptors and pathways for which radiopharmaceuticals have been developed, including [(123)I/(131)I]-metaiodobenzylguanidine (MIBG), [(111)In]pentetreotide, [(68)Ga] somatostatin analogs, [(18)F] fluorodeoxyglucose (FDG), [(11)C/(18)F] dihydroxyphenylalanine (DOPA), [(11)C] 5-hydroxytryptophan (5-HTP) (99m)Tc pentavalent dimercaptosuccinic acid ([(99m)Tc] (V) DMSA, and [(18)F] fluorodopamine (FDA). Here, we review the molecular imaging approaches for NET using various radiopharmaceuticals.
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Affiliation(s)
- Jorge A Carrasquillo
- Nuclear Medicine Service, Radiology Department Memorial Sloan-Kettering, New York, NY, USA.
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Abstract
Neuroendocrine tumors (NET) have several distinct pathophysiological features that can be addressed by specific radiolabeled probes. An overview on the different radiopharmaceuticals that have been developed for positron emission tomography (PET) of NET are presented. The focus is on fluordeoxyglucose (F-18 FDG), biogenic amine precursors, somatostatin analogs, and hormone syntheses markers. Due to the highly specific tracers lacking any clear anatomical landmarking, the advantages of integrated functional and morphological imaging systems such as PET-CT are obvious. Based on the up to now published literature and one's own experience, it is concluded that amine precursors (e.g. fluor-dihydroxyphenylalanin and hydroxytryptophane) should be employed in most gastroenteropancreatic NET, whereas F-18 FDG should be preserved for more aggressive less-differentiated NETs. Hormone syntheses markers have up to now only been used in few centers and their broad clinical value remains uncertain. The different available somatostatin analogs are the most promising tracers, since they can improve dosimetry in cases where peptide receptor radiotherapies are planned. Of specific interest are the somatostatin analogs addressing several subtypes of the somatostatin receptor (e.g. DOTANOC) that allow detecting also subtypes not expressing the "classically" addressed subtype 2 and 5. Since NET have a high variety of different features, the individual diagnostic approach using PET or integrated PET-CT should be tailored, depending on the histological classification and the differentiation of the tumor.
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Havekes B, King K, Lai EW, Romijn JA, Corssmit EPM, Pacak K. New imaging approaches to phaeochromocytomas and paragangliomas. Clin Endocrinol (Oxf) 2010; 72:137-45. [PMID: 19508681 PMCID: PMC2966973 DOI: 10.1111/j.1365-2265.2009.03648.x] [Citation(s) in RCA: 99] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Formerly used concepts for phaeochromocytomas and paragangliomas have been challenged by recent discoveries that at least 24% of tumours are familial and thereby often multiple in various locations throughout the body. Furthermore, tumours are often malignant and perhaps more aggressive if associated with SDHB gene mutations. Some paragangliomas are clinically silent and may present only with dopamine hypersecretion. In the current era where CT and MRI are more commonly used, tumours are more often found as incidentalomas and MRI may be less specific for phaeochromocytoma and paraganglioma than previously thought. Because of unique tumour characteristics (e.g. the presence of cell membrane and intracellular vesicular norepinephrine transporters) these tumours were 'born' to be imaged by means of specific functional imaging approaches. Moreover, additional recent discoveries related to apoptosis, hypoxia, acidosis, anaerobic glycolysis and angiogenesis, often disturbed in tumour cells, open new options and challenges to specifically image phaeochromocytomas and paragangliomas and possibly link those results to their pathophysiology, genotypic alterations and metastatic potential. Functional imaging, especially represented by positron emission tomography (PET), offers an excellent approach by which tumour-specific processes can be detected, evaluated and seen in the context of tumour-specific behaviour and its genetic signature. In this review, we address the recent developments in new functional imaging modalities for phaeochromocytoma and paraganglioma and provide the reader with suggested imaging approaches in various phaeochromocytomas and paragangliomas of sympathetic origin. Current imaging algorithms of head and neck parasympathetic paragangliomas are not discussed. Finally, this review outlines some future perspectives of functional imaging of these tumours.
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Affiliation(s)
- Bas Havekes
- Department of Internal Medicine, Division of Endocrinology, University Hospital Maastricht, Maastricht, The Netherlands
- Reproductive and Adult Endocrinology Program, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland, USA
| | - Kathryn King
- Reproductive and Adult Endocrinology Program, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland, USA
| | - Edwin W. Lai
- Reproductive and Adult Endocrinology Program, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland, USA
| | - Johannes A. Romijn
- Department of Endocrinology and Metabolism, Leiden University Medical Center, Leiden, The Netherlands
| | - Eleonora P. M. Corssmit
- Department of Endocrinology and Metabolism, Leiden University Medical Center, Leiden, The Netherlands
| | - Karel Pacak
- Reproductive and Adult Endocrinology Program, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland, USA
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Naji M, Hodolic M, El-Refai S, Khan S, Marzola MC, Rubello D, Al-Nahhas A. Endocrine tumors: the evolving role of positron emission tomography in diagnosis and management. J Endocrinol Invest 2010; 33:54-60. [PMID: 19820296 DOI: 10.1007/bf03346550] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Endocrine tumors comprise a range of benign and malignant conditions that produce a spectrum of clinical symptoms and signs depending on the specific hormones they produce. The symptoms and presentations of these tumors are often independent of their size and location. Because of their expression of cell membrane receptors or production of specific types of hormones or peptides, endocrine tumors can be identified with functional radionuclide imaging much more readily compared to standard cross-sectional imaging. In recent years, 18F-fluoro-deoxy- D-glucose positron emission tomography (18F-FDG-PET) has emerged as a useful tool for diagnosing and assessing many tumors. In this review we describe how PET, using 18F-FDG and other radiopharmaceuticals can be useful in the diagnosis and management of a wide range of endocrine tumors.
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Affiliation(s)
- M Naji
- Department for Nuclear Medicine, Hammersmith Hospital, London, UK
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Timmers HJLM, Chen CC, Carrasquillo JA, Whatley M, Ling A, Havekes B, Eisenhofer G, Martiniova L, Adams KT, Pacak K. Comparison of 18F-fluoro-L-DOPA, 18F-fluoro-deoxyglucose, and 18F-fluorodopamine PET and 123I-MIBG scintigraphy in the localization of pheochromocytoma and paraganglioma. J Clin Endocrinol Metab 2009; 94:4757-67. [PMID: 19864450 PMCID: PMC2795662 DOI: 10.1210/jc.2009-1248] [Citation(s) in RCA: 310] [Impact Index Per Article: 20.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
CONTEXT Besides (123)I-metaiodobenzylguanidine (MIBG), positron emission tomography (PET) agents are available for the localization of paraganglioma (PGL), including (18)F-3,4-dihydroxyphenylalanine (DOPA), (18)F-fluoro-2-deoxy-D-glucose ((18)F-FDG), and (18)F-fluorodopamine ((18)F-FDA). OBJECTIVE The objective of the study was to establish the optimal approach to the functional imaging of PGL and examine the link between genotype-specific tumor biology and imaging. DESIGN This was a prospective observational study. INTERVENTION There were no interventions. PATIENTS Fifty-two patients (28 males, 24 females, aged 46.8 +/- 14.2 yr): 20 with nonmetastatic PGL (11 adrenal), 28 with metastatic PGL (13 adrenal), and four in whom PGL was ruled out; 22 PGLs were of the succinate dehydrogenase subunit B (SDHB) genotype. MAIN OUTCOME MEASURES Sensitivity of (18)F-DOPA, (18)F-FDG, and (18)F-FDA PET, (123)I-MIBG scintigraphy, computed tomography (CT), and magnetic resonance imaging (MRI) for the localization of PGL were measured. RESULTS Sensitivities for localizing nonmetastatic PGL were 100% for CT and/or MRI, 81% for (18)F-DOPA PET, 88% for (18)F-FDG PET/CT, 78% for (18)F-FDA PET/CT, and 78% for (123)I-MIBG scintigraphy. For metastatic PGL, sensitivity in reference to CT/MRI was 45% for (18)F-DOPA PET, 74% for (18)F-FDG PET/CT, 76% for (18)F-FDA PET/CT, and 57% for (123)I-MIBG scintigraphy. In patients with SDHB metastatic PGL, (18)F-FDA and (18)F-FDG have a higher sensitivity (82 and 83%) than (123)I-MIBG (57%) and (18)F-DOPA (20%). CONCLUSIONS (18)F-FDA PET/CT is the preferred technique for the localization of the primary PGL and to rule out metastases. Second best, equal alternatives are (18)F-DOPA PET and (123)I-MIBG scintigraphy. For patients with known metastatic PGL, we recommend (18)F-FDA PET in patients with an unknown genotype, (18)F-FDG or (18)F-FDA PET in SDHB mutation carriers, and (18)F-DOPA or (18)F-FDA PET in non-SDHB patients.
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Affiliation(s)
- Henri J L M Timmers
- Reproductive and Adult Endocrinology Program, Eunice Kennedy Shriver National Institutes of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland 20892, USA.
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Abstract
Pheochromocytomas/paragangliomas(PHEOs/PGLs) are rare but treacherous catecholamine-producing tumors which, if overlooked or improperly treated, will almost invariably prove fatal. Patients with MEN2 PHEOs have a high incidence of paroxysmal attacks and a higher prevalence of hypertension and other cardiovascular problems than do patients with Von-Hippel-Lindau (VHL) PHEOs. Compared to measurements of deconjugated metanephrines, plasma concentrations of free metanephrines are relatively independent of renal function and therefore more suitable for diagnosis of PHEO/PGL. Recently, the focus of Positron Emission Tomography (PET) imaging for these tumors has been the localization of PHEO. Although a limited number of studies are available, [18F]-fluorodopamine ([18F]DA) PET has been found to be the best overall imaging modality in the localization of PHEO. For adrenal PHEOs, this method seems to be comparable to other functional modalities such as [18F]-fluorodopa ([18F]DOPA) PET or [123I]-metaiodobenzylguanidine ([123I]MIBG)scintigraphy. For extraadrenal PHEOs, data are limited and more extensive studies are needed. In patients with metastatic PHEO, the sensitivity of [18F]DA PET is superior to [123I]MIBG. The so called "flip-flop" imaging showing superiority of non-specific [18F] flurodeoxyglucose (FDG) PET over specific [18F]DA PET has been described in rapidly progressive, often metastatic SDHB-associated PHEOs. Whether these data reflect PHEO cell dedifferentiation (e.g. losing Norepinephrine Transporter-NET) or increased metabolic rate remains to be established.
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Affiliation(s)
- Karel Pacak
- Reproductive and Adult Endocrinology Program, Section of Medical Neuroendocrinology, NICHD, National Institutes of Health, Bethesda, USA
| | - Graeme Eisenhofer
- Institute of Clinical Chemistry and Laboratory Medicine, Department of Medicine, University of Dresden, Dresden, Germany
| | - Ioannis Ilias
- Department of Endocrinology, “Elena Venizelou” Hospital, Athens, Greece
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Imani F, Agopian VG, Auerbach MS, Walter MA, Imani F, Benz MR, Dumont RA, Lai CK, Czernin JG, Yeh MW. 18F-FDOPA PET and PET/CT accurately localize pheochromocytomas. J Nucl Med 2009; 50:513-9. [PMID: 19289420 DOI: 10.2967/jnumed.108.058396] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
UNLABELLED Successful treatment of pheochromocytoma requires accurate diagnosis and localization of tumors. Herein, we investigated the accuracy of PET using 3,4-dihydroxy-6-(18)F-fluoro-phenylalanine ((18)F-FDOPA), an amino acid transporter substrate, as an independent marker for detection of benign and malignant pheochromocytomas. METHODS The study comprised 25 consecutive patients (9 men, 16 women) whose median age was 51 y (range, 25-68 y), with known or suspected pheochromocytoma. Eleven patients underwent standardized (18)F-FDOPA PET and 14 patients underwent (18)F-FDOPA PET/CT studies, with a median of 511 MBq of (18)F-FDOPA (range, 206-625 MBq). Two readers, unaware of the reports of other imaging studies and clinical data, analyzed all scans visually and quantitatively (maximum standardized uptake value [SUVmax] and maximum transverse diameter). Histology and long-term clinical follow-up served as the gold standard. Correlation between SUVmax of tumors and biochemical markers was evaluated. SUVmax of the benign and malignant tumors was compared. RESULTS Seventeen patients underwent surgery. Histology confirmed pheochromocytoma or paraganglioma in 11 cases (8 adrenal, including 2 malignant tumors, and 3 extraadrenal, including 1 malignant tumor). The diagnosis of pheochromocytoma was established by follow-up in 2 additional patients (1 adrenal and 1 unknown location) and ruled out in 6 patients. Visual analysis detected and localized pheochromocytoma in 11 of 13 patients without false-positive results (sensitivity, 84.6%; specificity, 100%; accuracy, 92%). These lesions had an SUVmax of 2.3-34.9 (median, 8.3). Evaluation of the false-negative cases revealed a 13 x 5 mm lesion with an SUVmax of 1.96 in 1 case; no lesion was localized in the second case using multiple additional modalities. Spearman nonparametric analysis did not show statistically significant correlation between SUVmax of the tumors and biochemical markers. The Mann-Whitney nonparametric test did not demonstrate a statistically significant difference between the SUVmax of (18)F-FDOPA in malignant and benign tumors. CONCLUSION (18)F-FDOPA PET and PET/CT are highly sensitive and specific tools that can provide additional independent information for diagnosis and localization of benign and malignant pheochromocytomas.
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Affiliation(s)
- Farzin Imani
- Ahmanson Biological Imaging Division, Department of Molecular and Medical Pharmacology, David Geffen School of Medicine at UCLA, Los Angeles, California, USA.
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Gross MD, Gauger PG, Djekidel M, Rubello D. The role of PET in the surgical approach to adrenal disease. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2009; 35:1137-45. [PMID: 19243910 DOI: 10.1016/j.ejso.2009.01.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2008] [Revised: 01/21/2009] [Accepted: 01/23/2009] [Indexed: 11/18/2022]
Abstract
BACKGROUND Appropriate surgical approach to diseases of the adrenal requires a diagnosis sufficient to determine the biochemical status of adrenal dysfunction and anatomic evaluation sufficient to differentiate unilateral from bilateral disease, intra-adrenal from extra-adrenal neoplasm, adrenal tumor recurrence or adrenal metastases. High resolution computed tomography (CT) and magnetic resonance have been the primary imaging modalities for the evaluation of anatomy, while scintigraphic studies have played a secondary role in diagnosis. The recent availability of functional imaging provided by positron emission tomography (PET) with radiopharmaceuticals designed to depict substrate precursor uptake, cellular metabolism or receptor binding in neoplasms and CT as a single modality, hybrid PET/CT, to directly correlate function and anatomy has had a significant impact upon the diagnostic and therapeutic approach to many cancers and has been applied to adrenal disease with some early success that we describe in this review. METHODS In addition to the authors' experience, a search of Medline and PubMed databases was performed using search terms: 'adrenal scintigraphy', 'positron tomography', 'computed tomography', 'adrenal surgery', 'adrenal mass', '(18)F-fluorodeoxyglucose', 'adrenal carcinoma', 'adrenal medulla' and 'pheochromocytoma'. CONCLUSIONS Present PET radiopharmaceuticals and their use in hybrid PET/CT have demonstrated efficacy in the preoperative and follow-up evaluation of neoplasms of the adrenal cortex and medulla that hopefully will continue to improve with the development of newer tracers that continue to exploit unusual characteristics of the adrenals.
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Affiliation(s)
- M D Gross
- Department of Radiology, Division of Nuclear Medicine, University of Michigan Medical Center and Department of Veterans Affairs Health System, Ann Arbor, Michigan USA.
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50
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Ilias I, Pacak K. A clinical overview of pheochromocytomas/paragangliomas and carcinoid tumors. Nucl Med Biol 2009; 35 Suppl 1:S27-34. [PMID: 18707631 DOI: 10.1016/j.nucmedbio.2008.04.007] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2008] [Revised: 04/23/2008] [Accepted: 04/23/2008] [Indexed: 01/02/2023]
Abstract
Pheochromocytomas/paragangliomas are rare tumors; most are sporadic. Biochemical proof of disease is better with measurement of plasma metanephrines and less cumbersome than determinations in urine; its implementation is expanding. Anatomical imaging with computed tomography or magnetic resonance imaging should be followed by functional (nuclear medicine) imaging: chromaffin tumor-specific methods are preferred. Treatment is surgical; for nonoperable disease other options are available. Overall 5-year survival is 50%. Carcinoid tumors derive from serotonin-producing enterochromaffin cells in the fore-, mid- or hindgut. Biochemical screening (and follow-up) is done with measurements of 5-hydroxyindoloacetic acid in urine. For most carcinoids, functional imaging is better than other modalities in localizing primary tumors. Surgery is the treatment of choice; nonresectable tumors are treated with somatostatin analogs or chemotherapy. Overall 5-year survival for patients with carcinoids is 67%.
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Affiliation(s)
- Ioannis Ilias
- Department of Endocrinology, E. Venizelou Hospital, Athens GR-11521, Greece.
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