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Response assessment in the context of immunomodulatory treatments represents a major challenge for the medical imaging community and requires a multidisciplinary approach with involvement of oncologists, radiologists, and nuclear medicine specialists. There is evolving evidence that [18F]FDG PET/CT is a useful diagnostic modality for this purpose. The clinical indications for, and the principal aspects of its standardization in this context have been detailed in the recently published “Joint EANM/SNMMI/ANZSNM practice guidelines/procedure standards on recommended use of [18F]FDG PET/CT imaging during immunomodulatory treatments in patients with solid tumors version 1.0”. These recommendations arose from a fruitful collaboration between international nuclear medicine societies and experts in cancer treatment. In this perspective, the key elements of the initiative are reported, summarizing the core aspects of the guidelines for radiologists and nuclear medicine physicians. Beyond the previous guidelines, this perspective adds further commentary on how this technology can advance development of novel therapeutic approaches and guide management of individual patients.

Response assessment in the context of immunomodulatory treatments represents a major challenge for the medical imaging community and requires a multidisciplinary approach with involvement of oncologists, radiologists, and nuclear medicine specialists. There is evolving evidence that [

The goal of this guideline/procedure standard is to assist nuclear medicine physicians, other nuclear medicine professionals, oncologists or other medical specialists for recommended use of [In a cooperative effort between the EANM, the SNMMI and the ANZSNM, clinical indications, recommended imaging procedures and reporting standards have been agreed upon and summarized in this joint guideline/procedure standard.The field of immuno-oncology is rapidly evolving, and this guideline/procedure standard should not be seen as definitive, but rather as a guidance document standardizing the use and interpretation of [The European Association of Nuclear Medicine (EANM) is a professional non-profit medical association founded in 1985 to facilitate worldwide communication among individuals pursuing clinical and academic excellence in nuclear medicine. The Society of Nuclear Medicine and Molecular Imaging (SNMMI) is an international scientific and professional organization founded in 1954 to promote science, technology and practical application of nuclear medicine. The Australian and New Zealand Society of Nuclear Medicine (ANZSNM), founded in 1969, represents the major professional society fostering the technical and professional development of nuclear medicine practice across Australia and New Zealand. It promotes excellence in the nuclear medicine profession through education, research and a commitment to the highest professional standards. EANM, SNMMI and ANZSNM members are physicians, technologists, physicists and scientists specialized in the research and clinical practice of nuclear medicine. All three societies will periodically put forth new standards/guidelines for nuclear medicine practice to help advance the science of nuclear medicine and improve service to patients. Existing standards/guidelines will be reviewed for revision or renewal, as appropriate, on their fifth anniversary or sooner, if indicated. Each standard/guideline, representing a policy statement by the EANM/SNMMI/ANZSNM, has undergone a thorough consensus process, entailing extensive review. These societies recognize that the safe and effective use of diagnostic nuclear medicine imaging requires particular training and skills, as described in each document. These standards/guidelines are educational tools designed to assist practitioners in providing appropriate and effective nuclear medicine care for patients. These guidelines are consensus documents based on current knowledge. They are not intended to be inflexible rules or requirements of practice, nor should they be used to establish a legal standard of care. For these reasons and those set forth below, the EANM, SNMMI and ANZSNM caution against the use of these standards/guidelines in litigation in which the clinical decisions of a practitioner are called into question. The ultimate judgment regarding the propriety of any specific procedure or course of action must be made by medical professionals considering the unique circumstances of each case. Thus, there is no implication that an action differing from what is laid out in the guidelines/procedure standards, standing alone, is below standard of care. To the contrary, a conscientious practitioner may responsibly adopt a course of action different from that set forth in the standards/guidelines when, in the reasonable judgment of the practitioner, such course of action is indicated by the condition of the patient, limitations of available resources or advances in knowledge or technology subsequent to publication of the guidelines/procedure standards. The practice of medicine involves not only the science, but also the art of dealing with the prevention, diagnosis, alleviation and treatment of disease. The variety and complexity of human conditions make it impossible for general guidelines to consistently allow for an accurate diagnosis to be reached or a particular treatment response to be predicted. Therefore, it should be recognized that adherence to these standards/ guidelines will not ensure a successful outcome. All that should be expected is that practitioners follow a reasonable course of action, based on their level of training, current knowledge, clinical practice guidelines, available resources and the needs/context of the patient being treated. The sole purpose of these guidelines is to assist practitioners in achieving this objective. The present guideline/procedure standard was developed collaboratively by the EANM, the SNMMI and the ANZSNM, with the support of international experts in the field. They summarize also the views of the Oncology and Theranostics and the Inflammation and Infection Committees of the EANM, as well as the procedure standards committee of the SNMMI, and reflect recommendations for which the EANM and SNMMI cannot be held responsible. The recommendations should be taken into the context of good practice of nuclear medicine and do not substitute for national and international legal or regulatory provisions.

Purpose The goal of this guideline/procedure standard is to assist nuclear medicine physicians, other nuclear medicine professionals, oncologists or other medical specialists for recommended use of [18F]FDG PET/CT in oncological patients undergoing immunotherapy, with special focus on response assessment in solid tumors. Methods In a cooperative effort between the EANM, the SNMMI and the ANZSNM, clinical indications, recommended imaging procedures and reporting standards have been agreed upon and summarized in this joint guideline/procedure standard. Conclusions The field of immuno-oncology is rapidly evolving, and this guideline/procedure standard should not be seen as definitive, but rather as a guidance document standardizing the use and interpretation of [18F]FDG PET/CT during immunotherapy. Local variations to this guideline should be taken into consideration. Preamble The European Association of Nuclear Medicine (EANM) is a professional non-profit medical association founded in 1985 to facilitate worldwide communication among individuals pursuing clinical and academic excellence in nuclear medicine. The Society of Nuclear Medicine and Molecular Imaging (SNMMI) is an international scientific and professional organization founded in 1954 to promote science, technology and practical application of nuclear medicine. The Australian and New Zealand Society of Nuclear Medicine (ANZSNM), founded in 1969, represents the major professional society fostering the technical and professional development of nuclear medicine practice across Australia and New Zealand. It promotes excellence in the nuclear medicine profession through education, research and a commitment to the highest professional standards. EANM, SNMMI and ANZSNM members are physicians, technologists, physicists and scientists specialized in the research and clinical practice of nuclear medicine. All three societies will periodically put forth new standards/guidelines for nuclear medicine practice to help advance the science of nuclear medicine and improve service to patients. Existing standards/guidelines will be reviewed for revision or renewal, as appropriate, on their fifth anniversary or sooner, if indicated. Each standard/guideline, representing a policy statement by the EANM/SNMMI/ANZSNM, has undergone a thorough consensus process, entailing extensive review. These societies recognize that the safe and effective use of diagnostic nuclear medicine imaging requires particular training and skills, as described in each document. These standards/guidelines are educational tools designed to assist practitioners in providing appropriate and effective nuclear medicine care for patients. These guidelines are consensus documents based on current knowledge. They are not intended to be inflexible rules or requirements of practice, nor should they be used to establish a legal standard of care. For these reasons and those set forth below, the EANM, SNMMI and ANZSNM caution against the use of these standards/guidelines in litigation in which the clinical decisions of a practitioner are called into question. The ultimate judgment regarding the propriety of any specific procedure or course of action must be made by medical professionals considering the unique circumstances of each case. Thus, there is no implication that an action differing from what is laid out in the guidelines/procedure standards, standing alone, is below standard of care. To the contrary, a conscientious practitioner may responsibly adopt a course of action different from that set forth in the standards/guidelines when, in the reasonable judgment of the practitioner, such course of action is indicated by the condition of the patient, limitations of available resources or advances in knowledge or technology subsequent to publication of the guidelines/procedure standards. The practice of medicine involves not only the science, but also the art of dealing with the prevention, diagnosis, alleviation and treatment of disease. The variety and complexity of human conditions make it impossible for general guidelines to consistently allow for an accurate diagnosis to be reached or a particular treatment response to be predicted. Therefore, it should be recognized that adherence to these standards/ guidelines will not ensure a successful outcome. All that should be expected is that practitioners follow a reasonable course of action, based on their level of training, current knowledge, clinical practice guidelines, available resources and the needs/context of the patient being treated. The sole purpose of these guidelines is to assist practitioners in achieving this objective. The present guideline/procedure standard was developed collaboratively by the EANM, the SNMMI and the ANZSNM, with the support of international experts in the field. They summarize also the views of the Oncology and Theranostics and the Inflammation and Infection Committees of the EANM, as well as the procedure standards committee of the SNMMI, and reflect recommendations for which the EANM and SNMMI cannot be held responsible. The recommendations should be taken into the context of good practice of nuclear medicine and do not substitute for national and international legal or regulatory provisions.

Background Radiation therapy (RT) plays a central role in management of central nervous system disease, in particular in the multimodality management of low(er) and high-grade CNS gliomas. New strategy that involved Proton Therapy (PT) have been experienced in the last years. No data are available about re-surgery of lesion irradiated with protons. Material and Methods We reviewed our single Unit experience of re-surgery of Lower-Grade Glioma patients that received, in their neuro-oncological history, a treatment with PT. We collect clinical data, intra-operative findings, histopathological features and oncological and clinical outcome after surgery. Results We collected three cases of young with an IDH1-mutated tumor that underwent to Proton Therapy (PT). In two cases PT was performed due to progression of disease, in one case as adjuvant therapy after first surgical treatment. In all cases we performed surgery within three years after PT. All patients complained drug resistant epilepsy after PT with symptom relief after surgery and one patient complained a spine fracture due to corticosteroids intake to control radionecrosis’s symptoms after PT. In the pre-operative work-up all patient performed a 11-C-Methionin PET scan that revealed an increase of tracer uptake in the suspected area of tumor progression. In one case advanced MRI protocol with PWI was performed to further distinguish and sample area of pseudoprogression and tumor progression. In two patients area of gliosis and necrosis was find at the histological examination. Conclusion Our experience, although limited to three case, provided a clinical and radiological example of the small cohort of patients that performed surgery after a Prothon Radiotherapy. Clinical presentation was heterogenous except a poor seizure control. Despite time elapsed since PT, areas of radionecrosis were found in the histopathological samples of 2/3 of patients. Moreover, we need to collect more data to draw a complete picture in this complex field.

Additional file 3: figure 3.: fused FDG-PET/CT images of a 67-year old male with a T4aN3 oropharyngeal cancer: Tref assessment negative for residual tumor according to all scales

Additional file 4: figure 4. fused FDG-PET/CT images of a 69-year old male with a T4aN2b laryngeal cancer: Nref assessment negative for residual tumor according to all scales

Additional file 2: figure 2. overall survival (Kaplan Meyer method)

Additional file 6: material. FDG-PET/CT analysis

Additional file 1: figure 1. progression-free survival (Kaplan Meyer method)

Additional file 5: table 1. positive predictive value and corresponding 95% CI of composite TNref for specific scores. PPV: positive predictive value

Prostate-specific antigen (PSA) flare is a well-known phenomenon in patients with prostate cancer, but its impact during radium-223 dichloride (We conducted a retrospective study of 168 patients with mCRPC (median age 69; median PSA 29.7) receivingImmediate PSA decline was observed in 49 patients (29.2%), whereas no PSA response was observed in 59 patients (35.1%). PSA flare (defined as rise after the first cycle followed by decrease below the baseline) was observed in 20 patients (11.9%) and PSA flare followed by a decrease from peak but not below baseline was observed in 40 (23.8%). The first flare subgroup had a median PFS and OS of 20.8 and 23.9 months, respectively. These outcomes were not significantly different from patients with immediate PSA decrease, but were significantly better than in patients with persistent PSA elevation (3.1 months for PFS and 11.5 months for OS, p 0.001). Moreover, the PSA flare group showed an alkaline phosphatase (ALP) decrease significantly greater than non-responders (p = 0.003). MetabolicThis report suggests that a flare does not necessarily indicate lack of response to

ALPPS on tumor proliferation remains a concern. The aim of this study was to investigate the impact of ALPPS on tumor growth in mice. Methods: The effect of ALPPS and 90% portal vein ligation (PVL) on colorectal liver and lung metastases was investigated in C57BL/6 mice. In vivo tumor progression was assessed by small animal magnetic resonance imaging (sMRI), histology and survival experiments. The effect of ALPPS, PVL and control sera onMC38 andCT26 colorectal cancer cell-lines was subsequently tested in vitro. One-way ANOVA test was used for comparison of multiple groups. Results: At day 14 and 21 after ALPPS, PVL or sham surgery, sMRI showed similar intrahepatic tumor numbers (p = 0.56/0.53), sizes (p = 0.45/0.98) and growth kinetics (p = 0.58/0.68). For both time points median tumor size in non-occluded lobes was similar in ALPPS and PVL groups as well as in the corresponding lobe in the sham group (2.4mm/12.3mm vs. 3.9mm/14.4mm vs. 4.5mm/14.9mm, p = 0.511/0.918). Median survival after tumor cell injection was not different between sham surgery and completion of ALPPS and PVL (36 days (IQR32-40) vs. 42 days (IQR36e48) vs. 39days (IQR35-42), p = 0.237). Likewise, pulmonary tumor load and in vitro cell proliferation were similar. Conclusion: This study provides evidence that ALPPS does not accelerate tumor growth rates compared with conventional two-stage procedure.

Neuroendocrine tumours (NET) are relatively rare neoplasms affecting principally the gastroenteropancreatic tract, but with potential ubiquitary location, as the neural crest cells, origin of this group of tumours, are dispersed in various organs and tissues. After the discovery of somatostatin receptors (SSTR) over-expression in this group of neoplasms, NET management has significantly improved. This is witnessed by the development of new tracers in positron emission tomography (PET) imaging of NETs belonging to the family of radio-labelled somatostatin analogues, that significantly improved the accuracy of diagnosis and, more recently, opened the way to the innovative targeted radionuclide therapies. First introduced in clinical application in 2005, 68Ga-DOTANOC (one of the most used radio-labelled somatostatin analog for PET imaging) has revealed promising results in preliminary studies for the main clinical indications: staging NET; suspected NET of unknown primary; follow-up, restaging and, finally, for pre- and post-treatment evaluation of receptor radionuclide therapies. Due to its technically simple production, favourable biodistribution, biokinetics, dosimetry and high affinity for SSTR and thanks to the possibility of hybrid scans PET/computed tomography (CT) with better spatial resolution and localisation of the lesions, 68Ga-DOTANOC can advance as the new gold standard for imaging in neuroendocrine tumours.

BACKGROUND: The surgical treatment of biliary atresia is still a great challenge for pediatric surgeons. Kasai's operation usually needs a wide, painful, muscle-cutting laparotomies that quite often are followed by pain and peritoneal adhesion. These possible complications may disturb the post-operative course and humper liver transplantation. Advancements in minimally invasive surgery have allowed even the most complex procedures to be approached using these techniques. METHODS: The authors present a case of successful Roux-en-Y laparoscopic portoenterostomy for the treatment of biliary atresia. We report a case of a 3-month-old patient with biliary atresia who weighted Kg 5,300 at the operation. The patient was placed in supine position. The procedure was performed with 4 trocars of 3 mm and 1 of 10 mm. The umbilical site was used for extracorporeal Roux-en-Y enteroenterostomy. CO2 was insufflated at a pressure of 8 mmHg and a flow of 0.5 L/min. A drain was placed through the lower trocar site with the tip near the anastomosis. RESULTS: The procedure was free of neither intraoperative nor post-operative complications. Feeding by nasogastric tube was started after 2 days. Total oral feeding was possible after 8 days. CONCLUSION: Laparoscopic approach to perform Kasai's operation is technically feasible and thanks to a magnified vision, it allows to abtain a good visualization of the portal structures with an adequate retraction of the liver. This procedure can avoid or decrease the post-operative complications such as pain, breathing difficulty, adhesions and resulting in very small scars. Anyway laparoscopic Kasaiportoenterostomy should be done by a surgeon with a good experience in laparoscopic hand-suturing and neonatal experience and with the support of an experienced in neonatal and infantile videosurgery anaesthesiologist.