Annibale Versari

Role of imaging studies in the diagnosis and follow-up of large-vessel vasculitis: an update

Imaging studies play a central role in diagnosing and monitoring giant-cell and Takayasu arteritis. Deep, large vessels can be examined by CT or MRI, while colour Doppler ultrasound and MRI have been used with promising results to investigate the temporal arteries. Positron emission tomography is very sensitive in detecting large-vessel inflammation, although it does not delineate the vessel wall. Imaging procedures can also be used to monitor the disease course. However, imaging signs of inflammation may sometimes persist despite clinical remission and, conversely, seemingly unaffected vessels may develop alterations later on.

Tocilizumab: a novel therapy for patients with large-vessel vasculitis

OBJECTIVEnTreatment of large-vessel vasculitis (LVV) remains challenging. Patients usually respond to glucocorticoid (GC) therapy, but often relapse on tapering of the GC dose or after GC withdrawal. In addition, GCs are fraught with numerous adverse events. The aim of this study was to assess the efficacy and safety of the anti-IL-6 receptor (IL-6R) antibody tocilizumab (TCZ) in patients with LVV.nnnMETHODSnFour patients with active LVV (two with GCA and two with Takayasu arteritis) received monthly TCZ infusions (8u2009mg/kg bodyweight) for 6 consecutive months. Two patients were treatment naïve, while two had relapsing disease. Disease activity and drug tolerability were assessed clinically and by laboratory tests at study entry and subsequently every month for 6 months of TCZ treatment, while an [(18)F]fluorodeoxyglucose PET (PET/CT) scan was performed before and after treatment. In addition, a semi-quantitative clinical evaluation was performed at baseline and at 3 and 6 months using the Indian Takayasu activity score and the Kerr indices. After TCZ, MTX was used as maintenance therapy.nnnRESULTSnAll patients treated with TCZ therapy had a satisfactory clinical and laboratory response, while PET/CT findings significantly improved in all cases. No serious adverse events were noted. Only one patient had a transient increase in liver enzymes.nnnCONCLUSIONSnIn this small group of patients with LVV, treatment with TCZ was effective and well tolerated. Further, larger studies are required to confirm our findings.

Images in cardiovascular medicine. Chronic periaortitis.

A 60-year-old woman presented in 2004 with fatigue, anorexia, and weight loss. Her erythrocyte sedimentation rate and C-reactive protein levels were elevated at 114 mm/h and 45 g/dL (normal values 6 g/dL), respectively, whereas autoimmune serology, including antinuclear antibodies, antibodies to extractable nuclear antigens, and antineutrophil cytoplasmic antibodies, and tests for common infectious diseases, including tuberculosis, were normal or negative. Occult neoplasm was suspected and computerized tomography (CT) of the abdomen and F18-fluorodeoxyglucose positron emission tomography (PET) were scheduled. CT showed concentric wall thickening of the aortic arch, ascending thoracic aorta, and proximal left internal carotid arteries, with a perivascular cuff around the abdominal aorta. PET disclosed increased tracer uptake at the ascending and abdominal aorta and, to a lesser extent, in the common iliac arteries. Chronic periaortitis (CP) was diagnosed on the basis of these symptoms and findings, and treatment with prednisone 1 mg · kg 1 · d 1 was begun, with marked clinical improvement and normalization of erythrocyte sedimentation rate and C-reactive protein level. A repeat CT scan demonstrated a reduction in the size of the abdominal periaortic cuff, and a second PET scan documented reduced tracer uptake in the ascending and abdominal aortas with unchanged iliac artery uptake. However, attempts to taper the glucocorticoid dose resulted in 3 flares over the subsequent 3 years that required retreatment with high-dose glucocorticoids in combination with methotrexate. At her last visit in 2007, the patient complained of fatigue. Her erythrocyte sedimentation rate was 72 mm/h and her C-reactive protein level was 7 g/dL. A PET/CT scan revealed increased tracer uptake in the aortic arch, ascending thoracic aorta, and abdominal aorta with an abdominal perivascular cuff, consistent with active vasculitis and CP, respectively (Figures 1 through 3). Magnetic resonance angiography of the lower thoracic and abdominal aortas disclosed narrowing of the lumen of the aorta below the renal arteries and of the proximal iliac arteries, and short tau inversion recovery sequences showed increased signal (consistent with inflammatory edema) of the vessel wall (Figure 4). A chest x-ray was unremarkable apart from an enlarged left hilum and a small retrosternal nodule that had previously been documented (Figure 5). ECG showed 1-mm ST-segment depression in leads V5 through V6 (Figure 6). Transthoracic echocardiography confirmed the presence of a thickened ascending aortic wall, with a periaortic hypoechoic halo consistent with periaortic inflammatory tissue (Figure 7). CP is a rare, mostly idiopathic, fibroinflammatory condition that ranges from inflammatory aneurysm of the abdominal aorta with or without perianeurysmal fibrosis to isolated retroperitoneal fibrosis.1 The clinical picture is usually characterized by constitutional symptoms and by dull abdominal Figure 1. F18-Fluorodeoxyglucose positron emission tomography (coronal view) showing increased tracer uptake in the ascending (arrow) and abdominal (arrowhead) aorta.

Radiolabeled Somatostatin Analogues in the Treatment of Non-GEP-NET Tumors

In the last two decades Peptide Receptor Radionuclide Therapy (PRRT) has acquired great importance as an alternative or complementary tool in the treatment of neuroendocrine tumors (NETs) and other somatostatin receptor (SSTR) positive tumors. Many experiences of PRRT using different radiopharmaceuticals, mainly beta-emitters 90Yttrium (90Y) and 177Lutetium (177Lu) labeled peptides, are reported in the literature with encouraging results in terms of tumor regression, self-assessed quality of life, and overall survival. SSTRs are mainly expressed in Gastro-Entero-Pancreatic neuroendocrine tumors (GEP-NETs) but in many other neoplasms (NETs and non-NETs) it is possible to find a high SSTR expression. Some of these are pheochromocytoma/paraganglioma, bronchial NET, thymic NET, meningioma, thyroid cancer (differentiated and medullary) and Merkel cell carcinoma.

Combined imaging approach to diagnose a meningioma in a patient with prostate and lung cancers

a Nuclear Medicine Unit, Department of Oncology and Advanced Technology, Arcispedale Santa Maria Nuova – IRCCS Reggio Emilia, Viale Risorgimento 80, 42123 Reggio Emilia, Italy b Neuroradiology Unit, Department of Diagnostic Imaging, Arcispedale Santa Maria Nuova – IRCCS Reggio Emilia, Viale Risorgimento 80, 42123 Reggio Emilia, Italy c Nuclear Medicine Unit, Department of Translational Research and Advanced Technologies in Medicine, University of Pisa, Via Savi 10, 56126 Pisa, Italy