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Importance: Data about the optimal timing for the initiation of peptide receptor radionuclide therapy (PRRT) for advanced, well-differentiated enteropancreatic neuroendocrine tumors are lacking. Objective: To evaluate the association of upfront PRRT vs upfront chemotherapy or targeted therapy with progression-free survival (PFS) among patients with advanced enteropancreatic neuroendocrine tumors who experienced disease progression after treatment with somatostatin analogues (SSAs). Design, setting, and participants: This retrospective, multicenter cohort study analyzed the clinical records from 25 Italian oncology centers for patients aged 18 years or older who had unresectable, locally advanced or metastatic, well-differentiated, grades 1 to 3 enteropancreatic neuroendocrine tumors and received either PRRT or chemotherapy or targeted therapy after experiencing disease progression after treatment with SSAs between January 24, 2000, and July 1, 2020. Propensity score matching was done to minimize the selection bias. Exposures: Upfront PRRT or upfront chemotherapy or targeted therapy. Main outcomes and measures: The main outcome was the difference in PFS among patients who received upfront PRRT vs among those who received upfront chemotherapy or targeted therapy. A secondary outcome was the difference in overall survival between these groups. Hazard ratios (HRs) were fitted in a multivariable Cox proportional hazards regression model to adjust for relevant factors associated with PFS and were corrected for interaction with these factors. Results: Of 508 evaluated patients (mean ([SD] age, 55.7 [0.5] years; 278 [54.7%] were male), 329 (64.8%) received upfront PRRT and 179 (35.2%) received upfront chemotherapy or targeted therapy. The matched group included 222 patients (124 [55.9%] male; mean [SD] age, 56.1 [0.8] years), with 111 in each treatment group. Median PFS was longer in the PRRT group than in the chemotherapy or targeted therapy group in the unmatched (2.5 years [95% CI, 2.3-3.0 years] vs 0.7 years [95% CI, 0.5-1.0 years]; HR, 0.35 [95% CI, 0.28-0.44; P

Distinguishing neoplastic from nonneoplastic intracerebral hematoma has great clinical relevance for the appropriate management of patients. Imaging is not always able to clearly identify a tumor-related intraparenchymal cerebral hemorrhage (ICH), especially in the acute phase, the diagnosis being frequently based on evolution patterns. The aim of this study was to test the value of (99m)Tc-methoxyisobutylisonitrile ((99m)Tc-MIBI) SPECT as a noninvasive diagnostic tool in early diagnosis of hemorrhagic brain neoplasm.We prospectively studied 29 patients harboring a nontraumatic acute onset of clinical deterioration caused by ICH with atypical clinical or neuroradiologic features. All patients underwent (99m)Tc-MIBI SPECT within 48 h from the clinical onset. Early and delayed images were obtained. Both visual and semiquantitative analyses were performed. The (99m)Tc-MIBI index was obtained from both early and delayed images and the retention index was calculated.In 19 patients (65.5%), a nonneoplastic hemorrhage (15 vascular degenerative diseases, 2 cavernous angiomas, 1 thrombosed middle cerebral artery giant aneurysm, and 1 sinus rectus thrombosis) was diagnosed by clinical and neuroradiologic follow-up or open surgery. In 10 patients (34.5%), a neoplastic hemorrhage (6 metastases, 2 glioblastomas multiforme, 1 ependymoma, and 1 intracranial angioblastic meningioma) was diagnosed by direct histologic typing (open surgery or stereotactic biopsy). In all neoplasm-related hemorrhages, a focal increased tracer uptake was observed in the area of the lesion, whereas no focal increased tracer uptake was noted in all nonneoplastic hematomas. A wide cutoff in the early ratio between neoplastic and nonneoplastic hemorrhages was found. Moreover, a statistically significant difference was found in the delayed ratio (P0.01) and the retention index (P0.05) between the 2 groups.Our data suggest that (99m)Tc-MIBI SPECT could play a role in the early noninvasive diagnostic work-up of hemorrhagic brain lesions, allowing a clear differentiation between neoplastic and nonneoplastic ICHs. The high availability and low cost of this nuclear medicine technique can be considered additional advantages.

Background The observation of gait abnormalities, parkinsonism and vascular lesions in elderly patients is often reported as vascular parkinsonism (VP). However the status of striatal dopamine transporter (DAT) and the effects of brain vascular lesions on motor features and levodopa responsiveness are poorly defined. Methods We recorded clinical features, chronic response to levodopa and vascular risk factors in a cross-sectional cohort of consecutive elderly patients with possible Parkinson's disease (PD) or VP recruited in 20 centers in Italy. Results We included a total of 158 patients. Onset of motor symptoms was asymmetric in 93 (59%) and symmetric in 65 patients (41%). Symmetric motor onset was associated with greater disease severity. Chronic levodopa response was positive in 75 (47.8%) and negative in 82 patients (52.2%). A negative response to levodopa was associated with greater frequency of symmetric onset of motor symptoms, worst disease severity, absence of dyskinesia and greater number of vascular risk factors. Frontal lobe showed largest vascular load. Striatal DAT was normal in 48 (30.4%) and abnormal in 110 (69.6%) patients. Patients with normal DAT binding showed higher vascular load at MRI. Significant predictive factors of worst disease severity and negative response to levodopa were hypertension, vascular lesions in basal ganglia/periventricular regions, and normal DAT uptake. Conclusions Multiple cerebral vascular lesions modify clinical presentation and severity in patients with parkinsonism and this is underlined by specific risk factors primarily hypertension. Striatal DAT assessment is helpful in identifying patients where therapy benefit is less likely.

The Authors, taking recent literature on tumoral pathology breast studies in to consideration, studied a group of patients with a node or a suspect adenous zone by clinical and instrumental examination with mammoscintigraphy. 22 patients were selected by clinical examination, mammography and ultrasonography. A mammoscintigraphy (Tc 99m Sestamibi) was performed before the surgical operation. The histologic examination revealed 14 cases of breast cancer; 12 of these (86%) resulted positive after scintigraphy, while 2 were false negative. In this study, the scintigraphic exam and its diagnostic accuracy were analyzed, both in relation to anatomical structure of the mammary gland (thick breast, fibrocystic mastopathy, postsurgical scars, etc.) and also in relation to characteristics of the suspected node, the nature of which was not possible to determine from other exams carried out. In conclusion, after comparison between our experience and those reported in literature, we conclude that because of its high specificity and sensibility the mammoscintigraphy exam assumes an important comparative index in obtaining elements for an additional evaluation when other instrumental examinations are dubious.

Aim: To evaluate the clinical value of PET imaging for an early prediction of tumor response to platinum-based therapy in patients with non-small cell lung cancer (NSCLC). In order to avoid unnecessary toxicity of ineffective chemotherapy treatment, an early identification of NSCLC patients who benefit from this therapy is mandatory. Materials and methods: Seventeen patients are enrolled prospectively: 18F-FDG-PET examinations are carried out before treatment and after the first course. The lesions with the highest uptake in each patient are evaluated according to EORTC, PERCIST and RECIST classifications to discriminate between patients who respond (complete and partial response) from those who do not respond (stable and progressive disease) to treatment. Metabolic Tumor Volume (MTV) and Total Lesion Glycolysis (TLG) are also used to evaluate therapeutic response. MTV indicates the volume of metabolically active tumors; TLG is the product between SUV mean and MTV. In literature, there are no cut-off points for therapy evaluation based on TLG or MTV variations (Δ) in sequential scans. In order to estimate cut-off values for these parameters, receiver operating characteristic (ROC) curves are used. RECIST classification is used as the outcome for the ROC analysis. Kaplan-Meier test is used to calculate Overall Survival (OS) time. OS is compared between responders and non-responders using a log-rank test. The level of statistical significance is defined as a p-value (p) of less than 0.05. Results: The ROC analysis indicates a cut-off point of -36% for ΔTLG, and -8% for ΔMTV. The Kaplan-Meier analysis shows that RECIST, ∆TLG, and ∆MTV prove to be a significant prognostic factor for predicting OS. For RECIST responder patients median OS is 595 days whereas for non-responder patients median OS is 238 days. ΔTLG shows a median OS of 492 days for responders and 238 days for non-responders. ΔMTV shows a median of 423 days for responders versus 188 days for non-responders. Conversely, EORTC and PERCIST classifications are inadequate to discriminate between responder and non-responder patients (p>0.13). For this reason, we use ROC analysis to propose an alternative PERCIST threshold of 17% for an early therapy monitoring. Conclusion: PET examinations provide an early identification of patients who benefit from platinum-based treatment. Results confirm that TLG proves a strong early prognostic factor in patients with NSCLC and could play a significant role in the field of personalized medicine, avoiding the unnecessary administration of non-curative and toxic drugs to preserve the patient’s quality of life.

To date, the virtual multidisciplinary tumor boards (vMTBs) are increasingly used to achieve high-quality treatment recommendations across health-care regions, which expands and develops the local MTB team to a regional or national expert network. This review describes the process of lung cancer-specific MTBs and the transition process from face-to-face tumor boards to virtual ones. The review also focuses on the project organization's description, advantages, and disadvantages. Semi-structured interviews identified five major themes for MTBs: current practice, attitudes, enablers, barriers, and benefits for the MTB. MTB teams exhibited positive responses to modeled data feedback. Virtualization reduces time spent for travel, allowing easier and timely patient discussions. This process requires a secure web platform to assure the respect of patients’ privacy and presents the same unanswered problems. The implementation of vMTB also permits the implementation of networks especially in areas with geographical barriers facilitating interaction between large referral cancer centers and tertiary or community hospitals as well as easier access to clinical trial opportunities. Studies aimed to improve preparations, structure, and conduct of MTBs, research methods to monitor their performance, teamwork, and outcomes are also outlined in this article. Analysis of literature shows that MTB participants discuss 5–8 cases per meeting and that the use of a vMTB for lung cancer and in particular stage III NSCLC and complex stage IV cases is widely accepted by most health professionals.Despite still-existing gaps, overall vMTB represents a unique opportunity to optimize patient management in apatient-centeredapproach.

Aim: A small number of studies evaluated the detection rate of lesions from bladder carcinoma (BC) of 18F-FDG PET/CT in the restaging process. However, the prognostic role of FDG PET/CT still remains unclear. The aim of the present study was to evaluate the accuracy, the effect upon treatment decision, and the prognostic value of FDG PET/CT in patients with suspected recurrent BC. Materials and Methods: Forty-one patients affected by BC underwent FDG PET/CT for restaging purpose. The diagnostic accuracy of visually interpreted FDG PET/CT was assessed compared to histology (n = 8), other diagnostic imaging modalities (contrast-enhanced CT in 38/41 patients and MRI in 15/41) and clinical follow-up (n = 41). Semiquantitative PET values (SUVmax, SUVmean, SUL, MTV, TLG) were calculated using a graph-based method. Progression-free survival (PFS) and overall survival (OS) were assessed by using Kaplan-Meier curves. The risk of progression (hazard ratio, HR) was computed by Cox regression analysis by considering all the available variables. Results: PET was considered positive in 21 of 41 patients. Of these, recurrent BC was confirmed in 20 (95%). Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of FDG PET/CT were 87%, 94%, 95%, 85%, 90%. AUC was 0.9 (95 %IC 0.8-1). Bayesian positive and negative likelihood ratios were 14.5 and 0.13, respectively. FDG PET/CT findings modified the therapeutic approach in 16 patients (modified therapy in 10 PET-positive patients, watch-and-wait in six PET-negative patients). PFS was significantly longer in patients with negative scan vs. those with pathological findings (85% vs. 24%, p < 0.05; HR = 12.4; p = 0.001). Moreover, an unremarkable study was associated with a longer OS (88% vs. 47% after 2years and 87% vs. 25% after 3 years, respectively, p < 0.05). Standardized uptake value (SUV)max > 6 and total lesion glycolysis (TLG) > 8.5 were recognized as the most accurate thresholds to predict PFS (2-year PFS 62% for SUVmax < 6 vs. 15% for SUVmax > 6, p = 0.018; 2-year PFS 66% for TLG < 8.5 vs. 18% for TLG > 8.5, p = 0.09). Conclusion: A very good diagnostic performance for FDG PET/CT was confirmed in patients with suspected recurrent BC. FDG PET/CT allowed for a change in treatment decision in about 40% of cases and showed an important prognostic value in assessing PFS and OS.

The aim of the present study was to evaluate the changes in cervical cancer glucose metabolism for different levels of cellular differentiation. The metabolic activity was measured by standardized uptake value (SUV), SUV normalized to lean body mass, metabolic tumor volume and total lesion glycolysis using fluorine-18 fluorodeoxyglucose positron emission tomography (PET). A correlation study of these values could be used to facilitate therapeutic choice and to improve clinical practice and outcome. This study considered 32 patients with diagnosed cervical cancers, at different International Federation of Gynecology and Obstetrics stages. Glucose metabolism was assessed by PET examination, and histological specimens were examined to determine their initial grade of differentiation. A correlation study of these values was evaluated. Histological examination showed that all cases were of squamous cell carcinoma. Regarding the differentiation of the tumor, 19 well- to moderately-differentiated tumors and 13 poorly-differentiated tumors were determined. Negative findings for correlations between metabolic parameters and initial grade of histological differentiation were found, and considering that histological grade has been shown to have no consistent prognostic value in cervical cancer treatment, PET imaging could play a significant role in cervical cancer prognosis.

The purpose of this study was to evaluate the clinical value of PET (Positron Emission Tomography) for early prediction of tumor response to platinum-based therapy in patients with nonsmall cell lung cancer (NSCLC). The evaluation was carried out comparing the standard treatment response using RECIST (Response Evaluation Criteria in Solid Tumors) with metabolic treatment response according to European Organization for Research and Treatment of Cancer (EORTC) recommendations, PET Response Criteria in Solid Tumors (PERCIST), Total Lesion Glycolysis (TLG) and Metabolic Tumor Volume (MTV). Seventeen inoperable patients with stage IV NSCLC were enrolled between October 2011 and June 2013: PET studies were carried out before the initiation of platinum-based therapy and after the first cycle of chemotherapy for an early therapy monitoring. The lesions with the highest uptake in each patient were evaluated according to EORTC recommendations considering a cut-off of 15% (EORTC15%) and 25% (EORTC25%) to discriminat between patients who respond from those who do not respond to treatment. Moreover, PERCIST and RECIST classifications were evaluated too. Receiver operating characteristic curves were used to obtain cut-off points for therapy evaluation based on variations of TLG and MTV in sequential scans. Overall Survival (OS) time was calculated by the Kaplan-Meier test. The Kaplan-Meier analysis showed that RECIST, EORTC15%, ∆TLG, and ∆MTV proved to be a significant prognostic factor for predicting OS (p-value ≤ 0.0251). For responder patients, median OS was 595 days for RECIST, 423 for EORTC15% and ∆MTV, 492 for ∆TLG. For nonresponder patients, median OS was 238 days for RECIST and ∆TLG, 194.5 for EORTC15%, and 188 for ∆MTV. No statistically significant difference was recognized between responder and non-responder patients according to EORTC25% and PERCIST classifications (p-value ≥ 0.13). In addition, a new threshold of 17% for PERCIST classification was proposed for an early therapy monitoring rather than the conventional cut-off of 30%. Even if this is a preliminary analysis, the results suggest that PET examinations could provide an early identification of patients who benefit from platinum-based treatment.