F. Fazio

[ 11 C]Choline uptake with PET/CT for the initial diagnosis of prostate cancer: relation to PSA levels, tumour stage and anti-androgenic therapy

PurposeThe accuracy of positron emission tomography (PET)/CT with [11C]choline for the detection of prostate cancer is not well established. We assessed the dependence of [11C]choline maximum standardized uptake values (SUVmax) in the prostate gland on cell malignancy, prostate-specific antigen (PSA) levels, Gleason score, tumour stage and anti-androgenic hormonal therapy.MethodsIn this prospective study, PET/CT with [11C]choline was performed in 19 prostate cancer patients who subsequently underwent prostatectomy with histologic sextant analysis (group A) and in six prostate cancer patients before and after anti-androgenic hormonal therapy (bicalutamide 150xa0mg/day; median treatment of 4xa0months; group B).ResultsIn group A, based on a sextant analysis with a [11C]choline SUVmax cutoff of 2.5 (as derived from a receiver-operating characteristic analysis), PET/CT showed sensitivity, specificity, positive predictive value, negative predictive value and accuracy of 72, 43, 64, 51 and 60%, respectively. In the patient-by-patient analysis, no significant correlation was detected between SUVmax and PSA levels, Gleason score or pathological stage. On the contrary, a significant (Pu2009<u20090.05) negative correlation was detected between SUVmax and anti-androgenic therapy both in univariate (r2u2009=u20090.24) and multivariate (r2u2009=u20090.48) analyses. Prostate [11C]choline uptake after bicalutamide therapy significantly (Pu2009<u20090.05) decreased compared to baseline (6.4u2009±u20094.6 and 11.8u2009±u20095.3, respectively; group B).ConclusionPET/CT with [11C]choline is not suitable for the initial diagnosis and local staging of prostate cancer. PET/CT with [11C]choline could be used to monitor the response to anti-androgenic therapy.

Integrated PET/CT as a first-line re-staging modality in patients with suspected recurrence of ovarian cancer

PurposeThe aims of this study were to compare CT with PET/CT results in patients with suspected ovarian cancer recurrence and to assess the impact of the PET/CT findings on their clinical management.MethodsThirty-two consecutive patients with suspected ovarian cancer recurrence were retrospectively included in the study. Abdominal contrast-enhanced CT and PET/CT with [18F]FDG, in addition to conventional follow-up, were performed in all 32 patients. After the comparison between CT and PET/CT results, based on clinical reports, changes in the clinical management of patients (intermodality changes) due to PET/CT information were analysed.ResultsTwenty of the 32 patients were positive at CT (62.5%) versus 29 (90.6%) at PET/CT. Intermodality changes in management, i.e. use of a different treatment modality, after PET/CT examination were indicated in 14/32 (44%) patients. In particular, before PET/CT study, the planned management was as follows: wait-and-see in 7/32 (22%), further instrumental examinations in 4/32 (12%), chemotherapy in 10/32 (31%), diagnostic surgical treatment in 6/32 (19%) and surgical treatment in the remaining 5/32 (16%). After PET/CT study, wait-and-see was indicated in 1/32 (3%), further instrumental examinations in 7/32 (22%), chemotherapy in 16/32 (50%), diagnostic surgical treatment in 2/32 (6%) and surgical treatment in the remaining 6/32 (19%).ConclusionIntegrated PET/CT could detect tumour relapse in a higher percentage of patients than could CT. A change in the clinical management was observed in 44% of cases when PET/CT information was added to conventional follow-up findings.

Diagnosis of local recurrence after radical prostatectomy

In the long‐term there is biochemical evidence of recurrent prostate carcinoma in ≈u200a40% of patients after radical prostatectomy (RP). Detecting the site of recurrence (local vs distant) is critical for defining the optimum treatment. Pathological and clinical variables, e.g. Gleason score, involvement of seminal vesicles or lymph nodes, margin status at surgery, and especially the timing and pattern of prostate‐specific antigen (PSA) recurrence, may help to predict the site of relapse. Transrectal ultrasonography (TRUS) of the prostatic fossa in association with TRUS‐guided needle biopsy is considered more sensitive than a digital rectal examination for detecting local recurrence, especially if PSA levels are low. Although it cannot detect minimal tumour mass at very low PSA levels (<1u2003ng/mL) TRUS biopsy is presently the most sensitive method for detecting local recurrence. Nevertheless, the conclusive role of biopsy of the vesico‐urethral anastomosis remains unclear. However, 111In‐capromab pendetide scintigraphy and [11C]‐choline tomography (which are better than conventional imaging for detecting metastatic tumour), have low detection rates for local disease and are considered complementary to TRUS in this setting. Patients with a high PSA after RP may be managed with external beam salvage radiotherapy. An initial PSA of <u200a1u2003ng/mL, Gleason score <u200a8 and radiation dose of 66–70u2003Gy seem to be key factors in determining success. Although a positive TRUS anastomotic biopsy may predict a better outcome after radiation therapy, the need to take a biopsy in the event of PSA failure remains under investigation. The value of salvage radiation to the prostatic bed for PSA‐only progression after RP remains in question.

Nonpalpable breast lesions: preoperative radiological guidance in radioguided occult lesion localisation (ROLL)

PurposeThis study evaluated the methods, technical aspects and impact of preoperative radiological guidance in radioguided occult lesion localisation (ROLL) for single nonpalpable breast lesions.Materials and methodsA total of 288 patients underwent ROLL before surgery. Human serum albumin macroaggregates labelled with 3.7–7.4 MBq of technetium99 were injected into the lesion. In the case of ultrasonographic guidance (221/288 patients), inoculum positioning resulted in a change of echogenicity at the lesion site. In the case of mammographic guidance (67/288 patients), iodinated contrast medium was injected following the radiotracer for subsequent mammographic evaluation. Patients underwent surgery within 24 h from ROLL. A gamma-detecting probe was used to locate the lesion during surgery and guide its removal. After excision, the specimen was examined by either ultrasonography or mammography to verify complete lesion removal before histological evaluation.ResultsThe lesion was correctly localised in 281/288 patients (97.5%). One ROLL procedure failed because surgery could not be performed within 24 h and the radioactivity decayed. Of the six incorrect localisations, 2 were due to the radiological guidance and 4 to technetium99 dispersion.ConclusionsRadiological guidance in ROLL ensured the outcome of the procedure of localisation and removal of single, nonpalpable breast lesions in the majority of cases.RiassuntoObiettivoScopo del presente lavoro è stato quello di valutare metodi, aspetti tecnici ed impatto della guida radiologica preoperatoria nella radioguided occult lesion localisation (ROLL) per lesioni mammarie singole non palpabili.Materiali e metodiDuecentottantotto pazienti sono state sottoposte a ROLL prima dell’intervento. All’interno della lesione sono stati iniettati macro-aggregati di albumina umana marcata con tecnezio99; nel caso di guida ecografica (221/288 soggetti), l’inoculo ha prodotto iperecogenicità in corrispondenza della lesione; nel caso di guida mammografica (67/288 soggetti), dopo il radiotracciante è stato inoculato mezzo di contrasto iodato per il successivo controllo mammografico. Le pazienti sono state sottoposte ad intervento chirurgico entro 24 ore dalla ROLL. Per localizzare la lesione e guidarne la rimozione chirurgica, è stata utilizzata una sonda per la rilevazione dei raggi gamma. Dopo l’escissione, il pezzo operatorio è stato esaminato con ecografia o mammografia per verificare la completa rimozione della lesione.RisultatiLa lesione è stata localizzata correttamente in 281/288 pazienti (97,5%). Una ROLL non ha avuto successo poiché non è stato possibile effettuare l’intervento chirurgico entro 24 ore. Delle 6 localizzazioni non riuscite, 2 sono da mettere in relazione alla guida radiologica e 4 alla dispersione del tecnezio99.ConclusioniLa guida radiologica nella ROLL ha garantito l’esito della localizzazione e rimozione di lesioni mammarie singole non palpabili nella maggioranza dei casi.

The Role of Imaging in the Diagnosis and Staging of Primary and Recurrent Rectal Cancer

Malignant tumors of the rectum are most commonly detected by fecal occult blood testing, digital rectal examination, barium enema or lower gastrointestinal endoscopy (rigid sigmoidoscopy, flexible sigmoidoscopy or colonoscopy). The decision regarding appropriate treatment in the patient with rectal cancer depends on accurate imaging of the tumor in an effort to define tumor depth, the presence of involved mesorectal nodal involvement, and any evidence of distant metastases at the time of initial diagnosis. In the former instance, delineation of confinement of the tumor to the mucosa or submucosa would enhance decision making regarding local therapies such as local excision of distal lesions, trans anal endomicrosurgery of small, more proximal tumors, photocoagulation or contact irradiation.

Nonpalpable breast lesions: preoperative radiological guidance in radioguided occult lesion localisation (ROLL) Lesioni mammarie non palpabili: la guida radiologica preoperatoria nella ROLL (radioguided occult lesion localisation)

PurposeThis study evaluated the methods, technical aspects and impact of preoperative radiological guidance in radioguided occult lesion localisation (ROLL) for single nonpalpable breast lesions.Materials and methodsA total of 288 patients underwent ROLL before surgery. Human serum albumin macroaggregates labelled with 3.7–7.4 MBq of technetium99 were injected into the lesion. In the case of ultrasonographic guidance (221/288 patients), inoculum positioning resulted in a change of echogenicity at the lesion site. In the case of mammographic guidance (67/288 patients), iodinated contrast medium was injected following the radiotracer for subsequent mammographic evaluation. Patients underwent surgery within 24 h from ROLL. A gamma-detecting probe was used to locate the lesion during surgery and guide its removal. After excision, the specimen was examined by either ultrasonography or mammography to verify complete lesion removal before histological evaluation.ResultsThe lesion was correctly localised in 281/288 patients (97.5%). One ROLL procedure failed because surgery could not be performed within 24 h and the radioactivity decayed. Of the six incorrect localisations, 2 were due to the radiological guidance and 4 to technetium99 dispersion.ConclusionsRadiological guidance in ROLL ensured the outcome of the procedure of localisation and removal of single, nonpalpable breast lesions in the majority of cases.RiassuntoObiettivoScopo del presente lavoro è stato quello di valutare metodi, aspetti tecnici ed impatto della guida radiologica preoperatoria nella radioguided occult lesion localisation (ROLL) per lesioni mammarie singole non palpabili.Materiali e metodiDuecentottantotto pazienti sono state sottoposte a ROLL prima dell’intervento. All’interno della lesione sono stati iniettati macro-aggregati di albumina umana marcata con tecnezio99; nel caso di guida ecografica (221/288 soggetti), l’inoculo ha prodotto iperecogenicità in corrispondenza della lesione; nel caso di guida mammografica (67/288 soggetti), dopo il radiotracciante è stato inoculato mezzo di contrasto iodato per il successivo controllo mammografico. Le pazienti sono state sottoposte ad intervento chirurgico entro 24 ore dalla ROLL. Per localizzare la lesione e guidarne la rimozione chirurgica, è stata utilizzata una sonda per la rilevazione dei raggi gamma. Dopo l’escissione, il pezzo operatorio è stato esaminato con ecografia o mammografia per verificare la completa rimozione della lesione.RisultatiLa lesione è stata localizzata correttamente in 281/288 pazienti (97,5%). Una ROLL non ha avuto successo poiché non è stato possibile effettuare l’intervento chirurgico entro 24 ore. Delle 6 localizzazioni non riuscite, 2 sono da mettere in relazione alla guida radiologica e 4 alla dispersione del tecnezio99.ConclusioniLa guida radiologica nella ROLL ha garantito l’esito della localizzazione e rimozione di lesioni mammarie singole non palpabili nella maggioranza dei casi.

Increased [11C]Choline Uptake in Bronchioloalveolar Cell Carcinoma with Negative [18F]FDG Uptake. A PET/CT and Pathology Study

A case of a patient with bronchioloalveolar cell predominate lung adenocarcinoma (BAC) studied using integrated Positron Emission Tomography and Computed Tomography (PET/CT) with both 18F-fluorodeoxyglucose ([18F]FDG-PET) and [11C]Choline ([11C]Choline-PET) is described, with the aim of evaluating a new non invasive imaging method to detect and stage BAC, and providing information on tumour biology in vivo. The information derived from combining the two tracers could help in distinguishing lung adenocarcinoma with large BAC components ([18F]FDG negative and [11C]Choline positive) from inflammatory lesion ([18F]FDG and [11C]Choline positive). In addition, the simultaneous use of two PET tracers, evaluating two different metabolic pathways, together with histopathologic, immunohistochemical and gene expression analysis, could help to improve understanding of tumour in vivo behaviour.