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In recent decades, numerous initiatives have been dedicated to assessing gender balance in the workplace. Evidence demonstrates that gender diversity is associated with better organization of daily work, continuing employment of exceptional workers, and higher institutional fnancial income [1, 2]. Furthermore, specifcally in the healthcare system, gender balance has been associated with better clinical outcomes [3, 4]. However, despite these facts, there is still a large gap between careers of men and women in the public and private sectors, both in healthcare and non-healthcare systems [5]. This appears to also be the case in the feld of nuclear medicine. To facilitate the involvement of women professionals in nuclear medicine and to encourage their active participation in the initiatives of the European Association of Nuclear Medicine (EANM), the Women Empowerment Task Force (WE-TF) was founded [6]. The WE-TF has two main goals: frst, to increase networking among women in the feld of nuclear medicine worldwide, and second, to provide a space for women to share their experiences regarding scientifc, educational, and career development. Activities aiming to achieve these goals will be coordinated by the WE-TF team, supported by the EANM office.The challenges encountered by the WE- TF were to frst determine possible reasons for the underrepresentation of women in EANM activities, and second to understand the need to promote equal gender participation as perceived by the nuclear medicine community.

Endometriosis is a common gynecologic condition that may be visualized on 18F-FDG PET/CT and mimic lesions of malignancy. We analyzed the interference of known or suspected endometriosis in reporting 18F-FDG PET/CT performed in another indication.The PET/CT images of 18 women with known (n = 15) or suspected (n = 3) endometriosis were analyzed. Based on clinical follow-up and results of other imaging, biopsy, and/or postsurgical histology, the presence of lesions of endometriosis at the time of 18F-FDG PET/CT was confirmed in 13 of 18 patients (72%). The per-patient positivity rate of 18F-FDG PET/CT was 8/18 (44%; 95% confidence interval, 22%-69%). The patient-based detection rate of 18F-FDG PET/CT in patients with confirmed lesions of endometriosis was 8/13 (62%; confidence interval, 32%-86%). On per-lesion/site basis, 18F-FDG PET/CT detected 11 of 20 sites (55%) of endometriosis. The SUVmax of these lesions/sites ranged between 1.8 and 5.3 (median, 3.8). In 9 of 18 patients (50%), a total of 13 non-endometriosis-related lesions/sites were detected by 18F-FDG PET/CT; their SUVmax ranged between 2.7 and 23 (median, 9.4).The interference of known or suspected endometriosis in reporting 18F-FDG PET/CT performed in another indication was limited but possible and should be kept in mind, even in postmenopausal women, as the oldest patient with 18F-FDG-positive endometriosis was aged 63 years. The lesions of endometriosis showed inconstant 18F-FDG uptake with overlap of SUVmax with low-grade malignancies. In our series, the greatest SUVmax value of lesion of endometriosis was 5.3, somewhat higher than the threshold of 4 previously proposed for identification of malignant transformation of endometriosis.

Following orchiectomy, patients with clinical stage I (CSI) testicular seminoma may be managed by active surveillance (S) or adjuvant treatment (radiotherapy or chemotherapy). In view of the published data on long-term toxicity, especially second malignant neoplasms (SMNs), adjuvant radiotherapy (ART) is currently no longer recommended as an adjuvant therapy option for these patients. The purpose of our recent study was to compare the impact of two selected treatment approaches - S versus adjuvant chemotherapy (ACT) on the survival of patients with CSI testicular seminoma. This cross-sectional study analyzed a total of 139 patients collected at a single center between 10/2011-5/2020, with CSI testicular seminoma, stratified into two groups according to risk-adapted therapeutic approaches. In the S group (low-risk - without rete testis invasion - RTI, primary tumor size 4 cm), consisting of 62 patients, who were treated with ACT, relapse occurred in 5 (8.1%) patients after a mean follow-up of 11.6 months. Overall survival of patients in both groups was 100% with a mean follow-up of 43.9 months. A statistically significant difference in progression-free survival (PFS) between these two groups was not found. Based on our findings, ACT seems to be an adequate treatment for patients with a high-risk of relapse, as well as S for those with a low-risk of relapse. Despite its excellent prognosis, optimal management of CSI testicular seminoma remains controversial, with variations in expert opinion and international guidelines.

IntroductionFludeoxyglucose (18F) (FDG) hybrid positron emission tomography/computed tomography (PET/CT) is currently a well-documented tool for diagnosis, staging, and therapeutic follow-up of lymphoma with significant impact on therapeutic decisions.Patient Concerns and InterventionsWe reported a case of a 71-year-old woman with diffuse large B-cell lymphoma (DLBCL) of the left gluteal muscles as a possible result of slow centrifugal migration of untreated neurolymphomatosis (NL) of the lumbosacral plexus suggested on FDG PET/CT 4 years ago, when the patient was complaining for weakness and numbness of the left leg, but the proposed biopsy of peripheral nerve was not performed. Four years later, no pathological FDG uptake was present in nerves and lymph nodes, but PET/CT detected multiple FDG-positive infiltrates in the left gluteal muscles, appearing as a continuation of previously involved nerves.DiagnosisThe biopsy of muscular infiltrates confirmed DLBCL.OutcomesThe therapy was started, and a complete remission was achieved after three lines of treatment.ConclusionThis case contributes to limited knowledge on development of skeletal muscle lymphoma (SML): It suggests the macroscopically isolated, FDG-positive SML involving more than one muscular compartment as a possible consequence of natural course of untreated primary NL previously revealed by peripheral neuropathy and suspected on FDG PET/CT. This observation further justifies the consideration of implementation of FDG PET/CT into diagnostic algorithm while evaluating the peripheral neuropathy, in which the NL, albeit rare, is a part of differential diagnosis.

A 61-year-old man after resection of well-differentiated midgut neuroendocrine neoplasia (NEN) was referred to 18F-fluorodihydroxyphenylalanine PET/CT for localization of recurrent midgut NEN in the context of clinical symptoms and mild elevation of serum CgA (chromogranin A) levels. Isolated hepatic focus of increased 18F-Fluorodihydroxyphenylalanine uptake was detected. The biopsy of this focus, followed by radiofrequency ablation, revealed a hepatic cavernous hemangioma. Complete remission of midgut NEN was confirmed during 4-year clinical and imaging follow-up. The persistent mild elevation of serum CgA was retrospectively attributed to treatment with proton-pump inhibitors.

BACKGROUND There is a clinical need for therapeutic alternative in patients with persisting painful arthritis of AC-joint and failure of previous treatments. However, no radiopharmaceutical is currently explicitly approved for radiosynoviorthesis of acromioclavicular joint. The aim of our study was to prospectively assess the efficacy and safety of radiosynoviorthesis of acromioclavicular joint using erbium-169 citrate. MATERIAL AND METHODS Radiosynoviorthesis of acromioclavicular joint was performed in 51 consecutive patients (18 males, 33 females) mean age 64.3 (range 43.8–82.6, median 63.6) years with clinically confirmed arthritis of 85 acromioclavicular joints. The efficacy of RSO was reported by patients according to 10-step visual analogue scale of pain (VAS) (0 = no pain, 10 = most severe pain) at 6 months after radiosynoviorthesis and by ranking the global therapeutic effect of RSO in 4 categories (1 = the best effect, 4 = no change). To assess the variation of blood perfusion in treated joints, the efficacy of RSO was also evaluated by variation of target (acromioclavicular joint)/non-target (soft tissue) uptake ratio (T/NTR) of metylendiphosphonate ( 99m Tc) measured as number of counts over region of interest on blood pool phase of two-phase bone scintigraphy performed before and 6 months after RSO. RESULTS Radiosynoviorthesis was followed by significant decrease in VAS, mean — 3.1 (-47%). Excellent, good, moderate and bad response was observed in 57 (67%), 25 (29%), 1 (1%) and in 2 (2%) of acromioclavicular joints respectively. A significant correlation between decrease of T/NTR and variation of VAS in % (ρ = 0.532, p < 0.0001) and between T/NTR and subjective evaluation of therapeutic effect in scale 1–4 (ρ = 0.388, p = 0.0002) was observed. However, it was not possible to identify the cut-off value of relative decrease in T/NTR showing sufficient sensitivity and specificity to detect the therapeutic response. CONCLUSION Results of this prospective study permit to conclude a good efficacy and safety of radiosynoviorthesis using erbium-169 citrate in a series of patients with arthritis of acromioclavicular joint in whom previous line(s) of treatment did not lead to satisfactory pain relief.

Purpose: Diverse radionuclide imaging techniques are available for the diagnosis, staging, and follow-up of phaeochromocytoma and paraganglioma (PPGL). Beyond their ability to detect and localise the disease, these imaging approaches variably characterise these tumours at the cellular and molecular levels and can guide therapy. Here we present updated guidelines jointly approved by the EANM and SNMMI for assisting nuclear medicine practitioners in not only the selection and performance of currently available single-photon emission computed tomography and positron emission tomography procedures, but also the interpretation and reporting of the results. Methods: Guidelines from related fields and relevant literature have been considered in consultation with leading experts involved in the management of PPGL. The provided information should be applied according to local laws and regulations as well as the availability of various radiopharmaceuticals. Conclusion: Since the European Association of Nuclear Medicine 2012 guidelines, the excellent results obtained with gallium-68 (68Ga)-labelled somatostatin analogues (SSAs) in recent years have simplified the imaging approach for PPGL patients that can also be used for selecting patients for peptide receptor radionuclide therapy as a potential alternative or complement to the traditional theranostic approach with iodine-123 (123I)/iodine-131 (131I)-labelled meta-iodobenzylguanidine. Genomic characterisation of subgroups with differing risk of lesion development and subsequent metastatic spread is refining the use of molecular imaging in the personalised approach to hereditary PPGL patients for detection, staging, and follow-up surveillance.

Neuroendocrine neoplasms are a heterogenous group of tumours, for which nuclear medicine plays an important role in the diagnostic work-up as well as in the targeted therapeutic options. This guideline is aimed to assist nuclear medicine physicians in recommending, performing, reporting and interpreting the results of somatostatin receptor (SSTR) PET/CT imaging usingThe previous procedural guideline by EANM regarding the use PET/CT tumour imaging with

Context:Preoperative ultrasonography and scintigraphy using 99mTc-sestamibi are commonly used to localize abnormal parathyroid glands. In cases of discrepant results between scintigraphy and ultrasonography, it is important to rely on another diagnostic imaging modality. 18F-fluorodeoxyglucose (FDG) and 11C-methionine positron emission tomography (PET) have been studied, but are imperfect to detect abnormal parathyroid glands. Recently, first cases of abnormal parathyroid glands taking-up radiolabelled choline were discovered incidentally in men referred to 11C-choline or 18F-fluorocholine (FCH)-PET/CT for prostate cancer. We checked if FCH uptake was a general feature of adenomatous or hyperplastic parathyroid glands.Methods:FCH-PET/CT was performed in 12 patients with primary (n = 8) or secondary hyperparathyroidism (1 dialyzed, 3 grafted) and with discordant or equivocal results on preoperative ultrasonography (US) and/or 123I/99mTc-sestamibi dual-phase scintigraphy. The results of the FCH-PET/CT were evaluated, with surgical exploration and histopathologic examination as the standard of truth.Results:On a per-patient level, the detection rate of FCH-PET/CT (at least one FCH focus corresponding to an abnormal parathyroid gland in a given patient) was 11/12 = 92%. FCH-PET/CT detected 18 foci interpreted as parathyroid glands and correctly localized 17 abnormal parathyroid glands (7 adenomas and 10 hyperplasias). On a per-lesion level, FCH-PET/CT results were 17 TP, 2 false negative ie, a lesion-based sensitivity of 89%, and 1 false positive.Conclusion:As the main result of this pilot study, we show that in patients with hyperparathyroidism and with discordant or equivocal results on scintigraphy or on ultrasonography, adenomatous or hyperplastic parathyroid glands can be localized by FCH-PET/CT with good accuracy. Furthermore, FCH-PET/CT can solve discrepant results between preoperative ultrasonography and scintigraphy and has thus a potential as a functional imaging modality in the detection of abnormal parathyroid glands. Our preliminary results are encouraging and prompt us to further evaluate FCH-PET/CT as a functional imaging agent in patients with biochemical hyperparathyroidism.

18fluorine-fluorodihydroxyphenylalanine (FDOPA) PET/CT is currently the first-line imaging technique to distinguish between focal and diffuse forms of congenital hyperinsulinism (CHI) and to accurately localize focal forms. However, this technique has a number of limitations, mainly the very small size of focal forms or inversely a very large focal form mimicking a diffuse form, and misinterpretation of physiologic uptake masking hot spots or inversely mimicking focal forms. The other limitation is the limited availability of the radiopharmaceutical. FDOPA PET/CT has no recognized competitor to date among the available morphologic and functional imaging techniques. Other potential approaches using specific tracers for positron emission tomography (PET) are discussed, using radiopharmaceuticals specific for β cell mass or targeting somatostatin receptors. These radiopharmaceuticals can be labeled with gallium-68, a PET emitter readily available in PET centers equipped with 68Ge/68Ga generators.

Accurate detection of hepatocellular carcinoma (HCC) foci in the liver and at the whole-body level has a significant impact on patient management. Functional whole-body imaging by PET (fused with CT or MRI) with spatial resolution compatible with the detection of lesions

Purpose & Methods: Neuroendocrine neoplasms are a heterogenous group of tumours, for which nuclear medicine plays an important role in the diagnostic work-up as well as in the targeted therapeutic options. This guideline is aimed to assist nuclear medicine physicians in recommending, performing, reporting and interpreting the results of somatostatin receptor (SSTR) PET/CT imaging using68Ga-DOTA-conjugated peptides, as well as18F-DOPA imaging for various neuroendocrine neoplasms. Results & Conclusion: The previous procedural guideline by EANM regarding the use PET/CT tumour imaging with68Ga-conjugated peptides has been revised and updated with the relevant and recent literature in the field with contribution of distinguished experts.

Presurgical identification of patients at high risk for early recurrence of hepatocellular carcinoma (HCC) after resection could warrant additional therapies. F-fluorodeoxyglucose (FDG) uptake by the tumour on preoperative PET can predict HCC recurrence after resection as effectively as poor differentiation or presence of microvascular invasion (MVI) on postsurgical histology. A better sensitivity for the detection of HCC nodules has been reported with F-fluorocholine (FCH), a PET tracer of lipid metabolism. This pilot study aimed to compare preoperative FDG and FCH PET/CT for predicting early recurrence of unifocal HCC, occurring within 6 months after surgical resection.FDG and FCH tumour uptakes were assessed on preoperative PET/CT by two masked readers. On FCH PET/CT, a photopenic lesion and a hot focus were considered as indicative of malignancy. During postoperative follow-up, recurrence was searched for by regularly performing CT and MRI.In 11 consecutive HCC patients, the detection rate was greater with FCH (80%) than with FDG (27%). After resection, the overall recurrence rate was 55%. Early recurrence occurred in four patients, who were the only ones with an FDG-positive and FCH-photopenic tumour, with a significant reduction in disease-free survival. On postsurgical histology, those four patients also presented with MVI and satellite nodules. Histological differentiation and capsule disruption appeared less accurate than PET/CT or MVI in predicting early recurrence.In unifocal HCC, the FCH photopenic pattern was associated with MVI and predicted early HCC recurrence after surgical resection as accurately as did an FDG uptake. Larger studies with FCH are warranted.

Erratum to : Guideline for PET/CT imaging of neuroendocrine neoplasms with 68Ga-DOTA-conjugated somatostatin receptor targeting peptides and 18F-DOPA.

Introduction: In a previous pilot study, PET/CT performed for suspected relapsing or progressive multiple myeloma (MM) revealed more lesions with FCH than with FDG. We then launched a prospective comparison of FDG and FCH PET/CT in MM at initial staging, restaging and during therapeutic follow-up. The IMPeTUs scoring system was proposed in 2016 by Nanni et al. to summarize the results of FDG PET/CT. However, the IMPeTUs scoring system is not designed to reflect by one single patient-based score the extent of the disease, as determined on radiotracer uptake. To compare the performance of those two PET radiotracers, we set a single patient-based score, derived from the IMPeTUs approach, and we applied it to the comparison of FDG and FCH PET/CT at various clinical situations of MM. Aim: To compare (1) the reproducibility of reading and scoring of FDG and FCH PET/CT in initial staging, restaging and therapeutic follow-up of MM, (2) the correlation between the scores on FDG or on FCH PET/CT and serum concentration of M-protein, a quantitative criterion reflecting the secretory activity of MM, recommended at diagnosis and as a part of evaluation of therapeutic response. Patients and methods: FDG and FCH PET/CT were performed in 105 patients (20 at initial staging, 37 at relapse and 48 during follow-up).The FDG and FCH PET/CTs were read in a random order with a wash out period by two experienced readers blinded to any patient's clinical data. They scored according to IMPeTUs scoring system, evaluating the number and intensity of foci of radiotracer uptake in 5 sites (spine, skull, extraspinal, visceral and nodal), the presence of diffuse axial and/or appendicular bone marrow uptake, of PET-positive lytic lesions, or of fractures. According to the number of visible foci in each site, the site-score was: 1: 0 focus, 2: 1-3 foci, 3: 4-10 foci or 4: >10 lesions. In case of diffuse bone marrow uptake by the axial or appendicular skeleton, the site-score 4 was attributed to the corresponding site, to integrate this pattern in one single score per site. A "SUMM" score, theoretically ranging from 5 to 20, was obtained by summing up the site-scores of the 5 sites. The kappa coefficient was calculated to evaluate the inter-reader agreement in determining the SUMM score.A consensus reading was finally performed, to solve discordances in scoring between the two readers. The paired Wilcoxon test was used to compare the consensual SUMM scores of PET/CT with FDG and FCH; the correlation coefficient between the consensual SUMM scores and M-protein level was calculated. Results:Before final consensus, the inter-reader agreement in determining the SUMM score was better with FCH (Kappa=0.90; CI=0.85-0.95) than with FDG (Kappa=0.75; CI=0.64-0.86). The analysis was then continued on the data of consensus reading. FCH showed more foci in 28 patients (4 at initial staging, 13 at relapse, 11 during follow up) and FDG in 14 patients (3 at initial staging, 4 at relapse, 7 during follow up). The SUMM score was significantly greater with FCH than with FDG (p=0.0027).M-protein was present in the serum of 95/105 patients. The correlation with serum M-protein level was significantly >0 for both SUMM scores, but loose for FDG (r=0.3, p=0.0029) and stronger for FCH (r=0.7, p5) was observed in 2 patients (1 referred for evaluation of relapsing MM and in one referred during therapeutic follow-up of MM). Conclusion: A patient-based "SUMM" score is proposed to characterize the extension and the number of foci on PET/CT imaging of MM. Using this SUMM score, a better inter-reader reproducibility, lesion detectability and correlation with serum M-protein was observed for FCH than for FDG, confirming FCH as a potential tracer in MM deserving further research. Disclosures Garderet: Celgene: Consultancy; Amgen: Consultancy; Takeda: Consultancy.

The clinical usefulness of 2-deoxy-2-[F-18]fluoro-D-glucose-positron emission tomography (FDG-PET) in head and neck squamous cell carcinoma (HNSCC) is now well-documented. However, its sensitivity is greater than its specificity due to false-positive results in inflammatory or infectious lesions, which are frequent in this area, in particular after treatment by surgery and/or radiotherapy. O-2-fluoro-(18F)-ethyl-L-thyrosine (FET) has been reported not to be taken up by such lesions, and a preliminary study indicated that this may be clinically useful in HNSCC. We performed a prospective study to compare the diagnostic performances of FDG and FET PET/CT in the different settings of HNSCC. Twenty-seven patients (20 men and seven women, aged 48–76, among 30 patients included) and 69 suspected cancer sites are now evaluable on basis of postsurgical histology and/or follow-up greater than 6 months; 15 patients were referred for initial staging and 12 during posttherapy follow-up, a recurrence being suspected in eight of them. FDG and FET PET/CT were performed on two different days, the patient fasting for 6 h, 1 h after injection of 5 MBq/kg of body mass of each radiopharmaceutical. Both PET/CT examinations were blind read more than 6 months after the end of inclusions in a random order for each tracer and with a time interval greater than 1 month between FDG and FET PET/CT blind readings. Overall diagnostic performances, derived from blind reading: FDG PET/CT on a per patient basis: sensitivity 100%, specificity 71%, accuracy 93%; FDG PET/CT on a per site basis: sensitivity 95%, specificity 63%, accuracy 83%; FET PET/CT on a per patient basis: sensitivity 70%, specificity 100%, accuracy 78%; FET PET/CT on a per site basis: sensitivity 64%, specificity 100%, accuracy 78%. At site level, sensitivity was significantly greater with FDG (p

Hybrid positron emission tomography/computed tomography (PET/CT) has now become available, as well as whole-body, low-dose multidetector row computed tomography (MDCT) or magnetic resonance imaging (MRI). The radioactive glucose analogue 18F-fluorodeoxyglucose (FDG) is the most widely used tracer but has a relatively low sensitivity in detecting multiple myeloma (MM). We compared FDG with a more recent metabolic tracer, 18F-fluorocholine (FCH), for the detection of MM lesions at time of disease relapse or progression. We analyzed the results of FDG and FCH imaging in 21 MM patients undergoing PET/CT for suspected relapsing or progressive MM. For each patient and each tracer, an on-site reader and a masked reader independently determined the number of intraosseous and extraosseous foci of tracer and the intensity of uptake as measured by their SUVmax and the corresponding target/non-target ratio (T/NT). In the skeleton of 21 patients, no foci were found for two cases, uncountable foci were observed in four patients, including some mismatched FCH/FDG foci. In the 15 patients with countable bone foci, the on-site reader detected 72 FDG foci vs. 127 FCH foci (+76 %), whereas the masked reader detected 69 FDG foci vs. 121 FCH foci (+75 %), both differences being significant. Interobserver agreement on the total number of bone foci was very high, with a kappa coefficient of 0.81 for FDG and 0.89 for FCH. Measurement of uptake in the matched foci that took up both tracers revealed a significantly higher median SUVmax and T/NT for FCH vs. FDG. Almost all unmatched foci were FCH-positive FDG-negative (57/59 = 97 % on-site and 56/60 = 93 % on masked reading); they were more frequently observed than matched foci in the head and neck region. These findings suggest that PET/CT performed for suspected relapsing or progressive MM would reveal more lesions when using FCH rather than FDG.

Introduction Following orchiectomy patients with clinical stage I (CSI) testicular seminoma may be managed by active surveillance (AS) or adjuvant treatment (radiotherapy or chemotherapy). In view of the published data on long-term toxicity, mainly second malignant neoplasms (SMNs), adjuvant radiotherapy (ART) is currently no longer recommended as adjuvant therapy for these patients. The purpose of our recent study was to compare the impact of two selected treatment approaches – AS versus adjuvant chemotherapy (ACT) on survival in patients with CSI testicular seminoma. Material and methods The cross-sectional study analyzed a total of 106 patients collected at a single centre between 4/2008–8/2015, with CSI testicular seminoma, stratified into two groups according to risk-adapted therapeutic approaches. Results In group A (low-risk), consisting of 84 patients, who underwent AS, relapse occurred in 10 (11.9%) patients after a mean follow-up of 13.8 months. In group B (high-risk), consisting of 22 patients, who were treated with ACT, relapse occurred in two (9.1%) patients after a mean follow-up of 13.8 months. Overall survival of patients in both groups was 100% with a mean follow-up of 25.3 months. The statistically significant difference in progression-free survival (PFS) between these two groups was not found. Conclusions ACT seems to be adequate treatment for patients with high-risk of relapse, as well as AS for those with low-risk of relapse. Despite its excellent prognosis, optimal management of CSI testicular seminoma remains controversial, with variations in expert opinion and international guidelines.

In prostate cancer, use of FDG, the radiopharmaceutical currently most widely used in oncology, is limited to the most aggressive cancers and, in the absence of another tracer, to attempting to localise occult recurrences detected biochemically (elevated PSA serum levels). Four other PET tracers are currently suggested in various situations of prostate cancer development: for guiding biopsies, for diagnosis and staging of the primary cancer and of local or metastatic recurrences, especially in bone, and for localizing occult biochemical recurrence. This article is illustrated by cases summarising our experience with fluoromethylcholine-(18F) and PET/CT. They cover a wide spectrum of clinical settings: localisation of intraprostatic neoplastic lesions, initial staging, monitoring treatment by ultrasound, detection of occult recurrences and characterisation of images on conventional imaging modalities, which are questionable or difficult to interpret.

To evaluate, in children with Hodgkin lymphoma (HL), the frequency and intensity of visually diffuse FDG uptake by selected organs at baseline (bPET) and on interim PET/CT (iPET), and to evaluate the relation between FDG uptake, metabolic response and evolution of the disease with treatment.Thirty children with HL had bPET and then iPET after two cycles of treatment, which were blind-read retrospectively. Excluding sites with focal uptake, diffuse FDG uptake by thymus, bone marrow at iliac crests, liver, spleen, and the spinal cord at the 12th thoracic vertebra (Th12) was evaluated visually using a three-point scoring method and semiquantitatively by measuring SUVmax. Visualisation of activated brown adipose tissue (BAT) was also quoted. Five children had refractory HL. Recurrence-free survival was determined for each patient. Nine patients relapsed; in 21 non-relapsing patients, the median follow-up period was 43 months (range: 28-61).On bPET, the rate of diffuse and intense (visual score = 3) FDG uptake was 48 % in the spleen, 43 % in the spinal cord at Th12, 37 % in bone marrow, 21 % in the thymus and 7 % in BAT. At least one of those sites showed diffuse and intense FDG uptake in 77 % of patients. On iPET, a significant decrease in SUVmax was observed in thymus, iliac crest bone marrow and spleen, but not in spinal cord. In contrast, the FDG uptake by the liver significantly increased. The absence of SUVmax increase in the liver between bPET and iPET was the best criterion to predict a refractory disease (PPV = 55 %, NPV = 100 %). Its area under ROC (AUC) was 0.9 vs. 0.73 for five-point Deauville criteria. For prediction of relapse, two criteria were derived from the evolution of diffuse uptake between bPET and iPET: no increase in liver uptake and an increase 5 % in spinal cord uptake. As compared with 13 patients who matched none of those criteria, the hazard ratio (HR) for relapse was 2.1 in 13 patients who matched one criterion, and 10.3 in four patients who matched both (Kaplan-Meier analysis p = 0.005).Diffuse and intense FDG uptake by organs is frequent in children with HL on bPET. On iPET, it is frequently reduced in all sites except the liver, which may pose problems for visual quotation of the FDG intensity of HL foci. The variation of SUVmax between bPET and iPET permitted us to achieve a prediction of refractory or relapsing HL that was at least as effective as using criteria based on FDG uptake by the HL lesions. The results of this retrospective pilot study need further validation.

FDG PET is useful when cancer in the head or neck (except for tumors of the salivary glands, which cannot be characterized accurately) is diagnosed or suspected but not confirmed by biopsy. It can, for example, find evidence of suspicious lymph nodes in clinically N0 necks, detect foci suggestive of distant metastases or second cancers, and provide useful prognostic information. Because it can be very difficult to identify anatomical structures and landmarks on PET images in the head and neck region, PET/CT fusion is very helpful in this area. In early assessment of chemotherapy, the absence of a significant reduction in FDG uptake after one or two cycles predicts lack of efficacy and thus indicates the need to modify the regimen. Conversely, the disappearance of FDG foci indicates effective treatment and good prognosis but cannot rule out the persistence of any malignant tissue at the end of treatment, especially neoadjuvant. Diagnostic impact is probably greatest in monitoring for recurrence and restaging known recurrence: FDG PET should be performed - perhaps routinely - early enough that curative options are still open, but long enough after the end of treatment to avoid false positive results from inflammation. The strategy and timing of FDG PET during follow-up should be determined in more detail in the future, as should the role (if any) of fluorotyrosine (FET) PET in squamous cell carcinoma.

In our hospital as in many others, primary lung cancer is the most frequent indication for FDG PET. Studies have assessed the clinical utility of this imaging modality in characterizing solitary pulmonary nodules or masses, initial staging, defining tumor volume in radiotherapy and searching for recurrence of or restaging non-small cell carcinoma; studies are currently underway to evaluate its use in early assessment of chemotherapy response. Small cell lung cancer has a high FDG uptake and PET/CT can be useful for rapid staging. False negative results may be due to pure bronchioloalveolar carcinomas and endocrine tumors. FDG-PET will certainly play a more important role in the diagnosis and follow-up of pleural cancers in the future. An unexpected positive FDG PET focus should be considered as a warning, but histological proof should precede any irrevocable decisions.

The effect of erythropoietin stimulation on bone marrow uptake of FDG has been well documented. Similar metabolic activation of bone marrow with (18)F-fluorocholine (FCH) has not been previously reported. FCH PET/CT was performed in a patient with biochemical recurrent prostate cancer who was receiving erythropoietin for hemochromatosis. Diffuse skeletal uptake of FCH was seen. (18)F-Fluoride PET/CT performed the following day demonstrates multiple abnormal focal bone metastases. Generalized skeletal uptake of FCH results in poor contrast between the metastases compared to noninvolved bone. The metabolic activation of bone marrow by erythropoietin could result in false-negative FCH results for detecting bone metastases.

INTRODUCTION Several treatments are proposed for castration-resistant prostate cancer (CRPC) at the metastatic stage. Monitoring of response using serum prostate-specific antigen (PSA) levels (sPSA) can be insufficient at this stage. Imaging has been proposed, in particular, nuclear medicine functional imaging and MRI, since response of predominant bone metastases is hardly evaluable on CT. Our aim was to evaluate in patients with CRPC with bone metastases, before and after various treatment lines, the evolution of sPSA, whole-body 18F-fluorocholine (FCH) PET/CT and spine MRI (sMRI) that has been proposed for detection of imminent malignant spinal cord compression. PATIENTS AND METHODS We retrospectively gathered a pilot series of 10 patients with CRPC metastatic to bone who had 47 PSA assays, FCH PET/CT, and spine-MRI (sMRI) performed concomitantly as routine examinations, before the beginning and at the end of 37 therapeutic intervals (TIs). Blinded reading of FCH PET/CT and sMRI was performed to evaluate visually whether or not the disease has been progressing (new lesions, greater size, or greater uptake intensity of known lesions) between the initial and the final examination of each TI. RESULTS Visual interpretations limited to spine FCH (sFCH) PET/CT and sMRI were in accordance for 34 TIs (92%): 14 progressions and 20 nonprogressions. In 2 cases, sFCH did not detect lesions visible on sMRI: one epiduritis and one 6-mm lesion. In 1 case, MRI missed a lesion in the sacrum that was detected on sFCH. When whole-body FCH (wbFCH) PET/CT was taken into account, the agreement with sMRI was limited to 29 TIs (78%). The 8 discrepant cases were all wbFCH positive and sMRI negative, that is, a significantly higher frequency of positivity for wbFCH (P < 0.008). Serum PSA levels increased by more than 25% during 21 TIs, whereas no progression was visible in 8 TIs on sMRI and in 2 TIs on wbFCH. In 5 TIs, sPSA decreased by more than 50%, and progression was never detected on imaging. CONCLUSION In detecting progression in patients with CRPC metastatic to bone, results of spine imaging with sMRI and sFCH PET/CT were highly correlated, whereas wbFCH PET/CT showed significantly more progression statues comparing to sMRI alone related to the exploration of other parts of the skeleton and of soft tissue.

Background. Fluorocholine(18F) (FCH) was introduced at the beginning of April 2010 in France, Slovenia and three other EU member states for the localisation of bone metastases of prostate cancer with PET. The aim of the study was to compare the evolution of diagnostic imaging in patients with prostate cancer using a new radiopharmaceutical FCH, observed in France and in Slovenia, and to quantify the consequence of the results of new imaging modality on the detection rate of abnormal metastases and recurrences of prostate cancer. Patients and methods. In two centres (France/Slovenia), a survey of the number of nuclear medicine examinations in patients with prostate cancer was performed, covering 5 quarters of the year since the introduction of FCH. For each examination, the clinical and biological circumstances were recorded, as well as the detection of bone or soft tissue foci. Results. Six hundred and eighty-eight nuclear medicine examinations were performed impatients with prostate cancer. Nuclear medicine examinations were performed for therapy monitoring and follow-up in 23% of cases. The number of FCH PET/CT grew rapidly between the 1st and 5th period of the observation (+220%), while the number of bone scintigraphies (BS) and fluoride(18F) PET/CTs decreased (-42% and -23% respectively). Fluorodeoxyglucose(18F) (FDG) PET/CT remained limited to few cases of castrate-resistant or metastatic prostate cancer in Paris. The proportion of negative results was significantly lower with FCH PET/CT (14%) than with BS (49%) or fluoride(18F) PET/CT (54%). For bone metastases, the detection rate was similar, but FCH PET/CT was performed on average at lower prostate-specific antigen (PSA) levels and was less frequently doubtful (4% vs. 28% for BS). FCH PET/CT also showed foci in prostatic bed (53% of cases) or in soft tissue (35% of cases). Conclusions. A rapid development of FCH PET/CT was observed in both centres and led to a higher detection rate of prostate cancer lesions.

18F-Sodium fluoride is a bone tracer with a high signal-to-noise ratio, but its dosimetry is higher than that of 99mTc-labeled phosphonates at the recommended activities. The study's purpose was to determine whether the reduction by half of F-sodium fluoride-injected activity, mimicked by a short-timed reconstruction image, simulating a total dose less than or equal to that of 99mTc-hydroxymethane diphosphonate scintigraphy, had an impact on the accuracy of PET semiquantitative measurements and image quality.Whole-body time-of-flight 18F-sodium fluoride PET/computed tomography (CT) images were acquired prospectively from 40 adult patients for detection of bone metastases. 18F-Sodium fluoride was administered according to the European Association of Nuclear Medicine (EANM) and Society of Nuclear Medicine (SNM) practice guidelines. From the acquired 1 min/bed position list-mode data, 30-s reconstructions were extracted. Measurements of maximum standard uptake value were recorded with a region of interest applied to the same location on the 1-min and 30-s images, which were displayed side by side, and were analyzed using Bland-Altman plots. A masked reading was performed by two senior nuclear medicine physicians who counted the foci of visually increased uptake.Bland-Altman plots showed an excellent agreement between the maximum standard uptake value measurements of the 60- and 30-s images. The paired Wilcoxon test results between the corresponding 60- and 30-s images read by masked readers A and B were not significant (P=0.15 and 0.19, respectively).Reducing acquisition duration by half or injecting half of the activity recommended by the EANM and SNM practice guidelines can lead to 18F-sodium fluoride time-of-flight PET images of diagnostic quality, achieving a radiation dose less than or equal to that of 99mTc-labeled phosphonates.

Aim Bronchioloalveolar (BAC) cancer is a source of false-negative F-fluorodeoxyglucose (FDG) PET/computed tomography (CT) results. A few studies reported better diagnostic performances with PET tracers of lipid metabolism, C-choline, or C-acetate, for the detection of well-differentiated adenocarcinoma or BAC. F-fluorocholine (FCH) is a lipid analogue for PET imaging, with advantages in terms of logistics and image resolution. We carried out this prospective pilot study to evaluate whether FCH PET/CT could detect lung cancer with a BAC component and could be more sensitive than FDG in this aim. Methods Fifteen patients with a lung nodule or lesion suspected for BAC on CT and/or with a history of BAC had PET/CT 60-90 min after 5 MBq FDG/kg body mass and, on a separate day, 10-20 min after 4 MBq FCH/kg body mass. The standard of truth was histology and a 6-month follow-up. Results Nine patients (12 lesions) presented BAC or adenocarcinoma with BAC features, two patients presented adenocarcinoma without BAC features (five lesions) and four patients presented benign lesions (15 non-malignant sites). For both FCH and FDG, patient-based sensitivity was 78% for detecting cancer with a BAC component and 82% for detecting malignancy. Site-based sensitivity for detecting malignancy was 76 and 75% for detecting cancer with BAC features, for both radiopharmaceuticals. Specificity was similar for FCH and FDG (site-based 93 vs. 81%, NS). In these early-stage cancers, only one adrenal metastasis was observed that took up FCH and FDG. Conclusion In this population of patients with ground-glass opacities selected on CT suggestive of BAC or with a history of BAC and a recent lung anomaly on CT, FCH detected all malignant lesions with at least a 2.0 cm short axis. However, FDG had similar performance.

Prospectively evaluate the impact of fluorodeoxyglucose-fluorine-18 positron emission tomography (FDG-PET) in the management of recurrence of advanced head and neck squamous cell carcinoma during the first year after treatment.Seventy patients were followed-up every 6 to 8 weeks during the first year after initial combined curative therapy. FDG-PET, together with conventional imaging and endoscopy were performed systematically at 1 year (group A) or prompted earlier in case of clinically suspicious recurrence (group B). The referring physician evaluated the impact of FDG-PET on the patient's management. Another clinician checked the pertinence of decisions.FDG-PET had a therapeutic impact in 8 of 43 group A patients and in 16 of 27 group B patients; the overall rate was 34%. This change was pertinent in 5 of 8 and 14 of 16 cases, respectively. Overall pertinence rate of decisions was 90% versus 70% without FDG-PET.FDG-PET had a significant overall therapeutic impact; the induced decisions were either pertinent or just led to "futile" noninvasive examinations. Systematic FDG-PET had a significantly lesser impact in comparison with FDG-PET motivated by clinical suspicion.

In prostate cancer, use of FDG, the radiopharmaceutical currently most widely used in oncology, is limited to the most aggressive cancers and, in the absence of another tracer, to attempting to localise occult recurrences detected biochemically (elevated PSA serum levels). Four other PET tracers are currently suggested in various situations of prostate cancer development: for guiding biopsies, for diagnosis and staging of the primary cancer and of local or metastatic recurrences, especially in bone, and for localizing occult biochemical recurrence. This article is illustrated by cases summarising our experience with fluoromethylcholine-(18F) and PET/CT. They cover a wide spectrum of clinical settings: localisation of intraprostatic neoplastic lesions, initial staging, monitoring treatment by ultrasound, detection of occult recurrences and characterisation of images on conventional imaging modalities, which are questionable or difficult to interpret.

We compared (18)F-fluorocholine hybrid positron emission tomography/X-ray computed tomography (FCH-PET/CT) with ultrasonography (US) and scintigraphy in patients with hyperparathyroidism and discordant, or equivocal results of US and (123)I/(99m)Tc-sesta-methoxyisobutylisonitrile (sestaMIBI) dual-phase parathyroid scintigraphy. FCH-PET/CT was performed in 17 patients with primary (n = 11) lithium induced (n = 1) or secondary hyperparathyroidism (1 dialyzed, 4 renal-transplanted).The reference standard was based on results of surgical exploration and histopathological examination. The results of imaging modalities were evaluated, on site and by masked reading, on per-patient and per-lesion bases.In a first approach, equivocal images/foci were considered as negative. On a per-patient level, the sensitivity was for US 38%, for scintigraphy 69% by open and 94% by masked reading, and for FCH-PET/CT 88% by open and 94% by masked reading. On a per-lesion level, sensitivity was for US 42%, for scintigraphy 58% by open and 83% by masked reading, and for FCH-PET/CT 88% by open and 96% by masked reading. One ectopic adenoma was missed by the 3 imaging modalities. Considering equivocal images/foci as positive increased the accuracy of the open reading of scintigraphy or of FCH-PET/CT, but not of US. FCH-PET/CT was significantly superior to US in all approaches, whereas it was more sensitive than scintigraphy only for open reading considering equivocal images/foci as negative (P = 0.04). FCH uptake was more intense in adenomas than in hyperplastic parathyroid glands. Thyroid lesions were suspected in 9 patients. They may induce false-positive results as in one case of oncocytic thyroid adenoma, or false-negative results as in one case of intrathyroidal parathyroid adenoma. Thyroid cancer (4 cases) can be visualized with FCH as with (99m)Tc-sestaMIBI, but the intensity of uptake was moderate, similar to that of parathyroid hyperplasia.This pilot study confirmed that FCH-PET/CT is an adequate imaging tool in patients with primary or secondary hyperparathyroidism, since both adenomas and hyperplastic parathyroid glands can be detected. The sensitivity of FCH-PET/CT was better than that of US and was not inferior to that of dual-phase dual-isotope (123)I/(99m)Tc-scintigraphy. Further studies should evaluate whether FCH could replace (99m)Tc-sestaMIBI as the functional agent for parathyroid imaging, but US would still be useful to identify thyroid lesions.

FDG PET is useful when cancer in the head or neck (except for tumors of the salivary glands, which cannot be characterized accurately) is diagnosed or suspected but not confirmed by biopsy. It can, for example, find evidence of suspicious lymph nodes in clinically N0 necks, detect foci suggestive of distant metastases or second cancers, and provide useful prognostic information. Because it can be very difficult to identify anatomical structures and landmarks on PET images in the head and neck region, PET/CT fusion is very helpful in this area. In early assessment of chemotherapy, the absence of a significant reduction in FDG uptake after one or two cycles predicts lack of efficacy and thus indicates the need to modify the regimen. Conversely, the disappearance of FDG foci indicates effective treatment and good prognosis but cannot rule out the persistence of any malignant tissue at the end of treatment, especially neoadjuvant. Diagnostic impact is probably greatest in monitoring for recurrence and restaging known recurrence: FDG PET should be performed - perhaps routinely - early enough that curative options are still open, but long enough after the end of treatment to avoid false positive results from inflammation. The strategy and timing of FDG PET during follow-up should be determined in more detail in the future, as should the role (if any) of fluorotyrosine (FET) PET in squamous cell carcinoma.

6-Fluoro-((18)F)-L-3,4-dihydroxyphenylalanine (FDOPA) is an amino acid analogue for positron emission tomography (PET) imaging which has been registered since 2006 in several European Union (EU) countries and by several pharmaceutical firms. Neuroendocrine tumour (NET) imaging is part of its registered indications. NET functional imaging is a very competitive niche, competitors of FDOPA being two well-established radiopharmaceuticals for scintigraphy, (123)I-metaiodobenzylguanidine (MIBG) and (111)In-pentetreotide, and even more radiopharmaceuticals for PET, including fluorodeoxyglucose (FDG) and somatostatin analogues. Nevertheless, there is no universal single photon emission computed tomography (SPECT) or PET tracer for NET imaging, at least for the moment. FDOPA, as the other PET tracers, is superior in diagnostic performance in a limited number of precise NET types which are currently medullary thyroid cancer, catecholamine-producing tumours with a low aggressiveness and well-differentiated carcinoid tumours of the midgut, and in cases of congenital hyperinsulinism. This article reports on diagnostic performance and impact on management of FDOPA according to the NET type, emphasising the results of comparative studies with other radiopharmaceuticals. By pooling the results of the published studies with a defined standard of truth, patient-based sensitivity to detect recurrent medullary thyroid cancer was 70 % [95 % confidence interval (CI) 62.1-77.6] for FDOPA vs 44 % (95 % CI 35-53.4) for FDG; patient-based sensitivity to detect phaeochromocytoma/paraganglioma was 94 % (95 % CI 91.4-97.1) for FDOPA vs 69 % (95 % CI 60.2-77.1) for (123)I-MIBG; and patient-based sensitivity to detect midgut NET was 89 % (95 % CI 80.3-95.3) for FDOPA vs 80 % (95 % CI 69.2-88.4) for somatostatin receptor scintigraphy with a larger gap in lesion-based sensitivity (97 vs 49 %). Previously unpublished FDOPA results from our team are reported in some rare NET, such as small cell prostate cancer, or in emerging indications, such as metastatic NET of unknown primary (CUP-NET) or adrenocorticotropic hormone (ACTH) ectopic production. An evidence-based strategy in NET functional imaging is as yet affected by a low number of comparative studies. Then the suggested diagnostic trees, being a consequence of the analysis of present data, could be modified, for some indications, by a wider experience mainly involving face-to-face studies comparing FDOPA and (68)Ga-labelled peptides.