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Annals of Nuclear Medicine (v.26, #6)

The role of positron emission tomography using carbon-11 and fluorine-18 choline in tumors other than prostate cancer: a systematic review by Giorgio Treglia; Elisabetta Giovannini; Davide Di Franco; Maria Lucia Calcagni; Vittoria Rufini; Maria Picchio; Alessandro Giordano (pp. 451-461).

To systematically review published data on the role of positron emission tomography (PET) or PET/computed tomography (PET/CT) using either Carbon-11 (¹¹C) or Fluorine-18 (¹⁸F) choline tracer in tumors other than prostatic cancer. A comprehensive literature search of studies published in PubMed/MEDLINE and Embase databases through January 2012 and regarding ¹¹C-choline or ¹⁸F-choline PET or PET/CT in patients with tumors other than prostatic cancer was carried out. Fifty-two studies comprising 1800 patients were included and discussed. Brain tumors were evaluated in 15 articles, head and neck tumors in 6, thoracic tumors (including lung and mediastinal neoplasms) in 14, liver tumors (including hepatocellular carcinoma) in 5, gynecologic malignancies (including breast tumors) in 5, bladder and upper urinary tract tumors in 5, and musculoskeletal tumors in 7. Radiolabeled choline PET or PET/CT is useful to differentiate high-grade from low-grade gliomas and malignant from benign brain lesions, to early detect brain tumor recurrences and to guide the stereotactic biopsy sampling. The diagnostic accuracy of radiolabeled choline PET is superior compared to Fluorine-18 fluorodeoxyglucose (¹⁸F-FDG) PET in this setting. Radiolabeled choline PET or PET/CT seems to be accurate in differential diagnosis between malignant and benign thoracic lesions and in staging lung tumors; nevertheless, a superiority of radiolabeled choline compared to ¹⁸F-FDG has not been demonstrated in this setting, except for the detection of brain metastases. Few but significant studies on radiolabeled choline PET and PET/CT in patients with hepatocellular carcinoma (HCC) and musculoskeletal tumors are reported in the literature. The combination of radiolabeled choline and ¹⁸F-FDG PET increases the detection rate of HCC. The diagnostic accuracy of radiolabeled choline PET or PET/CT seems to be superior compared to ¹⁸F-FDG PET or PET/CT and conventional imaging methods in patients with bone and soft tissue tumors. Limited experience exists about the role of radiolabeled choline PET and PET/CT in patients with head and neck tumors, bladder cancer and gynecologic malignancies including breast cancer.

Keywords: Positron emission tomography; PET/CT; Choline; Fluorine-18; Carbon-11; Oncology

New semi-quantitative ¹²³I-MIBG estimation method compared with scoring system in follow-up of advanced neuroblastoma: utility of total MIBG retention ratio versus scoring method by Yuko Sano; Chio Okuyama; Tomoko Iehara; Shigenori Matsushima; Kei Yamada; Hajime Hosoi; Tsunehiko Nishimura (pp. 462-470).

The purpose of this study is to evaluate a new semi-quantitative estimation method using ¹²³I-MIBG retention ratio to assess response to chemotherapy for advanced neuroblastoma.Thirteen children with advanced neuroblastoma (International Neuroblastoma Risk Group Staging System: stage M) were examined for a total of 51 studies with ¹²³I-MIBG scintigraphy (before and during chemotherapy). We proposed a new semi-quantitative method using MIBG retention ratio (count obtained with delayed image/count obtained with early image with decay correction) to estimate MIBG accumulation. We analyzed total ¹²³I-MIBG retention ratio (TMRR: total body count obtained with delayed image/total body count obtained with early image with decay correction) and compared with a scoring method in terms of correlation with tumor markers.TMRR showed significantly higher correlations with urinary catecholamine metabolites before chemotherapy (VMA: r ² = 0.45, P < 0.05, HVA: r ² = 0.627, P < 0.01) than MIBG score (VMA: r ² = 0.19, P = 0.082, HVA: r ² = 0.25, P = 0.137). There were relatively good correlations between serial change of TMRR and those of urinary catecholamine metabolites (VMA: r ² = 0.274, P < 0.001, HVA: r ² = 0.448, P < 0.0001) compared with serial change of MIBG score and those of tumor markers (VMA: r ² = 0.01, P = 0.537, HVA: 0.084, P = 0.697) during chemotherapy for advanced neuroblastoma.TMRR could be a useful semi-quantitative method for estimating early response to chemotherapy of advanced neuroblastoma because of its high correlation with urine catecholamine metabolites.

Keywords: Advanced neuroblastoma; ¹²³I-MIBG scintigraphy; Scoring system; Urinary vanillylmandelic acid; Urinary homovanillic acid

Prediction of central lymph node metastasis from papillary thyroid microcarcinoma by ¹⁸F-fluorodeoxyglucose PET/CT and ultrasonography by Byung Hyun Byun; Ung-Gill Jeong; Sun-Pyo Hong; Jung-Joon Min; Ari Chong; Ho-Chun Song; Hee-Seung Bom (pp. 471-477).

The presence of central lymph node (LN) metastasis increases the risk of cervical LN recurrence or distant metastasis in patients with papillary thyroid microcarcinoma (PTMC). We investigated the value of preoperative ¹⁸F-fluoro-2-deoxy-d-glucose-positron emission tomography (FDG PET)–computerized tomography (CT) and ultrasonography (US) to predict central LN metastasis from PTMC.Two hundred patients with newly diagnosed unifocal PTMC were enrolled. Preoperative FDG PET–CT was performed, and the highest SUV (SUV_max) of focally increased uptake at thyroid was measured. Tumor size was measured using preoperative US. Uni- and multivariate analyses were performed using the presence of focally increased uptake at thyroid (FDG positivity), SUV_max, tumor size, and clinical risk factor for central LN metastasis. ROC curves for risk factors were then analyzed. These analyses were undertaken in two groups: the all patients group and the FDG-positive group. Finally, we combined risk factors associated with central LN metastasis to improve predictive accuracy.Tumor size >6 mm was associated with central LN metastasis. FDG positivity was identified in 110 patients (55.0 %) and the SUV_max ranged from 1.8 to 12.8 (median 3.0). In FDG-positive group, SUV_max >2.8 was associated with central LN metastasis. Addition of SUV_max >2.8 to size >6 mm of PTMC improved sensitivity of predicting central LN metastasis from 55.0 to 67.5 %, while specificity remained at 70.6 %.Both FDG PET–CT and US are valuable for preoperative prediction of central LN metastasis from PTMC. Combined use of SUV_max and tumor size improves sensitivity without changing specificity.

Keywords: Papillary thyroid microcarcinoma; FDG PET; Lymph node; Metastasis

¹⁸F-FLT PET performs better than ¹⁸F-FDG PET in differentiating malignant uterine corpus tumors from benign leiomyoma by Tomohiko Yamane; Aki Takaoka; Masato Kita; Yukihiro Imai; Michio Senda (pp. 478-484).

The aim of this study is to test the hypothesis that positron emission tomography (PET) with 3′-deoxy-3′-[¹⁸F]-fluorothymidine (¹⁸F-FLT) can differentiate malignancy from benign leiomyoma better than PET with 2-deoxy-2-[¹⁸F]fluoro-d-glucose (¹⁸F-FDG), and to evaluate whether ¹⁸F-FLT and ¹⁸F-FDG uptake correlate with immunohistochemical index of cell proliferation.The protocol of this prospective study was approved by the institutional ethics committee, and all patients gave written informed consent. Fifteen patients (aged 26–65 years, median 44 years) with uterine corpus tumor which has the possibility of being leiomyosarcoma underwent ¹⁸F-FLT and ¹⁸F-FDG PET scans. Maximum standard uptake value (SUV_max) of PET scans and Ki-67 labeling index of surgical specimens were evaluated. Mann–Whitney’s U test was used for comparing uptakes between benign and malignant, and linear regression analysis was used for evaluating the correlation between Ki-67 labeling index and SUV_max.Five cases were diagnosed as malignant (leiomyosarcoma for 3 cases, and carcinoma for 2 cases), and the others were benign leiomyoma. Sensitivity and negative predictive value of both tracers for detecting malignancy was 100 %. Specificity, positive predictive value and accuracy of ¹⁸F-FLT PET were higher than those of ¹⁸F-FDG PET. Difference in SUV_max between malignant and benign was significant for ¹⁸F-FLT PET (P < 0.01), but not for ¹⁸F-FDG PET. While all the malignant cases showed positive uptake in both tracers, a case of leiomyosarcoma with huge necrosis showed relatively low uptake. Uptake of ¹⁸F-FLT showed better correlation with Ki-67 labeling index compared with ¹⁸F-FDG (R 2 = 0.91 vs. R 2 = 0.26).Negative findings on additional ¹⁸F-FDG or ¹⁸F-FLT PET may rule out the possibility of malignancy for the patients with suspected leiomyosarcoma diagnosed by conventional methods. ¹⁸F-FLT PET is superior to ¹⁸F-FDG PET in differentiating malignant from benign leiomyoma. Moreover, ¹⁸F-FLT uptake correlated well with the immunohistochemical index of cell proliferation.

Keywords: ¹⁸F-FLT PET; ¹⁸F-FDG PET; Uterine corpus tumor; Uterine leiomyosarcoma; Uterine leiomyoma

EORTC QLQ-BM22 and QLQ-C30 quality of life scores in patients with painful bone metastases of prostate cancer treated with strontium-89 radionuclide therapy by Shinji Kurosaka; Takefumi Satoh; Edward Chow; Yuji Asano; Ken-ichi Tabata; Masaki Kimura; Hideyasu Tsumura; Kazumasa Matsumoto; Hiromichi Ishiyama; Yusuke Inoue; Kazushige Hayakawa; Shiro Baba (pp. 485-491).

Approximately 80 % of patients with prostate cancer will develop bone metastases, which often lead to bone pain and skeletal-related events. Sr-89 is an established alternative for the palliation of bone pain in prostate cancer. We aimed to assess the effect of Sr-89 radionuclide therapy on quality of life (QOL) in prostate cancer patients with painful bone metastases.Thirteen patients received a single intravenous injection of Sr-89 at a dose of 2.0 MBq/kg. All patients underwent QOL evaluation prior to Sr-89 treatment and 1, 2, and 3 months afterward using the Japanese version of the EORTC QLQ-BM22, EORTC QLQ-C30, a VAS, and face scale. We also evaluated PSA and ALP response and toxicity of the Sr-89 therapy.The pain characteristics subscale of the EORTC QLQ-BM22 was significantly reduced from 1 month onward compared with the baseline. The functional interference and psychosocial aspects subscales were significantly higher than baseline from 2 months onward. At 2 months, VAS indicated a significant reduction in pain as compared to the baseline. Sr-89 therapy caused a nonsignificant reduction in PSA and ALP levels. No patients had leukocyte toxicity, and one patient had grade 3 platelet toxicity.Sr-89 radionuclide therapy can provide not only reduced pain characteristics but also better psychosocial aspects and functional interference in patients with painful bone metastases of prostate cancer.

Keywords: Prostate cancer; Bone metastases; Quality of life; Strontium-89

Dual-time-point ¹⁸F-FDG PET/CT in patients with colorectal cancer: clinical value of early delayed scanning by Kanae K. Miyake; Yuji Nakamoto; Kaori Togashi (pp. 492-500).

In dual-time-point PET/CT, early delayed scanning (D-1) just after the completion of whole body scanning (E) is easy to perform without additional radiation exposure and repositioning. Our aim was to assess the clinical value of D-1 compared with conventional delayed scanning (D-2).Our institutional review board approved this retrospective study. Fifty-four patients with known or suspected colorectal cancer underwent ¹⁸F-FDG PET/CT at our institution. The E scan at 1-h post-injection was followed by D-1 at 85 ± 7 min post-injection and D-2 at 124 ± 7 min post-injection. The clinical value of D-1 was evaluated by comparing diagnostic performance with D-2 for differentiating physiologic from pathological uptake and for staging colorectal cancer. Colonoscopic findings, histopathological results and clinical follow-up including radiological findings were used as reference standards.Thirty-two, eight and 73 focal or short segmental FDG foci by physiologic processes in the colon/rectum, the small intestine and the ureter, respectively, noted in the E scan were evaluated in this study. Using D-1 and D-2, 14/32 (44 %) and 17/32 (53 %) in the colon/rectum, 5/8 (63 %) and 8/8 (100 %) in the small intestine, and 55/73 (75 %) and 69/73 (95 %) in the ureter, respectively, were accurately interpreted as physiologic with the change of intensity and/or shape/location. A significant difference between D-1 and D-2 was observed in the ureter, but not in the bowel. The 55 colorectal cancers were finally diagnosed in 52 patients. In the staging of colorectal cancer, there were no significant differences among the three scans in the lesion-based detectability, the patient-based sensitivity, specificity and accuracy for the identification of primary tumors, nodal and hepatic metastases, and dissemination.Neither D-1 nor D-2 improved staging of colorectal cancer. However, delayed scans yielded information useful for differentiating physiologic uptake from pathological uptake and D-1 may provide comparable efficacy with D-2 in the bowel. Because of the ease of acquisition, the D-1 scan was considered a practical way to reduce false-positives in the abdomen and possibly helpful to avoid unnecessary additional invasive examinations, such as colonoscopy.

Keywords: Dual-time-point FDG PET/CT; Colorectal cancer; Physiologic uptake; Early delayed scan

Detection of recurrent prostate cancer with 18F-fluorocholine PET/CT in relation to PSA level at the time of imaging by Sandi A. Kwee; Marc N. Coel; John Lim (pp. 501-507).

To evaluate fluorine-18 fluorocholine (FCH) PET/CT for the detection of recurrent prostate cancer in relation to prostate-specific antigen (PSA) level.FCH PET/CT was performed in 50 patients with rising PSA levels at follow-up of primary treatment of prostate cancer (radical prostatectomy in 28, radiation therapy in 13, and brachytherapy in 9). PET detection rates were determined at various PSA thresholds and examined by receiver operating characteristic analysis.Findings consistent with recurrent prostate cancer were noted on FCH PET/CT in 31/50 (62 %) patients, with positive findings in 17/18 (94 %), and 11/13 (85 %), 2/7 (29 %), and 1/12 (8 %) patients with PSA >4, >2–4, >0.5–2, and ≤0.5 ng/mL, respectively. These findings were indicative of local/regional recurrence in 23 cases and systemic recurrence in 8 cases, with only a single route of recurrence (i.e., either hematogenous, lymphatic, or intraprostatic) in 84 % of PET scans with positive findings. Abnormal tumor activity was detected in 88 % of patients with a PSA level of 1.1 ng/mL or higher, and in only 6 % of patients with a PSA level below this threshold value.FCH PET/CT may serve to identify the route of tumor progression in patients with recurrent prostate cancer; however, the likelihood of tumor detection may be related to the PSA level at the time of imaging.

Keywords: Fluorocholine; Prostate cancer; Positron emission tomography

Management of fear of radiation exposure in carers of outpatients treated with iodine-131 by Phillipe J. Calais; Andrew C. Page; J. Harvey Turner (pp. 508-514).

To characterise potential fear of radiation exposure in a normal population of individuals who have volunteered to care for a radioactive family member or friend after outpatient radioimmunotherapy (RIT) treatment for cancer, and obtain their knowing and willing acceptance of the risk.Over 750 carers of 300 patients confined to their homes for 1 week following outpatient iodine-131 rituximab RIT of lymphoma were interviewed by a nuclear medicine physicist according to a multi-visit integrated protocol designed to minimise radiation exposure, define risk and gain informed consent.Median radiation exposure of carers was 0.49 mSv (range 0.01–3.7 mSv) which is below the Western Australian regulatory limit of 5 mSv for consenting adult carers of radioactive patients. After signing a declaration of consent, only 2 carers of 750 abrogated their responsibility and none of those who carried out their duties expressed residual concerns at the end of the exit interview with respect to their radiation exposure.Fear of radiation exposure in a normal population may be characterised as a normal emotional response. In the special case of carers of radioactive patients, this fear may be successfully managed by rational, authoritative and empathic explanation to define the risk and gain willing acceptance within the context of domiciliary patient care.

Keywords: Relative risk; Radioactivity exposure; Radiophobia

Intravascular large B-cell lymphoma with diffuse FDG uptake in the lung by ¹⁸FDG-PET/CT without chest CT findings by Hiroyuki Yamashita; Akitake Suzuki; Yuko Takahashi; Kazuo Kubota; Toshikazu Kano; Akio Mimori (pp. 515-521).

We report a rare case of intravascular large B-cell lymphoma (IVLBCL) with diffuse fluorodeoxyglucose (FDG) uptake in the lung by ¹⁸FDG-positron emission tomography/computed tomography (PET/CT). CT showed nodular shadow, whereas diffuse FDG uptake in PET/CT suggested IVLBCL in the lung. A random skin biopsy provided histological evidence of IVLBCL. The patient responded well to combination chemotherapy. Only two cases of IVLBCL in which diffuse pulmonary FDG uptake was demonstrated have been reported previously. FDG-PET/CT plus random skin biopsy may be useful for the early diagnosis of IVLBCL with pulmonary involvement even without convincing radiological findings in the lung.

Keywords: Intravascular large B-cell lymphoma (IVLBCL); ¹⁸F-fluorodeoxyglucose-positron emission tomography/computed tomography (¹⁸FDG-PET/CT); Random skin biopsy

Lung amyloid nodule detected by ^99mTc-aprotinin scintigraphy by Satoru Ishii; Kazuo Kubota; Ryogo Minamimoto; Rikiya Kouketu; Miyako Morooka; Shigeo Kawai; Yuichiro Takeda; Nobuyuki Kobayashi; Haruhito Sugiyama (pp. 522-526).

We present a case in which an amyloid lung nodule was diagnosed preoperatively by amyloid scintigraphy ^99mTc-aprotinin. A 65-year-old man complained of marked weight loss (9 kg) over a period of 6 months. An abnormal shadow in the middle field of the right lung was detected on chest X-ray, corresponding to a 16-mm nodule in the right middle lobe on thoracic computed tomography (CT). Total protein and immunoglobulin G levels were elevated to 8.3 and 2245 mg/dl, respectively, but other blood tests including several tumor marker levels and Cryptococcus antibodies were all within normal range. Fluorodeoxyglucose positron emission tomography showed no uptake by the lung nodule, so lung amyloidosis was considered as differential diagnosis. To avoid risk of bleeding on bronchoscopy, noninvasive amyloid scintigraphy using ^99mTc-aprotinin was first performed. A nodular, abnormal accumulation was observed in the right middle lung lobe. Diagnostic imaging strongly suggested amyloidosis, so video-assisted thoracic surgery was performed rather than bronchoscopy. Pathological samples showed positive staining with Congo red, and A-λ amyloidosis was diagnosed on the basis of immunostaining. Scintigraphy using ^99mTc-aprotinin offers a useful, noninvasive method for assessing lung amyloidosis.

Keywords: Amyloidosis; ^99mTc-aprotinin scintigraphy; Solitary pulmonary nodule; FDG-PET

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Annals of Nuclear Medicine (v.26, #6)

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Annals of Nuclear Medicine (v.26, #6)