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Introduction: Prostate cancer (PC) is the second most commonly diagnosed cancer in males. 68Ga-PSMA PET/CT, a non-invasive diagnostic tool to evaluate PC with prostate-specific membrane antigen (PSMA) expression, has emerged as a more accurate alternative to assess disease staging. We aimed to identify predictors of positive 68Ga-PSMA PET and the accuracy of this technique. Materials and methods: Diagnostic accuracy cross-sectional study with prospective and retrospective approaches. We performed a comprehensive literature search on PubMed, Cochrane Library, and Embase database in search of studies including PC patients submitted to radical prostatectomy or radiotherapy with curative intent and presented biochemical recurrence following ASTRO 1996 criteria. A total of 35 studies involving 3910 patients submitted to 68-Ga-PSMA PET were included and independently assessed by two authors: 8 studies on diagnosis, four on staging, and 23 studies on restaging purposes. The significance level was α=0.05. Results: pooled sensitivity and specificity were 0.90 (0.86-0.93) and 0.90 (0.82-0.96), respectively, for diagnostic purposes; as for staging, pooled sensitivity and specificity were 0.93 (0.86-0.98) and 0.96 (0.92-0.99), respectively. In the restaging scenario, pooled sensitivity and specificity were 0.76 (0.74-0.78) and 0.45 (0.27-0.58), respectively, considering the identification of prostate cancer in each described situation. We also obtained specificity and sensitivity results for PSA subdivisions. Conclusion: 68Ga-PSMA PET provides higher sensitivity and specificity than traditional imaging for prostate cancer.

Biochemical recurrence (BCR) is a clinical challenge in prostate cancer (PCa) patients as recurrence localization guides subsequent therapies. The use of positron emission tomography (PET) with prostate-specific membrane antigen (PSMA) presents better accuracy than standard imaging practice. This prospective, multicenter, international study evaluates the diagnostic performance and clinical impact of PSMA-PET/CT in evaluating BCR in Pca in a worldwide scenario. Methods: Patients were recruited from 17 centers in 15 countries. Inclusion encompassed histopathology-proven prostatic adenocarcinoma with previous primary treatment and clinically established BCR, with serum PSA < 4 ng/mL or < 10 ng/mL with negative MR and bone scintigraphy. All patients underwent PET/CT scanning with 68Ga-PSMA-11 as radiotracer. Images and data were centrally reviewed. Multivariate logistic regression analysis was applied to identify the independent predictors of positive PSMA results. Variables were selected for this regression model based on significant associations in the univariate analysis and previous clinical knowledge: Gleason Score, PSA at PET, PSA doubling time and primary treatment strategy. All patients were followed for a minimum of 6 months. Results: From a total of 1004 patients, 77.7% were treated initially with radical prostatectomy while 22.3% with radiotherapy. Overall 65.1% presented PSMA-PET/CT positive scans. PSMA-PET/CT positivity was correlated with Gleason score, PSA at PET time, PSA doubling time and radiotherapy as primary treatment (p

Background: Socioeconomic status has been linked to ischemic heart disease (IHD). High-income neighborhoods may expose individuals to a walking-promoting built environment for daily activities (walkability). Data from the association between income and IHD is lacking in middle-income countries (MIC). It is also uncertain whether walkability mediates this association. Objectives: To investigate whether: income is associated with IHD in a MIC; and whether neighborhood walkability mediates the income-IHD association. Methods: This cross-sectional study evaluated 44,589 patients referred for myocardial perfusion imaging (SPECT-MPI). Income and walkability were derived from participants’ residential census tract. Walkability quantitative score combined four variables: street connectivity, residential density, commercial density, and mixed land use. IHD was defined by an abnormal myocardial perfusion during a SPECT-MPI study. We used adjusted mixed effects models to evaluate the association between income level and IHD; and performed a mediation analysis to measure the percentage of the income-IHD association mediated by walkability. Results: From 26,415 participants, those living in the lowest income tertile census tract were more physically inactive (79.1 vs 75.8 vs 72.7%) when compared to higher income census tracts (pConclusions: Income was independently associated with higher prevalence of IHD in a MIC. Although walkability was associated with census tract income, it did not mediate the income-IHD association.

The purpose of this study was to assess the predictive and prognostic value of interim FDG PET (iPET) in evaluating early response to immunochemotherapy after 2 cycles (PET-2) in diffuse large B-cell lymphoma (DLBCL) by applying 2 different methods of interpretation: the Deauville visual 5-point scale (5-PS) and a change in SUV (ΔSUV) by semiquantitative evaluation. Methods: In total, 145 patients with newly diagnosed DLBCL underwent pretreatment PET and PET-2 assessment. PET-2 was classified according to both 5-PS and percentage ΔSUV. Receiver-operating-characteristic analysis was performed to compare the accuracy of the 2 methods for predicting progression-free survival. Survival estimates, based on each method separately and combined, were calculated for iPET-positive (iPET+) and iPET-negative (iPET-) groups and compared. Results: Both with 5-PS and with ΔSUV-based evaluations, significant differences were found between the progression-free survival of iPET- and iPET+ patient groups (P < 0.001). Visually, the best negative predictive value (NPV) and positive predictive value (PPV) occurred when iPET was defined as positive if the Deauville score was 4-5 (89% and 59%, respectively). Using the 66% ΔSUV cutoff reported previously, NPV and PPV were 80% and 76%, respectively. ΔSUV at the 48.9% cutoff, reported for the first time here, produced 100% specificity along with the highest sensitivity (24%). The 5-PS and a semiquantitative ΔSUV of less than 48.9% for each PET-2 gave the same PET-2 classification (positive or negative) in 70% (102/145) of all patients. This combined classification delivered NPV and PPV of 89% and 100%, respectively, and all iPET+ patients failed to achieve or remain in remission. Conclusion: In this large consistently treated and assessed series of DLBCL patients, iPET had good prognostic value interpreted either visually or semiquantitatively. We determined that the most effective ΔSUV cutoff was 48.9% and that when combined with 5-PS assessment, a positive PET-2 result was highly predictive of treatment failure.cases, and MRI in 92.5% of cases; no false negative cases were observed. These results suggest the use of PET/CT as a unique diagnostic imaging tool after CCRT, to correctly assess residual and progression disease.

Simple Summary Visceral involvement in prostate cancer (PCa) represents a negative prognostic factor. Liver metastases typically occur in systemic, late-stage, castration-resistant prostate cancer (CRPC). The diagnostic performance of [68Ga]Ga-PSMA-11-PET for visceral metastases of CRPC patients has never been systematically assessed. Our aim was to evaluate the diagnostic performance of PSMA-PET compared to conventional imaging, i.e., CT or MRI, or liver biopsy in the detection of liver metastases in CRPC patients. The secondary aim was to assess the ability of radiomics to predict the presence of liver metastases. Regarding liver metastases assessment in CRPC patients, [68Ga]-PSMA-11-PET demonstrated moderate sensitivity while high specificity, positive predictive value, and reproducibility compared to conventional imaging and liver biopsy. However, nuclear medicine physicians should carefully assess the liver parenchyma on PET images, especially in patients at higher risk for liver metastases and with high PSA values. Moreover, radiomic features may aid in recognizing higher-risk patients to develop them. Background: To evaluate the diagnostic performance of PSMA-PET compared to conventional imaging/liver biopsy in the detection of liver metastases in CRPC patients. Moreover, we evaluated a PSMA-PET/CT-based radiomic model able to identify liver metastases. Methods: Multicenter retrospective study enrolling patients with the following inclusion criteria: (a) proven CRPC patients, (b) PSMA-PET and conventional imaging/liver biopsy performed in a 6 months timeframe, (c) no therapy changes between PSMA-PET and conventional imaging/liver biopsy. PSMA-PET sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy for liver metastases were calculated. After the extraction of radiomic features, a prediction model for liver metastases identification was developed. Results: Sixty CRPC patients were enrolled. Within 6 months before or after PSMA-PET, conventional imaging and liver biopsy identified 24/60 (40%) patients with liver metastases. PSMA-PET sensitivity, specificity, PPV, NPV, and accuracy for liver metastases were 0.58, 0.92, 0.82, 0.77, and 0.78, respectively. Either number of liver metastases and the maximum lesion diameter were significantly associated with the presence of a positive PSMA-PET (p < 0.05). On multivariate regression analysis, the radiomic feature-based model combining sphericity, and the moment of inverse difference (Idm), had an AUC of 0.807 (95% CI:0.686-0.920). Conclusion: For liver metastases assessment, [68Ga]Ga-PSMA-11-PET demonstrated moderate sensitivity while high specificity, PPV, and inter-reader agreement compared to conventional imaging/liver biopsy in CRPC patients.

During the past 10 years, performing real-time molecular imaging with positron emission tomography (PET) in combination with computed tomography (CT) during interventional procedures has undergone rapid development. Keeping in mind the interest of the nuclear medicine readers, an update is provided of the current workflows using real-time PET/CT in percutaneous biopsies and tumor ablations. The clinical utility of PET/CT guided biopsies in cancer patients with lung, liver, lymphoma, and bone tumors are reviewed. Several technological developments, including the introduction of new PET tracers and robotic arms as well as opportunities provided through acquiring radioactive biopsy specimens are briefly reviewed.

Background: MR is an important imaging modality for evaluating musculoskeletal malignancies owing to its high soft tissue contrast and its ability to acquire multiparametric information. PET provides quantitative molecular and physiologic information and is a critical tool in the diagnosis and staging of several malignancies. PET/MR, which can take advantage of its constituent modalities, is uniquely suited for evaluating skeletal metastases. We reviewed the current evidence of PET/MR in assessing for skeletal metastases and provided recommendations for its use. Methods: We searched for the peer reviewed literature related to the usage of PET/MR in the settings of osseous metastases. In addition, expert opinions, practices, and protocols of major research institutions performing research on PET/MR of skeletal metastases were considered. Results: Peer-reviewed published literature was included. Nuclear medicine and radiology experts, including those from 13 major PET/MR centers, shared the gained expertise on PET/MR use for evaluating skeletal metastases and contributed to a consensus expert opinion statement. [18F]-FDG and non [18F]-FDG PET/MR may provide key advantages over PET/CT in the evaluation for osseous metastases in several primary malignancies. Conclusion: PET/MR should be considered for staging of malignancies where there is a high likelihood of osseous metastatic disease based on the characteristics of the primary malignancy, hight clinical suspicious and in case, where the presence of osseous metastases will have an impact on patient management. Appropriate choice of tumor-specific radiopharmaceuticals, as well as stringent adherence to PET and MR protocols, should be employed. © 2021, The Author(s), under exclusive licence to Springer-Verlag GmbH, DE part of Springer Nature.

Pediatric lymphomas represent a number of different conditions which can be quite heterogeneous. Accurate diagnosis, staging, and response assessment are essential. 18F-FDG PET-CT often provides additional anatomical and functional information. Conventional imaging is often used in follow-up based on clinical suspicion. PET/CT is more accurate than radiological imaging and is useful in the management of childhood lymphomas. PET-CT might be helpful in patients with clinical relapse to assess the extent of disease. The article will illustrate the role of 18F-FDG PET-CT for evaluating treatment response in paediatric patients.

The [68Ga]PSMA PET/CT has been an option on clinical research tools to stage and to restage prostate cancer patients, although, with promising results, this radiopharmaceutical cannot be commercialized yet. Hence, up to date, [68Ga]PSMA has been used in a clinical research context. Once regulatory body approved it for marketing, health systems are responsible for the reimbursement decision. Health Technology Assessments (HTA) tools should be considered to base and to help decision-makers to spread or not this new technology. Regarding [68Ga]PSMA, under HTA framework, the present study searched for secondary studies and hence assessed three systematic reviews with meta-analyses published considering prostate cancer patients in different scenarios, same imaging technology but different comparators and outputs. The secondary studies considered outputs such as accuracy, detectability, positivity and change of management. Using AMSTAR-2, the meta-analysis methods and results were evaluated with 16 questions able to identify critical weaknesses, such as risk of bias, publication bias, true effect, and study heterogeneity. To increase the observational number of patients, to register positive and negative findings, and consolidate regional and multi-center clinical data which were suggestions on study design, structure and statistics made to improve the quality in future primary and secondary studies.

The authors P. Orellana and N. El-Haj were inadvertently deleted in the original paper.

Guidelines recommend true whole-body 18F-FDG PET/CT scans from vertex to toes in pediatric lymphoma patients, although this suggestion has not been validated in large clinical trials. The objective of the study was to evaluate the incidence and clinical impact of lesions outside the "eyes to thighs" regular field of view (R-FOV) in 18F-FDG PET/CT staging (sPET) and interim (iPET) scans in pediatric lymphoma patients. Methods: True whole-body sPET and iPET scans were prospectively obtained in pediatric lymphoma patients (11 worldwide centers). Expert panel central review of sPET and iPET scans were evaluated for lymphoma lesions outside the R-FOV and clinical relevance of these findings. Results: A total of 610 scans were obtained in 305 patients. The sPET scans did not show lesions outside the R-FOV in 91.8% of the patients, whereas in 8.2% patients the sPET scans demonstrated lesions also outside the R-FOV (soft tissue, bone, bone marrow, and skin); however, the presence of these lesions did not change the clinical stage of any patient and did not affect treatment decision. Among the 305 iPET scans, there were no new positive 18F-FDG-avid lesions outside the R-FOV, when compared with their paired sPET scans. A single lesion outside the R-FOV on iPET occurred in 1 patient (0.3%), with the primary lesion diagnosed in the femur on sPET that persisted on iPET. Conclusion: The identification of additional lesions outside the R-FOV (eyes to thighs) using 18F-FDG PET/CT has no impact in the definition of the clinical stage of disease and minimal impact in the treatment definition of patients with pediatric lymphoma. As so, R-FOV for both sPET and iPET scans could be performed.

Treating patients with diffuse large Bcell lymphoma (DLBCL) remains a challenge, with a remission rate of 75% at 2 years from diagnosis. The International Prognostic Index (IPI) [1] and molecularcharacterization [2] are employed in the stratification and relapse prediction. Additionally, 18F-fluorodeoxyglucose positron emission tomography (PET) and computed tomography (CT) have now become part of standard care in differentiating metabolic activity of the disease from fibrosisor necrosis [3]. Early optimism that the speed of response to treatment, as indicated by an interim-PET (iPET) scan after 2?3 cycles of chemotherapy, might reliably predict cure has not been fulfilled [4].To investigate the role of both an interim and an end-treatment-PET (ePET) scan for the management of DLBCL in an international setting, at a time when PET centers were becoming established globally, the International Atomic Energy Agency (IAEA) sponsored a study across 7 countries in Europe, South Asia, Southeast Asia, and South America [5]. This study, the largest study to date, found that 34% of cases were iPET+ after 2 or 3 cycles of standard chemotherapy (R-CHOP), but 54% of the iPET+ cases became ePET?; and that these ?slow responders? had relatively good outcomes at 2 years (event-free survival, EFS: 86%). Notably, the study found that by combining a negative iPET scan with 2 clinical components of the IPI (normal LDH and good performance status), it was possible to identify a population, 35% of all cases, 98% of whom were disease free 2 years after diagnosis. By contrast, iPET+ cases that remained PET+ at the end of treatment had dismal outcomes. These findings raisethe important question of how to separate slow-responding iPET+ cases who are PET? at the end treatment, who are destined for good survival, from those who will fail to achieve a complete or stable remission by continuing standard therapy. Fil: Omidvar, Nader. Cardiff University; Reino Unido Fil: Tekin, Nilgun. Ankara Üniversitesi; Turquía Fil: Conget, Paulette. Universidad del Desarrollo; Chile Fil: Bruna, Flavia Alejandra. Universidad del Desarrollo; Chile. Consejo Nacional de Investigaciones Científicas y Técnicas. Centro Científico Tecnológico Conicet - Mendoza. Instituto de Medicina y Biología Experimental de Cuyo; Argentina Fil: Timar, Botond. Semmelweis Egyetem; Hungría Fil: Gagyi, Eva. Semmelweis Egyetem; Hungría Fil: Basak, Ranjan. Tata Memorial Hospital; India Fil: Auewarakul, Chirayu. Mahidol University; Tailandia Fil: Sritana, Narongrit. Mahidol University; Tailandia Fil: Cerci, Juliano Julio. Department of Nuclear Medicine, Quanta Diagnóstico e Terapia; Brasil Fil: DImamay, Mark Pierre. St Luke's Medical Centre; Filipinas Fil: Gyorke, Tamas. Semmelweis University; Hungría Fil: Redondo, Francisca. Fundación Arturo López Pérez; Chile Fil: Nair, Reena. Tata Memorial Hospital; India Fil: Gorospe, Charity. St Luke's Medical Centre; Filipinas Fil: Paez, DIana. International Atomic Energy Agency; Austria Fil: Fanti, Stefano. Universidad de Bologna; Italia Fil: Ozdag, Hilal. Ankara Üniversitesi; Turquía Fil: Padua, Rose Ann. Université Paris Diderot - Paris 7; Francia Fil: Carr, Robert. Guy’s and St. Thomas’ Hospital; Reino Unido

Objective: To investigate, in a large prospective multicenter study, whether 2-[18F]-fluoro-2-deoxy-d-glucose-positron emission tomography is sufficiently accurate to identify clinically important bone marrow involvement by Hodgkin's lymphoma to replace routine bone marrow biopsy in a developing tropical country. Methods: Patients newly diagnosed with Hodgkin's lymphoma were recruited from six cancer centers in Brazil. All were staged by the results of positron emission tomography/computed tomography that were centrally reviewed and by iliac crest bone marrow biopsy. Patients were classified as having marrow disease if they had lymphoma identified by marrow biopsy histology or had focal 2-[18F]-fluoro-2-deoxy-d-glucose marrow uptake that resolved following chemotherapy. Results: A total of 246 participants were recruited from six different centers and 62 (25.2%) were judged to have Hodgkin's lymphoma in the bone marrow. Positron emission tomography and biopsies were concordant in 206 patients (83%). Positron emission tomography correctly identified marrow disease in 59/62 patients (95.1%) and marrow biopsy in 25/62 patients (40.3%). In 22/62 (35.4%) patients, the two techniques were concordant in the diagnosis of marrow involvement. Of the forty discordant results, positron emission tomography found bone marrow involvement in 37 patients, upstaging 22 to stage IV and having an impact on therapeutic decision in nine cases given their reallocation from early to advanced stage. Three false negative positron emission tomography results were obtained with bone marrow biopsy giving positive findings. All three cases were classified as stage IV regardless of bone marrow findings implying no modification in the clinical management. The sensitivity, specificity and accuracy of positron emission tomography for detecting bone marrow disease were 95%, 100% and 98% and for bone marrow biopsy they were 40%, 100% and 84%, respectively. Conclusion: We conclude that positron emission tomography can replace marrow biopsy in Brazilian patients with Hodgkin's lymphoma without compromising clinical management. Keywords: Hodgkin's lymphoma, FDG-PET, Positron-emission tomography, Bone marrow biopsy, Lymphoma staging

PURPOSE: To compare FDG PET/CT and CT for the guidance of percutaneous biopsies with histological confirmation of lesions. METHODS: We prospectively evaluated 323 patients of whom 181 underwent FDG PET/CT-guided biopsy (total 188 biopsies) and 142 underwent CT-guided biopsy (total 146 biopsies). Biopsies were performed using the same PET/CT scanner with a fluoroscopic imaging system. Technical feasibility, clinical success and complication rates in the two groups were evaluated. RESULTS: Of the 188 biopsies with PET/CT guidance, 182 (96.8%) were successful with conclusive tissue samples obtained and of the 146 biopsies with CT guidance, 137 (93.8%) were successful. Therefore, 6 of 188 biopsies (3.1%) with PET/CT guidance and 9 of 146 (6.1%) with CT guidance were inconclusive (p = 0.19). Due to inconclusive histological results, 4 of the 188 lesions (2.1%) were rebiopsied with PET/CT guidance and 3 of 146 lesions (2.0%) were rebiopsied with CT guidance. Histology demonstrated that 142 of 188 lesions (75.5%) were malignant, and 40 (21.2%) were benign in the PET/CT-guided group, while 89 of 146 lesions (60.9%) were malignant and 48 (32.8%) were benign in the CT-guided group (p = 0.004 and 0.01, respectively). Patients with a histological diagnosis of benign lesion had no recurrence of disease with a minimum of 6 months follow-up. Of the 188 PET/CT-guided biopsies, 6 (3.1%) were repeat biopsies due to a previous nondiagnostic CT-guided biopsy performed in a different diagnostic centre. The interval between the two biopsies was less than a month in all cases. Histology revealed five malignant lesions and one benign lesion among these. The complication rate in the PET/CT-guided biopsy group was 12.7% (24 of 188), while in the CT-guided group, was 9.5% (14 of 146, p = 0.26). Therefore, there was no significant difference in complication rates between PET/CT and CT guidance. CONCLUSION: PET/CT-guided biopsy is already known to be a feasible and accurate method in the diagnostic work-up of suspected malignant lesions. This prospective analysis of a large number of patients demonstrated the feasibility and advantages of using PET/CT as the imaging method of choice for biopsy guidance, especially where FDG-avid foci do not show corresponding lesions on the CT scan. There were no significant differences in the ability to obtain a diagnostic specimen or in the complication rates between PET/CT and CT guidance.

The coronavirus disease 2019 (COVID-19) pandemic has placed significant challenges on health-care systems worldwide, whether in the preparation, response, or recovery phase of the pandemic. This has been primarily managed by dramatically reducing in- and outpatient services for other diseases and implementing infection prevention and control measures. The impact of the pandemic on nuclear medicine departments and their services has not yet been established. The aim of this online survey was to evaluate the impact of COVID-19 on nuclear medicine departments. Methods: A web-based questionnaire, made available from April 16 to May 3, 2020, was designed to determine the impact of the pandemic on in- and outpatient nuclear medicine departments, including the number of procedures, employee health, availability of radiotracers and other essential supplies, and availability of personal protective equipment. The survey also inquired about operational aspects and types of facilities as well as other challenges. Results: A total of 434 responses from 72 countries were registered and analyzed. Respondents reported an average decline of 54% in diagnostic procedures. PET/CT scans decreased by an average of 36%, whereas sentinel lymph-node procedures decreased by 45%, lung scans by 56%, bone scans by 60%, myocardial studies by 66%, and thyroid studies by 67%. Of all participating centers, 81% performed radionuclide therapies, and they reported a reduction of 45% on average in the last 4 wk, ranging from over 76% in Latin America and South East Asia to 16% in South Korea and Singapore. Survey results showed that 52% of participating sites limited their 99mTc/99Mo generator purchases, and 12% of them temporarily cancelled orders. Insufficient supplies of essential materials (radioisotopes, generators, and kits) were reported, especially for 99mTc/99Mo generators and 131I, particularly in Africa, Asia, and Latin America. Conclusion: Both diagnostic and therapeutic nuclear medicine procedures declined precipitously, with countries worldwide being affected by the pandemic to a similar degree. Countries that were in the postpeak phase of the pandemic when they responded to the survey, such as South Korea and Singapore, reported a less pronounced impact on nuclear medicine services; however, the overall results of the survey showed that nuclear medicine services worldwide had been significantly impacted. In relation to staff health, 15% of respondents experienced COVID-19 infections within their own departments.

Introduction: Biochemical recurrence (BCR) is a major clinical challenge in patients with Prostate Cancer (PCa), as rising PSA occurs in about 20-30% of patients treated with radical prostatectomy and up to 60% in patients treated primarily with radiotherapy. Patients may have local recurrence in the pelvis or in distant sites. The location and burden of recurrent disease is mandatory in guiding subsequent therapies. Standard practice for BCR in PCa includes computed tomography and bone scintigraphy, both known for limited diagnostic performance. The use of positron emission tomography (PET) with prostate-specific membrane antigen (PSMA) was introduced in clinical practice in the past few years due to its better accuracy. The present phase 3, prospective, multicentric, international study was planned to evaluate the diagnostic performance and clinical impact of [68Ga]Ga-PSMA-11 PET/CT in evaluating patients with biochemical recurrent PCa; the study was promoted and supported by the IAEA. Methods: Patients with PCa who have undergone primary definitive treatment and presented with rising PSA levels were recruited to the study. Overall 17 centers from 15 countries (Azerbaijan, Brazil, Colombia, India, Israel, Italy, Jordan, Lebanon, Malaysia, Mexico, Pakistan, Poland, South Africa, Turkey, and Uruguay) were involved. Images and data were centrally reviewed; data were collected and assessed for site of findings ([68Ga]Ga-PSMA-11 pathologic uptake), positivity rate (percentage of patients with a positive [68Ga]Ga-PSMA-11 PET/CT) and impact on patient management. Regarding PET findings, a composite reference standard was used, including pathology, correlative imaging, PSA response; regarding management, the reference included changes in the treating physician’s documented clinical plans before and after PET; all patients have at least 6 months clinical follow-up. Results: 1198 patients were prospectively enrolled between November 2017 and December 2019; 1004 patients had complete data for final evaluation. [68Ga]Ga-PSMA-11 PET/CT was positive in 654/1004 patients (65.1%); lesions were identified as: prostate/prostatic bed only in 13.7% of the cases; pelvic lymph nodes only in 20.5%, and with any metastatic disease in 27.0%. There was a correlation between [68Ga]Ga-PSMA-11 PET/CT positivity and Gleason score (p

Patient exposure to radiation during the management of coronary heart disease (CHD) can be reduced with more efficient technologies in nuclear medicine, such as the Cadmium-Zinc-Telluride (CZT) gamma-camera for myocardial perfusion imaging (MPI) studies. However, it has been suggested that CZT has lower specificity, which might lead to more downstream radiological procedures, particularly among obese individuals. We evaluated 244 patients with suspected CHD who underwent CZT-SPECT and matched 1:1 according to sex, age, and body mass index (BMI) with those undergoing MPI study with the Anger gamma-camera (Anger-SPECT). The outcome was the total radiation exposure from the MPI study added to the radiation exposure from all subsequent cardiac examinations during a 90-day follow-up. The total radiation dose after 90 days was significantly lower in the CZT-SPECT group (6.4 ± 4.8 vs 9.5±4.9 mSv, P < .001). After adjusting for potential confounders, CZT-SPECT remained associated with lower total radiation dose, but it significantly attenuated among obese individuals (Beta coefficient − 3.73 ± 0.86 for BMI < 30 vs − 2.30 ± 0.92 for BMI ≥ 30 Kg/m2, P for interaction < 0.032). CZT-SPECT was associated with lower total radiation doses compared to Anger-SPECT, albeit this benefit may be attenuated in obese individuals.

Background The greater burden of coronary heart disease (CHD) comes from low-middle income countries (LMIC). Socioeconomic status, environmental factors, poor access to healthcare, physical inactivity and excess consumption of carbohydrates, have explained part of this burden. However, the association between income level and CHD in LMIC with marked social inequalities is not fully understood, and whether there is influence of neighborhood walkability (walking-promoting potential of the residential built environment for daily activities) in this association requires further investigation. Purpose To investigate to what level income is associated with ischemic CHD in a LMIC with great social inequalities and to explore the potential role of neighborhood walkability in this association. Methods We evaluated patients referred for myocardial perfusion imaging with SPECT (SPECT-MPI) from February 2010 to August 2017 at a reference imaging center in our city, Brazil. Each patient was georeferenced and the exposure variable was the average income in Brazilian currency (Real) per month, from the patient's residential census block. Ischemic CHD was defined by an abnormal myocardial perfusion (summed stress score >3) during a SPECT-MPI study. Walkability was measured by a score combining street connectivity, residential density, commercial density and mixed land use. We used mixed effects models to evaluate the association between income level and ischemic CHD, adjusted for potential confounders, and performed a mediation analysis to measure the percentage of this association mediated by walkability. Results From 26,810 participants, those living in the lowest tertile income neighborhoods were younger (61±12 vs 63±13 vs 65±12 yrs old); with higher body mass index (28.4±5 vs 27.7±5 vs 27.4±4 kg/m2); more likely to be women (52 vs 49 vs 47%), current smokers (10 vs 9 vs 8%), sedentary (79 vs 76 vs 73%), having diabetes (27 vs 24 vs 23%), hypertension (65 vs 62 vs 60%) and with known CHD (21 vs 20 vs 19%) when compared to the second and the highest tertiles respectively, all with p Figure 1. Association of income and CHD Conclusions In this large registry from a LMIC population, living in a lower-income neighborhood was associated with higher prevalence of ischemic CHD. Even though neighborhood walkability was directly associated with neighborhood income, it did not explain the association between income level and ischemic CHD.

Quantification of metabolic tumor volume (MTV) and total lesion glycolysis (TLG) can be time-consuming. We evaluated the performance of an automatic multifocal segmentation (MFS) method of quantification in patients with different stages of Hodgkin lymphoma, using the multiple VOI (MV) method as reference. Methods: This prospective bicentric study included 50 patients with Hodgkin lymphoma who underwent staging 18F-FGD PET/CT. The examinations were centrally reviewed and processed with commercial MFS software to obtain MTV and TLG using 2 fixed relative thresholds (40% and 20% of SUVmax) for each lesion. All PET/CT scans were processed using the MV and MFS methods. Interclass correlation coefficients and Bland-Altman plots were used for statistical analysis. Repeated calculations of MTV and TLG values by 2 observers with different degrees of PET/CT imaging experience were used to ascertain interobserver agreement on the MFS method. Results: The means and SDs obtained for the MTV with MV and MFS were, respectively, 736 ± 856 mL and 660 ± 699 mL for the 20% threshold and 313 ± 359 mL and 372 ± 434 mL for the 40% threshold. The time spent calculating the MTV was much shorter with the MFS method than with the MV method (median time, 11.6 min [range, 1-30 min] and 64.4 min [range, 1-240 min], respectively), especially in patients with advanced disease. Time spent was similar in patients with localized disease. There were no statistical differences between the MFS values obtained by the 2 different observers. Conclusion: MTV and TLG calculations using MFS are reproducible, generate similar results to those obtained with MV, and are much less timing-consuming. Main differences between the 2 methods were related to difficulties in avoiding overlay of VOIs in the MV technique. MV and MFS perform equally well in patients with a small number of lesions.

5078 Background: Biochemical recurrence (BCR) is a clinical challenge in prostate cancer (PCa) patients with impact on defintion of subsequent therapies. The use of positron emission tomography (PET) with prostate-specific membrane antigen (PSMA) presents better accuracy than standard imaging practice. This phase3, prospective, multicentric, international study evaluates the diagnostic performance and clinical impact of PSMA-PET/CT in evaluating BCR in PCa. Methods: Patients with PCa who have undergone primary definitive treatment and with rising PSA were recruited in the study. Overall 17 centers from 15 countries (Azerbaijan, Brazil, Colombia, India, Israel, Italy, Jordan, Lebanon, Malaysia, Mexico, Pakistan, Poland, South Africa, Turkey, and Uruguay) were involved. Images and data were centrally reviewed; data were collected for PSMA site of findings, positivity rate, defined as the percentage of patients with a positive 68Ga-PSMA PET/CT taking into account the composite standard: pathology, correlative imaging, PSA response, with at least 6 mo. clinical follow-up, and impact on patient management by determining changes in the treating physician’s documented clinical plans before and after 68Ga-PSMA PET/CT. Results: Were enrolled 1198 patients and presented final data from 1004 patients. 68Ga-PSMA PET/CT was positive in 654/1004 patients (65.1%); lesions were identified as: prostate/prostatic bed only in 13.7% cases; pelvic lymph nodes only 20.5%, and with any metastatic disease in 27.0%. There was a correlation between PSMA-PET/CT positivity and Gleason score (p

Bone marrow biopsy is recommended for staging of classical Hodgkin lymphoma. The aim of this study was to compare bone marrow evaluation by histology with that obtained by (18)F-fluorodeoxyglucose-positron emission tomography (FDG-PET). One hundred and three cases of Classical Hodgkin Lymphoma were reviewed. All patients were submitted to FDG-PET evaluation. Bone marrow biopsy results were compared with clinical data and FDG-PET results. Ninety-one cases had available bone marrow biopsies. Overall, there were 16 positive and one suspect case. In five cases, the FDG-PET scan was positive and biopsy was negative: 1/5 was found to correspond to a bone fracture, 3/5 showed marked reactive bone marrow changes and in 1/5 no explanation for the discrepancy was found. FDG-PET showed high sensitivity, supporting the idea that when it is negative, biopsy could be avoided. Care should be taken in patients with a positive FDG-PET, where confirmation by bone marrow biopsy should be recommended.

Background: PET/CT is well established as method for prognostic stratification in adult Hodgkin (HL) and Non-Hodgkin lymphoma (NHL). In pediatric lymphoma, there is no uniform system of prognostic stratification. This study evaluates the prognosis of interim FDG-PET/CT in HL and NHL pediatric patients in a large multicenter population from low-middle, upper-middle and high income countries. Methods: Eleven worldwide centers prospectively performed FDG-PET/CT studies on pediatric patients for staging and interim response evaluation. Clinical and PET/CT findings, events, and mortality data were collected. Expert panel performed central review of baseline and interim FDG-PET/CT examinations visually with Lugano classification (LC) and semi-quantitatively (including SUVmax and Delta SUVmax). LC scores of 1, 2, 3 and X were considered negative (LC-); LC scores 4 and 5 were considered positive (LC ). Prognostic analysis compared the 2-y event-free survival (EFS) rate to the PET2 results, and clinical data. Findings: Whole-body FDG-PET/CT acquisitions were performed in 250 patients (183 males; mean age = 10 ± 4 years; 70% with Hodgkin lymphoma) with clinical stage I-IV represented. There were 9 deaths and 46 events during follow-up and 194 (78%) patients with LC- interim studies. LC studies were significantly and independently associated with increased overall mortality (HR=8.96; p 0.002) and more events (HR 5.80; p

Introduction Prostate cancer still represents a major cause of morbidity, and still about 20% of men with the disease are diagnosed or will progress to the advanced stage without the possibility of curative treatment. Despite the recent advances in scientific and technological knowledge and the availability of new therapies, there is still considerable heterogeneity in the therapeutic approaches for metastatic prostate cancer. Objectives This article presents a summary of the I Brazilian Consensus on Advanced Prostate Cancer, conducted by the Brazilian Society of Urology and Brazilian Society of Clinical Oncology. Materials and Methods Experts were selected by the medical societies involved. Forty issues regarding controversial issues in advanced disease were previously elaborated. The panel met for consensus, with a threshold established for 2/3 of the participants. Results and Conclusions The treatment of advanced prostate cancer is complex, due to the existence of a large number of therapies, with different response profiles and toxicities. The panel addressed recommendations on preferred choice of therapies, indicators that would justify their change, and indicated some strategies for better sequencing of treatment in order to maximize the potential for disease control with the available therapeutic arsenal. The lack of consensus on some topics clearly indicates the absence of strong evidence for some decisions.

Background: The investigation of stable coronary artery disease (CAD) and its treatment depend on risk stratification for decision-making on the need for cardiac catheterization and revascularization. Objective: To analyze the procedures used in the diagnosis and invasive treatment of patients with CAD, at the Brazilian Unified Health System (SUS) in the cities of Curitiba, São Paulo and at InCor-FMUSP. Methods: Retrospective, descriptive, observational study of the diagnostic and therapeutic itineraries of the Brazilian public health care system patient, between groups submitted or not to prior noninvasive tests to invasive cardiac catheterization. Stress testing, stress echocardiography, perfusion scintigraphy, catheterization and percutaneous or surgical revascularization treatment procedures were quantified and the economic impact of the used strategies. Results: There are significant differences in the assessment of patients with suspected or known CAD in the metropolitan region in the three scenarios. Although functional testing procedures are most often used the direct costs of these procedures differ significantly (6.1% in Curitiba, 20% in São Paulo and 27% in InCor-FMUSP). Costs related to the procedures and invasive treatments represent 59.7% of the direct costs of SUS in São Paulo and 87.2% in Curitiba. In InCor-FMUSP, only 24.3% of patients with stable CAD submitted to CABG underwent a noninvasive test before the procedure. Conclusion: Although noninvasive functional tests are the ones most often requested for the assessment of patients with suspected or known CAD most of the costs are related to invasive procedures/treatments. In most revascularized patients, the documentation of ischemic burden was not performed by SUS. Fundamento: A investigação da doença arterial coronariana (DAC) estável e seu tratamento dependem da estratificação de risco para a decisão sobre a necessidade de cateterismo cardíaco e revascularização. Objetivo: Analisar os procedimentos utilizados no diagnóstico e tratamento invasivo dos pacientes com DAC do Sistema Único de Saúde (SUS) nos municípios de Curitiba, São Paulo e no IIncor- FMUSP. Métodos: Estudo retrospectivo, descritivo, observacional dos itinerários diagnósticos e terapêuticos dos pacientes do SUS, entre os grupos submetidos ou não a testes não invasivos prévios ao cateterismo cardíaco invasivo. Foram quantificados os procedimentos de teste ergométrico, ecocardiograma de estresse, cintilografia de perfusão, cateterismo e tratamento com revascularização percutânea ou cirúrgica e o impacto econômico destas estratégias utilizadas. Resultados: Existem diferenças importantes na avaliação do paciente com DAC suspeita ou conhecida nos três cenários. Apesar dos testes funcionais serem os procedimentos mais frequentemente utilizados, os custos diretos referentes a esses procedimentos diferem significativamente (6,1% em Curitiba, 20% em São Paulo e 27% no Incor-FMUSP). Os custos relacionados aos procedimentos e tratamentos invasivos representam 59,7% dos custos diretos do SUS em São Paulo e 87,2% em Curitiba. No Incor-FMUSP, apenas 24,3% dos pacientes com DAC estável submetidos à revascularização foram submetidos a um teste não invasivo antes do procedimento. Conclusão: Apesar dos testes funcionais não invasivos serem os exames mais frequentemente solicitados na avaliação de pacientes com DAC suspeita ou conhecida, a maior parte dos custos está relacionada a procedimento/tratamento invasivo. Na maioria dos pacientes revascularizados, não foi realizada a documentação da carga de isquemia dentro do SUS.

Positron emission tomography/computed tomography (PET/CT) has had a great impact in oncology; in this field, PET/CT-guided biopsy finds application in the evaluation of liver lesions, among others. The indication for this procedure should be individualized and taken into account the level of suspicion of malignancy and the need for diagnostic confirmation. PET/CT-guided biopsy is feasible and may optimize the diagnostic yield of image-guided interventions.

Nowadays several new imaging modalities are available for investigating prostate cancer (PCa) such as magnet resonance imaging (MRI) in the form of whole body MRI and pelvic multiparametric MRI and positron emission tomography (PET) using choline as radiotracers. Nevertheless, these modalities proved sub-optimal accuracy for detecting PCa metastases, particularly in the recurrence setting. A new molecular probe targeting the prostate specific membrane antigen (PSMA) has been recently developed for PET imaging. PSMA, the glutamate carboxypeptidase II, is a membrane bound metallo-peptidase over-expressed in PCa cells. It has been shown that PSMA based imaging offers higher tumor detection rate compared to choline PET/CT and radiological conventional imaging, especially at very low PSA levels during biochemical recurrence. In addition PSMA, as theranostics agent, allows both radiolabeling with diagnostic (e.g. 68Ga, 18F) or therapeutic nuclides (e.g. 177Lu, 225Ac). Initial results show that PSMA-targeted radioligand therapy can potentially delay disease progression in metastatic castrate-resistant PCa. Despite still investigational, the bombesin-based radiotracers and antagonist of gastrin releasing-peptide receptor (GRP) (RM2) and anti1-amino-3-18Ffluorocyclobutane-1-carboxylic acid (18F-FACBC) are emerging as possible alternatives for investigating PCa. Considering the wide diffusion of PCa in the Europe and the United States, the presence of these new diagnostic techniques able to detect the disease with high sensitivity and specificity might have a clinical impact on the management of patients. PET/CT imaging with new radiopharmaceuticals can implement the patient management identifying lesion(s) not detectable with conventional imaging procedures. In this review article will be discussed the most promising new PET radiopharmaceuticals (68Ga-PSMA-11, 18F-FACBC, 68Ga-RM2) available at the moment, focusing the attention on their accuracy and their impact on treatment strategy.

As a part of an international study on the molecular analysis of Diffuse Large B-cell Lymphoma (DLBCL), a robust protocol for gene expression analysis from RNA extraction to qRT-PCR using Formalin Fixed Paraffin Embedded tissues was developed. Here a study was conducted to define a strategy to validate the previously reported 6-gene (LMO2, BCL6, FN1, CCND2, SCYA3 and BCL2) model as predictor of prognosis in DLBCL. To avoid variation, all samples were tested in a single centre and single platform. This study comprised 8 countries (Brazil, Chile, Hungary, India, Philippines, S. Korea, Thailand and Turkey). Using the Kaplan-Meier and log rank test on patients (n=162) and two mortality risk groups (with those above and below the mean representing high and low risk groups) confirmed that the 6-gene predictor score correlates significantly with overall survival (OS, p < 0.01) but not with event free survival (EFS, p=0.18). Adding the International Prognostic Index (IPI) shows that the 6-gene predictor score correlates significantly with high IPI scores for OS (p < 0.05), whereas those with low IPI scores show a trend not reaching significance (p=0.08). This study defined an effective and economical qRT-PCR strategy and validated the 6-gene score as a predictor of OS in an international setting. Fil: Tekin, Nilgun. Ankara University. Biotechology Institute; Turquía Fil: Omidvar, Nader. Cardiff University; Reino Unido Fil: Morris, Tim Peter. Clinical Trials Unit at University College. Medical Research Council; Reino Unido Fil: Conget, Paulette. Universidad del Desarrollo; Chile Fil: Bruna, Flavia Alejandra. Universidad del Desarrollo; Chile. Consejo Nacional de Investigaciones Científicas y Técnicas. Centro Científico Tecnológico Conicet - Mendoza. Instituto de Medicina y Biología Experimental de Cuyo; Argentina Fil: Timar, Botond. Semmelweis University. Department of Pathology and Experimental Cancer Research; Hungría Fil: Gagyi, Eva. Semmelweis University. Department of Pathology and Experimental Cancer Research; Hungría Fil: Basak, Ranjan. Tata Memorial Hospital. Departments of Medical Oncology & Pathology; India Fil: Naik, Omkar. Tata Memorial Hospital. Departments of Medical Oncology & Pathology; India Fil: Auewarakul, Chirayu. Faculty of Medicine Sirira; Tailandia. Chulabhorn Cancer Centre; Tailandia Fil: Sritana, Narongrit. Faculty of Medicine Sirira; Tailandia. Chulabhorn Cancer Centre; Tailandia Fil: Levy, Debora. Chulabhorn Cancer Centre; Tailandia. Faculty of Medicine Sirira; Tailandia Fil: Cerci, Juliano Julio. Department of Nuclear Medicine. Quanta - Diagnóstico e Terapia; Brasil Fil: Bydlowski, Sergio Paulo. Universidade de Sao Paulo; Brasil Fil: Pereira, Juliana. Universidade de Sao Paulo; Brasil Fil: Dimamay, Mark Pierre. St. Lukes Medical. Research and Biotechnology Division; Filipinas Fil: Natividad, Filipinas. St. Lukes Medical. Research and Biotechnology Division; Filipinas Fil: Chung, June-Key. Seoul National University Hospital. Department of Nuclear Medicine; Corea del Sur Fil: Belder, Nevin. Ankara University. Biotechology Institute; Turquía Fil: Kuzu, Isinsu. Ankara University. Faculty of Medicina; Turquía Fil: Paez, Diana. International Atomic Energy Agency; Austria Fil: Dondi, Maurizio. International Atomic Energy Agency; Austria Fil: Carr, Robert. King’s College. Guy’s & St Thomas’ Hospital; Reino Unido Fil: Ozdag, Hilal. Ankara University. Faculty of Medicina; Turquía Fil: Padua, Rose Ann. Institut National de la Sante Et de la Recherche Médica; Francia. Université Paris-Diderot; Francia. Institut Universitaire d'Hématologie; Francia

Positron emission tomography (PET) is a sectional molecular imaging procedure that allows evaluation of the metabolism at a molecular and cellular level. For a PET scan, the patient is injected with a radiotracer, such as (18)F-fluorodeoxyglucose (FDG). FDG PET-computed tomography has become an established modality for metabolic staging and plays an important role in the major steps of evaluation and treatment of most lymphoma subtypes, with significant impact in the initial staging, posttherapy evaluation, and suspect of relapse of disease. However, whenever the information of PET results is translated to changing treatment, especially in cases of further treatment, biopsy confirmation should always be made when possible.

ObjectivesWe sought to assess the prognostic value and risk classification improvement using contemporary single-photon emission computed tomography myocardial perfusion imaging (SPECT-MPI) to predict all-cause mortality.BackgroundMyocardial perfusion is a strong estimator of prognosis. Evidence published to date has not established the added prognostic value of SPECT-MPI nor defined an approach to detect improve classification of risk in women from a developing nation.MethodsA total of 2,225 women referred for SPECT-MPI were followed by a mean period of 3.7 ± 1.4 years. SPECT-MPI results were classified as abnormal on the presence of any perfusion defect. Abnormal scans were further classified as with mild/moderate reversible, severe reversible, partial reversible, or fixed perfusion defects. Risk estimates for incident mortality were categorized as 2%/year using Cox proportional hazard models. Risk-adjusted models incorporated clinical risk factors, left ventricular ejection fraction (LVEF), and perfusion variables.ResultsAll-cause death occurred in 139 patients. SPECT-MPI significantly risk stratified the population; patients with abnormal scans had significantly higher death rates compared with patients with normal scans, 13.1% versus 4.0%, respectively (p < 0.001). Cox analysis demonstrated that after adjusting for clinical risk factors and LVEF, SPECT-MPI improved the model discrimination (integrated discrimination index = 0.009; p = 0.02), added significant incremental prognostic information (global chi-square increased from 87.7 to 127.1; p < 0.0001), and improved risk prediction (net reclassification improvement = 0.12; p = 0.005).ConclusionsSPECT-MPI added significant incremental prognostic information to clinical and left ventricular functional variables while enhancing the ability to classify this Brazilian female population into low- and high-risk categories of all-cause mortality.

Our objective was to assess the prognostic value of (18)F-FDG PET after 2 cycles of chemotherapy using doxorubicin, bleomycin, vinblastine, and dacarbazine (ABVD) in Hodgkin lymphoma (HL) patients overall and in subgroups of patients with early and advanced stages and with low and high risks according to the International Prognostic Score (IPS).One hundred fifteen patients with newly diagnosed HL were prospectively included in the study. All underwent standard ABVD therapy followed by consolidation radiotherapy in cases of bulky disease. After 2 cycles of ABVD, the patients were evaluated with PET (PET2). Prognostic analysis compared the 3-y event-free survival (EFS) rate to the PET2 results, clinical data, and IPS.Of the 104 evaluated patients, 93 achieved complete remission after first-line therapy. During a median follow-up of 36 mo, relapse or disease progression was seen in 22 patients. Treatment failure was seen in 16 of the 30 PET2-positive patients and in only 6 of the 74 PET2-negative patients. PET2 was the only significant prognostic factor. The 3-y EFS was 53.4% for PET2-positive patients and 90.5% for PET2-negative ones (P0.001). When patients were categorized according to low or high IPS risk and according to early or advanced stage of disease, PET2 was also significantly associated with treatment outcome.PET2 is an accurate and independent predictor of EFS in HL. A negative interim (18)F-FDG PET result is highly predictive of treatment success in overall HL patients, as well as in subgroups with early or advanced-stage disease and with low or high IPS risk.

Apresentamos uma lista de recomendações sobre a utilização de 18F-FDG PET em oncologia, no diagnóstico, estadiamento e detecção de recorrência ou progressão do câncer. Foi realizada pesquisa para identificar estudos controlados e revisões sistemáticas de literatura composta por estudos retrospectivos e prospectivos. As consequências e o impacto da 18F-FDG PET no manejo de pacientes oncológicos também foram avaliados. A 18F-FDG PET deve ser utilizada como ferramenta adicional aos métodos de imagem convencionais como tomografia computadorizada e ressonância magnética. Resultados positivos que sugiram alteração no manejo clínico devem ser confirmados por exame histopatológico. A 18F-FDG PET deve ser utilizada no manejo clínico apropriado para o diagnóstico de cânceres do sistema respiratório, cabeça e pescoço, sistema digestivo, mama, melanoma, órgão genitais, tireoide, sistema nervoso central, linfoma e tumor primário oculto. The authors present a list of recommendations on the utilization of 18F-FDG PET/CT in oncology for the diagnosis, staging and detection of cancer, as well as in the follow-up of the disease progression and possible recurrence. The recommendations were based on the analysis of controlled studies and a systematic review of the literature including both retrospective and prospective studies regarding the clinical usefulness and the impact of 18F-FDG PET/CT on the management of cancer patients. 18F-FDG PET/CT should be utilized as a supplement to other conventional imaging methods such as computed tomography and magnetic resonance imaging. Positive results suggesting changes in the clinical management should be confirmed by histopathological studies. 18F-FDG PET should be utilized in the diagnosis and appropriate clinical management of cancer involving the respiratory system, head and neck, digestive system, breast, genital organs, thyroid, central nervous system, besides melanomas, lymphomas and occult primary tumors.

Apresentamos uma lista de recomendações sobre a utilização de 18F-FDG PET em oncologia, no diagnóstico, estadiamento e detecção de recorrência ou progressão do câncer. Foi realizada pesquisa para identificar estudos controlados e revisões sistemáticas de literatura composta por estudos retrospectivos e prospectivos. As consequências e o impacto da 18F-FDG PET no manejo de pacientes oncológicos também foram avaliados. A 18F-FDG PET deve ser utilizada como ferramenta adicional aos métodos de imagem convencionais como tomografia computadorizada e ressonância magnética. Resultados positivos que sugiram alteração no manejo clínico devem ser confirmados por exame histopatológico. A 18F-FDG PET deve ser utilizada no manejo clínico apropriado para o diagnóstico de cânceres do sistema respiratório, cabeça e pescoço, sistema digestivo, mama, melanoma, órgão genitais, tireoide, sistema nervoso central, linfoma e tumor primário oculto.The authors present a list of recommendations on the utilization of 18F-FDG PET/CT in oncology for the diagnosis, staging and detection of cancer, as well as in the follow-up of the disease progression and possible recurrence. The recommendations were based on the analysis of controlled studies and a systematic review of the literature including both retrospective and prospective studies regarding the clinical usefulness and the impact of 18F-FDG PET/CT on the management of cancer patients. 18F-FDG PET/CT should be utilized as a supplement to other conventional imaging methods such as computed tomography and magnetic resonance imaging. Positive results suggesting changes in the clinical management should be confirmed by histopathological studies. 18F-FDG PET should be utilized in the diagnosis and appropriate clinical management of cancer involving the respiratory system, head and neck, digestive system, breast, genital organs, thyroid, central nervous system, besides melanomas, lymphomas and occult primary tumors.

Purpose To assess the cost effectiveness of fluorine-18–fluorodeoxyglucose positron emission tomography (FDG-PET) in patients with Hodgkin's lymphoma (HL) with unconfirmed complete remission (CRu) or partial remission (PR) after first-line treatment. Patients and Methods One hundred thirty patients with HL were prospectively studied. After treatment, all patients with CRu/PR were evaluated with FDG-PET. In addition, PET-negative patients were evaluated with standard follow-up, and PET-positive patients were evaluated with biopsies of the positive lesions. Local unit costs of procedures and tests were evaluated. Cost effectiveness was determined by evaluating projected annual economic impact of strategies without and with FDG-PET on HL management. Results After treatment, CRu/PR was observed in 50 (40.0%) of the 127 patients; the sensitivity, specificity, and positive and negative predictive values of FDG-PET were 100%, 92.0%, 92.3%, and 100%, respectively (accuracy of 95.9%). Local restaging costs without PET were $350,050 compared with $283,262 with PET, a 19% decrease. The incremental cost-effectiveness ratio is −$3,268 to detect one true case. PET costs represented 1% of total costs of HL treatment. Simulated costs in the 974 patients registered in the 2008 Brazilian public health care database showed that the strategy including restaging PET would have a total program cost of $56,498,314, which is $516,942 less than without restaging PET, resulting in a 1% cost saving. Conclusion FDG-PET demonstrated 95.9% accuracy in restaging for patients with HL with CRu/PR after first-line therapy. Given the observed probabilities, FDG-PET is highly cost effective and would reduce costs for the public health care program in Brazil.

With the consolidation of PET/CT-guided biopsy as an efficient diagnostic tool, this chapter describes possible indications for PET/CT-guided biopsy, detailed technical procedures, types of biopsy, techniques, and most common types of access to perform the biopsy.

When a suspicious lesion is found during a physical or imaging exam, histological characterization is frequently required. Early and accurate histologic diagnosis of a neoplastic condition requires tissue sampling and leads to the appropriate treatment.

Pancreatic cancer represents the fourth most common cause of cancer mortality among men and women worldwide, probably related to its usual delayed diagnosis and aggressive characteristics [1]. The interest in proper evaluation of pancreatic lesions and unveiling their histological aspects has been growing strong over the last years.

Biopsy procedures have been performed for more than a century, and percutaneous biopsy methodology was established in the 1940s. The technical advances in diagnostic imaging and biopsy procedures have evolved rapidly. As a consequence, the general safety and complication rate of the procedure have substantially improved. Even if complication rates are low, it is important to be able to identify and appropriately manage the complications. This chapter describes the most common acute complications related to biopsy procedures.

The objective of the study was to determine the diagnostic accuracy of (18)F-fluorodeoxyglucose ((18)F-FDG) positron emission tomography (PET) in the preoperative diagnosis of thyroid nodules with indeterminate fine-needle aspiration biopsy results.Forty-two consecutive patients with thyroid nodules with indeterminate cytological results participated in this study. Abnormal (18)F-FDG PET uptake was assessed visually and by measuring the maximum standardized uptake value (SUVmax) in thyroid topography. All these results were compared with the final pathological results.The presence of focal uptake correlated with a greater risk of malignancy (P = 0.018). All 11 malignant nodules had focal uptake (sensitivity of 100%). Of the 31 patients with benign nodules, there were 19 with positive uptake (specificity of 38.7%). The pre-PET probability of cancer was 26.2% (11 of 42), and this probability increased to 36.7% after PET for those patients whose exam showed focal uptake (11 of 30). The preoperative use of (18)F-FDG PET would result in a significant reduction (39%, 12 of 31) in the number of thyroidectomies performed in patients with benign lesions. SUVmax could not improve this degree of accuracy. There was no correlation between thyroid nodule size and SUVmax value (P = 0.96). Patients with carcinomas were younger than patients with benign lesions (P = 0.048). There was no other clinical, laboratory, or ultrasonographic variable related to malignancy.(18)F-FDG PET provides high sensitivity to malignant lesions and may be a potentially useful tool in the evaluation of thyroid nodules with indeterminate cytological findings. For these nodules the number of unnecessary thyroidectomies in a hypothetical algorithm using (18)F-FDG PET would be reduced by 39%.

PET/computed tomography (CT) combines the anatomic information from CT with PET metabolic characterization. 18F-fluorodeoxyglucose (FDG) PET is helpful to differentiate malignant lesions from benign ones, that usually show lower or no uptake. However, active inflammation or infectious disease might also present FDG uptake. Studies confirm the great value of PET/CT as the imaging method of choice for guiding biopsy procedures. Novel PET radiopharmaceuticals are also being investigated for guiding biopsies.

Pacientes com linfoma de Hodgkin (LH) tratados com poliquimioterpia com adriamicina, bleomicina, vincristina e doxorrubicina (ABVD) apresentam resposta terapêutica distinta. Para aprimorar a avaliação prognóstica e a abordagem terapêutica em LH objetivamos avaliar o valor prognóstico da PET-FDG após 2 ciclos de ABVD (PET2) em pacientes com LH. Foram incluídos nesse estudo prospectivo 115 pacientes com diagnóstico recente de LH no período de agosto de 2005 a dezembro de 2007. Os pacientes foram estadiados com exame clínico, laboratorial, tomografia computadorizada e PET-FDG (PET0). Todos os pacientes foram tratados com ABVD e aqueles com massa tumoral extensa foram tratados com radioterapia associada. Após dois ciclos de ABVD os pacientes foram submetidos a PET2. Nenhum tratamento foi alterado baseado na PET2. Foi avaliado o valor prognóstico dos fatores clínicos, Índice Prognóstico Internacional (IPI) e PET2 em relação à sobrevida livre de eventos (SLE) em três anos. Dos 104 pacientes que foram avaliados, 82 atingiram remissão completa e 22 pacientes apresentaram falha de tratamento durante a mediana de 36 meses de acompanhamento. A SG e SLE em três anos foi de 94,2% e 74,2% respectivamente. A SLE em três anos da PET2 positiva foi de 54,3%, enquanto da PET2 negativa foi de 90,5% (p< 0.001). Na análise de subgrupos de pacientes com estádio precoce, avançado, IPI baixo e alto risco, a PET2 também apresentou correlação estatisticamente significativa com o prognóstico. Concluímos que a PET2 é o melhor fator prognóstico independente na avaliação de pacientes com LH Patients with Hodgkin lymphoma (HL) treated with poliquimioteraphy with adriamycin, bleomycin, vincristine and doxorubicin (ABVD) have distinct therapeutic response. In order to improve the prognostic assessment and therapeutic approach in HL we have evaluated the prognostic value of FDG-PET after 2 cycles of ABVD (PET2). Were included in this prospective study 115 patients with newly diagnosed LH in the period of August 2005 to December 2007. The patients were staged with physical examination, laboratory, CT and PET-FDG (PET0). All patients were treated with ABVD and those with extensive tumor were treated with radiotherapy associated. After two cycles of ABVD patients underwent PET2. No treatment was changed based on PET2. We assessed the prognostic value of clinical factors, international prognostic score (IPS) and PET2 in relation to event-free survival (EFS) in three years. Of the 104 patients who finalized the evaluation, 82 achieved complete remission and 22 patients experienced treatment failure during the median of 36 months of follow-up. The EFS at three years was 74.2%. EFS in three years of PET2 positive was 54.3%, while the PET2 negative was 90.5% (p