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Next generation sequencing (NGS) is increasingly being used clinically to characterize the molecular alterations found in patients’ tumors. These testing results have the potential to affect clinical care by guiding therapeutic approaches based upon genotype. NGS based testing approaches have a distinct advantage over provider-ordered single gene testing in that they can detect unexpected, yet clinically important genetic changes. Here, we illustrate this principle with the case of a 33-year-old man with myeloid sarcoma that was refractory to six different chemotherapeutic regimens. Our clinical NGS assay detected an unanticipated FIP1L1-PDGFRA rearrangement in his tumor. The patient was immediately placed on Imatinib therapy to which he responded, and remains in remission 10 months after the rearrangement was initially detected.

The authors propose one possible vision for the transformative role that cancer imaging in an academic setting can play in the current era of personalized and precision medicine by sharing a conceptual model that is based on experience and lessons learned designing a multidisciplinary, integrated clinical and research practice at their institution. The authors' practice and focus are disease-centric rather than imaging-centric. A "wall-less" infrastructure has been developed, with bidirectional integration of preclinical and clinical cancer imaging research platforms, enabling rapid translation of novel cancer drugs from discovery to clinical trial evaluation. The talents and expertise of medical professionals, scientists, and staff members have been coordinated in a horizontal and vertical fashion through the creation of Cancer Imaging Consultation Services and the "Adopt-a-Radiologist" campaign. Subspecialized imaging consultation services at the hub of an outpatient cancer center facilitate patient decision support and management at the point of care. The Adopt-a-Radiologist campaign has led to the creation of a novel generation of imaging clinician-scientists, fostered new collaborations, increased clinical and academic productivity, and improved employee satisfaction. Translational cancer research is supported, with a focus on early in vivo testing of novel cancer drugs, co-clinical trials, and longitudinal tumor imaging metrics through the imaging research core laboratory. Finally, a dedicated cancer imaging fellowship has been developed, promoting the future generation of cancer imaging specialists as multidisciplinary, multitalented professionals who are trained to effectively communicate with clinical colleagues and positively influence patient care.

Cancer immunotherapy is changing the imaging evaluation of cancer treatment response and treatment-related toxic effects. New emerging patterns of treatment response and treatment-related toxic effects after treatment with immunomodulating agents have been observed. Treatment response after immunomodulatory therapy can be associated with significantly delayed decrease in tumor size, and new or enlarging tumors observed soon after completion of treatment may not reflect disease progression. In addition, activation of the immune system to fight cancer may lead to unwanted autoimmune-mediated toxic effects that could be mistaken for metastatic disease or misdiagnosed as a non-treatment-related process and delay appropriate clinical management. Radiologists must recognize the novel treatment response patterns and the wide range of autoimmune toxic effects, which should not be mistaken for treatment failure or metastatic disease progression.

Bone metastases are associated with increased morbidity and poor prognosis in castration-resistant prostate cancer. Since 2010, 5 systemic therapies for metastatic castration-resistant prostate cancer have been approved by the US Food and Drug Administration based on an improvement in overall survival, offering alternatives to docetaxel, a chemotherapeutic agent with modest effect and significant toxicity. These systemic treatments belong to different classes of medication such as immunotherapy, hormonal therapy, chemotherapy, and radionuclide therapy. Radium-223 dichloride ((223)RaCl2), approved in May 2013, is a novel α-emitting radiopharmaceutical that targets areas of increased bone turnover in bone metastases, delivering densely ionizing radiation within a short tissue range and causing more severe chromosomal damage than β-emitting radiopharmaceuticals. In this article, we review the clinical development of (223)RaCl2, focusing on its effects on pain relief, skeletal events, biochemical markers, overall survival, quality of life, and safety. We also outline the differences between (223)RaCl2 and the previously developed bone-seeking β-emitters and briefly present new trials on the horizon involving (223)RaCl2.

Purpose The purpose of this study was to determine the frequency of 2-deoxy-2-[ 18 F]fluoro-D-glucose (FDG) uptake in the intercostal respiratory muscles (ICM) of smokers versus nonsmokers using positron emission tomography (PET). Procedures Ninety-six whole-body PET/computed tomography (CT) scans were retrospectively reviewed; 61 studies were from smokers and 35 from nonsmokers. The ICM uptake from the lung apices to the level of the carina was visually scored with respect to FDG intensity as follows: 0 = uptake less than or equal to lung uptake; 1 = greater than lung, but less than mediastinal blood pool; 2 = equal to mediastinal blood pool; and 3 = greater than mediastinal blood pool. Results In smokers, 30 out of 61 (49.2%) PET/CT scans had uptake that localized to ICM, compared to 3/35 (8.6%) studies in nonsmokers. Average ICM uptake was significantly different between smokers and nonsmokers (0.787 ± 0.933 and 0.143 ± 0.494, respectively; P Conclusion Increased FDG uptake in ICM is a physiologic pattern of uptake that is frequently seen and is more common in smokers.

Background: Inflammatory breast cancer (IBC) is a virulent subtype of locally advanced breast cancer that accounts for 1–5% of all breast cancers diagnosed in the United States. Conventional therapy for IBC (preoperative chemotherapy, mastectomy, radiation therapy) results in a median 5 year overall survival of 50%, which supports the need for investigation into the molecular distinctiveness of IBC, with the ultimate goal of developing effective therapeutic agents that target these molecular changes. Some of the distinctive molecular characteristics of IBC include the presence of a substantial proportion of CD44+/CD24- breast cancer cells that express stem cell-like characteristics, over-expression of E-cadherin, and extensive formation of tumor emboli. Examination of breast tumors and pre-clinical data suggests that the JAK2/STAT3 pathway is active in CD44+/CD24- breast cancer cells, and is stimulated by various mechanisms associated with IBC, such as high IL-6 levels. We investigated the role of JAK2/STAT3 activation in IBC as preclinical evidence to pursue JAK2 targeted therapy for IBC in a clinical setting. Methods: Using de-identified breast tissue specimens from both untreated and treated IBC patients obtained on a protocol approved by our institutional review board; we performed immunohistochemical (IHC) and multicolor immunofluorescence analysis to detect the presence of CD44+/CD24- cells and the fraction of activated phospho-STAT3 (pSTAT3). The number of cells positive for pSTAT3 was assessed pre and post-treatment. We also analyzed the status of CD44+/CD24- cells and pSTAT3 in SUM149 and SUM190 IBC cell lines, and an IBC xenograft model (IDC31) derived from primary tumor obtained from an IBC patient. We tested the efficacy of multiple different JAK2 inhibitors to inhibit the growth and viability of cell cultures and xenografts. Results: All IBCs were highly enriched in CD44+/CD24- cells, with approximately 80% of all cancer cells within tumors displaying this phenotype. About 85% of IBC cases show activation of pSTAT3, and a significant fraction (40%) of CD44+/CD24- cells were pSTAT3 positive. Interestingly, the fraction of pSTAT3+ cells was lower in the CD44+/CD24- cells in post treatment samples from triple negative but not from luminal tumors. JAK2 inhibition significantly decreased the proliferation of pSTAT3+ IBC cells lines in vitro and the growth of pSTAT3+ xenografts including the IBC model ICD31. Discussion: Specific molecular characteristics of IBC result in a unique and virulent disease course. Based upon a predominance of CD44+/CD24- breast cancer stem cells present in IBC, we investigated the JAK2/STAT3 pathway in IBC tissue specimens, cell lines and an IBC xenograft model. Our preclinical data demonstrates a highly active JAK2/STAT3 pathway in IBC which lends itself to exploration of the efficacy of a JAK2 inhibitor in the treatment of this disease. A phase I/II study is underway to evaluate combination ruxolitinib and chemotherapy for the primary treatment of triple negative IBC. Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P4-06-01.

Nuclear medicine is rapidly evolving. Major factors affecting the field are the advent of hybrid imaging, an increasing emphasis on evidence-based medicine, and a growing recognition of the potential of personalized medicine. Molecular imaging, which is a fundamental part of nuclear medicine, has an

466 Background: BM frequently occur in pts with mRCC and are associated with worse survival. The primary aim was to investigate the effect of radium-223 with VEGF TT on bone turnover markers (BTMs) in mRCC pts with BM. Methods: Pts were stratified into cohort 1 (C1) if treatment (tx) naive (n=15) to receive pazopanib 800 mg daily or cohort 2 (C2) if previously treated (n=15) to receive sorafenib (SOR) 400 mg twice BID and could escalate to 600 mg BID at progression. All pts received radium-223 55 kBq/kg every 4 weeks x 6. A safety run-in was performed after 6 pts per cohort completed 2 cycles with criteria to halt enrollment if grade ≥3 tx-related adverse events (TRAEs) were observed in ≥80% of pts. Herein, we report the results of the safety run-in and early safety, biomarker, and imaging data for C2. Results: In the safety run-in, 5/12 (42%) pts experienced TRAEs including anemia, fatigue, liver test elevation, amylase elevation, rash, hand-foot-syndrome, and hypertension, and therefore enrollment continued. In C2, most pts had clear cell mRCC (n=10, 67%) and 47% (n=7) had liver metastases. 60% (n=9) received ≥3 prior txs. At the time of analysis, 8 (53%) pts discontinued tx with both agents for progression and 1 (7%) for toxicity. 5 pts (33%) received 6 doses of radium-223 and 2 (13%) remain on tx. 4 pts (27%) had SOR reductions and 4 (27%) had escalations. 5 pts (33%) had grade 3 TRAEs. Changes in BTM were assessed (Table). 33% of pts (n=5) had stable disease by RECIST, 27% (n=4) by Positron Emission Tomography Response Criteria in Solid Tumors, and 40% by MD Anderson Bone Response Criteria at first response assessment (FRA). Conclusions: Early data suggests that tx with radium-223 and SOR is safe and feasible. Tx resulted in early declines in BTM. Longer follow-up is needed to characterize the safety and effect on BTM. Clinical trial information: NCT02406521. [Table: see text]

Background: HER2 negative(neg) inflammatory breast cancer(IBC) exhibits relative resistance to chemotherapy evidenced by pCR(pathologic complete response rate) rates of 12-25% with preoperative taxane/anthracycline regimens. Eribulin(Eisai®) inhibits microtubular function via sequestration of tubulin into nonfunctional aggregates, thus being effective against taxane-resistant cancer. Preclinical data shows 2 mechanisms of action: reversion of EMT(epithelial to mesenchymal transition) and normalization of tumor vascularity. Treatment of triple negative breast cancer(TNBC) cell-lines with eribulin results in downregulation of mesenchymal markers with concomitant increase in expression of classical epithelial markers(Yoshida BJC 2014). In PDX models, eribulin improved blood perfusion in central region of tumors, increased vessel density, reduced vessel diameter, and reduced hypoxia. IBC is highly angiogenic, with increased microvessel density, higher fraction of proliferating endothelial cells and greater expression of pro-angiogenic genes compared with non-IBC(McCarthy CCR 2002). This preoperative study(EAC) exploits the angiogenic properties of IBC with the treatment scheme of eribulin(E) followed by doxorubicin/cyclosphosphamide(AC) in newly diagnosed HER2neg IBC. Methods: Pts with HER2neg Stage III (cT4d,any N,M0) IBC are eligible if they have not received prior therapy for BC, have adequate organ function, cardiac ejection fraction > 50%, and willing to undergo 2 research biopsies (rbx) of the affected breast. Following baseline rbx, pts receive cycle 1, day(d)1 eribulin 1.4 mg/m2. A 2nd rbx occurs on d8, prior to dosing of E. Following 3 more cycles of E(1.4mg/m2 d1,d8,every 21d), pts receive 4 cycles of dose-dense AC(A-60 mg/m2,C-600mg/m2 every 14d). Pts with adequate disease response undergo mastectomy/axillary lymph node dissection followed by chest wall/regional lymph node radiation. Adjuvant endocrine therapy is used if hormone receptor positive. An imaging sub-study evaluates tumor perfusion via DCE-MRI pre and post 1st dose E. Correlatives: To investigate whether E induces reversion of EMT in IBC, expression of 10 EMT-related genes are determined in each rbx, and normalization of tumor vessel phenotype are assessed by expression of 15 angiogenesis-related genes in rbx by RT-qPCR. Gene expression will be repeated on residual tumor at mastectomy. An imaging sub-study of DCE-MRI (10 pts) will assess vascular remodeling via changes in Ktrans , ve and vp determination of IBC region of interest, core and rim and changes in the iAUC computed pre and post 1st dose E. Statistics: The primary endpoint is pCR. A Simon two-stage design is used. If the proportion of pts having pCR is < 0.10 then EAC is considered minimally effective, versus alternative hypothesis that EAC is worthy of further study if proportion pCR > 0.30. In the 1st stage, if < 2/16 pts have pCR, the study is stopped; if > 3 pts have pCR, the study proceeds. In the 2nd stage, EAC is rejected if < 4 of 25 pts have a pCR(α=0.10;β=0.10). Up to 25 pts will be enrolled. Secondary endpoints are residual cancer burden, disease-free survival, time to treatment failure and overall survival. Clinical trial information: NCT02623972. Citation Format: Overmoyer B, Goel S, Regan M, Hirshfield-Bartek J, Schlosnagel E, Yeh E, Qin L, Bellon J, Nakhlis F, Jacene H, Winer E. A phase 2 study of eribulin followed by doxorubicin and cyclophosphamide as preoperative therapy for HER2-negative inflammatory breast cancer [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr OT1-01-07.

Background: Inflammatory breast cancer (IBC) continues to have a poor prognosis despite standard tri-modality treatment with chemotherapy, mastectomy and radiation. Current methods of assessing primary tumor response (i.e., clinical exam and breast magnetic resonance imaging [MRI]) are limited for distinguishing residual tumor from responsive disease because of persistent morphologic changes in the breast. Therefore, the inability to accurately assess tumor response during treatment often results in the continuation of ineffective systemic chemotherapy until definitive pathologic evaluation at mastectomy. IBC has a highly angiogenic phenotype which is believed to play a role in this tumor's aggressiveness. The novel radiotracer Zirconium-89 (89Zr)-bevacizumab was developed for imaging tumor angiogenesis with PET. We hypothesize that, as an imaging biomarker of angiogenesis, 89Zr-bevacizumab-PET/CT is a more specific noninvasive functional imaging modality for detecting the presence of tumor angiogenesis compared to current diagnostic methods and will serve as a predictor of response to therapy in patients (pts) with IBC. Methods: Pts with newly diagnosed HER2neg IBC who will receive preoperative chemotherapy are eligible for this pilot study. 89Zr-bevacizumab-PET/CT, breast MRI and FDG-PET/CT are performed before, after 2 cycles, and at the completion of preoperative therapy. Biopsies of primary IBC tumors are obtained prior to and after 2 cycles of preoperative therapy. At the completion of preoperative therapy, pts proceed to mastectomy or biopsy if ineligible to proceed to mastectomy based on current standards for assessing primary tumor response, i.e., clinical exam, breast MRI and lack of systemic progression. At the time of mastectomy, standard evaluation of the surgical specimen will determine pathologic response of IBC to preoperative chemotherapy. A research sample will be collected if residual cancer is present at the time of mastectomy for histologic evaluation of tumor angiogenesis. Objectives/Correlatives: The primary objective is to determine feasibility of 89Zr-bevacizumab-PET/CT imaging in pts with IBC. The primary endpoint is assessment of radiolabeling of chelated bevacizumab and number of successfully acquired 89Zr-bevacizumab-PET/CT scans. Correlative studies will be performed on IBC tissue to assess extent of angiogenesis including microvessel density, vessel diameter, vascular pericyte coverage and tumor VEGF levels. Secondary objectives are: 1) To determine if 89Zr-bevacizumab accumulation in primary IBC tumors correlates with the extent of angiogenesis determined by correlative analysis on IBC tissue; 2) To assess the predictive value of 89Zr-bevacizumab-PET/CT after 2 cycles and at the end of preoperative therapy for determining pathologic response at mastectomy as given by residual cancer burden. Statistics: This is an accrual, not statistical based, feasibility justification. Planned sample size is 10 in order to make a preliminary statement about feasibility and ability for 89Zr-bevacizumab-PET/CT to serve as a surrogate in vivo biomarker of tumor angiogenesis and response to preoperative chemotherapy. Clinical Trial Information: NCT01894451. Citation Format: Jacene HA, Overmoyer B, Schlosnagle EJ, Abbott A, Yeh E, Paolino J, Goel S, Culhane A, Bellon JR, Nakhlis F, Hirshfield-Bartek J, Van den Abbeele A. Pilot study of zirconium-89 bevacizumab positron emission tomography for imaging angiogenesis in patients with inflammatory breast carcinoma receiving preoperative chemotherapy [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr OT2-02-03.

Efforts have been made to minimize the damage to adjacent normal tissues during radiotherapy, primarily by shifting from the use of conventional radiotherapy to more advanced techniques. Reviewing the overall pattern on combined anatomic and functional imaging can enhance diagnostic accuracy. Several radiotracers can be used; [(18)F]fluorodeoxyglucose is the most common. Familiarity with the type and timing of previous radiation therapy, the spectrum of imaging findings after radiation injury, and the appropriate use of the different radiotracers can be crucial. This article summarizes postradiation histologic findings and multimodality imaging findings, with emphasis on PET/computed tomography.

The rationale for the use of radioimmunotherapy (RIT) in cancer is that radiolabeled monoclonal antibodies specifically target and irradiate tumor cells while sparing normal tissues. The specific tumor targeting theoretically allows higher doses of radiation to be delivered to tumor as compared to external beam radiation because the effects of the radiation on normal tissues is lesser with RIT. An additional advantage of RIT is that the beta-emissions of the radiolabel target surrounding malignant cells via the cross-fire effect, probably killing those not reached by unlabeled antibody. Tositumomab and Iodine (I 131) tositumomab (Bexxar® therapeutic regimen) is RIT directed against the CD20 antigen which is effective for the treatment of B-cell non-Hodgkin lymphoma (NHL). This chapter discusses the rationale, development, clinical applications and practical aspects of delivering tositumomab and Iodine (I 131) tositumomab (Bexxar® therapeutic regimen).

We report a case documenting fluorodeoxyglucose (FDG) accumulation in upper abdominal lymph nodes resulting from acute hepatitis C infection. A 42-year-old African-American female with a history of metastatic breast carcinoma was found to have hypermetabolic porta hepatic, peripancreatic, and paraaortic lymphadenopathy and hypermetabolism in the spleen on a surveillance FDG positron emission tomography/computed tomography (PET/CT) scan. Concurrently, she was diagnosed with acute hepatitis C infection. Antiviral therapy was not recommended secondary to the low level of detectable virus at the time of diagnosis. Her breast cancer therapy regimen was continued unaltered. FDG PET/CT scan was repeated 2 months later as a result of concern that the hypermetabolic lymph nodes represented metastatic disease; however, the scan revealed complete resolution of the previously abnormal findings. The resolution of the lymphadenopathy and the patient's clinical course led to the conclusion that the most likely explanation for the FDG PET/CT findings was inflammation secondary to acute hepatitis C infection and not metastatic breast carcinoma. Inflammatory and infectious processes accumulate FDG, occasionally resulting in false-positives for malignancy. Infected macrophages in the lymph nodes draining the liver in this case and stimulation of a cellular immune response by the hepatitis C virus, with resultant cytokine production by cytotoxic and T-helper cells, offer possible explanations for the findings seen on FDG PET/CT in this case. This case highlights the importance of clinical history and laboratory correlation for the proper interpretation of FDG PET scans.

Inflammatory breast cancer (IBC) is a rare breast cancer with a highly virulent course and low 5-year survival rate. Trimodality treatment that includes preoperative chemotherapy, mastectomy, and radiation therapy is the therapeutic mainstay and has been shown to improve prognosis. Proper diagnosis and staging of IBC is critical to treatment planning and requires a multidisciplinary approach that includes imaging. Patients with IBC typically present with rapid onset of breast erythema, edema, and peau d'orange. Both tissue diagnosis of malignancy and clinical findings of inflammatory disease are required to confirm diagnosis of IBC. Imaging is used to identify a biopsy target; direct biopsy; stage IBC; differentiate curable from incurable (stage IV) disease; and help plan chemotherapy, surgical management, and radiation therapy. Comparison of baseline and posttreatment images helps confirm and quantitate disease response. When imaging is used early in the course of therapy to noninvasively predict treatment response, optimal tailored strategies for management of IBC can be implemented. Imaging is vital to diagnosis and treatment planning for patients with IBC, and radiologists are an integral part of the multidisciplinary patient care team.

Purpose: Use of 2[18F]fluoro-2-deoxy-D-glucose positron emission tomography (FDG-PET) in postchemotherapy response assessment in follicular lymphoma is still a controversial issue. Here, we conducted the first systematic review and meta-analysis to determine the predictive value of FDG-PET in predicting outcome after chemotherapy of follicular lymphoma. Experimental Design: Comprehensive literature search in Ovid-MEDLINE and EMBASE databases was performed to identify studies which evaluate predictive value of end-therapy PET and/or computed tomography (CT) in patients with follicular lymphoma. To quantitatively compare the predictive value of PET and CT, pooled hazard ratios (HRs) comparing progression-free survival (PFS) between patients with positive and negative results were adopted as the primary indicators for meta-analysis. To explore the efficiency in determining complete remission (CR), pooled CR rates of PET- and CT-based response criteria were calculated. Pooling of these parameters was based on the random-effects model. Results: Review of 285 candidate articles identified eight eligible articles with a total of 577 patients for qualitative review and meta-analysis. The pooled HRs of end-therapy PET and CT were 5.1 [95% confidence interval (CI), 3.7–7.2] and 2.6 (95% CI, 1.2–5.8), respectively, which implies that PET is more predictive of PFS after chemotherapy than CT. The pooled CR rates of PET- and CT-based response criteria were 75% (95% CI, 70–79%) and 63% (95% CI, 53–73%), respectively, which implies that PET is more efficient in distinguishing CR (without residual disease) from other states with residual disease. In addition, qualitative systematic review indicates the same findings. Conclusions: Consistent evidence favoring PET-based treatment assessment should be considered in the management of patients with follicular lymphoma. Clin Cancer Res; 19(23); 6566–77. ©2013 AACR.

Purpose: Standard treatment for IBC includes preoperative systemic therapy (PST), followed by mastectomy (M) and adjuvant radiation (R). Determining the optimal sequencing of M and R after PST may be difficult when clinical changes suggest residual disease within breast skin. With the goal of selecting appropriate patients (pts) for M prior to R, we correlated pathologic disease response in breast skin with changes in skin thickness and enhancement determined by MRI. Methods: An IRB approved database of IBC pts evaluated at Dana Farber Cancer Institute (DFCI) from 1997-2013 was used for retrospective analysis. 40 pts met criteria: confirmed diagnosis of IBC, completed PST followed by M without preoperative R. Baseline and post-PST breast MRI imaging was reviewed. Using the ACR BI-RADS lexicon, we recorded skin thickness, qualitative enhancement and kinetic analysis using computer-aided detection post-processing software. Findings were correlated with pathologic response in skin found at M. Results: MRI showed baseline skin thickening in all 40 pts (median 6mm, range 3-13mm). Although 34 (85%) had persistent skin thickening post-PST (median 4 mm, range MRI showed qualitative skin enhancement at baseline in 39/40 pts. 29 (73%) had medium/fast initial phase kinetics: 25 persistent delayed phase kinetics, 2 wash-out, 2 plateau. 20 pts had residual qualitative skin enhancement post-PST; 11 pts (28%) had medium/fast initial phase kinetics, all persistent delayed kinetics. The decrease in skin thickness was significantly greater among the 19 pts achieving resolution of skin enhancement post-PST compared with the decrease in skin thickness among the 20 pts with residual skin enhancement (p=0.02). 8 pts (20%) had residual tumor within the skin at M. All 8 pts had thicker skin on post-PST MRI (median 5 mm, range 3-13mm) compared with pts without residual disease in the skin (median 3.5mm, range Conclusion: Although IBC pts have skin thickening demonstrated by MRI at baseline, there is a statistically significant reduction in the skin thickness following successful PST. This correlates with a reduction in enhancement of the skin shown by MRI imaging. More substantial and persistent skin thickening with enhancement was seen in the setting of residual dermal lymphatic involvement following the completion of PST, though this study is too small to detect any significant correlation. Since an accurate assessment of residual disease in breast skin is vital in determining the optimal sequencing of M and R following PST in IBC pts, MRI evaluation of skin thickness and enhancement may be a useful tool to predict residual disease and guide surgical management of IBC. Citation Format: Yeh E, Rives A, Guo H, Regan M, Birdwell R, Nakhlis F, Bellon J, Warren L, Hirshfield-Bartek J, Jacene H, Dominici L, Overmoyer B. MRI changes in breast skin following preoperative therapy for inflammatory breast cancer (IBC). [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P4-02-08.

OBJECTIVE. PET/CT with 18F-FDG shows metabolically active disease and is widely used for the diagnosis and follow-up of patients with cancer. Nonmetabolically active renal pathology may be missed without close attention to the CT portion of the study, whereas metabolically active pathology may be missed on PET because of physiologic tracer excretion in the kidneys. This article illustrates primary lesions of the kidney on FDG PET/CT with emphasis on key anatomic features and the appearance of tracer uptake. CONCLUSION. Close attention to both the FDG PET and CT portions of the study is essential to interpret renal pathology correctly on FDG PET/CT examinations.

A 72-year-old Caucasian man presenting with non-specific upper abdominal pain had asymmetric soft tissue thickening of the small bowel wall on computed tomography (CT), which was pathologically proven to be leiomyosarcoma (LMS). At the same time point patient had incidentally but retrospectively detected lesion in IVC on CT scan which was subsequently imaged with PET/CT and MRI and was histologically proven to be also LMS. We present clinical and imaging features along with pedigree of this unique case of synchronous primary LMS involving the small bowel and inferior vena cava in a patient with RB1 gene mutation and a significant family history of multiple malignancies. To our knowledge, the synchronous primary LMS at two different sites has not been described. Clinicians and radiologists should keep in mind the possibility of a synchronous primary LMS in patients with genetic predisposition before making the diagnosis of a metastatic lesion or other malignancy as localized primary tumors remain potentially curable, whereas metastatic sarcoma is most often incurable.

Background Merkel cell carcinoma (MCC) is a rare and lethal cutaneous neuroendocrine carcinoma. Imaging is crucial for accurate staging, which remains a strong predictor of survival, as well as earlier detection of recurrence and progression, which are common despite aggressive management. There is no consensus on the role of initial and subsequent imaging for MCC. Objective We sought to evaluate the use of 2-fluoro-[ 18 F]-deoxy-2-D-glucose (FDG)-positron emission tomography (PET)/computed tomography (CT) in the management of MCC. Methods In all, 270 FDG-PET/CT studies were performed in 97 patients with pathology-proven MCC at the Dana-Farber/Brigham and Women's Cancer Center, Boston, Mass, from August 2003 to December 2010. Results FDG-PET/CT scans were obtained as part of the initial (61 scans in 61 patients) and subsequent (209 scans in 79 patients) treatment strategies. MCCs were FDG-avid with a mean maximum standardized uptake value of primary lesions of 6.5 (range 1.3-12.9) and a mean maximum standardized uptake value of regional and distant metastases of 7.2 (range 1.5-9.9). FDG-PET/CT upstaged 16% of patients who underwent baseline scans. FDG-PET/CT studies showed that bone and bone-marrow metastases were more common than previously reported, and were often undetected by CT. Limitations Our study is limited by its retrospective design, and potential referral bias associated with a tertiary care center. Conclusions FDG-PET/CT performed as part of the initial management strategy tended to upstage patients with more advanced disease. FDG-PET/CT performed as part of the subsequent treatment strategy identified metastatic disease, particularly in bone/bone marrow, which was not seen on CT. FDG-PET/CT imaging is a valuable staging and restaging tool in MCC management.

In classical Hodgkin lymphoma, circulating clonotypic malignant cells express CD20, which potentially explains the observed activity of rituximab. This multicenter phase 2 study investigated the combination of rituximab-ABVD (doxorubicin, bleomycin, vinblastine, dacarbazine) for stage II-IV untreated classical Hodgkin lymphoma. A goal was to assess the behavior of circulating clonotypic B cells clinically. Of 49 evaluable patients, 69% had stage IIB-IV disease; 8% had CD20+ Hodgkin and Reed-Sternberg cells. Rituximab-ABVD was generally well tolerated. Delivered relative dose intensity was 94% for AVD and 79% for bleomycin. After 6 cycles, 81% of patients were in complete remission. Only 8% received radiation therapy. The actuarial 3-year event-free and overall survival rates were 83% and 98%, respectively. EBV copy number in plasma fell dramatically during cycle 1 in patients with EBV+ tumors. Persistence of detectable circulating clonotypic B cells was associated with a greater relapse frequency ( P < .05). Rituximab-ABVD and clonotypic B cells warrant additional study in classical Hodgkin lymphoma. This trial was registered at [www.clinicaltrials.gov][1] as [NCT00369681][2]. [1]: http://www.clinicaltrials.gov [2]: /lookup/external-ref?link_type=CLINTRIALGOV&access_num=NCT00369681&atom=%2Fbloodjournal%2F119%2F18%2F4129.atom

This study aimed at identifying clinical factors for predicting hematologic toxicity after radioimmunotherapy with (90)Y-ibritumomab tiuxetan or (131)I-tositumomab in clinical practice. Hematologic data were available from 14 non-Hodgkin lymphoma patients treated with (90)Y-ibritumomab tiuxetan and 18 who received (131)I-tositumomab. The percentage baseline at nadir and 4 wk post nadir and the time to nadir were selected as the toxicity indicators for both platelets and neutrophils. Multiple linear regression analysis was performed to identify significant predictors (P < 0.05) of each indicator. For both platelets and neutrophils, pooled and separate analyses of (90)Y-ibritumomab tiuxetan and (131)I-tositumomab data yielded the time elapsed since the last chemotherapy as the only significant predictor of the percentage baseline at nadir. The extent of bone marrow involvement was not a significant factor in this study, possibly because of the short time elapsed since the last chemotherapy of the 7 patients with bone marrow involvement. Because both treatments were designed to deliver a comparable bone marrow dose, this factor also was not significant. None of the 14 factors considered was predictive of the time to nadir. The R(2) value for the model predicting percentage baseline at nadir was 0.60 for platelets and 0.40 for neutrophils. This model predicted the platelet and neutrophil toxicity grade to within ±1 for 28 and 30 of the 32 patients, respectively. For the 7 patients predicted with grade I thrombocytopenia, 6 of whom had actual grade I-II, dosing might be increased to improve treatment efficacy. The elapsed time since the last chemotherapy can be used to predict hematologic toxicity and customize the current dosing method in radioimmunotherapy.

Preoperative imaging studies have an important role in facilitating successful localization of adenomas for surgeons. Their use has increased and parallels the recent growth of minimally invasive parathyroidectomy. Based on findings that scintigraphy is reported to have the highest accuracy for localization of adenomas when compared with anatomic imaging techniques, this article discusses the current role and limitations of imaging, with a focus on scintigraphy, in the evaluation of patients before surgery for hyperparathyroidism.

To determine if anatomically "nonmeasurable" disease in bone marrow (BM) is assessable for response to therapy by [(18)F]-2-fluoro-2-deoxy-D-glucose (FDG) positron emission tomography (PET)/computed tomography (CT).FDG PET/CT images of 27 patients with lymphoma, FDG-avid bone marrow (BM) lesions, andor=1 FDG-avid, tumor-involved lymph node (LN) at baseline were retrospectively reviewed. FDG uptake in target LNs and BM foci was determined pre- and posttherapy using the standardized uptake value corrected for lean body mass (SUL(mean)). Size of the same target LNs was measured pre- and posttherapy on CT. Percentage decreases of LN size and LN and BM SUL were calculated. Response was classified according to revised International Workshop Criteria (IWC) with and without modification for metabolic evaluation of BM and correlated to overall survival. Statistical analyses were performed using paired t-tests, Pearson correlation coefficients, and z-tests.LN size, LN SUL(mean), and BM SUL(mean) were significantly higher pre- versus posttherapy (2337 mm(2) +/- 1810 vs. 309 mm(2) +/- 323; 6.94 +/- 4.96 vs. 1.02 +/- 1.00; and 6.81 +/- 4.58 to 1.84 +/- 1.58, all P.001, respectively). After therapy, significant correlation was found between percentage declines of LN size and SUL(mean) of LNs (r = 0.84, P.001) or BM (r = 0.56, P = .002) and SUL(mean) of LN and BM (r = 0.76, P.001). Including a metabolic assessment of BM correctly altered overall response assessment in 5/27 (19%) patients and better predicted overall survival than revised IWC.Anatomically "unmeasurable" BM infiltration with lymphoma behaves similarly to LN disease after therapy and is "measurable" by FDG PET/CT. FDG PET/CT is valuable for monitoring tumor response in "measurable" disease and BM, which was previously considered "unmeasurable" by anatomical imaging.

We preoperatively determined the accuracy of 18F-FDG PET/CT for differentiating fixed muscle hypertrophy and fibrotic stenoses from acute transmural inflammatory stenoses in patients with Crohn9s disease (CD) scheduled to undergo surgical resection for obstructive symptoms. Methods: Seventeen patients with known CD prospectively underwent 18F-FDG PET/CT before already-planned surgery for obstructive symptoms. Image interpretation was by consensus of 2 readers with knowledge of patient participation in the study but not of other clinical history. Lesions were qualitatively graded on a 5-point scale for the presence of increased 18F-FDG uptake consistent with active inflammation. Maximum lean standardized uptake value (SULmax) was determined for lesions scored 1 or more. Imaging results were compared with the pathologic grading of inflammation and predominant histopathologic subtype for each patient9s surgical specimen, whether mainly inflammation, fibrosis, or muscle hypertrophy. Results: Thirteen of the 17 patients underwent surgery (median, 28 d after PET/CT; range, 2–148 d), and 12 of these 13 had histopathologic correlation. Despite the predominant histopathologic subtype (inflammation, 5; fibrosis, 4; and muscle hypertrophy, 3), acute and chronic inflammation, fibrosis (median, 50%; range, 40%−90%), and muscle hypertrophy (median, 20-fold thickening; range, 9- to 40-fold thickening) were found in all patients. SULmax was significantly higher in severe than in mild-to-moderate chronic inflammation (8.2 ± 2.8 vs. 4.7 ± 2.5, P = 0.04). No patient with predominantly fibrosis or muscle hypertrophy (n = 7) had an SULmax greater than 8. Visually, 10 of 12 patients on PET/CT were considered to have active inflammation of the bowel. Conclusion: Patients with CD who undergo surgery for obstructive symptoms have histopathologically mixed findings of inflammation, fibrosis, and muscle hypertrophy. Qualitative PET interpretations were quite sensitive, but additional semiquantitative analyses using SULmax helped identify patients with active inflammation. This information may be beneficial for referring gastroenterologists considering medical therapy versus surgery for patients with CD who present with obstructive symptoms.

The purpose of this article is to review the status and limitations of anatomic tumor response metrics including the World Health Organization (WHO) criteria, the Response Evaluation Criteria in Solid Tumors (RECIST), and RECIST 1.1. This article also reviews qualitative and quantitative approaches to metabolic tumor response assessment with (18)F-FDG PET and proposes a draft framework for PET Response Criteria in Solid Tumors (PERCIST), version 1.0.PubMed searches, including searches for the terms RECIST, positron, WHO, FDG, cancer (including specific types), treatment response, region of interest, and derivative references, were performed. Abstracts and articles judged most relevant to the goals of this report were reviewed with emphasis on limitations and strengths of the anatomic and PET approaches to treatment response assessment. On the basis of these data and the authors' experience, draft criteria were formulated for PET tumor response to treatment.Approximately 3,000 potentially relevant references were screened. Anatomic imaging alone using standard WHO, RECIST, and RECIST 1.1 criteria is widely applied but still has limitations in response assessments. For example, despite effective treatment, changes in tumor size can be minimal in tumors such as lymphomas, sarcoma, hepatomas, mesothelioma, and gastrointestinal stromal tumor. CT tumor density, contrast enhancement, or MRI characteristics appear more informative than size but are not yet routinely applied. RECIST criteria may show progression of tumor more slowly than WHO criteria. RECIST 1.1 criteria (assessing a maximum of 5 tumor foci, vs. 10 in RECIST) result in a higher complete response rate than the original RECIST criteria, at least in lymph nodes. Variability appears greater in assessing progression than in assessing response. Qualitative and quantitative approaches to (18)F-FDG PET response assessment have been applied and require a consistent PET methodology to allow quantitative assessments. Statistically significant changes in tumor standardized uptake value (SUV) occur in careful test-retest studies of high-SUV tumors, with a change of 20% in SUV of a region 1 cm or larger in diameter; however, medically relevant beneficial changes are often associated with a 30% or greater decline. The more extensive the therapy, the greater the decline in SUV with most effective treatments. Important components of the proposed PERCIST criteria include assessing normal reference tissue values in a 3-cm-diameter region of interest in the liver, using a consistent PET protocol, using a fixed small region of interest about 1 cm(3) in volume (1.2-cm diameter) in the most active region of metabolically active tumors to minimize statistical variability, assessing tumor size, treating SUV lean measurements in the 1 (up to 5 optional) most metabolically active tumor focus as a continuous variable, requiring a 30% decline in SUV for "response," and deferring to RECIST 1.1 in cases that do not have (18)F-FDG avidity or are technically unsuitable. Criteria to define progression of tumor-absent new lesions are uncertain but are proposed.Anatomic imaging alone using standard WHO, RECIST, and RECIST 1.1 criteria have limitations, particularly in assessing the activity of newer cancer therapies that stabilize disease, whereas (18)F-FDG PET appears particularly valuable in such cases. The proposed PERCIST 1.0 criteria should serve as a starting point for use in clinical trials and in structured quantitative clinical reporting. Undoubtedly, subsequent revisions and enhancements will be required as validation studies are undertaken in varying diseases and treatments.

Purpose Positron emission tomography (PET) with [18F]fluorodeoxyglucose (FDG-PET) has increasingly been used to evaluate the efficacy of anticancer agents. We investigated the role of FDG-PET as a predictive marker for response to mammalian target of rapamycin (mTOR) inhibition in advanced solid tumor patients and in murine xenograft models. Patients and Methods Thirty-four rapamycin-treated patients with assessable baseline and treatment FDG-PET and computed tomography scans were analyzed from two clinical trials. Clinical response was evaluated according to Response Evaluation Criteria in Solid Tumors, and FDG-PET response was evaluated by quantitative changes and European Organisation for Research and Treatment of Cancer (EORTC) criteria. Six murine xenograft tumor models were treated with temsirolimus. Small animal FDG-PET scans were performed at baseline and during treatment. The tumors were analyzed for the expression of pAkt and GLUT1. Results Fifty percent of patients with increased FDG-PET uptake and 46% with decreased uptake had progressive disease (PD). No objective response was observed. By EORTC criteria, the sensitivity of progressive metabolic disease on FDG-PET in predicting PD was 19%. Preclinical studies demonstrated similar findings, and FDG-PET response correlated with pAkt activation and plasma membrane GLUT1 expression. Conclusion FDG-PET is not predictive of proliferative response to mTOR inhibitor therapy in both clinical and preclinical studies. Our findings suggest that mTOR inhibitors suppress the formation of mTORC2 complex, resulting in the inhibition of Akt and glycolysis independent of proliferation in a subset of tumors. Changes in FDG-PET may be a pharmacodynamic marker for Akt activation during mTOR inhibitor therapy. FDG-PET may be used to identify patients with persistent Akt activation following mTOR inhibitor therapy.

The purpose of the study was to assess prospectively the impact of recombinant human TSH (rhTSH) administration on positron emission tomography (PET)/computed tomography (CT) imaging in differentiated thyroid cancer patients who, after primary treatment, had a suppressed or stimulated serum thyroglobulin greater than 10 ng/ml and no radioactive iodine uptake consistent with thyroid cancer on a whole body scan.PET/CT was performed before (basal PET) and 24-48 h after rhTSH administration (rhTSH-PET) in 63 patients (52 papillary and 11 follicular thyroid cancers). Images were blindly analyzed by two readers. The proposed treatment plan was prospectively assessed before basal PET, after basal PET, and again after rhTSH-PET.A total of 108 lesions were detected in 48 organs in 30 patients. rhTSH-PET was significantly more sensitive than basal PET for the detection of lesions (95 vs. 81%; P = 0.001) and tended to be more sensitive for the detection of involved organs (94 vs. 79%; P = 0.054). However, basal PET and rhTSH-PET did not have significantly different sensitivity for detecting patients with any lesions (49 vs. 54%; P = 0.42). Changes in treatment management plan occurred in 19% of the patients after basal PET. Lesions found only by rhTSH-PET contributed to an altered therapeutic plan in eight patients, among whom only four were true-positive on pathology (6%).The use of rhTSH for 2-[18F]-fluoro-2-deoxy-D-glucose-PET/CT significantly increased the number of lesions detected, but the numbers of patients in whom any lesion was detected were no different between basal and rhTSH-stimulated PET/CT scans. Treatment changes due to true positive lesions occurred in 6% of cases.

We retrospectively evaluated 18F-FDG PET/CT for monitoring the response of non-Hodgkin's lymphoma to radioimmunotherapy.A total of 33 clinical patients received 131I-tositumomab (n=23) or 90Y-ibritumomab tiuxetan (n=10) and underwent 18F-FDG PET/CT scans before radioimmunotherapy and at 12 wk after radioimmunotherapy. A third scan was performed on 13 patients at 24 wk after radioimmunotherapy, 12 of whom did not receive interval therapy. Tumor metabolic activity was assessed before and after radioimmunotherapy visually and quantitatively by lean maximum standardized uptake value (SUVlean max). Response was assessed by the International Workshop Criteria (IWC) and Revised IWC, which includes 18F-FDG PET (IWC-PET).Mean SUVlean max decreased from baseline in 244 target lesions 12 wk after radioimmunotherapy (from 6.51+/-4.05 to 3.94+/-4.41; P0.01), regardless of response at 12 wk after radioimmunotherapy (Por=0.02). After radioimmunotherapy, SUVlean max was lower for responders than for nonresponders (Por=0.01). Median percentage change in SUVlean max of target lesions per patient was -51% (-95% to 97%). No significant difference in decline in SUVlean max between patients who received 131I-tositumomab and those who received 90Y-ibritumomab tiuxetan was demonstrated (-31%+/-51% vs. -47%+/-46%; P=0.38). Patients with greater than a 52% decline in SUVlean max tended toward longer survival (P=0.09) than those with lesser declines. The 12-wk overall response rate to radioimmunotherapy based on IWC was 42% (14/33); complete response rate was 15% (5/33). Eleven of 12 patients with progression at 12 wk had new disease sites, and in 4 patients, new disease sites were the only sites of progression. Of 108 lesions evaluated at 12 and 24 wk after radioimmunotherapy, 49 resolved at 12 wk and remained resolved at 24 wk, 17 gradually declined in SUV over 24 wk, and 37 initially decreased at 12 wk but increased at 24 wk. PET showed disease progression at 24 wk in 10 of 13 patients; 7 patients had new lesions and 1 was reclassified from partial response to complete response.In non-Hodgkin's lymphoma, 18F-FDG uptake in tumors typically drops significantly after radioimmunotherapy. A continued decline in tumor SUVlean max between 12 and 24 wk without additional therapy can occur, suggesting a need for delayed-response assessment. In patients who progress after radioimmunotherapy, new sites of disease commonly develop, rather than recurrence or progression at previous disease sites. Large declines in 18F-FDG uptake tend to be seen in those with the longest progression-free survival.

Fibrous dysplasia (FD) accounts for 7% of benign bone tumors. It is a developmental disorder of unclear etiology. The lamellar cancellous bone of the medullary cavity is replaced with immature fibroosseous tissue. We describe a case of FD of the skull in a patient of advanced age (69 years) with recent diagnosis of colon cancer, which changed its FDG activity and CT appearance within 10 months of follow-up. Surgical biopsy confirmed FD. Several case reports describe FDG-avid FD, but conversion of metabolic activity late in life is probably unusual.

Noninvasive methods for quantifying tumor blood flow (TBF) have a potentially important role in the field of drug development. 15O-water PET has been used in several studies aimed at monitoring response to novel treatments. Assessing the significance of changes in TBF requires knowledge of the reproducibility of the technique. This article quantifies the reproducibility of the 15O-water technique for TBF applications. Methods: A total of 43 pairs of replicate 15O-water studies were performed on 23 different patients with cancer. TBF was estimated using a standard, single-compartment model, and the replicate data were used to assess the reproducibility of the method. Results: The magnitude of the differences between replicate flow measurements was found to be proportional to their means. TBF was measured with a within-subject coefficient of variation of 13.4% and a repeatability of 37.1%. The volume of distribution was measured with a within-subject coefficient of variation of 8.6% and a repeatability of 24.0%. Conclusion:15O-water PET can be used to measure TBF with a reproducibility that is consistent with other applications of the technique. The short half-life of the isotope permits multiple replicate studies to be performed during the same imaging session, allowing the reproducibility of the average flow estimate to be adapted to the required task. 15O-water PET is a powerful and robust tool for TBF quantification.

UNLABELLED: (18)F-FDG PET has been reported to have reduced sensitivity in detecting bronchioloalveolar carcinoma (BAC) versus lung cancers with other histologies. However, there are CT characteristics that are suggestive of BAC, and potentially these could be useful to refine diagnostic criteria so PET/CT can be more accurate in the diagnosis of BAC. We correlated tumor size and density obtained with CT and glucose metabolism obtained with (18)F-FDG PET in patients with BAC and adenocarcinoma with BAC components (Adeno+BAC) to determine the roles of both the anatomic and the functional components of the PET/CT examination in diagnosing this disease. Also, the correlation between tumor size and (18)F-FDG uptake or Hounsfield unit (HU) value was determined in these 2 groups. METHODS: This was a retrospective study on a consecutive series of 53 patients with 57 pathology-proven lesions (26 BAC, 31 Adeno+BAC) who underwent (18)F-FDG PET/CT scans. The standardized uptake value (SUV) and average HUs reported were obtained for the tumors. The tumor size, (18)F-FDG uptake, and HU values in both groups were compared. The correlation between metabolic (SUV) and CT (HU) characteristics for the lesions and tumor size was assessed using the Pearson correlation coefficient. RESULTS: A total of 26 lesions with pure BAC had a median SUVmax of 1.48 (range, 0.63-4.54). A total of 81% of patients with BAC (21/26 lesions) had SUVmax values of less than 2.5. Thirty-one lesions diagnosed as Adeno+BAC had a median SUVmax of 6.03 (range, 2.45-24) (P < 0.0001 vs. BAC). The mean SUVmax (1.77 +/- 0.99) of BAC was much lower than that of Adeno+BAC (6.55 +/- 4.33) (P < 0.0001). Maximum HU in BAC lesions (-111.96 +/- 123.92) was substantially lower than that in Adeno+BAC (82.03 +/- 33.77) lesions (P < 0.0001). The average maximum tumor dimension in the lung window was much smaller for BACs (17.63 +/- 5.5) than for Adeno+BACs (49.38 +/- 27.5) (P < 0.0001). A strong positive correlation between tumor size and HU was observed in the Adeno+BAC group (P = 0.0002). CONCLUSION: PET/CT can help differentiate between BAC and Adeno+BAC by using tumor size, CT density, and metabolic activity. Pure BAC exhibits smaller size, lower (18)F-FDG uptake, and lower tumor density than does Adeno+BAC. Many BACs have low SUVs (

e16076 Background: R223, an alpha-emitting radioisotope, has emerged as a viable treatment option for patients with CRPC with bone metastases. Despite the benefits on quality of life and improvemen...

In 1964, a report published by McCormack noted that the amount and complexity of nuclear medicine procedures was increasing and he suggested the 3 months of nuclear medicine training that diagnostic radiology residents were receiving at that time was probably not adequate (1). The minimum requirement of time in nuclear medicine training was subsequently increased to 6 months, where it has remained until recently. In March 2004, the American Board of Radiology decreased the nuclear medicine minimum training requirement to 4 months. This was primarily in response to the reduction in hourly training requirements of the Nuclear Regulatory Commission (NRC) for licensure (2,3). The growth of new nuclear medicine modalities such as positron emission tomography (PET)/computed tomography (CT), single-photon-emission computed tomography/CT, and molecular imaging would suggest that more time is needed for nuclear medicine training. Given the recent reduction in time for training, it is important to identify aspects of resident training in nuclear medicine that can be improved on. This study was undertaken under the sponsorship of the Society of Nuclear Medicine (SNM) Committee on Education, the SNM Young Professionals Committee, and the SNM Program Directors Association, which are working to develop new educational tools for resident training in nuclear medicine.

To describe increased 2-deoxy-2-[(18)F] fluoro-D-glucose (FDG) uptake in the scalene muscles in a large population of patients referred for evaluation with FDG positron emission tomography/computed tomography (PET/CT) imaging.The study met criteria for institutional review board exemption. FDG PET/CT images from 410 patients (179 males; mean age 56.8 years, range 6-88) were retrospectively reviewed for the presence or absence of FDG uptake in the neck that corresponded to the scalene muscles on the concurrent CT scan. Medical records were reviewed and data including age, sex, smoking history, reason for referral, and history of obstructive airways disease, thoracotomy, and thoracic radiation were recorded and evaluated.One hundred and forty-seven of the 410 scans (36%) demonstrated increased FDG uptake on PET that corresponded to the scalene muscles on the CT scan. The uptake was most often bilateral, symmetrical, and linear (n = 117). Other patterns of scalene muscle uptake included unilateral and linear uptake (n = 27) and unilateral and focal uptake (n = 3). Scalene muscle uptake was more common in patients referred for evaluation of lung carcinomas compared to other types of tumors (52% vs. 32%, p = 0.05).Linear FDG uptake in scalene muscles is a commonly seen pattern on PET/CT. This finding should be recognized as a distinct entity and not misinterpreted on transverse images as metastatic disease.

The purpose of this study was to evaluate the effects of pegfilgrastim, a long-acting granulocyte colony-stimulating factor, on the normal biodistribution of (18)F-FDG in an animal model and in humans.Two groups of 12 rats received a single subcutaneous injection of either normal saline or pegfilgrastim. One, 7, 14, and 21 d after injection, biodistribution studies were performed 1 h after (18)F-FDG injection. Sixteen breast cancer patients underwent baseline (18)F-FDG PET/CT and, approximately 1 wk after receiving 1 dose of docetaxel and adjunctive pegfilgrastim, follow-up (18)F-FDG PET/CT (scan 2). Standardized uptake values corrected for lean body mass (SUL) were determined for several normal organs before and after therapy.In rats, bone marrow (18)F-FDG uptake (standardized uptake value) was higher in the pegfilgrastim group 1 d after injection (mean +/- SD, 8.3 +/- 4.1 vs. 2.5 +/- 0.2, P0.05), whereas (18)F-FDG uptake in blood was lower (0.41 +/- 0.06 vs. 0.49 +/- 0.01, P0.05). In patients, mean SUL was higher in bone marrow (4.49 +/- 1.50 vs. 1.33 +/- 0.22, P0.0001), spleen (3.29 +/- 0.83 vs. 1.23 +/- 0.23, P0.0001), and liver (1.45 +/- 0.25 vs. 1.31 +/- 0.23, P = 0.01) but lower in brain (4.18 +/- 0.76 vs. 5.14 +/- 1.44, P0.01) on scan 2 than on the baseline scan.In both the animal model and humans, pegfilgrastim markedly increased bone marrow uptake of (18)F-FDG and reduced (18)F-FDG uptake in some normal tissues. These profound alterations in (18)F-FDG biodistribution induced by pegfilgrastim must be considered when one is evaluating quantitative (18)F-FDG PET scans for tumor response to therapy.

The role of 2-[fluorine 18]fluoro-2-deoxy-D-glucose (FDG) positron emission tomography (PET) in combination with computed tomography (CT) in the evaluation of pelvic malignancies has been rapidly growing in recent years. FDG PET has proved to be valuable in the evaluation of a variety of pelvic malignancies, including colorectal cancer, uterine cervical cancer, ovarian cancer, endometrial cancer, and non-Hodgkin lymphoma. However, a number of pitfalls are commonly encountered at FDG PET, including normal physiologic activity in bowel, ovaries, endometrium, and blood vessels and focal retained activity in ureters, bladder diverticula, pelvic kidneys, and urinary diversions. The use of an in-line FDG PET-CT system, with special attention given to proper patient preparation and scanning protocol, often provides valuable information to help localize and define disease and avoid potential diagnostic pitfalls.

The purpose of this study was to determine the frequency of 2-deoxy-2-[18F]fluoro-D-glucose (FDG) uptake in the intercostal respiratory muscles (ICM) of smokers versus nonsmokers using positron emission tomography (PET).Ninety-six whole-body PET/computed tomography (CT) scans were retrospectively reviewed; 61 studies were from smokers and 35 from nonsmokers. The ICM uptake from the lung apices to the level of the carina was visually scored with respect to FDG intensity as follows: 0 = uptake less than or equal to lung uptake; 1 = greater than lung, but less than mediastinal blood pool; 2 = equal to mediastinal blood pool; and 3 = greater than mediastinal blood pool.In smokers, 30 out of 61 (49.2%) PET/CT scans had uptake that localized to ICM, compared to 3/35 (8.6%) studies in nonsmokers. Average ICM uptake was significantly different between smokers and nonsmokers (0.787 +/- 0.933 and 0.143 +/- 0.494, respectively; P0.01).Increased FDG uptake in ICM is a physiologic pattern of uptake that is frequently seen and is more common in smokers.

F-18 FDG PET/CT has become a useful technique in the evaluation of pulmonary lesions. We present a case of markedly increased and diffuse pulmonary F-18 FDG activity in a patient with acute respiratory distress syndrome (ARDS). High rates of glucose utilization by the inflammatory cells involved in the pathogenesis of ARDS might explain the increased pulmonary F-18 FDG uptake we observed. In the proper clinical setting, ARDS should be considered in the differential diagnosis of patients with diffusely increased F-18 FDG activity in the lungs.