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The detection and characterization of coronary artery stenosis and atherosclerosis using imaging tools are key for clinical decision-making in patients with known or suspected coronary artery disease. In this regard, imaging-based quantification can be improved by choosing the most appropriate imaging modality for diagnosis, treatment and procedural planning. In this Consensus Statement, we provide clinical consensus recommendations on the optimal use of different imaging techniques in various patient populations and describe the advances in imaging technology. Clinical consensus recommendations on the appropriateness of each imaging technique for direct coronary artery visualization were derived through a three-step, real-time Delphi process that took place before, during and after the Second International Quantitative Cardiovascular Imaging Meeting in September 2022. According to the Delphi survey answers, CT is the method of choice to rule out obstructive stenosis in patients with an intermediate pre-test probability of coronary artery disease and enables quantitative assessment of coronary plaque with respect to dimensions, composition, location and related risk of future cardiovascular events, whereas MRI facilitates the visualization of coronary plaque and can be used in experienced centres as a radiation-free, second-line option for non-invasive coronary angiography. PET has the greatest potential for quantifying inflammation in coronary plaque but SPECT currently has a limited role in clinical coronary artery stenosis and atherosclerosis imaging. Invasive coronary angiography is the reference standard for stenosis assessment but cannot characterize coronary plaques. Finally, intravascular ultrasonography and optical coherence tomography are the most important invasive imaging modalities for the identification of plaques at high risk of rupture. The recommendations made in this Consensus Statement will help clinicians to choose the most appropriate imaging modality on the basis of the specific clinical scenario, individual patient characteristics and the availability of each imaging modality.

Background. Idiopathic pulmonary fibrosis (IPF) is a progressive disease for which two antifibrotic drugs recently were approved. However, an unmet need exists to predict responses to antifibrotic treatment, such as pirfenidone. Recent data suggest that upregulated expression of CXCR4 is indicative of outcomes in IPF. Research Question. Can quantitative, molecular imaging of pulmonary CXCR4 expression as a biomarker for disease activity predict response to the targeted treatment pirfenidone and prognosis in patients with IPF? Study Design and Methods. CXCR4 expression was analyzed by immunohistochemistry examination of lung tissues and reverse-transcriptase polymerase chain reaction analysis of BAL. PET-CT scanning with the specific CXCR4 ligand 68Ga-pentixafor was performed in 28 IPF patients and compared with baseline clinical characteristics. In 16 patients, a follow-up scan was obtained 6 to 12 weeks after initiation of treatment with pirfenidone. Patients were followed up in our outpatient clinic for > 12 month. Results. Immunohistochemistry analysis showed high CXCR4 staining of epithelial cells and macrophages in areas with vast fibrotic remodeling. Targeted PET scanning revealed CXCR4 upregulation in fibrotic areas of the lungs, particularly in zones with subpleural honeycombing. Baseline CXCR4 signal demonstrated a significant correlation with Gender Age Physiology stage (r = 0.44; P = .02) and with high-resolution CT scan score (r = 0.38; P = .04). Early changes in CXCR4 signal after initiation of pirfenidone treatment correlated with the long-term course of FVC after 12 months (r = −0.75; P = .0008). Moreover, patients with a high pulmonary CXCR4 signal on follow-up PET scan after 6 weeks into treatment demonstrated a statistically significant worse outcome at 12 months (P = .002). In multiple regression analysis, pulmonary CXCR4 signal on follow-up PET scan emerged as the only independent predictor of long-term outcome (P = .0226). Interpretation. CXCR4-targeted PET imaging identified disease activity and predicted outcome of IPF patients treated with pirfenidone. It may serve as a future biomarker for personalized guidance of antifibrotic treatment.

Ziel/Aim: Estimation of tumor load in multiple myeloma (MM) is challenging. The biomarker ß2 microglobulin (ß2M) is widely used to estimate myeloma cell mass and prognosis, but serum levels are influenced by a variety of factors such as varying secretion by myeloma cell clones and renal function. High serum levels of lactic dehydrogenase (LDH) have been shown to identify high-grade lymphoma-like myeloma. PET/CT is a useful tool for assessment of MM, particularly by identifying prognostically relevant, metabolically active disease.Aim of this study was to further characterize the association between whole-body metabolic tumor burden and serum markers in MM. Methodik/Methods: We retrospectively recruited 31 patients (55.7± 9.2 y) who had underwent whole-body FDG PET/CT (48 scans) for assessment of relapse or progressive disease after hematopoietic stem cell transplantation. Patients with at least one FDG-positive lesion were included. Metabolic tumor burden (MTV) was determined using an automatic segmentation algorithm (Rover ABX GmbH), and was tested for correlation with serum ß2M (primary hypothesis) as well as with LDH, albumin, creatinine, calcium and gamma globulin (explorative tests). Ergebnisse/Results: Median metabolic tumor burden was 71.4ml (range: 5-1318ml). ß2M did not demonstrate a significant correlation with metabolic tumor burden (Spearman rho=0.070, p=0.649). PET-defined myeloma burden was significantly correlated with LDH (rho=0.388, p=0.006). There was a tendency towards correlation with albumin (rho=-0.270, p=0.063). None of the other serum markers correlated with MTV. Schlussfolgerungen/Conclusions: PET-defined tumor burden provides incremental information over ß2M. FDG-uptake and ß2M define only partly overlapping measures of myeloma cell mass. PET may preferably identify high-grade lymphoma-like myeloma.

Hintergrund: Mit der Positronenemissionstomographie (PET) steht ein Verfahren in der klinischen Bildgebung zur Verfügung, dass bei Durchführung als Hybridverfahren mit Computertomographie (CT) oder Magnetresonanztomographie (MRT) die simultane Erfassung anatomischer und molekularer Informationen ermöglicht. Die PET besitzt eine hohe Sensitivität zur Detektion von Tumormanifestationen. Unterschiedliche Radiopharmaka dienen der Charakterisierung verschiedener Stoffwechselprozesse oder der Analyse der Expression von Rezeptoren, Enzymen und weiteren molekularen Zielstrukturen. Methode: Selektive Literaturrecherche in PubMed unter Bezug auf nationale und internationale Leitlinien sowie systematische Übersichtsarbeiten und Metaanalysen. Ergebnisse: Etablierte PET Radiopharmaka wie 2-[18F]Fluor-2-desoxyglukose ([18F]FDG) erlauben die Darstellung physiologischer Prozesse auf molekularer Ebene und können entscheidende Informationen für die klinische Versorgung liefern. Für die PET stehen in zunehmendem Umfang neben gut erforschten und evaluierten auch neuere Radiopharmaka zur nicht-invasiven Phänotypisierung von Tumorerkrankungen zur Verfügung, beispielsweise zur Analyse der Expression des prostataspezifischen Membranantigens (PSMA) oder von Chemokinrezeptoren (z.B. CXCR4) auf Tumorzellen. Schlussfolgerung: Die PET stellt einen wichtigen Bestandteil diagnostischer Algorithmen in der Onkologie dar, kann die Präzision der Diagnostik verbessern und helfen, die Therapie zu individualisieren. Eine zunehmende Anzahl an PET Radiopharmaka erweitert die verfügbaren Bildgebungsoptionen. Viele Radiopharmaka erlauben neben der nicht-invasiven Analyse der Expression therapeutisch relevanter Zielstrukturen auch eine nachfolgende zielgerichtete Radionuklidtherapie.