J. R. Buscombe

EANM/SNMMI Guideline for 18F-FDG Use in Inflammation and Infection

1Department of Nuclear Medicine, Universite Catholique de Louvain, Brussels, Belgium; 2Department of Nuclear Medicine, Cambridge Biomedical Campus, Cambridge, United Kingdom; 3Nuclear Medicine, Istituto Clinico Humanitas, Milan, Italy; 4Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah; 5Department of Radiology and Radiological Sciences, Vanderbilt University Medical Center, Nashville, Tennessee; 6Department of Nuclear Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts; 7Department of Nuclear Medicine, Rambam Health Care Campus, Haifa, Israel; 8Nuclear Medicine Department, Hospital Universitario de Bellvitge, Barcelona, Spain; and 9Nuclear Medicine Unit, Faculty of Medicine and Psychology, University “Sapienza,” Rome, Italy

Efficacy of radionuclide treatment DOTATATE Y-90 in patients with progressive metastatic gastroenteropancreatic neuroendocrine carcinomas (GEP-NETs): a phase II study

BACKGROUND To evaluate the clinical and radiological effectiveness of [DOTA(0), D-Phe(1), Tyr(3)]-octreotate (DOTATATE) Y-90 in patients with extensive progressive gastroenteropancreatic neuroendocrine carcinomas (GEP-NETs). MATERIALS AND METHODS Sixty patients with histologically proven GEP-NETs were treated with DOTATATE Y-90. Clinical responses were assessed 6 weeks after completing therapy and then after each of the 3- to 6-month intervals. The radiological response was classified according to RECIST criteria. RESULTS At 6 months after final treatment, radiological partial response (PR; at least a 30% decrease in the sum of the longest diameter of target lesions) was observed in 13 patients (23%), and the remaining patients had stable disease (SD; less than 30% decrease in the sum of the longest diameter of target lesions or less than 20% increase in the sum of the longest diameter of target lesions) (77%). Clinical PR at 6 months was in 43 patients (72%), nine patients had SD and progressive disease (PD) was noted in eight patients. Median progression-free survival (PFS) was 17 months, while the median overall survival (OS) was 22 months. In eight patients with early PD, the PFS was 4.5 and OS 9.5 months, while in those with SD or PR, PFS and OS were 19.5 and 23.5 months, respectively. After 12 months of follow-up, five patients had World Health Organization (WHO) grade 2 or 3 renal toxicity. Haematological toxicity (WHO grade 3 and 4) was noted during therapy in 10% of patients and persisted in 5%. CONCLUSIONS DOTATATE Y-90 therapy is effective and relatively safe in patients with GEP-NET. Standard doses of DOTATATE Y-90 result in a relatively low risk of myelotoxicity. However, due to ongoing risk of renal toxicity, careful monitoring of the kidney is recommended.

111In-pentetreotide scintigraphy: procedure guidelines for tumour imaging.

This document provides general information about somatostatin receptor scintigraphy with 111In-pentetreotide. This guideline should not be regarded as the only approach to visualise tumours expressing somatostatin receptors or as exclusive of other nuclear medicine procedures useful to obtain comparable results. The aim of this guideline is to assist nuclear medicine physicians in recommending, performing, reporting and interpreting the results of 111In-pentetreotide scintigraphy.

Sentinel node in breast cancer procedural guidelines.

ContentProcedure guidelines for scintigraphic detection of sentinel node in breast cancer are presented.AuthorsThe paper was written by several experts in this field on behalf of the European Association of Nuclear Medicine Oncology and Dosimetry committees and approved by the Executive Committee.

99mTc-human immunoglobulin (HIG)--first results of a new agent for the localization of infection and inflammation.

Technetium (99mTc) labelled, polyclonal human immunoglobulin (HIG) is a new agent that detects focal infection and inflammation. This new agent was compared in 40 patients with the accepted standard, namely111In-oxine-labelled leucocytes. This comparison resulted in a sensitivity of 94% and a specificity of 96% for99mTc-HIG when111In-oxine leucocytes were defined as giving the true result. The new agent was shown to localize both sepsis and active inflammatory bowel disease (IBD). There was 100% concordance in the 16 patients with IBD who were imaged with both99mTc-HIG and111In-oxine leucocytes. Discordant results were obtained in one case of suspected osteomyelitis, which was false-positive on the99mTc-HIG scan, and one case of pyrexia of unkown origin when the99mTc-HIG was false-negative and the111In-oxine leucocyte scan demonstrated accumulation of tracer in the caecum at 24 h post-injection. Normal distribution for99mTc-HIG demonstrated activity in the kidneys and bladder and that 50% of the tracer is cleared through the kidneys during the first 24 h post-injection. There were no major or minor side-effects.

Breast scintigraphy: procedure guidelines for tumour imaging

The purpose of this document is to provide general infor-mation about bone scintigraphy in oncology. Theseguidelines describe procedures currently in routine clini-cal use but should not be interpreted as excluding alterna-tive procedures also employed to obtain equivalent data.It must be remembered that the resources and facilitiesavailable to care for patients may vary from one countryto another and from one medical institution to another.This document has been prepared primarily for nuclearmedicine physicians and is intended to offer assistance inoptimising the diagnostic information that can currentlybe obtained from bone scintigraphy. The correspondingguidelines from the Society of Nuclear Medicine (SNM)have been taken into consideration, reviewed and partial-ly integrated into this text. In addition, the literature onthis topic has been reviewed and discussed by an interna-tional group of distinguished experts.

FDG-PET: procedure guidelines for tumour imaging

F]fluorodeoxyglucose positron emission tomography (FDG-PET) in oncology. These guidelinesdo not include all the existing procedures for FDG-PETbut describe only the most common FDG-PET protocolsused in the current clinical routine studies. For this rea-son, some techniques, such as dynamic tomographicstudies, and some instruments, such as gamma camerasfor coincidence imaging, are only touched upon. Theguidelines should therefore not be taken as inclusive ofall possible PET procedures or exclusive of other nuclearmedicine procedures useful to obtain comparable results.It should be remembered that the resources and the facil-ities available for patient care may vary from one coun-try to another and from one medical institution to an-other. The present guide has been prepared for nuclearmedicine physicians and is intended to offer assistance inoptimising the diagnostic information that can currentlybe obtained from FDG-PET imaging. The Guidelines ofthe Society of Nuclear Medicine (SNM), the ProceduresGuidelines for Brain Imaging Using FGD (EANM) andthe existing guidelines for PET of some European Soci-eties have been reviewed and integrated into the presenttext. The same has been done with the most relevant

Fluoro-deoxyglucose positron emission tomography imaging for the detection of occult disease in multiple myeloma

Summary. Positron emission tomography with 2‐deoxy‐2‐[18]fluoro‐d‐glucose (FDG‐PET) imaging has been extensively used to detect occult metastatic malignant lesions in patients with carcinoma. We describe its use in three patients with multiple myeloma, each representing a particular clinical situation in which this imaging modality offered advantages over plain radiography, computerized tomography or magnetic resonance imaging. FDG‐PET provides a whole body image showing sites of occult disease. This is of particular value in patients with non‐secretory myeloma, solitary plasmacytoma or for those that relapse with focal disease following autologous or allogeneic stem cell transplantation.

Detection of Atherosclerotic Inflammation by 68Ga-DOTATATE PET Compared to [18F]FDG PET Imaging

Background Inflammation drives atherosclerotic plaque rupture. Although inflammation can be measured using fluorine-18-labeled fluorodeoxyglucose positron emission tomography ([18F]FDG PET), [18F]FDG lacks cell specificity, and coronary imaging is unreliable because of myocardial spillover. Objectives This study tested the efficacy of gallium-68-labeled DOTATATE (68Ga-DOTATATE), a somatostatin receptor subtype-2 (SST2)-binding PET tracer, for imaging atherosclerotic inflammation. Methods We confirmed 68Ga-DOTATATE binding in macrophages and excised carotid plaques. 68Ga-DOTATATE PET imaging was compared to [18F]FDG PET imaging in 42 patients with atherosclerosis. Results Target SSTR2 gene expression occurred exclusively in “proinflammatory” M1 macrophages, specific 68Ga-DOTATATE ligand binding to SST2 receptors occurred in CD68-positive macrophage-rich carotid plaque regions, and carotid SSTR2 mRNA was highly correlated with in vivo 68Ga-DOTATATE PET signals (r = 0.89; 95% confidence interval [CI]: 0.28 to 0.99; p = 0.02). 68Ga-DOTATATE mean of maximum tissue-to-blood ratios (mTBRmax) correctly identified culprit versus nonculprit arteries in patients with acute coronary syndrome (median difference: 0.69; interquartile range [IQR]: 0.22 to 1.15; p = 0.008) and transient ischemic attack/stroke (median difference: 0.13; IQR: 0.07 to 0.32; p = 0.003). 68Ga-DOTATATE mTBRmax predicted high-risk coronary computed tomography features (receiver operating characteristics area under the curve [ROC AUC]: 0.86; 95% CI: 0.80 to 0.92; p < 0.0001), and correlated with Framingham risk score (r = 0.53; 95% CI: 0.32 to 0.69; p <0.0001) and [18F]FDG uptake (r = 0.73; 95% CI: 0.64 to 0.81; p < 0.0001). [18F]FDG mTBRmax differentiated culprit from nonculprit carotid lesions (median difference: 0.12; IQR: 0.0 to 0.23; p = 0.008) and high-risk from lower-risk coronary arteries (ROC AUC: 0.76; 95% CI: 0.62 to 0.91; p = 0.002); however, myocardial [18F]FDG spillover rendered coronary [18F]FDG scans uninterpretable in 27 patients (64%). Coronary 68Ga-DOTATATE PET scans were readable in all patients. Conclusions We validated 68Ga-DOTATATE PET as a novel marker of atherosclerotic inflammation and confirmed that 68Ga-DOTATATE offers superior coronary imaging, excellent macrophage specificity, and better power to discriminate high-risk versus low-risk coronary lesions than [18F]FDG. (Vascular Inflammation Imaging Using Somatostatin Receptor Positron Emission Tomography [VISION]; NCT02021188)

SPECT/CT in sentinel node imaging.

Sentinel node lymphoscintigraphy and biopsy has become standard practice for lymphatic staging in early-stage breast cancer and melanoma. More recently, sentinel node lymphoscintigraphy has also been used in head and neck squamous cell cancers and other solid tumours. Single photon emission computed tomography/computed tomography (SPECT/CT) is a new tool and this article reviews its potential application in sentinel node imaging. SPECT/CT provides complementary functional and anatomical information and has been shown to be superior to planar imaging in a number of indications. The advantages include more accurate anatomical localization, identification of false positives (due to contamination or spillover from the injection site), reduction in the number of false negatives (visualization of nodes not seen on planar imaging) and alteration of the surgical approach. We thus believe that sentinel lymph node SPECT/CT can provide valuable information before sentinel lymph node biopsy and advocate its use in a range of tumours such as truncal and head and neck melanomas.