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BackgroundThe International Myeloma Working Group recommends the use of 18-fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) for treatment response evaluation, as it is superior to magnetic resonance imaging (MRI). However, at initial staging, the sensitivity of FDG-PET remains inferior to that of MRI. Therefore, there is a need for an imaging technique that could have a sensitivity equal to that of MRI at diagnosis and could serve to evaluate therapy. 18F-choline has shown increased sensitivity when compared with 18-FDG, with about 75% more lesions detected in patients with relapsed or progressive multiple myeloma (MM). ObjectiveOur primary objective is to prospectively compare the detection rate of bone lesions by 18F-choline PET/CT (FCH-PET) and FDG-PET in newly diagnosed MM. Our secondary objectives are to assess the accuracy of both PET modalities for the detection of bone lesions and the diagnosis of diffuse disease, to assess the detection rate of extramedullary lesions. MethodsWe will prospectively include 30 patients in a paired comparative accuracy study. Patients with de novo MM will undergo FCH-PET, FDG-PET, and whole-body MRI (WB-MRI) within a 3-week period. WB-MRI will be composed of conventional sequences on the spine and pelvis and of whole-body diffusion axial sequences. The following 6 skeletal areas will be defined: skull, sternum/costal grid, spine, pelvis, superior limbs, and inferior limbs. The number of focal lesions, their respective localization, and intensity of uptake will be retrieved for each skeletal area. Readings will be performed blinded from other imaging techniques. The reference standard will be WB-MRI. Focal lesions present on PET/CT but not on WB-MRI will require a decision made with a consensus of experts based on clinical and imaging data. The number of bone lesions and number of extramedullary lesions will be compared using the Wilcoxon test. The accuracy of FCH-PET and FDG-PET will be compared using the McNemar test. ResultsThe study started in September 2019, and enrollment is ongoing. As of June 2020, 8 participants have been included. Data collection is expected to be completed in June 2021, and the results are expected to be available in December 2021. ConclusionsThis study will assess if FCH-PET is superior to FDG-PET for the evaluation of MM tumor burden. This will pave the way for future prospective evaluations of the prognostic value of 18-FCH for treatment response evaluation in MM patients. Additionally, this work may provide new perspectives for better assessment of the risk of smoldering MM progressing to MM. Trial RegistrationClinicalTrials.gov NCT03891914; https://clinicaltrials.gov/ct2/show/NCT03891914 International Registered Report Identifier (IRRID)DERR1-10.2196/17850

Hepatocellular carcinoma (HCC) is one of the most common neoplasms worldwide and the third most common cause of cancer-related death. Several liver-targeted intra-arterial therapies are available for unresectable HCC, including selective internal radiation therapy (SIRT) and trans-arterial chemoembolization (TACE). Those two are the most used treatment modalities in localized non-operable HCC. TACE is the treatment option for patients with stage B, according to the BCLC staging system. In contrast, SIRT does not have an official role in the treatment algorithm, but recent studies showed promising outcomes in patients treated with SIRT. Although TACE is globally a safe procedure, it might provoke several vascular complications such as spasms, inflammatory constriction, and, in severe cases, occlusion, dissection, or collateralization. Hence, it is acclaimed that those complications could restrain the targeted response of the radio-embolization when we use it as second-line therapy post TACE. In this study, we will assess the efficacity of SIRT using Yttrium 90 Microspheres post incomplete or failure response to TACE. In our retrospective study, we had 23 patients who met the inclusion criteria. Furthermore, those patients have been followed radiologically and biologically. Then, we evaluated the therapeutic effect according to the mRECIST criteria, in addition to the personalized dose analysis. We found 8 patients were treated with TheraSphere®, with a median tumor absorbed dose of 445 Gy, while 15 received SIR-Spheres® treatment with a mean tumor dose of 268 Gy. After radiological analysis, 56.5% of the patients had a complete response, and 17.3% showed partial response, whereas 13% had stable disease and 13% had progressive disease. For patients treated with SIRT after an incomplete response or failure to TACE, we found an objective response rate of 73.8%. Despite the known vascular complications of TACE, SIRT can give a favorable response. [ABSTRACT FROM AUTHOR]

Simple Summary: Patients suffering from disseminated, progressive, neuroendocrine neoplasms with a sufficient amount of somatostatin receptors and good kidney function can be treated with radioactive hormone-like molecules to prolong their life. In this study, the radioactivity in one tumor per patient at each treatment cycle was calculated and compared between 23 patients with pancreatic and 25 patients with small intestinal neuroendocrine neoplasia. Both types of tumors absorb a larger amount of radioactivity during early cycles that subsequently decline in the later cycles. This finding was more pronounced in the pancreatic tumors, which also expressed higher blood perfusion in the early cycles, known to facilitate the effect of radiation. This could be part of the reason why the pancreatic tumors shrunk more rapidly than the small intestinal ones. Our results also imply that increased administered activity in the early therapy cycles may be beneficial, at least in pancreatic neuroendocrine tumor patients. Dosimetry during peptide receptor radionuclide therapy (PRRT) has mainly focused on normal organs and less on the tumors. The absorbed dose in one target tumor per patient and several response related factors were assessed in 23 pancreatic neuroendocrine neoplasms (P-NENs) and 25 small-intestinal NEN (SI-NENs) during PRRT with 177Lu-DOTATATE. The total administered activity per patient was (mean ± standard error of mean (SEM) 31.8 ± 1.9 GBq for P-NENs and 36 ± 1.94 GBq for SI-NENs. The absorbed tumor dose was 143.5 ± 2 Gy in P-NENs, 168.2 ± 2 Gy in SI-NENs. For both NEN types, a dose–response relationship was found between the absorbed dose and tumor shrinkage, which was more pronounced in P-NENs. A significant drop in the absorbed dose per cycle was shown during the course of PRRT. Tumor vascularization was higher in P-NENs than in SI-NENs at baseline but equal post-PRRT. The time to progression (RECIST 1.1) was similar for patients with P-NEN (mean ± SEM 30 ± 1 months) and SI-NEN (33 ± 1 months). In conclusion, a dose response relationship was established for both P-NENs and SI-NENs and a significant drop in the absorbed dose per cycle was shown during the course of PRRT, which warrants further investigation to understand the factors impacting PRRT to improve personalized treatment protocol design. [ABSTRACT FROM AUTHOR]

Simple Summary: Smoldering multiple myeloma is a heterogenous precursor state of multiple myeloma—both the time until progression and the cause of progression vary within this subgroup. While the number of focal lesions in whole-body MRI (magnetic resonance imaging) is known to be of prognostic value, we investigated whether additional parameters like the size or growth dynamics of focal lesions or precisely quantified diffuse infiltration are connected to risk and cause of progression. We found that both the size and dynamics of focal lesions correlate with progression to multiple myeloma and with existence/appearance of corresponding osteolytic lesions in near-term computed tomography (CT) scans. Furthermore, a score combining intensity and extent of diffuse infiltration showed connections with risk of progression and decrease in hemoglobin. We conclude that these parameters from whole-body MRI can help to predict the clinical course of disease in smoldering multiple myeloma (SMM) patients, with implications for diagnostic follow-up and possibly more specified therapeutic approaches in the future. The purpose of this study was to analyze size and growth dynamics of focal lesions (FL) as well as to quantify diffuse infiltration (DI) in untreated smoldering multiple myeloma (SMM) patients and correlate those MRI features with timepoint and cause of progression. We investigated 199 whole-body magnetic resonance imaging (wb-MRI) scans originating from longitudinal imaging of 60 SMM patients and 39 computed tomography (CT) scans for corresponding osteolytic lesions (OL) in 17 patients. All FLs >5 mm were manually segmented to quantify volume and growth dynamics, and DI was scored, rating four compartments separately in T1- and fat-saturated T2-weighted images. The majority of patients with at least two FLs showed substantial spatial heterogeneity in growth dynamics. The volume of the largest FL (p = 0.001, c-index 0.72), the speed of growth of the fastest growing FL (p = 0.003, c-index 0.75), the DI score (DIS, p = 0.014, c-index 0.67), and its dynamic over time (DIS dynamic, p < 0.001, c-index 0.67) all significantly correlated with the time to progression. Size and growth dynamics of FLs correlated significantly with presence/appearance of OL in CT within 2 years after the respective MRI assessment (p = 0.016 and p = 0.022). DIS correlated with decrease of hemoglobin (p < 0.001). In conclusion, size and growth dynamics of FLs correlate with prognosis and local bone destruction. Connections between MRI findings and progression patterns (fast growing FL—OL; DIS—hemoglobin decrease) might enable more precise diagnostic and therapeutic approaches for SMM patients in the future. [ABSTRACT FROM AUTHOR]

The remarkably good prognosis and long-term survival in differentiated thyroid cancer (DTC) are significantly reduced in patients with distant metastasis (DM). Multi-site metastases are associated with a high mortality rate reaching 92% at 5 years necessitating early diagnosis and treatment. The most common site of metastases are the lungs, followed by the bone, with the former having better prognosis than the latter due to late detection. A number of factors contribute to the development of DM including large and multifocal primary tumour, extrathyroidal extension, aggressive histology and advanced age. In patients with good (131)I uptake, (131)I therapy appears highly effective and should be offered up to a cumulative activity of 22 GBq. Other measures such as surgery, radiotherapy, arterial embolisation and cementoplasty may be required. If there is low or no (131)I uptake, FDG-PET should be obtained due to its prognostic impact. It may help in selecting patients for other modalities such as cytotoxic chemotherapy and redifferentiation therapy by 13-cis retinoic acid. The development of tyrosine kinase inhibitors has raised hopes in providing alternative therapy for bone metastasis, especially in older age groups with poorly differentiated tumours with no (131)I uptake but good uptake of FDG.

About 4000 people are diagnosed with thyroid carcinoma each year in France and as many as one in three adult patients have thyroid nodules on sonography. Nine in ten cases are differentiated (DTC). DTC may recur in the neck or metastasize very late, and final outcomes should therefore only be assessed after at least 20 years of follow-up. The goals of this study were to provide a reference for the evaluation of other protocols, to evaluate the benefits and risks of radioiodine, and to identify the most effective management option. We examined 25-year outcomes in a series of 850 DTC patients who were operated on and monitored with the same protocols. We used an original classification (Ext-Tg) that includes both the initial extension and the thyroglobulin (Tg) level at the end of initial treatment. The low-risk group, composed of patients with Tg <10 microg/l after ablation of thyroid remnants, included patients at stage 1 (microcarcinoma, n=268), stage 2 (intra-thyroidal carcinoma, n=310), and stage 3 (DTC with node invasion, n=142). Stage 4 disease consisted of DTC with some non excisable tumor in the neck, and/or metastasis, and/or stimulated Tg >10 microg/l after remnant ablation. Most patients had total thyroidectomy followed by radioiodine ablation, periodic monitoring adapted to the stage, and suppressive therapy. At 25 years the actuarial rates of cancer-related death among patients with initial stage 1, 2, 3 and 4 disease were respectively 0%, 1,4%, 0% and 46,9%. The overall recurrence rates were respectively 3,6%, 3,8%, 5,3% and 44,5%. The rates of cervical recurrence necessitating surgery were 3,8%, 2,4%, 3,4% and 23,7%. Serious complications of treatment, including radioiodine, were rare. We conclude that:--good long-term results are more likely to be obtained when total thyroidectomy and radioiodine are combined with an early detection of recurrences (before they are visible by traditional imaging methods);--patients must be strictly staged in order to guide the modalities and duration of follow-up, and the Ext-TG classification seems more appropriate than all those which do not consider the Tg level at the end of initial treatment;--in experienced hands the benefits of total surgical ablation of the tumor greatly outweigh the potential risks;--radioiodine is effective and safe when appropriate measures are taken to prevent complications, and the long-term eficacy of surveillance without total body scanning should be verified before being universally adopted;--cost-reduction should focus on diagnosis, screening, and the selection of nodules eligible for surgery, rather than on monitoring of patients with DTC. DTC is thus a paradigm of a disease in which it is possible to optimize the long-term results and to lower costs by monitoring small and non-suspect nodules.

Recent progresses in the ability to obtain a secure diagnosis and preoperative localisation have resulted in a lower threshold for surgery of primary hyperparathyroidism. We questioned whether these trends have been accompanied by an improvement in surgical results, or changes in the profile of the disease among operated patients. From a total of 511 operations (499 patients), we retrospectively investigated the data from three successive periods of 10 years each: (1973-1982: 73 operations; (1983-1992): 155 operations; (1993-2002): 283 operations. Rates of surgical failure, defined as persistent hypercalcaemia at six months, have progressively declined: 6.8%, 1.3% and 0.7% respectively. There also has been a decline in the rates of permanent hypoparathyroidism or laryngeal nerve injury. However, these complications were highly influenced by the underlying pathology (surgery for single adenoma versus surgery for multiple gland disease) and by the need for concomitant thyroid surgery. Considering signs and symptoms, the frequency of kidney stones has declined from 50% to 29.7%, while the rate of patients diagnosed at routine screening has increased from 19% to 39%. The prevalence of parathyroid cancer among operated patients has successively declined from 6.8% to 1.3%, then 0% during the last period. Our data suggest that present improvement in the success rate of parathyroid surgery be partly due to improvement in preoperative localisation. Among imaging techniques, subtraction scintigraphy, based on the simultaneous recording of technetium-99m-sestamibi and iodine-123, provided the highest rate of accurate location (92.6%). Because this imaging technique depicted a majority of cases of multiple parathyroid gland disease at prospective evaluation (14 out of 15), we now use it to select appropriate cases for a focussed surgery under local anaesthesia, without the additional need for intraoperative PTH monitoring. The present good surgical results would justify surgery even for elderly or asymptomatic patients. Surgery carried out before appearance of symptoms seems beneficial. Only asymptomatic patients with a short life expectancy may be denied surgery.