Ettore Pelosi

Preoperative intrathoracic lymph node staging in patients with non-small-cell lung cancer: accuracy of integrated positron emission tomography and computed tomography

OBJECTIVE To evaluate the accuracy of integrated positron emission tomography with 18F-fluoro-2-deoxy-D-glucose (FDG) and computed tomography (PET/CT) in preoperative intrathoracic lymph node staging in patients with non-small-cell lung cancer (NSCLC) and to ascertain the role of invasive staging in verifying positron emission tomography (PET)/computed tomography (CT) results. METHODS Retrospective, single institution study of consecutive patients with suspected or pathologically proven, potentially resectable NSCLC undergoing integrated PET/CT scanning in the same PET centre. Lymph node staging was pathologically confirmed on tissue specimens obtained at mediastinoscopy and/or thoracotomy. Statistical evaluation of PET/CT results was performed on a per-patient and per-nodal-station bases. RESULTS A total of 1001 nodal stations (723 mediastinal, 148 hilar and 130 intrapulmonary) were evaluated in 159 patients. Nodes were positive for malignancy in 48 (30.2%) out of 159 patients (N1=17; N2=30; N3=1) and 71 (7.1%) out of 1001 nodal stations (N1=24; N2=46; N3=1). At univariate analysis, lymph node involvement was significantly associated (p<0.05) with the following primary tumour characteristics: increasing diameter, maximum standardised uptake value >9, central location and presence of vascular invasion. PET/CT staged the disease correctly in 128 out of 159 patients (80.5%), overstaging occurred in nine patients (5.7%) and understaging in 22 patients (13.8%). The overall sensitivity, specificity, positive and negative predictive values, and accuracy of PET/CT for detecting metastatic lymph nodes were 54.2%, 91.9%, 74.3%, 82.3% and 80.5% on a per-patient basis, and 57.7%, 98.5%, 74.5%, 96.8% and 95.6% on per-nodal-station basis. With regard to N2/N3 disease, PET/CT accuracy was 84.9% and 95.3% on a per-patient basis and on per-nodal-station basis, respectively. Referring to nodal size, PET/CT sensitivity to detect malignant involvement was 32.4% (12/37) in nodes <10mm, and 85.3% (29/34) in nodes > or = 10mm. CONCLUSION Our data show that integrated PET/CT provides high specificity but low sensitivity and accuracy in intrathoracic nodal staging of NSCLC patients and underscore the continued need for surgical staging.

Role of whole-body 18F-choline PET/CT in disease detection in patients with biochemical relapse after radical treatment for prostate cancer

PurposeThe aim of this study was to evaluate the role of whole body 18F-choline (FCH) positron emission tomography—computed tomography (PET-CT) in detecting and localising disease recurrence in patients presenting biochemical relapse after radical treatment for prostate cancer.Materials and methodsFifty-six consecutive patients with increased serum prostate-specific antigen (PSA) levels after radical prostatectomy were included in the study. None of them was receiving hormone treatment at the time of the examination or had been treated during the previous 6 months. All patients underwent whole-body 18F-choline PET imaging, and the pathological findings were compared with those of further imaging exams, biopsy and follow-up. On the basis of the PSA levels, we divided our patient population into three subgroups: PSA≤1, 15 ng/ml.ResultsOverall, the PET scan detected disease relapse in 42.9% of cases (24/56). PET sensitivity was closely related to serum PSA levels, showing values of 20%, 44% and 81.8% in the PSA≤1, 15ng/ml subgroups, respectively.ConclusionsIn patients with biochemical relapse after radical treatment for prostate cancer, 18F-choline PET-CT represents a single step, whole-body, noninvasive study that allows disease detection and localisation. The disease detection rate is related to serum PSA levels.RiassuntoObiettivoLo scopo di questo studio è stato quello di valutare il ruolo dell’esame PET/TC con 18F-colina nella identificazione e localizzazione di recidiva di malattia in pazienti sottoposti a trattamento radicale per neoplasia prostatica, in presenza di attuale recidiva biochimica.Materiali e metodiSono stati inclusi 56 pazienti consecutivi, sottoposti a prostatectomia radicale e con livelli serici di PSA in incremento. Al momento dell’esame, nessuno di loro era in trattamento ormonale né lo era stato nei sei mesi precedenti. Tutti i pazienti sono stati sottoposti ad esame PET/TC total-body con 18F-colina; i reperti patologici sono stati confrontati con ulteriori esami strumentali e/o con la biopsia e/o col follow-up clinico. Sulla base dei livelli serici di PSA, abbiamo suddiviso la nostra popolazione in tre sottogruppi: PSA ≤1, 15 ng/ml.RisultatiL’esame PET ha identificato la ripresa di malattia nel 42,9% dei casi (24/56). La sensibilità è risultata strettamente correlata ai livelli serici di PSA; infatti essa è stata del 20%, del 44% e dello 81% rispettivamente, nei sottogruppi con PSA ≤1, 15 ng/ml.ConclusioniNei pazienti trattati radicalmente per carcinoma della prostata, in presenza di recidiva biochimica, l’esame PET/TC total-body con 18F-colina rappresenta un’indagine singola e non invasiva, che consente di identificare e localizzare la recidiva di malattia; la sua percentuale di identificazione è correlata con i livelli serici del PSA.

Value of integrated PET/CT for lesion localisation in cancer patients: a comparative study

The aim of this study was to retrospectively compare the value of integrated PET/CT and separate PET plus morphological imaging studies for lesion localisation in cancer patients. Two different series of consecutive patients who had previously been treated for neoplastic disease were considered. One series consisted of 105 patients who had undergone [18F]fluorodeoxyglucose (FDG) PET/CT (n=70) or [11C]choline PET/CT (n=35) studies (PET/CT group). The other series comprised 105 patients who had undergone FDG PET scan (n=70) or [11C]choline PET scan (n=35) alone; in this series, PET findings were correlated with the results of morphological imaging (MI) studies, i.e. CT (n=92) or MR imaging (n=13) (PET+MI group). Regions of abnormal tracer uptake at PET scanning were classified as ambiguous or unambiguous depending on their precise anatomical localisation. A total of 207 and 196 lesions were found in the PET/CT and PET+MI groups, respectively. The difference in terms of number of lesions per patient detected with the two imaging protocols was not statistically significant (P=0.718). When analysis of lesion localisation was performed, there were 7/207 (3.4%) and 30/196 (15.3%) ambiguous lesions in the PET/CT and PET+MI groups, respectively. The number of ambiguous lesions was significantly higher in the PET+MI group than in the PET/CT group (χ2=15.768, P<0.0001). Comparison of the effect of use of the different tracers on reporting of PET/CT versus PET+MI revealed that the improvement in the final report in [11C]choline PET/CT studies was similar to that observed in [18F]FDG studies. In cancer patients, PET/CT shows higher diagnostic accuracy for lesion localisation than PET plus morphological imaging studies performed independently. This result does not seem to be affected by the type of tracer used.

Role of whole-body [18F] fluorodeoxyglucose positron emission tomography/computed tomography (FDG-PET/CT) and conventional techniques in the staging of patients with Hodgkin and aggressive non Hodgkin lymphoma.

PurposeThe aim of this study was to evaluate the role of [18F]fluorodeoxyglucose positron emission tomography/computed tomography (FDG-PET/CT) in the staging of Hodgkin’s and aggressive non-Hodgkin’s lymphoma (HL and NHL), comparing it with conventional diagnostic methods, i.e. contrast-enhanced CT and bone marrow biopsy.Materials and methodsSixty-five consecutive patients (30 HL and 35 NHL) who underwent conventional disease staging and FDG-PET/CT were included. Concordance between conventional methods and PET was established when both procedures identified the same disease stage. Discordant findings were investigated further by using other diagnostic techniques (ultrasonography or magnetic resonance imaging) and/or clinical follow-up.ResultsPET correctly staged 93.8% of enrolled patients (61/65), whereas conventional techniques correctly staged 89.2% (58/65; p=NS, gC2 test). There was complete concordance in 54/65 patients (83.1%); among the remaining 11 cases, PET upstaged eight patients (seven true positive and one false positive), and downstaged three (all false negative). In 5/65 patients, chemotherapy treatment was modified on the basis of PET findings.ConclusionsOur data confirm the high accuracy of FDG-PET/CT in staging HL and NHL. FDG-PET/CT should therefore be used routinely in the initial evaluation of both patient subgroups.RiassuntoObiettivoScopo di questo studio è stato quello di valutare il ruolo dell’esame PET/TC total body con 18F-fluorodesossiglucosio (FDG-PET/TC) nella stadiazione dei linfomi di Hodgkin (LH) e non-Hodgkin aggressivi (NHL), confrontandolo con le tecniche convenzionali di stadiazione (TC con mezzo di contrasto e biopsia osteo-midollare).Materiali e metodiSono stati inclusi 65 pazienti consecutivi (30 LH e 35 NHL) che hanno eseguito stadiazione convenzionale e FDG-PET/TC. Le due procedure sono state definite concordanti quando entrambe hanno identificato il medesimo stadio di malattia; in caso di discordanza sono state eseguiti altri esami (ecografia o risonanza magnetica) e/o follow-up clinico.RisultatiL’esame PET ha consentito di stadiare correttamente 61/65 pazienti (93,8%), le metodiche convenzionali 58/65 (89,2%; p=ns, test gC2). Nella stadiazione, entrambe le tecniche risultavano concordare in 54/65 casi (83,1%); nei restanti 11 casi, l’esame PET ha determinato una sovrastadiazione in 8 pazienti (7 veri positivi ed 1 falso positivo) e una sotto-stadiazione in 3 casi (tutti falsi negativi). Sulla base dei risultati PET il trattamento chemioterapico è stato modificato in 5 pazienti.ConclusioniI nostri dati confermano l’elevata accuratezza diagnostica dell’esame FDG-PET/TC nella stadiazione dei LH e LNH. Questo ne suggerisce un uso di routine nell’iter di stadiazione.

Cardiac effects of hexarelin in hypopituitary adults.

Growth hormone (GH)-releasing peptides possess specific pituitary, hypothalamic, and myocardial receptors. Seven adult male patients with GH deficiency (GHD) (age, mean+/-S.E.M.: 42.0+/-4.0 year) were studied by equilibrium radionuclide angiocardiography after i.v. administration of hexarelin, a peptide GH secretagogue. Data for these patients were compared with those for nine adult male controls (37.0+/-2.7 year). The GH response to hexarelin was negligible in patients with GHD compared to control subjects (CS) (peak: 1.9+/-0.9 vs. 45.7+/-3.6 microg/l, P<0.001). Basal left ventricular ejection fraction (LVEF) in patients with GHD was lower than that in CS (50+/-1% vs. 63+/-2%, P<0.001). Hexarelin administration increased LVEF both in patients with GHD and in CS (peak: 57+/-2 vs. 70+/-2, respectively, P<0.05 vs. baseline) without changing catecholamine levels, mean blood pressure (MBP), or cardiac output in either group. In conclusion, the acute administration of hexarelin exerts a short-lasting positive inotropic effect in humans, probably GH-independent and mediated by specific myocardial receptors for GH secretagogues.

Comparison of Positron Emission Tomography Scanning and Sentinel Node Biopsy in the Detection of Inguinal Node Metastases in Patients With Anal Cancer

BACKGROUND Inguinal lymph node metastases in patients with anal cancer are an independent prognostic factor for local failure and overall mortality. Inguinal lymph node status can be adequately assessed with sentinel node biopsy, and the radiotherapy strategy can subsequently be changed. We compared this technique vs. dedicated 18F-fluorodeoxyglucose positron emission tomography (PET) to determine which was the better tool for staging inguinal lymph nodes. METHODS AND MATERIALS In our department, 27 patients (9 men and 18 women) underwent both inguinal sentinel node biopsy and PET-CT. PET-CT was performed before treatment and then at 1 and 3 months after treatment. RESULTS PET-CT scans detected no inguinal metastases in 20 of 27 patients and metastases in the remaining 7. Histologic analysis of the sentinel lymph node detected metastases in only three patients (four PET-CT false positives). HIV status was not found to influence the results. None of the patients negative at sentinel node biopsy developed metastases during the follow-up period. PET-CT had a sensitivity of 100%, with a negative predictive value of 100%. Owing to the high number of false positives, PET-CT specificity was 83%, and positive predictive value was 43%. CONCLUSIONS In this series of patients with anal cancer, inguinal sentinel node biopsy was superior to PET-CT for staging inguinal lymph nodes.

Role of integrated PET/CT with [18F]-FDG in the management of patients with fever of unknown origin: a single-centre experience

PurposeFever of unknown origin (FUO) is a diagnostic challenge for the wide range of possible causes involved. The aim of our work was to evaluate the role of [18F]-fluorodeoxyglucose positron emission tomography computed tomography ([18F]-FDG-PET/CT) in managing patients with classical FUO.Materials and methodsTwenty-four consecutive patients (16 women, eight men; mean age, 56.5 years) with a diagnosis of FUO based on routine investigations were retrospectively studied. All underwent [18F]-FDG-PET/CT, which was considered true positive when the result was in agreement with the final diagnosis.ResultsA final diagnosis was reached in 17 of 24 patients (vasculitis, n=5; autoimmune disorder, n=2; neoplasm, n=3; infectious disease, n=6; biliary microlithiasis, n=1). In the remaining seven cases, no final diagnosis was established. PET-CT was useful in identifying aetiology in 11 patients, showing a diagnostic yield of 46% (11/24). Among the 11 cases with a negative PET scan, 10 did not show a worsening of the clinical condition.ConclusionsThis study underlines the crucial role of [18F]-FDG-PET/CT in managing patients with FUO. If prospective trials on this topic confirm the present findings, PET/CT should be incorporated in the routine diagnostic work-up of patients with classical FUO.RiassuntoObiettivoLa febbre di origine sconosciuta (FUO) rappresenta una vera e propria sfida diagnostica a causa dell’elevato numero dei possibili fattori eziologici. Lo scopo di questo studio è stato quello di valutare il ruolo della tomografia a emissione di positroni/tomografia computerizzata con (18F)-fluorodesossiglucosio [(18F)FDGPET/TC] nel management clinico di pazienti con FUOMateriali e metodiAbbiamo incluso, retrospettivamente, ventiquattro pazienti consecutivi (16 femmine e 8 maschi) di età media 56,5 anni, nei quali, dopo gli esami di routine, era stata posta diagnosi di FUO classica. Tutti i pazienti hanno eseguito l’esame PET/TC, che è stato considerato vero positivo quando in accordo con la diagnosi finaleRisultatiIn 17 pazienti si è raggiunta una diagnosi finale: vasculite (5), malattia auto-immune (2), neoplasia (3), malattia infettiva (6), micro-litiasi biliare (1). Nei restanti 7 casi, la diagnosi finale non è stata ottenuta. L’esame PET/TC è stato utile per identificare l’eziologia in 11 su 24 pazienti (46%). Tuttavia, è rilevante il fatto che tra gli 11 casi con esame PET negativo, 10 non hanno mostrato alcun peggioramento clinicoConclusioniQuesto studio sottolinea il ruolo cruciale dell’esame (18F)FDG-PET/TC nella gestione clinica dei pazienti con FUO classica. Se ulteriori studi prospettici su questo argomento confermeranno gli attuali risultati, l’esame PET/TC dovrebbe essere incluso nella routine diagnostica di questi pazienti

Dual-phase FDG-PET: delayed acquisition improves hepatic detectability of pathological uptake

PurposeThe aim of this study was to evaluate whether the acquisition of delayed images could improve the detectability of liver pathological uptakes.Materials and methodsNinety-five consecutive patients with suspected liver metastases underwent a dual-phase positron emission tomography (PET) scan. All patients underwent a whole-body PET/computed tomography (CT) scan (PET-1) acquired 1 h post [18F]fluorodeoxyglucose (FDG) injection, and a liver PET/CT scan [that is, one or two fields of view (FOV) of the upper abdomen; PET-2] acquired 2 h postinjection. In all cases, image reconstruction was performed as 3D reconstruction algorithm Fourier rebinning (FORE) iterative, FOV 50 cm, image matrix size 128×128. Both studies were evaluated qualitatively and semiquantitatively [background standard uptake values (SUV)mean of the liver, lesion SUVmax and SUVmean and ratio SUVmean lesion/background).ResultsThirty-seven of 95 patients (38.9%) presented liver lesions at both PET-1 and PET-2 exams, whereas there were two (2.2%) only at PET-2. Eighty-one liver lesions were identified at both PET studies, whereas there were nine (11.1%) only at PET-2. Furthermore, at PET-2, we had a statistically significant reduction of SUVmean background values (p<0.001, Wilcoxon test) and a concomitant increase of SUVmean lesion values (p<0.001, Wilcoxon test), ratio lesion to background (p<0.001, Wilcoxon test).ConclusionsAcquisition of delayed images improved the hepatic detection of pathological FDG uptake.RiassuntoObiettivoScopo di questo studio è stato quello di valutare se in pazienti con sospette secondarietà epatiche, la riacquisizione di immagini, 2 ore dopo la somministrazione del radiofarmaco (tardiva), comporta un miglioramento della sensibilità dell’esame PET.Materiali e metodiSono stati inclusi 95 pazienti consecutivi con sospette metastasi epatiche. Tutti hanno eseguito esame PET/TC total body 1 ora dopo la somministrazione di FDG (PET-1). In tutti i casi, 2 ore dopo l’iniezione, è stata eseguita una seconda acquisizione mirata sull’addome superiore (PET-2). La ricostruzione delle immagini è stata eseguita con algoritmo 3D FORE iterativo (FOV 50 cm, dimensione della matrice 128×128). Entrambi gli esami sono stati valutati qualitativamente e semi-quantitativamente (SUVmedio fondo del fegato, SUVmax e SUVmedio della lesione e rapporto SUVmedio lesione/fondo).RisultatiTrentasette dei 95 pazienti (38,9%) hanno presentato anomale iperfissazioni di radiofarmaco a livello epatico in entrambi gli esami PET; 2 pazienti (2,2%) sono risultati positivi solo in PET-2. Entrambi gli esami hanno messo in evidenza 81 lesioni epatiche, mentre altre 9 (11,1%) sono state evidenziate solo con l’esame PET-2. Inoltre in PET-2 si notava una riduzione significativa del SUVmedio del fondo (p<0,001, Wilcoxon test) ed un contemporaneo aumento del SUVmedio della lesione (p<0,001, Wilcoxon test) e del rapporto lesione/fondo (p<0,001, Wilcoxon test).ConclusioniLa riacquisizione tardiva di immagini PET aumenta la capacità dell’esame PET di identificare fissazioni patologiche di FDG a livello epatico.

Impact of axillary nodal metastases on lymphatic mapping and sentinel lymph node identification rate in patients with early stage breast cancer

PurposeThe aim of this study was to define the impact of the presence of axillary nodal metastases on lymphatic mapping and sentinel lymph node (SLN) identification rate in patients with early breast cancer.MethodsTwo hundred and forty-six lymphatic mapping procedures were performed with both labelled nanocolloid and blue dye, followed by SLN biopsy and/or complete axillary dissection. The following parameters were recorded: patient’s age, tumour laterality and location, tumour size, tumour histology, tumour stage, tumour grade, lymphovascular invasion, radiotracer injection site (subdermal–peritumoural/peri-areolar), SLN visualisation at lymphoscintigraphy, SLN metastases (presence/absence, size) and other axillary metastases (presence/absence, number). Discriminant analysis was used to analyse the data.ResultsSLNs were identified by labelled nanocolloid alone in 94.7% of tumours, by blue dye alone in 93.5% and by the combined technique in 99.2%. Discriminant analysis showed the gamma probe SLN identification rate to be significantly limited by the presence of axillary nodal metastases. In particular, the size of SLN metastases and the number of other axillary metastases were the most important variables in reducing the gamma probe SLN identification rate (p=0.004 and p=0.002, respectively). On the other hand, high tumour grade was the only parameter limiting the blue dye SLN identification rate.ConclusionThe accuracy of lymphatic mapping with labelled nanocolloid is limited by the presence of axillary nodal metastases, and particularly by the degree of SLN tumoural invasion and the presence and number of other axillary nodal metastases. Neither of these elements seems to interfere with the blue dye identification rate. The combination of the two tracers maximises the SLN identification rate.

Early Response to Chemotherapy in Patients With Non–Small-Cell Lung Cancer Assessed by [18F]-Fluoro-Deoxy-D-Glucose Positron Emission Tomography and Computed Tomography

BACKGROUND This study aimed to demonstrate that patients who exhibit a tumor metabolic response to first-line chemotherapy seen on FDG-PET and computed tomography (CT) would survive longer than those who did not show such a response, comparing this evaluation with the morphologic response seen on CT. PATIENTS AND METHODS Images were acquired in 22 consecutive patients with advanced non-small-cell lung cancer (NSCLC) randomized to receive carboplatin/paclitaxel/sorafenib or placebo. FDG-PET was performed within 4 weeks before (PET1) and 2 weeks after starting treatment (PET2). Similarly, CT (CT1) was performed at baseline and then every 2 cycles (6 weeks) during treatment (CT2). Responders and nonresponders were identified with FDG-PET, and metabolic response was then compared with morphologic changes detected by spiral CT. RESULTS Twenty-one of 22 patients completed this study. In terms of progression-free survival (PFS) (45 vs. 22.2 weeks) and overall survival (OS) (77 vs. 47.7 weeks), we observed a trend that was not statistically significant for patients whose response after 2 weeks of treatment was seen on FDG-PET (P = .22 for PFS; P = .15 for OS). CONCLUSION Patients with advanced NSCLC who had a positive outcome, as evidenced by prolonged survival, were those who showed a tumor metabolic response seen on FDG-PET.