Biochemical recurrence (BCR) after prostate cancer surgery is common, even after additional salvage radiotherapy. BCR might be explained by target miss. Improved diagnostic accuracy provided by PET could potentially circumvent this therapeutic gap. Therefore, we evaluated consecutive 68 Ga-prostate-specific membrane antigen (PSMA) PET/CT, 11 C-choline PET/CT, and standard CT imaging in the same patient with regard to TNM-stage migration and accordingly adapted curative radiotherapy options including ablative treatment of oligometastases (n # 5). The cost efficacy of PET-versus CT-based treatment was also calculated. Methods: The prospective register database (064/2013BO1) was retrospectively searched for patients fulfilling the following 3 inclusion criteria: BCR after radical prostatectomy (pT2-pT4 pN0-pN1 cM0, postoperative radiotherapy allowed); 11 C-choline PET/CT, 68 Ga-PSMA PET/CT, and diagnostic CT performed within 24 h; and available clinical data. Ten treatment routines were defined according to current practice. Furthermore, intention-to-treat and treatment-related costs depending on the shift of TNM stage after imaging were analyzed. Eighty-three patients were eligible (median prostate-specific antigen level, 1.9 ng/mL). Results: Both PET examinations led to concordant results in 72% of patients, whereas the concordance of TNM staging between 68 Ga-PSMA PET and diagnostic CT was only 36%. Incorrect staging would lead to "wrong" treatment and therefore to additional costs. A 68 Ga-PSMA PET study would be cost-effective if additional costs do not exceed €3,844 ($4,312) (vs. CT). The number needed to image was 2 (for CT) and 4 (for 11 C-choline PET) to avoid 1 incorrect treatment. In addition, 68 Ga-PSMA PET staging enabled new curative options in half the patients with previous radiotherapy who otherwise receive palliative androgen deprivation therapy. Conclusion: 68 Ga-PSMA PET/CT is cost-effective in all patients with regard to avoidance of incorrect treatment. It enabled new curative options for patients with previous radiotherapy who are usually treated palliatively. Therefore, 68 Ga-PSMA PET/CT staging should become standard for BCR after surgery with or without radiotherapy.
Cholangiocarcinoma (CC) is the second most common primary hepatobiliary tumour, and it is increasing in incidence. Imaging characteristics, behaviour, and therapeutic strategies in CC differ significantly, depending on the morphology and location of the tumour. In cross-sectional imaging, CCs can be classified according to the growth pattern (mass-forming, periductal infiltrating, intraductal) and the location (intrahepatic, perihilar, extrahepatic/distal). The prognosis of CC is unfavourable and surgical resection is the only curative treatment option; thus, early diagnosis (also in recurrent disease) and accurate staging including the evaluation of lymph node involvement and vascular infiltration is crucial. However, the diagnostic evaluation of CC is challenging due to the heterogeneous nature of the tumour. Diagnostic modalities used in the imaging of CC include transabdominal ultrasound, endosonography, computed tomography, magnetic resonance imaging with cholangiopancreatography, and hybrid imaging such as positron emission tomography/computed tomography. In this review, the potential of cross-sectional imaging modalities in primary staging, treatment monitoring, and detection of recurrent disease will be discussed.
To provide clinically relevant criteria for differentiation between the athlete’s heart and similar appearing hypertrophic (HCM), dilated (DCM), and arrhythmogenic right-ventricular cardiomyopathy (ARVC) in MRI. 40 top-level athletes were prospectively examined with cardiac MR (CMR) in two university centres and compared to retrospectively recruited patients diagnosed with HCM (n = 14), ARVC (n = 18), and DCM (n = 48). Analysed MR imaging parameters in the whole study cohort included morphology, functional parameters and late gadolinium enhancement (LGE). Mean left-ventricular enddiastolic volume index (LVEDVI) was high in athletes (105 ml/m2) but significantly lower compared to DCM (132 ml/m2; p = 0.001). Mean LV ejection fraction (EF) was 61% in athletes, below normal in 7 (18%) athletes vs. EF 29% in DCM, below normal in 46 (96%) patients (p < 0.0001). Mean RV-EF was 54% in athletes vs. 60% in HCM, 46% in ARVC, and 41% in DCM (p < 0.0001). Mean interventricular myocardial thickness was 10 mm in athletes vs. 12 mm in HCM (p = 0.0005), 9 mm in ARVC, and 9 mm in DCM. LGE was present in 1 (5%) athlete, 8 (57%) HCM, 10 (56%) ARVC, and 21 (44%) DCM patients (p < 0.0001). Healthy athletes’ hearts are characterized by both hypertrophy and dilation, low EF of both ventricles at rest, and increased interventricular septal thickness with a low prevalence of LGE. Differentiation of athlete’s heart from other non-ischemic cardiomyopathies in MRI can be challenging due to a significant overlap of characteristics also seen in HCM, ARVC, and DCM.
The study confirms the high impact of PET/CT on clinical management in patients with advanced melanoma planned for radical metastasectomy. PET/CT resulted in frequent management changes, preventing futile surgery in half of the patients.
Background: We evaluated efficacy and toxicity of 68 Ga-PSMA-Positron Emission Tomography/ Computed Tomography (PET/CT)-directed stereotactic body radiotherapy and image-guided radiotherapy (SBRT/IGRT) for oligometastases of prostate cancer recurrences after previous surgery. Methods: Nineteen patients were analyzed within a prospective PET-registry study (064/2013BO1) and retrospectively analyzed (807/2017BO2) fulfilling the following inclusion criteria: biochemical recurrence after radical prostatectomy, five 68 Ga-PSMA-PET/CT positive lesions. Biochemical control was evaluated with EORTC (European Organization for Research and Treatment of Cancer)-and Phenix-definitions. Toxicity was scored according to CTCAE-criteria v. 4.03. Results: A total of 38 oligometastases (19 patients, 2 with re-treatment) were treated with SBRT/IGRT from October 2014 to July 2017. 68 Ga-PSMA-PET/CT-positive lesions were detected on average 39 months (5-139) after prostatectomy (pT2b-3b pN0-1 cM0). Mean PSA (Prostate-specific antigen)-level at time of imaging reached 2.2 ng/mL (range 0.2-10.1). PET/CT-positive lesions were treated with different fractionation schedules reaching biological equivalent doses (BED) of 116.7-230.0 Gy. Concomitant androgen deprivation therapy (ADT) was given in seven patients. After a median follow-up of 17 months (4-42) all patients were alive. Estimated 1-year PSA-control (n ¼ 19) reached 80.8% (Phenix) and 67.5% (EORTC). A PSA-decline (!50%) was detected in 16/19 patients after radiotherapy. Higher graded G3þ-acute toxicity did not occur. Temporary late G3-proctitis was detected in one patient. Conclusions: Reaching of nadir 0.1 or 0.2 ng/mL was associated by improved DMFS (distant metastases free survival) and could serve as a surrogate endpoint for RT of oligometastases after initial prostatectomy. Short term effects of 68 Ga-PSMA-PET/CT-based ablative radiotherapy for oligometastases demonstrated an acceptable toxicity profile and favorable biochemical response.
Background Detection of pulmonary nodules in MRI requires fast imaging strategies without respiratory motion impairment, such as single-breath-hold Cartesian VIBE. As patients with pulmonary diseases have limited breath-hold capacities, this study investigates the clinical feasibility of non-Cartesian Spiral VIBE under free-breathing compared to CT as the gold standard. Methods Prospective analysis of 27 oncological patients examined in PET/CT and PET/MR. A novel motion-robust 3D ultrashort-echo-time (UTE) MR sequence was evaluated in comparison with CT and conventional breath-hold MR. CT scans were performed under breath-hold in end-expiratory and end-inspiratory position (CT ex, CT in). MR data was acquired with non-contrast-enhanced breath-hold Cartesian VIBE followed by a free-breathing 3D UTE Spiral VIBE. Impact of respiratory motion on pulmonary evaluation was investigated by two readers in Cartesian VIBE, followed by UTE Spiral VIBE and CT ex and the reference standard of CT in. Diagnostic accuracy was calculated, and visual image quality assessed. Results Higher detection rate and sensitivity of pulmonary nodules in free-breathing UTE Spiral VIBE in comparison with breath-hold Cartesian VIBE were found for lesions > 10 mm (UTE Spiral VIBE/VIBE/CT ex): 93%/54%/100%; Lesions 5–10 mm: 67%/25%/ 92%; Lesions < 5 mm: 11%/11%/78%. Lobe-based analysis revealed sensitivities and specificities of 64%/96%/41% and 96%/93%/100% for UTE Spiral VIBE/VIBE/CT ex. Conclusion Free-breathing UTE Spiral VIBE indicates higher sensitivity for detection of pulmonary nodules than breath-hold Cartesian VIBE and is a promising but time-consuming approach. However, sensitivity and specificity of inspiratory CT remain superior in comparison and should be preferred for detection of pulmonary lesions.
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