Roberto Delgado-Bolton

FDG PET/CT: EANM procedure guidelines for tumour imaging: version 2.0

The purpose of these guidelines is to assist physicians in recommending, performing, interpreting and reporting the results of FDG PET/CT for oncological imaging of adult patients. PET is a quantitative imaging technique and therefore requires a common quality control (QC)/quality assurance (QA) procedure to maintain the accuracy and precision of quantitation. Repeatability and reproducibility are two essential requirements for any quantitative measurement and/or imaging biomarker. Repeatability relates to the uncertainty in obtaining the same result in the same patient when he or she is examined more than once on the same system. However, imaging biomarkers should also have adequate reproducibility, i.e. the ability to yield the same result in the same patient when that patient is examined on different systems and at different imaging sites. Adequate repeatability and reproducibility are essential for the clinical management of patients and the use of FDG PET/CT within multicentre trials. A common standardised imaging procedure will help promote the appropriate use of FDG PET/CT imaging and increase the value of publications and, therefore, their contribution to evidence-based medicine. Moreover, consistency in numerical values between platforms and institutes that acquire the data will potentially enhance the role of semiquantitative and quantitative image interpretation. Precision and accuracy are additionally important as FDG PET/CT is used to evaluate tumour response as well as for diagnosis, prognosis and staging. Therefore both the previous and these new guidelines specifically aim to achieve standardised uptake value harmonisation in multicentre settings.

Meta-analysis of the performance of 18F-FDG PET in cutaneous melanoma

IntroductionThe aim of this study was to perform a systematic review of the literature to evaluate the accuracy of FDG-PET in staging and restaging of cutaneous melanoma.MethodsSystematic methods were used to identify, select, and evaluate the methodologic quality of the studies as well as to summarize the overall findings of sensitivity and specificity. The search strategy consisted of identifying studies published between 2000 and 2006. Inclusion criteria were studies that evaluated the diagnostic performance of FDG-PET in staging/restaging of cutaneous melanoma. The results were compared and pooled with a meta-analysis published previously that included studies published until 1999. The meta-analysis included 95% confidence intervals (CI) of sensitivity, specificity, likelihood-ratio (LR), and diagnostic-odds-ratio (DOR).ResultsThe quantitative meta-analysis included 24 studies that were analysed in two groups: eight studies were included only in the regional staging analysis (group I), 13 studies were included only in the detection of distant metastases analysis (group II), and three studies were included in both analyses. Compliance with the methodologic-quality criteria was acceptable. We analysed the results of data presented in patients, lesions, basins, lymph-nodes, areas, and scans. Regarding the performance of FDG-PET in the detection of metastases, the pooled studies presented homogeneity for the negative-LR (0.15; 95% CI, 0.10–0.22) when analyzing lesions. When analyzing scans, there was global homogeneity for specificity (0.86; 95% CI, 0.77–0.92), positive-LR (5.86; 95% CI, 3.64–9.43), and DOR (37.89; 95% CI, 15.80–90.86). The pooled studies presented heterogeneity for the other items analysed. Regarding the detection of regional metastases, when analyzing lymph-nodes there was global homogeneity for specificity (0.99; 95% CI, 0.97–0.99; P = 0.101). The meta-regression evidenced that the variable that most influenced the DOR of the different studies and that can explain the heterogeneity was the year of publication; this may be related to the evolution of PET technology and an improvement of sensitivity/specificity.ConclusionFDG-PET is not useful in the evaluation of regional metastases, as it does not detect microscopic disease. However, FDG-PET could be useful in the detection of distant metastases, and could suggest its utility in the management of patients with cutaneous melanoma.

The EANM practice guidelines for bone scintigraphy

PurposeThe radionuclide bone scan is the cornerstone of skeletal nuclear medicine imaging. Bone scintigraphy is a highly sensitive diagnostic nuclear medicine imaging technique that uses a radiotracer to evaluate the distribution of active bone formation in the skeleton related to malignant and benign disease, as well as physiological processes.MethodsThe European Association of Nuclear Medicine (EANM) has written and approved these guidelines to promote the use of nuclear medicine procedures of high quality.ConclusionThe present guidelines offer assistance to nuclear medicine practitioners in optimizing the diagnostic procedure and interpreting bone scintigraphy. These guidelines describe the protocols that are currently accepted and used routinely, but do not include all existing procedures. They should therefore not be taken as exclusive of other nuclear medicine modalities that can be used to obtain comparable results. It is important to remember that the resources and facilities available for patient care may vary.

[Meta-analysis of the diagnostic performance of 18F-FDG PET in renal cell carcinoma].

AIM Renal cell carcinoma is the most frequent solid kidney tumor. At present, PET is not the imaging test of choice, the helical CT being the best method to assess these patients. The aim of the study was to perform a meta-analysis of the literature to evaluate the performance and accuracy of 18F-FDG PET in the detection of primary disease, recurrence and metastasis of renal cell carcinoma. MATERIALS AND METHODS A systematic search was done of the available literature in primary and secondary databases published until October 2004 indexed in MEDLINE and CANCERLIT. Exclusion/inclusion criteria were applied. Their quality was evaluated using the Flynn criteria and joint estimators of sensitivity (S), specificity (Sp), likelihood ratios (LR), diagnostic odds ratio (DOR) and summary ROC (SROC) curve were obtained. The presence of the threshold effect was evaluated and the summary ROC (SROC) curve was calculated. RESULTS Seven out of 46 studies fulfilled the inclusion criteria and were analyzed. Three studies evaluated the use of 18F-FDG PET in the differential diagnosis of renal masses. Two studies analyzed restaging and two analyzed the role of 18F-FDG PET in the detection of metastatic disease. All the selected studies were classified according to Flynns criteria. We found the highest S in restaging with S 0.87 (95 % CI, 0.75-0.95) and in metastases detection with S 0.72 (95 % CI, 0.56-0.85) as well as the high Sp in differential diagnosis of renal masses. CONCLUSIONS The results of this meta-analysis suggest that 18F-FDG PET can be useful in restaging and detection of metastatic disease, based on its acceptable S and Sp. However, the performance of 18F-FDG PET in the detection of primary disease is limited, but this may improve with the new PET/CT systems.

Guideline for PET/CT imaging of neuroendocrine neoplasms with 68Ga-DOTA-conjugated somatostatin receptor targeting peptides and 18F–DOPA

Purpose & MethodsNeuroendocrine neoplasms are a heterogenous group of tumours, for which nuclear medicine plays an important role in the diagnostic work-up as well as in the targeted therapeutic options. This guideline is aimed to assist nuclear medicine physicians in recommending, performing, reporting and interpreting the results of somatostatin receptor (SSTR) PET/CT imaging using 68Ga-DOTA-conjugated peptides, as well as 18F-DOPA imaging for various neuroendocrine neoplasms.Results & ConclusionThe previous procedural guideline by EANM regarding the use PET/CT tumour imaging with 68Ga-conjugated peptides has been revised and updated with the relevant and recent literature in the field with contribution of distinguished experts.

SPECT-TAC: una nueva herramienta para la localización del ganglio centinela en pacientes con cáncer de mama

Resumen Introduccion La biopsia selectiva del ganglio centinela es una herramienta que ha demostrado ser eficaz en la estadificacion linfatica, evitando realizar linfadenectomias a pacientes que no van a beneficiarse de ellas. Objetivo Determinar las ventajas de la SPECT-TAC frente a la gammagrafia convencional en la localizacion prequirurgica del ganglio centinela. Material y metodos Se trata de un estudio prospectivo con 25 pacientes divididas en dos grupos, segun hubiesen recibido o no quimioterapia neoadyuvante (grupo A, n = 19 sin quimioterapia previa; grupo B, n = 6 con quimioterapia), a las que se les realizo la gammagrafia planar convencional y un estudio con un equipo hibrido SPECT-TAC de baja dosis. Se realizo la localizacion intraoperatoria con sonda portatil resecando todos los depositos existentes en la axila. Resultados La SPECT-TAC determino correctamente el numero y localizacion de los ganglios en 17 de 19 pacientes del grupo A, frente a 12 de 19 pacientes en las que lo hizo la gammagrafia. La concordancia de la SPECT-TAC con los hallazgos de la cirugia fue muy buena (indice kappa 0,91), mientras que la gammagrafia presento una concordancia moderada (indice kappa 0,57). Conclusiones La SPECT-TAC se constituye como una herramienta nueva que aporta al cirujano una informacion exacta de la localizacion de los ganglios centinela, permitiendo orientar de inicio el acto quirurgico a la busqueda exclusiva de los ganglios observados en las imagenes.

Meta-análisis de la eficacia diagnóstica de la PET-FDG en pacientes con sospecha de recurrencia por cáncer de ovario

Resumen Objetivo El objetivo de este trabajo ha sido realizar un meta-analisis de la literatura para evaluar la exactitud de la PET-FDG en la deteccion de la recurrencia en pacientes con cancer de ovario. Metodos La estrategia de la busqueda consistio en identificar los trabajos publicados entre noviembre de 1972 y octubre del 2003 indexados en las bases del MEDLINE y CANCERLITE. Los criterios de inclusion fueron las publicaciones que valorasen la recurrencia por cancer de ovario mediante PET-FDG. Los criterios de exclusion fueron los trabajos duplicados o publicados previamente. El analisis estadistico incluyo los intervalos de confianza (IC) al 95 % de la sensibilidad (S), especificidad (Ep) y del logaritmo natural de la odss ratio (ln OR). Resultados Se analizaron diecisiete trabajos. La S y la Ep, fueron 0,94 (IC 95 %, 0,93-0,96) y 0,65 (IC 95 %, 0,46-0,85), respectivamente. El ln OR presento una homogeneidad global y valores significativos en > del 75 % de las publicaciones. Conclusiones Segun nuestro meta-analisis, la PET-FDG tiene una elevada S y una Ep intermedia, con pocos resultados falsos negativos. Estos resultados preliminares sugieren que la PET-FDG puede representar un medio efectivo de identificar la recurrencia en pacientes con cancer de ovario.

EANM guideline for radionuclide therapy with radium-223 of metastatic castration-resistant prostate cancer

Radium Ra-223 dichloride (radium-223, Xofigo®) is a targeted alpha therapy approved for the treatment of castration-resistant prostate cancer (CRPC) with symptomatic bone metastases and no known visceral metastatic disease. Radium-223 is the first targeted alpha therapy in this indication providing a new treatment option, with evidence of a significant survival benefit, both in overall survival and in the time to the first symptomatic skeletal-related event. The skeleton is the most common metastatic site in patients with advanced prostate cancer. Bone metastases are a clinically significant cause of morbidity and mortality, often resulting in bone pain, pathologic fracture, or spinal cord compression necessitating treatment. Radium-223 is selectively accumulated in the bone, specifically in areas of high bone turnover, by forming complexes with the mineral hydroxyapatite (the inorganic matrix of the bone). The alpha radiation generated during the radioactive decay of radium-223 produces a palliative anti-tumour effect on the bone metastases. The purpose of this guideline is to assist nuclear medicine specialists in evaluating patients who might be candidates for treatment using radium-223, planning and performing this treatment, understanding and evaluating its consequences, and improving patient management during therapy and follow-up.

Impacto de la tomografía por emisión de positrones mediante 18-Fluoro-2-Desoxi-D-Glucosa (PET-FDG) en el manejo terapéutico de pacientes con recurrencia secundaria a cáncer de ovario

Resumen Objetivo La deteccion de la recurrencia secundaria a cancer de ovario es un problema de importancia notoria, pudiendo mediante un diagnostico correcto ofrecer alternativas utiles en el manejo de las pacientes. El objetivo de este estudio ha sido valorar el impacto terapeutico de la PET-FDG en la recurrencia por cancer de ovario. Material y metodos Se han incluido 43 enfermas con cancer de ovario en las que se efectuo el estudio PET-FDG ante la sospecha diagnostica de recidiva. Los resultados de la PET-FDG se confirmaron por histopatologia y seguimiento clinico mayor de 12 meses. Se ha comparado el impacto en el manejo de las pacientes basado en los metodos convencionales de imagen, con el plan de tratamiento considerando los hallazgos de la PET-FDG, clasificando el impacto de la PET-FDG como alto, medio, bajo o no impacto. Los cambios en el manejo terapeutico de las enfermas, han sido clasificados como intermodalidad o intramodalidad. Resultados El estudio PET-FDG obtuvo un impacto alto en el manejo terapeutico de 28 pacientes (65,1 %), un impacto medio en 2 pacientes (4,6 %), un impacto bajo en 9 pacientes (20,9 %), y no tuvo impacto en 4 enfermas (9,3 %). La PET-FDG indujo un cambio intermodalidad en 27 pacientes (62,8 %); un cambio intramodalidad en 3 pacientes (7 %); y finalmente en 13 enfermas (30,2 %), no produjo ningun cambio en el tratamiento. Conclusiones La PET-FDG proporciona una informacion adicional con respecto a los metodos diagnosticos de imagen convencional, permitiendo efectuar cambios en el manejo terapeutico en la mayoria de las enfermas.

Appropriate use criteria for 18F-FDG PET/CT in restaging and treatment response assessment of malignant disease

Precision medicine is evolving to include a variety of data to optimize patient care and improve outcome. Multimodality imaging is paving the way toward this goal. PET/CT with 18F-FDG is now established as an important imaging modality in many clinical conditions, particularly in oncology (1,2). Many tumors demonstrate high glucose metabolism as one of the hallmarks of cancer (3). PET/CT provides combined anatomic and physiologic (glucose metabolism) information that may be used for initial diagnosis, staging, restaging, treatment response assessment, and prognosis in patients with cancer. Moreover, PET information can contribute significantly when other imaging modalities are equivocal. The purpose of this document is to describe the appropriate use of PET/CT* in the response assessment and restaging of patients with cancer. Our focus here is on common cancers in which the use of PET/CT has been most relevant for clinical practice. Restaging is broadly defined to include the phase of the disease after initial diagnosis and treatment. This phase may entail local recurrence, distant metastatic disease, and assessment of response to a variety of treatments after the disease recurs. The goal of these recommendations is to guide the appropriate use of PET/CT in assessing treatment response after therapy and in evaluating imaging of patients with suspected recurrent cancer. Although the terms response assessment and restaging are frequently used in the discussion of cancer treatment, no consensus definition exists regarding the time frame that differentiates these 2 terms. Indeed, the time interval at which a patient transitions from response assessment to restaging likely varies in relation to tumor biology, therapeutic regimen, and other factors. For the purposes of this work, the term assessment of response is taken to mean the period in which the intended target of the therapeutic regimen is being evaluated, whereas the term restaging of disease is taken to mean the period in which there is concern for new or progressive disease after completion of prior therapy. Moreover, this document excludes “initial staging” and “surveillance.” Representatives from the Society of Nuclear Medicine and Molecular Imaging (SNMMI), the European Association of Nuclear Medicine (EANM), the American Society of Clinical Oncology (ASCO), the American College of Nuclear Medicine (ACNM), the Society for Pediatric Radiology (SPR), and the Canadian Association of Nuclear Medicine (CANM) assembled under the auspices of an autonomous workgroup to develop the following appropriate use criteria (AUC). This process was performed in accordance with the Protecting Access to Medicare Act of 2014 (4). This legislation requires that all referring physicians consult AUC by using a clinical decision support mechanism before ordering advanced diagnostic imaging services. These services include diagnostic MRI, CT, and nuclear medicine procedures such as PET, among other services specified by the Secretary of Health and Human Services in consultation with physician specialty organizations and other stakeholders (4). These AUC are intended to aid referring medical practitioners in the appropriate use of PET/CT for restaging of breast cancer, colorectal cancer, lymphoma, lung cancer, melanoma, sarcoma, and head and neck cancer.